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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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2
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Nappi F. Assessing emerging causes of mitral regurgitation: atrial functional mitral regurgitation. J Int Med Res 2024; 52:3000605241240583. [PMID: 38565223 PMCID: PMC10993687 DOI: 10.1177/03000605241240583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 03/02/2024] [Indexed: 04/04/2024] Open
Abstract
Functional or secondary mitral regurgitation is linked to increased cardiovascular morbidity and mortality. From a mechanical perspective, secondary mitral regurgitation occurs due to an imbalance between the forces that tether the mitral leaflets and those that close them. This results in incomplete coaptation. Most commonly, functional mitral regurgitation, which occurs in both ischaemic and non-ischaemic disease states, is usually caused by dysfunction and changes in the left ventricle. Atrial functional mitral regurgitation (AFMR) is a disease state that has been more recently recognized. It occurs when mitral annular enlargement is associated with left atrial dilatation, preserving left ventricular geometry and function. AFMR is typically seen in patients with chronic atrial fibrillation or heart failure who have a conserved ejection fraction. Published reports and ongoing investigations vary in how they define AFMR. This publication examines the pathophysiology of AFMR and highlights the importance of having a common working standard for the definition of AFMR to ensure consistency in the data reported and to drive forward the much needed research into the outcomes and treatment strategies in this area. Several studies have reported that restrictive annuloplasty and transcatheter edge-to-edge repair can reduce mitral regurgitation and improve symptoms. This narrative review will explore the pathophysiology, echocardiographic diagnosis and treatment of AFMR.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, France
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3
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Kumar K, Simpson TF, Golwala H, Chhatriwalla AK, Chadderdon SM, Smith RL, Song HK, Reeves RR, Sorajja P, Zahr FE. Mitral Valve Transcatheter Edge-to-Edge Repair Volumes and Trends. J Interv Cardiol 2023; 2023:6617035. [PMID: 38149109 PMCID: PMC10751158 DOI: 10.1155/2023/6617035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 08/10/2023] [Accepted: 11/06/2023] [Indexed: 12/28/2023] Open
Abstract
Background Despite an association between operator volumes and procedural success, there remains an incomplete understanding of the contemporary utilization and procedural volumes for mitral valve transcatheter edge-to-edge repair (MTEER). We aimed to identify annual operator procedural volumes, temporal trends, and geographic variability for MTEER among Medicare patients in the United States (US). Methods We queried the National Medicare Provider Utilization and Payment Database for a CPT code (33418) specific for MitraClip device from 2015 through 2019. We analyzed annual operator procedural volumes and incidence and identified longitudinal and geographic trends in MTEER utilization. Results From 2015 through 2019, a total of 27,034 MTEER procedures were performed among Medicare patients in the US. The nationwide incidence increased from 6.2 per 100,000 patients in 2015 to 23.8 per 100,000 patients in 2019, a 283% increase over the study period (Ptrend < 0.001). The incidence of MTEER by state varied by nearly 900% (range 5.5 to 54.9 per 100,000 person-years). In 2019, the mean annual MTEER operator annual volume was 9.1 MTEER procedures and had grown from 6.2 per year in 2015. Conclusions In this nationwide study of Medicare beneficiaries in the United States, we identified a significant and sustained increase in the utilization of MTEER devices and operators and growth in annual procedural volumes from 2015 through 2019 with considerable variability in utilization by state. Further studies are needed to understand the clinical impact of variability in utilization and the optimal procedural volumes to ensure high efficacy outcomes and maintain critical access to MTEER therapies.
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Affiliation(s)
- Kris Kumar
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
| | - Timothy F. Simpson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Harsh Golwala
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Adnan K. Chhatriwalla
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Scott M. Chadderdon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | | | - Howard K. Song
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Ryan R. Reeves
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Firas E. Zahr
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
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4
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Oezpeker UC, Hoefer D, Barbieri F, Gollmann-Tepekoeylue C, Johannes H, Clemens E, Suat E, Adel S, Sasa R, Mueller L, Grimm M, Bonaros N. Isolated annuloplasty in elderly patients with secondary mitral valve regurgitation: short- and long-term outcomes with a less invasive approach. Front Cardiovasc Med 2023; 10:1193156. [PMID: 37915742 PMCID: PMC10617676 DOI: 10.3389/fcvm.2023.1193156] [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: 03/24/2023] [Accepted: 09/06/2023] [Indexed: 11/03/2023] Open
Abstract
Background Long-term outcomes of elderly and frail patients with secondary mitral valve regurgitation (MR) are inconclusive. Especially in patients with co-morbidities such as atherosclerosis who are suffering from heart failure, optimal medical therapy (OMT) is the preferred therapy relative to surgical or percutaneous interventions. It remains challenging to identify the most successful therapy to improve symptoms and increase life expectancy. To reduce surgical trauma for these patients, minimally invasive mitral valve surgery (MIMVS) was developed; this has shown promising medium-term results, but there is still a lack of evidence regarding long-term results. The aim of this investigation was to describe the long-term outcomes of less invasive mitral valve surgery (MVS) in elderly patients. Methods In this longitudinal retrospective analysis, 67 patients (aged ≥70 years) with secondary MR who underwent MV repair ± tricuspid valve repair (TVR) were identified. MVS was performed via minithoracotomy (MT) in most cases (n = 54); in patients with contraindications for MIMVS, partial upper sternotomy (PS) was the preferred route for surgical access (n = 13). The appropriate access route was chosen according to the patient's clinical condition and comorbidities. We analyzed reoperation-free long-term survival, combined operative success (lack of residual MR, conversion to MV replacement, or larger thoracic incisions), and perioperative safety (at 30 days: mortality, re-thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation, stroke, myocardial infarction). In a subgroup analysis, we compared long-term survival in MVS patients with and without TVR. Results The median age of patients (62.7% female) was 74 years (interquartile range: 72-76 years), with a median EuroSCORE2 of 2.8% (1.5%-4.6%) and N-terminal pro-brain natriuretic peptide plasma levels of 1,434 ng/L (1035-2149 ng/L). The median follow-up period was 5.6 years (2.7-8.5 years). The reoperation-free long-term survival rate up to 10 years was 66.2%. Combined operative success and perioperative safety were achieved in 94% and 76% of patients, respectively. Additional TVR was performed in 56.7% of patients, without any significant difference in survival rates compared to the group without TVR (p = 0.417; HR 1.473, 95% CI 0.578-3.757). Conclusion Less invasive MV repair for secondary MR shows excellent operative success and safety in selected patients. Freedom from significant MR and from the need for reoperation indicates long-lasting efficacy. These results should be considered in heart team discussions regarding allocation of patients to surgical mitral procedures.
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Affiliation(s)
- Ulvi Cenk Oezpeker
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Hoefer
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Fabian Barbieri
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Berlin, Germany
| | | | - Holfeld Johannes
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Engler Clemens
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ersahin Suat
- Department of Cardiovascular Surgery, Sakarya University, Adapazari, Türkiye
| | - Sakic Adel
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rajsic Sasa
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Ludwig Mueller
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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5
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Gaidulis G, Padala M. Computational Modeling of the Subject-Specific Effects of Annuloplasty Ring Sizing on the Mitral Valve to Repair Functional Mitral Regurgitation. Ann Biomed Eng 2023; 51:1984-2000. [PMID: 37344691 PMCID: PMC10826925 DOI: 10.1007/s10439-023-03219-9] [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: 12/21/2022] [Accepted: 04/21/2023] [Indexed: 06/23/2023]
Abstract
Surgical repair of functional mitral regurgitation (FMR) that occurs in nearly 60% of heart failure (HF) patients is currently performed with undersizing mitral annuloplasty (UMA), which lacks short- and long-term durability. Heterogeneity in valve geometry makes tailoring this repair to each patient challenging, and predictive models that can help with planning this surgery are lacking. In this study, we present a 3D echo-derived computational model, to enable subject-specific, pre-surgical planning of the repair. Three computational models of the mitral valve were created from 3D echo data obtained in three pigs with HF and FMR. An annuloplasty ring model in seven sizes was created, each ring was deployed, and post-repair valve closure was simulated. The results indicate that large annuloplasty rings (> 32 mm) were not effective in eliminating regurgitant gaps nor in restoring leaflet coaptation or reducing leaflet stresses and chordal tension. Smaller rings (≤ 32 mm) restored better systolic valve closure in all investigated cases,but excessive valve tethering and restricted motion of the leaflets were still present. This computational study demonstrates that for effective correction of FMR, the extent of annular reduction differs between subjects, and overly reducing the annulus has deleterious effects on the valve.
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Affiliation(s)
- Gediminas Gaidulis
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, USA.
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA.
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6
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Lander MM, Brener MI, Goel K, Tang PC, Verlinden NJ, Zalawadiya S, Lindenfeld J, Kanwar MK. Mitral Interventions in Heart Failure. JACC. HEART FAILURE 2023; 11:1055-1069. [PMID: 37611988 DOI: 10.1016/j.jchf.2023.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Abstract
Patients with heart failure with reduced ejection fraction who have secondary mitral regurgitation (SMR) have poorer outcomes and quality of life than those without SMR. Guideline-directed medical therapy is the cornerstone of SMR treatment. Careful evaluation of landmark trials using mitral transcatheter edge-to-edge repair in SMR has led to an improved understanding of who will benefit from percutaneous interventions with emphasis on a multidisciplinary approach. The success with mitral transcatheter edge-to-edge repair in SMR has also spurred the evaluation of its role in populations that were not initially studied, such as end-stage heart failure and cardiogenic shock. A spectrum of transcatheter devices in development and clinical trials promise to further provide a growing array of management options for heart failure with reduced ejection fraction patients with symptomatic SMR.
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Affiliation(s)
- Matthew M Lander
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Michael I Brener
- Division of Cardiology at Columbia University Irving Medical Center, New York, New York, USA
| | - Kashish Goel
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan J Verlinden
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sandip Zalawadiya
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
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7
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Cocchieri R, van de Wetering B, Baan J, Driessen A, Riezebos R, van Tuijl S, de Mol B. The evolution of technical prerequisites and local boundary conditions for optimization of mitral valve interventions-Emphasis on skills development and institutional risk performance. Front Cardiovasc Med 2023; 10:1101337. [PMID: 37547244 PMCID: PMC10402900 DOI: 10.3389/fcvm.2023.1101337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/29/2023] [Indexed: 08/08/2023] Open
Abstract
This viewpoint report describes how the evolution of transcatheter mitral valve intervention (TMVI) is influenced by lessons learned from three evolutionary tracks: (1) the development of treatment from mitral valve surgery (MVS) to transcutaneous procedures; (2) the evolution of biomedical engineering for research and development resulting in predictable and safe clinical use; (3) the adaptation to local conditions, impact of transcatheter aortic valve replacement (TAVR) experience and creation of infrastructure for skills development and risk management. Thanks to developments in computer science and biostatistics, an increasing number of reports regarding clinical safety and effectiveness is generated. A full toolbox of techniques, devices and support technology is now available, especially in surgery. There is no doubt that the injury associated with a minimally invasive access reduces perioperative risks, but it may affect the effectiveness of the treatment due to incomplete correction. Based on literature, solutions and performance standards are formulated with an emphasis in technology and positive outcome. Despite references to Heart Team decision making, boundary conditions such as hospital infrastructure, caseload, skills training and perioperative risk management remain underexposed. The role of Biomedical Engineering is exclusively defined by the Research and Development (R&D) cycle including the impact of human factor engineering (HFE). Feasibility studies generate estimations of strengths and safety limitations. Usability testing reveals user friendliness and safety margins of clinical use. Apart from a certification requirement, this information should have an impact on the definition of necessary skills levels and consequent required training. Physicians Preference Testing (PPT) and use of a biosimulator are recommended. The example of the interaction between two Amsterdam heart centers describes the evolution of a professional ecosystem that can facilitate innovation. Adaptation to local conditions in terms of infrastructure, referrals and reimbursement, appears essential for the evolution of a complete mitral valve disease management program. Efficacy of institutional risk management performance (IRMP) and sufficient team skills should be embedded in an appropriate infrastructure that enables scale and offers complete and safe solutions for mitral valve disease. The longstanding evolution of mitral valve therapies is the result of working devices embedded in an ecosystem focused on developing skills and effective risk management actions.
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Affiliation(s)
| | | | - Jan Baan
- Amsterdam University Center, Technical University Eindhoven, Amsterdam, Netherlands
| | - Antoine Driessen
- Amsterdam University Center, Technical University Eindhoven, Amsterdam, Netherlands
| | | | | | - Bas de Mol
- LifeTec Group BV, Eindhoven, Netherlands
- Amsterdam University Center, Technical University Eindhoven, Amsterdam, Netherlands
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8
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Nappi F, Avtaar Singh SS. Distinctive Signs of Disease as Deterrents for the Endothelial Function: A Systematic Review. Metabolites 2023; 13:metabo13030430. [PMID: 36984870 PMCID: PMC10057506 DOI: 10.3390/metabo13030430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Endothelial integrity plays a major role in homeostasis and is responsive to the numerous endogenous factors released. While its functional role in vascular tone is well described, its role in the pathophysiology of cardiovascular disease is of interest as a potential therapeutic target. We performed a systematic review to provide an overview of new therapeutic and diagnostic targets for the treatment of coronary artery disease related to endothelial dysfunction. Databases of PubMed, Ovid’s version of MEDLINE, and EMBASE were interrogated with appropriate search terms. Inclusion criteria have been met by 28 studies that were included in the final systematic review. We identified inflammation, pulmonary hypertension, diabetes mellitus and Fabry disease as pathophysiological mechanisms and explored the therapeutic options related to these conditions including medications such as Canakinumab. Endothelial dysfunction has a key role in several different pathophysiological processes which can be targeted for therapeutic options. Ongoing research should be targeted at making the transition to clinical practice. Further research is also needed on understanding the amelioration of endothelial dysfunction with the use of cardiovascular medications.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
- Correspondence: ; Tel.: +33-149334104; Fax: +33-149334119
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9
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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: 0] [Impact Index Per Article: 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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10
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Campos-Arjona R, Rodríguez-Capitán J, Martínez-Carmona JD, Lavreshin A, Fernández-Romero L, Melero-Tejedor JM, Jiménez-Navarro M. Prognosis for Mitral Valve Repair Surgery in Functional Mitral Regurgitation. Ann Thorac Cardiovasc Surg 2022; 28:342-348. [PMID: 35851568 PMCID: PMC9585337 DOI: 10.5761/atcs.oa.22-00051] [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] [Indexed: 11/16/2022] Open
Abstract
Purpose: Our aim was to evaluate the development of new significant mitral regurgitation and long-term survival after mitral repair surgery in functional mitral regurgitation. Methods: A retrospective observational analysis of the recurrence of functional mitral regurgitation (ischemic and nonischemic) and global mortality during follow-up of 176 patients who underwent mitral repair surgery between 1999 and 2018 in our center was conducted. Results: The etiology of functional mitral regurgitation was ischemic in 55.7% of cases. After surgery, mitral regurgitation was 0-I in 92.3% of cases. We conducted a long-term clinical follow-up of a mean 42.2 months and an echocardiographic follow-up of a mean 41.8 months. We observed mitral regurgitation of at least grade II in 52 patients (36.9%). Survival at 1, 3, and 5 years was 78.8%, 66.7%, and 52.3%, respectively. Predictive factors for global mortality were age (hazard ratio = 1.038, p = 0.01) and a depressed preoperative ejection fraction. After a competing risk analysis, we found the only predictive factor for the recurrence of mitral regurgitation in our series to be age (sub-hazard ratio = 1.03, 95% confidence interval = 1.01–1.06, p = 0.016). Conclusion: Repair surgery for functional mitral regurgitation shows age as the only independent predictor of recurrence. Age and depressed ejection fraction were predictors of mortality.
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Affiliation(s)
- Rafael Campos-Arjona
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Jorge Rodríguez-Capitán
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - José D Martínez-Carmona
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Alexey Lavreshin
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Loudes Fernández-Romero
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - José M Melero-Tejedor
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Manuel Jiménez-Navarro
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
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11
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Noly PE, Pagani FD, Obadia JF, Bouchard D, Bolling SF, Ailawadi G, Tang PC. The role of surgery for secondary mitral regurgitation and heart failure in the era of transcatheter mitral valve therapies. Rev Cardiovasc Med 2022; 23:87. [PMID: 35345254 PMCID: PMC11178038 DOI: 10.31083/j.rcm2303087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/18/2021] [Accepted: 11/26/2021] [Indexed: 04/26/2024] Open
Abstract
The approach to the management of mitral valve (MV) disease and heart failure (HF) has dramatically changed over the last decades. It is well recognized that severe mitral regurgitation secondary to ischemic or non-ischemic cardiomyopathy is associated with an excess risk of mortality. Understanding the impact of the surgical treatment modality on mortality outcomes has been difficult due to the broad spectrum of secondary mitral regurgitation (SMR) phenotypes and lack of randomized surgical clinical trials. Over the last 30 years, surgeons have failed to provide compelling evidence to convince the medical community of the need to treat SMR in patients with severe HF. Therefore, the surgical treatment of SMR has never gained uniform acceptance as a significant option among patients suffering from SMR. Recent evidence from randomized trials in a non-surgical eligible patients treated with transcatheter therapies, has provided a new perspective on SMR treatment. Recently published European and American guidelines confirm the key role of percutaneous treatment of SMR and in parallel, these guidelines reinforce the role of mitral valve surgery in patients who require surgical revascularization. Complex mitral valve repair combining subvalvular apparatus repair along with annuloplasty seems to be a promising approach in selected patients in selected centers. Meanwhile, mitral valve replacement has become the preferred surgical strategy in most patients with advanced heart failure and severe LV remodeling or high risk of recurrent mitral regurgitation. In this comprehensive review, we aimed to discuss the role of mitral surgery for SMR in patients with heart failure in the contemporary era and to provide a practical approach for its surgical management.
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Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, University of Montreal, Montreal, QC H1T 1C8, Canada
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109-5864, USA
| | - Françis D. Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109-5864, USA
| | - Jean-Fançois Obadia
- Department of Cardiac Surgery, “Louis Pradel” Cardiologic Hospital, 69001 Lyon, France
| | - Denis Bouchard
- Department of Cardiac Surgery, University of Montreal, Montreal, QC H1T 1C8, Canada
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109-5864, USA
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109-5864, USA
| | - Paul C. Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109-5864, USA
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12
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Imbrie-Moore AM, Zhu Y, Bandy-Vizcaino T, Park MH, Wilkerson RJ, Woo YJ. Ex Vivo Model of Ischemic Mitral Regurgitation and Analysis of Adjunctive Papillary Muscle Repair. Ann Biomed Eng 2021; 49:3412-3424. [PMID: 34734363 DOI: 10.1007/s10439-021-02879-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 10/15/2021] [Indexed: 01/24/2023]
Abstract
Ischemic mitral regurgitation (IMR) is particularly challenging to repair with lasting durability due to the complex valvular and subvalvular pathologies resulting from left ventricular dysfunction. Ex vivo simulation is uniquely suited to quantitatively analyze the repair biomechanics, but advancements are needed to model the nuanced IMR disease state. Here we present a novel IMR model featuring a dilation device with precise dilatation control that preserves annular elasticity to enable accurate ex vivo analysis of surgical repair. Coupled with augmented papillary muscle head positioning, the enhanced heart simulator system successfully modeled IMR pre- and post-surgical intervention and enabled the analysis of adjunctive subvalvular papillary muscle repair to alleviate regurgitation recurrence. The model resulted in an increase in regurgitant fraction: 11.6 ± 1.7% to 36.1 ± 4.4% (p < 0.001). Adjunctive papillary muscle head fusion was analyzed relative to a simple restrictive ring annuloplasty repair and, while both repairs successfully eliminated regurgitation initially, the addition of the adjunctive subvalvular repair reduced regurgitation recurrence: 30.4 ± 5.7% vs. 12.5 ± 2.6% (p = 0.002). Ultimately, this system demonstrates the success of adjunctive papillary muscle head fusion in repairing IMR as well as provides a platform to optimize surgical techniques for increased repair durability.
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Affiliation(s)
- Annabel M Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA.,Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA.,Department of Bioengineering, Stanford University, Stanford, CA, USA
| | | | - Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA.,Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Robert J Wilkerson
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA. .,Department of Bioengineering, Stanford University, Stanford, CA, USA.
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13
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Pausch J, Sequeira Gross T, Müller L, von Stumm M, Kloth B, Reichenspurner H, Girdauskas E. Subannular repair for functional mitral regurgitation type IIIb in patients with ischaemic versus dilated cardiomyopathy. Eur J Cardiothorac Surg 2021; 60:122-130. [PMID: 33693797 DOI: 10.1093/ejcts/ezab048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/08/2020] [Accepted: 01/08/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Functional mitral regurgitation (FMR) is a sequel of left ventricular (LV) remodelling in heart failure patients. Relocation of both papillary muscles aims to specifically address mitral leaflet tethering to improve long-term durability of modern FMR repair. Nevertheless, the prognostic impact of the underlying cardiomyopathy on the outcome after FMR repair is unknown. METHODS We analysed 84 consecutive heart failure patients with severe FMR, LV ejection fraction <40%, LV end-diastolic diameter ≥55 mm and tenting height >10 mm, who underwent ring annuloplasty and simultaneous bilateral papillary muscles relocation between June 2016 and March 2019. One-year outcome of 54 patients with ischaemic cardiomyopathy ('ICM group') was prospectively compared to the remaining 30 patients with dilated cardiomyopathy ('DCM group'). RESULTS One-year survival was similar in both groups (96% in the 'ICM group' vs 97% in the 'DCM group'; P = 0.93). Furthermore, primary composite outcome (i.e. freedom from death or mitral regurgitation ≥ 2) at 1-year postoperatively was comparable between the study groups (94%in the 'ICM group' vs 87% in the 'DCM group'; P = 0.10). LV end-diastolic diameter 1-year after surgery was significantly reduced, as compared to preoperative values, in the 'DCM group' (P = 0.018), but not in the 'ICM group' (P = 0.058). Improvement of New York Heart Association functional class and reduction of serum levels of N-terminal pro-B natriuretic peptide at 1 year was comparable in both study groups. CONCLUSIONS Standardized relocation of both papillary muscles to correct FMR resulted in very satisfactory in-hospital and 1-year outcomes, in both ICM and DCM. DCM patients showed similar improvement in heart failure symptoms and LV re-remodelling compared to ICM patients. Subannular repair is developing towards a valid therapeutic option in heart failure patients presenting with severe FMR.
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Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Tatiana Sequeira Gross
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Lisa Müller
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Benjamin Kloth
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
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14
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Exploring the Operative Strategy for Secondary Mitral Regurgitation: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3466813. [PMID: 34258260 PMCID: PMC8245239 DOI: 10.1155/2021/3466813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/05/2021] [Accepted: 06/16/2021] [Indexed: 01/16/2023]
Abstract
Background Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option. Methods A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library. Results We identified 6 different strategies for treating secondary mitral valve regurgitation: mitral valve replacement, restrictive mitral annuloplasty, surgical revascularization (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, ring and string procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted. Conclusion There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.
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15
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Gao B, Zhou Z, Jing T, Wang S, Parameswaran S, He Z. Mitral valve cleft gapping mechanism in functional mitral regurgitation: An in-vitro study. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2021. [DOI: 10.1016/j.medntd.2021.100061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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16
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Nappi F, Iervolino A, Avtaar Singh SS. Thromboembolic Complications of SARS-CoV-2 and Metabolic Derangements: Suggestions from Clinical Practice Evidence to Causative Agents. Metabolites 2021; 11:341. [PMID: 34070672 PMCID: PMC8229698 DOI: 10.3390/metabo11060341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 01/08/2023] Open
Abstract
Severe Acute Respiratory Syndrome (SARS) Coronavirus (CoV)-2 is a recently identified positive sense single-strand RNA (ssRNA) β-coronavirus. The viral spike proteins infect human hosts by binding to the cellular receptor angiotensin-converting enzyme 2 (ACE2). The infection causes a systemic illness involving cell metabolism. This widespread involvement is implicated in the pathophysiology of the illness which ranges from mild to severe, requiring multi organ support, ranging from oxygen supplementation to full cardiovascular and respiratory support. Patients with multiple co-existing comorbidities are also at a higher risk. The aim of this review is to explore the exact mechanisms by which COVID-19 affects patients systemically with a primary focus on the bleeding and thrombotic complications linked with the disease. Issues surrounding the thrombotic complications following administration of the ChAdOx1 nCoV-19 (Astra-Zeneca-Oxford) vaccine have also been illustrated. Risk stratification and treatment options in these patients should be tailored according to clinical severity with input from a multidisciplinary team.
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Affiliation(s)
- Francesco Nappi
- Centre Cardiologique du Nord de Saint-Denis, Department of Cardiac Surgery, 93200 Saint-Denis, France
| | - Adelaide Iervolino
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy;
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank G81 4DY, UK;
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17
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Kagiyama N, Toki M, Yuri T, Aritaka S, Hayashida A, Sengupta PP, Yoshida K. Physiological and prognostic differences between types of exercise stress echocardiography for functional mitral regurgitation. Open Heart 2021; 8:openhrt-2021-001583. [PMID: 33888592 PMCID: PMC8070867 DOI: 10.1136/openhrt-2021-001583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/03/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Secondary mitral regurgitation (MR) demonstrates dynamic change during exercise. This prospective observational study aimed to compare exercise stress echocardiography (ESE) where handgrip exercise (handgrip-ESE) or semisupine ergometer exercise was performed (ergometer-ESE) for patients with secondary MR. Methods Handgrip-ESE and symptom-limited ergometer-ESE were performed for 53 patients (median age (IQR): 68 (58–78) years; 70% male) on the same day. Baseline global longitudinal strain (GLS) was 9.2% (6.0%–14.0%) and MR volume was 20 (14–26) mL. All-cause death and cardiac hospitalisation were tracked for median 439 (101–507) days. Results Handgrip-ESE induced slightly but significantly greater degrees of MR increase (median one grade increase; p<0.001) than ergometer-ESE, although the changes in other parameters, including GLS (+1.1% vs −0.6%, p<0.001), were significantly smaller. Correlations between the two examinations with respect to the changes in the echocardiographic parameters were weak. Kaplan-Meier analyses revealed poor improvement in GLS during ergometer-ESE, but not the change in MR, was associated with adverse events (p=0.0065). No echocardiographic change observed during handgrip-ESE was prognostic. After adjusting for a clinical risk score, GLS changes during ergometer-ESE remained significant in predicting the adverse events (HR 0.39, p=0.03) A subgroup analysis in patients with moderate or greater MR at baseline (n=27) showed the same results as in the entire cohort. Conclusions The physiological and prognostic implications of handgrip-ESE and ergometer-ESE findings significantly differ in patients with left ventricular dysfunction and secondary MR. The type of exercise to be performed in ESE should be carefully selected.
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Affiliation(s)
- Nobuyuki Kagiyama
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan .,Department of Cardiovascular Biology and Medicine, Juntendo University, Tokyo, Japan
| | - Misako Toki
- Department of Clinical Laboratory, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Takuya Yuri
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Shingo Aritaka
- Department of Clinical Laboratory, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Akihiro Hayashida
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Partho P Sengupta
- Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
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18
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Vinciguerra M, Grigioni F, Romiti S, Benfari G, Rose D, Spadaccio C, Cimino S, De Bellis A, Greco E. Ischemic Mitral Regurgitation: A Multifaceted Syndrome with Evolving Therapies. Biomedicines 2021; 9:biomedicines9050447. [PMID: 33919263 PMCID: PMC8143318 DOI: 10.3390/biomedicines9050447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/24/2022] Open
Abstract
Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.
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Affiliation(s)
- Mattia Vinciguerra
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
- Correspondence:
| | - Francesco Grigioni
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico, University of Rome, 00128 Rome, Italy;
| | - Silvia Romiti
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, 37219 Verona, Italy;
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David Rose
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
| | - Cristiano Spadaccio
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK
| | - Sara Cimino
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Antonio De Bellis
- Department of Cardiology and Cardiac Surgery, Casa di Cura “S. Michele”, 81024 Maddaloni, Caserta, Italy;
| | - Ernesto Greco
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
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19
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The Use of Radial Artery for CABG: An Update. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5528006. [PMID: 33928147 PMCID: PMC8049807 DOI: 10.1155/2021/5528006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/21/2021] [Accepted: 03/26/2021] [Indexed: 11/17/2022]
Abstract
We used the radial artery as a second target conduit for coronary artery bypass grafting since 1971. However, randomized clinical studies have demonstrated differences in clinical outcomes between the radial artery and other grafts because these trials are underpowered. As we proceed toward 50 years of experience with radial artery grafting, we examined the literature to define the best second-best target vessel for coronary artery bypass grafting. The literature was reviewed with emphasis, and a large number of randomized controlled trials, propensity-matched observational series, and meta-analyses were identified with a large patient population who received arterial conduit and saphenous vein grafts. The radial artery has been shown to be effective and safe when used as a second target conduit for coronary artery bypass grafting. Results and patency rates were superior to those for saphenous vein grafting. It has also been shown that the radial artery is a safe and effective graft as a third conduit into the territory of the artery right coronary artery. However, there is little evidence based on a few comparable series limiting the use of the gastroepiploic artery. In its fifth decade of use, we can finally deduced that the aorto-to-coronary radial bypass graft is the conduit of choice for coronary operations after the left internal thoracic artery to the left anterior descending artery.
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20
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Khader AA, Allaf M, Lu OW, Lazopoulos G, Moscarelli M, Kendall S, Salmasi MY, Athanasiou T. Does the clinical effectiveness of Mitraclip compare with surgical repair for mitral regurgitation? J Card Surg 2021; 36:1103-1119. [PMID: 33428247 DOI: 10.1111/jocs.15298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/05/2020] [Accepted: 11/22/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgical repair of the mitral valve has long been the established therapy for degenerative mitral regurgitation (MR). Newer transcatheter methods over the last decade, such as the MitraClip, serve to restore mitral function with reduced procedural burden and enhanced recovery. This study aims to compare the shortterm and midterm outcomes of MitraClip insertion with surgical repair for MR. METHODS A systematic review of the literature was conducted for studies comparing outcomes between surgical repair and MitraClip. The initial search returned 1850 titles, from which 12 studies satisfied the inclusion criteria (one randomized controlled trial and 11 retrospective studies). RESULTS The final analysis comprised 4219 patients (MitraClip 1210; surgery 3009). Operative mortality was not different between the groups (odds ratio [OR] = 1.63, 95% confidence interval [CI]: [0.63-4.23]; p = .317). Length of hospital stay was significantly shorter in the MitraClip group (standardized mean difference [SMD] = 0.882, 95% CI: [0.77-0.99]; p < .001) with considerable heterogeneity (I2 > 90%; p < .001). The rate of reoperation on the mitral valve was lower in the surgical group (OR = 0.392; 95% CI: [0.188-0.817]; p = .012) as was the rate of MR recurrence grade moderate or above (OR = 0.29; 95% CI: [0.19-0.46]; p < .001) during midterm follow up. Long term survival (4-5 years) was also similar between both groups (hazard ratio = 0.70; 95% CI: [0.35-1.41]; p = .323). CONCLUSIONS This study highlights the superior midterm durability of surgical valve repair for MR compared with the MitraClip.
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Affiliation(s)
- Ashiq A Khader
- Department of Medicine, Imperial College London, London, UK
| | - Mohammed Allaf
- Department of Medicine, Imperial College London, London, UK
| | - Oscar W Lu
- Division of Biosciences, University College London, London, UK.,Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - George Lazopoulos
- Department of Cardio-thoracic Surgery, University Hospital of Heraklion, Crete, Greece
| | - Marco Moscarelli
- Department of Cardiovascular Surgery, GVM Care and Research, Lugo, Ravenna, Italy
| | - Simon Kendall
- Deparment of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
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21
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Lo Presti S, Baruqui DL, Perez J, Vadasseril BJ, Escolar E, Horvath SA, Mihos CG. The Role of False Tendons in Left Ventricular Remodeling and Secondary Mitral Regurgitation After Acute Myocardial Infarction. J Cardiovasc Imaging 2021; 29:46-56. [PMID: 33511800 PMCID: PMC7847792 DOI: 10.4250/jcvi.2020.0112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/20/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Left ventricular false tendons (LVFT) are common structures visualized on transthoracic echocardiography (TTE). The present study tested the hypothesis that LVFT, via a possible 'constraint' mechanism, attenuate left ventricular (LV) remodeling and secondary mitral regurgitation after acute myocardial infarction. METHODS Seventy-one patients admitted to the Coronary Care Unit following an ST-elevation (n = 63) or non-ST-elevation (n = 8) myocardial infarction were analyzed; 29 (41%) had LVFT, and 42 (59%) did not (no-LVFT). All had a TTE and at least 1 follow-up study after revascularization. The χ² analysis, Student's t-test, and Mann Whitney U test were used for the statistical analyses. RESULTS The mean age (64 vs. 66 years), left ventricular ejection fraction (LVEF) (41% vs. 39%), left ventricular end-diastolic diameter (LVEDd) index (23 mm/m² for both), and prevalence of ≥ moderate secondary/functional mitral regurgitation (MR) (17% vs. 14%) were similar between the LVFT and no-LVFT groups. At 1-year follow-up, there was no significant difference in chamber remodeling amongst the LVFT versus no-LVFT group when assessed by: 1) ≥ 10% decrease in the relative LVEF (24% vs. 26%; p = 0.83); 2) ≥ 10% increase in the LVEDd index (41% vs. 38%, p = 0.98); and, 3) ≥ 10% increase in the LV mass index (48% vs. 41%, p = 0.68). There was no difference in the prevalence of ≥ moderate secondary/functional MR (17% vs. 12%, p = 0.77). Outcomes remained similar when stratifying by LVFT morphology or ischemic territory. CONCLUSIONS In patients with mild to moderate LV dysfunction and normal chamber size, LVFT do not affect the development of LV remodeling or secondary/functional MR post-myocardial infarction.
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Affiliation(s)
- Saberio Lo Presti
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Diego Lugo Baruqui
- Department of Internal Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Jorge Perez
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Ben Johns Vadasseril
- Department of Internal Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Mount Sinai Medical Center, Miami Beach, FL, USA
- Coronary Care Unit, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Sofia A Horvath
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Mount Sinai Medical Center, Miami Beach, FL, USA
- Echocardiography Laboratory, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Christos G Mihos
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Mount Sinai Medical Center, Miami Beach, FL, USA
- Echocardiography Laboratory, Mount Sinai Medical Center, Miami Beach, FL, USA. ,
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22
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Fábián B, Osadczuk A, Bárány L, Baksa G, Rácz G, Ruttkay T. Real 3D Visualization of the Circumflex Artery Surrounding the Mitral Annulus. Thorac Cardiovasc Surg 2020; 70:87-92. [PMID: 33086404 DOI: 10.1055/s-0040-1715181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The circumflex coronary artery is located close to the mitral annulus. Consequently, it is not immune to iatrogenic damage during mitral valve procedures. Our objective was to visualize the circumflex artery from a surgeon's point of view, emphasizing its proximity. Furthermore, comparing it to coronary angiograms might support preoperative planning. METHODS Ten adult human hearts preserved in 4% formaldehyde solution were investigated (left coronary artery injected with contrast agent). After performing coronary angiographies from LAO (left anterior oblique) 40/cranial 20, RAO (right anterior oblique) 10/cranial 40, and true lateral projections, anatomical preparations were performed. Images were captured throughout the full course of the circumflex coronary artery from multiple angles. Finally, the mean distances were measured in every 5 mm between the investigated artery and the annulus of the mitral valve. RESULTS Three-dimensional model of the circumflex coronary artery and its surroundings was successfully achieved from a left atrial surgical viewpoint. The main branches were identified on the coronary angiograms. The closest distance was measured under the region of the left auricle (2.02 ± 0.69 mm; 1-3.1 mm). Afterward, the circumflex artery was observed to make a loop away from the annular region. CONCLUSION Our observations show correlation with previous anatomical studies and case reports addressing iatrogenic lesions on the circumflex coronary artery. Based on all these, we could determine a "danger zone" on the vessel. The simultaneous evaluation of the anatomical preparations and the angiograms might improve the acknowledgment of this vulnerable region serving to avoid any damage to the coronary artery.
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Affiliation(s)
- Bálint Fábián
- Department of Anatomy, Histology and Embryology, Laboratory for Applied and Clinical Anatomy, Semmelweis University, Budapest, Hungary
| | - András Osadczuk
- Department of Cardiology, Szent Rafael Hospital, Zala County, Zalaegerszeg, Hungary
| | - László Bárány
- Department of Anatomy, Histology and Embryology, Laboratory for Applied and Clinical Anatomy, Semmelweis University, Budapest, Hungary
| | - Gábor Baksa
- Department of Anatomy, Histology and Embryology, Laboratory for Applied and Clinical Anatomy, Semmelweis University, Budapest, Hungary
| | - Gergely Rácz
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Tamás Ruttkay
- Department of Anatomy, Histology and Embryology, Laboratory for Applied and Clinical Anatomy, Semmelweis University, Budapest, Hungary
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23
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Yadava OP, Pomar JL. Functional mitral regurgitation. Indian J Thorac Cardiovasc Surg 2020; 36:154. [PMID: 33061196 DOI: 10.1007/s12055-019-00806-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022] Open
Abstract
Dr. O.P. Yadava, Editor-in-Chief, IJTC, and Dr. J.L. Pomar, Former President, EACTS, discuss issues related to secondary mitral regurgitation (MR). Though it is considered a ventricular disease, mitral valve leaflets are not entirely normal. Alignment of subvalvular apparatus plays a more dominant role than annular dilatation. Early repair is preferred.
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Affiliation(s)
| | - Jose Luis Pomar
- University of Barcelona, Barcelona, Spain.,EACTS, Windsor, UK
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von Stumm M, Dudde F, Gasser S, Sequeira-Gross T, Pausch J, Sinning C, Reichenspurner H, Girdauskas E. Prognostic value of mitral valve tenting area in patients with functional mitral regurgitation. Interact Cardiovasc Thorac Surg 2020; 30:431-438. [PMID: 31808513 DOI: 10.1093/icvts/ivz291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/25/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Mitral valve (MV) repair in functional mitral regurgitation is still associated with suboptimal outcomes. Our goal was to determine whether the clinical outcome following MV repair correlates with preoperative tenting parameters. METHODS We retrospectively identified consecutive patients with functional mitral regurgitation who underwent an isolated MV annuloplasty during a 7-year period (2010-2016) from our institutional database. Preoperative tenting parameters (i.e. tenting height, coaptation length, tenting area, posterior mitral leaflet and anterior mitral leaflet angles and interpapillary muscle distance) were systematically measured. The primary end point was the composite of survival and freedom from adverse cardiac events. The follow-up protocol consisted of a structured clinical questionnaire and an analysis of the echocardiographic data. RESULTS A total of 240 patients (mean age 67.8 ± 9.8 years, 57% of men) were analysed. The overall 5-year survival rate for the whole study cohort was 74.7 ± 4.2%, and freedom from adverse cardiac events was 84.8 ± 3.4%. A tenting area ≥2.4 cm2 was identified as a cut-off value, independently predicting the composite primary study end point (hazard ratio 2.0; P = 0.03). Furthermore, a Kaplan-Meier analysis revealed a strong tendency towards worse 5-year outcomes in patients with a tenting area ≥2.4 cm2 (n = 153) versus patients with a tenting area <2.4 cm2 (n = 87) (65.3 ± 5.5% vs 77.1 ± 6.3%; P = 0.06). CONCLUSIONS MV annuloplasty is associated with acceptable clinical and echocardiographic outcomes in patients with functional mitral regurgitation 5 years postoperatively. A preoperative tenting area ≥2.4 cm2 showed a strong trend towards a worse 5-year survival rate and an increased risk of adverse cardiac events after an isolated MV annuloplasty.
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Affiliation(s)
- Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Dudde
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Gasser
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatiana Sequeira-Gross
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Nappi F, Nenna A, Sing SSA, Timofeeva I, Mihos C, Gentile F, Chello M. Mitral regurgitation: lessons learned from COAPT and MITRA-Fr. J Thorac Dis 2020; 12:2936-2944. [PMID: 32642206 PMCID: PMC7330366 DOI: 10.21037/jtd.2020.01.67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Sanjeet Singh Avvtar Sing
- Department of Cardiac Surgery, Golden Jubilee National Hospital. Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Irina Timofeeva
- Department of Imaging, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Christos Mihos
- Echocardiography Lab, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami, USA
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Michler RE. Wisdom of experience or faculty of reason: Ischemic mitral regurgitation trials—Cardiothoracic Surgical Trials Network and beyond. JTCVS OPEN 2020; 1:12-16. [PMID: 36003200 PMCID: PMC9390135 DOI: 10.1016/j.xjon.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 11/09/2019] [Accepted: 12/13/2019] [Indexed: 11/12/2022]
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Saeed MY, Van Story D, Payne CJ, Wamala I, Shin B, Bautista-Salinas D, Zurakowski D, del Nido PJ, Walsh CJ, Vasilyev NV. Dynamic Augmentation of Left Ventricle and Mitral Valve Function With an Implantable Soft Robotic Device. JACC Basic Transl Sci 2020; 5:229-242. [PMID: 32215347 PMCID: PMC7091510 DOI: 10.1016/j.jacbts.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 01/18/2023]
Abstract
Left ventricular failure is strongly associated with secondary mitral valve regurgitation. Implantable soft robotic devices are an emerging technology that enables augmentation of a native function of a target tissue. We demonstrate the ability of a novel soft robotic ventricular assist device to dynamically augment left ventricular contraction, provide native pulsatile flow, simultaneously reshape the mitral valve apparatus, and eliminate the associated regurgitation in an Short-term large animal model of acute left ventricular systolic dysfunction.
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Key Words
- FS, fractional shortening
- HF, heart failure
- IQR, interquartile range
- IVS, interventricular septum
- LHF, left heart failure
- LV, left ventricular
- LVEDP, left ventricular end-diastolic pressure
- LVSD, left ventricular systolic dysfunction
- MV, mitral valve
- MVR, mitral valve regurgitation
- RV, right ventricle
- SRVAD, soft robotic ventricular assist device
- left ventricular systolic dysfunction
- mitral valve
- secondary mitral regurgitation
- soft robotic
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Affiliation(s)
- Mossab Y. Saeed
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Van Story
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Payne
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts
- John A. Paulson Harvard School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts
| | - Isaac Wamala
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Borami Shin
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Bautista-Salinas
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- School of Industrial Engineering, Technical University of Cartagena, Cartagena, Spain
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro J. del Nido
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Conor J. Walsh
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts
- John A. Paulson Harvard School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts
| | - Nikolay V. Vasilyev
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Fabris E, De Luca A, Vitrella G, Stolfo D, Masè M, Korcova R, Merlo M, Rakar S, Van't Hof AWJ, Kedhi E, Perkan A, Sinagra G. Treatment of Functional Mitral Regurgitation in Heart Failure. Curr Cardiol Rep 2019; 21:139. [PMID: 31734930 DOI: 10.1007/s11886-019-1221-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW To analyze the current state of the art of functional mitral regurgitation (FMR) treatment. RECENT FINDINGS The first-line treatment of severe FMR consists of guideline medical therapy (GMT) and resynchronization therapy when indicated; the impact of new medical therapies like sacubitril/valsartan needs further assessment. Valvular intervention may be considered in FMR symptomatic patients despite GMT, and can be performed surgically or percutaneously. MitraClip is a safe percutaneous procedure associated with symptoms improvement. Recently, the COAPT trial showed superior outcomes for MitraClip versus GMT contrasting the MITRA-FR trial which showed no benefit of MitraClip compared with GMT. These results should be interpreted as complementary rather than opposite. The COAPT trial provided a "proof of concept" that percutaneous treatment of severe FMR in patients without too advanced left ventricular disease translates into a prognostic benefit. Careful patient selection will play a critical role in defining the clinical niche for successful interventions.
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Affiliation(s)
- Enrico Fabris
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy.
| | - Antonio De Luca
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Giancarlo Vitrella
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Davide Stolfo
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Marco Masè
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Renata Korcova
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Marco Merlo
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Serena Rakar
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Arnoud W J Van't Hof
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Cardiology, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Andrea Perkan
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy
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Abstract
Functional mitral regurgitation (FMR) in the setting of left ventricular (LV) dysfunction and heart failure portends a poor prognosis. Guideline-directed medical therapy remains the cornerstone of initial treatment, with emphasis placed on treatment of the underlying LV dysfunction, as FMR is a secondary phenomenon and a disease due to LV remodeling. Surgical correction of FMR is controversial because it typically does not address the underlying mechanism and etiology of the condition. However, new, minimally invasive transcatheter therapies, in particular the MitraClip system, have shown promise in the treatment of FMR in selected patients. This review will summarize the pathophysiology underlying FMR, the prognosis of patients with heart failure and FMR, and the various medical and procedural treatment options currently available and under investigation.
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30
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Affiliation(s)
- Piergiorgio Tozzi
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois CHUV, University of Lausanne, Switzerland
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Reply: Pathoanatomic considerations for ischemic mitral regurgitation: Highlighting the importance of anatomic and physiologic asymmetry. J Thorac Cardiovasc Surg 2019; 158:e92-e93. [PMID: 31043317 DOI: 10.1016/j.jtcvs.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 11/21/2022]
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Geometric distortion of the mitral valve apparatus in ischemic mitral regurgitation: Should we really forfeit the opportunity for a complete repair? J Thorac Cardiovasc Surg 2019; 158:e91-e92. [PMID: 31036355 DOI: 10.1016/j.jtcvs.2019.03.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/23/2022]
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Risk of Ischemic Mitral Regurgitation Recurrence After Combined Valvular and Subvalvular Repair. Ann Thorac Surg 2019; 108:536-543. [PMID: 30684477 DOI: 10.1016/j.athoracsur.2018.12.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mitral valve repair (MVr) combined with papillary muscle approximation (PMA) may improve repair durability in severe ischemic mitral regurgitation (MR), when compared with MVr alone. We sought to identify preoperative transthoracic echocardiographic markers associated with MR recurrence after MVr with PMA. METHODS A post-hoc analysis was performed on patients with severe ischemic MR who underwent coronary artery bypass graft surgery with MVr with PMA in the papillary muscle approximation randomized trial. The PMA was performed utilizing a 4-mm polytetrafluoroethylene graft placed around the papillary muscles. Linear regression analyses and receiver-operating characteristic curves were used to identify echocardiographic variables and diagnostic models associated with recurrent MR. RESULTS There were 48 patients with a mean age of 63 ± 7 years, a left ventricular ejection fraction of 35% ± 5%, and a left ventricular end-diastolic diameter of 63 ± 3 mm. Of these, 37 patients had baseline and 5-year follow-up echocardiograms, with moderate-to-severe MR recurring in 27%. Linear regression analyses revealed associations between preoperative pulmonary artery systolic pressure (standardized beta coefficient, β = 0.49/mm Hg, p = 0.002), MV tenting area (β = 0.47/cm2, p = 0.004), a symmetric MV tethering pattern (β = 0.44, p = 0.007), and left ventricular end-diastolic diameter (β = 0.37/mm, p = 0.02) with follow-up MR grade. The presence of both MV tenting area 3.1 cm2 or greater (area under the curve 0.822) and left ventricular end-diastolic diameter of 64 mm or greater (area under the curve 0.801) was the most robust discriminative model for moderate-to-severe MR recurrence (specificity 92%, sensitivity 69%, area under the curve 0.804, p = 0.003). CONCLUSIONS In patients undergoing coronary artery bypass graft surgery with MVr plus PMA, the extent of baseline MV apparatus and left ventricle geometric remodeling identifies patients at increased risk for MR recurrence.
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