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Yafasov M, Olsen FJ, Shabib A, Skaarup KG, Lassen MCH, Johansen ND, Jensen MT, Jensen GB, Schnohr P, Møgelvang R, Biering-Sørensen T. Even mild mitral regurgitation is associated with incident atrial fibrillation in the general population. Eur Heart J Cardiovasc Imaging 2024; 25:579-586. [PMID: 38078897 DOI: 10.1093/ehjci/jead337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 10/19/2023] [Accepted: 12/05/2023] [Indexed: 02/04/2024] Open
Abstract
AIMS Mitral regurgitation (MR) can be difficult to quantify. We sought to investigate whether the MR jet area to left atrial (LA) area ratio (MR/LA ratio) method for quantifying MRs can be used to predict incident atrial fibrillation (AF) in the general population. METHODS AND RESULTS The study included 4466 participants from the 5th Copenhagen City Heart Study, a prospective general population study, who underwent transthoracic echocardiography. MR jet area was measured and indexed to LA area. The endpoint was incident AF. MR was quantified in 4042 participants (mean age: 57 years, 43% men). Of these, 198 (4.9%) developed AF during a median follow-up period of 5.3 years (interquartile range: 4.4-6.1 years). MR was present in 1938 participants (48%) including 1593 (39%) trace/mild MRs (MR/LA ratio ≤ 20% and ≤4 cm2). In unadjusted analysis, MR/LA ratio was associated with incident AF [HR: 1.06 (1.00-1.13), P = 0.042 per 5% increase] but not after adjusting for CHARGE-AF score. However, the association was modified by age (P for interaction = 0.034), such that MR/LA ratio was associated with AF only in participants ≤ 73 years. In these participants, MR/LA ratio 'was' independently associated with AF after adjusting for CHARGE-AF score [HR: 1.14 (1.06-1.24), P = 0.001, per 5% increase]. This finding persisted when restricting the analysis to participants without moderate or severe MR and normal LA size [HR: 1.35 (1.09-1.68), P = 0.005, per 5% increase]. CONCLUSION MR, including even trace regurgitations quantified by MR/LA ratio, is independently associated with incident AF in individuals ≤ 73 years of age.
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Affiliation(s)
- Marat Yafasov
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Niels Andersens Vej 65, entrance 8, 3rd floor on the right, p. 835, 2900 Hellerup, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Niels Andersens Vej 65, entrance 8, 3rd floor on the right, p. 835, 2900 Hellerup, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
| | - Ali Shabib
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Niels Andersens Vej 65, entrance 8, 3rd floor on the right, p. 835, 2900 Hellerup, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
| | - Kristoffer Grundtvig Skaarup
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Niels Andersens Vej 65, entrance 8, 3rd floor on the right, p. 835, 2900 Hellerup, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
| | - Mats Christian Højbjerg Lassen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Niels Andersens Vej 65, entrance 8, 3rd floor on the right, p. 835, 2900 Hellerup, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
| | - Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Niels Andersens Vej 65, entrance 8, 3rd floor on the right, p. 835, 2900 Hellerup, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Dept. of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Magnus T Jensen
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730 Herlev, Denmark
| | - Gorm Boje Jensen
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
| | - Peter Schnohr
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
| | - Rasmus Møgelvang
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Niels Andersens Vej 65, entrance 8, 3rd floor on the right, p. 835, 2900 Hellerup, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital-Herlev Hospital, Borgmester Ib Juuls Vej 73, opgang 7, 4. etage, M1, 2730 Herlev, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Dept. of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Duncan CF, Bowcock E, Pathan F, Orde SR. Mitral regurgitation in the critically ill: the devil is in the detail. Ann Intensive Care 2023; 13:67. [PMID: 37530859 PMCID: PMC10397171 DOI: 10.1186/s13613-023-01163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.
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Affiliation(s)
- Chris F Duncan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia.
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- Nepean Clinical School of Medicine, Charles Perkin Centre Nepean, University of Sydney, Kingswood, Sydney, NSW, 2747, Australia
| | - Sam R Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
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Bennati L, Vergara C, Giambruno V, Fumagalli I, Corno AF, Quarteroni A, Puppini G, Luciani GB. An Image-Based Computational Fluid Dynamics Study of Mitral Regurgitation in Presence of Prolapse. Cardiovasc Eng Technol 2023; 14:457-475. [PMID: 37069336 PMCID: PMC10412498 DOI: 10.1007/s13239-023-00665-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/12/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE In this work we performed an imaged-based computational study of the systolic fluid dynamics in presence of mitral valve regurgitation (MVR). In particular, we compared healthy and different regurgitant scenarios with the aim of quantifying different hemodynamic quantities. METHODS We performed computational fluid dynamic (CFD) simulations in the left ventricle, left atrium and aortic root, with a resistive immersed method, a turbulence model, and with imposed systolic wall motion reconstructed from Cine-MRI images, which allowed us to segment also the mitral valve. For the regurgitant scenarios we considered an increase of the heart rate and a dilation of the left ventricle. RESULTS Our results highlighted that MVR gave rise to regurgitant jets through the mitral orifice impinging against the atrial walls and scratching against the mitral valve leading to high values of wall shear stresses (WSSs) with respect to the healthy case. CONCLUSION CFD with prescribed wall motion and immersed mitral valve revealed to be an effective tool to quantitatively describe hemodynamics in case of MVR and to compare different regurgitant scenarios. Our findings highlighted in particular the presence of transition to turbulence in the atrium and allowed us to quantify some important cardiac indices such as cardiac output and WSS.
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Affiliation(s)
- Lorenzo Bennati
- Department of Surgery, Dentistry, Pediatrics, and Obstetrics/Gynecology, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37134 Verona, Italy
| | - Christian Vergara
- LaBS, Dipartimento di Chimica, Materiali e Ingegneria Chimica “Giulio Natta”, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy
| | - Vincenzo Giambruno
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Pediatrics, and Obstetrics/Gynecology, University of Verona, O. C. M. Piazzale Stefani 1, 37126 Verona, Italy
| | - Ivan Fumagalli
- MOX, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy
| | - Antonio Francesco Corno
- Children’s Heart Institute, McGovern Medical School, UT Health, 6431 Fannin Street, Houston, TX 77030 USA
| | - Alfio Quarteroni
- MOX, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy
- École Polytechnique Fédérale de Lausanne, Rte Cantonale, 1015 Lausanne, Switzerland
| | - Giovanni Puppini
- Department of Radiology, University of Verona, O. C. M. Piazzale Stefani 1, 37126 Verona, Italy
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Pediatrics, and Obstetrics/Gynecology, University of Verona, O. C. M. Piazzale Stefani 1, 37126 Verona, Italy
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Zhou J, Lee S, Liu Y, Chan JSK, Li G, Wong WT, Jeevaratnam K, Cheng SH, Liu T, Tse G, Zhang Q. Predicting Stroke and Mortality in Mitral Regurgitation: A Machine Learning Approach. Curr Probl Cardiol 2023; 48:101464. [PMID: 36261105 DOI: 10.1016/j.cpcardiol.2022.101464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 10/13/2022] [Indexed: 01/04/2023]
Abstract
We hypothesized that an interpretable gradient boosting machine (GBM) model considering comorbidities, P-wave and echocardiographic measurements, can better predict mortality and cerebrovascular events in mitral regurgitation (MR). Patients from a tertiary center were analyzed. The GBM model was used as an interpretable statistical approach to identify the leading indicators of high-risk patients with either outcome of CVAs and all-cause mortality. A total of 706 patients were included. GBM analysis showed that age, systolic blood pressure, diastolic blood pressure, plasma albumin levels, mean P-wave duration (PWD), MR regurgitant volume, left ventricular ejection fraction (LVEF), left atrial dimension at end-systole (LADs), velocity-time integral (VTI) and effective regurgitant orifice were significant predictors of TIA/stroke. Age, sodium, urea and albumin levels, platelet count, mean PWD, LVEF, LADs, left ventricular dimension at end systole (LVDs) and VTI were significant predictors of all-cause mortality. The GBM demonstrates the best predictive performance in terms of precision, sensitivity c-statistic and F1-score compared to logistic regression, decision tree, random forest, support vector machine, and artificial neural networks. Gradient boosting model incorporating clinical data from different investigative modalities significantly improves risk prediction performance and identify key indicators for outcome prediction in MR.
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Affiliation(s)
- Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Sharen Lee
- Heart Failure and Structural Heart Disease Unit, Cardiovascular Analytics Group, China-UK Collaboration, Hong Kong, China
| | - Yingzhi Liu
- Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Jeffrey Shi Kai Chan
- Heart Failure and Structural Heart Disease Unit, Cardiovascular Analytics Group, China-UK Collaboration, Hong Kong, China
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China
| | | | - Shuk Han Cheng
- Department of Biomedical Sciences, City University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China; Kent and Medway Medical School, Canterbury, Kent, UK.
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, China.
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Rudiktyo E, Yonas E, Cramer MJ, Siswanto BB, Doevendans PA, Soesanto AM. Impact of Rheumatic Process in Left and Right Ventricular Function in Patients with Mitral Regurgitation. Glob Heart 2023; 18:15. [PMID: 36936249 PMCID: PMC10022539 DOI: 10.5334/gh.1192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/16/2023] [Indexed: 03/19/2023] Open
Abstract
Background Mitral regurgitation (MR) burdens the left and right ventricles with a volume or pressure overload that leads to a series of compensatory adaptations that eventually lead to ventricular dysfunction, and it is well known that in rheumatic heart disease (RHD) that the inflammatory process not only occurs in the valve but also involves the myocardial and pericardial layers. However, whether the inflammatory process in rheumatic MR is associated with ventricular function besides hemodynamic changes is not yet established. Purpose Evaluate whether rheumatic etiology is associated with ventricular dysfunction in patients with chronic MR. Methods The study population comprised patients aged 18 years or older included in the registry who had echocardiography performed at the National Cardiovascular Center Harapan Kita in Indonesia during the study period with isolated primary MR due to rheumatic etiology and degenerative process with at least moderate regurgitation. Results The current study included 1,130 patients with significant isolated degenerative MR and 276 patients with rheumatic MR. Patients with rheumatic MR were younger and had a higher prevalence of atrial fibrillation and pulmonary hypertension, worse left ventricle (LV) ejection fraction and tricuspid annular plane systolic excursion (TAPSE) value, and larger left atrium (LA) dimension compared to patients with degenerative mitral regurgitation (MR). Gender, age, LV end-systolic diameter, rheumatic etiology, and TAPSE were independently associated with more impaired LV ejection fraction. Whereas low LV ejection fraction, LV end-systolic diameter, and tricuspid peak velocity (TR) peak velocity >3.4 m/s were independently associated with more reduced right ventricle (RV) systolic function (Table 3). Conclusions Rheumatic etiology was independently associated with more impaired left ventricular function; however, rheumatic etiology was not associated with reduced right ventricular systolic function in a patient with significant chronic MR.
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Affiliation(s)
- Estu Rudiktyo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia–National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Emir Yonas
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia–National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Maarten J. Cramer
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bambang B. Siswanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia–National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Pieter A. Doevendans
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
- Central Military Hospital Utrecht, the Netherlands
- Netherlands Heart Institute Utrecht the Netherlands
| | - Amiliana M. Soesanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia–National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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Choong Hou KOH. Utility of Cardiopulmonary Exercise Test in Mitral Valve Transcatheter Edge-to-Edge Repair. Curr Probl Cardiol 2022:101196. [DOI: 10.1016/j.cpcardiol.2022.101196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/02/2022] [Indexed: 11/03/2022]
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Corporan D, Segura A, Padala M. Ultrastructural Adaptation of the Cardiomyocyte to Chronic Mitral Regurgitation. Front Cardiovasc Med 2021; 8:714774. [PMID: 34733889 PMCID: PMC8559873 DOI: 10.3389/fcvm.2021.714774] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/14/2021] [Indexed: 01/18/2023] Open
Abstract
Introduction: Mitral regurgitation (MR) imposes volume overload on the left ventricle (LV) and elevates wall stress, triggering its adverse remodeling. Pronounced LV dilation, minimal wall thinning, and a gradual decline in cardiac ejection fraction (EF) are observed. The structural changes in the myocardium that define these gross, organ level remodeling are not known. Cardiomyocyte elongation and slippage have both been hypothesized, but neither are confirmed, nor are the changes to the cardiomyocyte structure known. Using a rodent model of MR, we used immunohistochemistry and transmission electron microscopy (TEM) to describe the ultrastructural remodeling of the cardiomyocyte. Methods: Twenty-four male Sprague-Dawley rats (350–400 g) were assigned to two groups: group (1) rats induced with severe MR (n = 18) and group (2) control rats that were healthy and age and weight matched (n = 6). MR was induced in the beating heart using a 23-G ultrasound-guided, transapical needle to perforate the anterior mitral leaflet, and the rats were followed to 2, 10, and 20 weeks (n = 6/time-point). Echocardiography was performed to quantify MR severity and to measure LV volume and function at each time-point. Explanted myocardial tissue were examined with TEM and immunohistochemistry to investigate the ultrastructural changes. Results: MR induced rapid and significant increase in end-diastolic volume (EDV), with a 50% increase by 2 weeks, compared with control. Rise in end-systolic volume (ESV) was more gradual; however, by 20 weeks, both EDV and ESV in MR rats were increased by 126% compared with control. A significant decline in EF was measured at 10 weeks of MR. At the ultrastructural level, as early as 2 weeks after MR, cardiomyocyte elongation and increase in cross-sectional area were observed. TEM depicted sarcomere shortening, with loss of Z-line and I-band. Desmin, a cytoskeletal protein that is uniformly distributed along the length of the cardiomyocyte, was disorganized and localized to the intercalated disc, in the rats induced with MR and not in the controls. In the rats with MR, the linear registry of the mitochondrial arrangement along the sarcomeres was lost, with mitochondrial fragmentation, aggregation around the nucleus, and irregularities in the cristae. Discussion: In the setting of chronic mitral regurgitation, LV dilatation occured by cardiomyocyte elongation, which manifests at the subcellular level as distinct ultrastructural alterations of the sarcomere, cytoskeleton, and mitochondria. Since the cytoskeleton not only provides tensegrity but has functional consequences on myocyte function, further investigation into the impact of cytoskeletal remodeling on progressive heart failure or recovery of function upon correcting the valve lesion are needed.
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Affiliation(s)
- Daniella Corporan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, GE, United States.,Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, Emory University, Atlanta, GE, United States
| | - Ana Segura
- Department of Pathology, Texas Heart Institute, Houston, TX, United States
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, GE, United States.,Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, Emory University, Atlanta, GE, United States
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Functional mitral regurgitation combined with increased early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio is associated with a poor prognosis in patients with shock. Chin Med J (Engl) 2021; 134:2299-2305. [PMID: 34629416 PMCID: PMC8509966 DOI: 10.1097/cm9.0000000000001756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Functional mitral regurgitation (FMR) is common in critically ill patients and may cause left atrial (LA) pressure elevation. This study aims to explore the prognostic impact of synergistic LA pressure elevation and FMR in patients with shock. METHODS We retrospectively screened 130 consecutive patients of 175 patients with shock from April 2016 to June 2017. The incidence and impact of FMR and early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio (E/e') ≥ 4 within 6 h of shock on the prognosis of patients were evaluated. Finally, the synergistic effect of FMR and E/e' were assessed by combination, grouping, and trend analyses. RESULTS Forty-four patients (33.8%) had FMR, and 15 patients (11.5%) had E/e' elevation. A multivariate analysis revealed FMR and E/e' as independent correlated factors for 28-day mortality (P = 0.043 and 0.028, respectively). The Kaplan-Meier survival analysis revealed a significant difference in survival between patients with and without FMR (χ2 = 7.672, P = 0.006) and between the E/e' ≥ 14 and E/e' < 14 groups (χ2 = 19.351, P < 0.010). Twenty-eight-day mortality was significantly different among the four groups (χ2 = 30.141, P < 0.010). The risk of 28-day mortality was significantly higher in group 4 (E/e' ≥ 14 with FMR) compared with groups 1 (E/e' < 14 without FMR) and 2 (E/e' < 14 with FMR) (P = 0.001 and 0.046, respectively). CONCLUSIONS Patients with shock can be identified by the presence of FMR. FMR and E/e' are independent risk factors for a poor prognosis in these patients, and prognosis is worst when FMR and E/e' ≥ 14 are present. It may be possible to improve prognosis by reducing LA pressure and E/e'. TRIAL REGISTRATION ClinicalTrials.gov, NCT03082326.
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De Jesus T, Alashry MM, Padang R, Pislaru SV, Nkomo VT, Pellikka PA, Pislaru C. Intrinsic cardiac elastography in patients with primary mitral regurgitation: predictive role after mitral valve repair. Eur Heart J Cardiovasc Imaging 2021; 22:912-921. [PMID: 32533173 DOI: 10.1093/ehjci/jeaa117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/17/2020] [Accepted: 04/27/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Chronic volume-overload can impair systolic and diastolic myocardial properties. We tested the hypothesis that Intrinsic Cardiac Elastography may detect alterations in passive myocardial elasticity in patients with chronic severe mitral regurgitation (MR) and predict worsening left ventricular (LV) function after mitral valve repair (MVr). METHODS AND RESULTS Comprehensive transthoracic echocardiography and cardiac elastography were performed in 80 patients with primary MR (prolapse and/or flail leaflets) of varying severity and compared with 40 normal subjects. In patients who underwent MVr (n = 51), elastography measurements were related to changes in left ventricular ejection fraction (LVEF) at short-term (3-4 days post-op) and mid-term (1 year) follow-up. Most patients were asymptomatic or mildly symptomatic and had preserved LVEF (>60%). Intrinsic velocity propagation (iVP) of myocardial stretch, a direct measure of myocardial stiffness, was higher in patients with severe MR {median 2.0 [interquartile range (IQR) 1.5-2.2] m/s, range 1.1-3.4 m/s; n = 56} compared to normal subjects [median 1.7 (IQR 1.5-1.8) m/s; n = 40; P = 0.0005], but not in those with mild or moderate MR [median 1.7 (IQR 1.4-1.9) m/s; n = 24]. A higher iVP was associated with more severe LV volume-overload and LV and left atrial enlargement (P < 0.05 for all). In patients undergoing MVr, a higher iVP independently predicted a larger drop in LVEF post-intervention (short-term, P = 0.001; 1 year, P = 0.007), incrementally to pre-operative LVEF (P < 0.05). CONCLUSION Non-invasive measurements of myocardial stiffness were able to predict functional deterioration after MVr for chronic primary MR. Further studies should investigate the mechanisms and practical utility of this novel measurement.
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Affiliation(s)
- Tais De Jesus
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Mahmoud M Alashry
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
Severe mitral valve regurgitation (MR) carries a significant burden both in prognosis and quality of life of patients, as well as on healthcare systems, with high rates of hospitalization for heart failure. While mitral valve surgery constitutes the first-line treatment option for primary MR in suitable patients, surgical treatment for secondary severe MR remains controversial, with a substantial lack of evidence on a survival benefit. In recent decades, percutaneous mitral valve repair has emerged as an alternative treatment for patients deemed not suitable for surgery. Among several devices under development or evaluation, the MitraClip system is the most widespread and is supported by the strongest evidence. While the role of MitraClip in patients with chronic primary MR who are not deemed suitable for surgery is well established, with consistent data showing improvement in both prognosis and quality of life, MitraClip treatment in secondary MR is a rapidly evolving field. Two recent randomized clinical trials generated apparently controversial results but actually provided an interesting pathophysiologic frame that could help discerning patients who will benefit from the procedure versus patients who will not. In this review, we will discuss current treatment options for mitral regurgitation, focusing on percutaneous mitral valve repair with the MitraClip system.
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11
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Corporan D, Kono T, Onohara D, Padala M. An Image Guided Transapical Mitral Valve Leaflet Puncture Model of Controlled Volume Overload from Mitral Regurgitation in the Rat. J Vis Exp 2020. [PMID: 32510479 DOI: 10.3791/61029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Mitral regurgitation (MR) is a widely prevalent heart valve lesion, which causes cardiac remodeling and leads to congestive heart failure. Though the risks of uncorrected MR and its poor prognosis are known, the longitudinal changes in cardiac function, structure and remodeling are incompletely understood. This knowledge gap has limited our understanding of the optimal timing for MR correction, and the benefit that early versus late MR correction may have on the left ventricle. To investigate the molecular mechanisms that underlie left ventricular remodeling in the setting of MR, animal models are necessary. Traditionally, the aorto-caval fistula model has been used to induce volume overload, which differs from clinically relevant lesions such as MR. MR represents a low-pressure volume overload hemodynamic stressor, which requires animal models that mimic this condition. Herein, we describe a rodent model of severe MR in which the anterior leaflet of the rat mitral valve is perforated with a 23G needle, in a beating heart, with echocardiographic image guidance. The severity of MR is assessed and confirmed with echocardiography, and the reproducibility of the model is reported.
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Affiliation(s)
- Daniella Corporan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown
| | - Takanori Kono
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown
| | - Daisuke Onohara
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown; Division of Cardiothoracic Surgery, Joseph P. Whitehead Department of Surgery, Emory University School of Medicine;
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Hachiro K, Kinoshita T, Asai T, Suzuki T. Impact of Mitral Surgery for Mitral Regurgitation on Coexisting Aortic Regurgitation. Ann Thorac Cardiovasc Surg 2020; 26:79-83. [PMID: 31391382 PMCID: PMC7184037 DOI: 10.5761/atcs.oa.19-00141] [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
Background: There is no clear finding on the course of coexisting aortic regurgitation (AR) after treatment of mitral regurgitation (MR). We investigated the effect of mitral surgery for MR on coexisting AR. Methods: Between January 2008 and December 2016, 75 patients underwent mitral surgery for MR coexisting mild AR. Of these, 65 patients who were available to follow-up postoperative echocardiographic tests 1 year after surgery were included in the present study. Patients were divided into two groups according to the degree of postoperative AR. We investigated the predictive factors for continued AR and perioperative cardiac function. Results: In all, 22 patients’ AR improved and became less than mild and 43 patients’ persisted at mild or increased. The predictive factor for continued AR was left atrial diameter >50 mm (P = 0.021, odds ratio = 4.739, 95% confidence interval: 1.259–17.846) in multivariate logistic regression analysis. No patients underwent reoperation for continued AR in both groups. However, one patient was rehospitalized for heart failure in the continued AR group. Conclusion: Left atrial diameter may be an important prognostic factor for continued AR after mitral surgery for MR. MR with mild AR should be treated as soon as before the left atrium expands.
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Affiliation(s)
- Kohei Hachiro
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takeshi Kinoshita
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
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Cohen L, Sagi I, Bigelman E, Solomonov I, Aloshin A, Ben-Shoshan J, Rozenbaum Z, Keren G, Entin-Meer M. Cardiac remodeling secondary to chronic volume overload is attenuated by a novel MMP9/2 blocking antibody. PLoS One 2020; 15:e0231202. [PMID: 32271823 PMCID: PMC7145114 DOI: 10.1371/journal.pone.0231202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 03/18/2020] [Indexed: 12/18/2022] Open
Abstract
Objective Monoclonal antibody derivatives are promising drugs for the treatment of various diseases due to their high matrix metalloproteinases (MMP) active site specificity. We studied the effects of a novel antibody, SDS3, which specifically recognizes the mature active site of MMP9/2 during ventricular remodeling progression in a mouse model of chronic volume overload (VO). Methods VO was induced by creating an aortocaval fistula (ACF) in 10- to 12-week-old C57BL male mice. The VO-induced mice were treated with either vehicle control (PBS) or with SDS3 twice weekly by intraperitoneal (ip) injection. The relative changes in cardiac parameters between baseline (day 1) and end-point (day 30), were evaluated by echocardiography. The effects of SDS3 treatment on cardiac fibrosis, cardiomyocyte volume, and cardiac inflammation were tested by cardiac staining with Masson's trichrome, wheat Germ Agglutinin (WGA), and CD45, respectively. Serum levels of TNFα and IL-6 with and without SDS3 treatment were tested by ELISA. Results SDS3 significantly reduced cardiac dilatation, left ventricular (LV) mass, and cardiomyocyte hypertrophy compared to the vehicle treated animals. The antibody also reduced the heart-to-body weight ratio of the ACF animals to values comparable to those of the controls. Interestingly, the SDS3 group underwent significant reduction of cardiac inflammation and pro-inflammatory cytokine production, indicating a regulatory role for MMP9/2 in tissue remodeling, possibly by tumor necrosis factor alpha (TNFα) activation. In addition, significant changes in the expression of proteins related to mitochondrial function were observed in ACF animals, these changes were reversed following treatment with SDS3. Conclusion The data suggest that MMP9/2 blockage with SDS3 attenuates myocardial remodeling associated with chronic VO by three potential pathways: downregulating the extracellular matrix proteolytic cleavage, reducing the cardiac inflammatory responses, and preserving the cardiac mitochondrial structure and function.
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Affiliation(s)
- Lena Cohen
- Laboratory of Cardiovascular Research, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Irit Sagi
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israel
| | - Einat Bigelman
- Laboratory of Cardiovascular Research, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Inna Solomonov
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israel
| | - Anna Aloshin
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israel
| | - Jeremy Ben-Shoshan
- Laboratory of Cardiovascular Research, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zach Rozenbaum
- Laboratory of Cardiovascular Research, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gad Keren
- Laboratory of Cardiovascular Research, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Entin-Meer
- Laboratory of Cardiovascular Research, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- * E-mail:
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McCutcheon K, Dickens C, van Pelt J, Dix-Peek T, Grinter S, McCutcheon L, Patel A, Hale M, Tsabedze N, Vachiat A, Zachariah D, Duarte R, Janssens S, Manga P. Dynamic Changes in the Molecular Signature of Adverse Left Ventricular Remodeling in Patients With Compensated and Decompensated Chronic Primary Mitral Regurgitation. Circ Heart Fail 2019; 12:e005974. [PMID: 31510777 DOI: 10.1161/circheartfailure.119.005974] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is no proven medical therapy that attenuates adverse left ventricular remodeling in patients with chronic primary mitral regurgitation (CPMR). Identification of molecular pathways important in the progression of left ventricular remodeling in patients with CPMR may lead to development of new therapeutic strategies. METHODS AND RESULTS We performed baseline echocardiographic, cardiac catheterization, and serum NT-pro-BNP analysis in patients with severe CPMR awaiting mitral valve surgery and stratified the study population into compensated or decompensated CPMR. We obtained left ventricular endomyocardial biopsies (n=12) for mRNA expression analysis, and compared baseline transcript levels of 109 genes important in volume-overload left ventricular remodeling with levels in normal hearts (n=5) and between patients with compensated (n=6) versus decompensated (n=6) CPMR. Patients were then randomized to treatment with and without carvedilol and followed until the time of surgery (mean follow-up 8.3 months) when repeat endomyocardial biopsies were obtained to correlate transcriptional dynamics with indices of adverse remodeling. CPMR was associated with increased NPPA expression levels (21.6-fold, P=0.004), decreased transcripts of genes important in cell survival, and enrichment of extracellular matrix genes. Decompensated CPMR was associated with downregulation of SERCA2 (0.77-fold, P=0.009) and mitochondrial gene expression levels and upregulation of genes related to inflammation, the extracellular matrix, and apoptosis, which were refractory to carvedilol therapy. CONCLUSIONS Transition to decompensated CPMR is associated with calcium dysregulation, increased expression of inflammatory, extracellular matrix and apoptotic genes, and downregulation of genes important in bioenergetics. These changes are not attenuated by carvedilol therapy and highlight the need for development of specific combinatorial therapies, targeting myocardial inflammation and apoptosis, together with urgent surgical or percutaneous valve interventions.
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Affiliation(s)
- Keir McCutcheon
- Division of Cardiology, Department of Internal Medicine (K.M., S.G., L.M., N.T., A.V., D.Z., P.M.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa.,Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium (K.M., S.J.)
| | - Caroline Dickens
- Molecular Biology Laboratory, Department of Internal Medicine (C.D., T.D.-P., R.D.), University of the Witwatersrand, Johannesburg, South Africa
| | - Jos van Pelt
- Department of Clinical Digestive Oncology, Faculty of Medicine, Katholieke Universiteit, Leuven and Leuven Cancer Institute, Leuven, Belgium (J.v.P.)
| | - Therese Dix-Peek
- Molecular Biology Laboratory, Department of Internal Medicine (C.D., T.D.-P., R.D.), University of the Witwatersrand, Johannesburg, South Africa
| | - Sacha Grinter
- Division of Cardiology, Department of Internal Medicine (K.M., S.G., L.M., N.T., A.V., D.Z., P.M.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa
| | - Lindsay McCutcheon
- Division of Cardiology, Department of Internal Medicine (K.M., S.G., L.M., N.T., A.V., D.Z., P.M.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa
| | - Atulkumar Patel
- Department of Cardiothoracic Surgery (A.P.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa
| | - Martin Hale
- Department of Anatomical Pathology (M.H.), University of the Witwatersrand, Johannesburg, South Africa
| | - Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine (K.M., S.G., L.M., N.T., A.V., D.Z., P.M.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa
| | - Ahmed Vachiat
- Division of Cardiology, Department of Internal Medicine (K.M., S.G., L.M., N.T., A.V., D.Z., P.M.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa
| | - Don Zachariah
- Division of Cardiology, Department of Internal Medicine (K.M., S.G., L.M., N.T., A.V., D.Z., P.M.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa
| | - Raquel Duarte
- Molecular Biology Laboratory, Department of Internal Medicine (C.D., T.D.-P., R.D.), University of the Witwatersrand, Johannesburg, South Africa
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium (K.M., S.J.).,Department of Cardiovascular Sciences, Katholieke Universiteit, Leuven, Belgium (S.J.)
| | - Pravin Manga
- Division of Cardiology, Department of Internal Medicine (K.M., S.G., L.M., N.T., A.V., D.Z., P.M.), Charlotte Maxeke Johannesburg Academic Hospital & University of the Witwatersrand, Johannesburg, South Africa
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Fu H, Chen Q. Mesenchymal stem cell therapy for heart failure: a meta-analysis. Herz 2018; 45:557-563. [PMID: 30341444 DOI: 10.1007/s00059-018-4762-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/30/2018] [Accepted: 09/13/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Mesenchymal stem cell (MSC) treatment has emerged as an important adjunct therapy for heart failure. However, the use of MSC to treat heart failure has not been well established. We conducted a systematic review and meta-analysis to evaluate the efficacy of MSC treatment for heart failure. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched. Randomized controlled trials (RCTs) assessing the influence of MSC treatment on cardiac function in heart failure were included in this analysis. Two investigators independently searched the articles, extracted data, and assessed the quality of the included studies. Meta-analysis was performed using the fixed-effect model or random-effect model when appropriate. RESULTS Six RCTs involving 625 patients were included in the meta-analysis. Compared with control interventions in heart failure patients, MSC treatment had no significant influence on cardiovascular death (RR = 0.76; 95% CI = 0.38-1.52; p = 0.43); however, it was associated with significantly increased left ventricular ejection fraction (LVEF; mean = 9.64; 95% CI = 7.56-11.71; p < 0.00001) and reduced rehospitalization rate (RR = 0.41; 95% CI = 0.23-0.73; p = 0.003). In addition, no significant difference between the two groups was observed for the incidence of myocardial infarction (RR = 0.72; 95% CI = 0.10-5.02; p = 0.74), the recurrence of heart failure (RR = 0.88; 95% CI = 0.28-2.81; p = 0.83), and total death (RR = 0.68; 95% CI = 0.37-1.25; p = 0.21). CONCLUSION Although MSC treatment can significantly improve LVEF and reduce rehospitalization rates, it does not have a significant influence on cardiovascular death, myocardial infarction, heart failure, and total death.
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Affiliation(s)
- H Fu
- Department of Cardiology, Medical School, Jiangjin Central Hospital of Chongqing, No. 725 Jiangzhou Road Jiangjin district, 402260, Chongqing, China
| | - Q Chen
- Department of Cardiology, Medical School, Jiangjin Central Hospital of Chongqing, No. 725 Jiangzhou Road Jiangjin district, 402260, Chongqing, China.
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