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Cramariuc D, Alfraidi H, Nagata Y, Levine RA, van Kampen A, Andrews C, Hung J. Atrial Dysfunction in Significant Atrial Functional Mitral Regurgitation: Phenotypes and Prognostic Implications. Circ Cardiovasc Imaging 2023; 16:e015089. [PMID: 37158081 DOI: 10.1161/circimaging.122.015089] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Atrial functional mitral regurgitation (AFMR) is associated with increased morbidity and mortality. Left atrial (LA) size and function in AFMR are poorly characterized. We aimed to assess LA function by reservoir strain (LASr) and estimated reservoir work (LAWr) and their impact on outcome in AFMR. METHODS Consecutive patients at our institution between 2001 and 2019 and with significant (moderate or greater) AFMR were examined. LAWr was estimated as LASr×LA reservoir volume, and patients were grouped by median LASr and LAWr. Outcomes were all-cause death or heart failure hospitalizations. RESULTS Five hundred fifteen AFMR patients were followed up for 5 (1-17) years. Patients had previously documented atrial fibrillation (AF; 37%), heart failure with preserved ejection fraction (HFpEF) without AF (24%), or both (HFpEF+AF, 39%). LA volume was largest in AF, while LA function parameters were most impaired in the combined HFpEF+AF group. During follow-up, patients with low LASr or LAWr had higher risk of death (P<0.001) and heart failure hospitalization (P<0.05). In Cox regression analyses, low LASr and LAWr, but not LA volume or left ventricular function, were associated with a higher risk of death (LASr: hazard ratio, 2.3 [95% CI, 1.6-3.5]; LAWr: hazard ratio, 3.4 [95% CI, 2.4-4.9]; both P<0.001) after adjustment for clinical and echocardiographic confounders. Low LASr and LAWr were strongest associated with death in HFpEF and HFpEF+AF. CONCLUSIONS LA reservoir function but not LA size is a robust predictor of outcome in significant AFMR. This provides mechanistic insights into the interplay of functional versus geometric LA changes in AFMR.
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Affiliation(s)
- Dana Cramariuc
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway (D.C.)
- Department of Clinical Science, University of Bergen, Norway (D.C.)
| | | | - Yasufumi Nagata
- Division of Cardiology, Cardiac Ultrasound Laboratory (Y.N., R.A.L., C.A., J.H.)
| | - Robert A Levine
- Division of Cardiology, Cardiac Ultrasound Laboratory (Y.N., R.A.L., C.A., J.H.)
| | - Antonia van Kampen
- Division of Cardiac Surgery (A.v.K.)
- Massachusetts General Hospital, Harvard Medical School, Boston. University Department of Cardiac Surgery, Leipzig Heart Center, Germany (A.v.K.)
| | - Carl Andrews
- Division of Cardiology, Cardiac Ultrasound Laboratory (Y.N., R.A.L., C.A., J.H.)
| | - Judy Hung
- Division of Cardiology, Cardiac Ultrasound Laboratory (Y.N., R.A.L., C.A., J.H.)
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Nagata Y, Bertrand PB, Baliyan V, Kochav J, Kagan RD, Ujka K, Alfraidi H, van Kampen A, Morningstar JE, Dal-Bianco JP, Melnitchouk S, Holmvang G, Borger MA, Moore R, Hua L, Sultana R, Calle PV, Yum B, Guerrero JL, Neilan TG, Picard MH, Kim J, Delling FN, Hung J, Norris RA, Weinsaft JW, Levine RA. Abnormal Mechanics Relate to Myocardial Fibrosis and Ventricular Arrhythmias in Patients With Mitral Valve Prolapse. Circ Cardiovasc Imaging 2023; 16:e014963. [PMID: 37071717 PMCID: PMC10108844 DOI: 10.1161/circimaging.122.014963] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/08/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND The relation between ventricular arrhythmia and fibrosis in mitral valve prolapse (MVP) is reported, but underlying valve-induced mechanisms remain unknown. We evaluated the association between abnormal MVP-related mechanics and myocardial fibrosis, and their association with arrhythmia. METHODS We studied 113 patients with MVP with both echocardiogram and gadolinium cardiac magnetic resonance imaging for myocardial fibrosis. Two-dimensional and speckle-tracking echocardiography evaluated mitral regurgitation, superior leaflet and papillary muscle displacement with associated exaggerated basal myocardial systolic curling, and myocardial longitudinal strain. Follow-up assessed arrhythmic events (nonsustained or sustained ventricular tachycardia or ventricular fibrillation). RESULTS Myocardial fibrosis was observed in 43 patients with MVP, predominantly in the basal-midventricular inferior-lateral wall and papillary muscles. Patients with MVP with fibrosis had greater mitral regurgitation, prolapse, and superior papillary muscle displacement with basal curling and more impaired inferior-posterior basal strain than those without fibrosis (P<0.001). An abnormal strain pattern with distinct peaks pre-end-systole and post-end-systole in inferior-lateral wall was frequent in patients with fibrosis (81 versus 26%, P<0.001) but absent in patients without MVP with basal inferior-lateral wall fibrosis (n=20). During median follow-up of 1008 days, 36 of 87 patients with MVP with >6-month follow-up developed ventricular arrhythmias associated (univariable) with fibrosis, greater prolapse, mitral annular disjunction, and double-peak strain. In multivariable analysis, double-peak strain showed incremental risk of arrhythmia over fibrosis. CONCLUSIONS Basal inferior-posterior myocardial fibrosis in MVP is associated with abnormal MVP-related myocardial mechanics, which are potentially associated with ventricular arrhythmia. These associations suggest pathophysiological links between MVP-related mechanical abnormalities and myocardial fibrosis, which also may relate to ventricular arrhythmia and offer potential imaging markers of increased arrhythmic risk.
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Affiliation(s)
- Yasufumi Nagata
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Philippe B. Bertrand
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Vinit Baliyan
- Department of Radiology (V.B., G.H.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Kochav
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Ruth D. Kagan
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Kristian Ujka
- School of Cardiovascular Disease, University of Pisa, Italy (K.U.)
| | - Hassan Alfraidi
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Antonia van Kampen
- Cardiac Surgery (A.v.K., S.M.), Massachusetts General Hospital, Harvard Medical School, Boston
- University Department for Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Saxony, Germany (A.v.K., M.A.B.)
| | - Jordan E. Morningstar
- Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston (J.E.M., R.M., R.A.N.)
| | - Jacob P. Dal-Bianco
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Serguei Melnitchouk
- Cardiac Surgery (A.v.K., S.M.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Godtfred Holmvang
- Department of Radiology (V.B., G.H.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael A. Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Saxony, Germany (A.v.K., M.A.B.)
| | - Reece Moore
- Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston (J.E.M., R.M., R.A.N.)
| | - Lanqi Hua
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Razia Sultana
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Pablo Villar Calle
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Brian Yum
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - J. Luis Guerrero
- Surgical Cardiovascular Laboratory (J.L.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Tomas G. Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (T.G.N.)
| | - Michael H. Picard
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jiwon Kim
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Francesca N. Delling
- Division of Cardiovascular Medicine, University of California, San Francisco (F.N.D.)
| | - Judy Hung
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Russell A. Norris
- Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston (J.E.M., R.M., R.A.N.)
| | - Jonathan W. Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
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