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Lupieri A, S A Passos L, Levine RA, Nizet V, Aikawa E. Lymphangiogenesis in Rheumatic Heart Valve Disease: A New Factor in the Pathogenic Conundrum. Arterioscler Thromb Vasc Biol 2024; 44:822-825. [PMID: 38357818 PMCID: PMC10978236 DOI: 10.1161/atvbaha.124.320708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Adrien Lupieri
- The Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.L., L.S.A.P., E.A.)
- Harvard Medical School, Boston, MA (A.L., L.S.A.P., R.A.L., E.A.)
| | - Livia S A Passos
- The Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.L., L.S.A.P., E.A.)
- Harvard Medical School, Boston, MA (A.L., L.S.A.P., R.A.L., E.A.)
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, MA (R.A.L.)
- Harvard Medical School, Boston, MA (A.L., L.S.A.P., R.A.L., E.A.)
| | - Victor Nizet
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla (V.N.)
| | - Elena Aikawa
- The Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.L., L.S.A.P., E.A.)
- Center for Interdisciplinary Cardiovascular Sciences, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.A.)
- Harvard Medical School, Boston, MA (A.L., L.S.A.P., R.A.L., E.A.)
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Park MH, van Kampen A, Zhu Y, Melnitchouk S, Levine RA, Borger MA, Woo YJ. Neochordal Goldilocks: Analyzing the biomechanics of neochord length on papillary muscle forces suggests higher tolerance to shorter neochordae. J Thorac Cardiovasc Surg 2024; 167:e78-e89. [PMID: 37160219 DOI: 10.1016/j.jtcvs.2023.04.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Estimating neochord lengths during mitral valve repair is challenging, because approximation must be performed largely based on intuition and surgical experience. Little data exist on quantifying the effects of neochord length misestimation. We aimed to evaluate the impact of neochord length on papillary muscle forces and mitral valve hemodynamics, which is especially pertinent because increased forces have been linked to aberrant mitral valve biomechanics. METHODS Porcine mitral valves (n = 8) were mounted in an ex vivo heart simulator, and papillary muscles were fixed to high-resolution strain gauges while hemodynamic data were recorded. We used an adjustable system to modulate neochord lengths. Optimal length was qualitatively verified by a single experienced operator, and neochordae were randomly lengthened or shortened in 1-mm increments up to ±5 mm from the optimal length. RESULTS Optimal length neochordae resulted in the lowest peak composite papillary muscle forces (6.94 ± 0.29 N), significantly different from all lengths greater than ±1 mm. Both longer and shorter neochordae increased forces linearly according to difference from optimal length. Both peak papillary muscle forces and mitral regurgitation scaled more aggressively for longer versus shorter neochordae by factors of 1.6 and 6.9, respectively. CONCLUSIONS Leveraging precision ex vivo heart simulation, we found that millimeter-level neochord length differences can result in significant differences in papillary muscle forces and mitral regurgitation, thereby altering valvular biomechanics. Differences in lengthened versus shortened neochordae scaling of forces and mitral regurgitation may indicate different levels of biomechanical tolerance toward longer and shorter neochordae. Our findings highlight the need for more thorough biomechanical understanding of neochordal mitral valve repair.
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Affiliation(s)
- Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Bioengineering, Stanford University, Stanford, Calif
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Michael A Borger
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Bioengineering, Stanford University, Stanford, Calif.
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Namasivayam M, Churchill TW, Capoulade R, Pibarot P, Danik JS, Picard MH, Levine RA, Hung J. Combined Value of Dimensionless Index and Transvalvular Flow Rate in Risk Stratification of Aortic Stenosis. Am J Cardiol 2024; 213:69-71. [PMID: 38103765 PMCID: PMC10842843 DOI: 10.1016/j.amjcard.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/02/2023] [Revised: 11/18/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Aortic stenosis (AS) is difficult to phenotype. The metrics of severity are frequently discordant, making prognostication challenging. Flow state is central to accurately determining severity. We sought to evaluate the prognostic value of dimensionless index (DI) and transvalvular flow rate (Q) in AS. We evaluated 2 independent, longitudinal registries of ≥ moderate severity AS (aortic valve area ≤1.5 cm2 or mean gradient ≥20 mm Hg) with complete data follow-up. In the primary cohort (n = 1,104, 77 ± 11 years, 40% female), the DI and Q category significantly predicted mortality (p <0.001) (Figure 1), with the highest risk being low DI and low Q (DI <0.25, Q ≤210 mL/s). In the validation cohort (n = 939, 70 ± 13 years, 42% female), similar results were seen in Kaplan-Meier (p <0.001) and multivariable Cox model analyses (p <0.01). We advocate for wider combined use of DI and Q in AS assessment to augment current diagnostic and prognostic approaches.
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Affiliation(s)
- Mayooran Namasivayam
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Cardiology, St. Vincent's Hospital, and Heart Valve Disease and Artificial Intelligence Laboratory, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
| | - Timothy W Churchill
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Romain Capoulade
- University of Nantes, Nantes University Hospital, National Center for Scientific Research, National Institute of Health and Medical Research, Thorax Institute, F-44000, Nantes, France
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Jacqueline S Danik
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Spampinato RA, Marin-Cuartas M, van Kampen A, Fahr F, Sieg F, Strotdrees E, Jahnke C, Klaeske K, Wiesner K, Morningstar JE, Nagata Y, Izquierdo-Garcia D, Dieterlen MT, Norris RA, Levine RA, Paetsch I, Borger MA. Left ventricular fibrosis and CMR tissue characterization of papillary muscles in mitral valve prolapse patients. Int J Cardiovasc Imaging 2024; 40:213-224. [PMID: 37891450 DOI: 10.1007/s10554-023-02985-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Mitral valve prolapse (MVP) is associated with left ventricle (LV) fibrosis, including the papillary muscles (PM), which is in turn linked to malignant arrhythmias. This study aims to evaluate comprehensive tissue characterization of the PM by cardiovascular magnetic resonance (CMR) imaging and its association with LV fibrosis observed by intraoperative biopsies. METHODS MVP patients with indication for surgery due to severe mitral regurgitation (n = 19) underwent a preoperative CMR with characterization of the PM: dark-appearance on cine, T1 mapping, conventional bright blood (BB) and dark blood (DB) late gadolinium enhancement (LGE). CMR T1 mapping was performed on 21 healthy volunteers as controls. LV inferobasal myocardial biopsies were obtained in MVP patients and compared to CMR findings. RESULTS MVP patients (54 ± 10 years old, 14 male) had a dark-appearance of the PM with higher native T1 and extracellular volume (ECV) values compared with healthy volunteers (1096 ± 78ms vs. 994 ± 54ms and 33.9 ± 5.6% vs. 25.9 ± 3.1%, respectively, p < 0.001). Seventeen MVP patients (89.5%) had fibrosis by biopsy. BB-LGE + in LV and PM was identified in 5 (26.3%) patients, while DB-LGE + was observed in LV in 9 (47.4%) and in PM in 15 (78.9%) patients. DB-LGE + in PM was the only technique that showed no difference with detection of LV fibrosis by biopsy. Posteromedial PM was more frequently affected than the anterolateral (73.7% vs. 36.8%, p = 0.039) and correlated with biopsy-proven LV fibrosis (Rho 0.529, p = 0.029). CONCLUSIONS CMR imaging in MVP patients referred for surgery shows a dark-appearance of the PM with higher T1 and ECV values compared with healthy volunteers. The presence of a positive DB-LGE at the posteromedial PM by CMR may serve as a better predictor of biopsy-proven LV inferobasal fibrosis than conventional CMR techniques.
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Affiliation(s)
- Ricardo A Spampinato
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany.
| | - Mateo Marin-Cuartas
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Antonia van Kampen
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Florian Fahr
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Franz Sieg
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Elfriede Strotdrees
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Cosima Jahnke
- Department of Cardiology and Electrophysiology, Leipzig Heart Center, Leipzig, Germany
| | - Kristin Klaeske
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Karoline Wiesner
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Jordan E Morningstar
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Izquierdo-Garcia
- The Institute for Innovation in Imaging, Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Russell A Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ingo Paetsch
- Department of Cardiology and Electrophysiology, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
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Soares JR, Carvalho VT, Lodi-Junqueira L, Fonseca IMG, Athayde GRS, de Sales IF, Caldas ACDP, Carvalho PEDP, Matos TKG, Mello LA, Esteves WAM, Tan TC, Levine RA, Hung J, Nunes MCP. Assessment of the left atrial volume and function following percutaneous mitral balloon valvuloplasty: Insights into acute and late impact of atrial fibrillation on atrial remodeling. Int J Cardiol 2024; 394:131361. [PMID: 37709205 DOI: 10.1016/j.ijcard.2023.131361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 08/20/2023] [Accepted: 09/11/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Rheumatic mitral stenosis (MS) leads to LA remodeling with disordered electrical activation that may revert with valve intervention. This study aimed to assess the acute and late impact of percutaneous mitral balloon valvuloplasty (PMBV) on LA volume and function in patients with atrial fibrillation (AF) compared with sinus rhythm. METHODS A total of 167 patients with severe MS undergoing PMBV were prospectively enrolled. LA volumes and function were measured by three-dimensional echocardiography (3DE) pre PMBV, within 24 to 48 h after PMBV, and at 1 year. RESULTS Mean age was 43.5 ± 11.8 years old, and 142 (85%) patients were women. At baseline, 46 patients (27.5%) were in permanent AF, and 62 (37.1%) classified as New York Heart Association functional class III or IV. In sinus rhythm population, LA volumes decreased immediately after PMBV and continue to decrease at 1-year follow-up. LA emptying fraction increased from 23.6 ± 10.4% to 33.8 ± 11.9% acutely after the procedure (p < 0.001), and to 37.2 ± 13.2% at 1-year follow-up (p = 0.028). Patients with AF only had a significant decrease in LA minimum volume immediately after PMBV, with no significant changes in maximum volume either immediately or at follow-up. In these patients, LA emptying fraction increased immediately after the procedure from 15.8 ± 9.9% to 22.8 ± 9.8 (p = 0.001) with no evidence for additional improvement at the 1-year follow-up. Age, and post-procedural mean gradient were identified as the most significant factors associated with the absolute changes in LA function between baseline and the 1-year follow-up. CONCLUSIONS In patients with severe MS, the impact of PMBV on LA volume and function varies according to cardiac rhythm. In patients in sinus rhythm, the procedure leads to improvement of LA volumes and function both acutely and at 1-year follow-up. Patients with AF had a lesser improvement in LA function immediately after the procedure, without further improvement over time despite adequate relief of valve obstruction.
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Affiliation(s)
- Juliana Rodrigues Soares
- Post Graduation Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Vinicius Tostes Carvalho
- Post Graduation Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Lucas Lodi-Junqueira
- Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Guilherme Rafael Sant'Anna Athayde
- Post Graduation Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Igor Ferreira de Sales
- Post Graduation Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Ana Clara de Paula Caldas
- Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Luana Aguiar Mello
- Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - William Antonio M Esteves
- Post Graduation Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Timothy C Tan
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert A Levine
- Department of Cardiology, Blacktown Hospital, University of Western Sydney, NSW, Australia
| | - Judy Hung
- Department of Cardiology, Blacktown Hospital, University of Western Sydney, NSW, Australia
| | - Maria Carmo Pereira Nunes
- Post Graduation Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
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Tao CY, Satheesh K, Levine RA, Dragan IF. Assessing the effectiveness of a collaborative educational initiative engaging different learners. J Dent Educ 2023; 87 Suppl 3:1780-1782. [PMID: 37004156 DOI: 10.1002/jdd.13213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/09/2023] [Accepted: 03/18/2023] [Indexed: 04/03/2023]
Affiliation(s)
- Chih-Yun Tao
- Assistant Clinical Professor of Periodontology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Keerthana Satheesh
- Associate Professor and Chair of Periodontology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Robert A Levine
- Clinical Assistant Professor in Periodontology & Implantology, Kornberg School of Dentistry at Temple University, Philadelphia, Pennsylvania, USA
| | - Irina F Dragan
- Adjunct Associate Professor of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts, USA
- Lecturer on Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, USA
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Abstract
From low-resolution images in the 1960s to current high-resolution technology, ultrasound has proven to be the initial imaging modality of choice for thyroid application. Point-of-care ultrasound has brought the technology to the thyroid specialist. Combined with physical examination, it provides real-time information regarding goiter, thyroid nodules, and thyroid cancer. Ultrasound-guided fine-needle aspiration biopsy has become the accepted norm, with biopsies rarely performed using palpation alone. Advantages of ultrasound-guided biopsy include precise placement of the needle within the nodule, selective sampling of areas with suspicious features, and accurate direction of the biopsy needle to actively growing viable cells in the periphery of the nodule. Education of endocrinologists in thyroid ultrasound began in the late 1990s and by 2016 more than 6000 clinicians had completed an ultrasound course. Concurrent with this rapid expansion of use of thyroid ultrasound was a rise in the diagnosis of small papillary carcinomas, which might have otherwise remained indolent and undetected. The 2009 American Thyroid Association Guidelines for the Management of Thyroid Nodules and Thyroid Cancer recommended biopsy for all solid hypoechoic nodules measuring larger than 1 cm. Attempting to decrease the frequency of biopsies of low-risk nodules, subsequent guidelines have focused on identifying and selectively biopsying those thyroid nodules at higher risk of clinically significant carcinoma based on ultrasound appearance. A major role for thyroid ultrasound has been in both preoperative staging and mapping to help determine the extent of surgery, as well as postoperative monitoring for locoregional soft tissue or lymph node metastases. With the recognition that the increase in papillary carcinoma was predominantly a result of early diagnosis of small often indolent cancers, active surveillance has become a promising management strategy for papillary thyroid microcarcinomas. Thyroid ultrasound is essential to active surveillance of thyroid cancer. Easy access to high-quality ultrasound studies is a requirement for a successful active surveillance program. Thyroid ultrasound has been used to facilitate interventional procedures, including treatment of thyroid nodules, treatment of recurrent thyroid cancer, and therapy of papillary thyroid microcarcinoma.
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Affiliation(s)
- Robert A Levine
- Department of Endocrinology, Thyroid Center of New Hampshire, Nashua, New Hampshire, USA
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Levine RA, Saleh MHA, Dias DR, Ganeles J, Araújo MG, Renouard F, Pinsky HM, Miller PD, Wang HL. Periodontal Regeneration Risk Assessment in the Treatment of Intrabony Defects. Clin Adv Periodontics 2023. [PMID: 37326232 DOI: 10.1002/cap.10254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Regenerative approaches performed in periodontal seems to be efficient in treating intrabony defects. There are, however, many factors that may affect the predictability of the regeneration procedures. The present article aimed to propose a new risk assessment tool for treating periodontal intrabony defects by regenerative therapy. METHODS Different variables that could affect the success of a regenerative procedure were considered based on their impact (i) on the wound healing potential, promoting wound stability, cells, and angiogenesis, or (ii) on the ability to clean the root surface and keeping an optimal plaque control or (iii) on aesthetics (risk for gingival recession). RESULTS The risk assessment variables were divided into a patient, tooth, defect, and operator level. Patient-related factors include medical conditions such as diabetes, smoking habit, plaque control, compliance with supportive care, and expectations. Tooth-related factors include prognosis, traumatic occlusal forces or mobility, endodontic status, root surface topography, soft tissue anatomy, and gingival phenotype. Defect-associated factors include local anatomy (number of residual bone walls, width, and depth), furcation involvement, cleansability, and number of sides of the root involved. Operator-related factors should not be neglected and include the clinician's level of experience, the presence of environmental stress factors, and the use of checklists in the daily routine. CONCLUSIONS Using a risk assessment comprised of patient-, tooth-, defect- and operator-level factors can aid the clinician in identifying challenging characteristics and the treatment decision process. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert A Levine
- Department of Periodontology and Implantology, Temple University Kornberg School of Dentistry, Philadelphia, Pennsylvania, USA
| | - Muhammad H A Saleh
- Department of Periodontics and Oral Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Debora R Dias
- Department of Dentistry, State University of Maringá, Maringá, Paraná, Brazil
| | - Jeffrey Ganeles
- Department of Periodontology, Nova Southeastern University College of Dental Medicine, Ft. Lauderdale, Florida, USA
| | - Maurício G Araújo
- Department of Dentistry, State University of Maringá, Maringá, Paraná, Brazil
| | | | | | - Preston D Miller
- Retired as a Clinical Professor, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hom-Lay Wang
- Department of Periodontics and Oral Medicine, University of Michigan, Ann Arbor, Michigan, USA
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9
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Spampinato RA, Marin-Cuartas M, Kampen A, Fahr F, Sieg F, Strotdrees E, Jahnke C, Klaeske K, Wiesner K, Morningstar JE, Nagata Y, Izquierdo-Garcia D, Dieterlen MT, Norris RA, Levine RA, Paetsch I, Borger MA. Left Ventricular Fibrosis and CMR Tissue Characterization of Papillary Muscles in Mitral Valve Prolapse Patients. Res Sq 2023:rs.3.rs-2936590. [PMID: 37292932 PMCID: PMC10246246 DOI: 10.21203/rs.3.rs-2936590/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose Mitral valve prolapse (MVP) is associated with left ventricle (LV) fibrosis, including the papillary muscles (PM), which is in turn linked to malignant arrhythmias. This study aims to evaluate comprehensive tissue characterization of the PM by cardiovascular magnetic resonance (CMR) imaging and its association with LV fibrosis observed by intraoperative biopsies. Methods MVP patients with indication for surgery due to severe mitral regurgitation (n=19) underwent a preoperative CMR with characterization of the PM: dark-appearance on cine, T1 mapping, conventional bright blood (BB) and dark blood (DB) late gadolinium enhancement (LGE). CMR T1 mapping was performed on 21 healthy volunteers as controls. LV inferobasal myocardial biopsies were obtained in MVP patients and compared to CMR findings. Results MVP patients (54±10 years old, 14 male) had a dark-appearance of the PM with higher native T1 and extracellular volume (ECV) values compared with healthy volunteers (1096±78ms vs 994±54ms and 33.9±5.6% vs 25.9±3.1%, respectively, p<0.001). Seventeen MVP patients (89.5%) had fibrosis by biopsy. BB-LGE+ in LV and PM was identified in 5 (26.3%) patients, while DB-LGE+ was observed in LV in 9 (47.4%) and in PM in 15 (78.9%) patients. DB-LGE+ in PM was the only technique that showed no difference with detection of LV fibrosis by biopsy. Posteromedial PM was more frequently affected than the anterolateral (73.7% vs 36.8%, p=0.039) and correlated with biopsy-proven LV fibrosis (Rho 0.529, p=0.029). Conclusions CMR imaging in MVP patients referred for surgery shows a dark-appearance of the PM with higher T1 and ECV values compared with healthy volunteers. The presence of a positive DB-LGE at the posteromedial PM by CMR may serve as a better predictor of biopsy-proven LV inferobasal fibrosis than conventional CMR techniques.
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10
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van Kampen A, Morningstar JE, Goudot G, Ingels N, Wenk JF, Nagata Y, Yaghoubian KM, Norris RA, Borger MA, Melnitchouk S, Levine RA, Jensen MO. Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review. Bioengineering (Basel) 2023; 10:601. [PMID: 37237671 PMCID: PMC10215167 DOI: 10.3390/bioengineering10050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.
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Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Guillaume Goudot
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Neil Ingels
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY 40508, USA;
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Koushiar M. Yaghoubian
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Michael A. Borger
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Morten O. Jensen
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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11
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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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12
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Churchill TW, Yucel E, Bernard S, Namasivayam M, Nagata Y, Lau ES, Deferm S, He W, Danik JS, Sanborn DY, Picard MH, Levine RA, Hung J, Bertrand PB. Sex Differences in Extensive Mitral Annular Calcification With Associated Mitral Valve Dysfunction. Am J Cardiol 2023; 193:83-90. [PMID: 36881941 PMCID: PMC10066827 DOI: 10.1016/j.amjcard.2023.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
Mitral annular calcification (MAC)-related mitral valve (MV) dysfunction is an increasingly recognized entity, which confers a high burden of morbidity and mortality. Although more common among women, there is a paucity of data regarding how the phenotype of MAC and the associated adverse clinical implications may differ between women and men. A total of 3,524 patients with extensive MAC and significant MAC-related MV dysfunction (i.e., transmitral gradient ≥3 mm Hg) were retrospectively analyzed from a large institutional database, with the goal of defining gender differences in clinical and echocardiographic characteristics and the prognostic importance of MAC-related MV dysfunction. We stratified patients into low- (3 to 5 mm Hg), moderate- (5 to 10 mm Hg), and high- (≥10 mm Hg) gradient groups and analyzed the gender differences in phenotype and outcome. The primary outcome was all-cause mortality, assessed using adjusted Cox regression models. Women represented the majority (67%) of subjects, were older (79.3 ± 10.4 vs 75.5 ± 10.9 years, p <0.001) and had a lower burden of cardiovascular co-morbidities than men. Women had higher transmitral gradients (5.7 ± 2.7 vs 5.3 ± 2.6 mm Hg, p <0.001), more concentric hypertrophy (49% vs 33%), and more mitral regurgitation. The median survival was 3.4 years (95% confidence interval 3.0 to 3.6) among women and 3.0 years (95% confidence interval 2.6 to 4.5) among men. The adjusted survival was worse among men, and the prognostic impact of the transmitral gradient did not differ overall by gender. In conclusion, we describe important gender differences among patients with MAC-related MV dysfunction and show worse adjusted survival among men; although, the adverse prognostic impact of the transmitral gradient was similar between men and women.
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Affiliation(s)
- Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Evin Yucel
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Bernard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, New York University School of Medicine, New York University, New York, New York
| | - Mayooran Namasivayam
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Victor Chang Cardiac Research Institute, St. Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Yasufumi Nagata
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; The Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Emily S Lau
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sebastien Deferm
- Department of Cardiology, Mainz University Hospital, Mainz Germany
| | - Wei He
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline S Danik
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danita Y Sanborn
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philippe B Bertrand
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Ziekenhuis Oost-Limburg, Genk, Belgium
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13
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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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Levine RA, Dias DR, Saleh MHA, Ganeles J, Araújo MG. 7 Keys for Treatment of Periodontal Intrabony Defects. Compend Contin Educ Dent 2023; 44:184-190; quiz 191. [PMID: 37075724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Although technique-sensitive, periodontal regeneration seems efficient in treating intrabony defects; nonetheless, complete success can be difficult to attain. Seven keys for successful periodontal regeneration of intrabony defects, presented herein, encapsulate an evidence-based treatment planning and surgical protocol for achieving predictable outcomes. Utilizing a step-by-step approach, the seven keys offer periodontists a checklist for treating intrabony defects and include protocols for the planning, surgical, and postoperative phases of the treatment. This article describes the use of the seven keys checklist to achieve predictable regenerative outcomes at short-term and long-term follow-ups. A case report demonstrates the application of these seven keys.
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Affiliation(s)
- Robert A Levine
- Clinical Professor, Periodontology and Implantology, Kornberg School of Dentistry, Temple University, Philadelphia, Pennsylvania; Private Practice, Pennsylvania Center for Dental Implants and Periodontics, Philadelphia, Pennsylvania
| | - Debora Reis Dias
- PhD Candidate, State University of Maringá, Maringá, Paraná, Brazil
| | - Muhammad H A Saleh
- Clinical Assistant Professor, Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Michigan
| | - Jeffrey Ganeles
- Adjunct Associate Professor, Nova Southeastern University College of Dental Medicine, Fort Lauderdale, Florida; Private Practice in Periodontics and Implant Dentistry, Boca Raton, Florida
| | - Maurício G Araújo
- Associate Professor, State University of Maringá, Maringá, Paraná, Brazil; Private Practice in Dental Implants and Periodontics, Rio de Janeiro, Rio de Janeiro; Brazil
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15
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van Kampen A, Nagata Y, Huang ALI, Mohan N, Dal-Bianco JP, Hung JW, Borger MA, Levine RA, Sundt TM, Melnitchouk S. Left Atrial Function and Not Volume Predicts Mid-to-Late Atrial Fibrillation after Mitral Valve Repair. Eur J Cardiothorac Surg 2023; 63:7082539. [PMID: 36943376 DOI: 10.1093/ejcts/ezad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 09/09/2022] [Revised: 03/05/2023] [Accepted: 03/17/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVES Patients undergoing surgical mitral valve repair for degenerative mitral regurgitation are at risk of even late postoperative atrial fibrillation (AF). Left atrial (LA) functionhas been shown superior to LA volume in evaluating risk of AF in diverse cardiac conditions. We therefore investigated the prognostic value of LA function and volume in predicting mid-to-late postoperative AF after mitral valve repair (>30 days postoperatively). METHODS We retrospectively identified all patients who underwent mitral valve repair for degenerative mitral regurgitation between 2012-2019 at our institution. Exclusion criteria were preoperative AF, concomitant procedures, re-operations, missing or insufficiently processable preoperative echocardiograms, and missing follow-up. LA function and volume measurements were conducted using speckle-tracking strain echocardiographic analysis. Postoperative LA function was measured in a subgroup with sufficient postoperative echocardiograms. RESULTS We included 251 patients, of which 39 (15.5%) experienced AF in the mid-to-late postoperative period. Reduced LA strain parameters and more than mild preoperative tricuspid regurgitation were independently associated with mid-to-late postoperative AF. LA volume index had no association with mid-to-late postoperative AF in univariable analysis and did not improve performance of multivariable models. Patients with mid-to-late AF exhibited diminished improvement in LA function after surgery. CONCLUSION In mitral valve repair patients, LA function (but not volume) showed independent predictive value for mid-to-late postoperative AF. Including left atrial function into surgical decision making and approach may identify patients who will benefit from earlier intervention with the aim to prevent irreversible left atrial damage with consequent risk of postoperative AF.
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Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- University Clinic of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- The Second Department of Internal Medicine, The University of Occupational and Environmental Health, Fukuoka, Japan
| | - Alex Lin-I Huang
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Navyatha Mohan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Division of Cardiac Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jacob P Dal-Bianco
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Judy W Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael A Borger
- University Clinic of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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16
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Dieterlen MT, Klaeske K, Spampinato R, Marin-Cuartas M, Wiesner K, Morningstar J, Norris RA, Melnitchouk S, Levine RA, van Kampen A, Borger MA. Histopathological insights into mitral valve prolapse-induced fibrosis. Front Cardiovasc Med 2023; 10:1057986. [PMID: 36960475 PMCID: PMC10028262 DOI: 10.3389/fcvm.2023.1057986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/16/2023] [Indexed: 03/09/2023] Open
Abstract
Mitral valve prolapse (MVP) is a cardiac valve disease that not only affects the mitral valve (MV), provoking mitral regurgitation, but also leads to maladaptive structural changes in the heart. Such structural changes include the formation of left ventricular (LV) regionalized fibrosis, especially affecting the papillary muscles and inferobasal LV wall. The occurrence of regional fibrosis in MVP patients is hypothesized to be a consequence of increased mechanical stress on the papillary muscles and surrounding myocardium during systole and altered mitral annular motion. These mechanisms appear to induce fibrosis in valve-linked regions, independent of volume-overload remodeling effects of mitral regurgitation. In clinical practice, quantification of myocardial fibrosis is performed with cardiovascular magnetic resonance (CMR) imaging, even though CMR has sensitivity limitations in detecting myocardial fibrosis, especially in detecting interstitial fibrosis. Regional LV fibrosis is clinically relevant because even in the absence of mitral regurgitation, it has been associated with ventricular arrhythmias and sudden cardiac death in MVP patients. Myocardial fibrosis may also be associated with LV dysfunction following MV surgery. The current article provides an overview of current histopathological studies investigating LV fibrosis and remodeling in MVP patients. In addition, we elucidate the ability of histopathological studies to quantify fibrotic remodeling in MVP and gain deeper understanding of the pathophysiological processes. Furthermore, molecular changes such as alterations in collagen expression in MVP patients are reviewed.
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Affiliation(s)
- Maja-Theresa Dieterlen
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Kristin Klaeske
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Ricardo Spampinato
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Karoline Wiesner
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Jordan Morningstar
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Antonia van Kampen
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael A. Borger
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
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17
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Namasivayam M, Churchill T, Capoulade R, Pibarot P, Danik JS, Picard MH, Levine RA, Hung JW. THE FLOW KNOWS: VALUE OF DIMENSIONLESS INDEX AND TRANSVALVULAR FLOW RATE IN RISK STRATIFICATION OF AORTIC STENOSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01843-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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18
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Levine RA, Miller PD, Dias DR, Saleh MHA, Gopalakrishnan D, Fernandes G, Dukka H, Ehrmann K, Fava Ii PL, Araújo MG. Translating Clinical Outcomes to Patient Value Through Use of the Periodontal Risk Score: An Evidence-Based Treatment Approach. Compend Contin Educ Dent 2023; 44:18-24; quiz 25. [PMID: 36696274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Periodontitis is a chronic, multifactorial inflammatory disease characterized by progressive destruction of the tooth-supporting apparatus. Determining tooth prognosis is of central importance in clinical practice to help both the clinician and patient understand the risks and benefits of treatment while shedding light on the patient's long-term periodontal prognosis and aiding in the development of an individualized treatment plan. Several indexing-type systems have been proposed for determining the prognosis of periodontally involved teeth. The periodontal risk score (PRS) is a simple, evidence-based, motivational tool that can be used in daily clinical practice in both healthy and periodontally involved patients. The PRS incorporates systemic and lifestyle prognostic factors to achieve superior predictive accuracy. With the PRS, patients are encouraged to achieve a target score (representing an "excellent" prognosis) that can be realistically attained through compliance with a periodontal maintenance plan. The purpose of this article is to present to clinicians how to implement this evidence-based tool into their daily practices and thus help patients improve their long-term periodontal prognosis.
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Affiliation(s)
- Robert A Levine
- Clinical Professor, Periodontology and Implantology, Kornberg School of Dentistry, Temple University, Philadelphia, Pennsylvania; Private Practice, Pennsylvania Center for Dental Implants and Periodontics, Philadelphia, Pennsylvania
| | - Preston D Miller
- Former Clinical Professor of Periodontics, University of South Carolina, Charleston, South Carolina
| | - Debora R Dias
- PhD Candidate, State University of Maringá, Maringá, Paraná, Brazil
| | - Muhammad H A Saleh
- Adjunct Clinical Assistant Professor, Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Michigan
| | - Dharmarajan Gopalakrishnan
- Dean, Professor and Head (Chair), Department of Periodontology, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Gustavo Fernandes
- Adjunct Clinical Assistant Professor, Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Michigan
| | - HimaBindu Dukka
- Associate Professor, Department of Diagnosis and Oral Health; Adjunct Faculty, Department of Oral Immunology and Infectious Diseases; Director, Graduate Periodontics, University of Louisville School of Dentistry, Louisville, Kentucky
| | - Kellyann Ehrmann
- Private Practice, Pennsylvania Center for Dental Implants and Periodontics, Philadelphia, Pennsylvania
| | - Philip L Fava Ii
- Private Practice, Pennsylvania Center for Dental Implants and Periodontics, Philadelphia, Pennsylvania
| | - Maurício G Araújo
- Associate Professor, State University of Maringá, Maringá, Paraná, Brazil; Private Practice in Dental Implants and Periodontics, Rio de Janeiro, Rio de Janeiro, Brazil
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Delling FN, Noseworthy PA, Adams DH, Basso C, Borger M, Bouatia-Naji N, Elmariah S, Evans F, Gerstenfeld E, Hung J, Tourneau TL, Lewis J, Miller MA, Norris RA, Padala M, Perazzolo-Marra M, Shah DJ, Weinsaft JW, Enriquez-Sarano M, Levine RA. Research Opportunities in the Treatment of Mitral Valve Prolapse: JACC Expert Panel. J Am Coll Cardiol 2022; 80:2331-2347. [PMID: 36480975 PMCID: PMC9981237 DOI: 10.1016/j.jacc.2022.09.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/31/2022] [Accepted: 09/12/2022] [Indexed: 12/10/2022]
Abstract
In light of the adverse prognosis related to severe mitral regurgitation, heart failure, or sudden cardiac death in a subset of patients with mitral valve prolapse (MVP), identifying those at higher risk is key. For the first time in decades, researchers have the means to rapidly advance discovery in the field of MVP thanks to state-of-the-art imaging techniques, novel omics methodologies, and the potential for large-scale collaborations using web-based platforms. The National Heart, Lung, and Blood Institute recently initiated a webinar-based workshop to identify contemporary research opportunities in the treatment of MVP. This report summarizes 3 specific areas in the treatment of MVP that were the focus of the workshop: 1) improving management of degenerative mitral regurgitation and associated left ventricular systolic dysfunction; 2) preventing sudden cardiac death in MVP; and 3) understanding the mechanisms and progression of MVP through genetic studies and small and large animal models, with the potential of developing medical therapies.
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Affiliation(s)
- Francesca N. Delling
- Department of Medicine (Cardiovascular Division), University of California-San Francisco, San Francisco, California, USA
| | - Peter A. Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - David H. Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | | | - Sammy Elmariah
- Department of Medicine (Cardiovascular Division), University of California-San Francisco, San Francisco, California, USA,Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Frank Evans
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Edward Gerstenfeld
- Department of Medicine (Cardiovascular Division), University of California-San Francisco, San Francisco, California, USA
| | - Judy Hung
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thierry Le Tourneau
- Nantes Université, CHU Nantes, CNRS, INSERM, l’Institut du Thorax, Nantes, France
| | - John Lewis
- Heart Valve Voice US, Washington, DC, USA
| | - Marc A. Miller
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Muralidhar Padala
- Department of Surgery (Cardiothoracic Surgery Division), Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Dipan J. Shah
- Department of Cardiology, Houston Methodist, Weill Cornell Medical College, Houston, Texas, USA
| | | | | | - Robert A. Levine
- Massachusetts General Hospital Cardiac Ultrasound Laboratory, Boston, Massachusetts, USA
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20
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Marsit O, Levine RA, Beaudoin J. Reply. J Am Coll Cardiol 2022; 80:e215. [DOI: 10.1016/j.jacc.2022.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022]
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21
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Park MH, van Kampen A, Melnitchouk S, Wilkerson RJ, Nagata Y, Zhu Y, Wang H, Pandya PK, Morningstar JE, Borger MA, Levine RA, Woo YJ. Native and Post-Repair Residual Mitral Valve Prolapse Increases Forces Exerted on the Papillary Muscles: A Possible Mechanism for Localized Fibrosis? Circ Cardiovasc Interv 2022; 15:e011928. [PMID: 36538583 PMCID: PMC9782735 DOI: 10.1161/circinterventions.122.011928] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/07/2022] [Accepted: 10/24/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent studies have linked mitral valve prolapse to localized myocardial fibrosis, ventricular arrhythmia, and even sudden cardiac death independent of mitral regurgitation or hemodynamic dysfunction. The primary mechanistic theory is rooted in increased papillary muscle traction and forces due to prolapse, yet no biomechanical evidence exists showing increased forces. Our objective was to evaluate the biomechanical relationship between prolapse and papillary muscle forces, leveraging advances in ex vivo modeling and technologies. We hypothesized that mitral valve prolapse with limited hemodynamic dysfunction leads to significantly higher papillary muscle forces, which could be a possible trigger for cellular and electrophysiological changes in the papillary muscles and adjacent myocardium. METHODS We developed an ex vivo papillary muscle force transduction and novel neochord length adjustment system capable of modeling targeted prolapse. Using 3 unique ovine models of mitral valve prolapse (bileaflet or posterior leaflet prolapse), we directly measured hemodynamics and forces, comparing physiologic and prolapsing valves. RESULTS We found that bileaflet prolapse significantly increases papillary muscle forces by 5% to 15% compared with an optimally coapting valve, which are correlated with statistically significant decreases in coaptation length. Moreover, we observed significant changes in the force profiles for prolapsing valves when compared with normal controls. CONCLUSIONS We discovered that bileaflet prolapse with the absence of hemodynamic dysfunction results in significantly elevated forces and altered dynamics on the papillary muscles. Our work suggests that the sole reduction of mitral regurgitation without addressing reduced coaptation lengths and thus increased leaflet surface area exposed to ventricular pressure gradients (ie, billowing leaflets) is insufficient for an optimal repair.
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Affiliation(s)
- Matthew H. Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
- Department of Mechanical Engineering, Stanford University, Stanford, CA
| | - Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
- Department of Bioengineering, Stanford University, Stanford, CA
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
| | - Pearly K. Pandya
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
- Department of Mechanical Engineering, Stanford University, Stanford, CA
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
| | - Michael A. Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
- Department of Bioengineering, Stanford University, Stanford, CA
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22
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Zoghbi WA, Levine RA, Flachskampf F, Grayburn P, Gillam L, Leipsic J, Thomas JD, Kwong RY, Vandervoort P, Chandrashekhar Y. Atrial Functional Mitral Regurgitation: A JACC: Cardiovascular Imaging Expert Panel Viewpoint. JACC Cardiovasc Imaging 2022; 15:1870-1882. [PMID: 36357130 DOI: 10.1016/j.jcmg.2022.08.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [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] [Received: 04/22/2022] [Revised: 08/03/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Abstract
Functional or secondary mitral regurgitation (MR) is associated with increased cardiovascular morbidity and mortality. Mechanistically, secondary MR is attributable to an imbalance between mitral leaflet tethering and closure forces, leading to poor coaptation. The pathophysiology of functional MR is most often the result of abnormalities in left ventricular function and remodeling, seen in ischemic or nonischemic conditions. Less commonly and more recently recognized is the scenario in which left ventricular geometry and function are preserved, the culprit being mitral annular enlargement associated with left atrial dilatation, termed atrial functional mitral regurgitation (AFMR). This most commonly occurs in the setting of chronic atrial fibrillation or heart failure with preserved ejection fraction. There is variability in the published reports and in current investigations as to the definition of AFMR. This paper reviews the pathophysiology of AFMR and focus on the need for a collective definition of AFMR to facilitate consistency in reported data and enhance much-needed research into outcomes and treatment strategies in AFMR.
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Affiliation(s)
| | | | | | | | - Linda Gillam
- Morristown Medical Center, Morristown, New Jersey, USA
| | - Jonathon Leipsic
- Providence Health Care, Vancouver Coastal Health, Vancouver, Canada
| | - James D Thomas
- Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
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23
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Levine RA, Levine CS, Seidman MD. Guided Meditation (Hypnosis) and Whole Person Health. Otolaryngol Clin North Am 2022; 55:1077-1086. [DOI: 10.1016/j.otc.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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24
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Rosalia L, Ozturk C, Coll-Font J, Fan Y, Nagata Y, Singh M, Goswami D, Mauskapf A, Chen S, Eder RA, Goffer EM, Kim JH, Yurista S, Bonner BP, Foster AN, Levine RA, Edelman ER, Panagia M, Guerrero JL, Roche ET, Nguyen CT. A soft robotic sleeve mimicking the haemodynamics and biomechanics of left ventricular pressure overload and aortic stenosis. Nat Biomed Eng 2022; 6:1134-1147. [PMID: 36163494 PMCID: PMC9588718 DOI: 10.1038/s41551-022-00937-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/12/2022] [Indexed: 12/14/2022]
Abstract
Preclinical models of aortic stenosis can induce left ventricular pressure overload and coarsely control the severity of aortic constriction. However, they do not recapitulate the haemodynamics and flow patterns associated with the disease. Here we report the development of a customizable soft robotic aortic sleeve that can mimic the haemodynamics and biomechanics of aortic stenosis. By allowing for the adjustment of actuation patterns and blood-flow dynamics, the robotic sleeve recapitulates clinically relevant haemodynamics in a porcine model of aortic stenosis, as we show via in vivo echocardiography and catheterization studies, and a combination of in vitro and computational analyses. Using in vivo and in vitro magnetic resonance imaging, we also quantified the four-dimensional blood-flow velocity profiles associated with the disease and with bicommissural and unicommissural defects re-created by the robotic sleeve. The design of the sleeve, which can be adjusted on the basis of computed tomography data, allows for the design of patient-specific devices that may guide clinical decisions and improve the management and treatment of patients with aortic stenosis.
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Affiliation(s)
- Luca Rosalia
- Health Sciences and Technology Program, Harvard - Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA,Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Caglar Ozturk
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA
| | - Jaume Coll-Font
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Yiling Fan
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA,Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA,Department of Mechanical Engineering, Massachusetts Institute of Technology, 33 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, 55 Fruit Boston, MA 02114, USA,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Manisha Singh
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA
| | - Debkalpa Goswami
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA
| | - Adam Mauskapf
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, 55 Fruit Boston, MA 02114, USA
| | - Shi Chen
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Robert A. Eder
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Efrat M. Goffer
- Health Sciences and Technology Program, Harvard - Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA
| | - Jo H. Kim
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Salva Yurista
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Benjamin P. Bonner
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Anna N. Foster
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, 55 Fruit Boston, MA 02114, USA,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Elazer R. Edelman
- Health Sciences and Technology Program, Harvard - Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA,Brigham and Women’s Hospital, Cardiovascular Division, 75 Francis Street, Boston, MA 02115, USA
| | - Marcello Panagia
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,Cardiovascular Medicine Section, Department of Medicine, Boston University Medical Center, 715 Albany Street, Boston, MA 02118, USA
| | - Jose L. Guerrero
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA
| | - Ellen T. Roche
- Health Sciences and Technology Program, Harvard - Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 45 Carleton Street, Cambridge, MA 02139, USA,Department of Mechanical Engineering, Massachusetts Institute of Technology, 33 Massachusetts Avenue, Cambridge, MA 02139, USA,Correspondence and requests for materials should be addressed to ;
| | - Christopher T. Nguyen
- Health Sciences and Technology Program, Harvard - Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA,Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA,A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, 149 13th Street Charlestown, MA 02129, USA,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA,Cardiovascular Innovation Research Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA,Correspondence and requests for materials should be addressed to ;
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25
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Levine RA, Dias DR, Wang P, Araújo MG. Effect of Connective Tissue Graft Following Immediate Implant Placement on Esthetic Outcomes at Maxillary Central Incisor Sites: A Long-Term Cohort Study. INT J PERIODONT REST 2022; 42:e143-e151. [PMID: 36044696 DOI: 10.11607/prd.5773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The aim of this cohort study was to assess the effect of connective tissue graft (CTG) following immediate implant placement (IIP) at maxillary central incisors on esthetic outcomes, buccal bone thickness, soft tissue dimensional alterations, and patient-centered outcomes. Twenty-eight patients treated with IIP at maxillary central incisor sites with approximately 6 ± 4 years in function were divided according to the use of CTG (n = 17) or no CTG (n = 11). The primary variable of the study was the Pink and White Esthetic Score (PES/WES), evaluated in photographs taken before and after implant placement. The thickness of the buccal bone, midbuccal mucosal level (MBML) changes, and patient satisfaction were assessed and compared between the two groups. The results showed similar PES/WES before IIP between the CTG and no-CTG groups (13.5 ± 3.7 and 12.6 ± 3.2, respectively). After IIP, the PES/WES value in the CTG group was significantly higher (15 ± 2.5) than in the no-CTG group (12.1 ± 3.1) (P = .012). No significant differences in the buccal bone thickness, MBML, or patient satisfaction were observed in CTG and no-CTG groups. This study found that CTG following IIP and socket grafting promoted better esthetic outcomes.
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26
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Churchill TW, Yucel E, Deferm S, Levine RA, Hung J, Bertrand PB. Mitral Valve Dysfunction in Patients With Annular Calcification: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 80:739-751. [PMID: 35953139 PMCID: PMC10290884 DOI: 10.1016/j.jacc.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/24/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 10/15/2022]
Abstract
Mitral annular calcification (MAC) is a common clinical finding and is associated with adverse clinical outcomes, but the clinical impact of MAC-related mitral valve (MV) dysfunction remains underappreciated. Patients with MAC frequently have stenotic, regurgitant, or mixed valvular disease, and this valvular dysfunction is increasingly recognized to be independently associated with worse prognosis. MAC-related MV dysfunction is a distinct pathophysiologic entity, and importantly much of the diagnostic and therapeutic paradigm from published rheumatic MV disease research cannot be applied in this context, leaving important gaps in our knowledge. This review summarizes the current epidemiology, pathophysiology, diagnosis, and classification of MAC-related MV dysfunction and proposes both an integrative definition and an overarching approach to this important and increasingly recognized clinical condition.
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Affiliation(s)
- Timothy W Churchill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/TimChurchillMD
| | - Evin Yucel
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe B Bertrand
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.
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27
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Passos LSA, Nizet V, Levine RA, Aikawa E. Can we diagnose acute rheumatic fever early to maximize the success of secondary prophylaxis in rheumatic heart valve disease? Cardiovasc Res 2022; 118:e62-e65. [PMID: 35862716 PMCID: PMC9890620 DOI: 10.1093/cvr/cvac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Livia S A Passos
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nizet
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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28
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Kochav JD, Kim J, Judd R, Tak KA, Janjua E, Maciejewski AJ, Kim HW, Klem I, Heitner J, Shah D, Zoghbi WA, Shenoy C, Farzaneh-Far A, Polsani V, Villar-Calle P, Parker M, Judd KM, Khalique OK, Leon MB, Devereux RB, Levine RA, Kim RJ, Weinsaft JW. Myocardial Contractile Mechanics in Ischemic Mitral Regurgitation: Multicenter Data Using Stress Perfusion Cardiovascular Magnetic Resonance. JACC Cardiovasc Imaging 2022; 15:1212-1226. [PMID: 35798397 PMCID: PMC9273017 DOI: 10.1016/j.jcmg.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/20/2021] [Revised: 02/24/2022] [Accepted: 03/04/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Left ventricular (LV) ischemia has been variably associated with functional mitral regurgitation (FMR). Determinants of FMR in patients with ischemia are poorly understood. OBJECTIVES This study sought to test whether contractile mechanics in ischemic myocardium underlying the mitral valve have an impact on likelihood of FMR. METHODS Vasodilator stress perfusion cardiac magnetic resonance was performed in patients with coronary artery disease (CAD) at multiple centers. FMR severity was confirmed quantitatively via core lab analysis. To test relationship of contractile mechanics with ischemic FMR, regional wall motion and strain were assessed in patients with inducible ischemia and minimal (≤5% LV myocardium, nontransmural) infarction. RESULTS A total of 2,647 patients with CAD were studied; 34% had FMR (7% moderate or greater). FMR severity increased with presence (P < 0.001) and extent (P = 0.01) of subpapillary ischemia: patients with moderate or greater FMR had more subpapillary ischemia (odds ratio [OR]: 1.13 per 10% LV; 95% CI: 1.05-1.21; P = 0.001) independent of ischemia in remote regions (P = NS); moderate or greater FMR prevalence increased stepwise with extent of ischemia and infarction in subpapillary myocardium (P < 0.001); stronger associations between FMR and infarction paralleled greater wall motion scores in infarct-affected territories. Among patients with inducible ischemia and minimal infarction (n = 532), wall motion and radial strain analysis showed impaired subpapillary contractile mechanics to associate with moderate or greater FMR (P < 0.05) independent of remote regions (P = NS). Conversely, subpapillary ischemia without contractile dysfunction did not augment FMR likelihood. Mitral and interpapillary dimensions increased with subpapillary radial strain impairment; each remodeling parameter associated with impaired subpapillary strain (P < 0.05) independent of remote strain (P = NS). Subpapillary radial strain (OR: 1.13 per 5% [95% CI: 1.02-1.25]; P = 0.02) and mitral tenting area (OR: 1.05 per 10 mm2 [95% CI: 1.00-1.10]; P = 0.04) were associated with moderate or greater FMR controlling for global remodeling represented by LV end-systolic volume (P = NS): when substituting sphericity for LV volume, moderate or greater FMR remained independently associated with subpapillary radial strain impairment (OR: 1.22 per 5% [95% CI: 1.02-1.47]; P = 0.03). CONCLUSIONS Among patients with CAD and ischemia, FMR severity and adverse mitral apparatus remodeling increase in proportion to contractile dysfunction underlying the mitral valve.
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Affiliation(s)
- Jonathan D Kochav
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA.
| | - Jiwon Kim
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Robert Judd
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Katherine A Tak
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Emmad Janjua
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA; Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Han W Kim
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Igor Klem
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - John Heitner
- Division of Cardiology, New York Presbyterian Brooklyn Methodist Hospital, New York, New York, USA
| | - Dipan Shah
- Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Chetan Shenoy
- Division of Cardiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Afshin Farzaneh-Far
- Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Michele Parker
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin M Judd
- Heart Imaging Technologies, Durham, North Carolina, USA
| | - Omar K Khalique
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond J Kim
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
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29
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Paquin A, Marsit O, Deschênes V, Rouabhia D, Hadjadj S, Clisson M, Robitaille C, Aikawa E, Levine RA, Pibarot P, Clavel MA, Beaudoin J. Progression of aortic stenosis after an acute myocardial infarction. Open Heart 2022; 9:openhrt-2022-002046. [PMID: 35728891 PMCID: PMC9214429 DOI: 10.1136/openhrt-2022-002046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 05/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Myocardial infarction (MI) has been shown to induce fibrotic remodelling of the mitral and tricuspid valves. It is unknown whether MI also induces pathological remodelling of the aortic valve and alters aortic stenosis (AS) progression. We thus compared AS progression after an acute MI and in patients with/without history of MI, and assessed post-MI pathobiological changes within the aortic valve leaflets in a sheep model. Methods Serial echocardiograms in human patients with AS were retrospectively analysed and compared between 3 groups: (1) acute MI at baseline (n=68), (2) prior history of MI (n=45) and (3) controls without MI (n=101). Annualised progression rates of AS severity were compared between these 3 groups. In addition, aortic valves were harvested from 15 sheep: (1) induced inferior MI (n=10) and (2) controls without MI (n=5), for biological and histological analyses. Results In humans, the acute MI, previous MI and control groups had comparable baseline AS severity. Indexed aortic valve area (AVAi) declined faster in the acute MI group compared with controls (−0.07±0.06 vs −0.04±0.04 cm2/m2/year; p=0.004). After adjustment, acute MI status was significantly associated with faster AVAi progression (mean difference: −0.013 (95% CI −0.023 to −0.003) cm2/m2/year, p=0.008). In the post-MI experimental animal model, aortic valve thickness and qualitative/quantitative expression of collagen were significantly increased compared with controls. Conclusions The results of this study suggest that AS progression is accelerated following acute MI, which could be caused by increased collagen production and thickening of the aortic valve after the ischaemic event.
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Affiliation(s)
- Amélie Paquin
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.,Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ons Marsit
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Valérie Deschênes
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Dounia Rouabhia
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Sandra Hadjadj
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marine Clisson
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | | | - Elena Aikawa
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert A Levine
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
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Levine RA, Dias DR, Wang P, Araújo MG. Effect of the buccal gap width following immediate implant placement on the buccal bone wall: A retrospective cone-beam computed tomography analysis. Clin Implant Dent Relat Res 2022; 24:403-413. [PMID: 35605151 DOI: 10.1111/cid.13095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/22/2022] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effect of the buccal gap width on the clinical outcome of socket graft and immediate implant placement (IIP) at maxillary central incisor sites has not been investigated. Thus, the aim of the present study was to evaluate the effect of the width of the buccal gap on the thickness of the newly formed buccal wall. METHODS Forty-two patients and 51 maxillary central incisor sites treated with IIP and ridge preservation by means of graft of the buccal gap at the maxillary central incisor region were included in the study. The width of the buccal gap was measured and filled with deproteinized bovine bone mineral. Implant sites were divided into two groups: wide gap (WG, >2 mm; n = 34) and narrow gap (NG, ≤2 mm; n = 17). After at least 1 year in function (5 ± 4), CBCT scans were obtained and assessed by a calibrated examiner. The thickness of the buccal and palatal bone walls, the percentage of the implant height covered by bone in the buccal and palatal aspects and the position of the buccal and palatal crests were compared between the two groups. A linear regression model was performed to assess predictors of the thickness of the buccal bone. RESULTS The buccal bone was significantly thicker in the WG group than the NG group at all levels observed (overall 1.9 ± 0.9 mm and 0.5 ± 0.6 mm, respectively). The thickness of the palatal bone was similar between both groups (>2 mm). The percentage of the implant height covered by bone at the buccal aspect was significantly higher in the WG group (95 ± 16.6%) than in the NG group (59.4 ± 42.3%). The position of the buccal crest in relation to the implant shoulder was significantly more coronal (0.3 ± 2.2 mm) in the WG group than in the NG group (-4.7 ± 5.6 mm). The regression analysis model indicated that the width of the buccal gap was the only predictor of the thickness of the newly formed buccal bone wall (p < 0.001). CONCLUSION Grafting of >2 mm-wide buccal gaps following IIP promoted a thicker buccal bone wall.
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Affiliation(s)
- Robert A Levine
- Pennsylvania Center for Dental Implants and Periodontics, Philadelphia, Pennsylvania, USA.,Department of Periodontology and Implantology, Temple University Kornberg School of Dentistry, Philadelphia, Pennsylvania, USA
| | - Debora R Dias
- Department of Dentistry, State University of Maringá, Maringá, Paraná, Brazil
| | - Ping Wang
- Department of Restorative Dentistry, Temple University Kornberg School of Dentistry, Philadelphia, Pennsylvania, USA
| | - Maurício G Araújo
- Department of Dentistry, State University of Maringá, Maringá, Paraná, Brazil
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Rong LQ, Lopes AJ, Mitlak HW, Palumbo MC, Mick S, Kim J, Levine RA, Wong SC, Reisman M, Devereux RB, Gaudino M, Weinsaft JW. Relative Impact of Surgical Mitral Repair and MitraClip on Annular Remodeling-A Potential Mechanism for Therapeutic Response to Mitral Repair for Degenerative Mitral Regurgitation. J Cardiothorac Vasc Anesth 2022; 36:1279-1287. [PMID: 34600832 PMCID: PMC9027699 DOI: 10.1053/j.jvca.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/12/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Three-dimensional transesophageal echocardiography (TEE) is widely used to guide decision-making for mitral repair. The relative impact of surgical mitral valve repair (MVr) and MitraClip on annular remodeling is unknown. The aim was to determine the impact of both mitral repair strategies on annular geometry, including the primary outcome of annular circumference and area. DESIGN This was a retrospective observational study of patients who underwent mitral intervention between 2016 and 2020. SETTING Weill Cornell Medicine, a single, large, academic medical center. PARTICIPANTS The population comprised 50 patients with degenerative mitral regurgitation (MR) undergoing MVr. INTERVENTIONS Elective MVr and TEE. MEASUREMENTS AND MAIN RESULTS Patients undergoing MitraClip or surgical MVr were matched (1:1) for sex and coronary artery disease. Mitral annular geometry indices were quantified on intraprocedural three-dimensional TEE. Mild or less MR on follow-up transthoracic echocardiography defined optimal response. Patients undergoing MitraClip were older (80 ± eight v 66 ± six years; p < 0.001) but were otherwise similar to surgical patients. Patients undergoing MitraClip had larger baseline left atrial and ventricular sizes, increased tenting height, and volume (p < 0.01), with a trend toward increased annular area (p = 0.23). MitraClip and surgery both induced immediate mitral annular remodeling, including decreased area, circumference, and tenting height (p < 0.001), with greater remodeling with surgical repair. At follow-up (4.1 ± 9.0 months) optimal response (≤ mild MR) was ∼twofold more common with surgery than MitraClip (81% v 46%; p = 0.02). The relative reduction in annular circumference (odds ratio [OR] 1.05 [1.00-1.09] per cm; p = 0.04) and area (OR 1.03 [1.00-1.05] per cm2; p = 0.049) were both associated with optimal response. CONCLUSIONS Surgical MVr and MitraClip both reduce annular size, but repair-induced remodeling is greater with surgery and associated with an increased likelihood of optimal response.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY.
| | | | - Hannah W Mitlak
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Maria C Palumbo
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Stephanie Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - S Chiu Wong
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mark Reisman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Richard B Devereux
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jonathan W Weinsaft
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
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Alvandi Z, Nagata Y, Passos LSA, Hashemi Gheinani A, Guerrero JL, Wylie‐Sears J, Romero DC, Morris BA, Sullivan SM, Yaghoubian KM, Alvandi A, Adam RM, Aikawa E, Levine RA, Bischoff J. Wnt Site Signaling Inhibitor Secreted Frizzled‐Related Protein 3 Protects Mitral Valve Endothelium From Myocardial Infarction–Induced Endothelial‐to‐Mesenchymal Transition. J Am Heart Assoc 2022; 11:e023695. [PMID: 35348006 PMCID: PMC9075477 DOI: 10.1161/jaha.121.023695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
The onset and mechanisms of endothelial‐to‐mesenchymal transition (EndMT) in mitral valve (MV) leaflets following myocardial infarction (MI) are unknown, yet these events are closely linked to stiffening of leaflets and development of ischemic mitral regurgitation. We investigated whether circulating molecules present in plasma within days after MI incite EndMT in MV leaflets.
Methods and Results
We examined the onset of EndMT in MV leaflets from 9 sheep with inferior MI, 8 with sham surgery, and 6 naïve controls. Ovine MVs 8 to 10 days after inferior MI displayed EndMT, shown by increased vascular endothelial cadherin/α‐smooth muscle actin–positive cells. The effect of plasma on EndMT in MV endothelial cells (VECs) was assessed by quantitative polymerase chain reaction, migration assays, and immunofluorescence. In vitro, post‐MI plasma induced EndMT marker expression and enhanced migration of mitral VECs; sham plasma did not. Analysis of sham versus post‐MI plasma revealed a significant drop in the Wnt signaling antagonist sFRP3 (secreted frizzled‐related protein 3) in post‐MI plasma. Addition of recombinant sFRP3 to post‐MI plasma reversed its EndMT‐inducing effect on mitral VECs. RNA‐sequencing analysis of mitral VECs exposed to post‐MI plasma showed upregulated FOXM1 (forkhead box M1). Blocking FOXM1 reduced EndMT transcripts in mitral VECs treated with post‐MI plasma. Finally, FOXM1 induced by post‐MI plasma was downregulated by sFRP3.
Conclusions
Reduced sFRP3 in post‐MI plasma facilitates EndMT in mitral VECs by increasing the transcription factor FOXM1. Restoring sFRP3 levels or inhibiting FOXM1 soon after MI may provide a novel strategy to modulate EndMT in the MV to prevent ischemic mitral regurgitation and heart failure.
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Affiliation(s)
- Zahra Alvandi
- Vascular Biology Program Boston Children’s Hospital Boston MA
- Department of Surgery Harvard Medical School Boston MA
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory Massachusetts General HospitalHarvard Medical School Boston MA
| | | | - Ali Hashemi Gheinani
- Department of Surgery Harvard Medical School Boston MA
- Broad Institute of MIT and Harvard Cambridge MA
- Department of Urology Boston Children’s Hospital Boston MA
| | - J. Luis Guerrero
- Cardiac Ultrasound Laboratory Massachusetts General HospitalHarvard Medical School Boston MA
| | | | - Dayana Carolina Romero
- Cardiac Ultrasound Laboratory Massachusetts General HospitalHarvard Medical School Boston MA
| | - Brittan A. Morris
- Cardiac Ultrasound Laboratory Massachusetts General HospitalHarvard Medical School Boston MA
| | - Suzanne M. Sullivan
- Cardiac Ultrasound Laboratory Massachusetts General HospitalHarvard Medical School Boston MA
| | - Koushiar M. Yaghoubian
- Cardiac Ultrasound Laboratory Massachusetts General HospitalHarvard Medical School Boston MA
| | - Amirhossein Alvandi
- Department of Mathematics and Statistics University of Massachusetts Amherst MA
| | - Rosalyn M. Adam
- Department of Surgery Harvard Medical School Boston MA
- Department of Urology Boston Children’s Hospital Boston MA
| | - Elena Aikawa
- Center for Excellence in Vascular Biology Brigham and Women’s Hospital Harvard Medical School Boston MA
- Center for Interdisciplinary Cardiovascular Sciences Cardiovascular MedicineBrigham and Women’s HospitalHarvard Medical School Boston MA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory Massachusetts General HospitalHarvard Medical School Boston MA
| | - Joyce Bischoff
- Vascular Biology Program Boston Children’s Hospital Boston MA
- Department of Surgery Harvard Medical School Boston MA
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Gomes NFA, Silva VR, Levine RA, Esteves WAM, de Castro ML, Passos LSA, Dal-Bianco JP, Pantaleão AN, da Silva JLP, Tan TC, Dutra WO, Aikawa E, Hung J, Nunes MCP. Progression of Mitral Regurgitation in Rheumatic Valve Disease: Role of Left Atrial Remodeling. Front Cardiovasc Med 2022; 9:862382. [PMID: 35360029 PMCID: PMC8962951 DOI: 10.3389/fcvm.2022.862382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Mitral regurgitation (MR) is the most common valve abnormality in rheumatic heart disease (RHD) often associated with stenosis. Although the mechanism by which MR develops in RHD is primary, longstanding volume overload with left atrial (LA) remodeling may trigger the development of secondary MR, which can impact on the overall progression of MR. This study is aimed to assess the incidence and predictors of MR progression in patients with RHD. Methods Consecutive RHD patients with non-severe MR associated with any degree of mitral stenosis were selected. The primary endpoint was a progression of MR, which was defined as an increase of one grade in MR severity from baseline to the last follow-up echocardiogram. The risk of MR progression was estimated accounting for competing risks. Results The study included 539 patients, age of 46.2 ± 12 years and 83% were women. At a mean follow-up time of 4.2 years (interquartile range [IQR]: 1.2–6.9 years), 54 patients (10%) displayed MR progression with an overall incidence of 2.4 per 100 patient-years. Predictors of MR progression by the Cox model were age (adjusted hazard ratio [HR] 1.541, 95% CI 1.222–1.944), and LA volume (HR 1.137, 95% CI 1.054–1.226). By considering competing risk analysis, the direction of the association was similar for the rate (Cox model) and incidence (Fine-Gray model) of MR progression. In the model with LA volume, atrial fibrillation (AF) was no longer a predictor of MR progression. In the subgroup of patients in sinus rhythm, 59 had an onset of AF during follow-up, which was associated with progression of MR (HR 2.682; 95% CI 1.133–6.350). Conclusions In RHD patients with a full spectrum of MR severity, progression of MR occurs over time is predicted by age and LA volume. LA enlargement may play a role in the link between primary MR and secondary MR in patients with RHD.
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Affiliation(s)
- Nayana F. A. Gomes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vicente Rezende Silva
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Robert A. Levine
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - William A. M. Esteves
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Marildes Luiza de Castro
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Livia S. A. Passos
- The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jacob P. Dal-Bianco
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | | | | | - Timothy C. Tan
- Department of Cardiology, Blacktown Hospital, University of Western Sydney, Penrith, NSW, Australia
| | - Walderez O. Dutra
- Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, and National Institutes for Science and Technology, Belo Horizonte, Brazil
| | - Elena Aikawa
- The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Judy Hung
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Maria Carmo P. Nunes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
- *Correspondence: Maria Carmo P. Nunes
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Roselli C, Yu M, Nauffal V, Georges A, Yang Q, Love K, Weng LC, Delling FN, Maurya SR, Schrölkamp M, Tfelt-Hansen J, Hagège A, Jeunemaitre X, Debette S, Amouyel P, Guan W, Muehlschlegel JD, Body SC, Shah S, Samad Z, Kyryachenko S, Haynes C, Rienstra M, Le Tourneau T, Probst V, Roussel R, Wijdh-Den Hamer IJ, Siland JE, Knowlton KU, Jacques Schott J, Levine RA, Benjamin EJ, Vasan RS, Horne BD, Muhlestein JB, Benfari G, Enriquez-Sarano M, Natale A, Mohanty S, Trivedi C, Shoemaker MB, Yoneda ZT, Wells QS, Baker MT, Farber-Eger E, Michelena HI, Lundby A, Norris RA, Slaugenhaupt SA, Dina C, Lubitz SA, Bouatia-Naji N, Ellinor PT, Milan DJ. Genome-wide association study reveals novel genetic loci: a new polygenic risk score for mitral valve prolapse. Eur Heart J 2022; 43:1668-1680. [PMID: 35245370 PMCID: PMC9649914 DOI: 10.1093/eurheartj/ehac049] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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] [Received: 02/02/2021] [Revised: 08/18/2021] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Mitral valve prolapse (MVP) is a common valvular heart disease with a prevalence of >2% in the general adult population. Despite this high incidence, there is a limited understanding of the molecular mechanism of this disease, and no medical therapy is available for this disease. We aimed to elucidate the genetic basis of MVP in order to better understand this complex disorder. METHODS AND RESULTS We performed a meta-analysis of six genome-wide association studies that included 4884 cases and 434 649 controls. We identified 14 loci associated with MVP in our primary analysis and 2 additional loci associated with a subset of the samples that additionally underwent mitral valve surgery. Integration of epigenetic, transcriptional, and proteomic data identified candidate MVP genes including LMCD1, SPTBN1, LTBP2, TGFB2, NMB, and ALPK3. We created a polygenic risk score (PRS) for MVP and showed an improved MVP risk prediction beyond age, sex, and clinical risk factors. CONCLUSION We identified 14 genetic loci that are associated with MVP. Multiple analyses identified candidate genes including two transforming growth factor-β signalling molecules and spectrin β. We present the first PRS for MVP that could eventually aid risk stratification of patients for MVP screening in a clinical setting. These findings advance our understanding of this common valvular heart disease and may reveal novel therapeutic targets for intervention.
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Affiliation(s)
- Carolina Roselli
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA,Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mengyao Yu
- Université de Paris, PARCC, Inserm, F-75015 Paris, France
| | - Victor Nauffal
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA,Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Adrien Georges
- Université de Paris, PARCC, Inserm, F-75015 Paris, France
| | - Qiong Yang
- School of Public Health, Boston University, Boston, MA, USA
| | - Katie Love
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Lu Chen Weng
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA,Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Francesca N Delling
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Svetlana R Maurya
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, København 2200, Denmark
| | - Maren Schrölkamp
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, København 2200, Denmark
| | - Jacob Tfelt-Hansen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark,Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Albert Hagège
- Université de Paris, PARCC, Inserm, F-75015 Paris, France,Assistance Publique–Hôpitaux de Paris, Departments of Cardiology and Genetics, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Xavier Jeunemaitre
- Université de Paris, PARCC, Inserm, F-75015 Paris, France,Assistance Publique–Hôpitaux de Paris, Departments of Cardiology and Genetics, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Stéphanie Debette
- Bordeaux Population Health Research Center, Inserm Center U1219, University of Bordeaux, Bordeaux, France,Department of Neurology, Bordeaux University Hospital, Inserm U1219, Bordeaux, France
| | - Philippe Amouyel
- Univ. Lille, Inserm, Centre Hosp. Univ Lille, Institut Pasteur de Lille, UMR1167 – RID-AGE- Risk factors and molecular determinants of aging-related diseases, F-59000 Lille, France
| | - Wyliena Guan
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA,Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA,Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Simon C Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA
| | - Svati Shah
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Zainab Samad
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA,Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Carol Haynes
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thierry Le Tourneau
- l’institut du thorax, INSERM, CNRS, Univ Nantes, CHU Nantes, Nantes, France,l’institut du thorax, CHU Nantes, Nantes, France
| | - Vincent Probst
- l’institut du thorax, INSERM, CNRS, Univ Nantes, CHU Nantes, Nantes, France
| | - Ronan Roussel
- Cordeliers Research Centre, ImMeDiab Team, INSERM, Université de Paris, Paris, France,Hôpital Bichat-Claude-Bernard, APHP, Department of Diabetology, Paris, France
| | - Inez J Wijdh-Den Hamer
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joylene E Siland
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA,Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | | | - Robert A Levine
- Cardiac Ultrasound Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Emelia J Benjamin
- National Heart, Lung, and Blood Institute’s and Boston University’s, The Framingham Heart Study, Framingham, MA, USA,Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA, USA,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ramachandran S Vasan
- School of Public Health, Boston University, Boston, MA, USA,National Heart, Lung, and Blood Institute’s and Boston University’s, The Framingham Heart Study, Framingham, MA, USA,School of Medicine, Boston University, Boston, MA, USA
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA,Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Giovanni Benfari
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX, USA
| | - Moore B Shoemaker
- Department of Medicine, Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zachary T Yoneda
- Department of Medicine, Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Quinn S Wells
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael T Baker
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Farber-Eger
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Alicia Lundby
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, København 2200, Denmark,The Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, København 2200, Denmark
| | - Russell A Norris
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | - Patrick T Ellinor
- Corresponding authors. Tel: +1 617 459 4688, (D.J.M.); Tel: +1 617 724 8729, (P.T.E.)
| | - David J Milan
- Corresponding authors. Tel: +1 617 459 4688, (D.J.M.); Tel: +1 617 724 8729, (P.T.E.)
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Namasivayam M, Churchill T, Capoulade R, Pibarot P, Danik JS, Picard MH, Levine RA, Hung JW. DIMENSIONLESS INDEX COMPLEMENTS TRANSVALVULAR FLOW RATE IN SOLVING DISCORDANT LOW GRADIENT AORTIC STENOSIS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Passos LS, Jha PK, Becker-Greene D, Blaser MC, Romero D, Lupieri A, Sukhova GK, Libby P, Singh SA, Dutra WO, Aikawa M, Levine RA, Nunes MC, Aikawa E. Prothymosin Alpha: A Novel Contributor to Estradiol Receptor Alpha-Mediated CD8 + T-Cell Pathogenic Responses and Recognition of Type 1 Collagen in Rheumatic Heart Valve Disease. Circulation 2022; 145:531-548. [PMID: 35157519 PMCID: PMC8869797 DOI: 10.1161/circulationaha.121.057301] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Indexed: 12/20/2022]
Abstract
BACKGROUND Rheumatic heart valve disease (RHVD) is a leading cause of cardiovascular death in low- and middle-income countries and affects predominantly women. The underlying mechanisms of chronic valvular damage remain unexplored and regulators of sex predisposition are unknown. METHODS Proteomics analysis of human heart valves (nondiseased aortic valves, nondiseased mitral valves [NDMVs], valves from patients with rheumatic aortic valve disease, and valves from patients with rheumatic mitral valve disease; n=30) followed by system biology analysis identified ProTα (prothymosin alpha) as a protein associated with RHVD. Histology, multiparameter flow cytometry, and enzyme-linked immunosorbent assay confirmed the expression of ProTα. In vitro experiments using peripheral mononuclear cells and valvular interstitial cells were performed using multiparameter flow cytometry and quantitative polymerase chain reaction. In silico analysis of the RHVD and Streptococcuspyogenes proteomes were used to identify mimic epitopes. RESULTS A comparison of NDMV and nondiseased aortic valve proteomes established the baseline differences between nondiseased aortic and mitral valves. Thirteen unique proteins were enriched in NDMVs. Comparison of NDMVs versus valves from patients with rheumatic mitral valve disease and nondiseased aortic valves versus valves from patients with rheumatic aortic valve disease identified 213 proteins enriched in rheumatic valves. The expression of the 13 NDMV-enriched proteins was evaluated across the 213 proteins enriched in diseased valves, resulting in the discovery of ProTα common to valves from patients with rheumatic mitral valve disease and valves from patients with rheumatic aortic valve disease. ProTα plasma levels were significantly higher in patients with RHVD than in healthy individuals. Immunoreactive ProTα colocalized with CD8+ T cells in RHVD. Expression of ProTα and estrogen receptor alpha correlated strongly in circulating CD8+ T cells from patients with RHVD. Recombinant ProTα induced expression of the lytic proteins perforin and granzyme B by CD8+ T cells as well as higher estrogen receptor alpha expression. In addition, recombinant ProTα increased human leukocyte antigen class I levels in valvular interstitial cells. Treatment of CD8+ T cells with specific estrogen receptor alpha antagonist reduced the cytotoxic potential promoted by ProTα. In silico analysis of RHVD and Spyogenes proteomes revealed molecular mimicry between human type 1 collagen epitope and bacterial collagen-like protein, which induced CD8+ T-cell activation in vitro. CONCLUSIONS ProTα-dependent CD8+ T-cell cytotoxicity was associated with estrogen receptor alpha activity, implicating ProTα as a potential regulator of sex predisposition in RHVD. ProTα facilitated recognition of type 1 collagen mimic epitopes by CD8+ T cells, suggesting mechanisms provoking autoimmunity.
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Affiliation(s)
- Livia S.A. Passos
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Prabhash K. Jha
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Dakota Becker-Greene
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark C. Blaser
- Center for Interdisciplinary Cardiovascular Sciences, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Dayanna Romero
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Adrien Lupieri
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Galina K. Sukhova
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Libby
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sasha A. Singh
- Center for Interdisciplinary Cardiovascular Sciences, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Walderez O. Dutra
- Departamento de Morfologia, Instituto de Ciências Biológicas, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Masanori Aikawa
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Center for Interdisciplinary Cardiovascular Sciences, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Human Pathology, Sechenov First Moscow State Medical University, Moscow 119992, Russia
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maria C.P. Nunes
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Elena Aikawa
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Center for Interdisciplinary Cardiovascular Sciences, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Human Pathology, Sechenov First Moscow State Medical University, Moscow 119992, Russia
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Passos LSA, Becker-Greene D, Braulio R, Le TD, Gelape CL, de Almeida LFR, Rocha DPA, Gomes CAP, Esteves WAM, Passaglia LG, Dal-Bianco JP, Levine RA, Aikawa M, Hung J, Dutra WO, Nunes MCP, Aikawa E. Proinflammatory Matrix Metalloproteinase-1 Associates With Mitral Valve Leaflet Disruption Following Percutaneous Mitral Valvuloplasty. Front Cardiovasc Med 2022; 8:804111. [PMID: 35127864 PMCID: PMC8811173 DOI: 10.3389/fcvm.2021.804111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
Mitral regurgitation (MR) is a major complication of the percutaneous mitral valvuloplasty (PMV). Despite high technical expertise and cumulative experience with the procedure, the incidence rate of severe MR has not decreased. Although some of MR can be anticipated by echocardiographic analysis; leaflet tearing, which leads to the most dreaded type of MR, remains unpredictable. Irregular valvular collagen remodeling is likely to compromise tissue architecture and increase the tearing risk during PMV balloon inflation. In this study, we evaluated histological and molecular characteristics of excised mitral valves from patients with rheumatic mitral stenosis (MS) who underwent emergency surgery after PMV due to severe MR caused by leaflet tear. Those findings were compared with patients who underwent elective mitral valve replacement surgery owing to severe MS, in whom PMV was not indicated. In vitro assay using peripheral blood mononuclear cells was performed to better understand the impact of the cellular and molecular alterations identified in leaflet tear mitral valve specimens. Our analysis showed that focal infiltration of inflammatory cells contributes to accumulation of MMP-1 and IFN-γ in valve leaflets. Moreover, we showed that IFN-γ increase the expression of MMP-1 in CD14+ cells (monocytes) in vitro. Thus, inflammatory cells contribute to unevenly remodel collagen resulting in variable thickening causing abnormalities in leaflet architecture making them more susceptible to laceration.
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Affiliation(s)
- Livia S. A. Passos
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Dakota Becker-Greene
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Renato Braulio
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Thanh-Dat Le
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Cláudio L. Gelape
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Luís Felipe R. de Almeida
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Divino Pedro A. Rocha
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Carlos Augusto P. Gomes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - William A. M. Esteves
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Luiz G. Passaglia
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Jacob P. Dal-Bianco
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Masanori Aikawa
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
- Center for Interdisciplinary Cardiovascular Sciences, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
- Department of Human Pathology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Walderez O. Dutra
- Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais, Belo Horizonte, Brazil
| | - Maria Carmo P. Nunes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Elena Aikawa
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
- Center for Interdisciplinary Cardiovascular Sciences, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
- Department of Human Pathology, Sechenov First Moscow State Medical University, Moscow, Russia
- *Correspondence: Elena Aikawa
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Herrera JE, Herrera JA, Finizola B, García E, Velasco LE, Torres WR, D'empaire G, Octavio JA, Marqués JA, Levine RA, Palacios IF. First-in-human experience of preload regulation with percutaneous transluminal caval flow regulation in heart failure with reduced ejection fraction patients. ESC Heart Fail 2022; 9:1118-1126. [PMID: 35014208 PMCID: PMC8934920 DOI: 10.1002/ehf2.13780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/05/2021] [Indexed: 11/08/2022] Open
Abstract
AIMS This study aims to investigate the acute haemodynamic effects of percutaneous transluminal flow regulation (PTCR®) with an inferior vena cava regulator balloon in heart failure patients. Preload reduction in heart failure has been achieved with high potency diuretics. However, no study has been conducted in humans to assess the effect of inferior vena cava intermittent occlusion for preload reduction. METHODS AND RESULTS Six patients were included in the study: four men (55 ± 6 years old) and two women (63 ± 4 years old). Baseline evaluations included Doppler echocardiogram, coronary angiogram, and right heart catheterization. Caval balloon was kept inflated for 30 min, and right catheterization and control echocardiogram were performed while the balloon was still inflated. The balloon was then deflated and removed. Right haemodynamic variables were evaluated before balloon insertion and with the inflated balloon. The mean right atrial pressure decreased by 42.59% (P = 0.005); systolic right ventricular pressure decreased by 30.19% (P < 0.003); mean pulmonary arterial pressure decreased by 25.33% (P < 0.043); mean pulmonary capillary wedge pressure decreased by 31.37% (P > 0.016); and cardiac output increased by 9.92% (P < 0.175). CONCLUSIONS The haemodynamic and echocardiographic changes obtained in our study using PTCR® suggest that this innovative approach can play a beneficial role in the heart failure treatment.
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Affiliation(s)
- José E Herrera
- Asociación Cardiológica de Occidente, ASCARDIO, Universidad Central 'Lisandro Alvarado' (UCLA), Barquisimeto, Venezuela
| | - José A Herrera
- Asociación Cardiológica de Occidente, ASCARDIO, Universidad Central 'Lisandro Alvarado' (UCLA), Barquisimeto, Venezuela
| | - Bartolomé Finizola
- Asociación Cardiológica de Occidente, ASCARDIO, Universidad Central 'Lisandro Alvarado' (UCLA), Barquisimeto, Venezuela
| | - Eleazar García
- Asociación Cardiológica de Occidente, ASCARDIO, Universidad Central 'Lisandro Alvarado' (UCLA), Barquisimeto, Venezuela
| | - Luis E Velasco
- Asociación Cardiológica de Occidente, ASCARDIO, Universidad Central 'Lisandro Alvarado' (UCLA), Barquisimeto, Venezuela
| | - William R Torres
- Asociación Cardiológica de Occidente, ASCARDIO, Universidad Central 'Lisandro Alvarado' (UCLA), Barquisimeto, Venezuela
| | | | | | - Juan A Marqués
- Cardiología Experimental Universidad Central, Caracas, Venezuela
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Morningstar JE, Gensemer C, Moore R, Fulmer D, Beck TC, Wang C, Moore K, Guo L, Sieg F, Nagata Y, Bertrand P, Spampinato RA, Glover J, Poelzing S, Gourdie RG, Watts K, Richardson WJ, Levine RA, Borger MA, Norris RA. Mitral Valve Prolapse Induces Regionalized Myocardial Fibrosis. J Am Heart Assoc 2021; 10:e022332. [PMID: 34873924 PMCID: PMC9075228 DOI: 10.1161/jaha.121.022332] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/13/2021] [Indexed: 02/06/2023]
Abstract
Background Mitral valve prolapse (MVP) is one of the most common forms of cardiac valve disease and affects 2% to 3% of the population. Previous imaging reports have indicated that myocardial fibrosis is common in MVP and described its association with sudden cardiac death. These data combined with evidence for postrepair ventricular dysfunction in surgical patients with MVP support a link between fibrosis and MVP. Methods and Results We performed histopathologic analysis of left ventricular (LV) biopsies from peripapillary regions, inferobasal LV wall and apex on surgical patients with MVP, as well as in a mouse model of human MVP (Dzip1S14R/+). Tension-dependent molecular pathways were subsequently assessed using both computational modeling and cyclical stretch of primary human cardiac fibroblasts in vitro. Histopathology of LV biopsies revealed regionalized fibrosis in the peripapillary myocardium that correlated with increased macrophages and myofibroblasts. The MVP mouse model exhibited similar regional increases in collagen deposition that progress over time. As observed in the patient biopsies, increased macrophages and myofibroblasts were observed in fibrotic areas within the murine heart. Computational modeling revealed tension-dependent profibrotic cellular and molecular responses consistent with fibrosis locations related to valve-induced stress. These simulations also identified mechanosensing primary cilia as involved in profibrotic pathways, which was validated in vitro and in human biopsies. Finally, in vitro stretching of primary human cardiac fibroblasts showed that stretch directly activates profibrotic pathways and increases extracellular matrix protein production. Conclusions The presence of prominent regional LV fibrosis in patients and mice with MVP supports a relationship between MVP and progressive damaging effects on LV structure before overt alterations in cardiac function. The regionalized molecular and cellular changes suggest a reactive response of the papillary and inferobasal myocardium to increased chordal tension from a prolapsing valve. These studies raise the question whether surgical intervention on patients with MVP should occur earlier than indicated by current guidelines to prevent advanced LV fibrosis and potentially reduce residual risk of LV dysfunction and sudden cardiac death.
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Affiliation(s)
| | | | - Reece Moore
- Medical University of South CarolinaCharlestonSC
| | - Diana Fulmer
- Medical University of South CarolinaCharlestonSC
| | | | | | - Kelsey Moore
- Medical University of South CarolinaCharlestonSC
| | - Lilong Guo
- Medical University of South CarolinaCharlestonSC
| | - Franz Sieg
- Leipzig Heart InstituteUniversity of LeipzigGermany
| | - Yasufumi Nagata
- Cardiac Ultrasound LaboratoryCardiology DivisionMassachusetts General HospitalBostonMA
| | - Philippe Bertrand
- Cardiac Ultrasound LaboratoryCardiology DivisionMassachusetts General HospitalBostonMA
| | | | | | - Stephen Poelzing
- Center for Heart and Reparative Medicine ResearchFralin Biomedical Research InstituteVirginia TechRoanokeVA
| | - Robert G. Gourdie
- Center for Heart and Reparative Medicine ResearchFralin Biomedical Research InstituteVirginia TechRoanokeVA
| | - Kelsey Watts
- Biomedical Data Science and Informatics ProgramDepartment of BioengineeringClemson UniversityClemsonSC
| | - William J. Richardson
- Biomedical Data Science and Informatics ProgramDepartment of BioengineeringClemson UniversityClemsonSC
| | - Robert A. Levine
- Cardiac Ultrasound LaboratoryCardiology DivisionMassachusetts General HospitalBostonMA
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Levine RA, Ganeles J, Wang R. Short-Term Case Reports Demonstrating the Use of Volume-Stable Collagen Matrix. Compend Contin Educ Dent 2021; 42:520-526. [PMID: 34555914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
A proper diagnostic and treatment planning process for dental implant rehabilitations should include a checklist of key factors to help clinicians avoid potential complications. Such a checklist should encompass evaluation of the soft- and hard-tissue volume buccal to each implant, as this has been shown to aid in maintaining marginal bone levels long-term. Thus, as part of surgical planning, a decision to augment the soft tissue should be considered. The autogenous palatal graft has long been considered the "gold standard" for soft-tissue augmentation; however, the benefits of this approach should be weighed against the potential complications associated with a secondary surgical site as well as the patient's desire for as pain-free an experience as possible. The volume-stable collagen matrix (VSCM) is a promising material with favorable healing characteristics and volume thickness maintenance of up to 3 years in current literature. This article presents two cases that demonstrate the clinical advantages of a VSCM over the use of autogenous palatal grafts as part of the authors' "10 Keys" principles of augmenting the volume and thickness of peri-implant tissues.
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Affiliation(s)
- Robert A Levine
- Clinical Professor, Kornberg School of Dental Medicine, Temple University, Philadelphia, Pennsylvania; Clinical Associate Professor, Adams School of Dentistry, University of North Carolina, Chapel Hill, North Carolina; Diplomate, American Board of Periodontology; Fellow, International Team for Implantology; Fellow, Academy of Osseointegration; Private Practice, Dental Implants and Periodontics, Philadelphia, Pennsylvania
| | - Jeffrey Ganeles
- Adjunct Associate Professor, Nova Southeastern University College of Dental Medicine, Fort Lauderdale, Florida; Clinical Assistant Professor, Boston University Goldman School of Graduate Dentistry, Boston, Massachusetts; Diplomate, American Board of Periodontology; Fellow, International Team for Implantology; Fellow, Academy of Osseointegration; Private Practice, Periodontics and Dental Implant Surgery, Boca Raton, Florida
| | - Ron Wang
- Resident, Graduate Prosthodontics, Montefiore Medical Center, Bronx, New York
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Lupieri A, Nagata Y, Passos LSA, Beker-Greene D, Kirkwood KA, Wylie-Sears J, Alvandi Z, Higashi H, Hung JW, Singh SA, Bischoff J, Levine RA, Aikawa E. Integration of Functional Imaging, Cytometry, and Unbiased Proteomics Reveals New Features of Endothelial-to-Mesenchymal Transition in Ischemic Mitral Valve Regurgitation in Human Patients. Front Cardiovasc Med 2021; 8:688396. [PMID: 34458332 PMCID: PMC8387660 DOI: 10.3389/fcvm.2021.688396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Following myocardial infarction, mitral regurgitation (MR) is a common complication. Previous animal studies demonstrated the association of endothelial-to-mesenchymal transition (EndMT) with mitral valve (MV) remodeling. Nevertheless, little is known about how MV tissue responds to ischemic heart changes in humans. Methods: MVs were obtained by the Cardiothoracic Surgical Trials Network from 17 patients with ischemic mitral regurgitation (IMR). Echo-doppler imaging assessed MV function at time of resection. Cryosections of MVs were analyzed using a multi-faceted histology and immunofluorescence examination of cell populations. MVs were further analyzed using unbiased label-free proteomics. Echo-Doppler imaging, histo-cytometry measures and proteomic analysis were then integrated. Results: MVs from patients with greater MR exhibited proteomic changes associated with proteolysis-, inflammatory- and oxidative stress-related processes compared to MVs with less MR. Cryosections of MVs from patients with IMR displayed activated valvular interstitial cells (aVICs) and double positive CD31+ αSMA+ cells, a hallmark of EndMT. Univariable and multivariable association with echocardiography measures revealed a positive correlation of MR severity with both cellular and geometric changes (e.g., aVICs, EndMT, leaflet thickness, leaflet tenting). Finally, proteomic changes associated with EndMT showed gene-ontology enrichment in vesicle-, inflammatory- and oxidative stress-related processes. This discovery approach indicated new candidate proteins associated with EndMT regulation in IMR. Conclusion: We describe an atypical cellular composition and distinctive proteome of human MVs from patients with IMR, which highlighted new candidate proteins implicated in EndMT-related processes, associated with maladaptive MV fibrotic remodeling.
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Affiliation(s)
- Adrien Lupieri
- Division of Cardiovascular Medicine, Center for Excellence in Vascular Biology and Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory and Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Livia S A Passos
- Division of Cardiovascular Medicine, Center for Excellence in Vascular Biology and Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Dakota Beker-Greene
- Division of Cardiovascular Medicine, Center for Excellence in Vascular Biology and Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Katherine A Kirkwood
- Department of Population Health Science and Policy, Icahn School of Medicine, International Center for Health Outcomes and Innovation Research, New York, NY, United States
| | - Jill Wylie-Sears
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Department of Surgery and Harvard Medical School, Boston, MA, United States
| | - Zahra Alvandi
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Department of Surgery and Harvard Medical School, Boston, MA, United States
| | - Hideyuki Higashi
- Division of Cardiovascular Medicine, Center for Interdisciplinary Cardiovascular Sciences and Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Judy W Hung
- Echocardiography Laboratory, Division of Cardiology and Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Sasha A Singh
- Division of Cardiovascular Medicine, Center for Interdisciplinary Cardiovascular Sciences and Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Joyce Bischoff
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Department of Surgery and Harvard Medical School, Boston, MA, United States
| | - Robert A Levine
- Cardiac Ultrasound Laboratory and Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Elena Aikawa
- Division of Cardiovascular Medicine, Center for Excellence in Vascular Biology and Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Division of Cardiovascular Medicine, Center for Interdisciplinary Cardiovascular Sciences and Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Department of Human Pathology, Sechenov First Moscow State Medical University, Moscow, Russia
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Levine RA, Ganeles J, Wang P, Makrauer ZA, Araujo MG, Dias DR, Kan JY, Gonzaga L, Evans CDJ, Chen ST. Application of the 10 Keys for Replacement of Multiple Teeth in the Esthetic Zone. Compend Contin Educ Dent 2021; 42:F1-F11. [PMID: 34077670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Ten keys for successful esthetic-zone single immediate implants encapsulate in an evidence-based manner the treatment planning and replacement of single hopeless teeth in the maxillary anterior sextant. These include two treatment-planning, five surgical, and three prosthetic keys, which, collectively, aim to minimize soft- and hard-tissue complications for an optimal esthetic implant restoration. The Straightforward, Advanced, and Complex (SAC) classification is designed to aid clinicians in the treatment planning of dental implant cases. As per this classification, cases are stratified by the degree of surgical and restorative risk and complexity for both the surgical and prosthetic phases of treatment. A technique-sensitive and skill-demanding task, the replacement of multiple adjacent teeth in the esthetic zone poses significant challenges for clinicians and is considered a complex SAC procedure surgically and restoratively. This article presents a case report on the replacement of multiple adjacent teeth in the esthetic zone, demonstrating the use of 10 key principles to achieve an optimal esthetic outcome.
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Affiliation(s)
- Robert A Levine
- Clinical Professor, Periodontology and Implantology, Kornberg School of Dentistry, Temple University, Philadelphia, Pennsylvania; Diplomate, American Board of Periodontology; Fellow, International Team for Implantology; Private Practice in Dental Implants and Periodontics, Philadelphia, Pennsylvania
| | - Jeffrey Ganeles
- Adjunct Associate Professor, Nova Southeastern University College of Dental Medicine, Ft. Lauderdale, Florida; Diplomate, American Board of Periodontology; Fellow, International Team for Implantology; Private Practice in Periodontics and Implant Dentistry, Boca Raton, Florida
| | - Ping Wang
- Clinical Assistant Professor, Restorative Dentistry, Kornberg School of Dentistry, Temple University, Philadelphia, Pennsylvania; Fellow, International Team for Implantology
| | - Zola A Makrauer
- Adjunct Clinical Faculty, Restorative Dentistry, Kornberg School of Dentistry, Temple University, Philadelphia, Pennsylvania; Fellow, International Team for Implantology; Private Practice in Advanced Restorative Dentistry, Huntingdon Valley, Pennsylvania
| | - Mauricio G Araujo
- Head of Periodontics and Implant Dentistry Research Group, Department of Dentistry, State University of Maringa, Brazil; Fellow, International Team for Implantology; Private Practice in Dental Implants and Periodontics, Rio de Janeiro, Brazil
| | | | - Joseph Y Kan
- Professor, Loma Linda University School of Dentistry, Loma Linda, California; Private Practice in Prosthodontics and Implant Dentistry, Covina, California
| | - Luiz Gonzaga
- Clinical Assistant Professor, Center for Implant Dentistry, University of Florida, Gainesville, Florida; Fellow, International Team for Implantology
| | - Christopher D J Evans
- Fellow, International Team for Implantology; Private Practice in Prosthodontics and Implant Dentistry, Brighton, Australia
| | - Stephen T Chen
- Clinical Associate Professor, University of Melbourne, Melbourne, Australia; Fellow, International Team for Implantology, Private Practice in Dental Implants and Periodontics, Melbourne, Australia
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Bartko PE, Hülsmann M, Hung J, Pavo N, Levine RA, Pibarot P, Vahanian A, Stone GW, Goliasch G. Secondary valve regurgitation in patients with heart failure with preserved ejection fraction, heart failure with mid-range ejection fraction, and heart failure with reduced ejection fraction. Eur Heart J 2021; 41:2799-2810. [PMID: 32350503 DOI: 10.1093/eurheartj/ehaa129] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [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] [Received: 10/20/2019] [Revised: 01/12/2020] [Accepted: 02/12/2020] [Indexed: 12/27/2022] Open
Abstract
Secondary mitral regurgitation and secondary tricuspid regurgitation due to heart failure (HF) remain challenging in almost every aspect: increasing prevalence, poor prognosis, notoriously elusive in diagnosis, and complexity of therapeutic management. Recently, defined HF subgroups according to three ejection fraction (EF) ranges (reduced, mid-range, and preserved) have stimulated a structured understanding of the HF syndrome but the role of secondary valve regurgitation (SVR) across the spectrum of EF remains undefined. This review expands this structured understanding by consolidating the underlying phenotype of myocardial impairment with each type of SVR. Specifically, the current understanding, epidemiological considerations, impact, public health burden, mechanisms, and treatment options of SVR are discussed separately for each lesion across the HF spectrum. Furthermore, this review identifies important gaps in knowledge, future directions for research, and provides potential solutions for diagnosis and treatment. Mastering the challenge of SVR requires a multidisciplinary collaborative effort, both, in clinical practice and scientific approach to optimize patient outcomes.
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Affiliation(s)
- Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Philippe Pibarot
- Laval Hospital, Research Center Québec Heart Institute, Pavillon Ferdinand-Vandry 1050, avenue de la Médecine Local 4211, Laval University, Quebec City, Québec, Canada
| | - Alec Vahanian
- University of Paris, 5 Rue Thomas Mann, 75013 Paris, France
| | - Gregg W Stone
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Bertrand PB, Churchill TW, Yucel E, Namasivayam M, Bernard S, Nagata Y, He W, Andrews CT, Picard MH, Weyman AE, Levine RA, Hung J. Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunction. Eur Heart J 2021; 41:4321-4328. [PMID: 33221855 DOI: 10.1093/eurheartj/ehaa819] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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] [Received: 04/21/2020] [Revised: 06/21/2020] [Accepted: 09/22/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS The aim of this study was to define the natural history of patients with mitral annular calcification (MAC)-related mitral valve dysfunction and to assess the prognostic importance of mean transmitral pressure gradient (MG) and impact of concomitant mitral regurgitation (MR). METHODS AND RESULTS The institutional echocardiography database was examined from 2001 to 2019 for all patients with MAC and MG ≥3 mmHg. A total of 5754 patients were stratified by MG in low (3-5 mmHg, n = 3927), mid (5-10 mmHg, n = 1476), and high (≥10 mmHg, n = 351) gradient. The mean age was 78 ± 11 years, and 67% were female. MR was none/trace in 32%, mild in 42%, moderate in 23%, and severe in 3%. Primary outcome was all-cause mortality, and outcome models were adjusted for age, sex, and MAC-related risk factors (hypertension, diabetes, coronary artery disease, chronic kidney disease). Survival at 1, 5, and 10 years was 77%, 42%, and 18% in the low-gradient group; 73%, 38%, and 17% in the mid-gradient group; and 67%, 25%, and 11% in the high-gradient group, respectively (log-rank P < 0.001 between groups). MG was independently associated with mortality (adjusted HR 1.064 per 1 mmHg increase, 95% CI 1.049-1.080). MR severity was associated with mortality at low gradients (P < 0.001) but not at higher gradients (P = 0.166 and 0.372 in the mid- and high-gradient groups, respectively). CONCLUSION In MAC-related mitral valve dysfunction, mean transmitral gradient is associated with increased mortality after adjustment for age, sex, and MAC-related risk factors. Concomitant MR is associated with excess mortality in low-gradient ranges (3-5 mmHg) but gradually loses prognostic importance at higher gradients, indicating prognostic utility of transmitral gradient in MAC regardless of MR severity.
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Affiliation(s)
- Philippe B Bertrand
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Timothy W Churchill
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Evin Yucel
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Mayooran Namasivayam
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Samuel Bernard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Yasufumi Nagata
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Wei He
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Carl T Andrews
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Michael H Picard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Arthur E Weyman
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Judy Hung
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Levine RA, Katwal D, Lai PC, Bruce J, Scarfe WC, Bornstein MM. Early Loading of Posterior Nonsubmerged Titanium Implants with a Modified Sandblasted and Acid-Etched Surface: A Prospective Case Series with Up to 149 Months of Follow-up. INT J PERIODONT REST 2021; 41:51-59. [PMID: 33528451 DOI: 10.11607/prd.4703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The purpose of this prospective study was to evaluate the success rates and prosthetic complications of implants with a modified sandblasted and acid-etched (SLA) surface inserted for posterior single-implant crown restorations. Final crowns were placed 3 to 4 weeks after surgery, and patient follow-up spanned 10 years in a private practice setting. A total of 22 patients (8 women, 14 men) with 25 posterior implants placed (16 mandible, 9 maxilla) were selected, including only implants for posterior single-implant crowns with insertion torque values of ≥ 35 Ncm at placement. Twenty-one implants passed the reverse torque test at 3 to 4 weeks after implant placement, and final restorations were placed. Three patients (4 implants) had "spinners," and there was one patient dropout after completion of the final restoration. All patients were recalled for clinical exams, digital periapical radiographs, and clinical photos at short-term (≤ 5 years) and long-term (> 5 years) follow-up appointments. The Community Periodontal Index of Treatment Needs was also determined at the initial and follow-up visits. Crestal bone level was measured at crown placement (T1), short-term follow-up (T2; mean: 29.4 months), and long-term follow-up appointments (T3; mean: 114.4 months). Twenty patients (23 implants) returned for examination at T2, and 15 (18 implants) were available at T3. For the 17 implants available at all evaluations, statistically significant bone loss was found from T1 to T2 (0.23 ± 0.30 mm), and the mean crestal bone level appeared stable from T2 to T3. Based on clinical and radiographic findings, the success rate for the implants and restorations at T2 and T3 was graded as 100%. Therefore, it can be stated that an early loading protocol of 3 to 4 weeks using a modified SLA surface at premolar/molar single-tooth locations can result in favorable clinical and radiographic long-term results.
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Bertrand PB, Overbey JR, Zeng X, Levine RA, Ailawadi G, Acker MA, Smith PK, Thourani VH, Bagiella E, Miller MA, Gupta L, Mack MJ, Gillinov AM, Giustino G, Moskowitz AJ, Gelijns AC, Bowdish ME, O'Gara PT, Gammie JS, Hung J. Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation. J Am Coll Cardiol 2021; 77:713-724. [PMID: 33573741 DOI: 10.1016/j.jacc.2020.11.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 07/13/2020] [Revised: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain. OBJECTIVES The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery. METHODS Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years. RESULTS Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04). CONCLUSIONS After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).
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Affiliation(s)
- Philippe B Bertrand
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica R Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Xin Zeng
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gorav Ailawadi
- Section of Adult Cardiac Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Peter K Smith
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Vinod H Thourani
- Cardiothoracic Surgery, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marissa A Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lopa Gupta
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael J Mack
- Cardiothoracic Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, Texas, USA
| | - A Marc Gillinov
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gennaro Giustino
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Michael E Bowdish
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Namasivayam M, He W, Churchill TW, Capoulade R, Liu S, Lee H, Danik JS, Picard MH, Pibarot P, Levine RA, Hung J. Transvalvular Flow Rate Determines Prognostic Value of Aortic Valve Area in Aortic Stenosis. J Am Coll Cardiol 2020; 75:1758-1769. [PMID: 32299587 DOI: 10.1016/j.jacc.2020.02.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [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] [Received: 12/19/2019] [Revised: 02/01/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic valve area (AVA) ≤1.0 cm2 is a defining characteristic of severe aortic stenosis (AS). AVA can be underestimated at low transvalvular flow rate. Yet, the impact of flow rate on prognostic value of AVA ≤1.0 cm2 is unknown and is not incorporated into AS assessment. OBJECTIVES This study aimed to evaluate the effect of flow rate on prognostic value of AVA in AS. METHODS In total, 1,131 patients with moderate or severe AS and complete clinical follow-up were included as part of a longitudinal database. The effect of flow rate (ratio of stroke volume to ejection time) on prognostic value of AVA ≤1.0 cm2 for time to death was evaluated, adjusting for confounders. Sensitivity analysis was performed to identify the optimal cutoff for prognostic threshold of AVA. The findings were validated in a separate external longitudinal cohort of 939 patients. RESULTS Flow rate had a significant effect on prognostic value of AVA. AVA ≤1.0 cm2 was not prognostic for mortality (p = 0.15) if AVA was measured at flow rates below median (≤242 ml/s). In contrast, AVA ≤1.0 cm2 was highly prognostic for mortality (p = 0.003) if AVA was measured at flow rates above median (>242 ml/s). Findings were irrespective of multivariable adjustment for age, sex, and surgical/transcatheter aortic valve replacement (as time-dependent covariates); comorbidities; medications; and echocardiographic features. AVA ≤1.0 cm2 was also not an independent predictor of mortality below median flow rate in the validation cohort. The optimal flow rate cutoff for prognostic threshold was 210 ml/s. CONCLUSIONS Transvalvular flow rate determines prognostic value of AVA in AS. AVA measured at low flow rate is not a good prognostic marker and therefore not a good diagnostic marker for truly severe AS. Flow rate assessment should be incorporated into clinical diagnosis, classification, and prognosis of AS.
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Affiliation(s)
- Mayooran Namasivayam
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/MayoNamasivayam
| | - Wei He
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy W Churchill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Romain Capoulade
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000, Nantes, France; Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Shiying Liu
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hang Lee
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline S Danik
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Dal-Bianco JP, Levine RA, Hung J. Mitral Regurgitation Postinfarction: The Mitral Valve Adapts to the Times. Circ Cardiovasc Imaging 2020; 13:e012130. [PMID: 33317331 DOI: 10.1161/circimaging.120.012130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jacob P Dal-Bianco
- Massachusetts General Hospital, Division of Cardiology, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA (J.P.D-B., R.A.L., J.H.)
| | - Robert A Levine
- Massachusetts General Hospital, Division of Cardiology, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA (J.P.D-B., R.A.L., J.H.)
| | - Judy Hung
- Massachusetts General Hospital, Division of Cardiology, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA (J.P.D-B., R.A.L., J.H.)
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50
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Hei S, Iwataki M, Jang JY, Kuwaki H, Fukuda S, Kim YJ, Toki M, Onoue T, Hayashi A, Nishino S, Watanabe N, Hayashida A, Tsuda Y, Araki M, Nishimura Y, Song JK, Yoshida K, Levine RA, Otsuji Y. Relations of Augmented Systolic Annular Expansion and Leaflet/Papillary Muscle Dynamics in Late-Systolic Mitral Valve Prolapse Evaluated by Echocardiography with a Speckle Tracking Analysis. Int Heart J 2020; 61:970-978. [PMID: 32999196 DOI: 10.1536/ihj.20-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/18/2022]
Abstract
The mechanism of systolic annular expansion in mitral valve prolapse (MVP) is not clarified. Since annular expansion is systolic outward shift of MV leaflet/chorda tissue complex at superior and outer ends, annular expansion could be related to inward (superior) shift of the complex at another inferior and inner end of the papillary muscle (PM) tip and/or systolic lengthening of the tissue complex, especially MV leaflets.MV annulus systolic expansion, PMs' systolic superior shift, and MV leaflets' systolic lengthening were evaluated by echocardiography with a speckle tracking analysis in 25 normal subjects, 25 subjects with holo-systolic MVP and 20 subjects with late-systolic MVP.PMs' superior shift, MV leaflets' lengthening, MV annular area at the onset of systole and subsequent MV annulus expansion were significantly greater in late-systolic MVP than in holo-systolic MVP (4.6 ± 1.6 versus 1.5 ± 0.7 mm/m2, 2.5 ± 1.4 versus 0.6 ± 2.0 mm/m2, 6.8 ± 2.5 versus 5.7 ± 1.0 cm2/m2 and 1.6 ± 0.8 versus 0.1 ± 0.5 cm2/m2, P < 0.001, respectively). Multivariate analysis identified MV leaflets' lengthening and PMs' superior shift as independent factors associated with MV annular expansion.Conclusions: These results suggest that systolic MV annular expansion in MVP is related to abnormal MV leaflets' lengthening and PMs' superior shift.
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Affiliation(s)
- Soshi Hei
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Mai Iwataki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Jeong-Yoon Jang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Hiroshi Kuwaki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Shota Fukuda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Yun-Jeong Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Misako Toki
- Department of Clinical Laboratory, The Sakakibara Heart Institute of Okayama
| | - Takeshi Onoue
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Atsushi Hayashi
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Shun Nishino
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | | | - Yuki Tsuda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Masaru Araki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
| | - Yosuke Nishimura
- Department of Cardiovascular Surgery, University of Occupational and Environmental Health, School of Medicine
| | - Jae-Kwan Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, The Sakakibara Heart Institute of Okayama
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
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