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Schmid Daners M, Hall S, Sündermann S, Cesarovic N, Kron M, Falk V, Starck C, Meboldt M, Dual SA. Real-Time Ventricular Volume Measured Using the Intracardiac Electromyogram. ASAIO J 2021; 67:1312-1320. [PMID: 33899813 PMCID: PMC8614557 DOI: 10.1097/mat.0000000000001444] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Left ventricular end-diastolic volume (EDV) is an important parameter for monitoring patients with left ventricular assist devices (LVADs) and might be useful for automatic LVAD work adaptation. However, continuous information on the EDV is unavailable to date. The depolarization amplitude (DA) of the noncontact intracardiac electromyogram (iEMG) is physically related to the EDV. Here, we show how a left ventricular (LV) volume sensor based on the iEMG might provide beat-wise EDV estimates. The study was performed in six pigs while undergoing a series of controlled changes in hemodynamic states. The LV volume sensor consisted of four conventional pacemaker electrodes measuring the far-field iEMG inside the LV blood pool, using a novel unipolar amplifier. Simultaneously, noninvasive measurements of EDV and hematocrit were recorded. The proposed EDV predictor was tested for statistical significance using a mixed-effect model and associated confidence intervals. A statistically significant (p = 3e-07) negative correlation was confirmed between the DA of the iEMG and the EDV as measured by electric impedance at a slope of -0.069 (-0.089, -0.049) mV/mL. The DA was slightly decreased by increased hematocrit (p = 0.039) and moderately decreased with the opening of the thorax (p = 0.003). The DA of the iEMG proved to be a significant, independent predictor of EDV. The proposed LV volume sensor is simple to integrate into the inflow cannula of an LVAD and thus has the potential to inform the clinician about the state of LV volume in real time and to automatically control the LVAD.
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Affiliation(s)
| | - Sophie Hall
- From the Product Development Group Zurich, ETH Zurich, Zurich, Switzerland
| | - Simon Sündermann
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiovascular Surgery, Berlin, Germany
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Nikola Cesarovic
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Division for Surgical Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Mareike Kron
- Division for Surgical Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Volkmar Falk
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiovascular Surgery, Berlin, Germany
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Christoph Starck
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Steinbeis University Berlin, Institute (STI) of Cardiovascular Perfusion, Berlin, Germany
| | - Mirko Meboldt
- From the Product Development Group Zurich, ETH Zurich, Zurich, Switzerland
| | - Seraina A. Dual
- From the Product Development Group Zurich, ETH Zurich, Zurich, Switzerland
- Radiology, Stanford University, Stanford, California
- Cardiovascular Institute, Stanford University, Stanford, California
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Sartorio D, Borrello B, Tuttolomondo D, De Filippo M, Gaibazzi N. When 3D echocardiography truly makes the difference: a case report of mitral annular ring dehiscence. Acta Biomed 2021; 92:e2021469. [PMID: 34747393 PMCID: PMC10523029 DOI: 10.23750/abm.v92is1.12120] [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] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/10/2021] [Indexed: 11/23/2022]
Abstract
Real time 3D echocardiography has an established incremental diagnostic value over 2D imaging, especially during transesophageal evaluation of native and prosthetic heart valves. A 66 years old male patient, with an history of previous cardiac surgery for mitral annuloplasty and recurrent fever, came to the attention of our echo lab with an indication for transesophageal echocardiography after previous inconclusive transthoracic echocardiograms. Real time 3D echocardiography and 3D color doppler imaging resulted of outmost importance to clarify the presence of annular ring dehiscence, previously not well defined from 2D echocardiography imaging.
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Naguib KI, Attia MA, Bashandy MS, Reihan MS, Dabash TA, El-Salam ABA, Helal HH, Bahbah EI. The role of trans-thoracic echocardiography in the assessment of aortic annular diameter. Medicine (Baltimore) 2021; 100:e24682. [PMID: 33655932 PMCID: PMC7939191 DOI: 10.1097/md.0000000000024682] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/15/2021] [Indexed: 01/04/2023] Open
Abstract
We aimed to compare two-dimension transthoracic echocardiogram (2D-TTE) and three-dimension transthoracic echocardiogram (3D-TTE) measurements of the aortic annular diameter using multi-detector CT (MDCT) as a gold standard.This prospective observational study included 50 consecutive patients who came to the cardiology department, Al-Azhar University Hospital, New Damietta, for MDCT coronary angiography. The study was carried out in the period from July 2016 until February 2017. All patients were subjected to informed consent, clinical history, physical examination, transthoracic echocardiography 2D and 3D, and MDCT.The aortic annular areas measured by MDCT and 3D-TTE were significantly larger than areas by 2D-TTE. A good correlation (r = 0.82) was observed between the areas obtained by 3D-TTE and MDCT; however, the correlation between the values by 2D-TTE and MDCT was rough (r = 0.30). Eccentricity Index (EI) values in 28% of the patients were greater than 0.1, that is, the aortic annulus was elliptical.Accuracy of aortic annular diameter measurement by 3D-TTE was superior to that by 2D-TTE. Three-D TTE and MDCT revealed that the shape of the aortic annulus was elliptical in 28% to 30% respectively of study subjects. There is a strong concordance between the minimum and the maximum diameter determine by 3D-TTE and MDCT.
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Affiliation(s)
| | | | | | | | | | | | | | - Eshak I. Bahbah
- Faculty of Medicine, Al-Azhar University, Damietta
- Medical Research Group of Egypt,.Egypt
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Ahluwalia V, Osman F, Parmar J, Khan JN. 3D echocardiography allows rapid and accurate surgical planning in complex aortic root abscess cases. Echo Res Pract 2019; 6:ERP-19-0043.R1. [PMID: 31730045 PMCID: PMC6893311 DOI: 10.1530/erp-19-0043] [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: 07/26/2019] [Accepted: 10/23/2019] [Indexed: 11/18/2022] Open
Abstract
Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilized in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3DE-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.
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Affiliation(s)
- Viren Ahluwalia
- Department of Cardiology, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Faizel Osman
- Department of Cardiology, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Medical School, Warwick University, Coventry, UK
| | - Jitendra Parmar
- Department of Cardiology, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Jamal Nasir Khan
- Department of Cardiology, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
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Vasconcellos HD, Moreira HT, Ciuffo L, Nwabuo CC, Yared GS, Ambale-Venkatesh B, Armstrong AC, Kishi S, Reis JP, Liu K, Lloyd-Jones DM, Colangelo LA, Schreiner PJ, Sidney S, Gidding SS, Lima JAC. Cumulative blood pressure from early adulthood to middle age is associated with left atrial remodelling and subclinical dysfunction assessed by three-dimensional echocardiography: a prospective post hoc analysis from the coronary artery risk development in young adults study. Eur Heart J Cardiovasc Imaging 2018; 19:977-984. [PMID: 29982431 PMCID: PMC6102802 DOI: 10.1093/ehjci/jey086] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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: 04/05/2018] [Revised: 05/23/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022] Open
Abstract
Aims To evaluate the association of cumulative blood pressure (BP) from young adulthood to middle age with left atrial (LA) structure/function as assessed by three-dimensional echocardiography (3DE) in a large longitudinal bi-racial population study. Methods and results We conducted a prospective post hoc analysis of individuals enrolled at the Coronary Artery Risk Development in Young Adults, which is a multi-centre bi-racial cohort with 30 years of follow-up. Cumulative systolic and diastolic BP levels were defined by summing the product of average millimetres of mercury and the years between each two consecutive clinic visits over 30 years of follow-up. Multivariable linear regression analyses were used to assess the relationship between cumulative systolic and diastolic BP with 3DE LA structure and function, adjusting for demographics and traditional cardiovascular risk factors. A total of 1033 participants were included, mean age was 55.4 ± 3.5 years, 55.2% women, 43.9% blacks. Cumulative systolic BP had stronger correlations than cumulative diastolic BP. Higher cumulative systolic BP was independently associated with higher 3D LA volumes: maximum (β = 1.74, P = 0.004), pre-atrial contraction (β = 1.87, P < 0.001), minimum (β = 0.76, P = 0.04), total emptying (β = 0.98, P = 0.006), active emptying (β = 1.12, P < 0.001), and lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.02). Higher cumulative diastolic BP was independently associated with higher 3D LA active emptying volume (β = 0.66, P = 0.002), lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.004), and higher magnitude 3D LA late diastolic strain rate (β = -0.04, P = 0.05). Conclusion Higher cumulative BP from early adulthood throughout middle age was associated with adverse LA remodelling evaluated by 3D echocardiography.
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Affiliation(s)
- Henrique D Vasconcellos
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
- Department of Medicine, Federal University of Sao Francisco Valley, Av. Jose de Sa Manicoba, S/N, Centro, Petrolina, PE, Brazil
| | - Henrique T Moreira
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
- Division of Cardiology, Universidade of Sao Paulo, Ribeirao Preto, Av. Bandeirantes, 3.900 Monte Alegre, Ribeirão Preto, SP, Brazil
| | - Luisa Ciuffo
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
| | - Chike C Nwabuo
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
| | - Guilherme S Yared
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
| | - Bharath Ambale-Venkatesh
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
| | - Anderson C Armstrong
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
| | - Satoru Kishi
- Division of Diabetes, Memorial Hospital, 1 Izumicho Kanda, Chiyoda, Tokyo, Japan
| | - Jared P Reis
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, 31 Center Drive, Bethesda, MD, USA
| | - Kiang Liu
- Department of Preventive Medicine, Northwestern University, 675 N St Clair St STE 19-100, Chicago, IL, USA
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University, 675 N St Clair St STE 19-100, Chicago, IL, USA
| | - Laura A Colangelo
- Department of Preventive Medicine, Northwestern University, 675 N St Clair St STE 19-100, Chicago, IL, USA
| | - Pamela J Schreiner
- Division of Epidemiology and Community Health, University of Minnesota, 1300 S 2nd St, Minneapolis, MN, USA
| | - Stephen Sidney
- Division of Research, Department of Pediatrics, Kaiser Permanente Center, 3600 Broadway, Oakland, CA, USA
| | - Samuel S Gidding
- Division of Pediatrics Cardiology, Nemours Cardiac Center, 1600 Rockland Road Wilmington, DE, USA
| | - Joao A C Lima
- Division of Cardiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524, Baltimore, MD, USA
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Zhang Z, Zhu M, Ashraf M, Broberg CS, Sahn DJ, Song X. Right ventricular strain analysis from three-dimensional echocardiography by using temporally diffeomorphic motion estimation. Med Phys 2014; 41:122902. [PMID: 25471981 PMCID: PMC4241709 DOI: 10.1118/1.4901253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 10/02/2014] [Accepted: 10/15/2014] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Quantitative analysis of right ventricle (RV) motion is important for study of the mechanism of congenital and acquired diseases. Unlike left ventricle (LV), motion estimation of RV is more difficult because of its complex shape and thin myocardium. Although attempts of finite element models on MR images and speckle tracking on echocardiography have shown promising results on RV strain analysis, these methods can be improved since the temporal smoothness of the motion is not considered. METHODS The authors have proposed a temporally diffeomorphic motion estimation method in which a spatiotemporal transformation is estimated by optimization of a registration energy functional of the velocity field in their earlier work. The proposed motion estimation method is a fully automatic process for general image sequences. The authors apply the method by combining with a semiautomatic myocardium segmentation method to the RV strain analysis of three-dimensional (3D) echocardiographic sequences of five open-chest pigs under different steady states. RESULTS The authors compare the peak two-point strains derived by their method with those estimated from the sonomicrometry, the results show that they have high correlation. The motion of the right ventricular free wall is studied by using segmental strains. The baseline sequence results show that the segmental strains in their methods are consistent with results obtained by other image modalities such as MRI. The image sequences of pacing steady states show that segments with the largest strain variation coincide with the pacing sites. CONCLUSIONS The high correlation of the peak two-point strains of their method and sonomicrometry under different steady states demonstrates that their RV motion estimation has high accuracy. The closeness of the segmental strain of their method to those from MRI shows the feasibility of their method in the study of RV function by using 3D echocardiography. The strain analysis of the pacing steady states shows the potential utility of their method in study on RV diseases.
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Affiliation(s)
- Zhijun Zhang
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon 97239
| | - Meihua Zhu
- Department of Pediatric Cardiology, Oregon Health and Science University, Portland, Oregon 97239
| | - Muhammad Ashraf
- Department of Pediatric Cardiology, Oregon Health and Science University, Portland, Oregon 97239
| | - Craig S Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon 97239
| | - David J Sahn
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon 97239 and Department of Pediatric Cardiology, Oregon Health and Science University, Portland, Oregon 97239
| | - Xubo Song
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon 97239
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Burlina P, Sprouse C, Mukherjee R, DeMenthon D, Abraham T. Patient-specific mitral valve closure prediction using 3D echocardiography. Ultrasound Med Biol 2013; 39:769-783. [PMID: 23497987 PMCID: PMC3760036 DOI: 10.1016/j.ultrasmedbio.2012.11.009] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 11/08/2012] [Accepted: 11/12/2012] [Indexed: 06/01/2023]
Abstract
This article presents an approach to modeling the closure of the mitral valve using patient-specific anatomical information derived from 3D transesophageal echocardiography (TEE). Our approach uses physics-based modeling to solve for the stationary configuration of the closed valve structure from the patient-specific open valve structure, which is recovered using a user-in-the-loop, thin-tissue detector segmentation. The method uses a tensile shape-finding approach based on energy minimization. This method is employed to predict the aptitude of the mitral valve leaflets to coapt. We tested the method using 10 intraoperative 3D TEE sequences by comparing the closed valve configuration predicted from the segmented open valve with the segmented closed valve, taken as ground truth. Experiments show promising results, with prediction errors on par with 3D TEE resolution and with good potential for applications in pre-operative planning.
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Affiliation(s)
- Philippe Burlina
- The Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA.
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Pouch AM, Wang H, Takabe M, Jackson BM, Sehgal CM, Gorman JH, Gorman RC, Yushkevich PA. Automated segmentation and geometrical modeling of the tricuspid aortic valve in 3D echocardiographic images. Med Image Comput Comput Assist Interv 2013; 16:485-92. [PMID: 24505702 PMCID: PMC3918680 DOI: 10.1007/978-3-642-40811-3_61] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aortic valve has been described with variable anatomical definitions, and the consistency of 2D manual measurement of valve dimensions in medical image data has been questionable. Given the importance of image-based morphological assessment in the diagnosis and surgical treatment of aortic valve disease, there is considerable need to develop a standardized framework for 3D valve segmentation and shape representation. Towards this goal, this work integrates template-based medial modeling and multi-atlas label fusion techniques to automatically delineate and quantitatively describe aortic leaflet geometry in 3D echocardiographic (3DE) images, a challenging task that has been explored only to a limited extent. The method makes use of expert knowledge of aortic leaflet image appearance, generates segmentations with consistent topology, and establishes a shape-based coordinate system on the aortic leaflets that enables standardized automated measurements. In this study, the algorithm is evaluated on 11 3DE images of normal human aortic leaflets acquired at mid systole. The clinical relevance of the method is its ability to capture leaflet geometry in 3DE image data with minimal user interaction while producing consistent measurements of 3D aortic leaflet geometry.
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Affiliation(s)
- Alison M. Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Hongzhi Wang
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Manabu Takabe
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M. Jackson
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Chandra M. Sehgal
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A. Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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Solis J, McCarty D, Levine RA, Handschumacher MD, Fernandez-Friera L, Chen-Tournoux A, Mont L, Vidal B, Singh JP, Brugada J, Picard MH, Sitges M, Hung J. Mechanism of decrease in mitral regurgitation after cardiac resynchronization therapy: optimization of the force-balance relationship. Circ Cardiovasc Imaging 2009; 2:444-50. [PMID: 19920042 PMCID: PMC2821680 DOI: 10.1161/circimaging.108.823732] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been shown to reduce functional mitral regurgitation (MR). It has been proposed that the mechanism of MR reduction relates to geometric change or, alternatively, changes in left ventricular (LV) contractile function. Normal mitral valve (MV) function relies on a balance between tethering and closing forces on the MV leaflets. Functional MR results from a derangement of this force-balance relationship, and CRT may be an important modulator of MV function by its ability to enhance the force-balance relationship on the MV. We hypothesized that CRT improves the comprehensive force balance acting on the valve, including favorable changes in both geometry and LV contractile function. METHODS AND RESULTS We examined the effect of CRT on 34 patients with functional MR before and after CRT (209+/-81 days). MR regurgitant volume, closing forces on MV (derived from Doppler transmitral pressure gradients), including dP/dt and a factor (closing pressure ratio) expressing how long the peak closing gradient is maintained over systole (closing pressure ratio=velocity time integral/MR peak velocityxmitral regurgitation time), and dyssynchrony by tissue Doppler were measured. End-diastolic volume, end-systolic volume, mitral valve annular area (MAA) and contraction (percent change in MAA from end-diastole to midsystole), leaflet closing area (leaflet area during valve closure), and tenting volume (volume under leaflets to annular plane) were measured by 3D echocardiography. After CRT, end-diastolic volume (253+/-111 versus 221+/-110 mL, P<0.001) and end-systolic volume (206+/-97 versus 167+/-91 mL, P<0.001) decreased and ejection fraction (19+/-6 versus 27+/-9%, P<0.001) increased. MR regurgitant volume decreased from 35+/-17 to 23+/-14 mL (P<0.001), MAA from 11.6+/-3.5 to 10.5+/-3.1 cm(2) (P<0.001), leaflet closing area from 15.4+/-5 to 13.7+/-3.8 cm(2) (P<0.001), and tenting volume from 5.7+/-2.6 to 4.6+/-2.2 mL (P<0.001). Peak velocity (and therefore transmitral closing pressure) was more sustained throughout systole, as reflected by the increase in the closing pressure ratio (0.77+/-0.1 versus 0.84+/-0.1 before CRT versus after CRT, P=0.01); dP/dt also improved after CRT. There was no change in dyssynchrony or MAA contraction. CONCLUSIONS Reduction in MR after CRT is associated with favorable changes in MV geometry and closing forces on the MV. It does so by favorably affecting the force balance acting on the MV in 2 ways: reducing tethering through reversal of LV remodeling and increasing the systolic duration of peak transmitral closing pressures.
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Affiliation(s)
- Jorge Solis
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
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