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Izumi Y, Kagiyama N, Maekawara S, Terada M, Higuchi R, Saji M, Takamisawa I, Nanasato M, Isobe M. Transcatheter edge-to-edge mitral valve repair with extended clip arms for ventricular functional mitral regurgitation. J Cardiol 2023; 82:240-247. [PMID: 37116648 DOI: 10.1016/j.jjcc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND The new sizing options of the MitraClip system (Abbott Vascular, Abbott Park, IL, USA) with extended clip arms were recently developed. Its applicability and effectiveness for ventricular functional mitral regurgitation (VFMR) are yet to be investigated. METHODS We retrospectively reviewed consecutive patients with symptomatic VFMR who underwent transcatheter edge-to-edge repair between 2018 and 2022 at the Sakakibara Heart Institute. Pre- and post-procedural mitral valve morphologies were assessed using three-dimensional transesophageal echocardiography. RESULTS In a total of 104 VFMR patients, the posterior mitral leaflet length was 12.8 ± 2.8 mm and 92 % was indicative of the extended arm (≥9 mm). Although baseline VFMR was more severe in the patients treated with the extended arms (n = 35, XT group) than the patients treated with the standard arms (n = 69, NT group), the decrease in VFMR was greater in the XT group (delta three-dimensional vena contracta area - 43 ± 33 mm2 vs. -31 ± 22 mm2, p = 0.030) and residual VFMR was similar between the groups, with a significantly greater reduction in the mitral annulus anterior-posterior diameter (-4.9 ± 2.2 mm vs -3.1 ± 2.1 mm, p < 0.001) and mitral annulus area in the XT group. The use of extended arms was independently associated with shorter procedure time (81 ± 26 min vs 108 ± 41 min) after adjustment for device generation and the number of clips (p = 0.017). CONCLUSIONS Most VFMR patients had enough leaflet lengths for transcatheter edge-to-edge repair using the MitraClip with the extended arms, which was associated with shorter procedure time and a greater decrease in the mitral annular size.
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Affiliation(s)
- Yuki Izumi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Nobuyuki Kagiyama
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | | | - Mai Terada
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Ryosuke Higuchi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Itaru Takamisawa
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Mitsuaki Isobe
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
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2
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Shuvy M, Maisano F, Strauss BH. Transcatheter Mitral Edge-to-Edge Repair for Treatment of Acute Mitral Regurgitation. Can J Cardiol 2023; 39:1382-1389. [PMID: 37209883 DOI: 10.1016/j.cjca.2023.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/18/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023] Open
Abstract
Acute mitral regurgitation (AMR) is a medical emergency which may lead to rapid clinical deterioration and is associated with high morbidity and mortality. The severity of the clinical presentation varies according to several factors, ranging from cardiogenic shock to a milder presentation. The medical management of AMR includes intravenous diuretics, vasodilators, inotropic support, and potentially mechanical support to stabilise patients. Patients persisting with refractory symptoms despite optimal medical therapy are considered for surgical intervention, but high-risk patients deemed to be inoperable frequently experience poor outcomes. This review highlights the variety of clinical presentations of AMR and the pitfalls in diagnosis and management. The emerging role of transcatheter edge-to-edge repair (TEER), particularly in high-risk patients early after myocardial infarction requiring urgent intervention, has demonstrated feasibility and promising efficacy. TEER is well tolerated and improves hemodynamic parameters in AMR. In a recent analysis, the in-hospital and 1-year mortality rates were significantly higher with surgical mitral interventions compared with TEER. The global TEER experience for treating AMR is encouraging, with reports indicating improved clinical outcomes in high-risk patients and its potential as a bridge to recovery. Early recognition of AMR, validated criteria for patient selection, optimal timing of the intervention as well as long-term outcomes and additional prospective data should be addressed in future studies.
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Affiliation(s)
- Mony Shuvy
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, Jerusalem, Israel.
| | | | - Bradley H Strauss
- Reichmann Chair in Cardiovascular Research, Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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3
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Sharma H, Radhakrishnan A, Nightingale P, Brown S, May J, O'Connor K, Shakeel I, Zia N, Doshi SN, Townend JN, Myerson SG, Kirchhof P, Ludman PF, Adnan Nadir M, Steeds RP. Mitral Regurgitation Following Acute Myocardial Infarction Treated by Percutaneous Coronary Intervention-Prevalence, Risk factors, and Predictors of Outcome. Am J Cardiol 2021; 157:22-32. [PMID: 34417016 DOI: 10.1016/j.amjcard.2021.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 12/13/2022]
Abstract
Mitral regurgitation (MR) following acute myocardial infarction (AMI) worsens prognosis and reports of prevalence vary significantly. The objective was to determine prevalence, risk factors, and outcomes related to MR following AMI. We identified 1000 consecutive patients admitted with AMI in 2016/17 treated by percutaneous coronary intervention with pre-discharge transthoracic echocardiography. MR was observed in 294 of 1000 (29%), graded as mild (n = 224 [76%]), moderate (n = 61 [21%]) and severe (n = 9 [3%]). Compared with patients without MR, patients with MR were older (70 ± 12 vs 63 ± 13 years; p <0.001), with worse left ventricular ejection fraction (LVEF) (52 ± 15% vs 55 ± 11%; p <0.001) and creatinine clearance (69 ± 33 ml/min vs 90 ± 39 ml/min; p <0.001). They also had higher rates of hypertension (64% vs 55%; p = 0.012), heart failure (3.4% vs 1.1%; p = 0.014), previous MI (28% vs 20%; p = 0.005) and severe flow-limitation in the circumflex (50% vs 33%; p <0.001) or right coronary artery (51% vs 42%; p = 0.014). Prevalence and severity of MR were unaffected by AMI subtype. Revascularization later than 72 hours from symptom-onset was associated with increased likelihood of MR (33% vs 25%; p = 0.036) in patients with non-ST elevation myocardial infarction (NSTEMI). After a mean of 3.2 years, 56 of 288 (19%) patients with untreated MR died. Age and LVEF independently predicted mortality. The presence of even mild MR was associated with increased mortality (p = 0.029), despite accounting for confounders. In conclusion, MR is observed in over one-quarter of patients after AMI and associated with lower survival, even when mild. Prevalence and severity are independent of MI subtype, but MR was more common with delayed revascularization following NSTEMI.
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Dormer JD, Bhuiyan FI, Rahman N, Deaton N, Sheng J, Padala M, Desai JP, Fei B. Image Guided Mitral Valve Replacement: Registration of 3D Ultrasound and 2D X-ray Images. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2020; 11315:113150Z. [PMID: 32528217 PMCID: PMC7289184 DOI: 10.1117/12.2549407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Mitral valve repair or replacement is important in the treatment of mitral regurgitation. For valve replacement, a transcatheter approach had the possibility of decrease the invasiveness of the procedure while retaining the benefit of replacement over repair. However, fluoroscopy images acquired during the procedure provide no anatomical information regarding the placement of the probe tip once the catheter has entered a cardiac chamber. By using 3D ultrasound and registering the 3D ultrasound images to the fluoroscopy images, a physician can gain a greater understanding of the mitral valve region during transcatheter mitral valve replacement surgery. In this work, we present a graphical user interface which allows the registration of two co-planar X-ray images with 3D ultrasound during mitral valve replacement surgery.
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Affiliation(s)
- James D. Dormer
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX
| | - Fiaz Islam Bhuiyan
- Department of Electrical and Computer Engineering, University of Texas at Dallas, Richardson, TX
| | - Nahian Rahman
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Nancy Deaton
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Jun Sheng
- Department of Mechanical Engineering, University of California Riverside, Riverside, CA
| | - Muralidhar Padala
- Division of Cardiothoracic Surgery, Carlyle Fraser Heart Center, Emory University, Atlanta, GA
| | - Jaydev P. Desai
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Baowei Fei
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX
- Department of Radiology and Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX
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5
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Vidal-Perez R, Franco-Gutiérrez R, Pérez-Pérez AJ, Franco-Gutiérrez V, Gascón-Vázquez A, López-López A, Testa-Fernández AM, González-Juanatey C. Subclinical carotid atherosclerosis predicts all-cause mortality and cardiovascular events in obese patients with negative exercise echocardiography. World J Cardiol 2019; 11:24-37. [PMID: 30705740 PMCID: PMC6354075 DOI: 10.4330/wjc.v11.i1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/16/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obesity is a major health problem due to its high prevalence. The relationship between obesity and cardiovascular disease is unclear. Some studies agree that certain conditions associated with obesity, such as physical inactivity or cardiovascular risk factors, are responsible for cardiovascular risk excess among obese people. Carotid intima-media thickness and carotid plaques (CP) have been associated with cardiovascular adverse events in healthy populations, and recent data suggest a higher prevalence of subclinical carotid atherosclerosis in obese and metabolically unhealthy patients. However, there are no studies correlating subclinical atherosclerosis and adverse events (AE) in obese subjects. AIM To determine the association between carotid disease and AE in obese patients with negative exercise echocardiography (EE). METHODS From January 1, 2006 to December 31, 2010, 2000 consecutive patients with a suspicion of coronary artery disease were submitted for EE and carotid ultrasonography. Exclusion criteria included previous vascular disease, left ventricular ejection fraction < 50%, positive EE, significant valvular heart disease and inferior to submaximal EE. An AE was defined as all-cause mortality, myocardial infarction and cerebrovascular accident. Subclinical atherosclerosis was defined as CP presence according to Manheim and the American Society of Echocardiography Consensus. RESULTS Of the 652 patients who fulfilled the inclusion criteria, 226 (34.7%) had body mass indexes ≥ 30 kg/m2, and 76 of them (33.6%) had CP. During a mean follow-up time of 8.2 (2.1) years, 27 AE were found (11.9%). Mean event-free survival at 1, 5 and 10 years was 99.1% (0.6), 95.1% (1.4) and 86.5% (2.7), respectively. In univariate analysis, CP predicted AE [hazard ratio (HR) 2.52, 95% confidence interval (CI) 1.17-5.46; P = 0.019]. In multivariable analysis, the presence of CP remained a predictor of AE (HR 2.26, 95%CI 1.04-4.95, P = 0.041). Other predictors identified were glomerular filtration rate (HR 0.98, 95%CI 0.96-0.99; P = 0.023), peak metabolic equivalents (HR 0.83, 95%CI 0.70-0.99, P = 0.034) and moderate mitral regurgitation (HR 5.02, 95%CI 1.42-17.75, P = 0.012). CONCLUSION Subclinical atherosclerosis defined by CP predicts AE in obese patients with negative EE. These patients could benefit from aggressive prevention measures.
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Affiliation(s)
- Rafael Vidal-Perez
- Department of Cardiology, Hospital Universitario Lucus Augusti, Lugo 27003, Spain
| | | | | | | | | | - Andrea López-López
- Department of Cardiology, Hospital Universitario Lucus Augusti, Lugo 27003, Spain
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Ferket BS, Ailawadi G, Gelijns AC, Acker MA, Hohmann SF, Chang HL, Bouchard D, Meltzer DO, Michler RE, Moquete EG, Voisine P, Mullen JC, Lala A, Mack MJ, Gillinov AM, Thourani VH, Miller MA, Gammie JS, Parides MK, Bagiella E, Smith RL, Smith PK, Hung JW, Gupta LN, Rose EA, O’Gara PT, Moskowitz AJ, Taddei-Peters WC, Buxton D, Geller NL, Gordon D, Jeffries NO, Lee A, Moy CS, Gombos IK, Ralph J, Weisel RD, Gardner TJ, Ascheim DD, Moquete E, Chang H, Chase M, Foo J, Gupta L, Kirkwood K, Dobrev E, Levitan R, O’Sullivan K, Overbey J, Santos M, Williams D, Williams P, Ye X, Mack M, Adame T, Settele N, Adams J, Ryan W, Grayburn P, Chen FY, Nohria A, Cohn L, Shekar P, Aranki S, Couper G, Davidson M, Bolman RM, Lawrence R, Blackstone EH, Geither C, Berroteran L, Dolney D, Doud K, Fleming S, Palumbo R, Whitman C, Sankovic K, Sweeney DK, Pattakos G, Clarke PA, Argenziano M, Williams M, Goldsmith L, Smith CR, Naka Y, Stewart A, Schwartz A, Bell D, Van Patten D, Sreekanth S, Alexander JH, Milano CA, Glower DD, Mathew JP, Harrison JK, Welsh S, Berry MF, Parsa CJ, Tong BC, Williams JB, Ferguson TB, Kypson AP, Rodriguez E, Harris M, Akers B, O’Neal A, Puskas JD, Guyton R, Baer J, Baio K, Neill AA, Senechal M, Dagenais F, O’Connor K, Dussault G, Ballivian T, Keilani S, Speir AM, Magee P, Ad N, Keyte S, Dang M, Slaughter M, Headlee M, Moody H, Solankhi N, Birks E, Groh MA, Shell LE, Shepard SA, Trichon BH, Nanney T, Hampton LC, Mangusan R, D’Alessandro DA, DeRose JJ, Goldstein DJ, Bello R, Jakobleff W, Garcia M, Taub C, Spevak D, Swayze R, Sookraj N, Perrault LP, Basmadjian AJ, Bouchard D, Carrier M, Cartier R, Pellerin M, Tanguay JF, El-Hamamsy I, Denault A, Lacharité J, Robichaud S, Horvath KA, Corcoran PC, Siegenthaler MP, Murphy M, Iraola M, Greenberg A, Sai-Sudhakar C, Hasan A, McDavid A, Kinn B, Pagé P, Sirois C, Young CA, Beach D, Villanueva R, Woo YJ, Mayer ML, Bowdish M, Starnes VA, Shavalle D, Matthews R, Javadifar S, Romar L, Kron IL, Johnston K, Dent JM, Kern J, Keim J, Burks S, Gahring K, Bull DA, Desvigne-Nickens P, Dixon DO, Haigney M, Holubkov R, Jacobs A, Miller F, Murkin JM, Spertus J, Wechsler AS, Sellke F, McDonald CL, Byington R, Dickert N, Dixon DO, Ikonomidis JS, Williams DO, Yancy CW, Fang JC, Giannetti N, Richenbacher W, Rao V, Furie KL, Miller R, Pinney S, Roberts WC, Walsh MN, Hung J, Zeng X, Kilcullen N, Hung D, Keteyian S, Aldred H, Brawner C, Mathew J, Browndyke J, Toulgoat-Dubois Y. Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.117.004466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Bart S. Ferket
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville (G.A.)
| | - Annetine C. Gelijns
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Michael A. Acker
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia (M.A.A.)
| | | | - Helena L. Chang
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Denis Bouchard
- Montréal Heart Institute, University of Montréal, QC, Canada (D.B.)
| | | | - Robert E. Michler
- Department of Cardiovascular and Thoracic Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY (R.E.M.)
| | - Ellen G. Moquete
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Pierre Voisine
- Institut Universitaire de Cardiologie de Québec, Hôpital Laval, Canada (P.V.)
| | - John C. Mullen
- Division of Cardiac Surgery, University of Alberta, Edmonton, Canada (J.C.M.)
| | - Anuradha Lala
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Michael J. Mack
- Department of Cardiothoracic Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, TX (M.J.M., R.L.S.)
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, OH (A.M.G.)
| | - Vinod H. Thourani
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA and Department of Cardiac Surgery, Med-Star Heart & Vascular Institute, Washington, DC (V.H.T.)
| | - Marissa A. Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (M.A.M.)
| | - James S. Gammie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore (J.S.G.)
| | - Michael K. Parides
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Emilia Bagiella
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Robert L. Smith
- Department of Cardiothoracic Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, TX (M.J.M., R.L.S.)
| | - Peter K. Smith
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC (P.K.S.)
| | - Judy W. Hung
- Division of Cardiology, Massachusetts General Hospital, Boston (J.W.H.)
| | | | - Eric A. Rose
- Department of Cardiac Surgery, Mount Sinai Health System, New York, NY (E.A.R.)
| | - Patrick T. O’Gara
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (P.T.O.)
| | - Alan J. Moskowitz
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
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O'Driscoll JM, Gargallo-Fernandez P, Araco M, Perez-Lopez M, Sharma R. Baseline mitral regurgitation predicts outcome in patients referred for dobutamine stress echocardiography. Int J Cardiovasc Imaging 2017; 33:1711-1721. [PMID: 28685313 PMCID: PMC5682847 DOI: 10.1007/s10554-017-1163-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/08/2017] [Indexed: 12/22/2022]
Abstract
A number of parameters recorded during dobutamine stress echocardiography (DSE) are associated with worse outcome. However, the relative importance of baseline mitral regurgitation (MR) is unknown. The aim of this study was to assess the prevalence and associated implications of functional MR with long-term mortality in a large cohort of patients referred for DSE. 6745 patients (mean age 64.9 ± 12.2 years) were studied. Demographic, baseline and peak DSE data were collected. All-cause mortality was retrospectively analyzed. DSE was successfully completed in all patients with no adverse outcomes. MR was present in 1019 (15.1%) patients. During a mean follow up of 5.1 ± 1.8 years, 1642 (24.3%) patients died and MR was significantly associated with increased all-cause mortality (p < 0.001). With Kaplan-Meier analysis, survival was significantly worse for patients with moderate and severe MR (p < 0.001). With multivariate Cox regression analysis, moderate and severe MR (HR 2.78; 95% CI 2.17-3.57 and HR 3.62; 95% CI 2.89-4.53, respectively) were independently associated with all-cause mortality. The addition of MR to C statistic models significantly improved discrimination. MR is associated with all-cause mortality and adds incremental prognostic information among patients referred for DSE. The presence of MR should be taken into account when evaluating the prognostic significance of DSE results.
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Affiliation(s)
- Jamie M O'Driscoll
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
- School of Human and Life Sciences, Canterbury Christ Church University, Kent, UK
| | - Paula Gargallo-Fernandez
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Marco Araco
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Manuel Perez-Lopez
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Rajan Sharma
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK.
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8
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Acute Complications of Myocardial Infarction in the Current Era: Diagnosis and Management. J Investig Med 2016; 63:844-55. [PMID: 26295381 DOI: 10.1097/jim.0000000000000232] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Coronary heart disease is a major cause of mortality and morbidity worldwide. The incidence of mechanical complications of acute myocardial infarction (AMI) has gone down to less than 1% since the advent of percutaneous coronary intervention, but although mortality resulting from AMI has gone down in recent years, the burden remains high. Mechanical complications of AMI include cardiogenic shock, free wall rupture, ventricular septal rupture, acute mitral regurgitation, and right ventricular infarction. Detailed knowledge of the complications and their risk factors can help clinicians in making an early diagnosis. Prompt diagnosis with appropriate medical therapy and timely surgical intervention are necessary for favorable outcomes.
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Papillary Muscle Approximation Versus Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation. J Am Coll Cardiol 2016; 67:2334-2346. [PMID: 27199056 DOI: 10.1016/j.jacc.2016.03.478] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/07/2016] [Accepted: 03/07/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Guidelines recommend surgery for patients with severe ischemic mitral regurgitation (MR). Nonrandomized studies suggest that subvalvular repair is associated with longer survival, but randomized studies are lacking. OBJECTIVES This study sought to investigate the benefit of papillary muscle surgery on long-term clinical outcomes of patients with ischemic MR. METHODS Ninety-six patients with severe ischemic MR were randomized to either undersizing restrictive mitral annuloplasty (RA) or papillary muscle approximation with undersizing restrictive mitral annuloplasty (PMA) associated with complete surgical myocardial revascularization. The primary endpoint was change in left ventricular end-diastolic diameter (LVEDD) after 5 years, measured as the absolute difference from baseline, which was evaluated by paired Student t tests. Secondary endpoints included changes in echocardiographic parameters, overall mortality, the composite cardiac endpoint (major adverse cardiac and cerebrovascular events [MACCE]), and quality of life (QOL) during the 5-year follow-up. RESULTS At 5 years, mean LVEDD was 56.5 ± 5.7 mm with PMA versus 60.6 ± 4.6 mm with RA (mean change from baseline -5.8 ± 4.1 mm and -0.2 ± 2.3 mm, respectively; p < 0.001). Ejection fraction was 44.1 ± 6% in the PMA group versus 39.9 ± 3.9% in the RA group (mean change from baseline 8.8 ± 5.9% and 2.5 ± 4.3%, respectively; p < 0.001). There was no statistically significant difference in mortality at 5 years, but freedom from MACCE favored PMA in the last year of follow-up. PMA significantly reduced tenting height, tenting area, and interpapillary distance soon after surgery and for the long-term, and significantly lowered moderate-to-severe MR recurrence. No differences were found in QOL measures. CONCLUSIONS Compared with RA only, PMA exerted a long-term beneficial effect on left ventricular remodeling and more effectively restored the mitral valve geometric configuration in ischemic MR, which improved long-term cardiac outcomes, but did not produce differences in overall mortality and QOL.
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Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, Butcher JT, Carpentier A, Chaput M, Chester AH, Clusel C, Delling FN, Dietz HC, Dina C, Durst R, Fernandez-Friera L, Handschumacher MD, Jensen MO, Jeunemaitre XP, Le Marec H, Le Tourneau T, Markwald RR, Mérot J, Messas E, Milan DP, Neri T, Norris RA, Peal D, Perrocheau M, Probst V, Pucéat M, Rosenthal N, Solis J, Schott JJ, Schwammenthal E, Slaugenhaupt SA, Song JK, Yacoub MH. Mitral valve disease--morphology and mechanisms. Nat Rev Cardiol 2015; 12:689-710. [PMID: 26483167 DOI: 10.1038/nrcardio.2015.161] [Citation(s) in RCA: 253] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5E, Boston, MA 02114, USA
| | - Albert A Hagége
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | - Jacob P Dal-Bianco
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Nabila Bouatia-Naji
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Patrick Bruneval
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | - Alain Carpentier
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | | | - Francesca N Delling
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | | | - Christian Dina
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Ronen Durst
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Leticia Fernandez-Friera
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Mark D Handschumacher
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | - Xavier P Jeunemaitre
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Hervé Le Marec
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Thierry Le Tourneau
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Jean Mérot
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Emmanuel Messas
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - David P Milan
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Tui Neri
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - David Peal
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Maelle Perrocheau
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Vincent Probst
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Michael Pucéat
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - Jorge Solis
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jean-Jacques Schott
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Susan A Slaugenhaupt
- Center for Human Genetic Research, MGH Research Institute, Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Thoralf M Sundt
- From the Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston
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Li S, Barywani S, Fu M. Prognostic significance of mitral regurgitation in long-term all-cause mortality in patients aged ≥80years with acute coronary syndrome. Int J Cardiol 2014; 176:340-5. [DOI: 10.1016/j.ijcard.2014.06.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/28/2014] [Indexed: 11/27/2022]
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Predictors and prognosis of early ischemic mitral regurgitation in the era of primary percutaneous coronary revascularisation. Cardiovasc Ultrasound 2014; 12:14. [PMID: 24708546 PMCID: PMC3977603 DOI: 10.1186/1476-7120-12-14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/10/2014] [Indexed: 12/13/2022] Open
Abstract
Background Studies assessing ischemic mitral regurgitation (IMR) comprised of heterogeneous population and evaluated IMR in the subacute setting. The incidence of early IMR in the setting of primary PCI, its progression and clinical impact over time is still undetermined. We sought to determine the predictors and prognosis of early IMR after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Methods Using our primary PCI database, we screened for patients who underwent ≥2 transthoracic echocardiograms early (1–3 days) and late (1 year) following primary PCI. The primary outcomes were: (1) major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement (2) changes in quantitative echocardiographic assessments. Results From January 2006 to July 2012, we included 174 patients. Post-primary PCI IMR was absent in 95 patients (55%), mild in 60 (34%), and moderate to severe in 19 (11%). Early after primary PCI, IMR was independently predicted by an ischemic time > 540 min (OR: 2.92 [95% CI, 1.28 – 7.05]; p = 0.01), and female gender (OR: 3.06 [95% CI, 1.42 – 6.89]; p = 0.004). At a median follow-up of 366 days [34–582 days], IMR was documented in 44% of the entire cohort, with moderate to severe IMR accounting for 15%. During follow-up, MR regression (change ≥ 1 grade) was seen in 18% of patients. Moderate to severe IMR remained an independent predictor of MACE (HR: 2.58 [95% CI, 1.08 – 5.53]; p = 0.04). Conclusions After primary PCI, IMR is a frequent finding. Regression of early IMR during long-term follow-up is uncommon. Since moderate to severe IMR post-primary PCI appears to be correlated with worse outcomes, close follow-up is required.
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Paparella D, Malvindi PG, Romito R, Fiore G, Tupputi Schinosa LDL. Ischemic mitral regurgitation: pathophysiology, diagnosis and surgical treatment. Expert Rev Cardiovasc Ther 2014; 4:827-38. [PMID: 17173499 DOI: 10.1586/14779072.4.6.827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic mitral valve regurgitation often complicates acute myocardial infarction and also represents a negative prognostic factor for long-term survival in patients undergoing surgical myocardial revascularization. While severe mitral regurgitation should always be corrected during a coronary artery bypass operation, the decision making is more difficult in patients with a mild-to-moderate degree of regurgitation. Recent studies and experimental protocols have elucidated the pathophysiological mechanisms leading to mitral regurgitation with great interest in annular modifications and subvalvular alterations. These data suggest that new and integrated surgical approaches that address annuloplasty ring sizing, ring type selection and tethering phenomenon (i.e., chordal cutting, 'edge-to-edge' technique and left-ventricular plasty techniques) are required for a safer and durable valve repair. Transthoracic and transesophageal echocardiography are useful in determining the etiology and the degree of mitral regurgitation, to assess mitral deformation and to measure indexes of global and regional left-ventricular remodeling. Stress echocardiography may unmask higher degrees of mitral regurgitation. More data are needed in order to confirm the promising and interesting preliminary experimental findings of magnetic resonance imaging in diagnosis and clinical evaluation of ischemic mitral regurgitation.
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Affiliation(s)
- Domenico Paparella
- University of Bari, Division of Cardiac Surgery, Piazza Giulio Cesare 11, 70100 Bari, Italy.
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Shakil O, Jainandunsing JS, Ilic R, Matyal R, Mahmood F. Ischemic Mitral Regurgitation: An Intraoperative Echocardiographic Perspective. J Cardiothorac Vasc Anesth 2013; 27:573-85. [DOI: 10.1053/j.jvca.2012.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Indexed: 11/11/2022]
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Gelsomino S, van Garsse L, Lucà F, Parise O, Cheriex E, Rao CM, Gensini GF, Maessen J. Left ventricular strain in chronic ischemic mitral regurgitation in relation to mitral tethering pattern. J Am Soc Echocardiogr 2013; 26:370-380.e11. [PMID: 23415836 DOI: 10.1016/j.echo.2013.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this retrospective study was to explore whether different tethering patterns in chronic ischemic mitral regurgitation have different distributions of left ventricular (LV) systolic longitudinal, circumferential, and radial strain before and after mitral valve repair. METHODS Sixty-one patients with chronic ischemic mitral regurgitation who underwent mitral repair were divided on the basis of the preoperative anterior/posterior tethering angle ratio (cutoff value, 0.76). There were 29 patients with symmetric (group 1) and 32 with asymmetric (group 2) preoperative tethering patterns. Assessment of longitudinal peak systolic strain was performed offline by applying speckle-tracking imaging to the apical two-chamber, three-chamber, and four-chamber views of the left ventricle. Peak systolic radial and circumferential strain was obtained from short-axis views at the basal, middle, and apical levels. Twenty healthy subjects served as controls. RESULTS In group 1, baseline LV strain was impaired in all LV segments, with the worst values in the anterolateral, anterior, and inferolateral segments at the midventricular and basal levels. In contrast, asymmetric patients showed higher values in the inferior and inferoseptal walls and values closer to normal in the other segments. After surgery, all strain measurements showed significant improvements in all LV segments in group 2, whereas in Group 1, strain worsened in the inferoseptal, inferior, and anteroseptal walls and did not change in the other segments. CONCLUSIONS Patients with baseline symmetric tethering patterns showed more extensive abnormal strain, which was observed in all LV segments and was not reverted by surgery. These findings require confirmation in additional larger studies.
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Affiliation(s)
- Sandro Gelsomino
- Department of Heart and Vessels, Careggi Hospital, Florence, Italy.
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Pham T, Sun W. Characterization of the mechanical properties of the coronary sinus for percutaneous transvenous mitral annuloplasty. Acta Biomater 2010; 6:4336-44. [PMID: 20621635 DOI: 10.1016/j.actbio.2010.05.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 05/24/2010] [Accepted: 05/28/2010] [Indexed: 11/18/2022]
Abstract
The coronary sinus (CS) vessel serves as a conduit for the deployment of percutaneous transvenous mitral annuloplasty (PTMA) devices for the treatment of functional mitral regurgitation. Characterization of the mechanical response of the CS is an important step towards an understanding of tissue-device interaction in PTMA intervention. The purpose of this study was to investigate the mechanical properties of the porcine CS using the pressure-inflation test and constitutively model the wall behavior using a four fiber family strain energy function (SEF). The results showed that the CS exhibited an S-shaped pressure-radius response and could be dilated up to 88% at a pressure of 80mmHg. Excellent results from model fitting indicated that the four fiber family SEF could capture the experimental data well and could be used in future numerical simulations of tissue-device interaction. In addition, a histological study was performed to identify the micro-structure of the CS wall. We found a high content of striated myocardial fibers (SMFs) surrounding the CS wall, which was also mainly composed of SMFs, while the content of smooth muscle cells was very low. Elastin and collagen fibers were highly concentrated in the luminal and outer layers and sparsely distributed in the medial layer of the CS wall. These structural and mechanical properties of the CS should be taken into consideration in future PTMA device designs.
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Affiliation(s)
- Thuy Pham
- Tissue Mechanics Laboratory, Biomedical Engineering Program and Mechanical Engineering Department, University of Connecticut, Storrs, CT 06269, USA
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Engström AE, Vis MM, Bouma BJ, Claessen BE, Sjauw KD, Baan J, Meuwissen M, Koch KT, de Winter RJ, Tijssen JG, Piek JJ, Henriques JP. Mitral regurgitation is an independent predictor of 1-year mortality in ST-elevation myocardial infarction patients presenting in cardiogenic shock on admission. ACTA ACUST UNITED AC 2010; 12:51-7. [DOI: 10.3109/17482941003802148] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Gelsomino S, Lorusso R, De Cicco G, Billè G, Caciolli S, Rostagno C, Capecchi I, Chioccioli M, Stefàno P, Gensini GF. Does preoperative tethering symmetry affect left ventricular reverse remodeling after restrictive annuloplasty? Int J Cardiol 2010; 141:182-91. [PMID: 19157591 DOI: 10.1016/j.ijcard.2008.11.190] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Accepted: 11/29/2008] [Indexed: 11/16/2022]
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Arruda-Olson AM, Enriquez-Sarano M, Bursi F, Weston SA, Jaffe AS, Killian JM, Roger VL. Left ventricular function and C-reactive protein levels in acute myocardial infarction. Am J Cardiol 2010; 105:917-21. [PMID: 20346306 DOI: 10.1016/j.amjcard.2009.11.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 11/13/2009] [Accepted: 11/13/2009] [Indexed: 11/17/2022]
Abstract
To examine left ventricular (LV) function in patients after acute myocardial infarction (AMI) and assess its relation to C-reactive protein (CRP) as a measure of the early inflammatory response. We measured the CRP levels early after AMI and correlated them with the early structural and functional cardiac alterations. From November 2002 to December 2007, we prospectively enrolled community subjects who had experienced an AMI, as defined by standardized criteria, measured the CRP level, and obtained an echocardiogram. The study consisted of 514 patients (mean age 67 +/- 15 years, 59% men). CRP was measured early after symptom onset (median 6.1 hours; twenty-fifth to seventy-fifth percentile 2.2 to 11.1). The median CRP level was 4.8 mg/L (twenty-fifth to seventy-fifth percentile 1.8 to 24). The echocardiograms were obtained at a median of 1 day after AMI. The wall motion score index, LV ejection fraction, and LV diameter were similar across the CRP tertiles (all p >0.05). Greater CRP levels were associated with the presence of moderate or severe diastolic dysfunction (p = 0.002) and moderate or severe mitral regurgitation (p <0.001). The association with moderate or severe mitral regurgitation was independent of the clinical characteristics and ST-segment elevation status. In conclusion, at the initial phase of AMI, CRP elevation was associated with the presence and severity of mitral regurgitation and diastolic dysfunction. This suggests that inflammation is related to the ventricular remodeling processes, independently of LV systolic function.
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Affiliation(s)
- Adelaide M Arruda-Olson
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Chaput M, Handschumacher MD, Guerrero JL, Holmvang G, Dal-Bianco JP, Sullivan S, Vlahakes GJ, Hung J, Levine RA. Mitral leaflet adaptation to ventricular remodeling: prospective changes in a model of ischemic mitral regurgitation. Circulation 2009; 120:S99-103. [PMID: 19752393 DOI: 10.1161/circulationaha.109.844019] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation is caused by systolic traction on the mitral leaflets related to ventricular distortion. Little is known about how chronic tethering affects leaflet area, in part because it cannot be measured repeatedly in situ. Recently, a new method for 3D echocardiographic measurement of mitral leaflet area was developed and validated in vivo against sheep valves, later excised. Clinical studies (n=80) showed that mitral leaflet area increased by >30% in patients with inferior myocardial infarction and dilated cardiomyopathy versus normal; greater adaptation independently predicted less mitral regurgitation. This study explored whether mitral valve area changes over time within the same heart with ischemic mitral regurgitation. METHODS AND RESULTS Twelve sheep were studied at baseline and 3 months after inferior myocardial infarction by 3D echocardiography; 6 were untreated and 6 were treated initially with an epicardial patch to limit left ventricular dilation and mitral regurgitation. Untreated sheep developed left ventricular dilation at 3 months, with global dysfunction (mean+/-SD ejection fraction, 24+/-10% versus 44+/-10% with patching, P=0.02) and moderate mitral regurgitation (vena contracta, 5.0+/-1.0 versus 0.8+/-1.0 mm, P<0.0002). In untreated sheep, total diastolic leaflet area increased from 13.1+/-1.3 to 18.1+/-2.5 cm(2) (P=0.0001). In patched sheep, leaflet area at 3 months was not significantly different from baseline sheep values (13.0+/-1.1 versus baseline, 12.1+/-1.8 cm(2), P=0.31). CONCLUSIONS Mitral valve area, independent of systolic stretch, increases over time as the left ventricular remodels after inferior myocardial infarction. This increase, however, fails to compensate adequately for tethering to prevent mitral regurgitation. Understanding the mechanism of valve adaptation can potentially suggest new biological and surgical therapeutic targets.
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Affiliation(s)
- Miguel Chaput
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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de Varennes B, Chaturvedi R, Sidhu S, Côté AV, Shan WLP, Goyer C, Hatzakorzian R, Buithieu J, Sniderman A. Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation. Circulation 2009; 119:2837-43. [PMID: 19451349 DOI: 10.1161/circulationaha.108.831412] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Management of severe ischemic mitral regurgitation remains difficult with disappointing early and intermediate-term surgical results of valve repair. METHODS AND RESULTS Forty-four patients with severe (4+) Carpentier type IIIb ischemic mitral regurgitation underwent mitral valve repair, with or without surgical revascularization, by posterior leaflet extension with a patch of bovine pericardium and a remodeling annuloplasty. Serial echocardiography was performed preoperatively, intraoperatively, and postoperatively to assess mitral valve competence. The postoperative functional status of patients was assessed. The average Parsonnet score was 38+/-13. Thirty-day mortality was 11%, and late mortality was 14%. Mean follow-up was 38 months. The actuarial freedom from moderate or severe recurrent mitral regurgitation was 90% at 2 years, whereas 90% of patients were in New York Heart Association class I at 2 years. CONCLUSIONS Posterior leaflet extension with annuloplasty of the mitral valve for severe type IIIb ischemic regurgitation is a safe, effective method that provides good early and intermediate-term competence of the mitral valve and therefore good functional status.
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Nesković AN, Marinković J, Bojić M, Popović AD. Early mitral regurgitation after acute myocardial infarction does not contribute to subsequent left ventricular remodeling. Clin Cardiol 2009; 22:91-4. [PMID: 10068845 PMCID: PMC6655665 DOI: 10.1002/clc.4960220207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND It is well known that mitral regurgitation may lead to left ventricular dilation; however, the relationship between progressive left ventricular dilation after acute myocardial infarction (MI) and mitral regurgitation has not yet been clarified. HYPOTHESIS This study tested the hypothesis that early mitral regurgitation contributes to left ventricular remodeling after acute MI. METHODS We prospectively evaluated 131 consecutive patients by serial two-dimensional and Doppler echocardiography on Days 1, 2, 3, and 7, after 3 and 6 weeks, 3 and 6 months, and 1 year following acute MI. Patients were divided into two groups: those with mitral regurgitation in the first week after acute MI (Group 1, n = 34) and those without mitral regurgitation (Group 2, n = 81). RESULTS Over 1 year, a significant increase in end-diastolic volume index (from 62.1 +/- 12.9 to 70.5 +/- 23.6 ml/m2, p = 0.001) with a strong linear trend (F = 15.1, p < 0.001) was noted. Initial end-diastolic volume index was higher in Group 1 (65.6 +/- 13.3 vs. 60.4 +/- 12.5 ml/m2, p = 0.047), but this difference remained constant throughout the study (F = 1.76, p = NS). Therefore, the pattern of end-diastolic volume changes was similar in both groups during the period of observation. CONCLUSIONS These data indicate that early mitral regurgitation after acute MI does not contribute to subsequent left ventricular remodeling in the first year after myocardial infarction.
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Affiliation(s)
- A N Nesković
- Cardiovascular Research Center, Dedinje Cardiovascular Institute, Belgrade, Yugoslavia
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Harris KM, Pastorius CA, Duval S, Harwood E, Henry TD, Carabello BA, Hirsch AT. Practice variation among cardiovascular physicians in management of patients with mitral regurgitation. Am J Cardiol 2009; 103:255-61. [PMID: 19121447 DOI: 10.1016/j.amjcard.2008.09.065] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 09/09/2008] [Accepted: 09/09/2008] [Indexed: 11/26/2022]
Abstract
Severe mitral regurgitation (MR), whether isolated or with coronary disease, was associated with adverse clinical outcomes. However, clinician practice is characterized by different thresholds for treatment. No data exist that described current practice patterns, factors that affected these patterns, or whether physicians followed American College of Cardiology/American Heart Association guidelines in clinical practice for patients with MR. Cardiovascular specialists were surveyed using e-mail, and 1,076 physicians completed the survey (71% response rate), including adult cardiologists (94%) and cardiac surgeons (5%) who practiced in the United States (78%), Canada (5%), and other nations (17%). Wide variations were noted regarding rates of referral of asymptomatic patients with severe MR for mitral valve repair. There was geographic and specialty-dependent heterogeneity in practice. Most physicians (65%) used medications to delay the progression of MR in the absence of guideline recommendations. A minority (28%) of respondents routinely quantitated MR by calculating the effective regurgitant orifice area. In patients undergoing percutaneous coronary intervention, MR severity was not assessed before the procedure by 1 in 4 providers, and the presence of MR frequently did not affect clinical care decisions. In conclusion, considerable variability existed in the clinical management of MR, particularly regarding referral of asymptomatic patients for mitral valve reparative surgery. Medications were frequently used to treat asymptomatic patients with MR in the absence of evidence of pharmacologic efficacy. MR was frequently not considered a relevant factor before treatment of patients with coexistent coronary artery disease.
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Fonarow GC, Flaherty JD, Gheorghiade M. Introduction to ACCORD-PMI: the Advisory Council on Care Optimization to Reduce Death Post-MI. Am J Cardiol 2008; 102:1G-4G. [PMID: 18722185 DOI: 10.1016/j.amjcard.2008.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Gregg C Fonarow
- Ahmanson-University of California Los Angeles Cardiomyopathy Center, University of California, Los Angeles Medical Center, Los Angeles, California, USA
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Chaput M, Handschumacher MD, Tournoux F, Hua L, Guerrero JL, Vlahakes GJ, Levine RA. Mitral leaflet adaptation to ventricular remodeling: occurrence and adequacy in patients with functional mitral regurgitation. Circulation 2008; 118:845-52. [PMID: 18678770 DOI: 10.1161/circulationaha.107.749440] [Citation(s) in RCA: 195] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Functional mitral regurgitation (MR) is caused by systolic traction on the mitral leaflets related to ventricular distortion. Little is known about whether chronic tethering causes the mitral leaflet area to adapt to the geometric needs imposed by tethering, in part because of inability to reconstruct leaflet area in vivo. Our aim was to explore whether adaptive increases in leaflet area occur in patients with functional MR compared with normal subjects and to test the hypothesis that leaflet area influences MR severity. METHODS AND RESULTS A new method for 3-dimensional echocardiographic measurement of mitral leaflet area was developed and validated in vivo against 15 sheep heart valves, later excised. This method was then applied in 80 consecutive patients from 3 groups: patients with normal hearts by echocardiography (n=20), patients with functional MR caused by isolated inferior wall-motion abnormality or dilated cardiomyopathy (n=29), and patients with inferior wall-motion abnormality or dilated cardiomyopathy but no MR (n=31). Leaflet area was increased by 35+/-20% in patients with LV dysfunction compared with normal subjects. The ratio of leaflet to annular area was 1.95+/-0.40 and was not different among groups, which indicates a surplus leaflet area that adapts to left-heart changes. In contrast, the ratio of total leaflet area to the area required to close the orifice in midsystole was decreased in patients with functional MR compared with those with normal hearts (1.29+/-0.15 versus 1.78+/-0.39, P=0.001) and compared with patients with inferior wall-motion abnormality or dilated cardiomyopathy but no MR (1.81+/-0.38, P=0.001). After adjustment for measures of LV remodeling and tethering, a leaflet-to-closure area ratio <1.7 was associated with significant MR (odds ratio 23.2, 95% confidence interval 2.0 to 49.1, P=0.02). CONCLUSIONS Mitral leaflet area increases in response to chronic tethering in patients with inferior wall-motion abnormality and dilated cardiomyopathy, but the development of significant MR is associated with insufficient leaflet area relative to that demanded by tethering geometry. The varying adequacy of leaflet adaptation may explain in part the heterogeneity of this disease among patients. The results suggest the need to understand the mechanisms that underlie leaflet adaptation and whether leaflet area can potentially be modified as part of the therapeutic approach.
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Affiliation(s)
- Miguel Chaput
- Division of Cardiothoracic Surgery and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Kallikourdis A, Jacob S, Watson HG, Gibson G. Survival after sequential mechanical complications of acute myocardial infarction, complicated with heparin-induced thrombocytopenia and multiple organ failure: report of a case. J Card Surg 2008; 23:381-4. [PMID: 18598334 DOI: 10.1111/j.1540-8191.2008.00615.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ventricular wall rupture and acute mitral regurgitation due to papillary muscle rupture post-acute myocardial infarction are rare and dramatic mechanical complications. The operative mortality of both complications remains extremely high but this is the only treatment which has greatly improved the prognosis. CASE PRESENTATION We describe the course of a patient, who survived after left ventricular free wall rupture two days post-acute myocardial infarction. He underwent left ventricular rupture repair plus two coronary artery bypass grafting. On the fifth postoperative day he developed papillary muscle rupture and acute mitral valve regurgitation. He was reoperated as an emergency case for mitral valve replacement. The patient sustained numerous complications, such as renal failure, heparin-induced thrombocytopenia, sepsis, acute respiratory distress syndrome, and multiple organ failure. He was on continuous venous-venous hemofiltration for one week and underwent a tracheostomy on the ninth postoperative day. He remained on a ventilator for three weeks. The patient survived, was discharged home after six weeks, and remains in very good condition on follow-up so far. CONCLUSION The operative mortality of both complications remains high but this is the only treatment which improves the prognosis. Surviving both events is rare and few cases have been reported in the literature. This case highlights the necessity of careful echocardiographic examination in any patient presented with post-myocardial infarction new onset of hemodynamic instability. Identification of a single site of rupture does not eliminate the possibility of additional ruptures in the papillary muscle and intraventricular septum, and transesophageal echocardiography should be used to search for these entities. Although repair of each of these complications carries a high mortality, failure to address them will almost certainly result in death. Using standard surgical techniques, including preoperative intraaortic balloon pump insertion and careful postoperative management, successful outcome is possible.
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Affiliation(s)
- Antonios Kallikourdis
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.
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Agricola E, Galderisi M, Mele D, Ansalone G, Dini FL, Di Salvo G, Gallina S, Montisci R, Sciomer S, Di Bello V, Mondillo S, Marino PN. Mechanical dyssynchrony and functional mitral regurgitation: pathophysiology and clinical implications. J Cardiovasc Med (Hagerstown) 2008; 9:461-9. [DOI: 10.2459/jcm.0b013e3282ef39c5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Echocardiographic assessment of the incidence of mechanical complications during the early phase of myocardial infarction in the reperfusion era: a French multicentre prospective registry. Arch Cardiovasc Dis 2008; 101:41-7. [DOI: 10.1016/s1875-2136(08)70254-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pastorius CA, Henry TD, Harris KM. Long-term outcomes of patients with mitral regurgitation undergoing percutaneous coronary intervention. Am J Cardiol 2007; 100:1218-23. [PMID: 17920360 DOI: 10.1016/j.amjcard.2007.05.050] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 05/22/2007] [Accepted: 05/22/2007] [Indexed: 10/23/2022]
Abstract
The most appropriate treatment for patients with ischemic mitral regurgitation (MR) remains controversial. MR has prognostic importance in patients after myocardial infarction and those undergoing coronary artery bypass surgery, but the long-term outcomes after percutaneous coronary intervention (PCI) are less well defined. We evaluated patients who underwent PCI and had assessment of MR by left ventriculography and/or echocardiography in the year 2000. We determined effects of MR on 30-day and 5-year survival. The cohort included 711 patients (67% men) with an average age of 64.5 +/- 12.4 years. MR severity was divided into 3 strata: none (n = 420, 59%), mild (n = 209, 29%), and moderate to severe (n = 82, 12%). Patients with more severe MR differed from patients with mild or no MR in that they were older (p <0.001), more frequently women (p <0.001), and more likely to have a coronary artery bypass graft (p <0.001), myocardial infarction (p <0.001), and lower ejection fraction (p <0.001). Decreased survival rates were associated with increasing MR severity (none vs mild vs moderate to severe) at 30 days (100%, 98.7%, and 96.6%, respectively; p <0.0025) and 5 years (97%, 83.3%, and 57.5%; p <0.0001). MR was an important independent predictor of survival (hazard ratio 1.57, p <0.0009). In conclusion, patients with ischemic MR undergoing PCI have significantly decreased survival rates at 5 years, and severity of MR is an independent predictor of survival.
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Hung J, Chaput M, Guerrero JL, Handschumacher MD, Papakostas L, Sullivan S, Solis J, Levine RA. Persistent Reduction of Ischemic Mitral Regurgitation by Papillary Muscle Repositioning: Structural Stabilization of the Papillary Muscle Ventricular Wall Complex. Circulation 2007; 116:I259-63. [PMID: 17846314 DOI: 10.1161/circulationaha.106.679951] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recurrent ischemic mitral regurgitation (IMR) is frequent despite initial reduction by annuloplasty because continued LV remodeling increases tethering to the infarcted papillary muscle (PM). We have previously shown that PM repositioning by an external patch device can acutely reduce IMR. In this study, we tested the hypothesis that IMR reduction persists despite possible continued LV remodeling. METHODS AND RESULTS In 7 sheep, we used a chronic ischemic posterior infarct model that produces LV dilatation and MR over 10 weeks. An epicardial patch device was adjusted under echo guidance to reduce MR, with follow-up over a further 8 weeks and evaluation by 3D echo and sonomicrometry. In all 7 sheep, moderate IMR resolved with acute patch application and PM repositioning (6.5+/-1.8 mm to 0.6+/-1.3 mm proximal jet width, P<0.001) without decrease in LVEF (43+/-3% to 44+/-8%). Eight weeks after PM repositioning, MR was not significantly greater (0.6+/-1.3 mm versus 1.0+/-1.0 mm, P=NS) despite an increase in LV volumes in 3 animals (2 had increases of 50+/-15%). On average, LV volumes did not change significantly (ESV: 46+/-8 mL versus 49+/-15 mL; P=NS and EDV: 85+/-16 mL versus 89+/-30 mL; P=NS). LVEF was unchanged from acute to chronic patch (44+/-8% versus 43+/-8%). Contractility as end-systolic elastance did not decrease from the chronic MI to the acute and chronic patch stages, nor were there any significant changes in dP/dt, LV stiffness constant, or time constant of LV relaxation (Tau). CONCLUSION PM repositioning is persistently effective in reducing moderate chronic IMR, even when LV volume increases. This may reflect structural stabilization by an external patch device of the papillary muscle-LV wall complex that controls mitral valve tethering.
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Affiliation(s)
- Judy Hung
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Blake 256, 55 Fruit Street, Boston, MA 02114, USA.
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Roshanali F, Mandegar MH, Yousefnia MA, Rayatzadeh H, Alaeddini F. A Prospective Study of Predicting Factors in Ischemic Mitral Regurgitation Recurrence After Ring Annuloplasty. Ann Thorac Surg 2007; 84:745-9. [PMID: 17720370 DOI: 10.1016/j.athoracsur.2007.04.106] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Revised: 04/20/2007] [Accepted: 04/24/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation (IMR) is a complex lesion to repair, and its successful management requires an understanding of its mechanism and severity. Ring annuloplasty, currently the surgical treatment of choice for IMR, has failure rates as high as 30% in patients with functional IMR. We sought to study the variables that can predict IMR recurrence after ring annuloplasty. METHODS This is a prospective study of 114 patients with 3+ to 4+ IMR who underwent coronary artery bypass grafting and mitral valve annuloplasty with acceptable results at an approximately 2-year follow-up. Variables were compared in a failure group, comprising patients with 2+ or higher MR and a nonfailure group, consisting of those with less than +2 MR. RESULTS There were five postoperative in-hospital deaths. During follow-up, 14 patients died and 95 patients were evaluated. After a mean follow-up of 22.2 +/- 4.6 months for the nonfailure group and 18.6 +/- 5.6 months for the failure group, 23 patients (24.4%) exhibited annuloplasty failure. Some variables had an effect in our univariate analysis, but only interpapillary muscle distance had a relationship with recurrent MR in the multivariate analysis. Mean preoperative interpapillary muscle distance was 15.0 +/- 4.0 and 26.5 +/- 2.9 in the nonfailure group and failure group, respectively (p < 0.0001). CONCLUSIONS Interpapillary muscle distance, as a reliable index of dysfunctional subvalvular apparatus in patients with IMR, can predict late postrepair MR and indicate the need for a procedure complementary to annuloplasty.
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Nixdorff U, Klinghammer L, Wüstefeld G, Mohr-Kahaly S, von Bardeleben RS. Chronic Development of Ischaemic Mitral Regurgitation during Post-Infarction Remodelling. Cardiology 2006; 107:239-47. [PMID: 16953109 DOI: 10.1159/000095500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 04/06/2006] [Indexed: 02/01/2023]
Abstract
BACKGROUND/AIMS Mitral regurgitation (MR) following myocardial infarction (MI) may be a (sub)acute complication which independently predicts reduced survival. We sought to evaluate the chronic development of MR as potential consequence of left-ventricular (LV) remodelling, the latter being a long-term process. METHODS AND RESULTS Retrospectively, 103 post-MI patients were included according to a standardised Doppler echocardiogram <3 months following MI (20 +/- 25 days post-MI) and a follow-up examination >6 months after the first examination (5.1 +/- 3.1 years post-MI). Patients were clinically followed up for 7.6 +/- 2.7 years. Group I patients were defined as those showing new development or deterioration in one of three grades of MR, and group II those without this criterion (MR grade acute 0.17 vs. 0.27, p = 0.7, and chronic 1.53 vs. 0.19, p < 0.0001). Patient characteristics were similar in respect of age, gender, size and location of infarction. However, group I patients had coronary artery disease with more vessels involved. With regard to echocardiographic parameters of significantly enlarged LV chamber size in group I vs. group II, the significant decrease in LV performance was more pronounced and occurred concomitant with a higher degree of symptomatic congestive heart failure and greater need for heart failure medications in group I. Mortality in group I patients was 39 versus 9% in group II patients (p = 0.0002), approximating an odds ratio of 6.4697 (95% confidence interval: 2.211-18.931). CONCLUSION First of all, this retrospective study indicates that MR may be detected in patients after MI during a long-term follow-up most probably due to geometric distortions of LV remodelling resulting in a significantly higher mortality. Since this process is known to become irreversible at a certain point, serial echocardiography may help to detect MR in post-MI patients and thus pave the way for appropriate treatment.
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Affiliation(s)
- Uwe Nixdorff
- Second Medical Clinic, Friedrich Alexander University, Erlangen-Nuremberg, Germany.
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Al-Radi OO, Austin PC, Tu JV, David TE, Yau TM. Mitral repair versus replacement for ischemic mitral regurgitation. Ann Thorac Surg 2006; 79:1260-7; discussion 1260-7. [PMID: 15797060 DOI: 10.1016/j.athoracsur.2004.09.044] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2004] [Indexed: 11/25/2022]
Abstract
BACKGROUND We compared mitral repair to replacement in patients with chronic ischemic mitral regurgitation (IMR), due to left ventricular dysfunction (LV-IMR) or papillary muscle infarction (PM-IMR). METHODS Patients with IMR undergoing repair (n = 65) or replacement (n = 137) from 1990 to 2001 were evaluated. There were 87 patients with LV-IMR, and 115 patients with PM-IMR. Patients presenting in cardiogenic shock were excluded. Outcomes were evaluated by Cox survival analysis with propensity score adjustment and bootstrap validation. RESULTS Survival at 3, 5, and 9 years was, respectively, 0.94, 0.79, and 0.63 in the repair group, and 0.73, 0.67, and 0.59 in the replacement group. The hazard ratio (HR) of death for mitral repair versus replacement was not constant over the period of follow-up. Repair was associated with better early survival in the PM-IMR group, with an adjusted HR of 0.25 (95% confidence interval: 0.09 to 0.71) at 1 year. In the LV-IMR group and in patients with PM-IMR with high acuity and comorbidity, there was no significant survival advantage associated with repair. The beneficial effect of repair was not evident at late follow-up in either group. These findings were independent of the surgeon. Need for reoperation was more common after repair than after replacement (14% versus 3%, p = 0.003). CONCLUSIONS Patients with PM-IMR benefit from mitral repair with a significantly better early survival. However, the benefit of repair is not evident at longer follow-up. There was a nonsignificant trend toward greater early survival among patients with LV-IMR who underwent repair.
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Affiliation(s)
- Osman O Al-Radi
- Division of Cardiovascular Surgery, Toronto General Hospital, and the Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Borger MA, Alam A, Murphy PM, Doenst T, David TE. Chronic Ischemic Mitral Regurgitation: Repair, Replace or Rethink? Ann Thorac Surg 2006; 81:1153-61. [PMID: 16488757 DOI: 10.1016/j.athoracsur.2005.08.080] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Revised: 08/09/2005] [Accepted: 08/18/2005] [Indexed: 10/25/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a common complication of coronary artery disease and is the focus of a rapidly increasing amount of research. Mechanistic studies have determined that IMR is caused by apical displacement and tethering of the mitral valve leaflets after myocardial infarction, resulting in incomplete coaptation. Despite the relatively high prevalence of IMR, most centers have only a small surgical experience with this disorder. The result is that a number of different procedures have been recently developed without clear improvement in patient outcomes. The current review will examine the myriad surgical options for IMR with a focus on clinical outcomes.
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Affiliation(s)
- Michael A Borger
- Division of Cardiovascular Surgery, Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Bursi F, Enriquez-Sarano M, Jacobsen SJ, Roger VL. Mitral regurgitation after myocardial infarction: a review. Am J Med 2006; 119:103-12. [PMID: 16443408 DOI: 10.1016/j.amjmed.2005.08.025] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Accepted: 08/12/2005] [Indexed: 10/25/2022]
Abstract
Mitral regurgitation after myocardial infarction is the result of multifactorial processes involving local and global left ventricular remodeling. The prevalence of mitral regurgitation varies from 11% to 59%. Published studies differ greatly in design, inclusion criteria, duration of follow-up, and technique of mitral regurgitation assessment. However, they consistently indicate that mitral regurgitation after myocardial infarction carries an adverse prognosis with increased risk of death and heart failure independently of previously known indicators of risk after myocardial infarction. Mitral regurgitation is often clinically silent; therefore, it should be systematically evaluated by echocardiography. Standard color Doppler imaging is a highly sensitive method to detect even mild degrees of ischemic mitral regurgitation. One unique advantage of echocardiography is that it accurately quantifies the severity of mitral regurgitation by measuring the effective regurgitant orifice area and the regurgitant volume using Doppler methodology. Therefore, the evaluation should include precise quantification of the degree of mitral regurgitation to best appraise the ensuing risk. Current medical options rely chiefly on angiotensin converting enzyme-inhibitors and beta-blocker therapy, and surgical approaches offer future promise. Both categories of therapeutic approaches should be evaluated by randomized controlled trials.
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Affiliation(s)
- Francesca Bursi
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Giga V, Ostojic M, Vujisic-Tesic B, Djordjevic-Dikic A, Stepanovic J, Beleslin B, Petrovic M, Nedeljkovic M, Nedeljkovic I, Milic N. Exercise-induced changes in mitral regurgitation in patients with prior myocardial infarction and left ventricular dysfunction: relation to mitral deformation and left ventricular function and shape. Eur Heart J 2005; 26:1860-5. [PMID: 16055492 DOI: 10.1093/eurheartj/ehi431] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS The aim of this study was to assess the relationship between exercise-induced changes in mitral regurgitation (MR) and echocardiographic characteristics of mitral deformation, global left ventricular (LV) function and shape at rest and after exercise. METHODS AND RESULTS Forty consecutive patients with ischaemic MR due to prior myocardial infarction (MI), ejection fraction <45% in sinus rhythm underwent exercise-echocardiographic testing. Exercise-induced changes in effective regurgitant orifice (ERO) were compared with baseline and exercise-induced changes in mitral deformation and global LV function and shape. There was significant correlation between exercise-induced changes in ERO and changes in coaptation distance (r=0.80, P<0.0001), tenting area (r=0.79, P<0.0001) and mitral annular diameter (r=0.65, P<0.0001), as well as in end-systolic sphericity index (r=-0.50, P=0.001, respectively), and wall motion score index (r=0.44, P=0.004). In contrast, exercise-induced changes in ERO were not related to the echocardiographic features at rest. By stepwise multiple regression model, the exercise-induced changes in mitral deformation were found to independently correlate with exercise-induced changes in ERO (generalized r(2)=0.80, P<0.0001). CONCLUSION Exercise-induced changes in severity of ischaemic MR in patients with LV dysfunction due to prior MI were independently related to changes in mitral deformation.
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Affiliation(s)
- Vojislav Giga
- Department for Diagnostic and Catheterization Laboratories, Institute for Cardiovascular Disease, Clinical Center of Serbia, 8 Koste Todorovica, 11000 Belgrade, Yugoslavia
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Carasso S, Sandach A, Beinart R, Schwammenthal E, Sagie A, Kuperstein R, Behar S, Feinberg MS. Usefulness of four echocardiographic risk assessments in predicting 30-day outcome in acute myocardial infarction. Am J Cardiol 2005; 96:25-30. [PMID: 15979427 DOI: 10.1016/j.amjcard.2005.02.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Revised: 02/22/2005] [Accepted: 02/22/2005] [Indexed: 11/16/2022]
Abstract
One thousand fifty-one consecutive patients who had acute myocardial infarction were classified into 3 risk groups by 4 echocardiographic risk assessments: left ventricular ejection fraction, left ventricular filling pattern, estimated systolic pulmonary artery pressure, and mitral regurgitation, with 30-day mortality rates of 13.7%, 3.8%, and 1%, respectively (p <0.001). Independent echocardiographic and clinical predictors of 30-day mortality included age (10 years, hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.91 to 1.89), female gender (HR 2.12, 95% CI 0.94 to 4.74), Killip's class > or =II on admission (HR 3.09, 95% CI 1.38 to 7.11), group 2 (moderate) risk (HR 2.89, 95% CI 1.07 to 8.56), and group 1 (high) risk (HR 8.16, 95% CI 2.95 to 25.23).
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Affiliation(s)
- Shemy Carasso
- Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Grigioni F, Detaint D, Avierinos JF, Scott C, Tajik J, Enriquez-Sarano M. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction. J Am Coll Cardiol 2005; 45:260-7. [PMID: 15653025 DOI: 10.1016/j.jacc.2004.10.030] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 09/27/2004] [Accepted: 10/04/2004] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The purpose of this study was to define the contribution of ischemic mitral regurgitation (IMR) to the occurrence of congestive heart failure (CHF) after myocardial infarction (MI). BACKGROUND After MI, CHF is a frequent and serious complication, but its determinants and, particularly, the role of IMR are poorly defined. METHODS We analyzed 173 asymptomatic patients with previous Q-wave MI (>16 days) with echocardiographic quantitation of IMR (measuring effective regurgitant orifice [ERO] and regurgitant volume). The 102 patients with IMR were matched to 71 patients without IMR for age (71 +/- 11 years vs. 68 +/- 9 years; p = 0.11), gender (76% vs. 82% males; p = 0.41), and left ventricular ejection fraction (EF) (37 +/- 14% vs. 36 +/- 11%; p = 0.92). RESULTS Five-year rates of CHF and of CHF or cardiac death (CD) were 36 +/- 5% and 52 +/- 5%, respectively. Independent determinants of CHF were EF, sodium plasma level, and presence and degree of IMR (p < 0.0001). Five-year CHF rates were 18 +/- 5% without mitral regurgitation (MR), 53 +/- 7% with IMR, 46 +/- 9% with ERO 1 to 19 mm(2) and 68 +/- 12% with ERO > or =20 mm(2) (all p < 0.0001). The adjusted relative risk of CHF was 3.65 (95% confidence interval [CI] 1.86 to 7.75) for IMR presence and 4.42 (95% CI 1.9 to 10.5) for ERO > or =20 mm(2). The adjusted relative risk of CHF/CD was 2.97 (95% CI 1.77 to 5.16) for IMR presence and 4.4 (95% CI 2.4 to 8.2) for ERO > or =20 mm(2). CONCLUSIONS After MI, incidence of CHF and of CHF/CD are high even in patients with no or minimal symptoms at baseline and are higher in patients with IMR. Congestive heart failure is independently determined by larger ERO of IMR. These data suggest that detecting and quantifying IMR is essential for risk stratification after MI. Value of IMR treatment in improving post-MI outcome should be investigated.
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Affiliation(s)
- Francesco Grigioni
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Bursi F, Enriquez-Sarano M, Nkomo VT, Jacobsen SJ, Weston SA, Meverden RA, Roger VL. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 2005; 111:295-301. [PMID: 15655133 DOI: 10.1161/01.cir.0000151097.30779.04] [Citation(s) in RCA: 355] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND In case series, mitral regurgitation (MR) increased the risk of death after myocardial infarction (MI), yet the prevalence of MR, its incremental prognostic value over ejection fraction (EF), and its association with heart failure and death after MI in the community is not known. METHODS AND RESULTS The prevalence of MR and its association with heart failure and death were examined among 1331 patients within a geographically defined MI incidence cohort between 1988 and 1998. Echocardiography was performed within 30 days after MI in 773 patients (58%), and MR was present in 50% of cases, mild in 38%, and moderate or severe in 12%. Among patients with MR, a murmur was inconsistently detected clinically. After 4.7+/-3.3 years of follow-up, 109 episodes of heart failure and 335 deaths occurred. There was a graded positive association between the presence and severity of MR and heart failure or death. Moderate or severe MR was associated with a large increase in the risk of heart failure (relative risk 3.44, 95% CI 1.74 to 6.82, P<0.001) and death (relative risk 1.55, 95% CI 1.08 to 2.22, P=0.019) among 30-day survivors independent of age, gender, EF, and Killip class. CONCLUSIONS In the community, MR is frequent and often silent after MI. It carries information to predict heart failure or death among 30-day survivors independently of age, gender, EF, and Killip class. These findings, which are applicable to a large community-based MI cohort, suggest that the assessment of MR should be included in post-MI risk stratification.
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Affiliation(s)
- Francesca Bursi
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minn 55905, USA
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Brunschwig T, Eberli FR, Herren T. [Mechanical complications of acute myocardial infarction]. ZEITSCHRIFT FUR KARDIOLOGIE 2004; 93:897-907. [PMID: 15568150 DOI: 10.1007/s00392-004-0133-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2004] [Accepted: 06/21/2004] [Indexed: 05/01/2023]
Abstract
Rupture of the left ventricular myocardium during the course of an acute myocardial infarction may affect the free wall, the interventricular septum, or the papillary muscles. When a rupture occurs, it is referred to as a mechanical complication of acute myocardial infarction. All mechanical complications may lead to cardiogenic shock. However, the location of the rupture can often be suspected clinically. To confirm the diagnosis, echocardiography must be performed. Since the advent of thrombolytic therapy and percutaneous coronary intervention, the incidence of mechanical complications has declined. Even though mortality remains high, their recognition is important since survivors may have an excellent long-term prognosis. The cases convey two main messages: 1) Mechanical complications must be carefully searched for in any patient with an acute coronary syndrome and signs of cardiogenic shock and/or a systolic murmur. 2) Aggressive and timely medical and surgical treatment should be provided even though in a substantial proportion of these patients prognosis may be dismal.
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Affiliation(s)
- T Brunschwig
- Medizinische Klinik, Spital Limmattal, Urdorferstrasse 100, 8952 Schlieren, Schweiz
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42
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Nesta F, Otsuji Y, Handschumacher MD, Messas E, Leavitt M, Carpentier A, Levine RA, Hung J. Leaflet concavity: a rapid visual clue to the presence and mechanism of functional mitral regurgitation. J Am Soc Echocardiogr 2003; 16:1301-8. [PMID: 14652610 DOI: 10.1067/j.echo.2003.09.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Repairing mitral regurgitation (MR) requires an understanding of its mechanism. Evaluating restricted leaflet closure in functional MR is challenging. Tenting area between leaflets and annulus in long-axis (LAX) views correlates with MR, but is positive even in control subjects; in the 4-chamber view, the incomplete mitral leaflet closure (IMLC) tenting pattern may be subtle and variable. We tested the hypothesis that leaflet concavity toward the left atrium in the LAX view, a rapid visual clue indicating abnormal tethering predominantly by intermediate chords, is a strong indicator of functional MR. We reviewed 90 patients: 40 with inferior myocardial infarction and ejection fraction > or = 50%; 40 with global left ventricular dysfunction and ejection fraction < 50%; and 10 control subjects. We assessed leaflet shape (concave or convex toward the left atrium) and maximum systolic proximal MR jet width in the LAX views. To quantify shape, we measured the leaflet concavity area between the anterior leaflet and a line connecting its ends. Conventional IMLC area was also assessed. Patients with leaflet concavity had significantly greater MR than those without this finding (jet width of 4.6 +/- 0.7 vs 0.5 +/- 0.1 mm, P <.0001), indicating mild-moderate versus trace MR, with differences comparable in those with inferior myocardial infarction and left ventricular dysfunction. Leaflet concavity area most strongly predicted MR by multivariate regression (R(2) = 0.7). Conventional IMLC area did not uniquely distinguish patients with or without MR and correlated more weakly with MR (R(2) = 0.30 vs 0.73). Mitral leaflet concavity in the LAX view provides rapid and reliable recognition of functional MR, with greater reliability than IMLC area. This shape, consistent with tethering by intermediate chords, may have implications for potential intervention.
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Affiliation(s)
- Francesca Nesta
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, 02114, USA
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43
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Abstract
The surgical approach to ischemic mitral regurgitation (IMR) remains a topic of considerable controversy. Will coronary artery bypass alone suffice, or should the valve be intervened upon? The poor late survival of patients with IMR is well recognized, but it remains unknown if this can be altered by addressing the valve directly. And if surgery is undertaken, should the valve be repaired or replaced? The underlying mechanisms of IMR remain incompletely understood, and although current theory focuses on the role of alterations in ventricular geometry in its pathogenesis, IMR is most often addressed by annuloplasty alone. Is this sufficient, or does the ventricle itself require "remodeling?" The debate is confounded by imprecise terminology that fails to distinguish between acute and chronic disease, and active ischemia from completed infarction. Available clinical information is from retrospective studies with all of their inherent limitations and potential for bias. Still, progress is being made as increasing attention is focused on this clinically important entity.
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Affiliation(s)
- Chad E Hamner
- Division of Cardiovascular Surgery, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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44
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Hung J, Guerrero JL, Handschumacher MD, Supple G, Sullivan S, Levine RA. Reverse ventricular remodeling reduces ischemic mitral regurgitation: echo-guided device application in the beating heart. Circulation 2002; 106:2594-600. [PMID: 12427657 DOI: 10.1161/01.cir.0000038363.83133.6d] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In ischemic mitral regurgitation (MR), mitral leaflet closure is restricted by ventricular remodeling with displacement of the papillary muscles (PMs). Therapy is uncertain because ring annuloplasty does not alleviate PM displacement. We tested the hypothesis that echo-guided PM repositioning using an external device can reduce MR without compromising left ventricular (LV) function. METHODS AND RESULTS We studied 10 sheep with ischemic MR produced by circumflex ligation with inferior infarction, 6 acutely and 4 eight weeks after myocardial infarction (MI). A Dacron patch containing an inflatable balloon was placed over the PMs and adjusted under echo guidance to reverse LV remodeling and reposition the infarcted PM. 3D echo assessed mitral valve geometric changes. In 7 sheep, sonomicrometry and Millar catheters assessed changes in end-systolic and end-diastolic pressure-volume relationships, and microspheres were injected to assess coronary flow. Moderate MR after MI resolved with patch application alone (n=3) or echo-guided balloon inflation, which repositioned the infarcted PM, decreasing the PM tethering distance from 31.1+/-2.5 mm after MI to 26.8+/-1.8 with patch (P<0.01; baseline=25.5+/-1.5). LV contractility was unchanged (end-systolic slope=3.4+/-1.6 mm Hg/mL with patch versus 2.8+/-1.6 after MI). Although there was a nonsignificant trend for a mild increase in stiffness constant (0.07+/-0.05 mL(-1) versus 0.05+/-0.03 after MI, P=0.06), LV end-diastolic pressure was unchanged as MR resolved. Coronary flow to noninfarcted regions was not reduced. CONCLUSIONS An external device that repositions the PMs can reduce ischemic MR without compromising LV function. This relatively simple technique can be applied under echo guidance in the beating heart.
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Affiliation(s)
- Judy Hung
- Cardiac Ultrasound Laboratory and Surgical Cardiovascular Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Mass 02114, USA
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45
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Harris KM, Sundt TM, Aeppli D, Sharma R, Barzilai B. Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve? Ann Thorac Surg 2002; 74:1468-75. [PMID: 12440594 DOI: 10.1016/s0003-4975(02)03920-6] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation is known to be associated with poor long-term outcome after coronary artery bypass grafting; however, our ability to alter that outcome with intervention on the valve is unclear. The decision to address the valve is most challenging for patients with only moderate mitral regurgitation, particularly with the popularization of off-pump surgery. We therefore reviewed early and late outcomes of patients undergoing revascularization with or without mitral valve surgery. METHODS Patients with moderate mitral regurgitation undergoing revascularization with and without mitral surgery between January 1991 and September 1996 were identified retrospectively. Operative notes were reviewed and patients with structural valve disease excluded. Perioperative events and late outcomes as determined by telephone contact and search of the social security death index (survival data 97% complete) were compared. RESULTS One hundred seventy-six patients with moderate mitral regurgitation underwent revascularization alone (n = 142) or with mitral repair or replacement (n = 34). Those undergoing revascularization alone had a higher serum creatinine, somewhat less mitral regurgitation, and lower New York Heart Association functional class preoperatively. Operative mortality was greater with valve surgery (21% vs 9%, p = 0.047). Actuarial survival of both groups at 5 years was similar (52% vs 58%, p = NS); however, when stratified by preoperative functional class, those with more advanced heart failure preoperatively had superior late survival if their mitral valve was intervened upon. CONCLUSIONS The late survival of patients with ischemic mitral regurgitation undergoing coronary revascularization remains poor; however, intervention on the mitral valve appears to benefit those with symptomatic heart failure.
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46
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Abstract
Mitral valve regurgitation (MR) is a frequent Doppler echocardiographic finding in patients after acute myocardial infarction (AMI) and an independent predictor of long-term cardiovascular mortality. Reported risk factors include advanced age, prior myocardial infarction, infarct extension, and recurrent ischemia. During the early phase of AMI, transient ischemic MR is common and rarely causes hemodynamic compromise. However, when several chordae tendineae or a papillary muscle ruptures, acute left atrial and ventricular volume overload ensues, leading to abrupt hemodynamic deterioration with cardiogenic shock. Auscultation may be unrevealing due to decreased turbulence. Hence, the importance of a high index of suspicion for acute MR in any patient with acute pulmonary edema in the setting of AMI, especially if left ventricular systolic function is well preserved. Later, ventricular remodeling may lead to MR through annular dilatation or papillary muscle migration with malcoaptation of the leaflets. The widespread availability, ease of use and non-invasive nature of Doppler echocardiography have made it the standard diagnostic tool for detecting MR. Mechanical reperfusion of the infarct-related artery seems to be superior to fibrinolysis in decreasing its incidence acutely and in the long run. Nevertheless, when acute severe MR occurs, unless rapidly diagnosed and treated, this dreaded complication is associated with high morbidity and mortality. Prompt surgical intervention after hemodynamic stabilization is essential to ensure a good short-term and long-term prognosis. This review discusses the incidence, long-term prognosis, associated risk factors, complex pathophysiology, time of occurrence, clinical manifestations, diagnosis, and management of patients with MR after AMI.
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Affiliation(s)
- Yochai Birnbaum
- The Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas 77555-0553, USA.
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47
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Messas E, Guerrero JL, Handschumacher MD, Conrad C, Chow CM, Sullivan S, Yoganathan AP, Levine RA. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation 2001; 104:1958-63. [PMID: 11602501 DOI: 10.1161/hc4201.097135] [Citation(s) in RCA: 219] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) conveys adverse prognosis in ischemic heart disease. Because such MR is related to increased leaflet tethering by displaced attachments to the papillary muscles (PMs), it is incompletely treated by annular reduction. We therefore addressed the hypothesis that such MR can be reduced by cutting a limited number of critically positioned chordae to the leaflet base that most restrict closure but are not required to prevent prolapse. This was tested in 8 mitral valves: a porcine in vitro pilot with PM displacement and 7 sheep with acute inferobasal infarcts studied in vivo with three-dimensional (3D) echo to quantify MR in relation to 3D valve geometry. METHODS AND RESULTS In all 8 valves, PM displacement restricted leaflet closure, with anterior leaflet angulation at the basal chord insertion, and mild-to-moderate MR. Cutting the 2 central basal chordae reversed this without prolapse. In vivo, MR increased from 0.8+/-0.2 to 7.1+/-0.5 mL/beat after infarction and then decreased to 0.9+/-0.1 mL/beat with chordal cutting (P<0.0001); this paralleled changes in the 3D leaflet area required to cover the orifice as dictated by chordal tethering (r(2)=0.76). CONCLUSIONS Cutting a minimum number of basal chordae can improve coaptation and reduce ischemic MR. Such an approach also suggests the potential for future minimally invasive implementation.
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Affiliation(s)
- E Messas
- Cardiac Ultrasound Laboratory and Surgical Cardiovascular Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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48
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Stanley AW, Athanasuleas CL, Buckberg GD. Left ventricular remodeling and functional mitral regurgitation: mechanisms and therapy. Semin Thorac Cardiovasc Surg 2001; 13:486-95. [PMID: 11807745 DOI: 10.1053/stcs.2001.30135] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Myocardial damage that results in dysfunction and remodeling changes left ventricular shape and size. Mitral competence requires the functional integrity of all components of the mitral apparatus. Progressive remodeling ultimately leads to geometric distortion of multiple elements of the mitral apparatus, resulting in functional mitral regurgitation (MR). In this article, we examine the mechanisms of functional MR in the remodeled ventricle. Surgical treatment should aim to correct all abnormalities of the mitral apparatus. These include (1) revascularization of viable myocardium, (2) reduction of ventricular volume and restoration of shape, (3) realignment of papillary muscles, and (4) reduction of annular orifice size.
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Affiliation(s)
- A W Stanley
- Department of Cardiology, Norwood Clinic and Kemp-Carraway Heart Institute, Birmingham, AL, USA
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49
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Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001; 103:1759-64. [PMID: 11282907 DOI: 10.1161/01.cir.103.13.1759] [Citation(s) in RCA: 965] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Myocardial infarction (MI) can directly cause ischemic mitral regurgitation (IMR), which has been touted as an indicator of poor prognosis in acute and early phases after MI. However, in the chronic post-MI phase, prognostic implications of IMR presence and degree are poorly defined. METHODS AND RESULTS We analyzed 303 patients with previous (>16 days) Q-wave MI by ECG who underwent transthoracic echocardiography: 194 with IMR quantitatively assessed in routine practice and 109 without IMR matched for baseline age (71+/-11 versus 70+/-9 years, P=0.20), sex, and ejection fraction (EF, 33+/-14% versus 34+/-11%, P=0.14). In IMR patients, regurgitant volume (RVol) and effective regurgitant orifice (ERO) area were 36+/-24 mL/beat and 21+/-12 mm(2), respectively. After 5 years, total mortality and cardiac mortality for patients with IMR (62+/-5% and 50+/-6%, respectively) were higher than for those without IMR (39+/-6% and 30+/-5%, respectively) (both P<0.001). In multivariate analysis, independently of all baseline characteristics, particularly age and EF, the adjusted relative risks of total and cardiac mortality associated with the presence of IMR (1.88, P=0.003 and 1.83, P=0.014, respectively) and quantified degree of IMR defined by RVol >/=30 mL (2.05, P=0.002 and 2.01, P=0.009) and by ERO >/=20 mm(2) (2.23, P=0.003 and 2.38, P=0.004) were high. CONCLUSIONS In the chronic phase after MI, IMR presence is associated with excess mortality independently of baseline characteristics and degree of ventricular dysfunction. The mortality risk is related directly to the degree of IMR as defined by ERO and RVol. Therefore, IMR detection and quantification provide major information for risk stratification and clinical decision making in the chronic post-MI phase.
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Affiliation(s)
- F Grigioni
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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50
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Feinberg MS, Schwammenthal E, Shlizerman L, Porter A, Hod H, Friemark D, Matezky S, Boyko V, Mandelzweig L, Vered Z, Behar S, Sagie A. Prognostic significance of mild mitral regurgitation by color Doppler echocardiography in acute myocardial infarction. Am J Cardiol 2000; 86:903-7. [PMID: 11053696 DOI: 10.1016/s0002-9149(00)01119-x] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Mitral regurgitation (MR) complicating acute myocardial infarction (AMI) is associated with increased mortality. The prognostic significance of only mild MR detected by echocardiography in patients with AMI is unknown. This study assessed the long-term risk associated with mild MR detected by color Doppler echocardiography within the first 48 hours of admission in 417 consecutive patients with AMI. No MR was detected in 271 patients (65%), mild MR was seen in 121 patients (29%), and moderate or severe MR was noted in 25 patients (6%). One-year mortality rates were 4.8%, 12.4%, and 24%, respectively (p<0.001). Multivariate analysis revealed that mild MR was independently associated with increased 1-year mortality (p<0.05) after adjustment for age, gender, previous myocardial infarction, diabetes mellitus, systemic hypertension, Killip grade > or =2 on admission, and left ventricular ejection fraction < or =40%. The hazard ratio for 1-year mortality was 2.31 (95% confidence interval 1.03 to 5.20) for mild MR and 2.85 (95% confidence interval 0.95 to 8.51) for moderate or severe MR. Thus, mild MR detected by color Doppler echocardiography within the first 2 days of admission in patients with AMI is a significant independent risk predictor for 1-year all-cause mortality.
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Affiliation(s)
- M S Feinberg
- Chaim Sheba Medical Center, Tel Hashomer, Israel.
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