1
|
Yu M, Bouatia-Naji N. Insights into the Inherited Basis of Valvular Heart Disease. Curr Cardiol Rep 2024; 26:381-392. [PMID: 38581562 DOI: 10.1007/s11886-024-02041-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW: Increases in the availability of genetic data and advances in the tools and methods for their analyses have enabled well-powered genetic association studies that have significantly enhanced our understanding of the genetic factors underlying both rare and common valve diseases. Valvular heart diseases, such as congenital valve malformations and degenerative valve lesions, increase the risk of heart failure, arrhythmias, and sudden death. In this review, we provide an updated overview of our current understanding of the genetic mechanisms underlying valvular heart diseases. With a focus on discoveries from the past 5 years, we describe recent insights into genetic risk and underlying biological pathways. RECENT FINDINGS: Recently acquired knowledge around valvular heart disease genetics has provided important insights into novel mechanisms related to disease pathogenesis. Newly identified risk loci associated valvular heart disease mainly regulate the composition of the extracellular matrix, accelerate the endothelial-to-mesenchymal transition, contribute to cilia formation processes, and play roles in lipid metabolism. Large-scale genomic analyses have identified numerous risk loci, genes, and biological pathways associated with degenerative valve disease and congenital valve malformations. Shared risk genes suggest common mechanistic pathways for various valve pathologies. More recent studies have combined cardiac magnetic resonance imaging and machine learning to offer a novel approach for exploring genotype-phenotype relationships regarding valve disease. Progress in the field holds promise for targeted prevention, particularly through the application of polygenic risk scores, and innovative therapies based on the biological mechanisms for predominant forms of valvular heart diseases.
Collapse
Affiliation(s)
- Mengyao Yu
- Shanghai Pudong Hospital, Human Phenome Institute, Fudan University Pudong Medical Center, Zhangjiang Fudan International Innovation Center, Fundan University, 825 Zhangheng Road, Pudong District, Shanghai, 201203, China.
| | | |
Collapse
|
2
|
Schaff HV, Juarez-Casso FM. Treatment Strategies for Hypertrophic Cardiomyopathy: Surgical. Am J Cardiol 2024; 212S:S53-S63. [PMID: 38368037 DOI: 10.1016/j.amjcard.2023.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 02/19/2024]
Abstract
Septal myectomy is a well-established procedure for septal reduction in patients with obstructive hypertrophic cardiomyopathy (HCM) who have not responded to medical treatment. The surgical approach is tailored to the unique pathophysiology and septal morphology of the patient. Extended transaortic myectomy is the standard procedure for patients with isolated subaortic obstruction, the most common type of HCM. However, transapical myectomy is a useful adjunct for patients with long or midventricular obstruction and is our preferred technique for ventricular enlargement in patients with severe symptomatic diastolic heart failure because of extensive apical hypertrophy. Septal myectomy provides excellent postoperative outcomes as regards symptom relief and functional improvement, and operative morbidity and mortality rates are low in experienced centers. This article summarizes our current surgical management of patients with HCM and details operative methods and outcomes.
Collapse
Affiliation(s)
- Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | |
Collapse
|
3
|
Schaff HV, Wei X. Contemporary Surgical Management of Hypertrophic Cardiomyopathy. Ann Thorac Surg 2024; 117:271-281. [PMID: 37914148 DOI: 10.1016/j.athoracsur.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 11/03/2023]
Abstract
More than half of symptomatic patients with hypertrophic cardiomyopathy (HCM) have left ventricular outflow tract (LVOT) obstruction. Septal reduction therapy by septal myectomy can dramatically relieve exertional dyspnea, chest pain, and presyncope in properly selected patients and is an important management pathway for many patients. The distribution and degree of hypertrophy in patients with obstructive HCM are variable and, as discussed in this review, can influence clinical manifestations of the disease and surgical management. Subaortic septal hypertrophy is the most common phenotype of obstructive HCM associated with LVOT obstruction, but midventricular obstruction and apical hypertrophy may occur in isolation or in conjunction with subaortic septal hypertrophy. In many comprehensive HCM centers, transaortic septal myectomy is the preferred method of septal reduction therapy for symptomatic patients with obstructive HCM. Early surgical approaches aimed at alleviating left LVOT obstruction were hampered by a lack of understanding of the anatomy and pathophysiology of obstructive HCM. With the advent of Doppler echocardiography and, more recently, cardiac magnetic resonance imaging, surgeons can precisely assess the location and degree of obstruction, left ventricular size and function, and morphology and function of the mitral valve. This review discusses the current understanding of the role of septal myectomy in the management of patients with HCM and details contemporary operative methods.
Collapse
Affiliation(s)
- Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Xiang Wei
- Division of Cardiovascular Surgery, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
4
|
Wu Z, Nie C, Zhu C, Meng Y, Yang Q, Lu T, Lu Z, Liu X, Wang S. Mitral annular calcification in obstructive hypertrophic cardiomyopathy: Incidence, risk factors, and prognostic value after myectomy. Int J Cardiol 2023; 391:131266. [PMID: 37574021 DOI: 10.1016/j.ijcard.2023.131266] [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: 03/10/2023] [Revised: 07/31/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Mitral annular calcification (MAC) is a risk factor for cardiac surgery, but there is limited study on the prognosis value and the impact for valve function of MAC based on computed tomography (CT) diagnosis after myectomy for hypertrophic obstructive cardiomyopathy (OHCM). METHODS Consecutive OHCM patients underwent septal myectomy were compared according to the existence of MAC and its severity in preoperative CT scans. The survival data were evaluated and compared by Kaplan Meier analysis and log rank test. Cox regression analysis was used to evaluate the impact of MAC on endpoint events. RESULTS From the entire cohort of 1035 patients, 10.8% had MAC. In multivariate regression, female (OR = 2.23), age (OR = 1.07), aortic annular calcification (OR = 2.52), aortic calcification (OR = 2.56), systolic anterior motion of the mitral valve (SAM) (OR = 0.42), mitral valve thickening (OR = 2.13), and tricuspid regurgitation (OR = 3.12) were independent predictors of MAC. All-cause mortality (3.57% vs. 1.08%, p = 0.031), major adverse cardiovascular and cerebrovascular events (MACCE) (23.32% vs. 13.65%, p = 0.014), recurrent MR > 2+ (8.04% vs. 2.49%, p = 0.001) and NYHA III-IV (11.61% vs. 5.53%, p = 0.012) were more frequent in OHCM patients with MAC after myectomy. MAC was discovered to be an independent predictor of postoperative recurrent MR > 2+ after other risk factors were taken into account (HR 2.47, 95% CI 1.08-5.67, p = 0.0329). Moderate-to-severe MAC was an independent risk factor (HR 2.03, 95% CI 1.09-3.75, p = 0.0244) for long-term major adverse cardiovascular and cerebrovascular events (MACCE). CONCLUSION MAC was detected in one-tenth of OHCM patients in preoperative CT scanning and is mainly associated with aging and atherosclerosis. OHCM patients with MAC had a worse prognosis and more recurrent mitral valve regurgitation than those without MAC after septal myectomy.
Collapse
Affiliation(s)
- Zining Wu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Changrong Nie
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changsheng Zhu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanhai Meng
- Department of Adult Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiulan Yang
- Department of Adult Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Lu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengyang Lu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoxi Liu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
5
|
Tersalvi G, Gaiero L, Capriolo M, Cristoforetti Y, Salizzoni S, Senatore G, Pedrazzini G, Biasco L. Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1017. [PMID: 37374220 DOI: 10.3390/medicina59061017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation.
Collapse
Affiliation(s)
- Gregorio Tersalvi
- Department of Cardiology, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
- Department of Internal Medicine, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland
| | - Lorenzo Gaiero
- Division of Cardiology, Azienda Sanitaria Locale Torino 4, Ospedale di Ciriè, 10073 Ciriè, Italy
| | - Michele Capriolo
- Division of Cardiology, Azienda Sanitaria Locale Torino 4, Ospedale di Ciriè, 10073 Ciriè, Italy
| | - Yvonne Cristoforetti
- Division of Cardiology, Ospedale Gradenigo, Humanitas Torino, 10153 Turin, Italy
| | - Stefano Salizzoni
- Division of Cardiac Surgery, Città della Salute e della Scienza, Università degli Studi di Torino, 10126 Turin, Italy
| | - Gaetano Senatore
- Division of Cardiology, Azienda Sanitaria Locale Torino 4, Ospedale di Ciriè, 10073 Ciriè, Italy
| | - Giovanni Pedrazzini
- Department of Cardiology, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Luigi Biasco
- Division of Cardiology, Azienda Sanitaria Locale Torino 4, Ospedale di Ciriè, 10073 Ciriè, Italy
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| |
Collapse
|
6
|
Geske JB, Arslan M, Newman DB. Defining the Role of Mitral Annular Calcification in Mitral Valve Systolic Anterior Motion. J Am Soc Echocardiogr 2023; 36:428-430. [PMID: 36754728 DOI: 10.1016/j.echo.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 02/09/2023]
Affiliation(s)
- Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | | | - D Brian Newman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
7
|
Kim D, Seo J, Cho I, Hong G, Ha J, Shim CY. Prognostic Implication of Mitral Valve Disease and Its Progression in East Asian Patients With Hypertrophic Cardiomyopathy. J Am Heart Assoc 2023; 12:e024792. [PMID: 36688372 PMCID: PMC9973656 DOI: 10.1161/jaha.121.024792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Hypertrophic cardiomyopathy (HCM) is a genetic disorder affecting not only the myocardium but also the mitral valve (MV) and its apparatus. This study aimed to investigate the prognostic implication of MV disease and its progression in East Asian patients with HCM. Methods and Results We assessed MV structure and function on the indexed echocardiogram of 1185 patients with HCM (mean±SD age, 60±14 years; men, 67%) in a longitudinal HCM registry, and 667 patients who performed follow-up echocardiogram after 3 to 5 years were also analyzed. Progression of mitral regurgitation (MR) was defined as the increase of at least 1 grade. Clinical outcomes were defined as a composite of cardiovascular death, heart failure hospitalization, MV surgery or septal myectomy, and heart transplantation. Most of the entire cohort was nonobstructive type (n=1081 [91.2%]). A total of 278 patients (23.5%) showed at least mild MR on indexed echocardiogram. MR, systolic anterior motion, and mitral annular calcification were more prevalent in patients with obstructive HCM. During 7.0±4.0 years of follow-up, presence of MR was independently associated with poor clinical outcomes (hazard ratio [HR], 1.60 [95% CI, 1.07-2.40]; P=0.023). On follow-up echocardiogram, 67 (10.0%) patients showed MR progression, and it was independently associated with poor prognosis (HR, 2.46 [95% CI, 1.29-4.71]; P=0.007). Conclusions In East Asian patients with HCM whose major type is nonobstructive, MV disease is common. MR, systolic anterior motion, and mitral annular calcification are more prevalent in patients with obstructive HCM. The presence and progression of MR are associated with a poor prognosis in patients with HCM.
Collapse
Affiliation(s)
- Dae‐Young Kim
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Geu‐Ru Hong
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Jong‐Won Ha
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| |
Collapse
|
8
|
Holst KA, Schaff HV, Smedira NG, Habermann EB, Day CN, Badhwar V, Takayama H, McCarthy PM, Dearani JA. Impact of Hospital Volume on Outcomes of Septal Myectomy for Hypertrophic Cardiomyopathy. Ann Thorac Surg 2022; 114:2131-2138. [PMID: 35779600 DOI: 10.1016/j.athoracsur.2022.05.062] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/14/2022] [Accepted: 05/25/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Left ventricular outflow tract obstruction is common among symptomatic patients with hypertrophic cardiomyopathy, yet septal reduction by surgical myectomy (septal myectomy [SM]) is performed infrequently in many centers. This study examined the possible relationship between institutional case volume and early outcomes of SM. METHODS The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients with hypertrophic cardiomyopathy who underwent SM from January 2012 to December 2019. The study defined center case volume categories as <1, 1 to 4.99, 5 to 9.99, and ≥10 cases performed on average per year. RESULTS The study population included 5935 patients at 481 centers with 933 surgeons. The range of average center volume was <1 to 138 cases per year. Overall early mortality was 2.6%, ventricular septal defect (VSD) occurred in 1.9%, and complete heart block occurred in 9.0%. Concomitant mitral valve (MV) repair was performed in 28.7%, and MV replacement was performed in 17.1%. In multivariable analysis, the lowest annual case volume (average <1 case/y) was consistently associated with greater early mortality (odds ratio [OR], 5.4; CI, 3.0-9.9; P < .001), greater risk of VSD (OR, 9.3; CI ,4.2-20.4; P < .001), increased incidence of complete heart block (OR, 2.0; CI, 1.5-2.7; P < .001), and a higher likelihood of MV replacement (OR, 9.4; CI, 7.5-11.8; P < .001). CONCLUSIONS Volume of SM cases varies widely among institutions reporting to the Society of Thoracic Surgeons Adult Cardiac Surgery Database. There appears to be an important association between surgical experience, as reflected by institutional case volume, and early outcomes, including mortality, as well as the occurrence of VSD, heart block, and MV replacement.
Collapse
Affiliation(s)
- Kimberly A Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Courtney N Day
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Columbia University, New York, New York
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
9
|
Guigui SA, Torres C, Escolar E, Mihos CG. Systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: a narrative review. J Thorac Dis 2022; 14:2309-2325. [PMID: 35813751 PMCID: PMC9264047 DOI: 10.21037/jtd-22-182] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/15/2022] [Indexed: 11/06/2022]
Abstract
Background and Objective The prevalence of hypertrophic cardiomyopathy (HCM) is estimated to be 1 in 200 to 500 individuals, with systolic anterior motion (SAM) of the mitral valve (MV) and left ventricular outflow tract (LVOT) obstruction present in 60% to 70%. In this narrative review, we aim to elucidate the pathophysiology of SAM-septal contact and LVOT obstruction in HCM by presenting a detailed review on the anatomy of the MV apparatus in HCM, examining the various existing theories pertaining to the SAM phenomenon as supported by cardiac imaging, and providing a critical assessment of management strategies for SAM in HCM. Methods A literature review was performed using PubMed, EMBASE, Ovid, and the Cochrane Library, of all scientific articles published through December 2021. A focus was placed on descriptive studies, reports correlating echocardiographic findings with pathologic diagnosis, and outcomes studies. Key Content and Findings The pathophysiology of SAM involves the complex interplay between HCM morphology, MV apparatus anatomic abnormalities, and labile hemodynamic derangements. Echocardiography and cardiac magnetic resonance (CMR) vector flow mapping have identified drag forces, as opposed to the "Venturi effect", as the main hydraulic forces responsible for SAM. The degree of mitral regurgitation with SAM is variable, and its severity is correlated with degree of LVOT obstruction and outcomes. First line therapy for the amelioration of SAM and LVOT obstruction is medical therapy with beta-blockers, non-dihydropyridine calcium-channel blockers, and disopyramide, in conjunction with lifestyle modifications. In refractory cases septal reduction therapy is performed, which may be combined with a 'resect-plicate-release' procedure, anterior mitral leaflet extension, surgical edge-to-edge MV repair, anterior mitral leaflet retention plasty, or secondary chordal cutting. Conclusions Recent scientific advances in the field of HCM have allowed for a maturation of our understanding of the SAM phenomenon. Cardiac imaging plays a critical role in its diagnosis, treatment, and surveillance, and in our ability to apply the appropriate therapeutic regimens. The increasing prevalence of HCM places an emphasis on continued basic and clinical research to further improve outcomes for this challenging population.
Collapse
Affiliation(s)
- Sarah A Guigui
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christian Torres
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Coronary Care Unit, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| |
Collapse
|