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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: 12] [Impact Index Per Article: 6.0] [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.
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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
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Stassen J, Vandenbriele C, Claessen G, Jacobs B, Debaveye Y, Balthazar T. Ultrasound Diagnosis of Cardiac Arrest in an 81-Year-Old Postoperative Patient. Chest 2021; 160:e233-e236. [PMID: 34366050 DOI: 10.1016/j.chest.2020.07.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/19/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jan Stassen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Cardiac Intensive Care, University Hospitals Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Jacobs
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Tim Balthazar
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Cardiac Intensive Care, University Hospitals Leuven, Leuven, Belgium
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Zampieri M, Argirò A, Marchi A, Berteotti M, Targetti M, Fornaro A, Tomberli A, Stefàno P, Marchionni N, Olivotto I. Mavacamten, a Novel Therapeutic Strategy for Obstructive Hypertrophic Cardiomyopathy. Curr Cardiol Rep 2021; 23:79. [PMID: 34081217 DOI: 10.1007/s11886-021-01508-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Pharmacological treatment options for hypertrophic cardiomyopathy (HCM) are currently limited and comprise non-disease specific therapies such as β-blockers, non-dihydropyridine calcium channel blockers, and disopyramide. These agents that offer a variable degree of symptomatic relief, often suboptimal, are often limited by side-effects and fail to address the key molecular abnormalities of the disease. RECENT FINDINGS Mavacamten is a novel, first-in-class, allosteric inhibitor of cardiac myosin ATPase, which reduces actin-myosin cross-bridge formation, thereby reducing myocardial contractility and improving myocardial energetic consumption in experimental HCM models. Following a successful Phase 2 study, the recently published phase III, placebo-controlled, randomized EXPLORER-HCM trial demonstrated the efficacy and safety of mavacamten in reducing left ventricular outflow tract obstruction and ameliorating exercise capacity, New York Heart Association functional class and health status in patients with obstructive HCM. Mavacamten represents the first agent specifically developed for HCM successfully tested in a Phase III trial, to be registered soon for clinical use, representing a radical change of paradigm in the pharmacological treatment of HCM.
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Affiliation(s)
- Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.
| | - Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Alberto Marchi
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Martina Berteotti
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Mattia Targetti
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Division of General Cardiology, Careggi University Hospital, Florence, Italy
| | - Alessandra Fornaro
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Division of General Cardiology, Careggi University Hospital, Florence, Italy
| | - Alessia Tomberli
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Pierluigi Stefàno
- Division of Cardiac Surgery, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Division of General Cardiology, Careggi University Hospital, Florence, Italy
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4
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Kwon HM, Kim KS, Hwang GS. Systolic anterior motion of mitral chordae tendineae: prevalence and clinical implications in liver transplantation. Anesth Pain Med (Seoul) 2020; 15:187-192. [PMID: 33329812 PMCID: PMC7713819 DOI: 10.17085/apm.2020.15.2.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/23/2010] [Accepted: 09/23/2019] [Indexed: 11/17/2022] Open
Abstract
Background Although systolic anterior motion (SAM) of the mitral valve anterior leaflet is well-known to cause hemodynamic perturbation in many anesthetic situations, the prevalence and clinical implication of SAM of mitral chordae tendineae (chordal SAM) in liver transplantation (LT) has not been evaluated. We aimed to assess the impact of chordal SAM on intraoperative postreperfusion syndrome and short and long-term all-cause mortality. Methods We retrospectively evaluated 1751 LT recipients from January 2011 to June 2017 who had preoperative echocardiography. Echocardiography-derived parameters and the prevalence of post-reperfusion syndrome between those with chordal SAM and without chordal SAM were compared. The cumulative mortality rate according to the presence of chordal SAM was evaluated by the Kaplan-Meier survival curve. Results Of the enrolled recipients, 21 (1.2%) had chordal SAM in preoperative echocardiography. Compared to those without chordal SAM, patients with chordal SAM had a smaller end-systolic volume index (median 18 ml/m2 vs. 22 ml/m2, P = 0.015) and end-diastolic volume index (median 52 ml/m2 vs. 63 ml/m2, P = 0.011). However, there was no difference in systolic and diastolic function in echocardiography. The prevalence of intraoperative post-reperfusion syndrome did not show any difference (42.9% vs. 45.3%, P = 1.000). Over the mean 4.8-year follow-up, cumulative 90-day and overall mortality also did not show a difference (Log rank P > 0.05, both). Conclusions Preoperative screening of echocardiography in LT recipients detects 1.2% of chordal SAM. It is found with small left ventricular volume, but is not related with intraoperative post-reperfusion syndrome and short- and long-term postoperative all-cause mortality in LT.
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Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Corresponding author: Gyu-Sam Hwang, M.D. Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: 82-2-3010-3868, Fax: 82-2-470-1363, E-mail:
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Sabzwari SRA, Kimber JR, Ayele H, Khan N, Sheikh T, Akbar G, Feldman B. The Disappearing Murmur: Systolic Anterior Motion of the Mitral Valve Leaflet in a Non-hypertrophic Cardiomyopathy Patient. Cureus 2018; 10:e2855. [PMID: 30148008 PMCID: PMC6104906 DOI: 10.7759/cureus.2855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Systolic anterior motion (SAM) of the mitral valve is a well-known phenomenon associated with left ventricular outflow tract obstruction and hemodynamic compromise. This finding may occur in patients with or without hypertrophic cardiomyopathy. In this report, a patient with no prior medical history presented to the hospital with left-sided chest pain and high-risk echocardiogram (ECG) findings. Left heart catheterization with coronary angiography was negative for coronary artery disease. His initial examination was significant for a systolic murmur due to the underlying SAM, as demonstrated by transthoracic echocardiogram. During his hospitalization, he developed acute heart failure syndrome as a result of dynamic outflow tract obstruction. He was treated with fluid resuscitation with a resolution of his hemodynamic compromise. On a follow-up examination, there was no murmur and SAM was no longer present on echocardiogram. This case demonstrates the importance of recognizing the clinical manifestations of SAM as well as its role in maintaining an appropriate hemodynamic status.
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Affiliation(s)
| | - James R Kimber
- Cardiology, Lehigh Valley Health Network, Allentown, USA
| | - Hiwot Ayele
- Cardiology Fellowship, Lehigh Valley Health Network, Allentown, USA
| | - Nimra Khan
- Medicine, Florida Hospital, Orlando, USA
| | - Tarick Sheikh
- Internal Medicine, Lehigh Valley Health Network, Allentown, USA
| | - Ghulam Akbar
- Cardiology, Lehigh Valley Health Network, Allentown, USA
| | - Bruce Feldman
- Cardiology, Lehigh Valley Health Network, Allentown, USA
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Abstract
Echocardiography is a powerful and convenient tool used routinely in the cardiac evaluation of many patients. Improved resolution and visualization of cardiac anatomy has led to the discovery of many normal variant structures that have no known pathologic consequence. Importantly, these findings may masquerade as pathology prompting unnecessary further evaluation at the expense of anxiety, cost, or potential harm. This review provides an updated and comprehensive collection of normal anatomic variants on both transthoracic and transesophageal imaging.
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Uematsu S, Takaghi A, Imamura Y, Ashihara K, Hagiwara N. Clinical features of the systolic anterior motion of the mitral valve among patients without hypertrophic cardiomyopathy. J Cardiol 2017; 69:495-500. [DOI: 10.1016/j.jjcc.2016.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/24/2016] [Accepted: 04/14/2016] [Indexed: 11/16/2022]
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Cha JJ, Chung H, Yoon YW, Yoon JH, Kim JY, Min PK, Lee BK, Hong BK, Rim SJ, Kwon HM, Choi EY. Diverse geometric changes related to dynamic left ventricular outflow tract obstruction without overt hypertrophic cardiomyopathy. Cardiovasc Ultrasound 2014; 12:23. [PMID: 24993692 PMCID: PMC4086991 DOI: 10.1186/1476-7120-12-23] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/30/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dynamic left ventricular (LV) outflow tract (LVOT) obstruction (DLVOTO) is not infrequently observed in older individuals without overt hypertrophic cardiomyopathy (HCM). We sought to investigate associated geometric changes and then evaluate their clinical characteristics. METHODS A total of 168 patients with DLVOTO, which was defined as a trans-LVOT peak pressure gradient (PG) higher than 30 mmHg at rest or provoked by Valsalva maneuver (latent LVOTO) without fixed stenosis, were studied. Patients with classical HCM, acute myocardial infarction, stress induced cardiomyopathy or unstable hemodynamics which potentially induce transient-DLVOTO were excluded. RESULTS Their mean age was 71 ± 11 years and 98 (58%) patients were women. Patients were classified as pure sigmoid septum (n = 14) if they have basal septal bulging but diastolic thickness less than 15 mm, sigmoid septum with basal septal hypertrophy for a thickness ≥15 mm (n = 85), prominent papillary muscle (PM) (n = 20) defined by visually large PMs which occluded the LV cavity during systole or 1/2 LVESD, or as having a small LV cavity with concentric remodelling or hypertrophy (n = 49). The prominent PM group was younger, had a higher S' and lower E/e' than other groups. In all groups, a higher peak trans-LVOT PG was related (p < 0.10) to higher E/e', systolic blood pressure, relative wall thickness, and pulmonary arterial systolic pressure. In multivariate analysis, resting trans-LVOT PG correlated to pulmonary arterial pressure (ß = 0.226, p = 0.019) after adjustment for systolic blood pressure, relative wall thickness, and E/e'. CONCLUSIONS DLVOTO develops from various reasons, and patients with prominent PMs have distinct characteristics. We suggest to use DLVOTO-relieving medication might reduce pulmonary pressure in this group of patients.
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Affiliation(s)
| | | | - Young Won Yoon
- Division of Cardiology, Heart Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Ibrahim M, Rao C, Ashrafian H, Chaudhry U, Darzi A, Athanasiou T. Modern management of systolic anterior motion of the mitral valve. Eur J Cardiothorac Surg 2012; 41:1260-70. [DOI: 10.1093/ejcts/ezr232] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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10
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van Ramshorst J, Mollema SA, Delgado V, van der Wall EE, Schalij MJ, Atsma DE, Bax JJ. Relation of immediate decrease in ventricular septal strain after alcohol septal ablation for obstructive hypertrophic cardiomyopathy to long-term reduction in left ventricular outflow tract pressure gradient. Am J Cardiol 2009; 103:1592-7. [PMID: 19463521 DOI: 10.1016/j.amjcard.2009.01.373] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 01/31/2009] [Accepted: 01/31/2009] [Indexed: 12/25/2022]
Abstract
Alcohol septal ablation (ASA) aims to decrease left ventricular outflow tract (LVOT) obstruction in patients with obstructive hypertrophic cardiomyopathy (HC). To date, no diagnostic variables at baseline are available to predict long-term success of the procedure. We hypothesized that an immediate decrease in septal longitudinal strain after ASA would be associated with sustained LVOT gradient decrease after 6 months. ASA was performed in 22 patients with HC and severe drug-refractory symptoms. Clinical evaluation and 2-dimensional echocardiography were performed before, 1 day after, and 6 months after ASA. During 6-month follow-up, New York Heart Association class improved (2.7 +/- 0.5 vs 1.4 +/- 0.6, p <0.01) and LVOT gradient decreased (68 +/- 31 vs 21 +/- 21 mm Hg, p <0.01). Strain evaluation showed considerable decreases in basal septal strain (-12 +/- 3% vs -8 +/- 2%, p <0.01) and midseptal strain (-13 +/- 4% vs -8 +/- 3%, p <0.01) 1 day after ASA. Decreases in basal septal and midseptal strain 1 day after ASA were strongly related to the decrease in LVOT gradient during 6-month follow-up (r = 0.70, p <0.01, and r = 0.65, p <0.01, respectively). In conclusion, in patients with HC and severe drug-refractory symptoms, immediate decrease in septal strain after ASA is strongly related to a decrease in LVOT gradient after 6 months and might therefore serve as an early determinant for long-term success of the ASA procedure.
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Affiliation(s)
- Jan van Ramshorst
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Zywica K, Jenni R, Pellikka P, Faeh-Gunz A, Seifert B, Attenhofer Jost C. Dynamic left ventricular outflow tract obstruction evoked by exercise echocardiography: prevalence and predictive factors in a prospective study. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 9:665-71. [DOI: 10.1093/ejechocard/jen070] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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