1
|
Andrási TB, Glück AC, Talipov I, Volevski L, Vasiloi I. Sequential composite BIMA grafting for 3v-CAD: factors that predict successful outcome of the one-inflow and two-inflow revascularization techniques. Gen Thorac Cardiovasc Surg 2024; 72:656-667. [PMID: 38509384 PMCID: PMC11402859 DOI: 10.1007/s11748-024-02022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/25/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE The effect of one-inflow and two-inflow coronary surgical revascularization techniques inclosing skeletonized double mammary artery (BIMA) as T-graft on outcome is studied. METHODS Early ad mid-term outcome of complete BIMA revascularization (C-T-BIMA) versus left-sided BIMA with right-sided aorto-coronary bypass (L-T-BIMA + R-CABG) is quantified and analyzed by multivariate logistic regression, Cox-regression, and Kaplan-Meier analysis in a series of 204 consecutive patients treated for triple-vessel coronary disease (3v-CAD). RESULTS The L-T-BIMA + R-CABG technique (n = 104) enables higher number of total (4.02 ± 0.87 vs. 3.71 ± 0.69, p = 0.015) and right-sided (1.21 ± 0.43 vs. 1.02 ± 0.32, p = 0.001) coronary anastomoses, improves total bypass flow (125.88 ± 92.41 vs. 82.50 ± 49.26 ml, p < 0.0001) and bypass flow/anastomosis (31.83 ± 23.9 vs.22.77 ± 14.23, p = 0.001), and enhances completeness of revascularization (84% vs.69%, p = 0.014) compared to C-T-BIMA strategy (n = 100), respectively. Although the incidence of MACCE was comparable in the two groups (8% vs.1.2%, p = 0.055), the progression of functional mitral regurgitation (FMR) was significantly lower after L-T-BIMA + R-CABG, then after C-T-BIMA (47% vs.64%, p = 0.017). The use of C-T-BIMA-technique (HR = 4.2, p = 0.01) and preoperative RCA occlusion (HR = 3.006, p = 0.023) predicted FMR progression, whereas L-T-Graft + R-CABG technique protected against it (X2 = 14.04, p < 0.0001) independent of the anatomic and clinical complexity (Syntax score I: HR = 16.2, p = 0.156, Syntax score II: HR = 1.901, p = 0.751), of early- (0.96% vs.2%, p = 0.617) and mid-term mortality (5.8% vs.4%, p = 0.748) when compared to C-T-BIMA, respectively. CONCLUSIONS The two-inflow coronary revascularization by L-T-BIMA + R-CABG better protects against FMR progression without increasing MACCE and mortality. Older patients with RCA occlusion and reduced LV-EF benefit most from the two-inflow L-T-BIMA + R-CABG technique. Younger 3v-CAD patients with normal LV-EF can preferentially be managed with the one-inflow C-T-BIMA; however, long-term outcome remains to be revealed.
Collapse
Affiliation(s)
- Terézia B Andrási
- Department of Cardiac and Cardiovascular Surgery, Philipps University of Marburg, Baldingerstrasse 1, 35041, Marburg, Germany.
| | - Alannah C Glück
- Department of Cardiac and Cardiovascular Surgery, Philipps University of Marburg, Baldingerstrasse 1, 35041, Marburg, Germany
- School of Medicine, Philipps University of Marburg, Marburg, Germany
| | - Ildar Talipov
- Department of Cardiac and Cardiovascular Surgery, Philipps University of Marburg, Baldingerstrasse 1, 35041, Marburg, Germany
| | - Lachezar Volevski
- Department of Cardiac and Cardiovascular Surgery, Philipps University of Marburg, Baldingerstrasse 1, 35041, Marburg, Germany
- Department of Cardiac Surgery, Cardiac Center, Rotenburg an Der Fulda, Germany
- School of Medicine, Philipps University of Marburg, Marburg, Germany
| | - Ion Vasiloi
- Department of Cardiac Surgery, Cardiac Center, Rotenburg an Der Fulda, Germany
- School of Medicine, Philipps University of Marburg, Marburg, Germany
- Department of Cardiac Surgery, University of Basel, Basel, Switzerland
| |
Collapse
|
2
|
Nappi F. Atrial functional mitral regurgitation in cardiology and cardiac surgery. J Thorac Dis 2024; 16:5435-5456. [PMID: 39268136 PMCID: PMC11388212 DOI: 10.21037/jtd-24-189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/12/2024] [Indexed: 09/15/2024]
Abstract
Functional or secondary mitral regurgitation (MR) is a clear and present danger to cardiovascular health, with heightened morbidity and mortality rates. Secondary MR is caused by an imbalance between two sets of forces. There are two forces at play here. One keeps the mitral leaflets tethered, while the other closes them. The evidence clearly shows inadequate coaptation. Functional MR (FMR) is the typical form of MR. It is almost always caused by dysfunction and alterations of the left ventricle (LV) geometry. It occurs in both ischemic and non-ischemic disease states. Atrial FMR (AFMR) is a disease that has only recently come to be acknowledged. This phenomenon arises when mitral annular enlargement is caused by left atrial enlargement. This preserves the geometry and function of the LV. AFMR is most frequently encountered in individuals with chronic atrial fibrillation or heart failure, in whom a normal ejection fraction is present. Published studies and ongoing research vary in their definition of AFMR, but there is no doubt that AFMR exists. This review definitively explains the pathophysiology of AFMR and demonstrates the necessity of a common working standard for the definition of AFMR. This is essential to warrant cohesiveness in the data reported and to drive forward the much-needed research into the outcomes and treatment strategies in this critical field. A number of high-quality studies have demonstrated that restrictive mitral annuloplasty and transcatheter procedure based on edge-to-edge repair are effective in reducing MR and alleviating symptoms. The pathophysiology, echocardiographic diagnosis, and treatment of AFMR are thoroughly reviewed in this comprehensive review.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, France
| |
Collapse
|
3
|
Girdauskas E, Stock S, Favot E, Luani B, Sequeira-Gross T, Dumps C, von Stumm M, Owais T, von Scheidt W. Papillary Muscle Maneuvers: Pathophysiology-based Approach in Secondary Mitral Regurgitation. Rev Cardiovasc Med 2024; 25:283. [PMID: 39228498 PMCID: PMC11367014 DOI: 10.31083/j.rcm2508283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/12/2024] [Accepted: 06/03/2024] [Indexed: 09/05/2024] Open
Abstract
The treatment of secondary mitral regurgitation (SMR) remains challenging despite the implementation of modern heart failure medication and established catheter-based techniques. Only a subgroup of SMR patients benefit from mitral valve (MV) intervention, and the long-term prognostic benefit of different therapeutic approaches in SMR remains controversial. A literature search was conducted through PubMed and Embase databases to identify relevant studies addressing the pathophysiological background for papillary muscle maneuvers in SMR and currently available surgical techniques. Furthermore, the studies evaluating patients' selection criteria for papillary muscle maneuvers were specifically considered. Articles were selected based on quality and relevance. Over the last two decades, papillary muscle maneuvers have evolved as a pathophysiology-based treatment strategy to address left ventricular (LV) remodeling in SMR. In particular, patients with severe leaflet tenting and moderate heart failure phenotype seem to benefit most from papillary muscle maneuvers that improve LV geometry and thereby the durability of MV repair. We conclude that papillary muscle maneuvers are an evolving pathophysiology-based treatment strategy of ventricular SMR which target papillary muscle displacement due to LV remodeling.
Collapse
Affiliation(s)
- Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, 86150 Augsburg, Germany
| | - Sina Stock
- Department of Cardiothoracic Surgery, University Hospital Augsburg, 86150 Augsburg, Germany
| | - Elisa Favot
- Department of Cardiothoracic Surgery, University Hospital Augsburg, 86150 Augsburg, Germany
| | - Blerim Luani
- Department of Cardiology, Hospital Ingolstadt, 85049 Ingolstadt, Germany
| | - Tatiana Sequeira-Gross
- Department of Cardiothoracic Surgery, University Hospital Augsburg, 86150 Augsburg, Germany
| | - Christian Dumps
- Department of Anesthesiology and Intensive Care, University Hospital Augsburg, 86150 Augsburg, Germany
| | - Maria von Stumm
- Department of Congenital and Pediatric Cardiac Surgery, German Heart Center Munich, Technische Universität München, 80636 Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital Munich, Ludwids-Maximilians-University, 80539 Munich, Germany
| | - Tamer Owais
- Department of Cardiothoracic Surgery, University Hospital Augsburg, 86150 Augsburg, Germany
| | | |
Collapse
|
4
|
Wang M, Zhang H, Liu Z, Han J, Liu J, Zhang N, Li S, Tang W, Liu P, Tian B, Luo T, Wang J, Meng X, Ye H, Xu L, Zhang H, Jiang W. Scoring model based on cardiac CT and clinical factors to predict early good mitral valve repair in rheumatic mitral disease. Eur Radiol 2024; 34:4963-4976. [PMID: 38252276 DOI: 10.1007/s00330-023-10470-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 09/24/2023] [Accepted: 10/16/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE We aimed to evaluate the mitral valve calcification and mitral structure detected by cardiac computed tomography (cardiac CT) and establish a scoring model based on cardiac CT and clinical factors to predict early good mitral valve repair (EGMR) and guide surgical strategy in rheumatic mitral disease (RMD). MATERIALS AND METHODS This is a retrospective bi-center cohort study. Based on cardiac CT, mitral valve calcification and mitral structure in RMD were quantified and evaluated. The primary outcome was EGMR. A logical regression algorithm was applied to the scoring model. RESULTS A total of 579 patients were enrolled in our study from January 1, 2019, to August 31, 2022. Of these, 443 had baseline cardiac CT scans of adequate quality. The calcification quality score, calcification and thinnest part of the anterior leaflet clean zone, and papillary muscle symmetry were the independent CT factors of EGMR. Coronary artery disease and pulmonary artery pressure were the independent clinical factors of EGMR. Based on the above six factors, a scoring model was established. Sensitivity = 95% and specificity = 95% were presented with a cutoff value of 0.85 and 0.30 respectively. The area under the receiver operating characteristic of external validation set was 0.84 (95% confidence interval [CI] 0.73-0.93). CONCLUSIONS Mitral valve repair is recommended when the scoring model value > 0.85 and mitral valve replacement is prior when the scoring model value < 0.30. This model could assist in guiding surgical strategies for RMD. CLINICAL RELEVANCE STATEMENT The model established in this study can serve as a reference indicator for surgical repair in rheumatic mitral valve disease. KEY POINTS • Cardiac CT can reflect the mitral structure in detail, especially for valve calcification. • A model based on cardiac CT and clinical factors for predicting early good mitral valve repair was established. • The developed model can help cardiac surgeons formulate appropriate surgical strategies.
Collapse
Affiliation(s)
- Maozhou Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Hongkai Zhang
- Department of Radiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Vascular Diseases, Capital Medical University, Beijing, China
| | - Zhou Liu
- Center for Clinical and Epidemiologic Research, Beijing An Zhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jie Han
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Jing Liu
- Center for Clinical and Epidemiologic Research, Beijing An Zhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Nan Zhang
- Department of Radiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Vascular Diseases, Capital Medical University, Beijing, China
| | - Shuang Li
- Department of Radiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Vascular Diseases, Capital Medical University, Beijing, China
| | - Wenjie Tang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Peiyi Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Baiyu Tian
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Tiange Luo
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Jiangang Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Xu Meng
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Hongyu Ye
- Department of Cardiothoracic Surgery, Zhongshan City People's Hospital, Sun Wenzhong Road, Zhongshan, China.
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Vascular Diseases, Capital Medical University, Beijing, China.
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China.
| | - Wenjian Jiang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China.
| |
Collapse
|
5
|
Conradi L, Ludwig S, Sorajja P, Duncan A, Bethea B, Dahle G, Babaliaros V, Guerrero M, Thourani V, Dumonteil N, Modine T, Garatti A, Denti P, Leipsic J, Chuang ML, Blanke P, Muller DW, Badhwar V. Clinical outcomes and predictors of transapical transcatheter mitral valve replacement: the Tendyne Expanded Clinical Study. EUROINTERVENTION 2024; 20:e887-e897. [PMID: 39007829 PMCID: PMC11228541 DOI: 10.4244/eij-d-23-00904] [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: 10/24/2023] [Accepted: 04/15/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Transcatheter mitral valve replacement (TMVR) is a therapeutic option for patients with severe mitral regurgitation (MR) who are ineligible for conventional surgery. There are limited data on the outcomes of large patient cohorts treated with TMVR. AIMS This study aimed to investigate the outcomes and predictors of mortality for patients treated with transapical TMVR. METHODS This analysis represents the clinical experience of all patients enrolled in the Tendyne Expanded Clinical Study. Patients with symptomatic MR underwent transapical TMVR with the Tendyne system between November 2014 and June 2020. Outcomes and adverse events up to 2 years, as well as predictors of short-term mortality, were assessed. RESULTS A total of 191 patients were treated (74.1±8.0 years, 62.8% male, Society of Thoracic Surgeons Predicted Risk of Mortality 7.7±6.6%). Technical success was achieved in 96.9% (185/191), and there were no intraprocedural deaths. At 30-day, 1- and 2-year follow-up, the rates of all-cause mortality were 7.9%, 30.8% and 40.5%, respectively. Complete MR elimination (MR <1+) was observed in 99.3%, 99.1% and 96.3% of patients, respectively. TMVR treatment resulted in consistent improvement of New York Heart Association Functional Class and quality of life up to 2 years (both p<0.001). Independent predictors of early mortality were age (odds ratio [OR] 1.11; p=0.003), pulmonary hypertension (OR 3.83; p=0.007), and institutional experience (OR 0.40; p=0.047). CONCLUSIONS This study investigated clinical outcomes in the full cohort of patients included in the Tendyne Expanded Clinical Study. The Tendyne TMVR system successfully eliminated MR with no intraprocedural deaths, resulting in an improvement in symptoms and quality of life. Continued refinement of clinical and echocardiographic risks will be important to optimise longitudinal outcomes.
Collapse
Affiliation(s)
- Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Sebastian Ludwig
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- Cardiovascular Research Foundation, New York, NY, USA
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Brian Bethea
- MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gry Dahle
- Oslo University Hospital, Oslo, Norway
| | | | | | - Vinod Thourani
- Department of Cardiovascular Surgery, Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Nicolas Dumonteil
- Groupe Cardiovasculaire Interventionnel, Clinique Pasteur, Toulouse, France
| | - Thomas Modine
- Unité Médico Chirurgicale de Valvulopathie, Hôpital Haut Lévêque, CHU de Bordeaux, Pessac, France
| | - Andrea Garatti
- IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Paolo Denti
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
| | | | | | | | - David W Muller
- Cardiology Department, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Vinay Badhwar
- Department of Cardiovascular & Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| |
Collapse
|
6
|
Hage F, Hage A, Cervetti MR, Chu MWA. Mitral valve replacement in young patients: review and current challenges. Future Cardiol 2024:1-9. [PMID: 38985451 DOI: 10.1080/14796678.2024.2343592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 04/12/2024] [Indexed: 07/11/2024] Open
Abstract
Mitral valve repair is the ideal intervention for mitral valve disease with excellent long-term survival comparable to the age-matched general population. When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses. Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients. Patients presenting for mitral valve surgery after failed transcatheter mitral valve-in-valve have high rates of postoperative mortality and morbidity, exceeding those seen with reoperative mitral valve surgery, which poses issues in young patients who have a higher cumulative incidence of reintervention.
Collapse
Affiliation(s)
- Fadi Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Manuel R Cervetti
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| |
Collapse
|
7
|
Formica F, Gallingani A, Tuttolomondo D, Hernandez-Vaquero D, D'Alessandro S, Singh G, Benassi F, Grassa G, Pattuzzi C, Maestri F, Nicolini F. Long-term outcomes comparison of mitral valve repair or replacement for secondary mitral valve regurgitation. An updated systematic review and reconstructed time-to-event study-level meta-analysis. Curr Probl Cardiol 2024; 49:102636. [PMID: 38735348 DOI: 10.1016/j.cpcardiol.2024.102636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND AND AIM The ideal surgical intervention for secondary mitral regurgitation (SMR), a disease of the left ventricle not the mitral valve itself, is still debated. We performed an updated systematic review and study-level meta-analysis investigating mitral valve repair (MVr) versus mitral valve replacement (MVR) for adult patients with SMR, with or without coronary artery disease (CAD). METHODS PubMed, CENTRAL and EMBASE were searched for studies comparing MVr versus MVR. Randomized trial or observational studies were considered eligible. Primary endpoint was long-term mortality for any cause. Kaplan-Meier survival curves were reconstructed and compared with Cox linear regression. Landmark analysis and time-varying hazard ratio (HR) were analyzed. Sensitivity analyses included meta-regression and separate sub-analysis. A random effects model was used. RESULTS Twenty-three studies (MVr=3,727 and MVR=2,839) were included. One study was a randomized trial, and 19 studies were adjusted. The mean weighted follow-up was 3.7±2.8 years. MVR was associated with significative greater late mortality (HR=1.26; 95 % CI, 1.14-1.39; P<0.0001) at 10-year follow-up. There was a time-varying trend showing an increased risk of mortality in the first 2 years after MVR (HR=1.38; 95 % CI, 1.21-1.56; P<0.0001), after which this difference dissipated (HR=0.94; 95 % CI, 0.81-1.09; P=0.41). Separate sub-analyses showed comparable long-term mortality in patients with concomitant coronary surgery ≥90 %, left ventricle ejection fraction ≤40 %, and sub-valvular apparatus preservation rate of 100 %. CONCLUSIONS Compared to repair, MVR is associated with higher probability of mortality in the first 2 years following surgery, after which the two procedures showed comparable late mortality rate.
Collapse
Affiliation(s)
- Francesco Formica
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy.
| | - Alan Gallingani
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | | | | | | | - Gurmeet Singh
- Department of Critical Care Medicine and Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Filippo Benassi
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Giulia Grassa
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Claudia Pattuzzi
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | | | - Francesco Nicolini
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| |
Collapse
|
8
|
Chyou JY, Qin H, Butler J, Voors AA, Lam CSP. Sex-related similarities and differences in responses to heart failure therapies. Nat Rev Cardiol 2024; 21:498-516. [PMID: 38459252 DOI: 10.1038/s41569-024-00996-1] [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] [Accepted: 02/01/2024] [Indexed: 03/10/2024]
Abstract
Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.
Collapse
Affiliation(s)
- Janice Y Chyou
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hailun Qin
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-NUS Medical School, Singapore, Singapore.
| |
Collapse
|
9
|
Akashi J, Otsuji Y, Nishimura Y, Levine RA, Kataoka M. Updated pathophysiological overview of functional MR (ventricular and atrial). Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02047-5. [PMID: 38858323 DOI: 10.1007/s11748-024-02047-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/22/2024] [Indexed: 06/12/2024]
Abstract
Basic mechanism of ventricular functional mitral regurgitation (FMR) is subvalvular tethering. Left ventricular (LV) dilatation, in association with mitral valve (MV) annular dilatation, causes outward displacement of papillary muscles (PMs), which abnormally pulls or tethers MV leaflets, resulting in MV tenting, reduction in leaflets coaptation and MR. Because surgical annuloplasty does shorten distance between anterior and posterior MV annuli to improve coaptation but does not address this subvalvular tethering, ventricular FMR frequently persists or recurs in the chronic stage after surgical annuloplasty. This high incidence of persistent/recurrent MR requires additional procedures to reduce subvalvular tethering. Although patients occasionally show marked improvements after annuloplasty with surgical tethering reduction procedures such as PM approximation, evidence to support benefits of such surgery is limited, requiring further trials. Recently, MV adaptation or MV leaflets tissue growth associated with LV dilatation attracts attention. Patients with larger MV leaflets with significant LV dilatation/dysfunction show less MV tethering and MR compared to those with smaller MV leaflets but with similar LV remodeling, suggesting the protective or beneficial role of MV leaflets tissue growth against LV remodeling. The MV leaflets tissue growth has the potential to lead to novel strategies of treatment for ventricular FMR. It is well known that atrial FMR is frequent in patients with left atrial dilatation, typically in those with isolated atrial fibrillation. The degree of atrial FMR is usually mild, even when it is present, and occasionally moderate, and severe atrial FMR is really rare. It is known that only severe regurgitation causes heart failure in primary MR, resulting in description on indications of surgery or intervention for only severe MR in current guidelines. Therefore, this atrial FMR up to moderate degree did not attract attention for a long time. However, recent studies have shown that patients with only moderate atrial FMR develop severe heart failure, suggesting more aggressive indication of MV surgery or intervention for "moderate" regurgitation in patients with atrial FMR. Therefore, atrial FMR is now recognized highly important. The unveiled malignant nature of atrial FMR arises many questions, including (1) why patients with only moderate atrial FMR develop heart failure? (2) do patients with mild atrial FMR develop heart failure or not?, and many others. Atrial FMR seems even more mysterious after the unveiling of its significance.
Collapse
Affiliation(s)
- Jun Akashi
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yutaka Otsuji
- Department of Cardiovascular Medicine, Hagiwara Central Hospital, 1-10-1 Hagiwara, Yahatanishiku, Kitakyushu, 806-0059, Japan.
| | - Yosuke Nishimura
- Department of Cardiovascular Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, MA, USA
| | - Masaharu Kataoka
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| |
Collapse
|
10
|
Sideris K, Burri M, Mayr A, Voss S, Vitanova K, Prinzing A, Voss B, Amabile A, Geirsson A, Krane M, Guenzinger R. Functional Mitral Valve Regurgitation: Mitral Valve Repair or Replacement? Our "Road Map" for the Appropriate Strategy. J Clin Med 2024; 13:3264. [PMID: 38892978 PMCID: PMC11172680 DOI: 10.3390/jcm13113264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/14/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives: The optimal surgical approach for the treatment of functional mitral regurgitation (FMR) remains controversial. Current guidelines suggest that the surgical approach has to be tailored to the individual patient. The aim of the present study was to clarify further aspects of this tailored treatment. Methods: From 01/2006 to 12/2015, 390 patients underwent mitral valve (MV) surgery for FMR (ischemic n = 241, non-ischemic n = 149) at our institution. A regression analysis was used to determine the effect of MV repair or replacement on survival. The patients were analyzed according to the etiology of the MR (ischemic or non-ischemic), different age groups (<65 years, 65-75 years, and >75 years), LV function, and LV dimensions, as well as the underlying heart rhythm. Results: The overall survival rates for the repair group at 1, 5, and 8 years were 86.1 ± 1.9%, 70.6 ± 2.6%, and 55.1 ± 3.1%, respectively. For the same intervals, the survival rates in patients who underwent MV replacement were 75.9 ± 4.5%, 58.6 ± 5.4%, and 40.9 ± 6.4%, respectively (p = 0.003). Patients younger than 65 years, with an ischemic etiology of FMR, poor ejection fraction (<30%), severe dilatation of left ventricle (LVEDD > 60mm), and presence of atrial fibrillation had significantly higher mortality rates after MV replacement (HR, 3.0; CI, 1.3-6.9; p = 0.007). Patients between 65 and 75 years of age had a higher risk of death when undergoing mitral valve replacement (HR, 1.7; CI, 1.0-2.8; p = 0.04). In patients older than 75 years, the surgical approach (MV repair or replacement) had no effect on postoperative survival (HR, 0.8; CI, 0.4-1.3; p = 0.003). Conclusions: Our data demonstrate that, in patients younger than 65 years, the treatment of choice for FMR should be MV repair. This advantage was even more evident in patients with an ischemic origin of MR, a poor ejection fraction, a severe LV dilatation, and atrial fibrillation.
Collapse
Affiliation(s)
- Konstantinos Sideris
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| | - Melchior Burri
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| | - Antonia Mayr
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| | - Stephanie Voss
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| | - Keti Vitanova
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| | - Anatol Prinzing
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| | - Bernhard Voss
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| | - Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York City, NY 10032, USA
| | - Markus Krane
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA;
- DZHK (German Center for Cardiovascular Research)—Partner Site Munich Heart Alliance, 80636 Munich, Germany
| | - Ralf Guenzinger
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (K.S.); (A.P.)
| |
Collapse
|
11
|
Werner P, Aref T, Uyanik-Uenal K, Kocher A, Tozzi P, Laufer G, Andreas M. First-in-Man Study of a Novel, Balloon-Adjustable Mitral Annuloplasty Ring. J Clin Med 2024; 13:3214. [PMID: 38892924 PMCID: PMC11172768 DOI: 10.3390/jcm13113214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/09/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives: Mitral valve repair is the current standard approach for mitral valve regurgitation. However, patients suffering from functional mitral regurgitation have a significant risk of recurrent regurgitation. Adjustable mitral rings may provide a solution for this adverse event. Methods: A single-center, first-in-man clinical study was performed on patients suffering from mitral valve regurgitation. Patients were implanted with the study ring and followed for six months. A balloon catheter can be inserted into the study ring frame at any time after implantation and inflated independently in the areas P1, P2, or P3, which reduces the anterior-posterior diameter. Results: Five patients (75.4 ± 6.1 years; EuroSCORE II 2.1 ± 0.9%; three female) were successfully implanted. Mechanisms of mitral regurgitation were prolapse of the P2-segment in three patients and annular dilation in two patients. Surgical implantation according to the protocol was feasible and is described herein. Median cardiopulmonary bypass time and cross clamp time were 105 (118; 195) and 94 (90; 151) min, respectively. The median intensive care unit stay was 2 (2; 3) days. No perioperative, 30-day, or 6-month mortality was observed, and the repair was stable without residual or recurrent regurgitation ≥ grade 2. All patients reached the primary endpoint without device-related morbidity. Conclusions: Successful implantation was completed in five patients without device-related adverse events. Ring implantation was safe and feasible for all patients. The opportunity of post-implant adjustment to improve leaflet coaptation is a promising new therapeutic strategy that is assessed in a phase II study.
Collapse
Affiliation(s)
- Paul Werner
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Tandis Aref
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Keziban Uyanik-Uenal
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Alfred Kocher
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Piergiorgio Tozzi
- Department of Cardiovascular Surgery, Center Hospitalier Universitaire Vaudois, 1005 Lausanne, Switzerland;
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| |
Collapse
|
12
|
Lorusso R, Matteucci M, Lerakis S, Ronco D, Menicanti L, Sharma SK, Moreno PR. Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5. J Am Coll Cardiol 2024; 83:1917-1935. [PMID: 38719371 DOI: 10.1016/j.jacc.2024.02.044] [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: 11/28/2023] [Revised: 01/18/2024] [Accepted: 02/09/2024] [Indexed: 07/16/2024]
Abstract
Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.
Collapse
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Cardiac Surgery Unit, ASSTSette Laghi, Varese, Italy
| | - Stamatios Lerakis
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniele Ronco
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Cardiac Surgery Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Samin K Sharma
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pedro R Moreno
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Igor Palacios Fellows Foundation, Boston Massachusetts, USA.
| |
Collapse
|
13
|
Estévez-Loureiro R, Lorusso R, Taramasso M, Torregrossa G, Kini A, Moreno PR. Management of Severe Mitral Regurgitation in Patients With Acute Myocardial Infarction: JACC Focus Seminar 2/5. J Am Coll Cardiol 2024; 83:1799-1817. [PMID: 38692830 DOI: 10.1016/j.jacc.2023.09.840] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 05/03/2024]
Abstract
Severe acute mitral regurgitation after myocardial infarction includes partial and complete papillary muscle rupture or functional mitral regurgitation. Although its incidence is <1%, mitral regurgitation after acute myocardial infarction frequently causes hemodynamic instability, pulmonary edema, and cardiogenic shock. Medical management has the worst prognosis, and mortality has not changed in decades. Surgery represents the gold standard, but it is associated with high rates of morbidity and mortality. Recently, transcatheter interventions have opened a new door for management that may improve survival. Mechanical circulatory support restores vital organ perfusion and offers the opportunity for a steadier surgical repair. This review focuses on the diagnosis and the interventional management, both surgical and transcatheter, with a glance on future perspectives to enhance patient management and eventually decrease mortality.
Collapse
Affiliation(s)
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | | | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA; Department of Cardiothoracic Surgery, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Annapoorna Kini
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pedro R Moreno
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
14
|
Drake DH, Zhang P, Zimmerman KG, Morrow CD, Sidebotham DA. Anatomic, stage-based repair of secondary mitral valve disease. J Thorac Cardiovasc Surg 2024; 167:1733-1744. [PMID: 36775783 DOI: 10.1016/j.jtcvs.2023.01.006] [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: 09/12/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Intervention for repair of secondary mitral valve disease is frequently associated with recurrent regurgitation. We sought to determine if there was sufficient evidence to support inclusion of anatomic indices of leaflet dysfunction in the management of secondary mitral valve disease. METHODS We performed a systematic review and meta-analysis of published reports comparing anatomic indices of leaflet dysfunction with the complexity of valve repair and the outcome from intervention. Patients were stratified by the severity of leaflet dysfunction. A secondary analysis was performed comparing outcomes when procedural complexity was optimally matched to severity of leaflet dysfunction and when intervention was not matched to dysfunction. RESULTS We identified 6864 publications, of which 65 met inclusion criteria. An association between the severity of leaflet dysfunction and the procedural complexity was highly predictive of satisfactory freedom from recurrent regurgitation. Patients were categorized into 4 groups based on stratification of leaflet dysfunction. Satisfactory results were achieved in 93.7% of patients in whom repair complexity was appropriately matched to severity of leaflet dysfunction and in 68.8% in whom repair was not matched to dysfunction (odds ratio, 0.148; 95% confidence interval, 0.119-0.184; P < .0001). CONCLUSIONS For patients with secondary mitral valve disease, satisfactory outcome from valve repair improves when procedural complexity is matched to anatomic indices of leaflet dysfunction. Anatomic indices of leaflet dysfunction should be considered when planning interventions for secondary mitral regurgitation. Routine inclusion of anatomic indices in trial design and reporting should facilitate comparison of results and strengthen guidelines. There are sufficient data to support anatomic staging of secondary mitral valve disease.
Collapse
Affiliation(s)
- Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich; Department of Surgery, Munson Medical Center, Traverse City, Mich.
| | - Peng Zhang
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | | | - Cynthia D Morrow
- Health Systems, Management & Policy, Colorado School of Public Health, Aurora, Colo
| | - David A Sidebotham
- Department of Cardiothoracic Anaesthesia and Cardiothoracic Intensive Care, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
15
|
Misumi Y, Kawamura M, Yoshioka D, Kawamura T, Kawamura A, Ito Y, Mikami T, Taira M, Shimamura K, Miyagawa S. Restrictive annuloplasty or replacement on reverse remodeling for nonischemic dilated cardiomyopathy. J Cardiothorac Surg 2024; 19:201. [PMID: 38609986 PMCID: PMC11010381 DOI: 10.1186/s13019-024-02719-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND For patients with nonischemic dilated cardiomyopathy (NIDCM), the indications for and results of mitral surgery remain controversial. We reviewed a strategy of mitral repair and replacement for clinically relevant secondary mitral regurgitation (MR) in patients with NIDCM. METHODS We retrospectively reviewed 65 patients with advanced NIDCM (LVEF < 40%) who underwent mitral surgery. Of them, 47 (72%) underwent mitral annuloplasty and 18 (28%) replacement for secondary MR. The primary endpoint was postoperative reduction in indexed LV end-systolic volume (LVESVI). RESULTS At baseline, there was no intergroup difference in LVESVI (123 ± 47 vs. 147 ± 37 ml/m2, P = 0.055), LVEF (27 ± 8% vs. 25 ± 6%, P = 0.41), incidence of severe MR (57% (27/47) vs. 72% (13/18), P = 0.40), or EuroSCORE II score (6.2% vs. 7.6%, P = 0.90). At 6 months, the annuloplasty group reduced LVESVI to a greater degree than the replacement group (P < 0.001), yielding significantly smaller postoperative LVESVI (96 ± 59 vs. 154 ± 61 ml/m2, P < 0.001) and better LVEF (P < 0.001). The rates of moderate/severe recurrent MR were 17% (8/47) and 0%, respectively. Multivariable analysis demonstrated that mitral annuloplasty (OR 6.10, 95% CI 1.14-32.8, P = 0.035) was significantly associated with postoperative LV reverse remodeling. Cumulative survival was not different between the groups (P = 0.26). CONCLUSIONS In patients with NIDCM, mitral annuloplasty reduced LV volume to a greater degree than did mitral replacement. These findings may assist with surgical options for secondary MR associated with NIDCM.
Collapse
Affiliation(s)
- Yusuke Misumi
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan.
| | - Masashi Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Ai Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Yoshito Ito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Tsubasa Mikami
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Masaki Taira
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2-E1, Yamadaoka, Suita City, Osaka, 565-0871, Japan
| |
Collapse
|
16
|
Alsheebani S, Albert C, de Varennes B. Long-term follow-up of posterior mitral leaflet extension for Type IIIb ischemic mitral regurgitation. JTCVS OPEN 2024; 18:33-42. [PMID: 38690431 PMCID: PMC11056449 DOI: 10.1016/j.xjon.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 12/09/2023] [Accepted: 01/03/2024] [Indexed: 05/02/2024]
Abstract
Objective Ischemic mitral regurgitation (MR) is generally associated with very poor outcomes and disappointing results, despite a seemingly perfect initial repair and optimal revascularization. We previously published our intermediate-term results of posterior leaflet augmentation without follow-up extending beyond 4 years. Our objective is to assess long-term durability of the repair, survival, and the causes of late mortality. Methods Ninety-one patients with severe (4+) Carpentier Type IIIb ischemic MR underwent repair in a single center between 2003 and 2022 by method of posterior leaflet extension using a patch of bovine pericardium and a true-sized remodeling annuloplasty ring, with or without surgical revascularization. Serial echocardiography was performed over the years to ascertain valve competence and degree of ventricular remodeling, in addition to telephone follow-up and chart reviews. Results The average age of patients was 67 ± 9.6 years. Mean follow-up was 8 ± 5 years with some extending to almost 20 years. One-, 5-, and 10-year freedom from recurrent significant MR, characterized as moderate or severe MR, was 98.6%, 85.5%, and 71.3%, respectively. Thirty-day mortality was 6.5%. One-, 5-, and 10-year survival was 85.5%, 64.4%, and 43.3%, respectively. Of all the mortalities, only 17.5% were proven to be directly cardiac related. Conclusions The suggested repair technique offers satisfactory long-term outcomes with minimal residual regurgitation in surviving patients when used in context of ischemic MR. Despite durable repair, we have discovered that poor long-term survival is not directly related to cardiovascular causes.
Collapse
Affiliation(s)
| | - Carole Albert
- Division of Cardiac Surgery, Royal Victoria Hospital, Glen Site, Montreal, Quebec, Canada
| | - Benoit de Varennes
- McGill University Health Center, Montreal, Quebec, Canada
- Division of Cardiac Surgery, Royal Victoria Hospital, Glen Site, Montreal, Quebec, Canada
| |
Collapse
|
17
|
Boyle C, Nguyen K, Steiner J, Macon CJ, Marbach JA. Mitral Regurgitation Complicated by Cardiogenic Shock: Reassessing Risk Stratification and Therapeutic Strategies. Interv Cardiol Clin 2024; 13:191-205. [PMID: 38432762 DOI: 10.1016/j.iccl.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Mitral regurgitation complicated by cardiogenic shock creates a unique and devastating risk profile for patients and poses significant difficulties for physicians who lack a comprehensive range of effective management strategies. Supportive measures such as intravenous vasodilators, intra-aortic balloon pumps, and percutaneous ventricular assist devices are often necessary to stabilize patients prior to definitive treatment with surgical mitral valve replacement or trans-catheter edge-to-edge repair. This review evaluates the evidence for the available supportive and definitive management strategies in patients with mitral regurgitation complicated by cardiogenic shock and presents a framework to aid clinicians in navigating the complex clinical decision-making process. Additionally, the authors review emerging transcatheter mitral valve replacement technologies that hold promise for expanding the therapeutic armamentarium and improving patient outcomes.
Collapse
Affiliation(s)
- Carla Boyle
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Khoa Nguyen
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Jeffrey A Marbach
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA.
| |
Collapse
|
18
|
Wakasa S, Shingu Y. Rough-zone suspension with mitral valve replacement for ventricular functional mitral regurgitation. Gen Thorac Cardiovasc Surg 2024; 72:247-249. [PMID: 37917393 DOI: 10.1007/s11748-023-01982-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/06/2023] [Indexed: 11/04/2023]
Abstract
Chordal preservation is recommended in mitral valve replacement for functional mitral regurgitation to preserve left ventricular function. In contrast, papillary muscle suspension toward the anterior mitral annulus can induce left ventricular reverse remodeling after mitral valve replacement for functional mitral regurgitation. However, the extent of suspension depends on the surgeon's experience. Therefore, we developed a new concept of chordal preservation, called rough-zone suspension, which not only spares the subvalvular structure but also suspends the papillary muscles toward the annulus. This procedure is simple and reproducible for determining the extent of suspension, and can increase the probability of left ventricular reverse remodeling after mitral valve replacement for functional mitral regurgitation.
Collapse
Affiliation(s)
- Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-Ku, Sapporo, 060-8638, Japan.
| | - Yasushige Shingu
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-Ku, Sapporo, 060-8638, Japan
| |
Collapse
|
19
|
Das C, Al Awwa G, Mills EL, Lantz G. Minimally Invasive Mitral Valve Repair Using Transcatheter Chordal Attachments. Interv Cardiol Clin 2024; 13:257-269. [PMID: 38432768 DOI: 10.1016/j.iccl.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
The advent of transcatheter mitral chordal replacement techniques has offered an alternative approach that is less invasive and may be more suitable for select patients compared with surgical repair. These systems involve introducing artificial chordae, via catheter, to replace or supplement damaged or elongated natural chordae. These artificial chordae are anchored at one end to the mitral leaflet and the other end to the papillary muscle or directly to the left ventricular apex, restoring the leaflet's coaptation and reducing regurgitation. Early trials and studies suggest promising results in terms of safety and efficacy in reducing MR severity and improving symptoms.
Collapse
Affiliation(s)
- Chandan Das
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L353, Portland, OR 97239, USA
| | - Ghayth Al Awwa
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L353, Portland, OR 97239, USA
| | - Emmanuel L Mills
- Knight Cardiovascular Institute, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code UHN-62, Portland, OR 97239, USA
| | - Gurion Lantz
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L353, Portland, OR 97239, USA.
| |
Collapse
|
20
|
Prasad P, Chandrashekar P, Golwala H, Macon CJ, Steiner J. Functional Mitral Regurgitation: Patient Selection and Optimization. Interv Cardiol Clin 2024; 13:167-182. [PMID: 38432760 DOI: 10.1016/j.iccl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Functional mitral regurgitation appears commonly among all heart failure phenotypes and can affect symptom burden and degree of maladaptive remodeling. Transcatheter mitral valve edge-to-edge repair therapies recently became an important part of the routine heart failure armamentarium for carefully selected and medically optimized candidates. Patient selection is considering heart failure staging, relevant comorbidities, as well as anatomic criteria. Indications and device platforms are currently expanding.
Collapse
Affiliation(s)
- Pooja Prasad
- Division of Cardiology, University of California-San Francisco, 505 Parnassus Avenue, Suite M1182, Box 0124, San Francisco, CA 94143, USA
| | - Pranav Chandrashekar
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Harsh Golwala
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA.
| |
Collapse
|
21
|
Lee HA, Chang FC, Yeh JK, Tung YC, Wu VCC, Hsieh MJ, Chen CY, Yeh CH, Chu PH, Chen SW. Mitral Valve Repair vs. Replacement by Different Etiologies - A Nationwide Population-Based Cohort Study. Circ J 2024; 88:568-578. [PMID: 38281764 DOI: 10.1253/circj.cj-23-0640] [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] [Indexed: 01/30/2024]
Abstract
BACKGROUND When mitral valve (MV) surgery is indicated, repair is preferred over replacement; however, this preference is not supported by evidence from clinical trials. Furthermore, the benefits of MV repair may not be universal for all etiologies of MV disease. METHODS AND RESULTS This study identified a total of 18,428 patients who underwent MV repair (n=4,817) or MV replacement (n=13,611) during 2001-2018 from Taiwan's National Health Insurance Research Database. These patients were classified into 4 etiologies: infective endocarditis (IE, n=2,678), rheumatic heart disease (RHD, n=4,524), ischemic mitral regurgitation (IMR, n=3,893), and degenerative mitral regurgitation (DMR, n=7,333). After propensity matching, all-cause mortality during follow-up was lower among patients receiving MV repair than among patients receiving MV replacement in the IE, IMR, and DMR groups (hazard ratio [HR]=0.72, 95% confidence interval [CI]: 0.55-0.93; HR=0.82, 95% CI: 0.73-0.92; and HR 0.73, 95% CI: 0.64-0.84, respectively). However, in the RHD group, the MV reoperation rate was higher after MV repair than after MV replacement (subdistribution HR=1.91, 95% CI: 1.02-3.55). CONCLUSIONS In comparison with MV replacement, MV repair was associated with a lower late mortality in patients with IE, IMR, and DMR, and a higher risk of reoperation in patients with RHD.
Collapse
Affiliation(s)
- Hsiu-An Lee
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
- Division of Cardiovascular Surgery, Cardiovascular Center, Taichung Veterans General Hospital
| | - Feng-Cheng Chang
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Jih-Kai Yeh
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Ying-Chang Tung
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Ming-Jer Hsieh
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Chi-Hsiao Yeh
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center
| |
Collapse
|
22
|
Chang FC, Chen CY, Chan YH, Cheng YT, Lin CP, Wu VCC, Hung KC, Chu PH, Chou AH, Chen SW. Sex Differences in Epidemiological Distribution and Outcomes of Surgical Mitral Valve Disease. Circ J 2024; 88:579-588. [PMID: 38267036 DOI: 10.1253/circj.cj-23-0687] [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] [Indexed: 01/26/2024]
Abstract
BACKGROUND Mitral valve (MV) disease is the most common form of valvular heart disease. Findings that indicate women have a higher risk for unfavorable outcomes than men remain controversial. This study aimed to determine the sex-based differences in epidemiological distributions and outcomes of surgery for MV disease. METHODS AND RESULTS Overall, 18,572 patients (45.3% women) who underwent MV surgery between 2001 and 2018 were included. Outcomes included in-hospital death and all-cause mortality during follow up. Subgroup analysis was conducted across different etiologies, including infective endocarditis (IE), degenerative, ischemic, and rheumatic mitral pathology. The overall MV repair rate was lower in women than in men (20.5% vs. 30.6%). After matching, 6,362 pairs (woman : man=1 : 1) of patients were analyzed. Women had a slightly higher risk for in-hospital death than men (10.8% vs. 9.8%; odds ratio [OR]: 1.11, 95% confidence interval [CI]: 0.99-1.24; P=0.075). Women tended to have a higher incidence of de novo dialysis (9.8% vs. 8.6%; P=0.022) and longer intensive care unit stay (8 days vs. 7.1 days; P<0.001). Women with IE had poorer in-hospital outcomes than men; however, there were no sex differences in terms of all-cause mortality. CONCLUSIONS Sex-based differences of MV intervention still persist. Although long-term outcomes were comparable between sexes, women, especially those with IE, had worse perioperative outcomes than men.
Collapse
Affiliation(s)
- Feng-Cheng Chang
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Yi-Hsin Chan
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Yu-Ting Cheng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Chia-Pin Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center
| | | | - Kuo-Chun Hung
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center
| | - An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center
| |
Collapse
|
23
|
Gambardella I, Spadaccio C, Singh SSA, Shingu Y, Kunihara T, Wakasa S, Nappi F. Interpapillary muscle distance independently predicts recurrent mitral regurgitation. J Cardiothorac Surg 2024; 19:147. [PMID: 38509555 PMCID: PMC10953136 DOI: 10.1186/s13019-024-02631-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Ischaemic secondary mitral regurgitation (ISMR) after surgery is due to the displacement of papillary muscles resulting from progressive enlargement of the left ventricle end-diastolic diameter (LVEDD). Our aim was to prove that if the interpapillary muscle distance (IPMD) is surgically stabilized, an increase in LVEDD will not lead to a recurrence of ischaemic mitral regurgitation (MR). METHODS Ninety-six patients with ISMR, who underwent surgical revascularisation and annuloplasty, were randomly assigned in a 1:1 ratio to undergo papillary muscle approximation (PMA). At the 5-year follow-up, we assessed the correlation between PMA and echocardiographic improvements, the effect size of PMA on echocardiographic improvements, and a prediction model for recurrent MR using inferential tree analysis. RESULTS There was a significant correlation between PMA and enhancements in both the α and β angles (Spearman's rho > 0.7, p < 0.01). The α angle represents the angle between the annular plane and either the A2 annular-coaptation line or the P2 annular-coaptation line. The β angle indicates the angle between the annular plane and either the A2 annular-leaflet tip line or the P2 annular-leaflet tip line. PMA led to substantial improvements in LVEDD, tenting area, α and β angles, with a large effect size (Hedge's g ≥ 8, 95% CI ORs ≠ 1). The most reliable predictor of recurrent MR grade was the interpapillary distance, as only patients with an interpapillary distance greater than 40 mm developed ≥ 3 + grade MR. For patients with an IPMD of 40 mm or less, the best predictor of recurrent MR grade was LVEDD. Among the patients, only those with LVEDD greater than 62 mm showed moderate (2+) MR, while only those with LVEDD less than or equal to 62 mm had absent to mild (1+) MR. CONCLUSION Prediction of recurrent ischaemic MR is not independent of progressive LVEDD increase. PMA-based surgical procedure stabilises IPMD.
Collapse
Affiliation(s)
| | | | - Sanjeet S A Singh
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Yasushige Shingu
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Satoru Wakasa
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, France.
| |
Collapse
|
24
|
Deng MX, Barodi B, Elbatarny M, Yau TM. Considerations & challenges of mitral valve repair in females: diagnosis, pathology, and intervention. Curr Opin Cardiol 2024; 39:86-91. [PMID: 38116820 DOI: 10.1097/hco.0000000000001107] [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] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW Disparities in mitral valve (MV) repair outcomes exist between men and women. This review highlights sex-specific differences in MV disease aetiology, diagnosis, as well as timing and type of intervention. RECENT FINDINGS Females present with more complicated disease: anterior or bileaflet prolapse, leaflet dysplasia/thickening, mitral annular calcification, and mixed mitral lesions. The absence of indexed echocardiographic mitral regurgitation (MR) severity parameters contributes to delayed intervention in women, resulting in more severe symptom burden at time of surgery. The sequelae of chronic MR also necessitate concomitant procedures (e.g. tricuspid repair, arrhythmia surgery) at the time of mitral surgery. Complex MV pathology, greater patient acuity, and more complicated procedures collectively pose challenges to successful MV repair and postoperative recovery. As a consequence, women receive disproportionately more MV replacement than men. In-hospital mortality after MV repair is also greater in women than men. Long-term outcomes of MV repair are comparable after risk-adjustment for preoperative status; however, women experience a greater incidence of postoperative heart failure. SUMMARY To address the inequity in MV repair outcomes between sexes, indexed diagnostic measurements, diligent surveillance of asymptomatic MR, increased recruitment of women in large clinical trials, and mandatory reporting of sex-based subgroup analyses are recommended.
Collapse
Affiliation(s)
- Mimi Xiaoming Deng
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network
- Department of Surgery, University of Toronto, Canada
| | - Batol Barodi
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network
| | - Malak Elbatarny
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network
- Department of Surgery, University of Toronto, Canada
| | - Terrence M Yau
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network
- Department of Surgery, University of Toronto, Canada
| |
Collapse
|
25
|
Sugimori H, Nakao T, Okada Y, Okita Y, Yaku H, Kobayashi J, Uesugi H, Takanashi S, Ito T, Koyama T, Sakaguchi T, Yamamoto K, Yoshikawa Y, Sawa Y. Mid-term outcomes of surgical aortic valve replacement using a mosaic porcine bioprosthesis with concomitant mitral valve repair. Heart Vessels 2024; 39:252-265. [PMID: 37843552 DOI: 10.1007/s00380-023-02325-x] [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: 04/06/2022] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75 years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.
Collapse
Affiliation(s)
- Haruhiko Sugimori
- Department of Cardiovascular Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan.
| | - Tatsuya Nakao
- Department of Cardiovascular Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan
| | - Yukikatsu Okada
- Department of Cardiovascular Surgery, Midori Hospital, 1-16 Edayoshi, Nishi-ku, Kobe, Hyogo, 651-2133, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki General Hospital, 1-3-13 Kosobe-Machi, Takatsuki, Osaka, 569-1192, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshin-Machi, Suita, Osaka, 564-0018, Japan
| | - Hideyuki Uesugi
- Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto, Kumamoto, 861-4101, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Kawasaki Saiwai Hospital, 31-27 Omiya-Chyou, Saiwai-ku, Kawasaki, Kanagawa, 212-0014, Japan
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, 3-35 Michishita-Chyou, Nakamura-ku, Nagoya, Aichi, 453-0046, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1010, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, Hyogo College of Medicine, 1-3-6 Minatojima, Chuo-ku, Kobe, Hyogo, 650-0045, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Tottori University, 4-101 Koyama-Cho, Minami, Tottori, 680-8550, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| |
Collapse
|
26
|
Misumi Y, Kainuma S, Toda K, Miyagawa S, Yoshioka D, Hirayama A, Kitamura T, Komukai S, Sawa Y. Restrictive annuloplasty on remodeling and survival in patients with end-stage ischemic cardiomyopathy. J Thorac Cardiovasc Surg 2024; 167:1008-1019.e2. [PMID: 35811142 DOI: 10.1016/j.jtcvs.2022.04.049] [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: 06/01/2020] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To elucidate the influence of concomitant restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) reverse remodeling and survival in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG). METHODS This study comprised 157 patients with ischemic cardiomyopathy (LV ejection fraction ≤40%) who underwent CABG and completed echocardiographic examination at 1 year after surgery, with 84 (54%) undergoing concomitant RMA for clinically relevant ischemic mitral regurgitation. The primary end point was postoperative reduction in LV end-systolic volume index (LVESVI). The secondary end point was overall survival. Median follow-up was 5.1 years. RESULTS At baseline, patients who underwent CABG with RMA had a larger LVESVI (83 ± 23 vs 75 ± 24 mm; P = .046). One-year postoperatively, CABG with RMA reduced the LVESVI more than did CABG alone (37% vs 21% from baseline; P < .001), yielding nearly identical postoperative LVESVI (53 ± 27 vs 61 ± 26 mm; P = .065). In multivariable logistic regression analysis, concomitant RMA was associated with significant LV reverse remodeling (odds ratio, 2.79; 95% CI, 1.34-5.78; P = .006). The prevalence in moderate or severe mitral regurgitation was not different between the groups (7% vs 10%; P = .58). Survival rates were similar between the groups (5 years, 78% vs 83%; P = .35). CONCLUSIONS In patients with ischemic cardiomyopathy undergoing CABG, concomitant RMA was associated with significant reduction in LVESVI. The influence of LV reverse remodeling on survival remains undetermined.
Collapse
Affiliation(s)
- Yusuke Misumi
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Hirayama
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Sho Komukai
- Department of Biomedical Statistics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
| |
Collapse
|
27
|
Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 175] [Impact Index Per Article: 175.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
Collapse
|
28
|
Kawamura M, Monta O, Maeda S, Tsutsumi Y. Mitral valve repair for degenerative mitral regurgitation with Carpentier's functional classification type II in elderly patients: a single center experience. J Cardiothorac Surg 2024; 19:75. [PMID: 38331949 PMCID: PMC10854023 DOI: 10.1186/s13019-024-02578-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Mitral valve (MV) repair for Carpentier functional classification Type II (C-II) mitral regurgitation (MR) is widely accepted because of its efficacy. It is unclear whether MV repair has the same benefits in elderly patients as in younger patients because of their lower life expectancy. Herein, we examined the midterm results of MV repair for C-II mitral regurgitation, especially in patients aged ≧70 years. METHOD A retrospective review was performed on 176 patients who underwent MV repair for C-II mitral regurgitation with a median age of 65 years; 55 (31%) patients were ≧70 years, and 124 were male (71%). Lesions of the mitral valve were isolated from the anterior leaflet (48 patients), posterior leaflet (113 patients), and both leaflets (15 patients), and included seven patients with Barlow's disease. We compared the outcomes between patients aged ≧70 years (≧70 years; median age, 76 years) and those aged < 70 years (median age, 60 years). RESULTS In terms of the durability of MV repair in elderly patients, there were no significant differences in the rates of freedom from reoperation or MR recurrence at 5 years between patients aged < 70 years and those aged ≧70 years (reoperation:98% in < 70 years versus 89% in ≧70 years; P = 0.4053; MR recurrence:95% in < 70 years versus 81% in ≧70 years; P = 0.095). The mitral valve complexity was divided into two grades: Simple (isolated posterior mitral lesion) and Complex (isolated anterior lesion or both lesions). In patients aged < 70 years, there was no significant difference in the rate of freedom from MR recurrence at 5 years between the Simple and Complex groups (96% vs. 91%; P = 0.1029). In contrast, in patients aged ≧70 years, the MR recurrence rate at 3 years in Complex was significantly higher in the Complex group than in the Simple (100% vs. 80%; P = 0.0265). CONCLUSIONS We studied the outcomes of MV repair for C-II in MR. In elderly patients, MR recurrence was higher in complex lesions than in simple lesions. MV replacement may be considered for elderly patients with complex mitral valve lesions, if appropriately selected.
Collapse
Affiliation(s)
- Masashi Kawamura
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan.
| | - Osamu Monta
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan
| | - Shusaku Maeda
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan
| | - Yasushi Tsutsumi
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan
| |
Collapse
|
29
|
Zhang M, Wang J, Edmiston J. Underreporting of non-study cigarette use by study participants confounds the interpretation of results from ambulatory clinical trial of reduced nicotine cigarettes. Harm Reduct J 2024; 21:35. [PMID: 38331789 PMCID: PMC10854148 DOI: 10.1186/s12954-024-00953-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND As part of its comprehensive plan to significantly reduce the harm from tobacco products, the US Food and Drug Administration is establishing a product standard to lower nicotine in conventional cigarettes to make them "minimally addictive or non-addictive". Many clinical studies have investigated the potential impact of such a standard on smoking behavior and exposure to cigarette constituents. These ambulatory studies required participants who smoke to switch to reduced nicotine study cigarettes. In contrast to clinical trials on pharmaceuticals or medical devices, participants had ready access to non-study conventional nicotine cigarettes and high rates of non-study cigarette use were consistently reported. The magnitude of non-compliance, which could impact the interpretation of the study results, was not adequately assessed in these trials. METHODS We conducted a secondary analysis of data from a large, randomized trial of reduced nicotine cigarettes with 840 participants to estimate the magnitude of non-compliance, i.e., the average number of non-study cigarettes smoked per day by study participants assigned to reduced nicotine cigarettes. Individual participants' non-study cigarette use was estimated based on his/her urinary total nicotine equivalent level, the nicotine content of the study cigarette assigned and the self-reported number of cigarettes smoked, using a previously published method. RESULTS Our analysis showed that (1) there is a large variation in the number of non-study cigarettes smoked by participants within each group (coefficient of variation 90-232%); (2) participants in reduced nicotine cigarette groups underreported their mean number of non-study cigarettes smoked per day by 85-91%; and (3) the biochemical-based estimates indicate no reduction in the mean number of total cigarettes smoked per day for any group assigned to reduced nicotine cigarettes after accounting for non-study cigarettes. CONCLUSIONS High levels of non-compliance, in both the rate and magnitude of non-study cigarette use, are common in ambulatory reduced nicotine cigarette trials where participants have access to conventional nicotine non-study cigarettes. The potential impact of high non-compliance on study outcomes should be considered when interpreting the results from such ambulatory studies.
Collapse
Affiliation(s)
- Mingda Zhang
- Altria Client Services LLC, 601 E. Jackson Street, Richmond, VA, 23219, USA.
| | - Jingzhu Wang
- Altria Client Services LLC, 601 E. Jackson Street, Richmond, VA, 23219, USA
| | - Jeffery Edmiston
- Altria Client Services LLC, 601 E. Jackson Street, Richmond, VA, 23219, USA
| |
Collapse
|
30
|
Nantsios A, Ahmadvand A, Burwash IG, Chan V, Guo MH, Mesana T, Messika-Zeitoun D, Ramsay T, Rubens FD. Edge-to-edge with partial band mitral valve repair compared to replacement and undersized restrictive annuloplasty for ischemic mitral regurgitation. JTCVS Tech 2024; 23:26-43. [PMID: 38351991 PMCID: PMC10859650 DOI: 10.1016/j.xjtc.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/01/2023] [Accepted: 10/10/2023] [Indexed: 02/16/2024] Open
Abstract
Objective Evidence supports replacement over repair for ischemic mitral regurgitation due to improved durability; however, the latter often involves an undersized ring annuloplasty that does not include edge-to-edge approximation. The objective of this study was to evaluate the outcomes of replacement, edge-to-edge leaflet approximation with mild-undersized annuloplasty and undersized ring annuloplasty for ischemic mitral regurgitation. Methods This is a single-center retrospective study of patients undergoing mitral surgery for moderate-severe or greater ischemic mitral regurgitation, between 2004 and 2020, with mild-undersized annuloplasty, mitral valve replacement, or undersized restrictive annuloplasty (undersized ring annuloplasty). The primary outcome was all-cause mortality. Secondary outcomes included first recurrence of mitral regurgitation, heart failure hospitalization, and composite of valve-related events (bleeding, thromboembolism, endocarditis, and mitral valve reoperation). Results There were 121, 93, and 78 patients in the mitral valve replacement, mild-undersized annuloplasty, and undersized restrictive annuloplasty groups, respectively, with a median follow-up of 3.1, 5.9, and 3.8 years, respectively. Both mitral valve replacement (hazard ratio, 1.87; 95% CI, 1.029-3.415) and undersized restrictive annuloplasty (hazard ratio, 2.73; 95% CI, 1.480-5.061) were associated with worse survival compared with mild-undersized annuloplasty. At 2 years, the rate of mild-moderate mitral regurgitation was greater in the mild-undersized annuloplasty group compared with the mitral valve replacement group (P = .001) but less than in the undersized restrictive annuloplasty group (P = .001). The rate of recurrent moderate or greater mitral regurgitation at 2 years was similar between mild-undersized annuloplasty and mitral valve replacement groups but significantly higher after undersized restrictive annuloplasty (P < .0001). Mitral valve replacement and undersized restrictive annuloplasty were associated with a significant increase in the incidence of first heart failure hospitalization compared with mild-undersized annuloplasty (P < .001 and P = .001, respectively). Mitral valve replacement was associated with an increased incidence of valve-related events compared with mild-undersized annuloplasty (P = .002). Conclusions Surgical edge-to-edge approximation in addition to a mild-undersizing annuloplasty offers similar durability compared with replacement, with a lower rate of hospitalization for heart failure, and may confer a survival advantage.
Collapse
Affiliation(s)
- Alex Nantsios
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aryan Ahmadvand
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ian G. Burwash
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vincent Chan
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thierry Mesana
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Tim Ramsay
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Fraser D. Rubens
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
31
|
Lobdell KW, Grant MC, Salenger R. Temporary mechanical circulatory support & enhancing recovery after cardiac surgery. Curr Opin Anaesthesiol 2024; 37:16-23. [PMID: 38085881 DOI: 10.1097/aco.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery. RECENT FINDINGS Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing. SUMMARY Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.
Collapse
Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Michael C Grant
- Johns Hopkins University School of Medicine, Anesthesiology and Critical Care Medicine, Baltimore
| | - Rawn Salenger
- University of Maryland School of Medicine, Department of Surgery, Towson, Maryland, USA
| |
Collapse
|
32
|
Gedela M, Cangut B, Safi L, Krishnamoorthy P, Pandis D, El-Eshmawi A, Tang GHL. Mitral Valve Intervention in Elderly or High-Risk Patients: A Review of Current Surgical and Interventional Management. Can J Cardiol 2024; 40:250-262. [PMID: 38042339 DOI: 10.1016/j.cjca.2023.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/25/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023] Open
Abstract
Mitral regurgitation is a prevalent valvular disease, and its management has gained increasing importance because of the aging population. Although traditional surgery remains the gold standard, the field of transcatheter therapies, including transcatheter edge-to-edge repair and, more recently transcatheter mitral valve replacement are advancing and are being explored as viable alternatives, particularly for patients at high surgical risk. It is essential to emphasize the necessity of a multidisciplinary team approach, involving specialized valve teams, imaging experts, cardiac anaesthesiologists, and other relevant specialists, is crucial in achieving optimal outcomes. Furthermore, proper execution of procedures, postprocedural care, and diligent follow-up for these patients are essential components for successful results. It is essential to underscore that traditional mitral valve surgery continues to play a significant role. Simultaneously, it is important to acknowledge the expanding array of transcatheter interventions available for this specific patient population.
Collapse
Affiliation(s)
- Maheedhar Gedela
- Heartland Cardiology, Wesley Medical Center, Wichita, Kansas, USA
| | - Busra Cangut
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lucy Safi
- Division of Cardiology, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Parasuram Krishnamoorthy
- Division of Cardiology, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dimosthenis Pandis
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ahmed El-Eshmawi
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
33
|
Cheng YY, Shu MWS, Rubenis I, Vijayarajan V, Hsu ACY, Hyun K, Brieger D, Chow V, Kritharides L, Ng ACC. Trends in Isolated Mitral Valve Repair or Replacement Surgery in Australia: A Statewide Cohort Linkage Study. Heart Lung Circ 2024; 33:120-129. [PMID: 38160129 DOI: 10.1016/j.hlc.2023.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Global trends in mitral valve surgery (MVSx) suggest increasing repair compared with replacement, especially in the United States and European countries. The relative use, and outcomes of, MV repair and replacement in Australia are unknown. METHODS New South Wales residents who underwent isolated MVSx between 2001 and 2017 were identified from the Admitted-Patient-Data-Collection database. Mortality outcomes were tracked to 31 Dec 2018 and adjusted based on age, sex, urgency of operation, and comorbidity status. RESULTS The study cohort comprised 5,693 patients: 2020 (35%) underwent repair (MVr), 1,656 (29%) underwent mechanical replacement (mech.MVR), and 2017 (35%) underwent bioprosthetic replacement (bio.MVR). Respective median ages [interquartile range] were 67 yo [59-75 yo], 64 yo [55-71 yo], and 75 yo [68-80 yo] (p<0.001 across groups). Between 2001 and 2017, total MVSx increased steadily with population growth. Whereas the relative use of MVr remained static (34% to 38%), that for bio.MVR (22% to 50%) and mech.MVR (45% to 13%) changed significantly. MVr had the best outcome with 1.2% in-hospital, 2.5% 1-year, and 21.6% total cumulative mortality during a median follow-up of 6.5 years. Compared to MVr, the adjusted hazard ratio (aHR) for mech.MVR and bio.MVR for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) and 1.73 (95% CI=1.53-1.95), respectively. Heart failure and sepsis were the main cardiovascular and noncardiovascular causes of death in all groups. CONCLUSION In this statewide Australian cohort examined over 17 years, MVr is potentially underutilised despite having superior outcomes to MVR. Access to quality dataset which provides the indication for MVSx and quantitative clinical factors is critical to further improve MVr coverage and outcome MVSx.
Collapse
Affiliation(s)
- Yeu-Yao Cheng
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Matthew Wei Shun Shu
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Imants Rubenis
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | | | - Arielle Chin-Yu Hsu
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Karice Hyun
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | - David Brieger
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Vincent Chow
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Leonard Kritharides
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Austin Chin Chwan Ng
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|
34
|
Watt TMF, Brescia AA, Murray SL, Rosenbloom LM, Wisnielwski A, Burn D, Romano MA, Bolling SF. Does Sustained Reduction of Functional Mitral Regurgitation Impact Survival? Semin Thorac Cardiovasc Surg 2023; 36:37-46. [PMID: 37633624 DOI: 10.1053/j.semtcvs.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 08/28/2023]
Abstract
Functional mitral regurgitation (FMR) is associated with increased mortality and has been considered a marker for advanced heart disease, yet the value of mitral valve repair (MVr) in this population remains unclear. This study aims to evaluate the impact of reducing FMR burden through surgical MVr on survival. Patients with severe FMR who underwent MVr with an undersized, complete, rigid, annuloplasty between 2004 and 2017 were assessed (n = 201). Patients were categorized based on grade of recurrent FMR (0-4). Time-to-event Kaplan-Meier estimations of freedom from death or reoperation were performed using the log-rank test. Cox proportional hazards models evaluated all-cause mortality and reported in hazards ratios (HR) and 95% confidence intervals (CI). Patients were categorized by postoperative recurrent FMR: 45% (91/201) of patients had grade 0, 29% (58/201) grade 1, 20% (40/201) grade 2, 2% (4/201) grade 3%, and 4% (8/201) grade 4. The cumulative incidence of reoperation with death as a competing risk was higher in patients with grades ≥3 recurrent FMR compared to grades ≤2 (44.6% vs 14.6%, subhazard ratio 3.69 [95% CI, 1.17-11.6]; P = 0.026). Overall freedom from death or reoperation was superior for recurrent FMR grades ≤2 compared to grades ≥3 (log-rank P < 0.001). Increasing recurrent FMR grade was independently associated with mortality (HR 1.30 [95% CI, 1.07-1.59] P = 0.009). Reduced postoperative FMR grade resulted in an incrementally lower risk of death or reoperation after MVr. These results suggest that achieving a durable reduction in FMR burden improves long-term survival.
Collapse
Affiliation(s)
| | | | | | | | | | - David Burn
- Department of Mathematics, Quinnipiac University
| | | | | |
Collapse
|
35
|
Camaj A, Thourani VH, Gillam LD, Stone GW. Heart Failure and Secondary Mitral Regurgitation: A Contemporary Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101195. [PMID: 39131058 PMCID: PMC11308134 DOI: 10.1016/j.jscai.2023.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Secondary mitral regurgitation (SMR) in patients with heart failure (HF) is associated with significant morbidity and mortality. In recent decades, SMR has received increasing scientific attention. Advances in echocardiography, computed tomography and cardiac magnetic resonance imaging have refined our ability to diagnose, quantify and characterize SMR. Concurrently, the treatment options for this high-risk patient population have continued to evolve. Guideline-directed medical therapies including beta-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors target the underlying cardiomyopathy, and along with diuretics to treat pulmonary congestion, remain the cornerstone of therapy. Cardiac resynchronization therapy also reduces MR, alleviates symptoms and prolongs life in selected HF patients with SMR. While data supporting surgical mitral valve repair or replacement for SMR are limited, transcatheter edge-to-edge repair (TEER) has been demonstrated to improve survival, reduce the rate of hospitalization for heart failure, and improve functional capacity and quality-of-life in select patients with SMR who remain symptomatic despite medical therapy. Emerging transcatheter mitral valve repair and replacement technologies are undergoing investigation in TEER-eligible and TEER-ineligible patients. The optimal management of HF patients with SMR requires a multidisciplinary team of cardiologists, cardiac surgeons, imaging experts, and other organ specialists to select the best treatment approaches to improve the prognosis of these high-risk patients.
Collapse
Affiliation(s)
- Anton Camaj
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vinod H. Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Linda D. Gillam
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
| | - Gregg W. Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
36
|
Liu H, Simonian NT, Pouch AM, Iaizzo PA, Gorman JH, Gorman RC, Sacks MS. A Computational Pipeline for Patient-Specific Prediction of the Postoperative Mitral Valve Functional State. J Biomech Eng 2023; 145:111002. [PMID: 37382900 PMCID: PMC10405284 DOI: 10.1115/1.4062849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023]
Abstract
While mitral valve (MV) repair remains the preferred clinical option for mitral regurgitation (MR) treatment, long-term outcomes remain suboptimal and difficult to predict. Furthermore, pre-operative optimization is complicated by the heterogeneity of MR presentations and the multiplicity of potential repair configurations. In the present work, we established a patient-specific MV computational pipeline based strictly on standard-of-care pre-operative imaging data to quantitatively predict the post-repair MV functional state. First, we established human mitral valve chordae tendinae (MVCT) geometric characteristics obtained from five CT-imaged excised human hearts. From these data, we developed a finite-element model of the full patient-specific MV apparatus that included MVCT papillary muscle origins obtained from both the in vitro study and the pre-operative three-dimensional echocardiography images. To functionally tune the patient-specific MV mechanical behavior, we simulated pre-operative MV closure and iteratively updated the leaflet and MVCT prestrains to minimize the mismatch between the simulated and target end-systolic geometries. Using the resultant fully calibrated MV model, we simulated undersized ring annuloplasty (URA) by defining the annular geometry directly from the ring geometry. In three human cases, the postoperative geometries were predicted to 1 mm of the target, and the MV leaflet strain fields demonstrated close agreement with noninvasive strain estimation technique targets. Interestingly, our model predicted increased posterior leaflet tethering after URA in two recurrent patients, which is the likely driver of long-term MV repair failure. In summary, the present pipeline was able to predict postoperative outcomes from pre-operative clinical data alone. This approach can thus lay the foundation for optimal tailored surgical planning for more durable repair, as well as development of mitral valve digital twins.
Collapse
Affiliation(s)
- Hao Liu
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences, Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712-1229
| | - Natalie T. Simonian
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences, Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712-1229
| | - Alison M. Pouch
- Departments of Radiology and Bioengineering, University of Pennsylvania, Philadelphia, PA 19104
| | - Paul A. Iaizzo
- Visible Heart Laboratories, Department of Surgery, University of Minnesota, Minneapolis, MN 55455
| | - Joseph H. Gorman
- Gorman Cardiovascular Research Group, Department of Surgery, Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Robert C. Gorman
- Gorman Cardiovascular Research Group, Department of Surgery, Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Michael S. Sacks
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences, Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712-1229
| |
Collapse
|
37
|
Tsai YL, Lee CW, Huang WM, Cheng HM, Yu WC, Chen CH, Sung SH. Surgery for severe mitral regurgitation: The etiology matters. J Chin Med Assoc 2023; 86:869-875. [PMID: 37561050 DOI: 10.1097/jcma.0000000000000977] [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] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND While surgery has been the standard treatment for patients with severe primary mitral regurgitation (PMR), the role of surgery for severe secondary mitral regurgitation (SMR) remained debated. We therefore investigated the prognostic differences of surgery for patients with either severe PMR or SMR. METHODS Subjects hospitalized for heart failure were enrolled from 2002 to 2012. The severity of MR was assessed by continuity equation, and an effective regurgitant orifice area of ≥40 mm 2 was defined as severe. Long-term survival was then identified by the National Death Registry. RESULTS A total of 1143 subjects (66.4 ± 16.6 years, 65% men, and 59.7% PMR) with severe MR were analyzed. Compared with PMR, patients with SMR were older, had more comorbidities, greater left atrial and ventricular diameter, and less left ventricular ejection fraction (all p < 0.05). While 47.8% of PMR patients received mitral valve surgery, only 6.9% of SMR patients did. Surgical intervention crudely was associated with 54% reduction of all-cause mortality in PMR (hazard ratio, 0.46; 95% confident interval, 0.32-0.67), and 48% in the subpopulation with SMR (0.52, 0.30-0.91). Propensity score matching analysis demonstrated the survival benefits of mitral valve surgery was observed in patients with PMR (log rank p = 0.024), but not with SMR. Among the unoperated subjects, age, renal function, and right ventricular systolic pressure were common risk factors of mortality, regardless of MR etiology. CONCLUSION Mitral valve surgery for patients with heart failure and severe MR was associated with better survival in patients with PMR, but not in those with SMR.
Collapse
Affiliation(s)
- Yi-Lin Tsai
- Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ching-Wei Lee
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wei-Ming Huang
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hao-Min Cheng
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wen-Chung Yu
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chen-Huan Chen
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shih-Hsien Sung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| |
Collapse
|
38
|
Villaschi A, Pagnesi M, Stolfo D, Baldetti L, Lombardi CM, Adamo M, Loiacono F, Sammartino AM, Colombo G, Tomasoni D, Inciardi RM, Maccallini M, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Cappelletti AM, Sinagra G, Pini D, Metra M, Chiarito M. Ischemic Etiology in Advanced Heart Failure: Insight from the HELP-HF Registry. Am J Cardiol 2023; 204:268-275. [PMID: 37562192 DOI: 10.1016/j.amjcard.2023.07.114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Abstract
In patients with advanced heart failure (HF), defined according to the presence of at least one I-NEED-HELP criterium, the updated 2018 Heart Failure Association of the European Society of Cardiology (HFA-ESC) criteria for advanced HF identify a subgroup of patients with HF with worse prognosis, but whether ischemic etiology has a relevant prognostic impact in this very high-risk cohort is unknown. Patients from the HELP-HF registry were stratified according to ischemic etiology and presence of advanced HF based on 2018 HFA-ESC criteria. The primary end point was a composite of all-cause death and HF hospitalization at 1 year. Secondary end points were all-cause death, HF hospitalization, and cardiovascular death at 1 year. Ischemic etiology was a leading cause of HF, in both patients with advanced and nonadvanced HF (46.1% and 42.4%, respectively, p = 0.337). The risk of the primary end point (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.09 to 1.58) and all-cause mortality (HR 1.37, 95% CI 1.06 to 1.76) was increased in ischemic as compared with nonischemic patients. The risk of the primary end point was consistently higher in ischemic patients in both patients with advanced and nonadvanced HF (advanced HF, HR 1.50 95% CI 1.04 to 2.16; nonadvanced HF, HR 1.25 95% CI 1.01 to 1.56, pinteraction = 0.333), driven by an increased risk of mortality, mainly because of cardiovascular causes. In conclusion, ischemic etiology is the most common cause of HF in patients with at least one I-NEED-HELP marker and with or without advanced HF as defined by the 2018 HFA-ESC definition. In both patients with advanced and not-advanced HF, ischemic etiology carried an increased risk of worse prognosis.
Collapse
Affiliation(s)
- Alessandro Villaschi
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giada Colombo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marta Maccallini
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Gaia Gasparini
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Marco Montella
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Stefano Contessi
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniele Cocianni
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Giuseppe Barone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | | | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniela Pini
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy.
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Mauro Chiarito
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| |
Collapse
|
39
|
Asher SR, Ong CS, Malapero RJ, Heydarpour M, Malzberg GW, Shahram JT, Nguyen TB, Shook DC, Shernan SK, Shekar P, Kaneko T, Citro R, Muehlschlegel JD, Body SC. Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery. Front Cardiovasc Med 2023; 10:1202174. [PMID: 37840960 PMCID: PMC10570832 DOI: 10.3389/fcvm.2023.1202174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival. Methods Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity. Results Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not. Conclusions These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.
Collapse
Affiliation(s)
- Shyamal R. Asher
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, United States
| | - Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Raymond J. Malapero
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Mahyar Heydarpour
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Gregory W. Malzberg
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Jasmine T. Shahram
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Thy B. Nguyen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Douglas C. Shook
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Stanton K. Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Prem Shekar
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Rodolfo Citro
- Cardio-Thoracic-Vascular Department, University Hospital—San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Simon C. Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, United States
| |
Collapse
|
40
|
Gaidulis G, Padala M. Computational Modeling of the Subject-Specific Effects of Annuloplasty Ring Sizing on the Mitral Valve to Repair Functional Mitral Regurgitation. Ann Biomed Eng 2023; 51:1984-2000. [PMID: 37344691 PMCID: PMC10826925 DOI: 10.1007/s10439-023-03219-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/21/2023] [Indexed: 06/23/2023]
Abstract
Surgical repair of functional mitral regurgitation (FMR) that occurs in nearly 60% of heart failure (HF) patients is currently performed with undersizing mitral annuloplasty (UMA), which lacks short- and long-term durability. Heterogeneity in valve geometry makes tailoring this repair to each patient challenging, and predictive models that can help with planning this surgery are lacking. In this study, we present a 3D echo-derived computational model, to enable subject-specific, pre-surgical planning of the repair. Three computational models of the mitral valve were created from 3D echo data obtained in three pigs with HF and FMR. An annuloplasty ring model in seven sizes was created, each ring was deployed, and post-repair valve closure was simulated. The results indicate that large annuloplasty rings (> 32 mm) were not effective in eliminating regurgitant gaps nor in restoring leaflet coaptation or reducing leaflet stresses and chordal tension. Smaller rings (≤ 32 mm) restored better systolic valve closure in all investigated cases,but excessive valve tethering and restricted motion of the leaflets were still present. This computational study demonstrates that for effective correction of FMR, the extent of annular reduction differs between subjects, and overly reducing the annulus has deleterious effects on the valve.
Collapse
Affiliation(s)
- Gediminas Gaidulis
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, USA.
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA.
| |
Collapse
|
41
|
Nappi F, Avtaar Singh SS. Transcatheter edge-to-edge repair for secondary mitral regurgitation: what the clinician needs to know in the absence of robust data from international guidelines. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:333. [PMID: 37675329 PMCID: PMC10477641 DOI: 10.21037/atm-23-1521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/21/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | | |
Collapse
|
42
|
Pislaru SV, Nkomo VT. Subannular repair for secondary mitral regurgitation: a step towards peaceful conversations. Heart 2023; 109:1348-1349. [PMID: 37258096 DOI: 10.1136/heartjnl-2023-322609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Affiliation(s)
- Sorin V Pislaru
- Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
43
|
Pausch J, Harmel E, Reichenspurner H, Kempfert J, Kuntze T, Owais T, Holubec T, Walther T, Krane M, Vitanova K, Borger MA, Eden M, Hachaturyan V, Bramlage P, Falk V, Girdauskas E. Subannular repair in secondary mitral regurgitation with restricted leaflet motion during systole. Heart 2023; 109:1394-1400. [PMID: 37376817 DOI: 10.1136/heartjnl-2022-322239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/02/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVE Ventricular secondary mitral regurgitation (SMR) (Carpentier type IIIb) results from left ventricular (LV) remodelling, displacement of papillary muscles and tethering of mitral leaflets. The most appropriate treatment approach remains controversial. We aimed to assess the safety and efficacy of standardised relocation of both papillary muscles (subannular repair) at 1-year follow-up (FU). METHODS REFORM-MR (Reform-Mitral Regurgitation) is a prospective, multicentre registry that enrolled consecutive patients with ventricular SMR (Carpentier type IIIb) undergoing standardised subannular mitral valve (MV) repair in combination with annuloplasty at five sites in Germany. Here, we report survival, freedom from recurrence of MR >2+, freedom from major adverse cardiac and cerebrovascular events (MACCEs), including cardiovascular death, myocardial infarction, stroke, MV reintervention and echocardiographic parameters of residual leaflet tethering at 1-year FU. RESULTS A total of 94 patients (69.1% male) with a mean age of 65.1±9.7 years met the inclusion criteria. Advanced LV dysfunction (mean left ventricular ejection fraction 36.4±10.5%) and severe LV dilatation (mean left ventricular end-diastolic diameter 61.0±9.3 mm) resulted in severe mitral leaflet tethering (mean tenting height 10.6±3.0 mm) and an elevated mean EURO Score II of 4.8±4.6 prior to surgery. Subannular repair was successfully performed in all patients, without operative mortality or complications. One-year survival was 95.5%. At 12 months, a durable reduction of mitral leaflet tethering resulted in a low rate (4.2%) of recurrent MR >2+. In addition to a significant improvement in New York Heart Association (NYHA) class (22.4% patients in NYHA III/IV vs 64.5% patients at baseline, p<0.001), freedom from MACCE was observed in 91.1% of patients. CONCLUSIONS Our study demonstrates the safety and feasibility of standardised subannular repair to treat ventricular SMR (Carpentier type IIIb) in a multicentre setting. By addressing mitral leaflet tethering, papillary muscle relocation results in very satisfactory 1-year outcomes and has the potential to durably restore MV geometry; nevertheless, long-term FU is mandatory. TRIAL REGISTRATION NUMBER NCT03470155.
Collapse
Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany
| | - Eva Harmel
- I. Medical Clinic, University Hospital Augsburg, Augsburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Thomas Kuntze
- Department of Cardiac Surgery, Central Hospital Bad Berka, Bad Berka, Germany
| | - Tamer Owais
- Department of Cardiovascular and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Thomas Walther
- Department of Cardiovascular Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
- German Center for Cardiovascular Research, Partner Site Rhine-Main, Frankfurt, Germany
| | - Markus Krane
- Department of Cardiac Surgery, German Heart Center Munich, München, Germany
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Keti Vitanova
- Department of Cardiac Surgery, German Heart Center Munich, München, Germany
| | | | - Matthias Eden
- Department for Internal Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiovascular and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| |
Collapse
|
44
|
Liu Y, Cai Z, Xu L, Zheng Y, Chen M, Dong N, Chen S. Concomitant valve surgery is associated with worse outcomes in surgical treatments of post-infarction ventricular aneurysm. Front Cardiovasc Med 2023; 10:1194374. [PMID: 37655215 PMCID: PMC10465797 DOI: 10.3389/fcvm.2023.1194374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023] Open
Abstract
Objective To evaluate the impact of concomitant valve surgery on the prognosis of patients who experienced coronary artery bypass graft (CABG) with/without ventricular reconstruction for the ventricular aneurysm. Methods In our department, 354 patients underwent CABG with/without ventricular reconstruction for a ventricular aneurysm from July 23rd, 2000 to December 23rd, 2022. A total of 77 patients received concomitant valve surgery, 37 of whom underwent replacement, and 40 of whom underwent repair. The baseline characteristics, prognostic, and follow-up information were statically analyzed. Univariate and multivariate Cox regression analyses were applied to identify the risk factors of long-term outcomes. Results Compared with patients who did not undergo valvular surgery, patients who experienced concomitant valve surgical treatments had a significantly lower survival rate (p = 0.00022) and a longer total mechanical ventilation time. Subgroup analysis indicated that the options of repair or replacement exhibited no statistically significant difference in postoperative mortality (p = 0.44) and prognosis. The multivariate Cox regression analysis suggested that the pre-operative cholesterol level (HR = 1.68), postoperative IABP (HR = 6.29), NYHA level (HR = 2.84), and pre-operative triglyceride level (HR = 1.09) were independent and significant predictors for overall all-cause mortality after surgery. Conclusion Concomitant valve surgery was considerably related to a higher risk of postoperative mortality in patients with post-infarction ventricle aneurysms who underwent surgical treatments. No significant difference in the prognosis outcomes was observed between the operating methods of repair or replacement valve surgery.
Collapse
Affiliation(s)
| | | | | | | | | | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Si Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
45
|
Park MH, Marin-Cuartas M, Sellke M, Pandya PK, Zhu Y, Wilkerson RJ, Holzhey DM, Borger MA, Woo YJ. An analytical, mathematical annuloplasty ring curvature model for planning of valve-in-ring transcatheter mitral valve replacement. JTCVS Tech 2023; 20:45-54. [PMID: 37555034 PMCID: PMC10405166 DOI: 10.1016/j.xjtc.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/08/2023] [Accepted: 03/28/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES An increasing number of high-risk patients with previous mitral valve annuloplasty require transcatheter mitral valve replacement due to recurrent regurgitation. Annulus dilation with a transcatheter balloon is often performed before valve-in-ring transcatheter mitral valve replacement, which is believed to reduce misalignment and paravalvular leakage, yet little evidence exists to support this practice. Our objective was to generate intuitive annuloplasty ring analyses for improved valve-in-ring transcatheter mitral valve replacement planning. METHODS We generated a mathematical model that calculates image-tracked differential ring curvature to build quantifications for improved planning for valve-in-ring procedures. Carpentier-Edwards Physio M24 and M30 (n = 2 each), Physio II M24 and M26 (n = 3 each), LivaNova AnnuloFlex M26 (n = 2), and Edwards Geoform M28 (n = 2) rings were tested with a 30-mm Toray Inoue balloon inflated to maximum rated pressures. RESULTS Curvature variance reduces with larger ring sizes, indicating that larger rings are initially more circular than smaller ones. Evaluated semi-rigid and rigid rings showed little to no difference between pre- and post-dilation states. Annuloflex rings (flexible band) showed a postdilation variance reduction of 32.83% (P < .001) followed by an increase after 10 minutes of relaxation that was still reduced by 19.62% relative to the initial state (P < .001). CONCLUSIONS We discovered that balloon dilation does not significantly deform evaluated semi-rigid or rigid rings at maximum rated balloon pressures. This may mean that dilation for these conditions before valve-in-ring transcatheter mitral valve replacement is unnecessary. Our mathematical approach creates a foundation for extended classification of this practice, providing meaningful quantification of ring geometry.
Collapse
Affiliation(s)
- Matthew H. Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Mateo Marin-Cuartas
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Mark Sellke
- Department of Mathematics, Stanford University, Stanford, Calif
| | - Pearly K. Pandya
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Bioengineering, Stanford University, Stanford, Calif
| | | | - David M. Holzhey
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A. Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Bioengineering, Stanford University, Stanford, Calif
| |
Collapse
|
46
|
Lander MM, Brener MI, Goel K, Tang PC, Verlinden NJ, Zalawadiya S, Lindenfeld J, Kanwar MK. Mitral Interventions in Heart Failure. JACC. HEART FAILURE 2023; 11:1055-1069. [PMID: 37611988 DOI: 10.1016/j.jchf.2023.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Abstract
Patients with heart failure with reduced ejection fraction who have secondary mitral regurgitation (SMR) have poorer outcomes and quality of life than those without SMR. Guideline-directed medical therapy is the cornerstone of SMR treatment. Careful evaluation of landmark trials using mitral transcatheter edge-to-edge repair in SMR has led to an improved understanding of who will benefit from percutaneous interventions with emphasis on a multidisciplinary approach. The success with mitral transcatheter edge-to-edge repair in SMR has also spurred the evaluation of its role in populations that were not initially studied, such as end-stage heart failure and cardiogenic shock. A spectrum of transcatheter devices in development and clinical trials promise to further provide a growing array of management options for heart failure with reduced ejection fraction patients with symptomatic SMR.
Collapse
Affiliation(s)
- Matthew M Lander
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Michael I Brener
- Division of Cardiology at Columbia University Irving Medical Center, New York, New York, USA
| | - Kashish Goel
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan J Verlinden
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sandip Zalawadiya
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
47
|
Sharkey A, Mahmood F, Hai T, Khamooshian A, Gao Z, Amador Y, Khabbaz K. Regional geometric differences between regurgitant and non-regurgitant mitral valves in patients with coronary artery disease. Echocardiography 2023; 40:750-759. [PMID: 37002823 DOI: 10.1111/echo.15549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 04/04/2023] Open
Abstract
OBJECTIVE Demonstrate that regional geometric differences exist between regurgitant and non-regurgitant mitral valves (MV's) in patients with coronary artery disease and due to the heterogenous and regional nature of ischemic remodeling in patients with coronary artery disease (CAD), that the available anatomical reserve and likelihood of developing mitral regurgitation (MR) is variable in non-regurgitant MV's in patients with CAD. METHODS In this retrospective, observational study intraoperative three-dimensional transesophageal echocardiographic data was analyzed in patients undergoing coronary revascularization with MR (IMR group) and without MR (NMR group). Regional geometric differences between both groups were assessed and MV reserve which was defined as the increase in antero-posterior (AP) annular diameter from baseline that would lead to coaptation failure was calculated in three zones of the MV from antero-lateral (zone 1), middle (zone 2), and posteromedial (zone 3). MEASUREMENTS AND MAIN RESULTS There were 31 patients in the IMR group and 93 patients in the NMR group. Multiple regional geometric differences existed between both groups. Most significantly patients in the NMR group had significantly larger coaptation length and MV reserve than the IMR group in zones 1 (p-value = .005, .049) and 2 (p-value = .00, .00), comparable between the two groups in zone 3 (p-value = .436, .513). Depletion of the MV reserve was associated with posterior displacement of the coaptation point in zones 2 and 3. CONCLUSIONS There are significant regional geometric differences between regurgitant and non-regurgitant MV's in patients with coronary artery disease. Due to regional variations in available anatomical reserve and the risk of coaptation failure in patients with CAD, absence of MR is not synonymous with normal MV function.
Collapse
Affiliation(s)
- Aidan Sharkey
- Department of Anesthesia Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Feroze Mahmood
- Department of Anesthesia Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ting Hai
- Department of Anesthesiology, Peking University Peoples Hospital, Beijing, China
| | - Arash Khamooshian
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Zhifeng Gao
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Yannis Amador
- Department of Anesthesiology and Perioperative Medicine, Queens University, Kingston, Ontario, Canada
| | - Kamal Khabbaz
- Division of Cardiac Surgery, Roberta L Hines Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
48
|
Li J, Wei X. Outcomes and predictors of patients with moderate or severe functional mitral regurgitation and nonischemic dilated cardiomyopathy. Clin Cardiol 2023; 46:922-929. [PMID: 37322605 PMCID: PMC10436791 DOI: 10.1002/clc.24067] [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: 01/10/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Patients with functional mitral regurgitation (FMR) and nonischemic dilated cardiomyopathy (DCM) are associated with high mortality. OBJECTIVES Our study aimed to compare the clinical outcomes between different treatment strategies and identify predictors associated with the adverse outcomes. METHODS A total of 112 patients with moderate or severe FMR and nonischaemic DCM were included in our study. The primary composite outcome was all-cause death or unplanned hospitalization for heart failure. The secondary outcomes were individual components of the primary outcome and the cardiovascular death. RESULTS In this study, the primary composite outcome occurred in 26 patients (44.8%) in mitral valve repair (MVr) group and 37 patients (68.5%) in medical group (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.14-0.55; p < .001). The 1-, 3-, and 5-year survival rates for patients with MVr were 96.6%, 91.8%, and 77.4%, respectively, which were significantly higher than that of medical group: 81.2%, 71.9%, and 65.1%, respectively (HR, 0.32; 95% CI, 0.12-0.87; p = .03). Left ventricular ejection fraction (LVEF) < 41.5% (p < .001) and atrial fibrillation (p = .02) were independently associated with the primary outcome. LVEF < 41.5% (p = .007), renal insufficiency (p = .003), and left ventricular end-diastolic diameter > 66.5 mm (p < .001) were independently associated with heightened risk for all-cause death. CONCLUSION Compared with medical therapy, MVr was associated with a better prognosis in patients with moderate or severe FMR and nonischemic DCM. We observed that LVEF < 41.5% was the only independent predictor of the primary outcome and all individual components of secondary outcomes.
Collapse
Affiliation(s)
- Jiangtao Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
- Key Laboratory of Organ TransplantationMinistry of EducationWuhanHubeiChina
- NHC Key Laboratory of Organ TransplantationMinistry of HealthWuhanHubeiChina
| |
Collapse
|
49
|
Kim K, Kim HJ, Jung SH, Lee J, Kim JB. Functional Insufficiency of Mitral and Tricuspid Valves Associated With Atrial Fibrillation: Impact of Postoperative Atrial Fibrillation Recurrence on Surgical Outcomes. Korean Circ J 2023; 53:550-562. [PMID: 37525492 PMCID: PMC10435822 DOI: 10.4070/kcj.2022.0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/28/2023] [Accepted: 05/03/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To identify the factors associated with adverse outcomes following surgery for functional insufficiency of the mitral valve (MV) or tricuspid valve (TV) associated with atrial fibrillation (AF). METHODS We evaluated 100 patients (age, 66.5±10.0 years; 47 males) who consecutively underwent surgery for functional insufficiency of the MV or TV associated with AF between January 2000 and December 2020 at our center. The primary outcome was a composite endpoint of all-cause death, valve reoperation, congestive heart failure (CHF) requiring rehospitalization, and stroke. RESULTS During follow-up (532 patients-years [PYs]), adverse events included death in 16 (3.0%/yr), MV reoperation in 1 (0.2%/yr), CHF in 14 (2.6%/yr), and stroke in 5 (0.9%/yr) patients, demonstrating a 5-year rate of freedom from the primary endpoint of 69.5%. The rate of postoperative AF was high even in those who underwent AF ablation (n=92), with cumulative rates of 48.1% at 1 year and 60.2% at 5 years. In multivariable analyses, the primary outcome was significantly associated with age (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.02-1.10; p=0.005), chronic kidney disease (aHR, 7.76; 95% CI, 2.28-26.38; p=0.001), left atrial appendage exclusion (aHR, 0.35; 95% CI, 0.16-1.78; p=0.010), and postoperative AF as a time-varying covariate (aHR, 3.33; 95% CI, 1.50-7.40; p=0.003). CONCLUSION Among patients undergoing surgery for functional atrioventricular insufficiency associated with AF, a significant proportion showed recurrence of AF over time after concomitant AF ablation, which was significantly associated with poor clinical outcomes.
Collapse
Affiliation(s)
- Kitae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - JaeWon Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| |
Collapse
|
50
|
Kumar M, Thompson PD, Chen K. New Perspective on Pathophysiology and Management of Functional Mitral Regurgitation. Trends Cardiovasc Med 2023; 33:386-392. [PMID: 35259483 DOI: 10.1016/j.tcm.2022.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 12/31/2022]
Abstract
Functional mitral regurgitation (FMR) occurs as a result of global or segmental left ventricular (LV) dysfunction or left atrial dilatation, leading to mitral annular dilatation, papillary muscle displacement, mitral valve (MV) leaflet tethering, and leaflet remodeling. The prevalence of FMR continues to rise in the United States. Even mild FMR is associated with adverse clinical outcomes. Echocardiography is the primary imaging modality used to assess the type and severity of mitral regurgitation. FMR treatment depends on the etiology. Evidence-based pharmacologic and cardiac resynchronization therapies for underlying LV dysfunction remain the mainstay of treatment. Patients who remain symptomatic despite optimal medical therapy can be considered for surgical or percutaneous MV intervention. This article reviews the pathophysiology, imaging evaluation, and therapeutic options of FMR, highlighting the most recent developments in a rapidly evolving field.
Collapse
Affiliation(s)
- Manish Kumar
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
| | - Paul D Thompson
- Department of Cardiology, Hartford Hospital, Hartford, 06106, United States
| | - Kai Chen
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
| |
Collapse
|