1
|
Hasegawa H, Kuwajima K, Kagawa S, Yamane T, Rader F, Siegel RJ, Shiota T. Impact of eccentric jet on outcomes in patients with atrial functional mitral regurgitation: An echocardiographic study. Int J Cardiol 2023; 391:131342. [PMID: 37678430 DOI: 10.1016/j.ijcard.2023.131342] [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: 07/06/2023] [Revised: 08/17/2023] [Accepted: 09/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Previous studies have reported the mechanisms underlying atrial functional mitral regurgitation (A-FMR). Recently, A-FMR subtypes based on mitral regurgitation (MR) mechanisms were proposed: "central jet" due to insufficient leaflet remodeling and "eccentric jet" due to atriogenic tethering. However, their prognostic value remains unclear. Therefore, this study investigated the impact of A-FMR subtypes on clinical outcomes. METHODS Outpatients with significant A-FMR between January 2013 and December 2016 were retrospectively reviewed. They were classified into two subtypes according to the MR jet's direction. All-cause mortality, heart failure hospitalization, and any mitral valve interventions were the primary composite endpoint. RESULTS Among 101 patients with significant A-FMR, 32% had eccentric jet. The primary endpoint was observed in 56 patients during the follow-up period (median 0.7 years, range 0.1-4.2 years). Kaplan-Meier curves demonstrated that the composite endpoint was higher among patients with eccentric jet than those with central jet (log-rank p < 0.001). Eccentric jet (hazard ratio [HR] 2.46, 95% confidence interval [CI] 1.28-4.73; p = 0.007), age (HR 1.06, 95% CI 1.02-1.11; p = 0.002), symptoms (HR 6.22, 95% CI 2.18-17.8; p < 0.001), severe MR (HR 3.97, 95% CI 1.92-8.18; p < 0.001), and significant tricuspid regurgitation (TR; HR 2.00, 95% CI 1.01-3.97; p = 0.047) were independent predictors of the composite endpoint. CONCLUSIONS Patients with eccentric jet had poorer outcomes than those with central jet. Eccentric jet, age, symptoms, severe MR, and significant TR were independently associated with poor outcomes.
Collapse
Affiliation(s)
- Hiroko Hasegawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ken Kuwajima
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shunsuke Kagawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Takafumi Yamane
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
2
|
Incidence and causal association of functional atrial mitral regurgitation in HFpEF. Hellenic J Cardiol 2023; 69:51-56. [PMID: 36181999 DOI: 10.1016/j.hjc.2022.09.013] [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: 01/09/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is as common as heart failure with reduced ejection fraction. Atrial fibrillation (AF), as well as the presence of mitral regurgitation (MR), is highly prevalent in these patients. Atrial functional MR (AFMR) is a type of functional MR characterized by severe left atrial dilatation and remodeling with normal left ventricular (LV) dimensions and function. Dilatation of the mitral annulus is considered to be the main underlying mechanism, though the leaflets and the rest of the mitral apparatus play significant role in the development of MR, mainly in patients with long standing AF. There are several echocardiographic differences between atrial and ventricular functional MR, better identified with 3D echocardiography. Significant AFMR impairs prognosis, especially of patients with HFpEF, and this is important while they represent a group of under-diagnosed and under-treated patients. Finally, because focused medical evidence-based approach is not available yet, it seems that the prevention of left atrial dilatation and early restoration of sinus rhythm (SR) is the best therapeutic option.
Collapse
|
3
|
Secondary Mitral Regurgitation: Cardiac Remodeling, Diagnosis, and Management. STRUCTURAL HEART 2022. [DOI: 10.1016/j.shj.2022.100129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
4
|
Gavazzoni M, Heilbron F, Badano LP, Radu N, Cascella A, Tomaselli M, Perelli F, Caravita S, Baratto C, Parati G, Muraru D. The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype. Front Cardiovasc Med 2022; 9:1022755. [PMID: 36523369 PMCID: PMC9744784 DOI: 10.3389/fcvm.2022.1022755] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022] Open
Abstract
AimWe sought to evaluate the differences in prognosis between the atrial (A-STR) and the ventricular (V-STR) phenotypes of secondary tricuspid regurgitation.Materials and methodsConsecutive patients with moderate or severe STR referred for echocardiography were enrolled. A-STR and V-STR were defined according to the last ACC/AHA guidelines criteria. The primary endpoint was the composite of all-cause death and heart failure (HF) hospitalizations.ResultsA total of 211 patients were enrolled. The prevalence of A-STR in our cohort was 26%. Patients with A- STR were significantly older and with lower NYHA functional class than V-STR patients. The prevalence of severe STR was similar (28% in A-STR vs. 37% in V-STR, p = 0.291). A-STR patients had smaller tenting height (TH) (10 ± 4 mm vs. 12 ± 7 mm, p = 0.023), larger end-diastolic tricuspid annulus area (9 ± 2 cm2 vs. 7 ± 6 cm2/m2, p = 0.007), smaller right ventricular (RV) end-diastolic volumes (72 ± 27 ml/m2 vs. 92 ± 38 ml/m2; p = 0.001), and better RV longitudinal function (18 ± 7 mm vs. 16 ± 6 mm; p = 0.126 for TAPSE, and −21 ± 5% vs. −18 ± 5%; p = 0.006, for RV free-wall longitudinal strain, RVFWLS) than V-STR patients. Conversely, RV ejection fraction (RVEF, 48 ± 10% vs. 46 ± 11%, p = 0.257) and maximal right atrial volumes (64 ± 38 ml/m2 vs. 55 ± 23 ml/m2, p = 0.327) were similar between the two groups. After a median follow-up of 10 months, patients with V-STR had a 2.7-fold higher risk (HR: 2.7, 95% CI 95% = 1.3–5.7) of experiencing the combined endpoint than A-STR patients. The factors related to outcomes resulted different between the two STR phenotypes: TR-severity (HR: 5.8, CI 95% = 1, 4–25, P = 0.019) in A-STR patients; TR severity (HR 2.9, 95% CI 1.4–6.3, p = 0.005), RVEF (HR: 0.97, 95% CI 0.94–0.99, p = 0.044), and RVFWLS (HR: 0.93, 95% CI 0.85–0.98, p = 0.009) in V-STR.ConclusionAlmost one-third of patients referred to the echocardiography laboratory for significant STR have A-STR. A-STR patients had a lower incidence of the combined endpoint than V-STR patients. Moreover, while TR severity was the only independent factor associated to outcome in A-STR patients, TR severity and RV function were independently associated with outcome in V-STR patients.
Collapse
Affiliation(s)
- Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P. Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- *Correspondence: Luigi P. Badano,
| | - Noela Radu
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Emergency University Hospital Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Andrea Cascella
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Perelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Management, Information, and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| |
Collapse
|
5
|
Jiang GY, Xu J, Manning WJ, Markson LJ, Khabbaz KR, Garan AR, Sabe MA, Strom JB. Mitral Regurgitation and Mortality Risk in Medicare Beneficiaries With Heart Failure and Preserved Ejection Fraction. Am J Cardiol 2022; 183:40-47. [PMID: 36100504 DOI: 10.1016/j.amjcard.2022.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/01/2022] [Accepted: 07/11/2022] [Indexed: 11/01/2022]
Abstract
The association of mitral regurgitation (MR) severity and mortality in heart failure with preserved ejection fraction (HFpEF) is uncertain. We sought to evaluate the relation between MR severity on transthoracic echocardiography (TTE) and subsequent all-cause mortality in Medicare beneficiaries with HFpEF. We linked 57,608 patients referred for TTE at Beth Israel Deaconess Medical Center to Medicare inpatient claims from 2003 to 2017. In those with a history of HF and a physician-reported left ventricular ejection fraction ≥50%, we evaluated the relation of MR severity and time to the primary end point of all-cause mortality using Kaplan-Meier methods. A total of 7,778 individuals (14.5%) met inclusion criteria (mean age 75.5 years ± 11.9, 55.9% female). Over a median follow-up of 8.1 years, 2,016 (25.9%) died at a median (interquartile range) of 1.7 (0.3 to 4.1) years. At 1 year, 15.8% with 3 to 4+ MR had died versus 10.5% with 0 to 2+ MR (hazard ratio 1.54, 95% confidence interval 1.22 to 1.95, p <0.001). After multivariable adjustment, 3 to 4+ MR continued to be associated with increased all-cause mortality (hazard ratio 1.48, 95% confidence interval 1.14 to 1.94, p = 0.004) except in the subset with atrial fibrillation (interaction p = 0.03) or recent (<3 months) HF hospitalization (p = 0.54). In conclusion, in this large, single-institution retrospective study of Medicare beneficiaries with HFpEF who underwent TTE, moderate-to-severe and severe MR were significantly associated with an increased risk of all-cause mortality after multivariable adjustment, except in those with atrial fibrillation or recent HF. Prospective studies are needed to assess the role of MR reduction in mitigating this risk.
Collapse
Affiliation(s)
- Ginger Y Jiang
- Division of Cardiovascular Medicine, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Boston, Massachusetts
| | - Jiaman Xu
- Division of Cardiovascular Medicine, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Warren J Manning
- Division of Cardiovascular Medicine, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Radiology, Boston, Massachusetts
| | - Lawrence J Markson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Information Systems, Boston, Massachusetts
| | - Kamal R Khabbaz
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Marwa A Sabe
- Division of Cardiovascular Medicine, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| |
Collapse
|
6
|
Meng Q, Wan L, Duan F, Wang D, Tao J, Wang H. Mitral Annulus Geometry and Dynamic Motion Changes in Patients With Aortic Regurgitation: A Three-Dimensional Transesophageal Echocardiographic Study. J Cardiothorac Vasc Anesth 2022; 36:4001-4009. [PMID: 35811278 DOI: 10.1053/j.jvca.2022.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of the present study was to investigate the mitral annulus (MA) geometry and dynamic motion changes in patients with aortic regurgitation (AR) before and after aortic valve replacement (AVR). Moreover, the difference in the effect of the type of prosthetic aortic valve on MA was compared. DESIGN Prospective observational study. SETTING Cardiac operating room at a single hospital. PARTICIPANTS Eighty-two patients with isolated moderate-to-severe AR who underwent AVR. Forty patients with normal valves were enrolled as controls. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The MA geometry and dynamic motion throughout the cardiac cycle were evaluated semiautomatically by three-dimensional transesophageal echocardiography. The severity of functional mitral regurgitation was intraoperatively evaluated. All patients were divided into 2 groups depending on the type of prosthetic valve (mechanical valve and bioprosthetic valve groups). Before AVR, compared with the control group without AR, the AR group demonstrated larger MA dimensions and the MA geometry was flatter. The contraction fraction of the MA area, perimeter, and height during the whole cardiac cycle were larger in the AR group (p < 0.05 for all). After AVR, most MA geometric and dynamic parameters decreased and functional mitral regurgitation also improved. In the postoperative subset analyses, the mechanical valve group showed a larger contraction fraction of the MA area and perimeter than the bioprosthetic valve group (p < 0.05 for both). CONCLUSIONS The MA geometry and dynamic motion changed markedly in patients with AR. These spatial and dynamic changes were restored to a certain extent after surgical correction of the aortic valve. However, the effects produced by mechanical and bioprosthetic valves on MA were different.
Collapse
Affiliation(s)
- Qinglong Meng
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Linyuan Wan
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fujian Duan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dandan Wang
- Clinical Research, Siemens Healthineers Ltd., Shanghai, China
| | - Jia Tao
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Wang
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
7
|
Beltrami M, Dei LL, Milli M. The Role of the Left Atrium: From Multimodality Imaging to Clinical Practice: A Review. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081191. [PMID: 36013370 PMCID: PMC9410416 DOI: 10.3390/life12081191] [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: 06/27/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022]
Abstract
In recent years, new interest is growing in the left atrium (LA). LA functional analysis and measurement have an essential role in cardiac function evaluation. Left atrial size and function are key elements during the noninvasive analysis of diastolic function in several heart diseases. The LA represents a “neuroendocrine organ” with high sensitivity to the nervous, endocrine, and immune systems. New insights highlight the importance of left atrial structural, contractile, and/or electrophysiological changes, introducing the concept of “atrial cardiomyopathy”, which is closely linked to underlying heart disease, arrhythmias, and conditions such as aging. The diagnostic algorithm for atrial cardiomyopathy should follow a stepwise approach, combining risk factors, clinical characteristics, and imaging. Constant advances in imaging techniques offer superb opportunities for a comprehensive evaluation of LA function, underlying specific mechanisms, and patterns of progression. In this literature review, we aim to suggest a practical, stepwise algorithm with integrative multimodality imaging and a clinical approach for LA geometry and functional analysis. This integrates diastolic flow analysis with LA remodelling by the application of traditional and new diagnostic imaging techniques in several clinical settings such as heart failure (HF), atrial fibrillation (AF), coronary artery disease (CAD), and mitral regurgitation (MR).
Collapse
Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
- Correspondence: ; Tel.: +39-339-541-8158
| | - Lorenzo-Lupo Dei
- Cardiology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Massimo Milli
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
| |
Collapse
|
8
|
Kato Y, Okada A, Amaki M, Nishimura K, Kanzaki H, Kataoka Y, Miyamoto K, Hamatani Y, Amano M, Takahama H, Hasegawa T, Kusano K, Fujita T, Kobayashi J, Yasuda S, Izumi C. Three-dimensional echocardiography for predicting mitral stenosis after MitraClip for functional mitral regurgitation. J Echocardiogr 2022; 20:151-158. [PMID: 35084686 DOI: 10.1007/s12574-022-00564-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/25/2021] [Accepted: 01/09/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postprocedural mitral stenosis (MS), or increased transmitral mean pressure gradient (TMPG), is one of the limitations of transcatheter edge-to-edge mitral valve repair using MitraClip (Abbott Vascular Inc., Santa Clara, USA); however, the usefulness of three-dimensional transesophageal echocardiography (3D-TEE) for predicting postprocedural MS in functional mitral regurgitation (MR) has not been fully elucidated. METHODS Eighty-two consecutive functional MR patients who underwent transcatheter mitral valve repair using MitraClip were retrospectively studied. Postprocedural MS was defined as TMPG ≥ 5 mmHg by echocardiography. RESULTS Ten patients had postprocedural MS, and 3D-TEE showed that patients with postprocedural MS had smaller preprocedural mitral valve orifice area (MVOA), anteroposterior and mediolateral diameter, leaflet area, and annulus area. Receiver operating characteristic analysis showed that leaflet area (area under the curve (AUC) 0.829), annulus area (AUC 0.813), anteroposterior diameter (AUC 0.797) and mediolateral diameter (AUC 0.803) evaluated using 3D-TEE were predictors of postprocedural MS, and their predictive abilities were higher than those of preprocedural MVOA (AUC 0.756) and preprocedural TMPG (AUC 0.716). Adding leaflet area to TMPG and MVOA resulted in higher C-statistics for predicting postprocedural MS (from 0.716 to 0.845 and from 0.756 to 0.853, respectively). CONCLUSIONS In functional MR patients treated with MitraClip, leaflet area and annulus area evaluated using 3D-TEE had high predictive values for postprocedural MS, and their predictive abilities were higher than those of preprocedural TMPG or MVOA.
Collapse
Affiliation(s)
- Yuta Kato
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yasuhiro Hamatani
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takuya Hasegawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| |
Collapse
|
9
|
Uno G, Omori T, Shimada S, Rader F, Siegel RJ, Shiota T. Differences in mitral valve geometry between atrial and ventricular functional mitral regurgitation in patients with atrial fibrillation: a 3D transoesophageal echocardiography study. Eur Heart J Cardiovasc Imaging 2021; 22:1106-1116. [PMID: 34405882 DOI: 10.1093/ehjci/jeab130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/29/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS This study investigated geometric differences in mitral valve apparatus between atrial functional mitral regurgitation (A-FMR) and functional mitral regurgitation (FMR) with left ventricular (LV) dysfunction in patients with atrial fibrillation (AF) using 3D transoesophageal echocardiography (TOE). METHODS AND RESULTS In total, 135 moderate or greater FMR patients with persistent AF or atrial flutter underwent 3D TOE. Fifty-six patients had A-FMR, defined as preserved LV ejection fraction (LVEF) of ≥50% and normal LV wall motion. Seventy-nine patients had ventricular FMR (V-FMR), defined as LV dysfunction (LVEF of <50%) or LV wall motion abnormality. To evaluate mitral leaflet coaptation, the coapted area was calculated as follows: total leaflet area (TLA) in end-diastole - closed leaflet area in mid-systole. Although annular area (AA) did not significantly differ between the two groups, TLA was significantly smaller in A-FMR than in V-FMR (P = 0.005). TLA/AA, indicating the degree of the leaflet remodelling, was significantly smaller in A-FMR than in V-FMR (P < 0.001). A-FMR had significantly smaller posterior mitral leaflet tethering height and angle measured at three anteroposterior planes (lateral, central, and medial) than V-FMR (all P < 0.001). However, vena contracta width (VCW) measured on long-axis view on TOE and coapted area, which correlated with VCW (r = -0.464, P < 0.001), were similar between the two groups. CONCLUSION Mitral leaflet remodelling may be less in A-FMR compared with V-FMR. However, leaflet tethering was smaller in A-FMR than in V-FMR, and this may result in a similar degree of mitral leaflet coaptation and mitral regurgitation severity.
Collapse
Affiliation(s)
- Goki Uno
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Taku Omori
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Shunsuke Shimada
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| |
Collapse
|
10
|
Matta M, Ayoub C, Abou Hassan OK, Layoun H, Cremer PC, Hussein A, Schoenhagen P, Saliba WI, Rodriguez LL, Griffin BP, Kapadia SR, Harb SC. Anatomic and Functional Determinants of Atrial Functional Mitral Regurgitation. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2021.1943765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
11
|
Lancellotti P, Go YY. Atrial Secondary Mitral Regurgitation: Often Overlooked, But Never Forgotten. JACC Cardiovasc Imaging 2021; 14:809-811. [PMID: 33832664 DOI: 10.1016/j.jcmg.2021.03.003] [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] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium; Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, Italy; Anthea Hospital, Bari, Italy.
| | - Yun Yun Go
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore
| |
Collapse
|
12
|
Mesi O, Gad MM, Crane AD, Ramchand J, Puri R, Layoun H, Miyasaka R, Gillinov MA, Wierup P, Griffin BP, Kapadia SR, Harb SC. Severe Atrial Functional Mitral Regurgitation: Clinical and Echocardiographic Characteristics, Management and Outcomes. JACC Cardiovasc Imaging 2021; 14:797-808. [PMID: 33832663 DOI: 10.1016/j.jcmg.2021.02.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVES This study was designed to compare the clinical and echocardiographic characteristics, management, and outcomes of severe atrial functional mitral regurgitation (AFMR) to primary mitral regurgitation (PMR). BACKGROUND AFMR remains poorly defined clinically. METHODS Consecutive patients who underwent transesophageal echocardiography at our institution between 2011 and 2018 for severe mitral regurgitation with preserved left ventricular function were screened. We excluded patients with endocarditis, any form of cardiomyopathy, or prior mitral intervention. The absence of leaflet pathology defined AFMR. Outcomes included death and heart failure hospitalizations. RESULTS A total of 283 patients were included (AFMR = 14%, PMR = 86%). Compared to PMR, patients with AFMR had more comorbidities, including hypertension (94.9% vs. 76.2%; p = 0.015), diabetes mellitus (46.2% vs. 18.4%; p < 0.001), long-standing atrial fibrillation (28.2% vs. 13.1%; p = 0.015), prior nonmitral cardiac surgery (25.6% vs. 9.8%; p = 0.004), and pacemaker placement (33.3% vs. 13.5%; p = 0.002). They also had higher average E/e' (median [interquartile range]:16.04 [13.1 to 22.46] vs. 14.1 [10.89 to 19]; p = 0.036) and worse longitudinal left atrial strain peak positive value (16.86 ± 12.15% vs. 23.67 ± 14.09%; p = 0.002) compared to PMR. During follow-up (median: 22 months), patients with AFMR had worse survival (log-rank p = 0.009) and more heart failure hospitalizations (log-rank p = 0.002). They were also less likely to undergo mitral valve intervention (59.0% vs. 83.6%; p = 0.001), although surgery was associated with improved survival (log-rank p = 0.021). On multivariable regression analysis, AFMR was independently associated with mortality [adjusted odds ratio: 2.61, 95% confidence interval: 1.17 to 5.83; p = 0.02]. CONCLUSIONS AFMR constitutes an under-recognized high-risk group, with significant comorbidities, limited therapeutic options, and poor outcomes.
Collapse
Affiliation(s)
- Oltion Mesi
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed M Gad
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alejandro D Crane
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jay Ramchand
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rhonda Miyasaka
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marc A Gillinov
- Department of Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Per Wierup
- Department of Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| |
Collapse
|
13
|
Mitral Annular Dynamics in AF Versus Sinus Rhythm: Novel Insights Into the Mechanism of AFMR. JACC Cardiovasc Imaging 2021; 15:1-13. [PMID: 34274270 DOI: 10.1016/j.jcmg.2021.05.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/14/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study aimed to investigate mitral annular dynamics in atrial fibrillation (AF) and after sinus rhythm restoration, and to assess the relationship between annular dynamics and mitral regurgitation (MR). BACKGROUND AF can be associated with MR that improves after sinus rhythm restoration. Mechanisms underlying this atrial functional MR (AFMR) are ill-understood and generally attributed to left atrial remodeling. METHODS Fifty-three patients with persistent AF and normal left ventricular ejection fraction were prospectively examined by means of 3-dimensional transesophageal echocardiography before, immediately after, and 6 weeks after electric cardioversion to sinus rhythm. Annular motion was assessed during AF and in sinus rhythm with the use of 3-dimensional analysis software, and the relationship with MR severity was explored. RESULTS During AF and immediately after sinus rhythm restoration, the mitral annulus behaved relatively adynamically, with an overall change in annular area of 10.3% (95% CI: 8.7%-11.8%) and 12.2% (95% CI: 10.6%-13.8%), respectively. At follow-up, a significant increase in annular dynamics (19.0%; 95% CI: 17.4%-20.6%; P < 0.001) was observed, owing predominantly to an increase in presystolic contraction (P < 0.001). The effective regurgitant orifice area decreased from 0.15 cm2 (0.10 cm2-0.23 cm2) during AF to 0.09 cm2 (0.05 cm2-0.12 cm2) at follow-up (P < 0.001) in the total cohort, and from 0.27 (0.23-0.33) to 0.16 (0.12-0.29) in the subgroup with effective regurgitant orifice area (EROA) ≥0.20 cm2. The change in presystolic annular motion was the only independent determinant of the decrease in MR severity (P = 0.027), by optimizing annular-leaflet imbalance. Patients with more pronounced blunting of presystolic dynamics had a higher EROA (P < 0.001), because of a lower total-to-closed leaflet area ratio (P < 0.001) at each point in time. This ratio was the strongest independent determinant of AFMR severity (adjusted P = 0.003). CONCLUSIONS Mitral annular dynamics are impaired in AF, with blunted presystolic narrowing that contributes to AFMR. Sinus rhythm restoration allows gradual recovery of presystolic annular dynamics. Improved annular dynamics decrease AFMR severity by optimizing annular-leaflet imbalance, regardless of LA remodeling.
Collapse
|
14
|
Ortiz-Leon XA, Posada-Martinez EL, Trejo-Paredes MC, Ivey-Miranda JB, Pereira J, Crandall I, DaSilva P, Bouman E, Brooks A, Gerardi C, Ugonabo I, Chen W, Houle H, Akar JG, Lin BA, McNamara RL, Lombo-Lievano B, Arias-Godinez JA, Sugeng L. Understanding tricuspid valve remodelling in atrial fibrillation using three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging 2021; 21:747-755. [PMID: 32372089 DOI: 10.1093/ehjci/jeaa058] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/10/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Atrial fibrillation (AF) has been associated with tricuspid annulus (TA) dilation in patients with severe functional tricuspid regurgitation (TR); however, the impact of AF is less clear in patients without severe TR. Our aim was to characterize TA remodelling in patients with AF in the absence of severe TR using 3D transoesophageal echocardiography (TOE). METHODS AND RESULTS Ninety patients underwent clinically indicated transthoracic and TOE: non-structural (NS)-AF (n = 30); AF with left heart disease (LHD) (n = 30), and controls in sinus rhythm (n = 30). Three-dimensional TOE datasets were analysed to measure TA dimensions using novel dedicated tricuspid valve software. The NS-AF group showed biatrial dilatation and normal right ventricular (RV) size with decreased longitudinal function compared to controls, whereas the LHD-AF group showed biatrial dilatation, RV enlargement, decreased biventricular function, and higher systolic pulmonary artery pressure compared with the other groups. Indexed TA area, minimum diameter, maximum diameter, and total perimeter were significantly larger in the NS-AF group than in controls (measurements in end-diastole: 6.4 ± 1.1 vs. 5.0 ± 0.6 cm2/m2, 1.8 ± 0.3 vs. 1.6 ± 0.2 cm/m2, 2.1 ± 0.3 vs. 1.9 ± 0.2 cm/m2, and 6.6 ± 0.9 vs. 5.9 ± 0.7 cm/m2, respectively, all P < 0.05). There was no significant difference in any indexed TA parameter between AF groups. TA circularity index (ratio between minimum and maximal diameters) and TA fractional area change between end-diastole and end-systole were no different among the three groups. CONCLUSION AF is associated with right atrial and tricuspid annular remodelling independent of the presence of LHD in patients with intrinsically normal tricuspid leaflets without severe TR.
Collapse
Affiliation(s)
- Xochitl A Ortiz-Leon
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Edith L Posada-Martinez
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Maria C Trejo-Paredes
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Juan B Ivey-Miranda
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Jason Pereira
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Ian Crandall
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Paul DaSilva
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Eileen Bouman
- Ultrasound Business Unit, Advanced Development, Siemens Healthineers, 685 Middlefield Road Mountain View, CA 94043, USA
| | - Alyssa Brooks
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Christine Gerardi
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Ifeoma Ugonabo
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Wanwen Chen
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Helene Houle
- Ultrasound Business Unit, Advanced Development, Siemens Healthineers, 685 Middlefield Road Mountain View, CA 94043, USA
| | - Joseph G Akar
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Ben A Lin
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Robert L McNamara
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Bernardo Lombo-Lievano
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Jose A Arias-Godinez
- Laboratory of Echocardiography, National Institute of Cardiology, Juan Badiano 1, Belisario Domínguez Secc 16, Mexico City 14080, Mexico
| | - Lissa Sugeng
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| |
Collapse
|
15
|
Surgical considerations for atrial functional regurgitation of the mitral and tricuspid valves based on the etiological mechanism. Gen Thorac Cardiovasc Surg 2021; 69:1041-1049. [PMID: 33970433 PMCID: PMC8203518 DOI: 10.1007/s11748-021-01629-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 03/29/2021] [Indexed: 10/25/2022]
Abstract
Atrial functional mitral regurgitation is a hot research topic in the field of mitral valve disease. Atrial functional mitral regurgitation is distinctly different from ventricular functional mitral regurgitation. The surgical indications for atrial functional mitral regurgitation have not been well established because of the small amount of evidence gathered to date. Mitral annular plication with an artificial ring is an essential surgical procedure because dilatation of the mitral valve annulus is a main factor underlying this pathology. Most of these cases can be treated by mitral annuloplasty alone. However, additional procedures, such as application of artificial chordae to the anterior leaflet for pseudo-prolapse, and posterior leaflet augmentation with a pericardial patch, are required in advanced cases with a giant left atrium and extremely enlarged mitral annulus. Chronic atrial fibrillation causes enlargement of the right and left atria. This pathology is a bilateral atrioventricular valve disease (dual-valve disease). Therefore, the conventional guidelines of single-valve disease should not be applied. Although atrial functional tricuspid regurgitation is underappreciated, tricuspid annuloplasty should be considered for most patients to prevent future regurgitation. In addition to the mitral and tricuspid valve procedure, integrated surgical management, including plication of the atrium and left appendage closure, is required. This review summarizes the current considerations of surgical treatment for atrial functional regurgitation of the mitral and tricuspid valves based on the etiological mechanism.
Collapse
|
16
|
Breen TJ, Jain CC, Tan NY, Miranda WR, Nishimura RA. Paroxysmal Severe Mitral Regurgitation. Mayo Clin Proc 2021; 96:86-91. [PMID: 33413838 DOI: 10.1016/j.mayocp.2020.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 06/01/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the clinical presentation, pathophysiology, and treatment for "paroxysmal severe mitral regurgitation" (MR), which is an underappreciated cause of heart failure with preserved left ventricular ejection fraction. METHODS We retrospectively reviewed cases of transient severe MR that were evaluated at Mayo Clinic in Rochester, Minnesota, between January 1, 2006, and December 31, 2019. Paroxysmal severe MR was defined as the appearance of transient severe MR in patients with mild MR at rest, normal left ventricle (LV) size, left ventricular ejection fraction greater than 40%, and absence of obstructive coronary artery disease. RESULTS We identified 6 patients (5 women) with a median age of 68 years. There were 3 distinct mechanisms of paroxysmal severe MR, which we labeled types 1, 2, and 3. Type 1 MR was caused by LV dyssynchrony from a rate-dependent left bundle branch block, which led to apical leaflet tenting and incomplete coaptation. Type 2 MR occurred from mitral annular dilatation during maneuvers that increased left-sided volume. Type 3 MR was caused by coronary artery vasospasm with apical leaflet tenting. Treatments varied depending on the underlying cause and included cardiac resynchronization therapy for type 1, surgical valve replacement for type 2, and medical therapy for type 3. CONCLUSION Paroxysmal severe MR is a rare cause of heart failure in patients with preserved LV function. We have identified 3 distinct mechanisms that can lead to this dynamic process, with treatments varying based on the underlying cause.
Collapse
Affiliation(s)
- Thomas J Breen
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
17
|
Hirasawa K, Namazi F, Milhorini Pio S, Vo NM, Ajmone Marsan N, Bax JJ, Delgado V. Insufficient Mitral Leaflet Remodeling in Relation to Annular Dilation and Risk of Residual Mitral Regurgitation After MitraClip Implantation. JACC Cardiovasc Imaging 2020; 14:756-765. [PMID: 33129743 DOI: 10.1016/j.jcmg.2020.08.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The purpose of this study was to determine whether the mitral valve (MV) total leaflet area (TLA)-to-mitral annular area (MAA) (TLA/MAA) ratio measured using 3-dimensional (3D) transesophageal echocardiography (TEE) was associated with residual mitral regurgitation (MR) after MitraClip implantation in patients with secondary MR. BACKGROUND The factors influencing the results of MitraClip implantation for secondary MR are controversial. This study hypothesized that insufficient remodeling of the mitral leaflets relative to the annular dilation may be associated with significant MR after MitraClip implantation. METHODS This study included patients with secondary MR treated with MitraClips. Using 3D TEE dataset, the TLA in diastole and MAA in systole were measured with dedicated software. RESULTS In a total cohort of 119 patients (mean age 74 ± 9 years; 61% male), significant residual MR (≥2+) was present in 43 patients (36%). In patients with significant residual MR, MAA was greater than in patients without residual MR (10.7 ± 2.4 cm2 vs. 9.0 ± 2.1 cm2; p < 0.001) whereas no significant difference was observed in TLA (12.2 ± 2.6 cm2 vs. 12.0 ± 2.9 cm2; p = 0.836). TLA/MAA ratio was lower in patients with significant residual MR as compared to their counterparts (1.14 ± 0.15 vs. 1.34 ± 0.16; p < 0.001), suggesting insufficient leaflet remodeling relative to annular dilation. On receiver-operating characteristic curve analysis, the TLA/MAA ratio had better discriminative power to identify patients who will have significant residual MR compared to MAA alone (area under the curve [AUC]: 0.830 vs. 0.723; p = 0.049). CONCLUSIONS In patients with secondary MR, insufficient mitral leaflet remodeling relative to the annulus dilation, as reflected by a lower TLA/MAA ratio, is associated with significant residual MR after MitraClip implantation.
Collapse
Affiliation(s)
- Kensuke Hirasawa
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Center, Leiden, the Netherlands
| | - Farnaz Namazi
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan Milhorini Pio
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Center, Leiden, the Netherlands
| | - N Mai Vo
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Center, Leiden, the Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Center, Leiden, the Netherlands.
| | - Victoria Delgado
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
18
|
Mitral Valve Repair of Atrial Functional Mitral Regurgitation in Heart Failure with Preserved Ejection Fraction. J Clin Med 2020; 9:jcm9113432. [PMID: 33114639 PMCID: PMC7692676 DOI: 10.3390/jcm9113432] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 01/14/2023] Open
Abstract
Our objective was to describe the long-term effects of endoscopic mitral valve (MV) repair on outcome in patients with heart failure with preserved ejection fraction (HFpEF) and atrial functional mitral regurgitation (AFMR). In patients with HFpEF, even mild AFMR has been associated with poor outcome. The study population consisted of consecutive patients with HFpEF (left ventricular ejection fraction (LVEF) ≥ 50%, H2FPEF score ≥ 5) and AFMR, who underwent isolated, minimally invasive endoscopic MV repair (MVRepair group) (n = 131) or remained on standard of care (StanCare group) (n = 139). Patients with coronary artery disease or organic mitral regurgitation (MR) were excluded. Patients were matched using inverse probability of treatment weighting. Endpoints were all-cause mortality and a composite of all-cause mortality and HFpEF readmissions. The median follow-up was 5.03 years (interquartile range (IQR) 2.6–7.9 years). In the MVRepair group, the perioperative, 30-day, 1-year, and 5-year mortality were 0, 1%, 1%, and 12%, respectively. Additionally, 13 (10%) patients were readmitted for worsening HFpEF, while 2 (1%) individuals underwent redo MV surgery for recurrent MR. MVRepair compared with StanCare showed 21–29% (Standard Error (SE) 6–8%) and 19–26% (SE 6–8%) absolute risk reduction of all-cause mortality and HFpEF readmissions, respectively (all p < 0.05). MVRepair emerged as the strongest independent predictor of all-cause mortality (Hazard Ratio (HR) 0.16, 95% (Confidence Interval (CI) 0.07–0.34, p < 0.001) and HFpEF readmissions (HR 0.21, 95% CI 0.09–0.51, p < 0.001). At 5-year follow-up, in the MVRepair group, a total of 88% were alive and 80% were alive without readmission for HFpEF. We can conclude that endoscopic MV repair is associated with low perioperative mortality as well as high long-term efficacy, and appears to improve clinical outcome in patients with AFMR and HFpEF.
Collapse
|
19
|
Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
| | | |
Collapse
|
20
|
Kaneyuki D, Nakajima H, Asakura T, Yoshitake A, Tokunaga C, Tochii M, Hayashi J, Takazawa A, Izumida H, Iguchi A. Midterm results of mitral valve repair for atrial functional mitral regurgitation: a retrospective study. J Cardiothorac Surg 2020; 15:312. [PMID: 33046087 PMCID: PMC7552363 DOI: 10.1186/s13019-020-01362-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/05/2020] [Indexed: 12/21/2022] Open
Abstract
Background Annular dilation by left atrial remodeling is considered the main cause of atrial function mitral regurgitation. Although acceptable outcomes have been obtained using mitral ring annuloplasty alone for atrial functional mitral regurgitation, data assessing outcomes of this procedure are limited. Therefore, we aimed to assess midterm outcomes of mitral valve repair in patients with atrial functional mitral regurgitation. Methods We retrospectively studied 40 patients (mean age: 69 ± 9 years) who had atrial fibrillation that persisted for > 1 year, preserved left ventricular ejection fraction of > 40%, and mitral valve repair for atrial functional mitral regurgitation. The mean clinical follow-up duration was 42 ± 24 months. Results Mitral ring annuloplasty was performed for all patients. Additional repair including anterior mitral leaflet neochordoplasty was performed for 22 patients. Concomitant procedures included maze procedure in 20 patients and tricuspid ring annuloplasty in 31 patients. Follow-up echocardiography showed significant decreases in left atrial dimensions and left ventricular end-diastolic dimensions. Recurrent mitral regurgitation due to ring detachment or leaflet tethering was observed in five patients and was seen more frequently among those with preoperative left ventricular dilatation. Three patients without tricuspid ring annuloplasty or sinus rhythm recovery by maze procedure developed significant tricuspid regurgitation. Five patients who underwent the maze procedure showed sinus rhythm recovery. Rates of freedom from re-admission for heart failure at 1 and 5 years after surgery were 95 and 86%, respectively. Conclusions Mitral valve repair is not sufficient to prevent recurrent atrial functional mitral regurgitation in patients with preoperative left ventricular dilatation. Tricuspid ring annuloplasty may be required for long-term prevention of significant tricuspid regurgitation.
Collapse
Affiliation(s)
- Daisuke Kaneyuki
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan.
| | - Hiroyuki Nakajima
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Toshihisa Asakura
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Akihiro Yoshitake
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Chiho Tokunaga
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Masato Tochii
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Jun Hayashi
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Akitoshi Takazawa
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Hiroaki Izumida
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| | - Atsushi Iguchi
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama, 3501298, Japan
| |
Collapse
|
21
|
|
22
|
Ueno H, Imamura T, Kinugawa K. Update of Patient Selection and Therapeutic Strategy Using MitraClip. Int Heart J 2020; 61:636-640. [PMID: 32641639 DOI: 10.1536/ihj.20-013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patients with advanced heart failure often accompany severe function mitral regurgitation refractory to optimal medical therapy. Degenerative mitral regurgitation also develops due to various degeneration of mitral valve. Surgical intervention to the mitral valve might be effective in some cases, but it is challenging for the high-risk cases. Recently, percutaneous edge-to-edge mitral valve repair using the MitraClip system, which enables us to approach the mitral valve at relatively low risk, has developed. Two major prospective randomized control trials have been conducted to investigate the clinical advantage of MitraClip system over optimal medical therapy in patients with severe mitral regurgitation; both showed controversial conclusions. Now is a time to consider optimal patient selection and therapeutic strategy using MitraClip system.
Collapse
Affiliation(s)
- Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama
| | | | | |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW To review the prevalence and prognosis of atrial functional mitral regurgitation (AFMR), the distinctive echocardiographic and mechanistic findings, and the therapeutic implications of this newly described disorder. RECENT FINDINGS Initial studies identified an association between atrial fibrillation, mitral annular dilation, and significant mitral regurgitation despite a normal mitral valve and left ventricle. Accumulating data suggest that AFMR is not rare and may have a prognosis as poor as functional MR associated with LV remodeling. Echocardiography has played an important role in understanding the unique pathophysiology of AFMR, and proposed mechanisms include not only atrial remodeling, but structural and functional abnormalities of the LV (HFpEF shares a common pathophysiology) and insufficient leaflet growth. Timely rhythm control of atrial fibrillation and strategies that reduce diastolic pressure, left atrial and mitral annular enlargement, and that favorably affect mitral leaflet adaptation, are promising preventive and treatment options that warrant clinical study. SUMMARY Functional mitral regurgitation may be atrial in origin and should be considered in patients with (particularly long-standing) atrial fibrillation and in those with HFpEF.
Collapse
|
24
|
Kaneyuki D, Nakajima H, Asakura T, Yoshitake A, Tokunaga C, Tochii M, Hayashi J, Takazawa AT, Izumida H, Iguchi A. The change in the mitral-septal angle after surgery for atrial functional mitral regurgitation. Gen Thorac Cardiovasc Surg 2020; 69:1-7. [PMID: 32562053 DOI: 10.1007/s11748-020-01408-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/10/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The optimal surgical strategy for atrial functional mitral regurgitation remains uncertain. Preoperative mitral-septal angle ≤ 70° has been reported as a risk factor for an abnormal vortex pattern in mitral valve repair. This study aimed to elucidate the change in the mitral-septal angle after surgery for atrial functional mitral regurgitation and its effect on the mid-term outcomes. METHODS Forty patients underwent mitral valve repair for atrial functional mitral regurgitation. The mitral-septal angle was defined as the angle between the mitral annulus and the anteroseptal wall of the left ventricular mid-portion in the parasternal long-axis view on transthoracic echocardiography. All patients underwent mitral ring annuloplasty. Left atrial plication was performed in nine patients. The mean clinical follow-up period was 42 ± 24 months. RESULTS The ratio of left atrial volume to left ventricular end-systolic volume was negatively correlated with the preoperative mitral-septal angle. The postoperative mitral-septal angles were significantly smaller than the preoperative ones. The mitral-septal angle decreased with a decrease in the mitral annuloplasty ring size. Patients who underwent left atrial plication tended to show an increase in the mitral-septal angle postoperatively. There were no significant differences in mid-term morbidities, including heart failure, requiring re-hospitalization and mortalities between patients with postoperative MSA > 70° and those with postoperative MSA ≤ 70°. CONCLUSIONS Mitral ring annuloplasty negatively changed the mitral-septal angle, while left atrial plication may induce a positive change to the mitral-septal angle. An association between the mitral-septal angle and mid-term outcomes was not revealed in this study.
Collapse
Affiliation(s)
- Daisuke Kaneyuki
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan.
| | - Hiroyuki Nakajima
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Toshihisa Asakura
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Akihiro Yoshitake
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Chiho Tokunaga
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Masato Tochii
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Jun Hayashi
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Aki Toshi Takazawa
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Hiroaki Izumida
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| | - Atsushi Iguchi
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, 3501298, Japan
| |
Collapse
|
25
|
Kagiyama N, Mondillo S, Yoshida K, Mandoli GE, Cameli M. Subtypes of Atrial Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2020; 13:820-835. [DOI: 10.1016/j.jcmg.2019.01.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 10/26/2022]
|
26
|
Functional Regurgitation of Atrioventricular Valves and Atrial Fibrillation: An Elusive Pathophysiological Link Deserving Further Attention. J Am Soc Echocardiogr 2020; 33:42-53. [DOI: 10.1016/j.echo.2019.08.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 12/15/2022]
|
27
|
Abe Y, Takahashi Y, Shibata T. Functional mitral regurgitation, updated: ventricular or atrial? J Echocardiogr 2019; 18:1-8. [DOI: 10.1007/s12574-019-00453-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/23/2019] [Accepted: 10/28/2019] [Indexed: 01/09/2023]
|
28
|
Nishino S, Watanabe N, Ashikaga K, Morihisa K, Kuriyama N, Asada Y, Shibata Y. Reverse Remodeling of the Mitral Valve Complex After Radiofrequency Catheter Ablation for Atrial Fibrillation. Circ Cardiovasc Imaging 2019; 12:e009317. [DOI: 10.1161/circimaging.119.009317] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Mitral regurgitation is frequently complicated with atrial fibrillation without apparent organic changes in the leaflet, which occasionally improves after successful radiofrequency catheter ablation. We aimed to evaluate a possible geometric effect of radiofrequency catheter ablation on the mitral valve apparatus.
Methods:
Forty-three consecutive patients who underwent successful catheter ablation for persistent atrial fibrillation (maintaining sinus rhythm for 6 months after their procedure) were examined by serial real-time 3-dimensional transesophageal echocardiography before and 6 months after catheter ablation. Mitral valve complex geometry was measured using dedicated software for 3-dimensional transesophageal echocardiography.
Results:
Mitral valve apparatus showed significant reverse remodeling along with left atrial reverse remodeling 6 months after successful catheter ablation (50.5 [39.2–61.0] versus 36.4 [28.9–43.1] mL/m
2
;
P
<0.001). The degree of mitral regurgitation decreased in a majority of patients (mitral regurgitation jet area; 1.83 [0.78–3.09] versus 0.77 [0.36–1.47] cm
2
;
P
<0.001). Annular area significantly decreased (5.32±0.91 versus 4.73±0.76 cm
2
/m
2
;
P
<0.001) in both anterior-posterior and medial-lateral directions. Mitral annular contraction significantly recovered after maintaining sinus rhythm for 6 months (7.51 [4.82–9.62]% versus 9.71 [6.27–13.85]%;
P
=0.008). There were no significant changes in tenting volume or tenting height (0.46 [0.27–0.89] versus 0.51 [0.32–0.72] mL/m
2
,
P
=0.744; 2.34 [1.75–3.48] versus 2.76 [1.99–3.08] mm/m
2
,
P
=0.717). The leaflet surface area also significantly decreased after catheter ablation (5.74 [5.01–6.33] versus 5.19 [4.63–5.64] cm
2
/m
2
;
P
<0.001).
Conclusions:
Maintaining sinus rhythm after successful catheter ablation promotes reverse remodeling in the mitral valve apparatus and improves so-called atrial functional mitral regurgitation. The positive geometric effect of catheter ablation would be expected to be a possible contributor to better outcomes in patients with atrial fibrillation, in addition to the postprocedural freedom from rhythm disturbance.
Collapse
Affiliation(s)
- Shun Nishino
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, Japan (S.N., N.W., K.A., K.M., N.K., Y.S.)
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, Japan (S.N., N.W., K.A., K.M., N.K., Y.S.)
| | - Keiichi Ashikaga
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, Japan (S.N., N.W., K.A., K.M., N.K., Y.S.)
| | - Kenji Morihisa
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, Japan (S.N., N.W., K.A., K.M., N.K., Y.S.)
| | - Nehiro Kuriyama
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, Japan (S.N., N.W., K.A., K.M., N.K., Y.S.)
| | - Yujiro Asada
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Japan (Y.A.)
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, Japan (S.N., N.W., K.A., K.M., N.K., Y.S.)
| |
Collapse
|
29
|
Deferm S, Bertrand PB, Verbrugge FH, Verhaert D, Rega F, Thomas JD, Vandervoort PM. Atrial Functional Mitral Regurgitation. J Am Coll Cardiol 2019; 73:2465-2476. [DOI: 10.1016/j.jacc.2019.02.061] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
|
30
|
Kim DH, Heo R, Handschumacher MD, Lee S, Choi YS, Kim KR, Shin Y, Park HK, Bischoff J, Aikawa E, Song JM, Kang DH, Levine RA, Song JK. Mitral Valve Adaptation to Isolated Annular Dilation: Insights Into the Mechanism of Atrial Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2019; 12:665-677. [PMID: 29248661 PMCID: PMC5993562 DOI: 10.1016/j.jcmg.2017.09.013] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/14/2017] [Accepted: 09/22/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study hypothesized that compensatory mitral leaflet area (MLA) adaptation occurs in patients with persistent atrial fibrillation (AF) without left ventricular (LV) dysfunction but has limitations that augment mitral regurgitation (MR). The study also explored whether asymmetrical annular dilation is matched by relative leaflet enlargement. BACKGROUND Functional MR occurs in patients with AF and isolated annular dilation, but the relationship of MLA adaptation with annular area (AA) is unknown. METHODS Three-dimensional echocardiographic images were acquired from 86 patients with quantified MR: 53 with nonvalvular persistent AF (23 MR+ with moderate or greater MR, 30 MR-) without LV dysfunction or dilation and 33 normal controls. Comprehensive 3-dimensional analysis included total diastolic MLA, adaptation ratios of MLA to annular area and MLA to leaflet closure area, and annular and tenting geometry. RESULTS Total MLA was 22% larger in patients with AF than in controls, thus paralleling the increased AA. However, as AA increased, adaptive indices (MLA/AA ratio and ratio of MLA to closure area) plateaued, becoming lowest in MR+ patients (ratio of MLA to closure area = 1.63 ± 0.17 controls, 1.60 ± 0.11 MR-, 1.32 ± 0.10 MR+; p < 0.001). MR increased as the ratio of MLA to closure area decreased (R2 = 0.68; p < 0.001). The posterior-to-anterior MLA ratio remained constant, whereas the posterior-to-anterior mitral annulus perimeter increased (1.21 ± 0.16 controls, 1.32 ± 0.20 MR-, 1.46 ± 0.19 MR+; p < 0.001). Multivariate MR determinants were annular area, total MLA to closure area, and posterior-to-anterior perimeter ratios. CONCLUSIONS MLA adaptively increases in AF with isolated annular dilation and normal LV function. This compensatory enlargement becomes insufficient with greater annular dilation, and the leaflets fail to match asymmetrical annular remodeling, thereby increasing MR. These findings can potentially help optimize therapeutic options and motivate basic studies of adaptive growth processes.
Collapse
Affiliation(s)
- Dae-Hee Kim
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Ran Heo
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mark D Handschumacher
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahmin Lee
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yun-Sil Choi
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyu-Ri Kim
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yewon Shin
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hong-Kyung Park
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joyce Bischoff
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elena Aikawa
- Center for Excellence in Vascular Biology, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jong-Min Song
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Hyun Kang
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jae-Kwan Song
- Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| |
Collapse
|
31
|
Lancellotti P, Dulgheru R, Marchetta S, Oury C, Garbi M. Valve Disease in Heart Failure: Secondary but Not Irrelevant. Heart Fail Clin 2019; 15:219-227. [PMID: 30832813 DOI: 10.1016/j.hfc.2018.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Secondary regurgitation caused by the remodeling and dysfunction of the left or right heart chamber may complicate heart failure, worsening both symptoms and prognosis. Outcome studies have shown that patients' prognosis worsened as the severity of secondary regurgitation increases. Imaging and more specifically echocardiography plays a central role for diagnosis and serial assessment of secondary regurgitation as well as for timing the intervention and guiding the procedure.
Collapse
Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy.
| | - Raluca Dulgheru
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium
| | - Stella Marchetta
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium
| | - Cécile Oury
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium
| | - Madalina Garbi
- King's Health Partners, King's College Hospital NHS Foundation Trust, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| |
Collapse
|
32
|
Tang Z, Fan YT, Wang Y, Jin CN, Kwok KW, Lee APW. Mitral Annular and Left Ventricular Dynamics in Atrial Functional Mitral Regurgitation: A Three-Dimensional and Speckle-Tracking Echocardiographic Study. J Am Soc Echocardiogr 2019; 32:503-513. [PMID: 30679142 DOI: 10.1016/j.echo.2018.11.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) and left atrial (LA) enlargement may develop functional, normal leaflet motion mitral regurgitation (MR) without left ventricular (LV) remodeling. Mitral annular dynamics and LV mechanics are important for preserving normal mitral valve function. The aim of this study was to assess the annular and LV dynamics in patients with AF and functional MR. METHODS Twenty-one patients with AF with moderate or more MR (AFMR+ group), 46 matched patients with AF with no or mild MR (AFMR- group), and 19 normal patients were retrospectively studied. Mitral annular dynamics were quantitatively assessed using three-dimensional echocardiography. Systolic LV global longitudinal strain (GLS), global circumferential strain, and LA strain were measured using two-dimensional speckle-tracking echocardiography. RESULTS The normal annulus displayed presystolic followed by systolic contraction and increase in saddle shape (P < .01 for all). Presystolic annular dynamics were abolished in both groups of patients with AF (P > .05 vs normal). In contrast, systolic and total annular dynamics during the cardiac cycle were preserved in AFMR- patients (P > .10 vs normal) but impaired in AFMR+ patients (P < .05 vs normal and AFMR-). LV GLS (P < .0001) and LA strain (P = .02), but not LV global circumferential strain (P = .97), were impaired in AFMR+ compared with AFMR- patients despite comparable LA and LV volumes. MR severity correlated with systolic annular contraction (r = 0.64, P < .0001), saddle deepening (r = 0.53, P = .003), and LV GLS (r = 0.46, P < .0001). Multivariate analysis identified that impaired systolic contraction (odds ratio, 2.18; P = .001) and saddle deepening (odds ratio, 2.68; P = .04) were independently associated with MR. Excluding annular dynamics from the model, less negative LV GLS, but not LA strain, became associated with MR (odds ratio, 1.93; P < .0001). CONCLUSIONS In patients with AF and absent LA contraction, the normal predominantly "atriogenic" annular dynamics become "ventriculogenic." Isolated LA enlargement is insufficient to cause important MR without coexisting abnormal LV mechanics and annular dynamics during systole. "Atrial" functional MR may not be purely an atrial disorder.
Collapse
Affiliation(s)
- Zhe Tang
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China; Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yi-Ting Fan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Yu Wang
- Cardiology Department, Chinese PLA General Hospital, Beijing, China
| | - Chun-Na Jin
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Ka-Wai Kwok
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, China
| | - Alex Pui-Wai Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
| |
Collapse
|
33
|
Silbiger JJ. Mechanistic insights into atrial functional mitral regurgitation: Far more complicated than just left atrial remodeling. Echocardiography 2019; 36:164-169. [DOI: 10.1111/echo.14249] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/01/2018] [Accepted: 12/04/2018] [Indexed: 01/03/2023] Open
|
34
|
Hernández-Ramírez JM, Ortega-Trujillo JR. Insuficiencia mitral funcional auricular. Estudio ecocardiográfico tridimensional. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:347-353. [DOI: 10.1016/j.acmx.2017.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 11/29/2022] Open
|
35
|
Boilève V, Dreyfus J, Attias D, Scheuble A, Codogno I, Brochet E, Vahanian A, Messika-Zeitoun D. Predictors of mitral annulus enlargement? A real-time three-dimensional transesophageal study. Int J Cardiol 2018; 270:349-352. [PMID: 29907442 DOI: 10.1016/j.ijcard.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/29/2018] [Accepted: 06/04/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mitral annulus (MA) enlargement can be observed in various cardiac conditions but respective influence of left atrial (LA) and left ventricle (LV) size remained unclear. METHODS In 120 patients who underwent a clinically indicated 3D-transesophageal-echocardiography, 30 atrial fibrillation (AF), 30 secondary mitral regurgitation (SMR), 30 primary myxomatous mitral regurgitation (PMR) and 30 mitral stenosis (MS), we evaluated the association between MA area (MA-area) and LA volume (LAvol) measured using the biplane area-length method, end-diastolic (LVEDV) and end-systolic (LVESV) volumes measured using the biplane Simpson method. MA-area was measured based on 3D datasets using QLab10. RESULTS MA-area was correlated to LVEDV (r = 0.42, p < 0.0001), LVESV (r = 0.29, p = 0.001) but more markedly to LAvol (r = 0.62, p < 0.0001). Correlation between MA-area and LAvol was sustained in all subsets whereas MA-area was not correlated to LVEDV and LVESV in patients with SMR and with PMR (all p > 0.10). In multivariate analysis main predictors of MA-area were LAvol (p < 0.0001) and myxomatous etiology of MR (p = 0.0003) followed by LVEDV (p = 0.006) and LVESV (p = 0.02). CONCLUSION In a population of patients with a wide range of LA/LV size related to various conditions, LA volume and myxomatous MR etiology appeared as main predictors of MA size whereas LV size had a more modest influence.
Collapse
Affiliation(s)
- V Boilève
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat Hospital, Paris, France; Centre Cardiologique du Nord, Saint-Denis, France
| | - J Dreyfus
- Centre Cardiologique du Nord, Saint-Denis, France
| | - D Attias
- Centre Cardiologique du Nord, Saint-Denis, France
| | - A Scheuble
- Centre Cardiologique du Nord, Saint-Denis, France
| | - I Codogno
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - E Brochet
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - A Vahanian
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat Hospital, Paris, France; INSERM U1148, Bichat Hospital, Paris, France; University Paris VII, Faculté de Médecine Paris-Diderot, Paris, France
| | - D Messika-Zeitoun
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat Hospital, Paris, France; INSERM U1148, Bichat Hospital, Paris, France; University Paris VII, Faculté de Médecine Paris-Diderot, Paris, France; University of Ottawa Heart Institute, Ottawa, Canada.
| |
Collapse
|
36
|
Saito C, Minami Y, Arai K, Haruki S, Yagishita Y, Jujo K, Ashihara K, Hagiwara N. Prevalence, clinical characteristics, and outcome of atrial functional mitral regurgitation in hospitalized heart failure patients with atrial fibrillation. J Cardiol 2018; 72:292-299. [DOI: 10.1016/j.jjcc.2018.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/31/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
|
37
|
Cong T, Gu J, Lee APW, Shang Z, Sun Y, Sun Q, Wei H, Chen N, Sun S, Fu T. Quantitative analysis of mitral valve morphology in atrial functional mitral regurgitation using real-time 3-dimensional echocardiography atrial functional mitral regurgitation. Cardiovasc Ultrasound 2018; 16:13. [PMID: 30126422 PMCID: PMC6102822 DOI: 10.1186/s12947-018-0131-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/04/2018] [Indexed: 11/10/2022] Open
Abstract
Background Atrial fibrillation (AF) can result in atrial functional mitral regurgitation (MR), but the mechanism remains controversial. Few data about the relationship between the 3-dimensional morphology of the MV and the degree of MR in AF exist. Methods Real-time 3-dimensional transesophageal echocardiography (3D-TEE) of the MV was acquired in 168 patients with AF (57.7% persistent AF), including 25 (14.9%) patients with moderate to severe MR (the MR+ group) and 25 patients without AF as controls. The 3-dimensional geometry of the MV apparatus was acquired using dedicated quantification software. Results Compared with the group of patients with no or mild MR (the MR- group) and the controls, the MR+ group had a larger left atrium (LA), a more dilated mitral annulus (MA), a reduced annular height to commissural width ratio (AHCWR), indicating flattening of the annular saddle shape, and greater leaflet surfaces and tethering. MR severity was correlated with the MA area (r2 = 0.43, P < 0.01) and the annulus circumference (r2 = 0.38, P < 0.01). A logistic regression analysis indicated that the MA area (OR: 1.02, 95% CI: 1.01–1.03, P < 0.01), AHCWR (OR: 0.24, 95% CI: 0.14–0.35, P = 0.04) and MV tenting volume (OR: 3.24, 95% CI: 1.16–9.08, P = 0.03) were independent predictors of MR severity in AF patients. Conclusions The mechanisms of “atrial functional MR” are complex and include dilation of the MA, flattening of the annular saddle shape and greater leaflet tethering.
Collapse
Affiliation(s)
- Tao Cong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China.
| | - Jinping Gu
- Department of Intensive Care Unit, The Second Affiliated Hospital of Dalian Medical University, Liaoning, China
| | - Alex Pui-Wai Lee
- Division of Cardiology, Department of Medicine and Therapeutics, The Prince of Wales Hospital of Chinese University of Hong Kong, Hong Kong, China
| | - Zhijuan Shang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Yinghui Sun
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Qiaobing Sun
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Hong Wei
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Na Chen
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Siyao Sun
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Tingting Fu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| |
Collapse
|
38
|
Barakat AF, Raza MQ, Banerjee K, Tsutsui RS, Mentias A, Abdur Rehman K, Thakkar B, Gul S, Faruqui R, Krishnaswamy A, Rodriguez LL, Grimm R, Griffin B, Tuzcu EM, Kapadia SR. Long-term mortality in patients with severe secondary mitral regurgitation and normal left ventricular ejection fraction: interventional perspective. EUROINTERVENTION 2018; 13:1881-1888. [PMID: 29313818 DOI: 10.4244/eij-d-17-00561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Patients with severe secondary mitral regurgitation (MR) and normal ejection fraction are being excluded from clinical trials evaluating transcatheter mitral devices. We sought to evaluate the long-term mortality with medical management alone in this patient population. METHODS AND RESULTS We retrospectively evaluated patients diagnosed with ≥3+ MR at our institution over 15 years. Only patients with an ejection fraction ≥60% were included in the study. Those with degenerative mitral valve disease, papillary muscle dysfunction, or hypertrophic cardiomyopathy, and those who underwent mitral valve intervention were excluded. The study included 400 patients (age 71.1±14.8, 25.1% male, ejection fraction 62.5±3.6%). Mechanism of secondary MR was restricted valve motion, annular dilation and apical tethering in 91.5, 4.5 and 4%, respectively. One-year and three-year mortality were 19.1 and 26.3%, respectively. On multivariable Cox proportional regression analysis, older age, New York Heart Association functional Class III or IV, >3+ MR and larger left atrium were independent predictors of mortality. CONCLUSIONS Severe secondary MR with normal left ventricular systolic function has significant mortality with medical management alone. This initial observation needs to be confirmed in larger prospective studies. These patients should be included in future transcatheter clinical trials.
Collapse
Affiliation(s)
- Amr F Barakat
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Castellá M. Atrial fibrillation surgery and mitral repair. J Vis Surg 2018; 3:150. [PMID: 29302426 DOI: 10.21037/jovs.2017.08.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 08/22/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Manuel Castellá
- Department of Cardiovascular Surgery, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| |
Collapse
|
40
|
Thomas JD, Raissi SR. Atrial Fibrillation Begets Mitral Regurgitation, or Is it Vice Versa? JACC Cardiovasc Imaging 2017; 12:678-680. [PMID: 29248648 DOI: 10.1016/j.jcmg.2017.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 11/28/2022]
Affiliation(s)
- James D Thomas
- Division of Cardiology, Bluhm Cardiovascular Institute at Northwestern Feinberg School of Medicine, Chicago, Illinois.
| | - Sasan R Raissi
- Division of Cardiology, Bluhm Cardiovascular Institute at Northwestern Feinberg School of Medicine, Chicago, Illinois.
| |
Collapse
|
41
|
Abstract
Mitral regurgitation (MR) is the most prevalent cause of valvular heart disease (VHD) in western countries. In the Euro Heart Survey on VHD, MR was the second most common heart VHD requiring surgery. It is also the most common form of VHD in community and population-based studies from the United States. The categorization of MR based on causes and mechanisms is a major determinant of clinical outcome, of possible therapies for the MR and of the effectiveness of these therapies. Surgical mitral valve (MV) repair has been shown to improve survival in patients with severe primary MR compared with MV replacement. In addition, new percutaneous repair and replacement procedures have been recently developed. Hence, accurate understanding of the functional anatomy of the MV and the pathophysiologic principles underlying MR is needed to appropriately target valve lesions. Recent advances in cardiac imaging have allowed to deeply strengthen the knowledge of the function of the MV. The present review aims at describing the functional anatomy and pathophysiology of MR through different cardiac imaging modalities.
Collapse
|
42
|
Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: A study using three-dimensional transesophageal echocardiography. J Cardiol 2017; 70:584-590. [PMID: 28527865 DOI: 10.1016/j.jjcc.2017.03.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/27/2017] [Accepted: 03/27/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Functional mitral regurgitation (MR) can occur in patients with atrial fibrillation (AF) despite having preserved left ventricular (LV) systolic function. This MR is known as atrial functional MR. The aim of this study was to clarify the mechanism of atrial functional MR using real-time three-dimensional transesophageal echocardiography (3DTEE). METHODS Sixty patients underwent transthoracic echocardiography and 3DTEE: 16 patients with AF and significant non-organic MR and preserved LV ejection fraction (>50%) constituted the AF-MR group, 20 patients with AF and no significant MR formed the AF-NSMR group, and 24 normal subjects comprised the control group. RESULTS The left atrial volume index was significantly larger in the AF-MR group (95±41ml/m2) than in the AF-NSMR group (38±13ml/m2, p<0.05) or the control group (21±7ml/m2, p<0.05). The 3D annular circumference was significantly longer in the AF-MR group than in the AF-NSMR group. The annular-anterior leaflet coaptation angle was smaller in the AF-MR group than in the AF-NSMR group (11±6° vs. 18±9°, p<0.05). The annular-posterior leaflet coaptation angle was comparable between the two AF groups (26±12° vs. 28±10°), whereas the annular-posterior leaflet tip angle was larger in the AF-MR group than in the AF-NSMR group (59±13° vs. 44±11°, p<0.05). The posterior leaflet bending toward LV cavity was therefore significantly larger in the AF-MR group than in the AF-NSMR group (32±10° vs. 18±15°, p<0.05). CONCLUSIONS In patients with AF and significant functional MR occurring despite their preserved LV systolic function, the left atrium and mitral annulus were dilated and the anterior leaflet was flattened along the mitral annular plane, whereas the posterior leaflet was bent toward the LV cavity.
Collapse
|
43
|
Kagiyama N, Hayashida A, Toki M, Fukuda S, Ohara M, Hirohata A, Yamamoto K, Isobe M, Yoshida K. Insufficient Leaflet Remodeling in Patients With Atrial Fibrillation. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005451. [DOI: 10.1161/circimaging.116.005451] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 01/27/2017] [Indexed: 12/17/2022]
Abstract
Background—
The relationship between annular dilatation caused by atrial fibrillation (AF) and mitral regurgitation (MR) remains controversial. We hypothesized that the small ratio of total leaflet area/annulus area (TLA/AA), reflecting insufficient leaflet remodeling to annular dilatation, is a main component of MR in patients with AF.
Methods and Results—
Three-dimensional transesophageal echocardiographic data of the mitral valve were analyzed in 28 AF patients with moderate or severe MR (MR group), age- and sex-matched 56 AF patients with mild or less MR (non-MR group), and 16 control subjects. AA was significantly greater in both the MR (645±126 mm
2
/m
2
,
P
<0.001) and non-MR groups (568±121 mm
2
/m
2
,
P
=0.001) compared with control subjects (444±108 mm
2
/m
2
). However, TLA/AA was significantly smaller in the MR (1.29±0.10,
P
<0.001), but not in the non-MR group (1.65±0.24,
P
>0.99), compared with control subjects (1.70±0.29). In linear regression analysis, TLA/AA was inversely associated with the effective regurgitant orifice (
r
=−0.73,
P
<0.001). The area under the receiver-operating-characteristics curve of TLA/AA was significantly greater than that of AA (0.95 versus 0.72,
P
<0.001). Multivariable analysis revealed that small TLA/AA (
P
<0.001) was independently associated with significant MR, while AA was not (
P
=0.26).
Conclusions—
In patients with AF, insufficient leaflet remodeling to annular dilatation, rather than crude annular dilatation, was strongly associated with the severity of MR.
Collapse
Affiliation(s)
- Nobuyuki Kagiyama
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Akihiro Hayashida
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Misako Toki
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Shota Fukuda
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Minako Ohara
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Atsushi Hirohata
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Keizo Yamamoto
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Mitsuaki Isobe
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Kiyoshi Yoshida
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| |
Collapse
|
44
|
Liang JJ, Silvestry FE. Mechanistic insights into mitral regurgitation due to atrial fibrillation: “Atrial functional mitral regurgitation”. Trends Cardiovasc Med 2016; 26:681-689. [DOI: 10.1016/j.tcm.2016.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
|
45
|
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4683] [Impact Index Per Article: 585.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
|
46
|
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
47
|
Mihos CG, Capoulade R, Yucel E, Melnitchouk S, Hung J. Combined papillary muscle sling and ring annuloplasty for moderate-to-severe secondary mitral regurgitation. J Card Surg 2016; 31:664-671. [DOI: 10.1111/jocs.12843] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Christos G. Mihos
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
- Mount Sinai Heart Institute; Columbia University; Miami Beach Florida
| | - Romain Capoulade
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Evin Yucel
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Serguei Melnitchouk
- Department of Cardiac Surgery; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Judy Hung
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| |
Collapse
|
48
|
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1305] [Impact Index Per Article: 163.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| |
Collapse
|
49
|
Kajimoto K, Sato N, Takano T. Functional mitral regurgitation at discharge and outcomes in patients hospitalized for acute decompensated heart failure with a preserved or reduced ejection fraction. Eur J Heart Fail 2016; 18:1051-9. [PMID: 27212582 DOI: 10.1002/ejhf.562] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 02/26/2016] [Accepted: 04/06/2016] [Indexed: 11/07/2022] Open
Abstract
AIMS The relationship between functional mitral regurgitation (FMR), left ventricular ejection fraction (EF), and outcomes is unclear in acute decompensated heart failure (HF) patients. The aim of this study was to evaluate the relationship between FMR and post-discharge outcomes in HF patients with a preserved or reduced EF. METHODS AND RESULTS Of the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 3357 patients were evaluated to assess the association among FMR (none, mild, or moderate/severe) at discharge, a preserved or reduced EF, and the primary endpoint (all-cause mortality and readmission for HF). The median follow-up period after discharge was 530 (387-800) days. According to multivariate analysis, patients with either mild FMR or moderate/severe FMR from the preserved EF group had a significantly higher risk of reaching the endpoint than patients without FMR [hazard ratio (HR) 1.40; 95% confidence interval (CI) 1.14-1.72; P = 0.001 and HR 1.40; 95% CI 1.09-1.81; P = 0.009, respectively]. In the reduced EF group, patients with moderate or severe FMR had a significantly higher risk relative to patients without FMR (HR 1.41; 95% CI 1.07-1.86; P = 0.015), but there was no significant association of mild FMR with the risk of reaching the endpoint (HR 1.09; 95% CI 0.84-1.42; P = 0.510). CONCLUSION Our findings demonstrate that even mild FMR is associated with an increased risk of adverse outcomes in HF patients with a preserved EF, while moderate or severe FMR (but not mild FMR) is associated with adverse outcomes in HF patients with a reduced EF.
Collapse
Affiliation(s)
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Teruo Takano
- Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
50
|
Naoum C, Leipsic J, Cheung A, Ye J, Bilbey N, Mak G, Berger A, Dvir D, Arepalli C, Grewal J, Muller D, Murphy D, Hague C, Piazza N, Webb J, Blanke P. Mitral Annular Dimensions and Geometry in Patients With Functional Mitral Regurgitation and Mitral Valve Prolapse. JACC Cardiovasc Imaging 2016; 9:269-80. [DOI: 10.1016/j.jcmg.2015.08.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/18/2015] [Accepted: 08/20/2015] [Indexed: 02/03/2023]
|