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Tan T, Liu J, Fu B, Wei P, Zhu W, Zhuang J, Chen J, Guo H. Management of the mitral valve in thoracoscopic trans-mitral myectomy for hypertrophic obstructive cardiomyopathy. JTCVS Tech 2023; 22:39-48. [PMID: 38152188 PMCID: PMC10750849 DOI: 10.1016/j.xjtc.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/06/2023] [Accepted: 09/08/2023] [Indexed: 12/29/2023] Open
Abstract
Objective This study aimed to compare clinical outcomes of different mitral valve (MV) management methods in thoracoscopic transmitral myectomy (TTM) and guide surgeons' decision making for hypertrophic obstructive cardiomyopathy (HOCM). Methods Seventy-three consecutive patients (41 females; mean age, 53.7 ± 13.6 years) with HOCM who underwent TTM between January 2019 and October 2022 were enrolled and divided into 3 groups according to MV surgical strategy. Clinical outcomes were analyzed and compared among the groups. Results None of the patients experienced postoperative residual left ventricular outflow tract obstruction. Percentages of patients with mitral regurgitation (MR) grade ≥3+ (57.5% vs 1.4%) and systolic anterior motion (95.9% vs 2.7%) were significantly decreased postoperatively (P < .001 for both). The preoperative anterior mitral leaflet length was longer in patients in the anterior mitral leaflet direct reattachment group (median, 2.9 cm [interquartile range (IQR), 2.7-3.3 cm] vs 2.7 [IQR, 2.4-2.9 cm]; P = .018), but the postoperative coaptation length was shorter (mean, 8.3 ± 2.1 mm vs 11.1 ± 3.8 mm; P = .038). After a median echocardiography follow-up of 11.8 months, the left ventricular outflow tract gradient (LVOTG) and mitral regurgitation grades remained significantly improved in all 3 groups (P < .05 for all). Conclusions Total TTM in selected patients is safe and effective, and all 3 MV management strategies can significantly reduce the LVOTG while improving MR. Mitral valvuloplasty is the preferred initial management strategy over valve replacement except in the scenario of irreparable intrinsic MV disease and valvuloplasty failure.
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Affiliation(s)
- Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
- Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vascular Diseases, Beijing, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Jian Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Bingqi Fu
- Department of Structure Heart Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peijian Wei
- Department of Structure Heart Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Zhu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Huiming Guo
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
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Tohma R, Morimoto Y, Sato M, Yamada A. Systolic anterior motion of the mitral valve following mitral valve repair in the presence of narrow left ventricle outflow. BMJ Case Rep 2023; 16:e256345. [PMID: 38011948 PMCID: PMC10685962 DOI: 10.1136/bcr-2023-256345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Affiliation(s)
- Ryo Tohma
- Cardiovascular Surgery, Kitaharima Medical Center, Ono, Hyogo, Japan
| | | | - Masanobu Sato
- Cardiovascular Surgery, Kitaharima Medical Center, Ono, Hyogo, Japan
| | - Akitoshi Yamada
- Cardiovascular Surgery, Kitaharima Medical Center, Ono, Hyogo, Japan
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Duncan CF, Bowcock E, Pathan F, Orde SR. Mitral regurgitation in the critically ill: the devil is in the detail. Ann Intensive Care 2023; 13:67. [PMID: 37530859 PMCID: PMC10397171 DOI: 10.1186/s13613-023-01163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.
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Affiliation(s)
- Chris F Duncan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia.
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- Nepean Clinical School of Medicine, Charles Perkin Centre Nepean, University of Sydney, Kingswood, Sydney, NSW, 2747, Australia
| | - Sam R Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
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Triple Threat: Significant Concomitant Aortic Stenosis, Mitral Stenosis, and Systolic Anterior Motion of the Mitral Valve Causing Left Ventricular Outflow Tract Obstruction in Cardiac Surgical Patients. Case Rep Anesthesiol 2023; 2023:9995115. [PMID: 36968008 PMCID: PMC10038731 DOI: 10.1155/2023/9995115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/16/2023] [Accepted: 02/25/2023] [Indexed: 03/19/2023] Open
Abstract
Systolic anterior motion (SAM) describes a pathologic condition of the mitral valve in which the anterior leaflet is displaced anteriorly, resulting in a narrowed left ventricular outflow tract (LVOT). The implications of SAM may range in severity from clinically insignificant disease to severe LVOT obstruction resulting in hemodynamic collapse. While SAM is typically observed in patients with hypertrophic cardiomyopathy or following mitral valve repair, it may be seen in any setting in which the anatomy and function of the left ventricle has been altered. Here we discuss two patients who presented for aortic and mitral valve replacements for concomitant aortic and mitral stenosis. These cases were further complicated by the preoperative diagnosis of SAM in addition to the preexisting valvular lesions, further increasing the risk of sudden hemodynamic collapse and cardiac arrest.
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Leković A, Živković V, Nikolić S. Anomalous papillary muscle insertion into mitral valve leaflet: Autopsy study and implications. J Forensic Sci 2023; 68:176-184. [PMID: 36480239 DOI: 10.1111/1556-4029.15182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022]
Abstract
Anomalous papillary muscle (APM) insertion into the anterior mitral valve leaflet is often associated with hypertrophic cardiomyopathy (HCM) but is reported in other cases as a rare finding. Mere presence does not strictly imply hemodynamic disturbance, and several types exist, with various impacts on left ventricular outflow tract (LVOT) obstruction. The interpretation of isolated anomaly is challenging at autopsy because significant LVOT obstruction is dynamic. We analyzed autopsy cases with APM regarding the site of PM insertion and origin, number of PM bellies, anomalous insertions, heart weight, left ventricle (LV) thickness, LV endocardial fibrosis, subjects' age, sex, cause, and manner of death. A total of 20 cases were identified. Fourteen were identified incidentally, while in 670 systematically examined hearts, the APM was identified in six cases, indicating a prevalence of 0.9%. In eight cases, the manner of death was natural (one case with HCM), and in 12 non-natural. Type II anomaly of PM was most frequent (n = 8), followed by Type III (n = 7) and Type I (n = 5). Subjects who died of natural causes were significantly older and had heavier hearts (median 455 g vs. 330 g; p < 0.05) without difference in LV thickness (median 16 mm vs. 15 mm; p > 0.05). Histology performed in four cases showed a pattern of direct insertion of cardiomyocytes into the leaflet's thick fibrous tissue with a narrow overlapping zone. The APM is rare, can be easily overlooked, and does not imply significant pathology per se. We discussed proper assessment of the significance of this anomaly at autopsy.
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Affiliation(s)
- Aleksa Leković
- Institute of Forensic Medicine, University of Belgrade - School of Medicine, Belgrade, Serbia
| | - Vladimir Živković
- Institute of Forensic Medicine, University of Belgrade - School of Medicine, Belgrade, Serbia
| | - Slobodan Nikolić
- Institute of Forensic Medicine, University of Belgrade - School of Medicine, Belgrade, Serbia
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Systolic Anterior Motion of the Mitral Valve in the Presence of Annular Calcification. J Am Soc Echocardiogr 2022; 36:421-427. [PMID: 36529336 DOI: 10.1016/j.echo.2022.12.011] [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] [Received: 07/03/2022] [Revised: 11/19/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Mitral annular calcification (MAC) has been reported as a possible cause of systolic anterior motion (SAM) of the mitral valve and dynamic left ventricular outflow tract (LVOT) obstruction. While morphologic features predisposing to SAM in other clinical settings have been described, patients with MAC+SAM have not been systematically investigated. We hypothesized that bulky calcium deposits in the mitral annulus could displace the valve toward the septum, thus promoting development of SAM. METHODS We studied 30 patients with severe MAC who had SAM with septal contact. Three comparator groups (matched for age and sex) were developed: 30 controls without MAC or SAM, 30 with severe MAC but no SAM, and 30 with SAM but no MAC. RESULTS Significant differences were found across groups for mitral valve coaptation point-septal distance (CSD), anterior mitral leaflet (AML) length, left ventricular diastolic dimension, and ejection fraction. Comparing all MAC subjects (n = 60) with controls, CSD was less (20.5 ± 4.1 vs 23.2 ± 3.7 mm, P = .003) and ejection fraction was higher (67.7% ± 7.8% vs 60.9% ± 6.4%, P < .0001) in MAC patients. Within MAC subjects AML was longer (21.9 ± 3.0 vs 17.4 ± 2.2 mm, P < .0001) and CSD was smaller (18.0 ± 2.7 vs 23.1 ± 3.6 mm, P < .0001) when SAM was present despite similar height of the calcium bar in the 2 MAC groups (12.4 ± 2.9 vs 11.1 ± 3.1 mm, P = .11). Regression analysis confirmed AML length and CSD as independent predictors of SAM. MAC+SAM patients also had more echocardiographic risk factors for SAM (acute aortomitral angle, small LVOT, long AML, small CSD, and presence of a septal bump) than MAC/no-SAM patients (3.4 ± 0.9 vs 1.8 ± 1.0, P < .0001). CONCLUSIONS Bulky MAC appears to contribute to dynamic LVOT obstruction when it accumulates in such a way that the mitral valve is displaced anteriorly toward the septum. However, other features are also associated with SAM in these patients, particularly a long AML. A combination of morphologic features and favorable hemodynamics may be needed for SAM to develop in patients with severe MAC.
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Chou CJ, Lai YC, Ou SY, Chen CH. Unexpected systolic anterior motion of the mitral valve-related hypoxemia during transurethral resection of the prostate under spinal anesthesia: a case report. BMC Anesthesiol 2022; 22:207. [PMID: 35794519 PMCID: PMC9258149 DOI: 10.1186/s12871-022-01754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Dynamic obstruction of the left ventricular outflow tract resulting from systolic anterior motion of the mitral valve can be an unexpected cause of acute and severe perioperative hypotension in noncardiac surgery. We report a patient undergoing spinal anesthesia for transurethral resection of the prostate who experienced sudden hypoxemia caused by systolic anterior motion-induced mitral regurgitation but with a clinically picture simulating fluid overload. Case presentation An 83-year-old man with a history of hypertension was scheduled for transurethral resection of the prostate. One hour after spinal anesthesia, he developed acute restlessness and dyspnea, with pink frothy sputum and progressive hypoxemia. Slight hypertension was noted, and an electrocardiogram showed atrial fibrillation with a rapid ventricular response. Furosemide and nitroglycerin were thus administered for suspected fluid overload or transurethral resection of the prostate syndrome; however, he then became severely hypotensive. After tracheal intubation, intraoperative transesophageal echocardiography was promptly performed, which revealed an empty hypercontractile left ventricle, significant mitral regurgitation and mosaic flow signal in the left ventricular outflow tract. Following aggressive fluid therapy, his hemodynamic changes stabilized. Repeat echocardiography in intensive care unit confirmed the presence of systolic anterior motion of the anterior mitral leaflet obstructing the left ventricular outflow tract. We speculate that pulmonary edema was induced by systolic anterior motion-associated mitral regurgitation and rapid atrial fibrillation, and the initial management had worsened his hypovolemia and provoked left ventricular outflow tract obstruction and hemodynamic instability. Conclusions Pulmonary edema caused by systolic anterior motion of the mitral valve can be difficult to clinically differentiate from that induced by fluid overload. Therefore, bedside echocardiography is paramount for timely diagnosis and prompt initiation of appropriate therapy in the perioperative care setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01754-x.
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Morales KRDP, Romero CVE, Guacho WRL, Jaya DAS, Fonseca EKUN. Mid-ventricular obstruction in a patient with hypertrophic cardiomyopathy. EINSTEIN-SAO PAULO 2022; 20:eAI6672. [PMID: 35476079 PMCID: PMC9018060 DOI: 10.31744/einstein_journal/2022ai6672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/20/2021] [Indexed: 11/25/2022] Open
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9
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Morcous S, Kumar R, Patel M, Liang Y. Hypoxemia secondary to acute mitral regurgitation induced by systolic anterior motion of the mitral valve during lung transplantation. J Clin Anesth 2021; 75:110520. [PMID: 34798702 DOI: 10.1016/j.jclinane.2021.110520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Shaker Morcous
- Department of Anesthesiology (S.M., R.K., Y.L.), Department of Advanced Cardiopulmonary Therapies and Transplantation (M.P.), McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Rishi Kumar
- Department of Anesthesiology (S.M., R.K., Y.L.), Department of Advanced Cardiopulmonary Therapies and Transplantation (M.P.), McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Manish Patel
- Department of Anesthesiology (S.M., R.K., Y.L.), Department of Advanced Cardiopulmonary Therapies and Transplantation (M.P.), McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Yafen Liang
- Department of Anesthesiology (S.M., R.K., Y.L.), Department of Advanced Cardiopulmonary Therapies and Transplantation (M.P.), McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, United States of America.
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10
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Anwar AM, tenCate FJ. Echocardiographic evaluation of hypertrophic cardiomyopathy: A review of up-to-date knowledge and practical tips. Echocardiography 2021; 38:1795-1808. [PMID: 34555207 DOI: 10.1111/echo.15200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/24/2021] [Accepted: 08/23/2021] [Indexed: 11/27/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most frequent cardiac disease with genetic substrate, affecting about .2%-.5% of the population. The proper diagnosis is important for optimal management and follow-up. Echocardiography plays an essential role in the assessment of patients with HCM including diagnosis, screening, management formulation, prognosis, and follow up. It also helps to differentiate HCM from other diseases. The advancement of software and probe technology added many echo modalities and techniques that helped in refining the diagnostic and assessing the prognosis of patients with HCM. In this review, we briefly summarize how to integrate the different echocardiographic modalities to obtain comprehensive assessment supported by an updated knowledge of the latest guidelines and recently published articles. Many practical tips and tricks are included in this review to improve the diagnostic accuracy of echocardiography and minimize errors during interpretation.
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Affiliation(s)
- Ashraf M Anwar
- Department of Cardiology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia.,Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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Stassen J, Vandenbriele C, Claessen G, Jacobs B, Debaveye Y, Balthazar T. Ultrasound Diagnosis of Cardiac Arrest in an 81-Year-Old Postoperative Patient. Chest 2021; 160:e233-e236. [PMID: 34366050 DOI: 10.1016/j.chest.2020.07.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/19/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jan Stassen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Cardiac Intensive Care, University Hospitals Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Jacobs
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Tim Balthazar
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Cardiac Intensive Care, University Hospitals Leuven, Leuven, Belgium
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Suwa K, Akita K, Iguchi K, Ushio T, Maekawa Y. Hemodynamic change in patients with hypertrophic obstructive cardiomyopathy before and after alcohol septal ablation using 4D flow magnetic resonance imaging: a retrospective observational study. BMC Cardiovasc Disord 2021; 21:198. [PMID: 33879058 PMCID: PMC8059221 DOI: 10.1186/s12872-021-02003-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background The hemodynamics in the left ventricle (LV) and the ascending aorta (AAO) before and after alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM) is elucidated. Our objective was to evaluate the pattern changes in AAO and intra-LV flow assessed by four-dimensional (4D) flow magnetic resonance imaging (MRI) before and after ASA and to clarify the association between 4D flow MRI-derived hemodynamic characteristics and the peak pressure gradient (PPG) in patients with drug-refractory HOCM. Methods In this retrospective observational study, 11 patients with HOCM underwent 4D flow MRI before and a week after ASA. The 4D flow MRI included blood flow visualization and quantification using streamline images. The combined score of vortex and helix in AAO was analyzed. The duration and phase count of the AAO vortex or helix flow and the size of the intra-LV anterior vortex were quantified. The correlation between the changes in hemodynamics and the resting PPG at LV outflow tract was also analyzed. We used the paired t-test for the comparison between before and after ASA and the Pearson’s correlation coefficient for the analysis. Results The combined score for the incidence of vortex and/or helix flow in AAO after ASA was significantly lower than that before ASA (1.45 ± 0.52 vs. 1.09 ± 0.30, p = 0.046). The duration (744 ± 291 ms vs. 467 ± 258 ms, p < 0.001) and phase count (14.8 ± 4.4 phases vs. 10.5 ± 5.8 phases, p < 0.001) of the vortex or helix flow in AAO were significantly decreased after ASA. The LV anterior vortex area after ASA was significantly larger than that before ASA (1628 ± 420 mm2 vs. 2974 ± 539 mm2, p = 0.009). The delta phase count of the AAO vortex or helix before and a week after ASA was significantly correlated with delta PPG before and a week after ASA (R = 0.79, p = 0.004) and with delta PPG before and 6 months after ASA (R = 0.83, p = 0.002). Conclusions Lower vortex or helix flow in AAO and larger diastolic vortex flow in LV were observed after ASA, which suggests the possibility to detect the changes of aberrant hemodynamics in HOCM. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02003-8.
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Affiliation(s)
- Kenichiro Suwa
- Division of Cardiology, Internal Medicine 3, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192, Hamamatsu, Japan.
| | - Keitaro Akita
- Division of Cardiology, Internal Medicine 3, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192, Hamamatsu, Japan
| | - Keisuke Iguchi
- Division of Cardiology, Internal Medicine 3, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192, Hamamatsu, Japan
| | - Takasuke Ushio
- Department of Radiology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192, Hamamatsu, Japan
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine 3, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, 431-3192, Hamamatsu, Japan
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Kelley BP, Gazda C, Sivak JA, Vavalle JP, Weickert TT. Successful MitraClip Implantation in a Barlow's Valve: A Feasible Alternative? CASE (PHILADELPHIA, PA.) 2021; 5:73-77. [PMID: 33644518 PMCID: PMC7887515 DOI: 10.1016/j.case.2020.10.011] [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] [Indexed: 11/30/2022]
Abstract
•Barlow's disease is a degenerative mitral valvulopathy with highly complex anatomy. •Barlow's disease is classically unfavorable for TMVr using MitraClip. •Patients with Barlow's disease, SAM, and high surgical risk may be candidates for TMVr.
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Affiliation(s)
- Brian P Kelley
- Department of Medicine, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Casey Gazda
- Division of Cardiology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Joseph A Sivak
- Division of Cardiology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - John P Vavalle
- Division of Cardiology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Thelsa T Weickert
- Division of Cardiology, University of North Carolina Hospitals, Chapel Hill, North Carolina
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Cardiogenic Shock Secondary to Dynamic Left Ventricular Outflow Tract Obstruction and Apical Ballooning after Nonmitral Cardiovascular Surgery. Case Rep Crit Care 2020; 2020:8826187. [PMID: 33294231 PMCID: PMC7716751 DOI: 10.1155/2020/8826187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 10/18/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022] Open
Abstract
Background The dynamic obstruction of the left ventricular outflow tract (LVOT) is a well-known complication in mitral annuloplasty but rarely seen in nonmitral cardiovascular surgery. The dynamic LVOT obstruction can lead to hemodynamic instability, even shock and the treatment is significantly different from the standard approach. Case Presentation. We reported a case of low cardiac output syndrome (LCOS) with severe mitral regurgitation (MR), dramatically reduced left ventricular ejection fraction (LVEF) after coronary artery bypass grafting in a 72-year-old female requiring an escalation of inotropic support, volume restriction, and mechanical support. The detailed echocardiography combined with lung ultrasound revealed a dynamic systolic anterior movement of the anterior mitral leaflet (SAM), apical ballooning, and no significant lung congestion. Intravenous fluids were given, diuretics withdrawn, inotrope discontinued, and vasopressors uptitrated. The dynamic SAM was rapidly relieved, the hemodynamics was stabilized, and the LVEF was improving. The patient was discharged in good condition without residual LVOT obstruction and trace MR. Conclusion We strongly suggest that a detailed echocardiography should be performed in any patient who presents in shock to rule out a dynamic LVOT obstruction. Lung ultrasound should be a routine examination in addition to echocardiography. Once SAM is detected, treatment should be based on volume expansion, inotrope discontinuation, and a careful afterload increasing.
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15
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Tjørnild MJ, Carlson Hanse L, Skov SN, Nielsen SL, Hasenkam JM, Røpcke DM. Entire mitral valve reconstruction using porcine extracellular matrix: static in vitro evaluation. Eur J Cardiothorac Surg 2020; 55:1095-1103. [PMID: 30597010 DOI: 10.1093/ejcts/ezy416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/04/2018] [Accepted: 11/06/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To investigate the feasibility of reconstruction of the entire mitral valve using a tube graft made of 2-ply small intestinal submucosa extracellular matrix in vitro. METHODS Seven explanted mitral valves with intact subvalvular apparatus from 80 kg pigs were evaluated in a left heart simulator and served as controls. After testing the native valve, the leaflets and chordae tendineae were explanted, and the 2-ply small intestinal submucosa extracellular matrix (CorMatrix®; Cardiovascular Inc., Alpharetta, GA, USA) tube graft was implanted. The characterization was based on geometric data from digital images, papillary muscle force, annular tethering force and leaflet pressure force. RESULTS The tube grafts were fully functional without any signs of leakage, tearing or rupture during incrementally increased pressures from 0 mmHg to 120 mmHg. The posterior leaflet moved anteriorly and became larger after reconstruction when compared with the native valve. However, the mid coaptation point was preserved. The anterior papillary muscle force decreased significantly (5.2 N vs 4.4 N, P = 0.022 at 120 mmHg), and the posterior papillary muscle force increased significantly (4.8 N vs 5.6 N, P = 0.017 at 120 mmHg) after reconstruction. CONCLUSIONS The entire mitral valvular and subvalvular reconstruction with a 2-ply small intestinal submucosa extracellular matrix tube graft is feasible in an in vitro model. Our method of reconstruction increased the convexity of the anterior leaflet's coaptation line and significantly redistributed the papillary muscle force towards the posterior papillary muscle. These promising results and the prospect of the entire mitral valvular and subvalvular reconstruction warrant further in vivo evaluations.
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Affiliation(s)
- Marcell J Tjørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lisa Carlson Hanse
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren N Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sten L Nielsen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Diana M Røpcke
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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16
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Nguyen QS, Maus T. The C-Sept Space: Another Step Forward in the Superiority of 3-Dimensional Echocardiography-Based Measurements. J Cardiothorac Vasc Anesth 2020; 35:197-198. [PMID: 32962937 DOI: 10.1053/j.jvca.2020.08.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Quoc-Sy Nguyen
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA
| | - Timothy Maus
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA
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17
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SAM and Severe Mitral Regurgitation Post-Acute Type A Aortic Dissection Surgery Treated With MitraClip. JACC Case Rep 2020; 2:1582-1586. [PMID: 34317023 PMCID: PMC8302160 DOI: 10.1016/j.jaccas.2020.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 11/27/2022]
Abstract
Post-operative systolic anterior motion associated with mitral regurgitation can be a challenging combination. We present the case of a 64-year-old male patient managed by MitraClip (Abbott Laboratories, Abbott Park, Illinois) implantation for systolic anterior motion and severe mitral regurgitation in the early post-operative period after aortic dissection surgery. This is the first description of MitraClip use post–aortic dissection. (Level of Difficulty: Intermediate.)
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18
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Gourav KP, Kumar B, Bhat I, Mishra AK. Systolic anterior motion of mitral valve following resection of subaortic membrane and intracardiac repair of tetralogy of fallot. Ann Card Anaesth 2020; 23:357-360. [PMID: 32687100 PMCID: PMC7559953 DOI: 10.4103/aca.aca_194_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Systolic anterior motion (SAM) of the mitral valve is commonly observed in patients with hypertrophic obstructive cardiomyopathy and in few patients after mitral valve repair or aortic valve replacement. It may cause significant hemodynamic instability due to left ventricular outflow tract (LVOT) obstruction and resulting mitral regurgitation. Subaortic septal bulge is considered as a one of the risk factor for the development of SAM as it narrows the LVOT. We report a case of tetralogy of fallot with subaortic septal bulge who developed SAM of the anterior mitral leaflet, intraoperatively, after resection of a subaortic membrane.
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Affiliation(s)
- Krishna Prasad Gourav
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhupesh Kumar
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Imran Bhat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anand K Mishra
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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19
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Tjørnild MJ, Sørensen SW, Carlson Hanse L, Skov SN, Røpcke DM, Nielsen SL, Hasenkam JM. Mitral Valve Posterior Leaflet Reconstruction Using Extracellular Matrix: In Vitro Evaluation. Cardiovasc Eng Technol 2020; 11:405-415. [PMID: 32592143 DOI: 10.1007/s13239-020-00472-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the anatomical and functional effects of complete surgical reconstruction of the posterior mitral leaflet and associated chordae tendineae with a patch made of 2-ply small intestinal submucosal extracellular matrix in vitro. METHODS Seven explanted mitral valves with intact subvalvular apparatus from 80-kg pigs were evaluated in a left heart simulator and served as their own controls. After testing the native valve, the mitral posterior leaflet and associated chordae tendineae were excised and reconstructed by using the 2-ply small intestinal submucosa extracellular matrix patch. The characterization of the reconstruction was based on geometric data from digital images, papillary muscle force, annular tethering force and leaflet pressure force. RESULTS The reconstructed valves were fully functional without regurgitation, tearing or rupture during incrementally increased pressure from 0 to 120 mmHg. The leaflet areas were preserved after reconstruction, with a normal configuration of the coaptation line. However, the coaptation midpoint moved posteriorly after reconstruction (A2: 15.8 ± 1.4 vs. 18.9 ± 1.5 mm, p = 0.002, diff = 3.1 mm, 95% CI 1.3 to 4.8 mm). The anterior papillary muscle force increased significantly (3.9 vs. 4.6 N, p = 0.029, diff = 0.7 N, 95% CI 0.1 to 1.4 N at 120mmHg) after reconstruction. The posterior papillary muscle force, leaflet pressure force and annular pressure force did not change significantly. CONCLUSIONS In this in vitro model, mitral valve anatomy and function were comparable between the native mitral valve and our new surgical technique for complete reconstruction of the posterior mitral leaflet and associated chordae tendineae. These promising results warrant further in vivo evaluation.
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Affiliation(s)
- Marcell J Tjørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Orthopaedic Surgery, Randers Regional Hospital, Randers, Denmark.
| | - Søren W Sørensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lisa Carlson Hanse
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren N Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Diana M Røpcke
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sten L Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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20
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Jain CC, Newman DB, Geske JB. Mitral Valve Disease in Hypertrophic Cardiomyopathy:Evaluation and Management. Curr Cardiol Rep 2019; 21:136. [DOI: 10.1007/s11886-019-1231-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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