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Moving from left ventricular ejection fraction to deformation imaging in mitral valve regurgitation. Curr Probl Cardiol 2024; 49:102432. [PMID: 38309543 DOI: 10.1016/j.cpcardiol.2024.102432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
The increasing prevalence of valvular heart diseases, specifically mitral regurgitation (MR), underscores the need for a careful and timely approach to intervention. Severe MR, whether primary or secondary, when left untreated leads to adverse outcomes, emphasizing the critical role of a timely surgical or transcatheter intervention. While left ventricular ejection fraction (LVEF) remains the guideline-recommended measure for assessing left ventricle damage, emerging evidence raises concerns regarding its reliability in MR due to its volume-dependent nature. This review summarizes the existing literature on the role of LVEF and deformation imaging techniques, emphasizing the latter's potential in providing a more accurate evaluation of intrinsic myocardial function. Moreover, it advocates the need for an integrated approach that combines traditional with emerging measures, aiming to optimize the management of patients with MR. It attempts to highlight the need for future research to validate the clinical application of deformation imaging techniques through large-scale studies.
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Patient-Specific Quantitative In-Vivo Assessment of Human Mitral Valve Leaflet Strain Before and After MitraClip Repair. Cardiovasc Eng Technol 2023; 14:677-693. [PMID: 37670097 DOI: 10.1007/s13239-023-00680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/23/2023] [Indexed: 09/07/2023]
Abstract
PURPOSE Mitral regurgitation (MR) is a highly prevalent and deadly cardiac disease characterized by improper mitral valve (MV) leaflet coaptation. Among the plethora of available treatment strategies, the MitraClip is an especially safe option, but optimizing its long-term efficacy remains an urgent challenge. METHODS We applied our noninvasive image-based strain computation pipeline [1] to intraoperative transesophageal echocardiography datasets taken from ten patients undergoing MitraClip repair, spanning a range of MR etiologies and MitraClip configurations. We then analyzed MV leaflet strains before and after MitraClip implementation to develop a better understanding of (1) the pre-operative state of human regurgitant MV, and (2) the MitraClip's impact on the MV leaflet deformations. RESULTS The MV pre-operative strain fields were highly variable, underscoring both the heterogeneity of the MR in the patient population and the need for patient-specific treatment approaches. Similarly, there were no consistent overall post-operative strain patterns, although the average A2 segment radial strain difference between pre- and post-operative states was consistently positive. In contrast, the post-operative strain fields were better correlated to their respective pre-operative strain fields than to the inter-patient post-operative strain fields. This quantitative result implies that the patient specific pre-operative state of the MV guides its post-operative deformation, which suggests that the post-operative state can be predicted using pre-operative data-derived modelling alone. CONCLUSIONS The pre-operative MV leaflet strain patterns varied considerably across the range of MR disease states and after MitraClip repair. Despite large inter-patient heterogeneity, the post-operative deformation appears principally dictated by the pre-operative deformation state. This novel finding suggests that though the variation in MR functional state and MitraClip-induced deformation were substantial, the post-operative state can be predicted from the pre-operative data alone. This study suggests that, with use of larger patient cohort and corresponding long-term outcomes, quantitative predictive factors of MitraClip durability can be identified.
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Global Longitudinal Strain Predicts Outcomes in Patients with Reduced Left Ventricular Function Undergoing Transcatheter Edge-to-Edge Mitral Repair. J Clin Med 2023; 12:4116. [PMID: 37373808 PMCID: PMC10298909 DOI: 10.3390/jcm12124116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/09/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The timing and selection of optimal candidates for mitral transcatheter edge-to-edge valve repair remains to be fully determined, especially in cases with severely depressed left ventricular ejection fraction (LVEF). The objective of this study is to evaluate the prognostic value of myocardial strain (LVGLS) in this setting. METHODS Retrospectively, 172 consecutive patients with LVEF ≤40% and severe MR treated with MitraClip were included. Four groups were generated according to the LVEF (<30% or ≥30%) and median LVGLS. The primary end-point was cardiovascular mortality. RESULTS Procedural success was high (96.5%) and complications were rare. At one-year follow-up, 82.5% of patients maintained MR grade ≤2, 79.2% were at a NYHA class ≤II and a reduction of 80% in heart failure admissions was observed in all groups. Interestingly, among patients with a more depressed LVEF, LVGLS was found to be an independent predictor for cardiovascular mortality (HR: 3.3; 95% CI: 1.1-10, p = 0.023). CONCLUSIONS Mitral valve repair with MitraClip is safe and it improves the mid-term functional class of patients regardless of LVEF. LVGLS can help in the selection of optimal candidates and timing for this procedure, as well as in the recognition of those patients with worse prognoses.
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Speckle tracking echocardiography in early disease stages: a therapy modifier? J Cardiovasc Med (Hagerstown) 2023; 24:e55-e66. [PMID: 37052222 DOI: 10.2459/jcm.0000000000001422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Echocardiography has been included as a first-line tool in several international guidelines for the management of patients with various cardiac diseases. Beyond diagnosis, echocardiographic examination helps in characterizing the severity of the condition since the very first stages. In particular, the application of second-level techniques, speckle tracking echocardiography in particular, can also reveal a subclinical dysfunction, while the standard parameters are in the normality range. The present review describes the potentialities of advanced echocardiography in different settings, including arterial hypertension, atrial fibrillation, diastolic dysfunction, and oncological patients, thus opening up potential starting points for its application as a clinical routine changer.
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Prognostic value of left ventricular global longitudinal strain in mitral regurgitation: a systematic review. Heart Fail Rev 2023; 28:465-483. [PMID: 35900680 DOI: 10.1007/s10741-022-10265-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/04/2022]
Abstract
Conventional echocardiographic assessment may overestimate the left ventricular (LV) function in mitral regurgitation (MR). LV global longitudinal strain (GLS) is more sensitive marker to detect subclinical LV dysfunction. Multiple studies have investigated the prognostic value of LV-GLS in MR to examine its potential to determine the timing and indication of intervention. This systematic review aimed to assess the prognostic value of LV-GLS in patients with mitral regurgitation (MR) to define its clinical applicability. PUBMED and EMBASE were queried through July 2021 to identify studies investigating the prognostic value of LV-GLS in MR. A total of 24 observational studies with 5267 patients were identified. Sixteen studies investigated for primary MR, 7 studies for secondary MR, and 1 study for both. Most studies included patients who underwent intervention. There was significant heterogeneity in patient population, intervention status, follow-up period, LV-GLS cutoff value, outcomes, and statistical methods among the studies. Meta-analysis was not performed considering the significant variability. With exception to 1 study, all studies demonstrated significant association between impaired LV-GLS and worse clinical and echocardiographic outcomes in primary MR. Prognostic value of LV-GLS in secondary MR was less certain due to inconsistent findings and limited reporting. LV-GLS is a promising parameter of prognostication in primary MR and can be considered as alternative to determine the timing of intervention. However, the optimal cutoff value remains unclear. The prognostic value of LV-GLS in secondary MR is less clear. Further large-scale prospective study is warranted before its routine clinical application.
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[Clinical and echocardiographic parameters associated with the alteration of global longitudinal strain in secondary mitral regurgitation]. Ann Cardiol Angeiol (Paris) 2023; 72:36-40. [PMID: 36437148 DOI: 10.1016/j.ancard.2022.10.005] [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: 08/14/2022] [Revised: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Left ventricular systolic function may be overestimated in patients with secondary mitral regurgitation when using left ventricle ejection fraction. The Global longitudinal strain is a measure less dependent on left ventricle load. However, the clinical and echocardiographic parameters associated with the alteration of Global longitudinal strain in secondary mitral regurgitation have not been evaluated. MATERIAL AND METHODS A total of 96 patients (mean age 62.3 ± 12.1 years, 59.3% male) with secondary mitral regurgitation and low left ventricle ejection fraction < 50% were included. The study population was subdivided according to the Global longitudinal strain value with which an increased risk of all-cause mortality was associated (Global longitudinal strain < 7.0%, left ventricle systolic function impaired compared to Global longitudinal strain ≥ 7.0%, in absolute value). The clinical and echocardiographic endpoints are analysed in both groups of patients. RESULTS The strong and clear correlation between Global longitudinal strain (mean ± standard deviation: 7,2 ± 2,7) and parameters of systolic function (left ventricle ejection fraction mean ± standard deviation: 32,4 ± 8,0%) and contractility (dp/dt mean ± standard deviation: 682,5 ± 204,7 mmHg/s). the mean of left ventricle ejection fraction = 26.4 ± 5.3% in the Global longitudinal strain < 7 group, and the bivariate study using the 30% threshold shows that the Global longitudinal strain < 7 group presents a more altered left ventricle ejection fraction with odds ratio = 12, 5 (CI: 4.7-33.0) p < 0.001. In multivariate analysis of ultrasound parameters and linear regression shows a significant correlation between Global longitudinal strain and left ventricle ejection fraction (p < 0.001). The dp/dt analysis found a mean of 509.3 ± 99.1 mmHg/s in the Global longitudinal strain < 7 group and of 822.9 ± 154.1 in the Global longitudinal strain ≥ 7 group with significant difference (p < 0.001). In bivariate and multivariate analysis, the alteration of Global longitudinal strain is associated with a significantly lower dp / dt p < 0.001. CONCLUSION A Global longitudinal strain < 7 (in absolute value) reflects a severe impairment of left ventricle function. In addition, several parameters were associated with this severe alteration of the Global longitudinal strain, namely a lower left ventricle ejection fraction, a lower dp/dt and more severe symptoms permitting to characterized this group of patients in addition to an integration in a multiparametric evaluation of the secondary mitral regurgitation.
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Left ventricular remodeling, mechanics, and the COAPT trial. Front Cardiovasc Med 2023; 10:1124727. [PMID: 36798483 PMCID: PMC9928178 DOI: 10.3389/fcvm.2023.1124727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/16/2023] [Indexed: 02/01/2023] Open
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Impact of Left Ventricular Global Longitudinal Strain on Outcomes After Transcatheter Edge-to-Edge Repair in Secondary Mitral Regurgitation. Am J Cardiol 2022; 182:69-76. [PMID: 36075752 DOI: 10.1016/j.amjcard.2022.07.023] [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] [Received: 03/08/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 11/22/2022]
Abstract
Assessment of left ventricular (LV) systolic function is essential in patient selection for transcatheter edge-to-edge repair (TEER) in secondary mitral regurgitation (MR). Although LV ejection fraction (EF) is mostly used for assessing LV function, it represents the change of LV chamber size, but not myocardial contractility. LV global longitudinal strain (GLS) provides an alternative to assess LV systolic function in patients with secondary MR. This study included 380 patients with secondary MR (mean age 71.0 ± 13.0 years; 61.1% male) who underwent TEER. Patients were dichotomized based on baseline LV GLS (more impaired GLS [<7.0%] vs less impaired GLS [≥7%]) based on existing literature. The primary outcome was all-cause mortality, whereas the secondary outcome was the composite end point of all-cause mortality and heart failure hospitalization. The mean LV GLS was 8.1 ± 3.8%, and 162 patients had GLS <7%. Patients with more impaired GLS (<7%) were more likely to be male (68.5% vs 55.5%; p = 0.01) and have larger LV end-diastolic volume (110.5 ± 36.5 ml/m2 vs 92.9 ± 34.3 ml/m2; p <0.001) and lower LVEF (22.2 ± 8.9% vs 36.4 ± 14.5%; p <0.001) than those with less impaired GLS (≥7%). The number of clips used and residual MR were similar between the 2 groups. Patients with more impaired LV GLS (<7%) had significantly higher 2-year event rates of the primary outcome (38.2% vs 25.9%; log-rank p = 0.003) and the secondary outcome (52.5% vs 36.3%; log-rank p <0.001). Multivariate analysis showed that LV GLS (<7%) was independently associated with the primary outcome (hazard ratio 1.65, 95% confidence interval 1.16 to 2.34, p = 0.005) and the secondary outcome (hazard ratio 1.54, 95% confidence interval 1.08 to 2.20, p = 0.016) whereas such associations were not observed with LVEF. In conclusion, LV GLS (<7%) was independently associated with a higher risk of adverse events in patients with secondary MR who underwent TEER.
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Editorial: Advances in Percutaneous Coronary Intervention. Front Cardiovasc Med 2022; 9:914487. [PMID: 35845035 PMCID: PMC9276992 DOI: 10.3389/fcvm.2022.914487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
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Identification of Subclinical Myocardial Dysfunction and Association with Survival after Transcatheter Mitral Valve Repair. J Am Soc Echocardiogr 2020; 33:1474-1480. [PMID: 32919854 DOI: 10.1016/j.echo.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 06/27/2020] [Accepted: 07/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transcatheter mitral valve repair (TMVr) using edge-to-edge mitral valve clip is effective for patients with mitral regurgitation (MR) and high or prohibitive surgical risk. Global longitudinal strain (GLS) allows evaluation of subclinical myocardial dysfunction, but its incremental clinical utility into risk stratification, beyond traditional clinical parameters, is unknown in patients treated with TMVr. We sought to evaluate the association of baseline GLS with 1-year all-cause mortality in patients treated with TMVr using edge-to-edge mitral valve clip. METHODS We analyzed 155 patients who underwent transcatheter edge-to-edge mitral valve clip implantation (mean age, 83 ± 7 years; 48% were women; mean left ventricular ejection fraction, 56% ± 10%, Society of Thoracic Surgeons Predicted Risk of Mortality score for repair, 6.62% ± 5.22%). Baseline left ventricular GLS was obtained by two-dimensional speckle-tracking echocardiography, averaging 18 segments from three apical views. Receiver operating characteristic analyses were used to assess the GLS cut point associated with all-cause mortality. Multivariable models with Cox regression tested its relationship after adjustment for baseline comorbidities. RESULTS During a median follow-up of 316 days, all-cause deaths occurred in 30 patients at a median of 156 days after TMVr. The area under the curve of preoperative GLS associated with the outcome was 0.60, with a cutoff point of -14.5%. Baseline GLS > -14.5% was associated with 1-year mortality (hazard ratio = 2.50; 95% CI, 1.20-5.21; P = .02) before and after adjustment for baseline characteristics. After accounting for baseline characteristics, patients with GLS > -14.5% had worse 1-year mortality than those with GLS ≤ -14.5% (χ2P < .001). In nested Cox proportional hazards models, the addition of baseline GLS to Society of Thoracic Surgeons Predicted Risk of Mortality score, left ventricular ejection fraction, and the etiology of MR significantly increased the model χ2 value (χ2 = 12.32). CONCLUSIONS Baseline GLS is independently associated with 1-year all-cause mortality in patients who undergo TMVr, and its assessment improves risk stratification in these patients.
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MitraClip and left ventricular reverse remodelling: a strain imaging study. ESC Heart Fail 2020; 7:1409-1418. [PMID: 32432839 PMCID: PMC7373921 DOI: 10.1002/ehf2.12750] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/11/2020] [Accepted: 04/21/2020] [Indexed: 12/27/2022] Open
Abstract
AIMS The purpose of this study is to identify echocardiography predictors of clinical response and reverse left ventricular (LV) remodelling in patients with functional mitral regurgitation (FMR) treated with MitraClip. METHOD AND RESULTS We retrospectively analysed 86 high surgical risk patients with severe FMR; of those, 58 were implanted a MitraClip, and 28 received medical treatment and served as controls. At baseline and at 1-year follow-up, we performed clinical and echocardiography evaluation to assess global longitudinal strain (GLS) and myocardial work [global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE)]. Mitral regurgitation was significantly reduced after MitraClip implantation (3.7 ± 0.4 vs. 1.7 ± 0.8, P < 0.001), and the procedure was associated with improvement in brain natriuretic peptide levels (980 ± 1027 vs. 420 ± 338 pg/mL, P < 0.001), New York Heart Association class status (3.2 ± 0.55 vs. 2.0 ± 0.6, P < 0.001), 6-min walking test (233 ± 154 vs. 286 ± 114 m, P = 0.01) at follow-up and reduction of left ventricle end-systolic (LVESV) and left ventricle end-diastolic volumes (LVEDV) (152 ± 68 vs. 136 ± 43 mL, P = 0.004 & 219 ± 74 vs. 193 ± 66 mL, P = 0.001, respectively). MitraClip procedure was associated with improvement of LV performance and significant increase of GWI (607 ± 282 vs. 650 ± 260 mmHg%, P = 0.045) and GCW (854 ± 288 vs. 949 ± 325 mmHg%, P < 0.001). Baseline ejection fraction (EF), GLS, GWI, GCW, and effective regurgitant orifice area were the variables that were associated with reduction of LVEDV 1 year after intervention (P < 0.05 for all) and baseline GCW of the LV was the only variable associated with reduction of LVESV (P = 0.002). Receiver operating characteristic curve analysis identified that a GLS cut-off value of -8.65% (AUC 0.815, P = 0.007) was associated with a 20% reduction of the LVEDV with a sensitivity and specificity of 72% and 70%, respectively, and that a GCW cut-off value of 846 mmHg% (AUC 0.759, P = 0.007) was associated with a 10% reduction of LVESV with sensitivity and specificity 79% and 74%, respectively. CONCLUSIONS Mitral valve repair with MitraClip has positive clinical and echocardiographic impact in patients with FMR 1 year after implantation. Preserved GLS and GCW values appear to be associated with LV reverse remodelling post intervention.
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Abstract
Heart failure is a common debilitating illness, associated with significant morbidity and mortality, rehospitalisation and societal costs. Current guidelines and position statements emphasise the management of patients with overt symptomatic disease, but the increasing prevalence of congestive heart failure underscores the need to identify and manage patients with early left ventricular dysfunction prior to symptom onset. Asymptomatic left ventricular systolic dysfunction (ALVSD), classified as stage B heart failure, is defined as depressed left ventricular systolic function in the absence of clinical heart failure. Early initiation of therapies in patients with presumed ALVSD has been shown to lead to better outcomes. In this article, the authors clarify issues surrounding the definition and natural history of ALVSD, outline clinical tools that may be of value in identifying patients with ALVSD and highlight potential opportunities for future investigations to better address aspects of our understanding of this complex syndrome.
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Predictors of left ventricular reverse remodeling after percutaneous therapy for mitral regurgitation with the MitraClip system. Catheter Cardiovasc Interv 2020; 96:687-697. [PMID: 32104977 DOI: 10.1002/ccd.28779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 01/26/2020] [Accepted: 02/07/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To investigate the predictors and clinical impact of left ventricular reverse remodeling (LVRR) after MitraClip (MC) therapy for degenerative (DMR) and functional mitral regurgitation (FMR). BACKGROUND MC therapy induces LVRR in patients with mitral regurgitation (MR) at high-risk for surgery. However, specific data on predictors of LVRR therapy are limited. METHODS This study included 164 patients treated by MC implantation with complete clinical and echocardiographic evaluation at baseline, 6 months, and 12 months. LVRR was defined as a decrease of ≥10% of the left ventricular end-diastolic diameter after 12 months and was found in 49% of the patients. RESULTS LVRR was associated with significantly reduced event rate 2 years after MC procedure. In the total cohort, multivariate regression analysis determined severe recurrent/residual MR after 12 months (p = .010, odds ratio [OR] = 0.26), male gender (p = .050, OR = 0.49) and left ventricular ejection fraction (LVEF) <20% (p = .046, OR = 0.24) as predictors of absence of LVRR. In the subgroup analysis according to etiology of MR, multivariate regression analysis revealed severe recurrent/residual MR after 12 months (p = .04, OR = 0.184) to inversely predict LVRR only in the DMR subgroup. In FMR, residual severe tricuspid regurgitation (TR) inversely predicts LVRR (p = .032, OR = 0.361). CONCLUSIONS LVRR occurs in half of the patients after MC and is associated with reduced MACCE rates at follow-up. Combined information on residual/recurrent MR, baseline LVEF and gender predict LVRR after MC procedure. While residual/recurrent MR is the independent predictor for the absence of LVRR in DMR, in FMR only severe residual TR independently predict LVRR.
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Put a Strain on Secondary Mitral Regurgitation: Functional or Dysfunctional? J Am Coll Cardiol 2020; 75:759-762. [PMID: 32081285 DOI: 10.1016/j.jacc.2019.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
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Perioperative clinical utility of myocardial deformation imaging: a narrative review. Br J Anaesth 2019; 123:408-420. [DOI: 10.1016/j.bja.2019.04.065] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/09/2019] [Accepted: 04/28/2019] [Indexed: 01/25/2023] Open
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Speckle Tracking Strain Echocardiography: On Its Way into the Operating Room. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00342-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Home care for heart failure: can caregiver education prevent hospital admissions? A randomized trial in primary care. J Cardiovasc Med (Hagerstown) 2019; 20:30-38. [PMID: 30394960 DOI: 10.2459/jcm.0000000000000722] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM To assess the feasibility and effectiveness of a low-complexity, low-cost model of caregiver education in primary care, targeted to reduce hospitalizations of heart failure patients. METHODS A cluster-randomized, controlled, open trial was proposed to general practitioners, who were invited to identify patients with heart failure, exclusively managed at home and continuously attended by a caregiver. Participating general practitioners were then randomized to: usual treatment; caregiver education (educational session for recognizing early symptoms/signs of heart failure, with recording in a diary of a series of patient parameters, including body weight, blood pressure, heart rate). The patients were observed at baseline and during a 12-month follow-up. RESULTS Three hundred and thirteen patients were enrolled (163 in the intervention, 150 in the usual care group), 63% women, mean age 85.3 ± 7.7 years. At the end of the 12-month follow-up, a trend towards a lower incidence of hospitalizations was observed in the intervention group (hazard ratio 0.73; 95% CI 0.53-1.01 P = 0.061). Subgroup analysis showed that for patients with persistent/permanent atrial fibrillation, age less than 90 years or Barthel score equal to or greater than 50 a significant lower hospital admission rate occurred in the intervention group (hazard ratio 0.63; 95% CI 0.39-0.99; P = 0.048, hazard ratio 0.66; 95% CI 0.45-0.97; P = 0.036 and hazard ratio 0.61; 95% CI 0.41-0.89; P = 0.011, respectively). CONCLUSION Caregivers training for early recognition of symptoms/signs of worsening heart failure may be effective in reducing hospitalizations, although the benefit was evident only in specific patient subgroups (with persistent/permanent atrial fibrillation, age <90 years or Barthel score ≥ 50), with only a positive trend in the whole cohort. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03389841.
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Regional Left Ventricular Myocardial Dysfunction After Cardiac Surgery Characterized by 3-Dimensional Strain. Anesth Analg 2019; 128:854-864. [PMID: 30896605 PMCID: PMC9815834 DOI: 10.1213/ane.0000000000003785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Three-dimensional (3D) strain is an echocardiographic modality that can characterize left ventricular (LV) function with greater accuracy than ejection fraction. While decreases in global strain have been used to predict outcomes after cardiac surgery, changes in regional 3D longitudinal, circumferential, radial, and area strain have not been well described. The primary aim of this study was to define differential patterns in regional LV dysfunction after cardiac surgery using 3D speckle tracking strain imaging. Our secondary aim was to investigate whether changes in regional strain can predict postoperative outcomes, including length of intensive care unit stay and 1-year event-free survival. METHODS In this prospective clinical study, demographic, operative, echocardiographic, and clinical outcome data were collected on 182 patients undergoing aortic valve replacement, mitral valve repair or replacement, coronary artery bypass graft, and combined cardiac surgery. Three-dimensional transthoracic echocardiograms were performed preoperatively and on the second to fourth postoperative day. Blinded analysis was performed for LV regional longitudinal, circumferential, radial, and area strain in the 17-segment model. RESULTS Regional 3D longitudinal, circumferential, radial, and area strains were associated with differential patterns of myocardial dysfunction, depending on the surgical procedure performed and strain measure. Patients undergoing mitral valve repair or replacement had reduced function in the majority of myocardial segments, followed by coronary artery bypass graft, while patients undergoing aortic valve replacement had reduced function localized only to apical segments. After all types of cardiac surgery, segmental function in apical segments was reduced to a greater extent as compared to basal segments. Greater decrements in regional function were seen in circumferential and area strain, while smaller decrements were observed in longitudinal strain in all surgical patients. Both preoperative regional strain and change in regional strain preoperatively to postoperatively were correlated with reduced 1-year event-free survival, while postoperative strain was not predictive of outcomes. Only preoperative strain values were predictive of intensive care unit length of stay. CONCLUSIONS Changes in regional myocardial function, measured by 3D strain, varied by surgical procedure and strain type. Differences in regional LV function, from presurgery to postsurgery, were associated with worsened 1-year event-free survival. These findings suggest that postoperative changes in myocardial function are heterogeneous in nature, depending on the surgical procedure, and that these changes may have long-term impacts on outcome. Therefore, 3D regional strain may be used to identify patients at risk for worsened postoperative outcomes, allowing early interventions to mitigate risk.
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Big Health Data and Cardiovascular Diseases: A Challenge for Research, an Opportunity for Clinical Care. Front Med (Lausanne) 2019; 6:36. [PMID: 30873409 PMCID: PMC6401640 DOI: 10.3389/fmed.2019.00036] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/05/2019] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular disease (CVD) accounts for the majority of death and hospitalization, health care expenditures and loss of productivity in developed country. CVD research, thus, plays a key role for improving patients' outcomes as well as for the sustainability of health systems. The increasing costs and complexity of modern medicine along with the fragmentation in healthcare organizations interfere with improving quality care and represent a missed opportunity for research. The advancement in diagnosis, therapy and prognostic evaluation of patients with CVD, indeed, is frustrated by limited data access to selected small patient populations, not standardized nor computable definition of disease and lack of approved relevant patient-centered outcomes. These critical issues results in a deep mismatch between randomized controlled trials and real-world setting, heterogeneity in treatment response and wide inter-individual variation in prognosis. Big data approach combines millions of people's electronic health records (EHR) from different resources and provides a new methodology expanding data collection in three direction: high volume, wide variety and extreme acquisition speed. Large population studies based on EHR holds much promise due to low costs, diminished study participant burden, and reduced selection bias, thus offering an alternative to traditional ascertainment through biomedical screening and tracing processes. By merging and harmonizing large data sets, the researchers aspire to build algorithms that allow targeted and personalized CVD treatments. In current paper, we provide a critical review of big health data for cardiovascular research, focusing on the opportunities of this largely free data analytics and the challenges in its realization.
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Clinical application of echocardiographic-derived myocardial strain imaging in subclinical disease: a primer for cardiologists. Curr Opin Cardiol 2019; 34:147-155. [PMID: 30633076 DOI: 10.1097/hco.0000000000000592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PROPOSE OF REVIEW To highlight the evidence to support the measurement of left ventricular (LV) global longitudinal strain (GLS) in the risk assessment and management of patients with valvular heart disease. RECENT FINDINGS Subclinical myocardial dysfunction that is characterized by impaired LV GLS is often present in patients with valvular disease. The addition of GLS to the LV systolic function assessment refines disease classification and improves both prognosis and management of valvular disease. SUMMARY The measurement of global systolic function is essential in risk assessment and management of all patients with valvular heart disease. Although LV ejection fraction remains the main parameter of systolic function, strain measurement has emerged as a promising systolic function marker. Strain describes deformation of the myocardium that occurs during the cardiac cycle in the longitudinal, circumferential, and radial planes. Of all the regional strain deformation measurements, evidence gathered over the last decade has shown that GLS improves detection of systolic dysfunction beyond LV ejection fraction and provides additional prognostic information.
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Transcatheter Repair of Functional Mitral Regurgitation in Heart Failure Patients ― A Meta-Analysis of 23 Studies on MitraClip Implantation ―. Circ J 2018; 82:2800-2810. [DOI: 10.1253/circj.cj-18-0571] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Predictors of outcome in heart failure patients with severe functional mitral regurgitation undergoing MitraClip treatment. Int J Cardiol 2018; 284:50-58. [PMID: 30360995 DOI: 10.1016/j.ijcard.2018.10.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 10/14/2018] [Accepted: 10/15/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND The prognostic predictors of outcome in patients with functional mitral regurgitation (FMR) undergoing MitraClip implantation (MCi) are still poorly known. The aim of our study is to identify the baseline predictors of outcome in FMR patients candidate to MCi. METHODS All patients with symptomatic moderate-to-severe or severe FMR undergoing MCi at our institution were consecutively and prospectively enrolled. Baseline clinical and instrumental data were collected. Primary endpoint was the occurrence of cardiac death; secondary endpoints were all-cause death and the composite of cardiac death or rehospitalization for heart failure. RESULTS 74 patients (mean 71.6 ± 8.3 years) were enrolled. During follow-up (median 416.0 days), the primary endpoint occurred in 15 (20.3%), all-cause death in 26 (35.1%) and the composite endpoint in 25 (33.8%). At multivariate analysis, the left atrial volume index (LAVi; HR:1.02; P = 0.048) and the low peak oxygen uptake (peak VO2; HR:0.73; P = 0.018) increased the risk of cardiac death at follow-up; atrial fibrillation (AF; HR:2.69; P = 0.027) was independently associated to all-cause death and the low level of peak VO2 was an independent predictor of overall mortality (HR:0.70; P < 0.001) as well as of the composite endpoint (HR:0.73; P < 0.001). The ROC analysis identified a peak VO2 cut-off of 10.0 mL/kg/min as the best predictor for the three study endpoints; the best LAVi cut-off for cardiac death was 67 mL/m2. Kaplan-Meier analysis for the individual and combined outcome predictors confirmed their significant stratification ability during follow-up. CONCLUSIONS Peak VO2, along with LAVi and AF, identify FMR patients with the worst prognosis after MCi.
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Galectin-3 is associated with left ventricular reverse remodeling and outcome after percutaneous mitral valve repair. Int J Cardiol 2018; 263:104-110. [PMID: 29678512 DOI: 10.1016/j.ijcard.2018.04.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/26/2018] [Accepted: 04/05/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Plasma Galectin-3 is a marker of myocardial inflammation and fibrosis, was associated with left ventricular (LV) reverse remodeling after conventional surgical mitral valve repair (MVR) and predicted clinical events in patients undergoing transcatheter aortic valve replacement (TAVR). We aimed to evaluate the association between pre-interventional Galectin-3 levels and (1) reverse LV remodeling and (2) major adverse cardiovascular events (MACE) in patients undergoing percutaneous MVR. METHODS Forty-four consecutive patients (median age 79 years, LV ejection fraction 39.5 ± 11.4%, 91% in NYHA functional class ≥III) with symptomatic moderate to severe mitral regurgitation undergoing percutaneous MVR were prospectively included. Plasma Galectin-3 levels were measured before the procedure. Echocardiographic and clinical assessment was performed at baseline and after 3 months. LV reverse remodeling was prospectively defined as a ≥10% increase in global longitudinal strain. MACE included death, myocardial infarction, heart failure related rehospitalization and stroke and was assessed after a mean follow-up time of 2 years. RESULTS 72.7% of the patients showed LV reverse remodeling. Pre-interventional Galectin-3 < 10 ng/ml was an independent predictor of LV reverse remodeling (OR 10.3, 95% CI 1.2-83.9, p = 0.036). 25 patients (56.8%) experienced a MACE. Patients with Galectin-3 levels ≥ 10 ng/ml had significantly more MACE than patients with Galectin-3 levels < 10 ng/ml (100% vs. 45.5%, p = 0.003). Diabetes independently predicted MACE (HR 3.1, 95% CI 1.0-9.4, p = 0.049); Galectin-3 ≥ 10 ng/ml was of borderline significance (HR 2.2, 95% CI 0.9-5.4, p = 0.088). CONCLUSIONS Pre-interventional plasma Galectin-3 levels are associated with LV reverse remodeling and with clinical outcome after percutaneous MVR.
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Assessment of Left Ventricular Function by Echocardiography. JACC Cardiovasc Imaging 2018; 11:260-274. [DOI: 10.1016/j.jcmg.2017.11.017] [Citation(s) in RCA: 279] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 12/13/2022]
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