Effects of cardiac resynchronization therapy after inferior myocardial infarction on secondary mitral regurgitation and mitral valve geometry

Mihos, Christos G.; Yucel, Evin; Capoulade, Romain; Orencole, Mary; Upadhyay, Gaurav A.; Santana, Orlando; Singh, Jagmeet P.; Picard, Michael H.

doi:10.1111/pace.13255

Cited by 4 publications

(4 citation statements)

References 44 publications

(76 reference statements)

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“…In both circumstances, LV disease disproportionately undermines the support of a single leaflet so that the pathogenesis of MR resembles that of primary MR, even though global LV function is impaired . Interventions that target the dysfunctional valve apparatus can alleviate MR and favorably influence the clinical course . The causal pathway of MR in these patients differs from that seen in those with classic secondary MR, who demonstrate symmetrical displacement and tenting of both papillary muscles as a consequence of marked LV dilatation .…”

Section: Why a New Conceptual Framework Is Neededmentioning

confidence: 99%

“…Some patients with nonischemic cardiomyopathy have selective delayed activation of 1 papillary muscle (eg, the anterolateral insertion) . In others, papillary muscle dysfunction due to posteromedial or inferior infarction can lead to asymmetrical tethering of 1 leaflet . In both circumstances, LV disease disproportionately undermines the support of a single leaflet so that the pathogenesis of MR resembles that of primary MR, even though global LV function is impaired .…”

Section: Why a New Conceptual Framework Is Neededmentioning

confidence: 99%

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New Evidence Supporting a Novel Conceptual Framework for Distinguishing Proportionate and Disproportionate Functional Mitral Regurgitation

2020

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ImportanceTraditionally, physicians distinguished between mitral regurgitation (MR) as a determinant of outcomes and MR as a biomarker of left-ventricular (LV) dysfunction by designating the lesions as primary or secondary, respectively. In primary MR, leaflet abnormalities cause the MR, resulting in modest increases in LV end-diastolic volume over time, whereas in patients with classic secondary MR, LV dysfunction and dilatation lead to MR without structural leaflet abnormalities. However, certain patients with global LV disease (eg, those with left bundle branch block or regional wall motion abnormalities) have the features of primary MR and might respond favorably to interventions that aim to restore the proper functioning of the mitral valve apparatus.ObservationsA novel conceptual framework is proposed, which classifies patients with meaningful LV disease based on whether the severity of MR is proportionate or disproportionate to the LV end-diastolic volume. Treatments that reduce LV volumes (eg, neurohormonal antagonists) are effective in proportionate MR but not disproportionate MR. Conversely, procedures that restore mitral valve function (eg, cardiac resynchronization and mitral valve repair) are effective in patients with disproportionate MR but not in those with proportionate MR. The proposed framework explains the discordant findings in the Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation (MITRA-FR) and the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trials; differences in procedural success and medical therapy in the 2 studies cannot explain the different results. In addition, the small group of patients in the COAPT trial who had the features of proportionate MR and were similar to those enrolled in the MITRA-FR trial did not respond favorably to transcatheter mitral valve repair.Conclusions and RelevanceThe characterization of patients with functional MR into proportionate and disproportionate subtypes may explain the diverse range of responses to drug and device interventions that have been observed.

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Section: Why a New Conceptual Framework Is Neededmentioning

confidence: 99%

Section: Why a New Conceptual Framework Is Neededmentioning

confidence: 99%

New Evidence Supporting a Novel Conceptual Framework for Distinguishing Proportionate and Disproportionate Functional Mitral Regurgitation

2020

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“…Thirdly, selection of the coronary sinus branch implanted by cardiac magnetic resonance imaging, myocardial perfusion imaging, or speckle‐tracking echocardiography, to identify the nonscarred myocardial segments with the most delayed mechanical activation was not performed. This strategy may improve response to CRT and clinical outcomes, and the effect this may have had in the current cohort is unknown . Fourthly, the details regarding the type and specific guideline‐directed medical therapy utilized were available only at baseline, with no information regarding follow‐up alterations and compliance with treatment regimens available.…”

Section: Discussionmentioning

confidence: 99%

The effects of cardiac resynchronization therapy on left ventricular and mitral valve geometry and secondary mitral regurgitation in patients with left bundle branch block

et al. 2019

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Background Secondary mitral regurgitation (MR) is common in patients with left bundle branch block (LBBB) undergoing cardiac resynchronization therapy (CRT). We aimed to define CRT effects on left ventricular (LV) and mitral valve (MV) geometry, and their correlation with MR severity. Methods Forty‐one patients with LBBB and ≥mild secondary MR underwent CRT between 2009 and 2012, and had baseline and follow‐up echocardiograms available. Repeated measure and linear regression analyses were performed to assess for changes in MV and LV geometry and MR severity, and associations with follow‐up MR grade. Results The mean age and baseline QRS duration were 65.5 ± 14.9 years and 160 ± 24 ms. At a mean follow‐up of 2.6 ± 1.8 years, there was an increase in LV ejection fraction and reductions in LV end‐systolic volume index, MR grade, and end‐systolic interpapillary muscle distance (P < .05 for all). Linear correlations were observed between follow‐up MR grade and baseline MV tenting height (r = .44), left atrial volume index (r = .41), LV end‐systolic volume index (r = .4), MV tenting area (r = .38), LV ejection fraction (r = −.34), and end‐systolic interpapillary muscle distance (r = .34) (P < .05 for all). Multiple regression analysis revealed associations between follow‐up MR grade and baseline MV tenting height (β/mm = 0.42, P = .006) and left atrial volume index (β/mL/m2 = 0.4, P = .008), independent of QRS duration (β/ms=−0.07; P = 0.6) and nonischemic cardiomyopathy (β = −0.34, P = .02). Conclusions Cardiac resynchronization therapy in patients with LBBB and secondary MR results in LV and MV geometric reverse remodeling and decreases MR severity. Extent of baseline MV tethering is independently associated with persistent MR at follow‐up.

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“…La restauración de la posición del músculo papilar anterolateral después de la TRC fue uno de los predictores independientes de la reducción de la IM a los 6 meses de seguimiento. Además, gracias a una contracción mecánica más coordinada y más temprana de los segmentos basales del VI, en comparación con los más apicales, se puede lograr un aumento de la función sistólica del anillo mitral, incremento en las fuerzas de cierre y disminución de la retracción valvular, lo que conlleva a una reducción de la IM (34) . A la fecha no existe una clara indicación de TRC en IM grave en contexto de estimulación permanente por sí sola; por lo que en casos seleccionados el upgrade hacia la TRC pueden ser de beneficio, a fin de aliviar la regurgitación valvular por la mejoría de varios mecanismos involucrados e influir favorablemente en el curso clínico (35) .…”

Section: Parámetros Ecocardiográficos De Evaluación De La Asincronía Mecánica Ventricularunclassified

Different phenotypes of mitral regurgitation in patients with right apical ventricular pacing: An echocardiographic approach in a heterogeneity of clinical scenario

Azanza

Munín

Raggio

et al. 2021

Arch Peru Cardiol Cir Cardiovasc

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La estimulación artificial apical del ventrículo derecho (VD) ocasiona una activación asincrónica del ventrículo izquierdo (VI) y de los músculos papilares, lo cual determina un deterioro de la fracción de eyección del VI y un cierre inadecuado del aparato valvular con aparición de insuficiencia mitral (IM) de grado variable. El estudio de este escenario tiene relevancia en la toma de decisiones clínicas a fin de definir pacientes que se beneficien de una terapia de resincronización cardiaca (TRC) para aliviar la regurgitación mitral. Sin embargo, existe una amplia heterogeneidad de patologías que coexisten en pacientes con estimulación permanente con distintos grados de miocardiopatía asociada, lo que dificulta la determinación etiológica y empeora el estadio clínico. El estudio mediante ecocardiografía transtorácica permite la evaluación integral de la regurgitación valvular mitral y de parámetros de función ventricular y de asincronía mecánica como resultado de la estimulación.

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Effects of cardiac resynchronization therapy after inferior myocardial infarction on secondary mitral regurgitation and mitral valve geometry

Abstract: In patients with prior inferior myocardial infarction and no scar, CRT is associated with decreased MR severity, and improved papillary muscle alignment and LV systolic function at follow-up.

Cited by 4 publications

References 44 publications

New Evidence Supporting a Novel Conceptual Framework for Distinguishing Proportionate and Disproportionate Functional Mitral Regurgitation

New Evidence Supporting a Novel Conceptual Framework for Distinguishing Proportionate and Disproportionate Functional Mitral Regurgitation

The effects of cardiac resynchronization therapy on left ventricular and mitral valve geometry and secondary mitral regurgitation in patients with left bundle branch block

Different phenotypes of mitral regurgitation in patients with right apical ventricular pacing: An echocardiographic approach in a heterogeneity of clinical scenario

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