Exercise Dynamics in Secondary Mitral Regurgitation

Bertrand, P.; Schwammenthal, Ehud; Levine, Robert A.; Vandervoort, Pieter M.

doi:10.1161/circulationaha.116.025260

Cited by 80 publications

(32 citation statements)

References 141 publications

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“… 46 Diuretics, nitrates, and hydralazine also reduce LV preload and afterload and are associated with symptomatic improvement in patients with SMR. 18 , 47 …”

Section: Managementmentioning

confidence: 99%

The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Coats

Anker

Baumbach

et al. 2021

European Heart Journal

100

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Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current randomized trials require careful interpretation. This collaborative position statement, developed by four key associations of the European Society of Cardiology—the Heart Failure Association (HFA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association of Cardiovascular Imaging (EACVI), and European Heart Rhythm Association (EHRA)—presents an updated practical approach to the evaluation and management of patients with HF and SMR based upon a Heart Team approach.

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“… 46 Diuretics, nitrates, and hydralazine also reduce LV preload and afterload and are associated with symptomatic improvement in patients with SMR. 18 , 47 …”

Section: Managementmentioning

confidence: 99%

The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Coats

Anker

Baumbach

et al. 2021

European Heart Journal

100

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“…Sometimes, symptoms appear disproportionate to resting MR severity, seemingly only mild or mild-to-moderate. Given the dynamic nature of secondary MR, evaluation of regurgitation should be carried out under optimized loading conditions, and it is usually recommended that invasive procedures should be deferred until any medical therapy has been optimized ( 34 ). In this setting, exercise stress echocardiography may reveal exercise-induced severe MR and pulmonary hypertension undetected at rest ( 35 ).…”

Section: Diagnostic Assessment and Prognostic Relevancementioning

confidence: 99%

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology

Salvatore

Ricci

Dangas

et al. 2021

Front. Cardiovasc. Med.

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Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

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“…[ 53 , 54 ] During exercise, increasing the degree of functional MR leads to attenuation of increase in forward stroke volume and increased backward flow results in a disproportionate increase in left atrial and pulmonary pressures, therefore increasing the pulsatile load in the pulmonary circulation. [ 55 ] Worsening of MR during exercise has been associated with impaired exercise capacity, even when MR is modest at rest. [ 56 ]…”

Section: Mitral Valve Diseasesmentioning

confidence: 99%

Exercise Right Heart Catheterisation in Cardiovascular Diseases: A Guide to Interpretation and Considerations in the Management of Valvular Heart Disease

et al. 2021

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The use of exercise right heart catheterisation for the assessment of cardiovascular diseases has regained attention recently. Understanding physiologic haemodynamic exercise responses is key for the identification of abnormal haemodynamic patterns. Exercise total pulmonary resistance >3 Wood units identifies a deranged haemodynamic response and when total pulmonary resistance exceeds 3 Wood units, an exercise pulmonary artery wedge pressures/cardiac output slope >2 mmHg/l/min indicates the presence of underlying exercise-induced pulmonary hypertension related to left heart disease. In the evolving field of transcatheter interventions for valvular heart disease, exercise right heart catheterisation may objectively unmask symptoms and underlying haemodynamic abnormalities. Further studies are needed on the use of the procedure to inform the selection of patients who might receive the most benefit from transcatheter interventions for valvular heart diseases.

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Exercise Dynamics in Secondary Mitral Regurgitation

Cited by 80 publications

References 141 publications

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology

Exercise Right Heart Catheterisation in Cardiovascular Diseases: A Guide to Interpretation and Considerations in the Management of Valvular Heart Disease

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