Impact of untreated mild-to-moderate mitral regurgitation at the time of isolated aortic valve replacement on late adverse outcomes☆

Takeda, Koji; Matsumiya, Goro; Sakaguchi, Taichi; Miyagawa, Shigeru; Yamauchi, Takashi; Shudo, Yasuhiro; Izutani, Hironori; Sawa, Yoshiki

doi:10.1016/j.ejcts.2009.11.046

Cited by 38 publications

(39 citation statements)

References 25 publications

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“…Moreover, gradual restoration of pump function has been observed clinically in asymptomatic patients with mild to moderate MR and LV systolic dysfunction before intervention (32).…”

Section: Discussionmentioning

confidence: 99%

Temporal pattern of left ventricular structural and functional remodeling following reversal of volume overload heart failure

Hutchinson

Guggilam

Cismowski

et al. 2011

Journal of Applied Physiology

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Temporal pattern of left ventricular structural and functional remodeling following reversal of volume overload heart failure. J Appl Physiol 111: 1778 -1788. First published September 1, 2011 doi:10.1152/japplphysiol.00691.2011.-Current surgical management of volume overload-induced heart failure (HF) leads to variable recovery of left ventricular (LV) function despite a return of LV geometry. The mechanisms that prevent restoration of function are unknown but may be related to the timing of intervention and the degree of LV contractile impairment. This study determined whether reduction of aortocaval fistula (ACF)-induced LV volume overload during the compensatory stage of HF results in beneficial LV structural remodeling and restoration of pump function. Rats were subjected to ACF for 4 wk; a subset then received a load-reversal procedure by closing the shunt using a custom-made stent graft approach. Echocardiography or in vivo pressure-volume analysis was used to assess LV morphology and function in sham rats; rats subjected to 4-, 8-, or 15-wk ACF; and rats subjected to 4-wk ACF followed by 4-or 11-wk reversal. Structural and functional changes were correlated to LV collagen content, extracellular matrix (ECM) proteins, and hypertrophic markers. ACF-induced volume overload led to progressive LV chamber dilation and contractile dysfunction. Rats subjected to shortterm reversal (4-wk ACF ϩ 4-wk reversal) exhibited improved chamber dimensions (LV diastolic dimension) and LV compliance that were associated with ECM remodeling and normalization of atrial and brain natriuretic peptides. Load-independent parameters indicated LV systolic (preload recruitable stroke work, Ees) and diastolic dysfunction (tau, arterial elastance). These changes were associated with an altered ␣/␤-myosin heavy chain ratio. However, these changes were normalized to sham levels in long-term reversal rats (4-wk ACF ϩ 11-wk reversal). Acute hemodynamic changes following ACF reversal improve LV geometry, but LV dysfunction persists. Gradual restoration of function was related to normalization of eccentric hypertrophy, LV wall stress, and ECM remodeling. These results suggest that mild to moderate LV systolic dysfunction may be an important indicator of the ability of the myocardium to remodel following the reversal of hemodynamic overload.hemodynamics; cardiac remodeling/hypertrophy; collagen THE INCIDENCE OF HEART FAILURE (HF) is increasing due to an aging population and improved management of diseases that are precursors to ventricular dysfunction. The successes of therapeutic advances over the past decades have dramatically decreased mortality rates, such that the focus has now shifted towards reducing morbidities (12). As a result, cardiac remodeling has become a primary therapeutic target in patients with heart failure. Strategies to prevent or reverse adverse left ventricular (LV) remodeling include pharmacotherapy, surgical interventions, and device-based-therapies such as left ventricular assist devices (LVAD) and cardiac resynchro...

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“…Moreover, gradual restoration of pump function has been observed clinically in asymptomatic patients with mild to moderate MR and LV systolic dysfunction before intervention (32).…”

Section: Discussionmentioning

confidence: 99%

Temporal pattern of left ventricular structural and functional remodeling following reversal of volume overload heart failure

Hutchinson

Guggilam

Cismowski

et al. 2011

Journal of Applied Physiology

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“…However, there is substantial disagreement in the literature over the proportion of patients that will experience improvement in MR after AVR and the degree of improvement that can be expected is not well defined. 1 For these reasons, the appropriate management of intermediate degrees of MR in the setting of AVR is undefined and remains controversial, with some authors advocating for a more aggressive surgical approach 2,3,5,8 and others advocating a more conservative approach. 9,10 No randomized controlled clinical trials that address this issue have been published to date.…”

Section: Introductionmentioning

confidence: 99%

Quantitative evaluation of change in coexistent mitral regurgitation after aortic valve replacement

Kaczorowski

MacArthur

Howard

et al. 2013

The Journal of Thoracic and Cardiovascular Surgery

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Objective Management of intermediate degrees of mitral regurgitation (MR) during aortic valve replacement (AVR) for aortic stenosis remains controversial. We sought to evaluate the degree of reduction of MR in patients undergoing AVR, as well as the relationship between the pre-operative gradient across the aortic valve and the degree of reduction in MR. Methods We retrospectively analyzed demographic, intraoperative, and echocardiographic data on 802 patients that underwent AVR or aortic root replacement between January 2010 and March 2011. 578 patients underwent AVR or aortic root replacement without intervention on the mitral valve. We excluded 88 patients with severe aortic insufficiency, 3 patients that underwent ventricular assist device placement, 4 patients that underwent prior mitral valve replacement, and 21 patients with incomplete data yielding 462 patients for analysis. MR was graded for each patient and the degree of change in MR for each patient was determined by subtracting the grade of pre-operative MR from the degree of post-operative MR. Results Of the 462 patients, 289 patients had at least mild MR. On average, MR was downgraded by 0.24 degrees per patient for this cohort of 289 patients. Of the 56 patients with at least moderate MR, MR was downgraded 0.54 degrees per patient. Of 62 patients that underwent AVR only, had at least mild MR, and no evidence of structural mitral valve disease, downgrading of MR was 0.24 degrees per patient. Linear regression analysis revealed no relationship between reduction in MR and pre-operative gradient across the aortic valve. Conclusions Reduction in MR after relief of aortic outflow tract obstruction is modest at best. Further, the magnitude of the pre-operative gradient across the aortic valve has little influence on the degree of reduction in MR. These observations argue in favor of performing a prospective evaluation of the clinical benefits of addressing moderate MR at the time of aortic valve intervention.

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“…In a study by ruel et al 6 significant MR was associated with a higher incidence of heart failure symptoms in patients which had undergone aVr for as, but only when it was associated with at least one risk factor (left atrial diameter >5 cm, peak aortic gradient >60 mm hg, mean aortic gradient >40 mm Hg and atrial fibrillation). Takeda et al 9 showed a significantly higher rate of re-hospitalization for heart failure in patients with concomitant significant MR compared with non/trivial and, among patients with significant Mr, a trend for a higher re-admission rate for patients without any improvement in Mr after aVr. on the other hand, the partNer study 7 showed an improvement in Nyha functional class after both surgical aVr and taVr which was independent on the presence and severity of concomitant Mr. a similar result emerged from a study by toggweiler et al 12 on patients undergoing taVr, with a general improvement in Nyha class regardless of Mr grade.…”

Section: Significant Mr and Functional Status In Patients Undergoing Avrmentioning

confidence: 99%

“…several studies compared mortality in patients undergoing surgical AVR with and without significant MR (considered at least moderate or ++/++++): most of them showed an excess in mortality in patients with significant MR compared to those with no/trivial/mild Mr (4-7), but some failed to demonstrate this association 8,9 . a 2011 meta-analysis performed on 17 studies concluded that patients with moderate/severe Mr had higher mortality compared to mild or no Mr at 30 days (or 0.41; CI at 95%: 0.24-0.72), and worse survival at 3 years (hr 0.49; CI at 95%: 0.35-0.69), 5 years (hr 0.46; CI at 95%: 0.34-0.61) and 10 years (hr 0.61; CI at 95%: 0.40-0.92)after aVr 10 .…”

Section: Impact Of Significant Mr On Mortality In Patients Undergoingmentioning

confidence: 99%

Concomitant significant mitral regurgitation in patients with aortic valve stenosis undergoing valve replacement: Practical indications

Iudice¹,

Galderisi²

2015

ICFJ

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Significant mitral regurgitation (MR) - either of structural or functional origin - is a frequent condition in patients with severe aortic stenosis (AS), candidate to aortic valve replacement (AVR), and raises the problem whether or not to intervene on mitral valve at the same time. Surgical risk related to the double valve intervention is still significantly higher compared to isolated AVR and international guidelines do not always give definite indications in the presence of multiple valve disease. Furthermore, the increasing diffusion of transcatheter aortic valve replacement for patients at high surgical risk has risen the problem of leaving the concomitant MR untreated. This review is an attempt to give a practical guide for the decision-making process about the treatment strategy of patients with concomitant severe AS and significant MR, analyzing the impact of a persistent MR on prognosis after surgical or transcatheter AVR, the main predictors of MR improvement after isolated AVR - according to the current literature – and displaying the emerging approach involving transcatheter treatment of both AS and MR.

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Impact of untreated mild-to-moderate mitral regurgitation at the time of isolated aortic valve replacement on late adverse outcomes☆

Cited by 38 publications

References 25 publications

Temporal pattern of left ventricular structural and functional remodeling following reversal of volume overload heart failure

Temporal pattern of left ventricular structural and functional remodeling following reversal of volume overload heart failure

Quantitative evaluation of change in coexistent mitral regurgitation after aortic valve replacement

Concomitant significant mitral regurgitation in patients with aortic valve stenosis undergoing valve replacement: Practical indications

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