Mechanism of Recurrent Ischemic Mitral Regurgitation After Annuloplasty

Hung, Judy; Papakostas, Lampros; Tahta, Stephen A; Hardy, Bruce G.; Bollen, Bruce A.; Durán, Carlos M.G.; Levine, Robert A.

doi:10.1161/01.cir.0000138192.65015.45

Cited by 322 publications

(179 citation statements)

References 49 publications

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“…However, increased sphericity of the LV seems to be a maladaptive process because it increases wall stress, leads to greater LV remodeling, and is associated with poor clinical outcomes. [22][23][24][25][26] Echocardiographic measurement of LV mass estimation is performed using area-length method or truncated ellipsoid method. Using any of these 2D methods, the normal LV mass is defined as ≤88 g/m 2 in women and ≤102 g/m 2 in men.…”

Section: Assessment Of LV Mass and Geometrymentioning

confidence: 99%

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Omar

Bansal

Sengupta

2016

Circulation Research

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Echocardiography, given its safety, easy availability, and the ability to permit a comprehensive assessment of cardiac structure and function, is an indispensable tool in the evaluation and management of patients with heart failure (HF). From initial phenotyping and risk stratification to providing vital data for guiding therapeutic decision-making and monitoring, echocardiography plays a pivotal role in the care of HF patients. The recent advent of multiparametric approaches for myocardial deformation imaging has provided valuable insights in the pathogenesis of HF, elucidating distinct patterns of myocardial dysfunction and events that are associated with progression from subclinical stage to overt HF. At the same time, miniaturization of echocardiography has further expanded clinical application of echocardiography, with the use of pocket cardiac ultrasound as an adjunct to physical examination demonstrated to improve diagnostic accuracy and risk stratification. Furthermore, ongoing advances in the field of big data analytics promise to create an exciting opportunity to operationalize precision medicine as the new approach to healthcare delivery that aims to individualize patient care by integrating data extracted from clinical, laboratory, echocardiographic, and genetic assessments. evidence supporting the diagnosis of HF. Echocardiography is the most commonly used modality for this purpose because of its ease of application, noninvasive nature, safety, and ability to provide a vast amount of information about cardiac structure and function. Additionally, echocardiography also plays an important role in guiding therapeutic decision-making and in monitoring response to therapy. Over the past 3 decades, numerous advancements have occurred in the field of echocardiography that have helped improve our understanding of the morpho-functional aberrations occurring in HF. This review summarizes the recent advances in echocardiography as applicable to the evaluation and management of HF. Classification of Heart FailureTo facilitate clinical management, several attempts have been made to divide HF patients into categories that unify them according to their dominant clinical presentations. Thus, HF has often been described as low output failure or high output failure; forward failure or backward failure; systolic HF or diastolic HF; HFrEF or HF with preserved ejection fraction (HFpEF); and so on. More recently, HF has also been classified according to alterations in the mechanical function of the left ventricle (LV; Table 1). 6The classification of HF into systolic or diastolic HF appeared to be intuitive, categorizing patients based on the primary pathogenic abnormality, that is, impairment of cardiac contractility or impairment of filling. However, this description has now been abandoned with the recognition that these 2 entities are not mutually exclusive and have considerable overlap. Significant LV diastolic dysfunction is a ubiquitous occurrence in patients with systolic HF, whereas systolic dysfunction...

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Section: Assessment Of LV Mass and Geometrymentioning

confidence: 99%

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Omar

Bansal

Sengupta

2016

Circulation Research

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“…Numerous studies [23, 24,74,75,76,77,78,79,80,81,82,83] have reported a high rate of persistent and/or recurrent MR following restrictive MVA with an exponential relationship between the prevalence of postoperative MR and the length of follow-up (fig. 8).…”

Section: Treatment Of Ischemic Mrmentioning

confidence: 99%

“…Postoperative persistence or recurrence of MR, even if only mild, should not be considered benign, because this residual MR contributes to negative LV remodeling, which leads to a ‘vicious circle’ [74] where MR begets more MR. To this effect, 2 recent studies [23, 78] demonstrated that the presence of persistent or recurrent MR is associated with markedly worse outcomes.…”

Section: Treatment Of Ischemic Mrmentioning

confidence: 99%

Ischemic Mitral Regurgitation: A Complex Multifaceted Disease

et al. 2008

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Ischemic mitral regurgitation (MR) is a complex multifactorial disease that involves global and regional left ventricular remodeling as well as dysfunction and distortion of the components of the mitral valve including the chordae, annulus and leaflets. This is a frequent (13–59%) complication of myocardial infarction, which is associated with a poor prognosis. The suboptimal results obtained with the most commonly used surgical strategy, that is, restrictive annuloplasty combined with coronary artery bypass graft, emphasize the need to develop alternative or concomitant surgical techniques that directly target the causal mechanisms of the disease. A comprehensive assessment of mitral valve configuration and left ventricular geometry and function prior to surgery as well as an accurate quantification of MR severity at rest and during exercise may help improve patient risk stratification and better individualize the surgical strategy based on the patient’s specific characteristics. The purpose of this review is to summarize the current state of knowledge with regard to the definition, prevalence, mechanisms, outcome and treatment of ischemic MR.

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“…Undersized annuloplasty with complete ring, associated with CABG, presently is the most frequently performed surgical procedure to treat chronic IMR. However, recurrent MR can be expected in 1/3 of patients because of continued LV remodeling [11,12] . There are many reviews about of adding subvalvular procedures to mitral anuloplasty to reduce the tenting forces and improve the long-term repair results [13][14][15] .…”

Section: Open Controversial On Surgical Managementmentioning

confidence: 99%

“…In particular, recent research efforts concentrated on exercise echocardiography [5,30] . Hung et al [11] , for example, demonstrated as CABG alone left more patients with heart failure symptoms at rest and during exercise. This diagnostic tool should always be considered preoperatively because induced dyspnea, increased in MR severity and systolic pulmonary artery pressure are often disguised in patients with moderate IMR at rest.…”

Section: Future Perspectivesmentioning

confidence: 99%

Surgical management of moderate ischemic mitral valve regurgitation: Where do we stand?

Fattouch

Castrovinci

Murana

et al. 2014

WJC

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Ischemic mitral regurgitation (IMR) represents a common complication after myocardial infarction. The valve is anatomically normal and the incompetence is the result of papillary muscles displacement and annular dilatation, causing leaflets tethering. Functionally the leaflets present a restricted systolic motion due to tethering forces that displaces the coaptation surface toward the left ventricle apex. The patients present poor left ventricular function at the time of surgery and the severity of the mitral regurgitation increases the risk of mortality. Currently there is general agreement to treat surgically severe IMR nevertheless strong evidences for patient with moderate insufficiency remains poor and proper treatment debated. The most effective surgical approach for the treatment of IMR remains debated. Some authors demonstrated that coronary artery bypass graft (CABG) alone is beneficial in patients with IMR. Conversely, in most patients, moderate IMR will persist or worsen after CABG alone which translate in higher long-term mortality as a function of residual mitral regurgitation severity. A probable reason for this unclear surgical management of functional MR is due to the contemporary suboptimal results of reparative techniques. The standard surgical treatment of chronic IMR is CABG associated with undersized annuloplasty using complete ring. Though, the recurrence of mitral regurgitation remains high (> 30%) because of continous left ventricle remodeling. To get better long term results, in the last decade, several subvalvular procedures in adjunct to mitral anuloplasty have been developed. Among them, surgical papillary muscle relocation represents the most appreciated option capable to restore normal left ventricle geometry. In the next future new preoperative predictors of increased mitral regurgitation recurrence are certainly needed to find an individual time period of treatment in each patient with moderate IMR. Key words: Anatomy; Surgery; Cardiology; Valve; Mitral; Echocardiography Core tip: Moderate ischemic mitral regurgitation should always be considered in patients undergoing other cardiac surgery. Restrictive anuloplasty alone fails as valid treatment because often associated with persistence and high recurrence rate of mitral regurgitation due to continuous ventricular remodeling. Probably more aggressive repair procedures addressing the subvalvular mitral apparatus would help to find more durable results for this complex disease. In the next future new preoperative predictors of increased MR recurrence are certainly needed to find an individual time period of treatment in each patients with moderate ischemic mi- MINIREVIEWSSubmit a

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Mechanism of Recurrent Ischemic Mitral Regurgitation After Annuloplasty

Cited by 322 publications

References 49 publications

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Ischemic Mitral Regurgitation: A Complex Multifaceted Disease

Surgical management of moderate ischemic mitral valve regurgitation: Where do we stand?

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