Proportionate or disproportionate secondary mitral regurgitation: how to untangle the Gordian knot?

Kamoen, Victor; Calle, Simon; Buyzere, Marc De; Timmermans, Frank

doi:10.1136/heartjnl-2020-317040

Cited by 10 publications

(14 citation statements)

References 52 publications

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“…Furthermore, over-and underestimation of LV volumes in humans [64] and phantoms [65,66] have been described comparing different imaging methods, e.g., native 2D-and 3D echocardiography, contrast echocardiography, CMR, and computed tomography. Recently, conclusive LV volume assessment by 2D echocardiography was illustrated if image quality is adequate [67][68][69][70]. The differences in LV volumes between 2D echocardiography Table 2 Proposal to classify primary mitral regurgitation (PMR) more in detail with respect to specific echocardiographic findings, the chronicity of the underlying diseases, and the clinical complaints of the patients and CMR can be minimized by triplane, 3D-, and contrast echocardiography [71,72].…”

Section: The Rationale To Implement a Quantitative Mr Assessment To Characterize Mr Severitymentioning

confidence: 99%

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness

et al. 2021

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The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results. Graphic abstract

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Section: The Rationale To Implement a Quantitative Mr Assessment To Characterize Mr Severitymentioning

confidence: 99%

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness

et al. 2021

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“…Table 1 and Table 2 show the baseline clinical and echocardiographic characteristics of the patient population. Median PISA-EROA and PISA-RV was 0.17 [0.11-0.24] cm 2 and 29 [20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] mL, respectively. Median API was 122 [87-148] arbitrary units (au).…”

Section: Baseline Characteristicsmentioning

confidence: 99%

“…Median API was 122 [87-148] arbitrary units (au). Median LVEF and indexed LVEDV were 35 [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] % and 84 [66-107] mL/m 2 , respectively. Mean GLS was 9.8 (± 3.43) % and median GWI was 929 [610-1276] mmHg%.…”

Section: Baseline Characteristicsmentioning

confidence: 99%

“…Finally, LV contractility, even if perfectly measured, is only one piece of the puzzle in predicting outcome in FMR. Indeed, FMR is a complex clinical and hemodynamic pathology, where many different variables interact and compete when considering outcome [29]. "…”

Section: Gwi In Fmrmentioning

confidence: 99%

“…In patients with FMR, LV dysfunction relates to FMR both as a cause and a consequence [29]. As FMR is independently associated with outcome [29,30], targeting FMR with mitral intervention seems an obvious strategy.…”

Section: Myocardial Strain and Work: A New Tool For Selecting Fmr Patients For Mitral Intervention?mentioning

confidence: 99%

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Prognostic value of myocardial work and global longitudinal strain in patients with heart failure and functional mitral regurgitation

Verbeke

Calle

Kamoen

et al. 2021

Int J Cardiovasc Imaging

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In patients with heart failure and functional mitral regurgitation (FMR), the assessment of left ventricular (LV) function is important for risk stratification and decision making. As LV ejection fraction (LVEF) might not be an optimal metric for LV systolic performance in this population, alternatives such as global longitudinal strain (GLS) and global myocardial work index (GWI) have been proposed. In the present study, we investigated the prognostic value of GLS and GWI and compared these measures to other LV systolic performance parameters. A prospective and consecutive cohort of 181 patients (median age 72 years, 76% male) with LVEF < 50% and FMR underwent comprehensive echocardiographic examination including speckle tracking echocardiography and grading of FMR severity. During a median follow-up of 42 months, 72 cardiovascular (CV) events occurred. In univariate analysis, LVEF, GLS, GWI, mitral S', LV outflow tract time velocity integral, forward LVEF and LV ejection time were associated with CV events. After multivariate adjustment only GLS (hazard ratio (HR) = 0.884, p = 0.015) and GWI (HR = 0.927, p = 0.034) remained independently associated with CV events. There was no difference in the incremental prognostic value of GWI compared to GLS (delta -2 log likelihood = 0.8; p = 0.37). In this cohort of heart failure patients with FMR, GLS and GWI were independently associated with cardiovascular events, whereas other systolic performance parameters were not. However, GWI did not outperform GLS, and further research is required to determine the value of these strain-based measures in clinical practice.

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Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

Hagendorff¹,

Helfen

Brandt

et al. 2023

Clin Res Cardiol

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The assessment of valvular pathologies in multiple valvular heart disease by echocardiography remains challenging. Data on echocardiographic assessment—especially in patients with combined aortic and mitral regurgitation—are rare in the literature. The proposed integrative approach using semi-quantitative parameters to grade the severity of regurgitation often yields inconsistent findings and results in misinterpretation. Therefore, this proposal aims to focus on a practical systematic echocardiographic analysis to understand the pathophysiology and hemodynamics in patients with combined aortic and mitral regurgitation. The quantitative approach of grading the regurgitant severity of each compound might be helpful in elucidating the scenario in combined aortic and mitral regurgitation. To this end, both the individual regurgitant fraction of each valve and the total regurgitant fraction of both valves must be determined. This work also outlines the methodological issues and limitations of the quantitative approach by echocardiography. Finally, we present a proposal that enables verifiable assessment of regurgitant fractions. The overall interpretation of echocardiographic results includes the symptomatology of patients with combined aortic and mitral regurgitation and the individual treatment options with respect to their individual risk. In summary, a reproducible, verifiable, and transparent in-depth echocardiographic investigation might ensure consistent hemodynamic plausibility of the quantitative results in patients with combined aortic and mitral regurgitation. Graphic abstract The quantitative approach to assess LV volumes in combined AR and MR patients: explanation and algorithm of how to determine the relevant target parameters. LVSVeff—effective left ventricular (LV) stroke volume, LVSVforward—forward LV stroke volume through the aortic valve (AV), LVSVtot—total LV stroke volume, RegVolAR—regurgitant volume through the AV, RegVolMR—regurgitant volume through the mitral valve (MV), LVfilling volume = LVMV-Inflow − transmitral LV inflow, LVOT—left ventricular outflow tract, RFAR—regurgitant fraction of aortic regurgitation (AR), RFMR—regurgitant fraction of mitral regurgitation (MR), RVSVeff —effective right ventricular (RV) stroke volume, RVSVforward—forward RV stroke volume through the pulmonary valve, RVSVtot—total RV stroke volume.

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Proportionate or disproportionate secondary mitral regurgitation: how to untangle the Gordian knot?

Cited by 10 publications

References 52 publications

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness

Prognostic value of myocardial work and global longitudinal strain in patients with heart failure and functional mitral regurgitation

Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

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