scholarly journals Disproportionate mitral regurgitation: new entity or reflection of measurment errors?

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
J Ambrozic ◽  
M Rauber ◽  
N Skofic ◽  
J Toplisek ◽  
B Berlot ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Stroke Volume ◽  
Left Ventricular ◽  
Regurgitant Volume ◽  
Reduced Ejection Fraction ◽  
Funding Sources ◽  
End Diastolic Volume ◽  
The Difference ◽  
And Gender ◽  
Regurgitant Orifice Area

Abstract Funding Acknowledgements Type of funding sources: None. Background The results of recent studies of transcatheter mitral valve repair proposed a new conceptual framework that categorized mitral regurgitation (MR) into proportionate (propMR) or disproportionate (dispropMR) according to the relationship between effective regurgitant orifice area (EROA) and left ventricular (LV) end-diastolic volume (EDV). Purpose To determine the prevalence of dispropMR in consecutive heart failure patients with reduced ejection fraction (HFrEF) undergoing clinically indicated echocardiography over one year period and to examine characteristics of this new entity. Methods We retrospectively identified 179 patients(age:69 ± 12 years, male:132[74%]) with HFrEF who were classified more than mild MR by performing echocardiographer. Following parameters of MR severity were analysed: regurgitant volume(PISA-based regurgitant volume[RVol-PISA] and RVol calculated by the difference of total LV stroke volume by LV planimetry and Doppler-estimated effective LV stroke volume[RVol-SV]), PISA-based EROA and regurgitant fraction (RF). Grading of MR severity based on RVol was performed (mild:<30 ml, mild-moderate:30-44ml, moderate-severe:45-59 ml, severe:≥60 ml). The distinction between propMR and dispropMR was determined by using a proportionality scheme by Grayburn, considering ratio EROA/LVEDV. DispropMR was identified by the ratio greater than 0.14, while the others were classified as propMR. Results In our cohort, 49(27.4%)patients had dispropMR. Both MR groups were comparable in age and gender. DispropMR group had significantly smaller LV dimensions(LV end-diastolic diameter:59 ± 9mm vs. 65 ± 8mm,p < 0.001; LVEDV:164 ± 54ml vs. 222 ± 60ml,p < 0.001) and higher EF(41 ± 11% vs. 34 ± 9%, p < 0.001). Higher proportion of primary MR was noted in dispropMR group(15[31%] vs. 4[3.3%] patients, p < 0.001). Significant differences were observed in PISA-based quantification of MR between both groups (p < 0.001, for all), whereas RVol-SV was comparable(p = 0.667;Figure A). Discrepant grading in MR severity between RVol-PISA and RVol-SV methods was observed(p < 0.001), with significant high discordance in dispropMR(p < 0.001) and no significant differences in propMR(p = 0.187;Figure B). Additionally, difference in RVol assessed by PISA method and SV method were more prominent in dispropMR (RVol difference: dispropMR:27 ml[17-46] vs. propMR:13 ml[-4 to 24],p < 0.001). MR severity would be reclassified in a substantial proportion of dispropMR when considering RVol-SV. Conclusion Our results suggest that dispropMR may be found in roughly one fourth of echocardiographic studies in patients with HFrEF. DispropMR patients have less extensive LV remodelling and more severe MR based on PISA parameters compared to propMR. However, inconsistencies between parameters of MR severity in dispropMR might suggest echocardiographic limitations of quantitative grading of the MR severity or/and LV volume assessment rather than a new pathophysiological concept of disproportionate MR. Abstract Figure A, B

Secondary mitral regurgitation (part 1): volumetric quantification and analysis

Heart ◽  
2017 ◽  
Vol 104 (8) ◽  
pp. 634-638 ◽  
Author(s):  
William H Gaasch ◽  
Theo E Meyer
Keyword(s):  
Mitral Regurgitation ◽  
Left Ventricular ◽  
Volume Data ◽  
Regurgitant Volume ◽  
Optimal Method ◽  
End Diastolic Volume ◽  
Volumetric Quantification ◽  
Secondary Mitral Regurgitation ◽  
Lv Volume ◽  
Secondary Mr

Secondary mitral regurgitation (MR) develops as a consequence of left ventricular (LV) dilatation and dysfunction, which complicates its evaluation and management. The goal of this article is to review the assessment of secondary MR with special emphasis on quantification and analysis of LV volume data. At the present time, the optimal method for making these measurements appears to be cardiac MRI. In severe MR (both primary and secondary), the regurgitant fraction (RF) exceeds 50%, and as a result, the LV end diastolic volume (EDV) is increased. In secondary MR, the ejection fraction is depressed (generally <40%) and despite an RF >50%, the regurgitant volume (RegV) rarely meets the current published criteria for severe MR (>60 mL). The ratio of the RegV to EDV, which is very low in secondary MR, reflects the effect of the RegV on the ventricle and it may be predictive of the fractional change in LV size that can be expected after correction of MR. Accurate measurement of the volumetric parameters is essential to proper management of patients with secondary MR.

Disproportionate secondary mitral regurgitation: myths, misconceptions and clinical implications

Heart ◽  
2020 ◽  
pp. heartjnl-2020-316992
Author(s):  
Paul A Grayburn ◽  
Milton Packer ◽  
Anna Sannino ◽  
Gregg W Stone
Keyword(s):  
Mitral Regurgitation ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Mean Value ◽  
Left Ventricular ◽  
Functional Mitral Regurgitation ◽  
Lv Function ◽  
End Diastolic Volume ◽  
Regurgitant Orifice Area ◽  
And Function

Secondary (functional) mitral regurgitation (SMR) most commonly arises secondary to left ventricular (LV) dilation/dysfunction. The concept of disproportionately severe SMR was proposed to help explain the different results of two randomised trials of transcatheter edge-to-edge mitral valve repair (TEER) versus medical therapy. This concept is based on the fact that effective regurgitant orifice area (EROA) depends on LV end-diastolic volume (LVEDV), ejection fraction, regurgitant fraction and the velocity-time integral of SMR. This review focuses on the haemodynamic framework underlying the concept and the myths and misconceptions arising from it. Each component of EROA/LVEDV is prone to measurement error which can result in misclassification of individual patients. Moreover, EROA is typically measured at peak systole rather than its mean value over the duration of MR. This can result in physiologically impossible values of EROA or regurgitant volume. Although the EROA/LVEDV ratio (1) emphasises that grading MR severity needs to consider LV size and function and (2) helps explain the different outcomes between COAPT and MITRAFR, there are important factors that are not included. Among these are left atrial compliance, LV pressure and ejection fraction, pulmonary hypertension, right ventricular function and tricuspid regurgitation. Because medical therapy can reduce LV volumes and improve both LV function and SMR severity, the key to patient selection is forced titration of neurohormonal antagonists to the target doses that have been proven in clinical trials (along with cardiac resynchronisation when appropriate). Patients who continue to have symptomatic severe SMR after doing so should be considered for TEER.

scholarly journals Concordance and Discordance of Echocardiographic Parameters Recommended for Assessing the Severity of Mitral Regurgitation

2020 ◽  
Vol 13 (5) ◽  
Author(s):  
Seth Uretsky ◽  
Lillian Aldaia ◽  
Leo Marcoff ◽  
Konstantinos Koulogiannis ◽  
Edgar Argulian ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Left Atrial ◽  
Left Ventricular ◽  
Volume Index ◽  
Regurgitant Volume ◽  
Orifice Area ◽  
Vena Contracta ◽  
Echocardiographic Parameters ◽  
American Society ◽  
Regurgitant Orifice Area

Background: The American College of Cardiology/American Heart Association and American Society of Echocardiography guidelines recommend assessing several echocardiographic parameters when evaluating mitral regurgitation (MR) severity. These parameters can be discordant, making the assessment of MR challenging. The degree to which echocardiographic parameters of MR severity are concordant is not well studied. Methods: We enrolled 159 patients in a prospective multicenter study. Eight parameters were included in this analysis: proximal isovelocity surface area (PISA)–derived regurgitant volume, PISA-derived effective regurgitant orifice area, vena contracta, color Doppler jet/left atrial area, left atrial volume index, left ventricular end-diastolic volume index, peak E wave, and the presence of pulmonary vein systolic reversal. Each echocardiographic parameter was determined to represent severe or nonsevere MR according to the American Society of Echocardiography guidelines. A concordance score was calculated as so that a higher score reflects greater concordance. There was no discordance when all the echocardiographic parameters agreed and high discordance when 3 or 4 parameters were discordant. Results: The mean concordance score was 75±14% for the entire cohort. There were 9 (6%) patients with complete agreement of all parameters and 61 (38%) with high discordance. There was greater discordance in patients with severe MR but no difference between primary versus secondary or central versus eccentric jets. There was an improvement in concordance when only considering PISA-based regurgitant volume, PISA-based effective regurgitant orifice area, and vena contracta with agreement in 68% of patients. Conclusions: There was limited concordance between the echocardiographic parameters of MR severity, and the discordance was worse with more severe MR. Concordance improved when considering only 3 quantitative measures of vena contracta and PISA-based effective regurgitant orifice area and regurgitant volume. These findings highlight the challenges facing echocardiographers when assessing the severity of MR and emphasize the difficulty of using an integrated approach that incorporates multiple components. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04038879.

REGURGITANT VOLUME AND LEFT VENTRICULAR END-DIASTOLIC VOLUME RATIO: A NEW PROGNOSTIC INDICE IN PATIENTS WITH SECONDARY MITRAL REGURGITATION?

2019 ◽  
Vol 73 (9) ◽  
pp. 1955 ◽  
Author(s):  
Farnaz Namazi ◽  
Pieter van der Bijl ◽  
Vasileios Kamperidis ◽  
Suzanne van Wijngaarden ◽  
Nina Ajmone Marsan ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Volume Ratio ◽  
Left Ventricular ◽  
Regurgitant Volume ◽  
End Diastolic Volume ◽  
Secondary Mitral Regurgitation

scholarly journals Longitudinal change in left ventricular 4D flow kinetic energy after myocardial infarction

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
H Ben-Arzi ◽  
A Das ◽  
C Kelly ◽  
RJ Van Der Geest ◽  
A Chowdhary ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Kinetic Energy ◽  
Left Ventricular ◽  
Three Dimensions ◽  
Longitudinal Change ◽  
P Value ◽  
4D Flow ◽  
Longitudinal Changes ◽  
Funding Sources ◽  
End Diastolic Volume

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation HRUK Background. Four-dimensional flow (4D flow) cardiovascular magnetic resonance (CMR) imaging provides quantification of intra-cavity left ventricular (LV) flow kinetic energy (KE) parameters in three dimensions. Myocardial infarction (MI) is known to cause acute alterations in intra-cardiac blood flow but assessments of longitudinal changes are lacking. Purpose. Assess longitudinal changes in LV flow post ST-elevation myocardial infarction (STEMI). Method. Twenty acutely reperfused STEMI patients (13 men, 7 women, mean age 54 ± 9 years) underwent 3T CMR acutely (within 5-7 days) and 3 months post-MI.  CMR protocol included functional imaging, late gadolinium enhancement and 4D flow. Using Q-MASS, LV KE parameters were derived and indexed to LV end-diastolic volume (LVKEiEDV). Based on acute ejection fraction (EF), patients were grouped as follows: preserved (pEF) EF &gt;50%, reduced (rEF) EF &lt;50% including mild (rEF= 40-49%), moderate to severe (EF &lt;40%) impairment.  Results. Out of 20 patients, 13 had rEF acutely (7 mild rEF, 6 moderate to severe rEF). Acute LVKEiEDV parameters varied significantly between pEF and rEF (Table). At 3 months, pEF and mild rEF patients showed a significant (P &lt; 0.05) reduction in average, systolic and peak-A wave LVKEiEDV. Mild rEF patients also had significant (P &lt; 0.05) reduction in minimal and peak-E wave LVKEiEDV. However in patients with moderate to severe rEF in the acute scan, there were no significant change by 3 months (Figure). Conclusion. Following MI, 4D flow LVKE derived biomarkers significantly decreased over time in pEF and mild rEF groups but not in moderate to severe rEF group. 4D flow assessment might provide incremental prognostic value beyond EF assessment alone. Table pEF (n = 7) rEF (n = 13) V1 V2 P-value V1 V2 P-value EF(%) 56 ± 5 55 ± 4 0.40 41 ± 7 47 ± 9 0.01 Infarct Size(%) 31 ± 20 15 ± 9 0.04 18 ± 13† 16 ± 11 0.41 LV KEiEDV parameters Average(µJ/ml) 9 ± 2 7 ± 2 0.02 10 ± 3† 8 ± 3 0.01 Minimal(µJ/ml) 1 ± 0.6 1 ± 0.5 0.46 1.3 ± 0.5 1 ± 0.6 0.03 Systolic(µJ/ml) 10 ± 4 7 ± 2 &lt;0.01 12 ± 4† 7 ± 3 &lt;0.01 Diastolic(µJ/ml) 8 ± 3 7 ± 2 0.13 9 ± 3 8 ± 3 0.09 Peak-E wave(µJ/ml) 22 ± 9 23 ± 8 0.44 20 ± 7 18 ± 10 0.23 Peak-A wave(µJ/ml) 18 ± 10 11 ± 4 0.04 17 ± 9 14 ± 7 0.02 †P &lt; 0.05 V1 comparison between pEF and rEF Abstract Figure

Use of the Frank-Starling mechanism during submaximal versus maximal upright exercise

1986 ◽  
Vol 251 (6) ◽  
pp. H1101-H1105 ◽  
Author(s):  
G. D. Plotnick ◽  
L. C. Becker ◽  
M. L. Fisher ◽  
G. Gerstenblith ◽  
D. G. Renlund ◽  
...  
Keyword(s):  
Stroke Volume ◽  
Blood Pool ◽  
Left Ventricular ◽  
Peak Exercise ◽  
Vigorous Exercise ◽  
Systolic Volume ◽  
Early Exercise ◽  
End Diastolic Volume ◽  
Blood Pool Scintigraphy ◽  
End Systolic Volume

To evaluate the extent to which the Frank-Starling mechanism is utilized during successive stages of vigorous upright exercise, absolute left ventricular end-diastolic volume and ejection fraction were determined by gated blood pool scintigraphy at rest and during multilevel maximal upright bicycle exercise in 30 normal males aged 26-50 yr, who were able to exercise to 125 W or greater. Left ventricular end-systolic volume, stroke volume, and cardiac output were calculated at rest and during each successive 3-min stage of exercise [25, 50, 75, 100, and 125–225 W (peak)]. During early exercise (25 W), end-diastolic and stroke volumes increased (+17 +/- 1 and +31 +/- 4%, respectively), with no change in end-systolic volume. With further exercise (50–75 W) end-diastolic volume remained unchanged as end-systolic volume decreased (-12 +/- 4 and -24 + 5%, respectively). At peak exercise end-diastolic volume decreased to resting level, stroke volume remained at a plateau, and end-systolic volume further decreased (-48 +/- 7%). Thus the Frank-Starling mechanism is used early in exercise, perhaps because of a delay in sympathetic mobilization, and does not appear to play a role in the later stages of vigorous exercise.

scholarly journals Impact of Papillary Muscle Infarction on Ischemic Mitral Regurgitation Assessed by Magnetic Resonance Imaging

2017 ◽  
Vol 190 (01) ◽  
pp. 42-50 ◽  
Author(s):  
Christiane Bretschneider ◽  
Hannah-Klara Heinrich ◽  
Achim Seeger ◽  
Christof Burgstahler ◽  
Stephan Miller ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mitral Regurgitation ◽  
Left Ventricular Function ◽  
Ventricular Function ◽  
Papillary Muscle ◽  
Left Ventricular ◽  
Ischemic Mitral Regurgitation ◽  
Chronic Myocardial Infarction ◽  
End Diastolic Volume ◽  
Significant Difference

Objective Ischemic mitral regurgitation is a predictor of heart failure resulting in increased mortality in patients with chronic myocardial infarction. It is uncertain whether the presence of papillary muscle (PM) infarction contributes to the development of mitral regurgitation in patients with chronic myocardial infarction (MI). The aim of the present study was to assess the correlation of PM infarction depicted by MRI with mitral regurgitation and left ventricular function. Methods and Materials 48 patients with chronic MI and recent MRI and echocardiography were retrospectively included. The location and extent of MI depicted by MRI were correlated with left ventricular function assessed by MRI and mitral regurgitation assessed by echocardiography. The presence, location and extent of PM infarction depicted by late gadolinium enhancement (LGE-) MRI were correlated with functional parameters and compared with patients with chronic MI but no PM involvement. Results PM infarction was found in 11 of 48 patients (23 %) using LGE-MRI. 8/11 patients (73 %) with PM infarction and 22/37 patients (59 %) without PM involvement in MI had ischemic mitral regurgitation. There was no significant difference between location, extent of MI and presence of mitral regurgitation between patients with and without PM involvement in myocardial infarction. In 4/4 patients with complete and in 4/7 patients with partial PM infarction, mitral regurgitation was present. The normalized mean left ventricular end-diastolic volume was increased in patients with ischemic mitral regurgitation. Conclusion The presence of PM infarction does not correlate with ischemic mitral regurgitation. In patients with complete PM infarction and consequent discontinuity of viable tissue in the PM-chorda-mitral valve complex, the probability of developing ischemic mitral regurgitation seems to be increased. However, the severity of mitral regurgitation is not increased compared to patients with partial or no PM infarction. Key points  Citation Format

Abstract 2066: Does Mitral Regurgitation Regress After Aortic Valve Replacement For Aortic Stenosis ? A Prospective Multicenter Study

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Philippe Unger ◽  
Danièle Plein ◽  
Bernard Cosyns ◽  
Guy Van Camp ◽  
Olivier Xhaët ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Mitral Regurgitation ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Left Ventricular ◽  
Aortic Valve Area ◽  
Regurgitant Volume ◽  
Lv Ejection Fraction

Background: Mitral regurgitation (MR) is common in patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). Whether its severity may decrease after AVR remains controversial. Previous studies were mainly retrospective and the degree of MR was assessed at best semi-quantitatively. This study sought to prospectively and quantitatively assess how AVR may affect MR severity. Methods: Patients with AS scheduled for isolated AVR and presenting holosystolic MR which was not considered for replacement or repair were included. Previous mitral valve surgery; severe aortic regurgitation and poor acoustic windows were excluded. Thirty-five patients (mean age 77±7 years) were studied before (median 1, range 1– 41 days) and after AVR (median 7, range 4 –19 days). All patients underwent a comprehensive echocardiographic examination; MR was assessed by Doppler echocardiography using color flow mapping of the regurgitant jet and the PISA method. No patient had prolapsed or flail mitral leaflet as mechanism of MR. Results: Preoperative maximal and mean transaortic pressure gradients and aortic valve area were 74±26 mmHg, 44±16 mmHg, and 0.57±0.18 cm 2 , respectively. Left ventricular (LV) ejection fraction increased from 49±16 % to 55±15 % after AVR (p<0.001). LV end-diastolic volume decreased from 91±32 ml to 77±30 ml (p<0.001).The ratio of MR jet to left atrial area decreased from 30±16% to 20±14% (p<0.001). MR effective regurgitant orifice (ERO) and regurgitant volume decreased from 10±5 mm 2 to 8±6 mm 2 (p=0.015) and from 19±10 ml to 11±9 ml (p<0.0001). The decrease in ERO and in regurgitant volume was similar in patients with preserved or depressed LV ejection fraction (≤45 %) (2±3 vs 3±6 mm 2 and 7±9 vs 8±7 ml; p=NS, respectively). Conclusions: AVR is associated with an early postoperative reduction of the quantified degree of MR. This mainly results from a decrease in regurgitant volume and only modestly from a reduction in ERO, emphasizing the contributing role of the decrease in driving pressure accross the mitral regurgitant orifice.

Left ventricular-arterial coupling in conscious dogs

1991 ◽  
Vol 261 (1) ◽  
pp. H70-H76 ◽  
Author(s):  
W. C. Little ◽  
C. P. Cheng
Keyword(s):  
Stroke Volume ◽  
Systolic Pressure ◽  
Left Ventricular ◽  
Arterial System ◽  
Conscious Dogs ◽  
Stroke Work ◽  
Arterial Elastance ◽  
Inotropic State ◽  
End Diastolic Volume ◽  
Wide Range

We investigated the criteria for the coupling of the left ventricle (LV) and the arterial system to maximize LV stroke work (SW) and the transformation of LV pressure-volume area (PVA) to SW. We studied eight conscious dogs that were instrumented to measure LV pressure and determine LV volume from three ultrasonically determined dimensions. The LV end-systolic pressure (PES)-volume (VES) relation was determined by caval occlusion. Its slope (EES) was compared with the arterial elastance (EA) and determined as PES per stroke volume. At rest, with intact reflexes, EES/EA was 0.96 +/- 0.20 EES/EA was varied over a wide range (0.18-2.59) by the infusion of graded doses of phenylephrine and nitroprusside before and during administration of dobutamine. Maximum LV SW, at constant inotropic state and end-diastolic volume (VED), occurred when EES/EA equaled 0.99 +/- 0.15. At constant VED and contractile state, SW was within 20% of its maximum value when EES/EA was between 0.56 and 2.29. The conversion of LV PVA to SW increased as EES/EA increased. The shape of the observed relations of the SW to EES/EA and SW/PVA to EES/EA was similar to that predicted by the theoretical consideration of LV PES-VES and arterial PES-stroke volume relations. We conclude that the LV and arterial system produce maximum SW at constant VED when EES and EA are equal; however, the relation of SW to EES/EA has a broad plateau. Only when EA greatly exceeds EES does the SW fall substantially. However, the conversion of PVA to SW increases as EES/EA increases. These observations support the utility of analyzing LV-arterial coupling in the pressure-volume plane.

Comparison of left ventricular volumes by dye dilution and angiographic methods in the dog

1963 ◽  
Vol 204 (3) ◽  
pp. 446-450 ◽  
Author(s):  
Franz J. Hallermann ◽  
G. C. Rastelli ◽  
H. J. C. Swan
Keyword(s):  
Stroke Volume ◽  
Left Ventricular ◽  
Dilution Method ◽  
Left Ventricular Volumes ◽  
Heart Rates ◽  
Systolic Volume ◽  
End Diastolic Volume ◽  
End Systolic Volume ◽  
Fundamental Error ◽  
Indicator Dye

In each of 12 mongrel dogs, data for end-diastolic volume, end-systolic volume, and stroke volume of the left ventricle were obtained by two independent methods: the indicator dilution method and a radiographic method. While the values for stroke volume showed good agreement between the two methods, a significant and directionally constant difference was found between values for end-diastolic volume and end-systolic volume calculated by the two different methods. This was observed in dogs with fast heart rates (exceeding 150 beats/min), as well as in dogs with heart rates of about 100 beats/min. The findings strongly suggest that a fundamental error is present in estimations of volume based on the washout of an indicator dye.

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