5943Mechanistic insights of papillary muscle dyssynchrony mediated function mitral regurgitation and modulation by cardiac resynchronization

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
G Spinka ◽  
P Bartko ◽  
H Arfsten ◽  
G Heitzinger ◽  
N Pavo ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Left Ventricular ◽  
Time Difference ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Doppler Velocity ◽  
Conduction Delay ◽  
Regurgitant Volume ◽  
Vena Contracta

Abstract Abstract Background Mechanistic features of functional mitral regurgitation (FMR) include papillary muscle displacement due to left ventricular remodeling. Intraventricular conduction delay might further augment this condition by introducing interpapillary muscle dyssynchrony. Objectives To define this mechanism as a major contributing factor in FMR and prove the reversibility of FMR by interpapillary muscle resynchronization. Methods We enrolled 269 chronic HFrEF patients with conduction delay and comprehensively assessed dyssynchrony by complementary echocardiographic techniques. Opposing wall delay, calculated by speckle tracking, was determined as the time difference between peak longitudinal strain of the mid-anterior and inferior wall from a 2-chamber view. Furthermore, opposing wall delay was assessed as the time difference between peak strain values from tissue Doppler velocity-coded data of the mid-inferior septal and mid-lateral wall segments. Results Patients with severe FMR had markedly increased interpapillary longitudinal dyssynchrony (160ms [IQR 120–200]) compared to those with moderate (70ms [IQR 40–110]), no, or mild FMR (60ms [IQR 30–100]; P<0.001). Increased interpapillary muscle dyssynchrony was correlated with effective regurgitant orifice area (P<0.001; Figure A), regurgitant volume (P<0.001, Figure B) and vena contracta width (P<0.001, Figure C). Restoration of longitudinal papillary muscle synchronicity by cardiac resynchronization therapy (CRT) was correlated with FMR regression, as reflected by the reduction in regurgitant volume (P<0.001) and vena contracta width (P<0.001). Conversely, the improvement of FMR was associated with improved interpapillary radial (P=0.006) and longitudinal (P<0.001) dyssynchrony. The improvement of dyssynchrony-mediated FMR signified a better prognosis compared to no improvement in FMR during the 8-year follow-up period even after comprehensive adjustment by a bootstrap-selected confounder model (adj. HR of 0.41; 95% CI 0.18–0.91; P=0.028; Figure D). The results remained virtually unchanged after adjustment for left bundle branch block. Figure 1. Dyssynchrony-FMR-CRT Conclusion Intraventricular dyssynchrony introduces unequal contraction by papillary muscle bearing walls, which has an adverse effect on FMR. CRT can effectively restore interpapillary balance and thus create a less tented leaflet configuration, resulting in a clinically meaningful reduction of FMR. The restoration of papillary muscle synchronicity in dyssynchrony-mediated FMR translates into a significantly better prognosis.

scholarly journals Analysis of Risk Factors for Acute Heart Failure in Patients with Dilated Cardiomyopathy and Persistent Severe Functional Mitral Regurgitation Despite Cardiac Resynchronization Therapy

2020 ◽  
pp. 35-39
Author(s):  
R. V. Buriak ◽  
K. V. Rudenko ◽  
O. A. Krykunov
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Mitral Regurgitation ◽  
Cardiac Resynchronization Therapy ◽  
Dilated Cardiomyopathy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Reverse Remodeling ◽  
Resynchronization Therapy

Congestive heart failure resulting from non-ischemic dilated cardiomyopathy (DCM) with secondary functional mitral regurgitation (FMR) is associated with poor prognosis. Medical treatment results in a 1-year survival of 52% to 87% and a 5-year survival of 22% to 54%, with highest survivals observed in more recent years, probably reflecting improvements in medical therapy. Non-surgical interventions involve cardiac resynchronization therapy. In addition to medical treatment, cardiac resynchronization therapy (CRT) should be considered in patients with New York Heart Association (NYHA) class II– IV HF, left ventricular ejection fraction (LVEF) =35%, normal sinus rhythm and left bundle branch block with QRS >150 ms. In these patients, CRT can also facilitate left ventricular (LV) reverse remodeling and reduce associated FMR. The aim of this study was to investigate the features of symptomatology and to analyze the risk factors for acute heart failure (AHF) in patients with DCM and persistent severe functional mitral regurgitation despite CRT and optimal guideline-directed medical therapy (GDMT). Materials and methods. After providing informed consent, 144 patients with severe FMR were involved in the study. Concomitant tricuspid valve regurgitation was registered in 142 (98.6%) cases. The median LVEF was 27.0 (23.0-31.6)%. 40 (27.8%) patients had a permanent form of atrial fibrillation, and 24 (16.7%) patients had a first-degree atrioventricular node block. The median NT-proBNP was 2600 (2133-3200) pg/ml, indicating the presence of severe chronic heart failure. Results. The median term after CRT device implantation was 36 (3.5-60) months. A comparative analysis between DCM patients with and without CRT revealed statistically significant differences between clinical characteristics, namely: age (p=0.020), lower heart rate (p=0.004), lower hemoglobin (p=0.017), higher erythrocyte sedimentation rate (ESR) (p=0.000) and more frequent AHF at the hospital stage (p=0.030). The incidence of AHF at the hospital stage was 13.8% in patients with CRT and 3.5% in those without CRT. The calculated odds ratio of AHF was 4.44 (95% confidence interval (CI) 1.039-18.971), and the relative risk of AHF was 3.966 (95% CI 1.054-14.915). Discussion. FMR has been reported to persist in about 20% to 25% of CRT patients and, in an additional 10% to 15%, it may actually worsen after CRT. In this subset of CRT non-responders, reduced reverse remodeling, increased morbidity, and increased mortality have been reported compared with CRT patients in whom FMR was significantly reduced or abolished. Conclusions. The results of our study demonstrate that severe functional mitral regurgitation despite cardiac resynchronization therapy in patients with dilated cardiomyopathy is a significant risk factor for AHF and subsequent hospitalizations for heart failure.

scholarly journals Cardiac resynchronization therapy following Carillon® annuloplasty device for symptomatic heart failure and functional mitral regurgitation: a case report

2019 ◽  
Vol 3 (4) ◽  
pp. 1-5
Author(s):  
Haqeel A Jamil ◽  
Steven L Goldberg ◽  
Klaus K Witte
Keyword(s):  
Mitral Regurgitation ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular Systolic Dysfunction ◽  
Systolic Dysfunction ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Symptom Improvement ◽  
Resynchronization Therapy ◽  
Bundle Branch Block

Abstract Background  Symptomatic patients with significant left ventricular systolic dysfunction (LVSD) require a tailored treatment approach. Both functional mitral regurgitation (FMR) and left bundle branch block (LBBB) can develop, contributing to clinical deterioration, and worse prognosis despite optimal medical therapy (OMT). Case summary  We report the case of a symptomatic 60-year-old man on OMT with LVSD and significant FMR. His symptoms and FMR initially improved following transvenous mitral annuloplasty using the Carillon® Mitral Contour System® annuloplasty device. However, he subsequently developed LBBB with associated reduction in exercise capacity, for which he underwent cardiac resynchronization therapy, and ensuing symptom improvement and stabilization. Discussion  Our case describes how targeted device interventions can be combined synergistically to optimize patient symptoms.

scholarly journals P650Influence of fetunin-a level on progression of calcific aortic valve stenosis The COFRASA - GENERAC StudyP651Common carotid artery remodeling 1 year after aortic valve surgeryP652Low gradient aortic stenosis with preserved ejection fraction: reclassification of severity by 3D transesophageal echocardiography. P653Results of balloon aortic valvuloplasty in patients with impaired left ventricle ejection fraction.P654Burden of associated aortic regurgitation in patients with mitral regurgitationP655Differences in right ventricular mechanics in acute and chronic ischemic mitral regurgitation after inferoposterior myocardial infarctionP656Tricuspid regurgitation in patients operated for severe symptomatic native aortic stenosis: pre-operative determinantsP657Echocardiographic diagnosis in patients with prosthetic or annuloplasty ring dysfunction: correlation with surgical findingsP659Agreement analisys of different three-dimensional transoesophageal echocardiographic modalities and cardiac CT scan in aortic annulus sizing for transapical heart valve implantationP660Elevated gradients after TAVR are associated with increased rehospitalization, but have no impact on mortality and major adverse cardiac eventsP661Echocardiographic characteristics of post-TAVI thrombosis and endocarditis: single-centre experienceP662Impact of mixed aortic valve disease in long-term mortality after transcatheter aortic valve implantationP663Quantification of mitral regurgitation during interventional valve repair: correlation between haemodynamic parameters and 3D color Doppler echocardiographyP664Mitraclip in functional mitral regurgitation: are immediate results the same in ischemic and non ischemic etiology?P665Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a meta-analysisP666Regardless of the definition used, left ventricular reverse remodeling is not different in fibrosis positive and negative dilated cardiomyopathy patientsP667Heterogeneity of LV contractile function by multidimensional strain in patients with EF<35%: Insights for the hemodynamic burdenP668Ability of 99mTc-DPD scintigraphy to predict conduction disorders requiring permanent pacemaker in patients with transthyretin-related cardiac amyloidosisP669Provocation of left ventricular outflow tract obstruction using nitrate inhalation in hypertrophic cardiomyopathy: relation to electromechanical delayP670Could echocardiographic features differentiate Fabry cardiomyopathy from sarcomeric forms of hypertrophic cardiomyopathy?P671Pregnancy is well tolerated in women with arrhythmogenic right ventricular cardiomyopathy P672Glycogen storage cardiomyopathy (PRKAG2): do particular echocardiography findings in established and advanced techniques are helpful in suggesting the diagnosis?P673Improvement of arterial stiffness and myocardial deformation in patients with poorly controlled diabetes mellitus type 2 after optimization of antidiabetic medication

2016 ◽  
Vol 17 (suppl 2) ◽  
pp. ii130-ii136
Author(s):  
N. Kubota ◽  
J. Petrini ◽  
A. Gonzalez Gomez ◽  
DS. Sorysz ◽  
JM. Monteagudo Ruiz ◽  
...  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Aortic Valve ◽  
Mitral Regurgitation ◽  
Aortic Stenosis ◽  
Right Ventricular ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Reverse Remodeling ◽  
Ventricular Mechanics

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.

scholarly journals The role of three dimensional transeosephageal echocardiography in predicting the effect of cardiac resynchronization therapy on mitral regurgitation in patients with low ejection fraction heart fail

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
A Demirtola ◽  
TS Tan ◽  
A Mammadli ◽  
IM Akbulut ◽  
I Dincer
Keyword(s):  
Heart Failure ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Posterior Leaflet ◽  
Resynchronization Therapy ◽  
Significant Difference

Abstract Funding Acknowledgements Type of funding sources: None. Purpose Cardiac resynchronization therapy (CRT) has  a positive effect on the improvement of functional mitral regurgitation in patients with low ejection heart failure. However geometric changes in the mitral valve apparatus, subvalvular structures and their contribution to  the improvement of mitral regurgitation after CRT have not  been clearly defined. The aim of our study was to evaluate the geometric parameters of mitral valve apparatus measured with 3Dimensional (3D) transesophageal echocardiography (TEE) before CRT implantation and to determine the parameters predicting the improvement of mitral regurgitation after CRT. Methods Thirty patients with moderate or severe mitral regurgitation with low EF heart failure planned for CRT implantation and had an indication for TEE were included in the study. Effective regurgitant orifice (ERO) and regurgitant volume (RV) measurements were performed before CRT implantation. Detailed quantitative measurements of mitral valve were done from recorded images by 3D TEE. ERO, RV measurements were repeated to evaluate mitral regurgitation at the end of 3rd month. Results There were no significant changes in left ventricular EF and left ventricular diameters at the end of 3rd month, whereas ERO and RV values were decreased. A statistically significant difference was found in  posterior leaflet angle between mitral regurgitation responder and non-responder groups.  (28,93 ± 8,41 vs 41,25 ± 10,90, p = 0,006). Conclusion Heart failure patients with moderate or severe functional mitral regurgitation who underwent CRT implantation were found to have lower posterior leaflet angle measured by 3D TEE in the patient group whose mitral regurgitation improved after CRT. Abstract Figure.

P1809Impact of mitral regurgitation on clinical outcome in patients with cardiac sarcoidosis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
Y Yoshikazu ◽  
H Kimura ◽  
H Noumi ◽  
H Tsuchiya ◽  
T Hasegawa ◽  
...  
Keyword(s):  
Heart Failure ◽  
Clinical Outcome ◽  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Cardiac Event ◽  
Ventricular Remodeling ◽  
Cardiac Sarcoidosis ◽  
Left Ventricular ◽  
Volume Index ◽  
Cardiac Resynchronization

Abstract Background Mitral regurgitation (MR) is sometimes observed in cardiac sarcoidosis (CS), and might be related to worsening heart failure. However, mechanism and clinical significance of MR associated with CS remains undetermined. Methods We retrospectively analyzed consecutive 51 CS patients, and identified 16 patients with moderate to severe MR evaluated by quantitative echocardiography. According to the assessment of coaptation point and tenting height, main mechanisms of the 16 patients with MR were classified into prolapse (P) in 5, and tethering in 11 (T). Prednisolone was started from 30 mg/day, gradually tapered over a period of 6 months to a maintenance dose of 5 to 10 mg/day and continued a lifetime. Results At the first visit, patients with MR showed higher incidence of NYHA class IV heart failure as compared to those without MR (56 vs. 9%, p<0.001). Abnormal uptake of fluorine-18 fluorodeoxyglucose in the papillary muscle was more frequent in patients with MR than those without MR (63% vs. 23%, p<0.05). Patients with tethering MR showed higher incidence of complete atrioventricular block (T: 74% vs. P: 40% vs. without MR: 31%, p<0.05), significantly reduced left ventricular (LV) ejection fraction (T: 33±7% vs. P: 52±9% vs. without MR: 52±16%, p<0.001) and increased LV end-diastolic volume index (T: 100±52ml/m2 vs. P: 66±23ml vs. without MR: 62±21ml, p<0.001). During the mean follow-up of 108 months, cardiac-event free survival was significantly worse in patients with tethering MR as compared to the other patients (log-rank; 11.7, p<0.001). Six of the 11 patients with tethering MR received cardiac resynchronization therapy, and then did not experience further hospitalization due to decompensated heart failure for at least 2 years. Multivariate analysis identified tethering MR as an independent predictor of cardiac event (HR: 6.7, p<0.05). Conclusions MR associated with CS has variety of mechanisms including prolapse, tethering and inflammation of the LV papillary muscle, and may be related to ventricular remodeling and poor clinical outcome.

scholarly journals P912 Echocardiographic analysis of acute effects after treatment of functional mitral regurgitation by percutaneous mitral annuloplasty

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
S Stoebe ◽  
K Kreyer ◽  
D Lavall ◽  
U Laufs ◽  
A Hagendorff
Keyword(s):  
Mitral Regurgitation ◽  
Peak Power ◽  
Power Index ◽  
Left Ventricular ◽  
Functional Mitral Regurgitation ◽  
Acute Effects ◽  
Cardiac Efficiency ◽  
Mitral Annuloplasty ◽  
Vena Contracta ◽  
Lv Remodeling

Abstract Background Secondary or functional mitral regurgitation (FMR) is associated with increased morbidity and mortality, especially in heart failure patients, patients with many comorbidities and/or in the elderly. Previous studies about percutaneous mitral annuloplasty have shown evidence for long-term reduction of degree of FMR severity and left ventricular (LV) remodeling. In comparison to previous studies the present study did focus on the echocardiographic analysis of acute effects after percutaneous mitral annuloplasty (PMA). Methods Transthoracic echocardiography (TTE) has been performed in 30 patients with moderate or severe FMR before and after (± 3.5 days) percutaneous mitral annuloplasty (Carillon®). LV volumes and LV ejection fraction and semi-quantitative parameters, e.g. tenting Area, vena contracta and velocity-time-integral ratios of transmitral inflow and LV outflow (VTIMV/VTILVOT) were assessed. The assessment of the regurgitant volume (RV), regurgitant fraction (RF) and effective regurgitant orifice area (EROA) was quantitatively performed by the PISA method. RV and RF was also estimated by subtracting the effective forward stroke volume (SVLVOT, SVRVOT) from the total stroke volume (SVLV planimetry). Further, parameters of left ventricular contractility, e.g. global longitudinal strain (GLS), cardiac efficiency, peak power index etc., were assessed. Results a postinterventional reduction of degree of FMR severity was achieved in 25/30 patients (83%). In average, RF was reduced from 49 ± 11% to 34 ± 13% (p &lt; 0.001), RV from 33 ± 13ml to 25 ± 12ml (p &lt; 0.001) and EROA from 0.24 ± 0.1cm2 to 0.19 ± 0.1cm2 (p &lt; 0.05). Significant decreases were also noted for vena contracta and VTIMV/LVOT. DiamMV (long axis) was reduced from 3.6 ± 0.6cm to 3.4± 0.6cm (p &lt; 0.001), DiamMV (4-chamber view) from 3.9 ± 0.5cm to 3.6 ± 0.6cm (p &lt; 0 .05). In patients with sinus rhythm (SR) or pacemacer stimulation a considerably higher reduction of RF was observed (ΔRF 20 ± 12%) in comparison to patients with atrial fibrillation (ΔRF 10 ± 12%). No significant changes were obtained for parameters of LV remodeling and LV contractility, e.g. GLS, cardiac efficiency, peak power index. Conclusion A reduction of degree of FMR severity can be achieved by percutaneous mitral annuloplasty (PMA) and acute effects can be quantitatively assessed by echocardiography. Further data are necessary to evaluate whether these acute effects will maintain in follow-up investigations. Abstract P912 Figure. Fig1-Reduction of RF and VC after PMA

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