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

Heart ◽  
2020 ◽  
Vol 106 (22) ◽  
pp. 1719-1725
Author(s):  
Victor Kamoen ◽  
Simon Calle ◽  
Marc De Buyzere ◽  
Frank Timmermans
Keyword(s):  
Mitral Regurgitation ◽  
Left Ventricular ◽  
Regurgitant Fraction ◽  
Individual Patient Level ◽  
Depth Analysis ◽  
Patients With Heart Failure ◽  
Secondary Mitral Regurgitation ◽  
Intervention Trials ◽  
Therapeutic Decision Making ◽  
Ventricular Dimension

Recent randomised percutaneous mitral intervention trials in patients with heart failure with secondary mitral regurgitation (SMR) have yielded contrasting results. A ‘relative load’ or ‘proportionality’ conceptual framework for SMR has been proposed to partly explain the disparate results. The rationale behind the framework is that SMR depends on the left ventricular dimension and not vice versa. In this review, we provide an in-depth analysis of the proportionality parameters used in this framework and also discuss the regurgitant fraction. We also consider haemodynamic observations in SMR that may affect the interpretation and comparisons among proportionality parameters. The conclusion is that the proportionality concept remains hypothetical and requires prospective validation before envisaging its use at individual patient level for risk stratification or therapeutic decision-making.

The Results of the Use of Angiotensin Receptor Inhibitors and Neprilisin in Secondary Functional Mitral Regurgitation in Outpatient Practice

2020 ◽  
Vol 75 (5) ◽  
pp. 514-522
Author(s):  
Alexey S. Ryazanov ◽  
Konstantin I. Kapitonov ◽  
Mariya V. Makarovskaya ◽  
Alexey A. Kudryavtsev
Keyword(s):  
Heart Failure ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Effective Area ◽  
Left Ventricular ◽  
Functional Mitral Regurgitation ◽  
Angiotensin Receptor ◽  
Optimal Drug ◽  
Patients With Heart Failure ◽  
Valsartan Group

Background. Morbidity and mortality in patients with functional mitral regurgitation (FMR) remains high, however, no pharmacological therapy has been proven to be effective.Aimsto study the effect of sacubitrile/valsartan and valsartan on functional mitral regurgitation in chronic heart failure.Methods.This double-blind study randomly assigned sacubitrile/valsartan or valsartan in addition to standard drug therapy for heart failure among 100 patients with heart failure with chronic FMR (secondary to left ventricular (LV) dysfunction). The primary endpoint was a change in the effective area of the regurgitation hole during the 12-month follow-up. Secondary endpoints included changes in the volume of regurgitation, the final systolic volume of the left ventricle, the final diastolic volume of the left ventricle, and the area of incomplete closure of the mitral valves.Results.The decrease in the effective area of the regurgitation hole was significantly more pronounced in the sacubitrile/valsartan group than in the valsartan group (0.070.066against0.030.058sm2; p=0.018)in the treatment efficacy analysis, which included 100patients (100%). The regurgitation volume also significantly decreased in the sacubitrile/valsartan group compared to the valsartan group (mean difference:8.4ml; 95%CI, from 13.2 until 1.9;р=0.21). There were no significant differences between the groups regarding changes in the area ofincomplete closure of the mitral valves and LV volumes, with the exception of the index of the final LV diastolic volume (p=0.07).Conclusion.Among patients with secondary FMR, sacubitril/valsartan reduced MR more than valsartan. Thus, angiotensin receptor inhibitors and neprilysin can be considered for optimal drug treatment of patients with heart failure and FMR.

Left ventricular myocardial work in patients with secondary mitral regurgitation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
I Yedidya ◽  
R.P Lustosa ◽  
F Fortuni ◽  
P Van Der Bijl ◽  
F Namazi ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Speckle Tracking ◽  
Speckle Tracking Echocardiography ◽  
Blood Pressure Measurement ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Lv Function ◽  
Work Efficiency ◽  
Constructive Work ◽  
Secondary Mitral Regurgitation

Abstract Background Assessment of left ventricular (LV) function in patients with secondary mitral regurgitation (SMR) remains challenging because LV ejection fraction (LVEF) reflects changes in LV volume without taking into account the direction of the blood flow. LV global longitudinal strain better reflects active LV myocardial deformation but does not incorporate afterload. LV myocardial work derived from pressure-strain loops integrates speckle tracking echocardiography with non-invasive blood pressure measurement. Purpose To evaluate LV myocardial work components to better characterize LV function in patients with SMR. Methods 378 patients (72% men, median age 68 [range 60 to 74 years]) with various grades of SMR were retrospectively analysed. LV myocardial constructive work, wasted work and work efficiency were measured with speckle tracking echocardiography. Results 145 patients had mild SMR, 130 moderate SMR and 103 severe SMR. Patients with severe SMR had larger LV volumes, lower LVEF and more impaired LV GLS (Table 1). While LV constructive work was more impaired in patients with severe SMR, wasted work was lower as compared to mild SMR (Table 1). Consequently, patients with severe SMR had better myocardial work efficiency than patients with mild MR. This could reflect, the regurgitant volume which is pumped into a low pressure chamber (the left atrium) resulting in less myocardial wasted work and preservation of myocardial efficiency. Conclusion In patients with severe SMR, LVEF, LV GLS and myocardial constructive work are more impaired when compared to mild SMR. However, myocardial wasted work is lower, resulting in higher better LV myocardial work efficiency. Funding Acknowledgement Type of funding source: None

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.

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