Abstract 2265: Injection of a Biomaterial Polymer Results in Reverse Remodeling of Displaced Papillary Muscles and Reduction in Acute Ischemic Mitral Regurgitation

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Judy Hung ◽  
Jorge Solis ◽  
J. L Guerrero ◽  
Gavin Braithwaite ◽  
Orhun K Muratoglu ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Mitral Annulus ◽  
Left Ventricular ◽  
Ischemic Mitral Regurgitation ◽  
Reverse Remodeling ◽  
Inert Material ◽  
Stroke Work ◽  
Polymer Injection ◽  
Vena Contracta ◽  
Lv Remodeling

Ischemic mitral regurgitation (IMR) relates to papillary muscle (PM) displacement caused by left ventricular (LV) distortion. We tested the hypothesis that displaced PMs can be repositioned by injection of polyvinyl-alcohol (PVA) polymer, a biologically inert material specially formulated to produce an encapsulated, stable, resilient gel once injected into the myocardium. The aim is to alter the compliance of infarcted myocardium and realign the displaced PMs. Methods : 9 sheep underwent circumflex branch ligation to produce acute IMR. PVA polymer was then injected by echo guidance into the myocardium underlying the infarcted PM. Hemodynamic data, EF, Elastance (Emax), preload-recruitable stroke work (PRSW), relaxation constant tau, and echo data were measured post IMR and post PVA injection. Results : One animal died after coronary ligation and 2 had no IMR; MR was moderate in the remaining 6. PVA injection decreased MR vena contracta from 5±0.4mm to 2±0.7mm (p<0.0001), with decreased tethering distance from infarcted PM to mitral annulus (27±4 to 24±4mm, p<0.001). PVA injection did not significantly decrease EF (43±6% vs 37±4%, post IMR vs post PVA, p=ns), Emax (1.5±0.53 vs 1.6±0.42), PRSW (33±12 vs 31±5) or tau (63±49 ms vs 70±25 ms). Conclusions : PVA polymer injection can acutely reverse LV remodeling to reposition displaced PMs and decrease IMR without adverse effects on LV systolic or diastolic function. This new approach (to alter pathologic anatomy) offers an alternative for relieving IMR by correcting PM position, thus relieving tethering that causes IMR.

scholarly journals Mild Ischemic Mitral Regurgitation: Is Revascularization Enough for Every Patient?

2020 ◽  
Vol 23 (3) ◽  
pp. E370-E375
Author(s):  
Hunbo Shim ◽  
Ji-won Hwang ◽  
Won-Sang Chung ◽  
Chun Ki Kim ◽  
Byung Jo Park ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Mitral Regurgitation ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Mitral Annulus ◽  
Left Ventricular ◽  
Ischemic Mitral Regurgitation ◽  
Reverse Remodeling ◽  
Systolic Volume ◽  
One Year

Background: The progress of mild ischemic mitral regurgitation (MR) after isolated coronary artery bypass is not clear. We aimed to determine the proportion of patients with mild ischemic MR undergoing isolated coronary artery bypass grafting (CABG) presenting with regression of or persistent MR one year after CABG and to identify the significantly different echocardiographic variables between regressing and persistent MR. Methods: Sixty-three patients with preoperative mild ischemic MR were categorized into an MR-regression or an MR-persistence group one year after isolated CABG. The echocardiographic indices, indicating mitral leaflet configuration and remodeling of the left ventricle (LV), were measured before and one year after the surgery. Results: One year after CABG, MR regressed in 60% (38/63) and persisted in 40% (25/63) of the patients. The left ventricular diameter, volume, and sphericity and anteroposterior diameter of the mitral annulus improved only in the MR-regression group, while the ejection fraction improved in both groups (47.7% ± 12.4% from 40.1% ± 11.3%, P < .001 in the regression group and 43.2% ± 14.0% from 39.3% ± 11.6%, P = .035 in the persistence group). A >15% decrease in the LV end-systolic volume was noted more frequently in the MR-regression group (60.5% versus 30%, P = .027). The leaflet angle did not show asymmetry or significant changes in both groups. Conclusions: Isolated CABG improved mild MR in most patients with mild ischemic MR. These patients showed greater reverse remodeling after revascularization than the patients with persistent MR after isolated CABG. Additional tests, which can predict LV reverse remodeling, are needed to predict persistent MR.

Abstract 121: Improvement in Functional Mitral Regurgitation After Isolated Aortic Valve Replacement for Aortic Insufficiency

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Griffin Boll ◽  
Frederick Y Chen
Keyword(s):  
Aortic Valve ◽  
Mitral Regurgitation ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Aortic Insufficiency ◽  
Left Ventricular ◽  
Functional Mitral Regurgitation ◽  
Reverse Remodeling ◽  
Lv Remodeling

Objective: Aortic insufficiency (AI) can lead to left ventricular (LV) remodeling characterized by dilation and increased LV mass. This remodeling can cause altered mitral valve coaptation and functional mitral regurgitation (FMR). While there is growing evidence that aortic valve replacement (AVR) for aortic stenosis promotes sufficient ventricular reverse remodeling that FMR improves or resolves, this effect is not well characterized for patients with AI. Methods: All cases of AVR for AI that were performed at a single center between January 2003 and December 2015 were reviewed. Cases with any concomitant procedures, any degree of aortic stenosis, any evidence of ischemic etiology, absence of mitral regurgitation, or significant primary mitral pathology were excluded from analysis. The primary outcome was change in FMR after isolated AVR. Secondary outcomes included change in LV ejection fraction (EF), left atrial (LA) dimension, and change in end-diastolic and –systolic LV dimensions. Two-tailed paired t-test was used to evaluate for difference between the two time points. Results: Over the course of 13.4 years, 31 cases of isolated aortic valve replacement for pure aortic insufficiency with concurrent functional mitral regurgitation were identified. 54.8% (17/31) of cases had some evidence of bacteremia or aortic vegetations at time of surgery, with 41.9% (13/31) of cases completed urgently. Postoperatively, FMR was improved in 74.2% (23/31) of the patients, and decreased by a mean 1.0 ± 0.8 grades (1.6 ± 0.8 vs 0.6 ± 0.7, p < 0.001). There was no significant change in LV EF (50.5 ± 13.4 vs. 50.2 ± 12.9, p = 0.892) or LA dimension (42.5 ± 7.2 vs 40.7 ± 5.9, p = 0.341), but there were significant reductions in the dimension of the LV at end-diastole (56.7 ± 7.1 vs 47.7 ± 8.5, p < 0.001) and end-systole (38.5 ± 9.7 vs 34.0 ± 8.3, p = 0.011). Conclusions: Significant reduction in ventricular size and subsequent improvement in functional mitral regurgitation is expected after isolated aortic valve replacement for pure aortic insufficiency.

scholarly journals Mechanistic Insights Into Posterior Mitral Leaflet Inter-Scallop Malcoaptation During Acute Ischemic Mitral Regurgitation

Circulation ◽  
2002 ◽  
Vol 106 (12_suppl_1) ◽  
Author(s):  
David T. Lai ◽  
Frederick A. Tibayan ◽  
Truls Myrmel ◽  
Tomasz A. Timek ◽  
Paul Dagum ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
High Speed ◽  
Lateral Displacement ◽  
Three Dimensional ◽  
Mitral Annulus ◽  
Left Ventricular ◽  
Ischemic Mitral Regurgitation ◽  
Posterior Leaflet ◽  
Mitral Leaflet ◽  
Posterior Mitral Leaflet

Background Three-dimensional dynamics of the 3 individual scallops within the posterior mitral leaflet during acute ischemic mitral regurgitations have not been previously measured. Methods Radiopaque markers were sutured to the mitral annulus, papillary muscle tips, and leaflet edges in 13 sheep. Immediately postoperatively, under open-chest conditions, 3-D marker coordinates were obtained using high-speed biplane videofluoroscopy before and during echocardiographically verified acute ischemic mitral regurgitation produced by occlusion of the left circumflex coronary artery. Results During acute ischemic mitral regurgitation, at end systole, the anterolateral edge of the central scallop was displaced 0.8±0.9 mm laterally and 0.9±0.6 mm apically away from the anterolateral scallop; such displacement correlated with lateral displacement of the lateral annulus (R 2 =0.7, SEE=0.7 mm, P <0.001) and movement of the right lateral annulus away from the nonischemic anterior papillary tip (R 2 =0.6, SEE=0.8 mm, P =0.002), respectively. End-systolic displacement of the posteromedial edge of the central scallop was 1.4±0.9 mm anteriorly and 0.9±0.6 mm laterally away from the posteromedial scallop, corresponding to anterior displacement of the mid-lateral annulus (R 2 =0.5, SEE=1.0 mm, P <0.001). Conclusions Malcoaptation of the scallops within the posterior leaflet during acute left ventricular ischemia is a novel observation. The primary geometric mechanism underlying scallop malcoaptation in acute ischemic mitral regurgitation was annular dilatation, which hindered leaflet coaptation by drawing the individual scallops apart. These findings support the use of annular reduction in the repair of ischemic mitral regurgitation and also suture closure of prominent subcommissures between posterior leaflet scallops.

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

Abstract 1104: Polymer Injection Therapy to Reverse Remodel the Papillary Muscles: Efficacy in Reducing Mitral Regurgitation in a Chronic Ischemic Model

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Jorge Solis-Martin ◽  
Benjamin Johnson ◽  
J. Luis Guerrero ◽  
Mark Handschumacher ◽  
Suzanne Sullivan ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Ventricular Remodeling ◽  
Systolic Function ◽  
Left Ventricular Remodeling ◽  
Left Ventricular ◽  
Ischemic Mitral Regurgitation ◽  
Papillary Muscles ◽  
Vena Contracta ◽  
Left Ventricle Remodeling

Ischemic mitral regurgitation (IMR) relates to displacement of the papillary muscles from ischemic ventricular distortion. Recurrent IMR is frequent after annuloplasty, particularly when left ventricular remodeling continues to progress. Our hypothesis is that repositioning of the papillary muscles can be achieved by injection of polyvinyl-alcohol (PVA) polymer into the myocardium, in chronic MR with great left ventricle remodeling. Methods : we studied 8 sheep underwent ligation of circumflex branches to produce chronic ischemic MR over eight weeks. Once MR developed, PVA was injected into the myocardium underlying the infarcted PM. 2D and 3D echocardiograms were used pre infarct (baseline), pre PVA (Chronic MR) and post PVA. Hemodynamic data were obtained Results: One animal died, in the remaining 7 moderate MR developed. With PVA, the MR decreased significantly from moderate to trace-mild (vena contracta: 5.3 ± 0.9 mm vs 2.3 ± 0.9 mm, post MR vs post PVA; p<0.001). This was associated with a decrease in infarcted papillary muscle-to-mitral annulus tethering distance (33.1 ± 4.6 to 27.4±4.1 mm, post MR vs post PVA, P<0.05), tenting volume (2.1±0.3 to 1.6±0.4 mm, post MR vs post PVA, P<0.05) and leaflet area (9.4 ± 0.8 to 8.2 ± 0.7 mm, post MR vs post PVA, P<0.04). PVA was not associated with significant decreases in LVEF (41±2 % vs 39±2 %, p=ns). Conclusions : PVA polymer injections improve coaptation and reduce remodeling chronic MR without impairing LV systolic function. This new approach offers a potential alternative for relieving ischemic mitral regurgitation by correcting papillary muscle position, thus relieving tethering that causes ischemic mitral regurgitation.

Prior Angina Reduces Ischemic Mitral Regurgitation in Patients with ST-Elevation Myocardial Infarction, Role of Ischemic Preconditioning

2021 ◽  
Author(s):  
Ramime Ozel ◽  
Pelin Karaca Ozer ◽  
Nail Guven Serbest ◽  
Adem Atıcı ◽  
Imran Onur ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mitral Regurgitation ◽  
Ischemic Preconditioning ◽  
Troponin T ◽  
Left Ventricular ◽  
Ischemic Mitral Regurgitation ◽  
Proximal Isovelocity Surface Area ◽  
Lv Remodeling ◽  
St Elevation ◽  
Regurgitant Orifice Area

Abstract BackgroundMitral regurgitation may develop due to left ventricular (LV) remodeling within 3 months following acute myocardial infarction (AMI) and is called ischemic mitral regurgitation (IMR). Ischemic preconditioning (IPC) has been reported as the most important mechanism of the association between prior angina and the favorable outcome. The aim of this study was to investigate the effect of prior angina on the development and severity of IMR at 3rd month in patients with ST elevation MI (STEMI).MethodsFourty five (45) patients admitted with STEMI and at least mild IMR, revascularized by PCI were enrolled. According to presence of prior angina within 72 hours before STEMI, patients were then divided into two groups as angina (+) (n:26; 58%) and angina (-) (n:19; 42%). All patients underwent 2D transthoracic echocardiography at 1st, 3rd days and 3rd month. IMR was evaluated by proximal isovelocity surface area (PISA) method: PISA radius (PISA-r), effective regurgitant orifice area (EROA), regurgitant volume (Rvol). LV ejection fraction (EF %) was calculated by Simpson’s method. High sensitive troponin T (hs-TnT), creatine phosphokinase myocardial band (CK-MB) and N-terminal pro-brain natriuretic peptid (NTpro-BNP) levels were compared between two groups.ResultsAlthough PISA-r, EROA and Rvol were similar in both groups at 1st and 3rd days, all were significantly decreased (p=0.012, p=0.007, p=0.011, respectively) and EF was significantly increased (p< 0.001) in angina (+) group at 3rd month. NTpro-BNP and hs-TnT levels at 1st day and 3rd month were similar, however CK-MB level at 3rd month was found to be significantly lower in the angina (+) group (p=0.034).ConclusionAt the end of the 3rd month, it was observed that the severity of IMR evaluated by PISA method was decreased and EF increased significantly in patients who defined angina within 72 hours prior to STEMI, suggesting a relation with IPC.

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