Abstract 2663: How Do Cardiologists and Cardiothoracic Surgeons Treat Asymptomatic Mitral Regurgitation in Clinical Practice? An International Survey

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Kevin M Harris ◽  
Catherine A Pastorius ◽  
Eileen M Harwood ◽  
Sue Duval ◽  
Alan T Hirsch ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Mitral Regurgitation ◽  
Practice Patterns ◽  
Geographical Location ◽  
Lv Function ◽  
Asymptomatic Patients ◽  
The Usa ◽  
Asymptomatic Individuals ◽  
Regurgitant Orifice Area ◽  
Cardiac Surgeons

Background: Severe mitral regurgitation (MR) is known to be associated with adverse clinical outcomes. Thus, consensus-derived, evidence-based practice standards (e.g., ACC/AHA Guidelines for Management of Valvular Heart Disease) have been published. Yet, no data exist to describe whether physicians follow such standards in clinical practice for asymptomatic pts with MR. Methods: A random sample of cardiovascular specialists were surveyed by email and asked to complete 26 items that encompassed MR-related practice patterns. Results: 1035 physicians completed the survey (68% response rate) and the sample included adult cardiologists (95%) and cardiac surgeons (5%) who practice in the USA (84%), Canada (6%), and other nations (10%). When asked ``Do you refer asymptomatic patients with severe MR and normal LV function for MV repair?”, 28% responded yes/almost always, and 11% responded no/ rarely. There was geographic & specialty-dependent variation in practice (Table ). Patient referral for mitral surgery was based on risk markers, such as atrial fibrillation (18%) and pulmonary hypertension (17%) and anatomic factors (e.g., flail valve, 18%) and clinical variables (e.g., increased likelihood of repair, 19%). Most physicians (65%) use medications to delay progression of MR, with ACE-inhibitors utilized by 57%. Isolated posterior prolapse repair was repaired successfully >85% at their hospital by 61% (60% for cardiologists vs. 82% for surgeons, p=0.004). 28% of respondents almost always quantitate MR using effective regurgitant orifice area, while 30% rarely or never do so. Conclusions: Cardiologists frequently refer asymptomatic MR patients for mitral reparative surgery, but referral is often prompted by factors beyond those included in current guidelines. Practice patterns vary by physician type and by geographical location. Medications are frequently used to treat asymptomatic individuals with MR, in the absence of documented evidence of efficacy.

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 P903 Myocardial work in moderate to severe aortic versus primary mitral regurgitation

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M Bouziane ◽  
R E Dulgheru ◽  
S Marchetta ◽  
S Khaddi ◽  
F Cozza ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Lv Function ◽  
Severe Aortic Regurgitation ◽  
Asymptomatic Patients ◽  
Work Index ◽  
Valvular Stenosis ◽  
Primary Mitral Regurgitation ◽  
Global Work

Abstract Funding Acknowledgements None OnBehalf None BACKGROUND Myocardial work is an emerging non-invasive technic based on echocardiographic pressure-strain loops that assess left ventricular (LV) function. The method was studied in a large variety of pathologies, but its role in the assessment of valvular regurgitations is still unknown. PURPOSE To compare myocardial work indices in moderate and severe aortic and primary mitral regurgitation. METHODS Seventy-eight patients with moderate and severe aortic regurgitation (AR) or primary mitral regurgitation (MR) and preserved LV ejection fraction (LVEF > 50%) were retrospectively analyzed.. Patients with significant valvular stenosis were excluded. Demographic, clinical and echocardiographic data, including LV global longitudinal strain (GLS) and myocardial work indices, were assessed. RESULTS The mean age was 58 ± 14 years, and 46 patients (59%) were men. Thirty seven patients had moderate or severe AR and 41 patients had moderate or severe MR. The two groups were homogeneous in terms of demographic and clinical data, except for age. As expected, diastolic blood pressure was lower in patients with AR compared to MR group (67 ± 8 mmHg vs. 73 ± 10 mmHg, p = 0,003), patients with MR had a higher LVEF compared to AR group (63 ± 6% vs 59 ± 6%, p = 0,03), and a higher left atrial indexed volume (53 ± 16ml/m² vs 34 ± 12ml/m², p < 0.0001). Overall, GLS, myocardial work index (GWI) and myocardial constructive work (GCW) were significantly lower in patients with moderate or severe AR compared to MR ( -18,1 ±3% vs -21,3 ±3,3%, p < 0,0001; 1849 ± 393 vs 2285 ± 499, p < 0,0001; and 2194 ± 395 vs 2576 ± 594, p = 0,003, respectively). Global wasted work (GWW) and global work efficiency (GWE) were similar. When comparing only asymptomatic patients, results were similar, with higher GLS, GWI and GCW in moderate to severe MR vs. AR (-22,9 ± 3,4 vs.-18,4 ± 3,4%, p <0,001; 2446 ± 570 vs. 1927 ± 338, p = 0.001 and 2767 ± 688 vs. 2236 ± 377, p = 0.005). Interestingly, when comparing asymptomatic patients with a LVEF > 50% for AR, and LVEF > 60% for MR, GWI and GCW were significantly lower in MR group, despite higher GLS values (1852 ± 398 vs. 2322 ± 527, p < 0.001; 2194 ± 400 vs. 2615 ± 638, p = 0.005; -22,1 ± 3,3% vs. -18,2 ± 2,9, p < 0.001). CONCLUSION Patients with moderate to severe MR have higher values of GLS, global work index and global constructive myocardial work. This could translate into the fact that in moderate or severe MR, the myocardium develops a higher amount of work than in AR, maybe to account for the loss of stroke volume into the left atrium. In asymptomatic moderate to severe MR with LVEF > 60%, LV myocardium develops less work than in moderate to severe AR with a LVEF > 50%, suggesting maybe a compensated state.

scholarly journals Prevalence of Cam and Pincer Deformities in the X-Rays of Asymptomatic Individuals

2017 ◽  
Vol 2017 ◽  
pp. 1-6 ◽  
Author(s):  
Steffen Thier ◽  
Daniel Gerisch ◽  
Christel Weiss ◽  
Stefan Fickert ◽  
Alexander Brunner
Keyword(s):  
Clinical Practice ◽  
Femoroacetabular Impingement ◽  
X Rays ◽  
Femoral Offset ◽  
Center Edge ◽  
Asymptomatic Patients ◽  
Male Patients ◽  
Asymptomatic Individuals ◽  
Actual Prevalence ◽  
Unselected Cohort

Objective. The presence of radiological signs of femoroacetabular impingement (FAI) is not necessarily associated with symptoms. Hence, the prevalence of cam and pincer deformities in the overall population may be underestimated. The purpose of this study was to screen an unselected cohort of people without hip symptoms for native radiological signs of cam and pincer deformities to determine their actual prevalence. Materials and Methods. 110 asymptomatic patients had AP pelvis X-rays and cross-table hip X-rays performed. We evaluated the images for the presence of cross-over signs and measured lateral center edge (LCE) angles, alpha angles (α-angles), and femoral offset ratios. Results. Positive cross-over signs were seen in 34%; LCE angles > 40° in 13%; and femoral offset ratios < 0.18 in 43%. In 41% of the patients, α-angles were >50°. Male patients showed significantly higher α-angles, lower offset ratios, and a higher prevalence of cross-over signs. In contrast, female patients had significantly higher LCE angles. Conclusion. According to our data, radiological signs of cam and pincer deformities are common in asymptomatic people. In clinical practice, patients presenting with hip pain and radiological signs of FAI should undergo further diagnostic evaluation. However, in asymptomatic patients, no further evaluation is recommended.

Abstract 2260: Asymptomatic Patients with Severe Mitral Regurgitation and either Atrial Fibrillation or Pulmonary Hypertension Benefit from an Early Surgical Strategy

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Fabien Chenot ◽  
Patrick Montant ◽  
Bertin Nkodia Nsalampa ◽  
Céline Goffinet ◽  
Anne-Catherine Pouleur ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Hypertension ◽  
Mitral Regurgitation ◽  
Lv Function ◽  
Optimal Timing ◽  
Mitral Repair ◽  
Valvular Surgery ◽  
Asymptomatic Patients ◽  
Group I ◽  
Group Ii

Background. Degenerative mitral regurgitation (MR) is the second most frequent valvular heart disease in industrialized countries. Although there is consensus that valvular surgery should be advised in symptomatic patients (pts) with severe MR and in those with reduced LV function, there is persisting controversy regarding the optimal timing of intervention in asymptomatic pts with only atrial fibrillation or pulmonary hypertension, as shown by the corresponding class IIa recommendation in the recent guidelines. Methods. To test if asymptomatic pts with severe degenerative MR and either atrial fibrillation, pulmonary hypertension or both benefit from early surgery, the outcomes of 69 such pts (70 ± 12 years; 64% males) diagnosed by 2D-echo between 1990 and 2001 were analyzed. Pts with a LV ejection fraction below 60% or telesystolic diameter above 45 mm were not included. Group I comprised 46 pts undergoing mitral repair (within 3 months after diagnosis). Group II comprised 23 pts initially treated conservatively. Results. During follow-up, 3 Group II pts needed mitral surgery. Indications for surgery were according to class I current guidelines. Adjusted 10-year overall survival was better in Group I than in Group II pts (74 ± 8%, 11 ± 7%, p<0.0001). Similarly, adjusted 10-year cardiac event free survival, including the need for (redo) surgery was better in Group I than in Group II pts (72 ± 7%, 10 ± 10%, p<0.0001). Conclusion. Asymptomatic pts with severe MR complicated by either atrial fibrillation, pulmonary hypertension or both, clearly benefit from an early interventional strategy and should probably be operated on as soon as possible.

scholarly journals Assessment of global longitudinal strain by speckle tracking echocardiography in patients with severe primary mitral regurgitation

2021 ◽  
Vol 35 ◽  
pp. 19-25
Author(s):  
Nguyen Mai Huong ◽  
Vu Quynh Nga ◽  
Nguyen Quang Tuan
Keyword(s):  
Mitral Regurgitation ◽  
Speckle Tracking ◽  
Longitudinal Strain ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Lv Function ◽  
Optimal Timing ◽  
Lv Dysfunction ◽  
Asymptomatic Patients ◽  
Primary Mitral Regurgitation

Background: In asymptomatic patients with severe primary mitral regurgitation (PMR), early detection of left ventricular (LV) dysfunction indicates the optimal timing of mitral valve surgery and predictes impaired postoperative LV function. Objectives: Evaluation long longitudinal strain by Speckle Tracking in Patients with Severe Primary Mitral Regurgitation Methods and results: 35 preoperative patients with severe PMR and 25 age-matched healthy subjects at Hanoi Heart Hospital from June 2018 to September 2019. Patients with PMR had longitudinal dysfunction by comparison with controls, although EF were similar. Mean global myocardial longitudinal strain (GLS avg) has a linear correlation with FS (r² = 0.127, p <0.05) and EF biplane (r² = 0.216, p <0.005). Conclusion: Longitudinal LV deformation assessed by speckle tracking can detect subclinical LV dysfunction and predict impaired postoperative LV function in asymptomatic patients with severe PMR.

P763 Asymptomatic severe organic mitral regurgitation: Does the anatomic substrate affect the functional response to supine ergometry?

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
I Armenis ◽  
M Kontonika ◽  
M Marinou ◽  
A Motsi ◽  
G Athanassopoulos
Keyword(s):  
Decision Making ◽  
Mitral Regurgitation ◽  
Volume Effect ◽  
Left Ventricular ◽  
Rate Pressure Product ◽  
Lv Function ◽  
Grey Zone ◽  
Asymptomatic Patients ◽  
History Of

Abstract Asymptomatic severe mitral regurgitation (MR) remains a grey zone in decision making for intervention. The predictive role of left ventricular (LV) functional reserve remains uncertain and the potential role of the anatomical substrate has not been elucidated. Aim of the study was to compare the LV function and hemodynamic changes during supine ergometry (Ex) in asymptomatic severe MR between myxomatous (Myx) and degenerative (Deg) substrate. Methods 32 patients with Deg (male M/female F = 15/17) and 19 with MyxS (M/F = 7/12) were studied at rest (R) and Ex. We estimated heart rate (HR), rate-pressure product (HRxBP), LV endsystolic (LVESV)- enddiastolic volume (LVEDV), ejection fraction (EF), LV longitudinal strain (GLS), transmitral E wave (E), ratio E/e, peak tricuspid gradient (TrPG). To adjust for a potential volume effect on GLS, GLS was normalized to volumes and respective ratios were considered (GLS/LVESV, GLS/LVEDV). Parameters were measured at R and Ex and % changes were calculated : %d (Ex-R). Results Myx and Deg had similar chronotropic reserve and HR-BP. Myx were younger, and during Ex they had a greater LVEDV, a greater EF. a smaller E/e, and a smaller TrPG compared with Deg. Myx group, despite having a better GLS both at R and Ex, revealed a smaller % GLS improvement from R to Ex (15% vs 32%). The normalized GLS/LVESV and GLS/LVEDV were similar at R between Myx and Deg, but they showed a smaller improvement during Ex in Myx. (table-results) Conclusion Despite similar severity of MR, asymptomatic patients with MyxS revealed a different dynamic profile during Ex compared with Deg. The underlying MV substrate in organic MR might be related with a different LV adaptation to volume loading combined with subsequent uneven stress induced hemodynamic response. The disparities found might have implications both in the nature history of MR as well as in the decision making for intervention. RESULTS Parameter DegS MyxS p Age(years) 65 ± 11 44 ± 12 &lt;0. 001 LVEDV Ex (ml) 85 + 32 117 ± 41 =0. 007 EF Ex(%) 65 + 7 69 ± 8 =0. 05 GLS R(%) -17.6 ± 6.8 -22.2 ± 4.3 =0. 04 GLS Ex(%) -22 ± 4 -25.0 ± 5.7 =0. 05 % d (Ex-R) LV strain/endsystolic volume 0.84 ± 0.4 -0.54 ± 0.5 =0. 05 E/e" Ex 16.7 ± 8.8 9.7 ± 2.2 =0. 004 TrPG Ex(mmHg) 59 ± 11 44 ± 11 =0. 0001

Overview of Current Approaches to Aural Rehabilitation for Adults With Cochlear Implants

2020 ◽  
Vol 5 (5) ◽  
pp. 1175-1187
Author(s):  
Rachel Glade ◽  
Erin Taylor ◽  
Deborah S. Culbertson ◽  
Christin Ray
Keyword(s):  
Health Care ◽  
Clinical Practice ◽  
Cochlear Implants ◽  
Practice Patterns ◽  
The United States ◽  
Care Providers ◽  
Aural Rehabilitation ◽  
Starting Point ◽  
Clinical Models ◽  
Hearing Health

Purpose This clinical focus article provides an overview of clinical models currently being used for the provision of comprehensive aural rehabilitation (AR) for adults with cochlear implants (CIs) in the Unites States. Method Clinical AR models utilized by hearing health care providers from nine clinics across the United States were discussed with regard to interprofessional AR practice patterns in the adult CI population. The clinical models were presented in the context of existing knowledge and gaps in the literature. Future directions were proposed for optimizing the provision of AR for the adult CI patient population. Findings/Conclusions There is a general agreement that AR is an integral part of hearing health care for adults with CIs. While the provision of AR is feasible in different clinical practice settings, service delivery models are variable across hearing health care professionals and settings. AR may include interprofessional collaboration among surgeons, audiologists, and speech-language pathologists with varying roles based on the characteristics of a particular setting. Despite various existing barriers, the clinical practice patterns identified here provide a starting point toward a more standard approach to comprehensive AR for adults with CIs.

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