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

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.

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A Method for the Assessment of Mitral Valve Regurgitation Grade and Severity

Open Medicine Journal ◽

10.2174/1874220302007010013 ◽

2020 ◽

Vol 7 (1) ◽

pp. 13-15

Author(s):

Reida M. El Oakley ◽

Abdelkader Almanfi

Keyword(s):

Mitral Valve ◽

Mitral Valve Regurgitation ◽

Left Ventricular ◽

Valve Regurgitation ◽

Regurgitant Volume ◽

Orifice Area ◽

Vena Contracta ◽

Severity Scores ◽

Regurgitant Orifice Area

Background: Previous grading and severity scores of MR were based on a mix of objective echocardiographic data and subjective findings such as the presence or absence of symptoms. There is a need for a grade - and a severity -score for Mitral Valve Regurgitation (MR) that is based purely on objective findings and avoids the ambiguity of labelling the same degree of MR differently according to symptoms severity and/or the underlying etiology. Methods: We reviewed published reports regarding MR severity and grades and provided a method for the assessment of MR severity and grades based purely on objective data regardless of the symptom(s) and/or underlying cause(s) of MR. Objective Echocardiographic and/or Cardiac Magnetic Resonance (CMR) findings of Vena Contracta (VC) size in cm2, Effective Regurgitant Orifice area (ERO) in cm2, Effective Regurgitant Volume (ERV) in mls/beat, and Regurgitation Fraction (RF) as a percentage of the left ventricular stroke volume, were given a score value of A, B, C or D with increasing severity, thus ranging from the mildest degree“A” to most severe “D”. Results: As summarized in Table 4, MR severity ranged between 4 “As” to 4 “Ds”. Further elaboration regarding the parameter(s) most severely affected may be added to the score value, e.g., scoring MR with a VC = 0.60 cm2 associated with EROA = 0.4cm2, ERV = 60mls and RF = 45% will be 2D (EROA and ERV) MR, thereby avoiding overlap between various degrees of MR and/or further data manipulation to make other parameters fit one grade of MR or another. Conclusion: Applying this scoring/grading system to Echocardiographic and/or CMR studies of patients with mitral valve regurgitation will enhance our endeavors to use a clear and unified language regarding MR severity without compromising the quality of Echocardiographic or CMR findings and/or reporting.

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Impact of Valve Surgery on Serum Osteopontin Levels in Patients with Mitral Regurgitation

Cardiology ◽

10.1159/000368299 ◽

2015 ◽

Vol 130 (2) ◽

pp. 82-86

Author(s):

H.M. Gunes ◽

G.B. Guler ◽

E. Guler ◽

G.G. Demir ◽

S. Hatipoglu ◽

...

Keyword(s):

Mitral Regurgitation ◽

Left Ventricular ◽

Valve Surgery ◽

Lv Function ◽

Vena Contracta ◽

Atherosclerotic Lesions ◽

Lv Dysfunction ◽

Echocardiographic Parameters ◽

Artery Disease ◽

The Impact

Objective: Osteopontin (OPN), a sialoprotein present within atherosclerotic lesions, especially in calcified plaques, is linked to the progression of coronary artery disease and heart failure. We assessed the impact of valve surgery on serum OPN and left ventricular (LV) function in patients with mitral regurgitation (MR). Methods: Thirty-two patients with severe MR scheduled for surgery were included in the study. Echocardiography markers were assessed preoperatively and at 3 months following the surgery and matched with the serum OPN levels. Results: Valve surgery was associated with a reduction of the ejection fraction (EF) from 55.2 ± 6.3 to 48.8 ± 7.1% after surgery, p < 0.001. Following surgery, the OPN level was significantly higher than preoperatively (mean 245, range 36-2,284 ng/ml vs. 76, 6-486 ng/ml, p = 0.007). Preoperative OPN exhibited a slight negative correlation with the EF (r = -0.35, p = 0.04), and a moderate correlation with vena contracta (r = -0.38, p = 0.02). There were no other meaningful correlations between conventional echocardiographic parameters and OPN. Conclusion: Following valve surgery due to severe MR, patients exhibited a decrease in EF and an increase in OPN levels. The assessment of preoperative OPN failed to strongly predict probable LV dysfunction.

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P3764Morphological mechanisms of atrial functional mitral regurgitation in patients with atrial fibrillation

European Heart Journal ◽

10.1093/eurheartj/ehz745.0615 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K Nagaoka ◽

Y Mukai ◽

S Kawai ◽

S Takase ◽

K Sakamoto ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Ventricular Ejection Fraction ◽

Mitral Regurgitation ◽

Left Atrial ◽

Left Ventricular ◽

Volume Index ◽

Left Ventricular Ejection ◽

Functional Mitral Regurgitation ◽

Mitral Leaflet ◽

Ventricular Ejection Fraction

Abstract Background Atrial functional mitral regurgitation (AFMR) occurs in patients with atrial fibrillation. However, morphological mechanisms of AFMR are poorly understood. Purpose The purpose of this study was to examine the morphological characteristics in patients with AFMR. Methods Among consecutive 795 patients undergoing initial radiofrequency catheter ablation (RFCA) at our hospital, twenty-five patients with persistent AF accompanied by AFMR (≥ moderate) before RFCA (AFMR group) were studied. Age-matched 25 patients with persistent AF without MR were defined as a control group. Results Left ventricular ejection fraction (LVEF) was lower and left atrium volume index was larger in the AFMR group (Table). Mitral valve annulus diameter and length of anterior mitral leaflet (AML) were similar between groups, whereas length of posterior mitral leaflet (PML) was significantly shorter in the AFMR group. Smaller tethering angle of AML (γ in the figure) and shorter tethering height were significantly associated with the occurrence of AFMR, which were different from morphology of functional mitral regurgitation in patients with dilated LV. Multiple regression analysis revealed that less tenting height (p<0.05) and LA dilatation toward the posterior (p<0.01) were significantly related to AFMR. Echocardiographic parameters AFMR (n=25) Control (n=25) P value Age, y 69±8 66±10 NS Male, n (%) 9 (36) 20 (80) P=0.001 LVEF,% 60±9 67±6 P=0.004 LAD, mm 44±5 41±7 NS LAVI, ml/m2 56±17 41±13 P<0.001 MV diameter, mm 3.9±0.4 3.8±0.5 NS α angle, ° 34±9 35±7 NS β angle, ° 48±9 50±8 NS γ angle, ° 32±5 37±5 P=0.0005 AML length, mm 3.0±0.5 3.0±0.5 NS PML length, mm 2.1±0.1 2.4±0.1 P=0.03 Tenting height, mm 1.5±0.1 1.8±0.1 P=0.02 D, mm 0.8±0.3 0.5±0.3 P=0.001 LVEF: left ventricular ejection fraction; LAD: left atrial diameter; LAVI: left atrial volume index; AML: anterior mitral leaflet; PML: posterior mitral leaftlet. Conclusions AFMR occurs in patients with unique morphological features, such as less tethering height and LA dilatation toward the posterior.

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P1777Concordance and discordance among the recommended echocardiographic parameters for the assessment of mitral regurgitation severity

European Heart Journal ◽

10.1093/eurheartj/ehz748.0529 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Uretsky ◽

L Aldaia ◽

L Marcoff ◽

K Koulogiannis ◽

M Rosenthal ◽

...

Keyword(s):

Mitral Regurgitation ◽

Color Doppler ◽

Integrated Approach ◽

Volume Index ◽

Complete Agreement ◽

Severe Mitral Regurgitation ◽

Clinical Predictors ◽

Entire Cohort ◽

Vena Contracta ◽

Echocardiographic Parameters

Abstract Background The EACVI and ACC/AHA guidelines recommend assessing several echocardiographic parameters when evaluating mitral regurgitant severity. In a given patient, these parameters can be discordant making the assessment of mitral regurgitation challenging. Purpose To assess the degree to which echocardiographic parameters of MR severity are concordant. Methods This analysis included 131 consecutive patients with primary mitral regurgitation enrolled in a prospective multicenter study. Nine parameters were included in this analysis (PISA –derived regurgitant volume, PISA-derived EROA, vena contracta, color Doppler jet/LA area, LA volume index, LVEDVI, peak E wave, pulmonary vein systolic flow reversal, and presence of flail leaflet). Each echocardiographic parameter was determined to represent severe or nonsevere mitral regurgitation according to the guidelines. A concordance score was calculated as: (the number of concordant parameters/9) * 100 so that a higher score reflects greater concordance. Each echocardiogram was graded as having mild, moderate, or severe mitral regurgitation using the guideline recommended integrated approach. Results The mean concordance score was 74±13% for the entire cohort. There were 4 (4%) patients with complete agreement of all parameters and 32 (25%) with agreement of 5 of the 9 parameters. There was greater discordance in patients with severe MR and eccentric jets but no difference between patients with prolapse or flail leaflets (Figure 1). Clinical predictors of discordance were vena contracta and the peak E wave. Figure 1 Conclusion In this series, there was imperfect concordance between the recommended echocardiographic parameters of MR severity in patients undergoing evaluation for mitral regurgitation. The discordance was worse with more severe mitral regurgitation and there was no ideal predictor of discordance. These findings highlight the challenges facing echocardiographers when assessing the severity of mitral regurgitation and underscore the importance of using the integrated approach recommended by professional societal guidelines. Acknowledgement/Funding None

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P914 Changes of echocardiographic parameters in primary mitral regurgitation and determinants of symptom: an assessment from the Asian valve registry data

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.550 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

M Amano ◽

C Izumi ◽

Y J Kim ◽

S J Park ◽

S W Park ◽

...

Keyword(s):

Mitral Regurgitation ◽

Ejection Fraction ◽

Multivariable Analysis ◽

Left Ventricular ◽

Volume Index ◽

P Value ◽

Actual Measurement ◽

Determinant Factors ◽

Lv Mass ◽

Echocardiographic Parameters

Abstract [Background]Clinicians often have a difficulty in determining the presence of mitral regurgitation (MR)-relatedsymptoms because of subjectivity.However, there are few actual measurement data for echocardiographic left ventricular (LV) and left atrial (LA) size related to the severity of MR and the relationship between MR-related symptoms and these echocardiographic parameters. [Purpose] The purpose of this study was to clarify actual values for echocardiographic parameters related to severity of MR and determinant factors of MR-related symptoms. [Methods] Among patients enrolled in the Asian Valve Registry, we investigated 778 consecutive patients with primary MR showing sinus rhythm. Symptoms were determined by NYHA (≤ II or ≥ III). [Results]MR severity was mild in 106, moderate in 285, and severe in 387 patients. LA volume index, LV end-diastolic diameter, and LV mass index increased with increasing MR grade [LA volume index: 47.9 (mild), 56.2 (moderate), and 64.9 ml/m2(severe) (p < 0.001), LV end-diastolic diameter: 51.2, 54.5, 58.1 mm (p < 0.001), and LV mass index: 101, 109, 123 g/m2(p < 0.001)]. Regarding moderate and severe MR, 70 patients (10.4%) were symptomatic. Table shows multivariable analysis for being symptomatic in moderate and severe MR patients. LV mass index (p = 0.040), ejection fraction (p < 0.001), female gender (p = 0.004), and heart rate (p = 0.007) were independent factors for MR-related symptoms. [Conclusions] LV and LA parameters on echocardiography worsened as MR severity progressed. Larger LV mass index and lower ejection fraction were independent determinant factors for MR-related symptoms. We should also pay attention to LV hypertrophy in patients with primary MR. Determinant factors for mitral regurgita Model 1 Model 2 OR (95% CI) P-value OR (95% CI) P-value Age, per 1-y increment 1.03 (1.00-1.05) 0.035 1.02 (0.99-1.05) 0.053 Sex (female) 2.23 (1.20-4.16) 0.011 2.28 (1.31-3.98) 0.004 Hear rate, per 1 bpm increment 1.03 (1.00-1.05) 0.025 1.03 (1.01-1.05) 0.007 LVDs index, per 1 mm increment 0.99 (0.90-1.09) 0.90 EF, per 1% increment 0.95 (0.92-0.99) 0.019 0.96 (0.93-0.98) <0.001 LV mass index, per 10 g/m2increment 1.12 (1.01-1.25) 0.033 1.09 (1.005-1.18) 0.040 LA volume index, per 10 mL/m2increment 0.96 (0.90-1.03) 0.23 E wave, per 1cm/s increment 1.81 (0.70-4.66) 0.23 TR pressure gradient >40 mmHg 2.11 (0.97-4.57) 0.057 Hypertention 1.40 (0.75-2.63) 0.29

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

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.080 ◽

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

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Mitral regurgitation attenuates thrombotic risk in nonrheumatic atrial fibrillation: a new CHA2DS2-VASc score risk modifier?

EP Europace ◽

10.1093/europace/euab116.264 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

SL Van Laer ◽

KM Winkler ◽

S Verreyen ◽

H Miljoen ◽

A Sarkozy ◽

...

Keyword(s):

Atrial Fibrillation ◽

Mitral Regurgitation ◽

Left Atrial ◽

Left Ventricular ◽

Volume Index ◽

Left Ventricular Ejection ◽

Thrombotic Risk ◽

C Statistic ◽

Atrial Thrombosis ◽

Risk Modifier

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: Atrial fibrillation (AF) carries a thrombotic risk related to left atrial blood stasis. Many risk scores, such as the CHA2DS2-VASc score, have been developed to guide physicians in initiating anticoagulant therapy. However, the risk prediction with these models is modest at best (C-statistic = 0.6). The presence of mitral regurgitation (MR) has been shown to reduce thrombotic risk in patients with rheumatic AF. In nonrheumatic AF, direct evidence of a lower thrombotic risk in patients with MR is still controversial. Purpose The current study assessed the effect of MR on thrombotic risk in nonrheumatic AF patients. Methods The prevalence of atrial thrombosis, defined as the presence of left atrial appendage thrombus (LAAT) and/or left atrial spontaneous echo contrast (LASEC) grade >2, was determined in 686 consecutive nonrheumatic AF patients without (adequate) anticoagulation scheduled for transoesophageal echocardiography before electrical cardioversion and was related to the severity of MR adjusted for the CHA2DS2-VASc score. The independent predictors of atrial thrombosis were assessed by stepwise multiple logistic regression analysis. Results A total of 103 (15%) patients had severe MR, 210 (31%) had moderate MR, and 373 (54%) had no-mild MR; the median CHA2DS2-VASc score was 3.0 (IQR 2.0-4.0). Atrial thrombosis (LAAT and/or LASEC grade >2) was observed in 118 patients (17%). The prevalence of atrial thrombosis decreased with increasing MR severity: 19.9% versus 15.2% versus 11.6% for no-mild, moderate, and severe MR, respectively (p for trend = 0.03) (Figure 1). Patients with moderate and severe MR had a lower risk of atrial thrombosis than patients with no-mild MR, with adjusted odds ratios (ORs) of 0.51 (95% CI 0.31-0.84) and 0.24 (95% CI 0.11-0.49), respectively. The other independent predictors of atrial thrombosis were: the CHA2DS2-VASc score with an adjusted OR of 1.25 (95% CI 1.10-1.42), poor left ventricular ejection fraction (LVEF, <40%) with an adjusted OR of 4.08 (95% CI 2.56-6.50), and large left atrial volume index (LAVI, >37 ml/m²) with an adjusted OR of 1.90 (95% CI 1.19-3.03) (Figure 1, upper right corner). The C-statistic of the regression model increased significantly (p = 0.0003) from 0.62 to 0.75 by adding MR grade, LVEF, and LAVI to the univariate CHA2DS2-VASc score model. The protective effect of MR was present across all levels of the CHA2DS2-VASc score and the presence of moderate-severe MR in patients with an intermediate CHA2DS2-VASc score (2-3) lowered the atrial thrombotic risk to the level of patients with a low CHA2DS2-VASc score (0-1). Conclusion Our data show that the presence of MR attenuated the atrial thrombotic risk by more than 50% in patients with nonrheumatic AF, independent of the CHA2DS2-VASc risk score. Moderate to severe MR can therefore be considered a new risk modifier of the CHA2DS2-VASc score, which might help refine the indication of anticoagulants in AF patients. Abstract Figure 1. Thrombotic risk per MR grade.

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606 Predictive value of left atrial and left ventricular strain for the detection of atrial fibrillation in patients with cryptogenic stroke

European Heart Journal Supplements ◽

10.1093/eurheartj/suab127.003 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Gabriella Bufano ◽

Francesco Radico ◽

Carolina Maria D’Angelo ◽

Francesca Pierfelice ◽

Maria Vittoria De Angelis ◽

...

Keyword(s):

Atrial Fibrillation ◽

Predictive Value ◽

Left Atrial ◽

Longitudinal Strain ◽

Cryptogenic Stroke ◽

Left Ventricular ◽

Volume Index ◽

Lv Function ◽

Ecg Monitoring ◽

Echocardiographic Parameters

Abstract Aims Cryptogenic stroke (CS) is associated with high rate of recurrences and adverse outcomes at long-term follow-up, especially in light of its unknown etiology that often leads to ineffective secondary prevention. In such scenario, asymptomatic misdiagnosed atrial fibrillation (AF) episodes could play an important pathophysiological role. Some studies have pointed left atrial (LA) and left ventricular (LV) systolic and diastolic dysfunction as surrogate markers of AF. The aim of this study was to evaluate the relationship between echocardiographic parameters of LA and LV function, and the occurrence of AF revealed by continuous electrocardiogram (ECG) monitoring in a cohort of CS patients. Methods and results This is a single-centre prospective cohort study. Seventy-two CS patients with continuous ECG monitoring with insertable cardiac monitor (ICM) underwent transthoracic echocardiography (TTE). TTE was focused on LA and LV function, including both standard and longitudinal strain-derived parameters. All detected AF episodes lasting more than 2 min were considered. Patients with and without AF were homogeneous in all baseline characteristics, except for CHA2DS2-VASc score, which was significantly higher in AF group, and prevalence of hypercholesterolaemia, that was significantly higher in no-AF group. ICM revealed AF in 23 patients (32%), on average 196 days after ICM implantation. Among echocardiographic parameters, LV ejection fraction (LVEF, P = 0.007), LA end systolic area (LAES area, P = 0.006), LA volume index (LAVI, P = 0.008), total LA emptying fraction (LATEF, P = 0.013), E velocity (P = 0.042), pulmonary veins AR duration (P = 0.01), septal and median TDI E/e′ (respectively, P = 0.045 and P = 0.039), peak atrial longitudinal strain (PALS) in 4-chamber and in 2-chamber view (respectively, P < 0.001 and P = 0.011), peak atrial contraction strain (PACS, P < 0.001), LA conduit strain (P = 0.005), and LV longitudinal strain (LVLS, P = 0.001) were significantly associated to the occurrence of AF, suggesting worst atrial function in AF group. Furthermore, multivariable regression analysis revealed that PACS and LV strain were the only echocardiographic parameters independently associated with AF [confidence interval (CI) 95%: 0.48–0.90, P = 0.005 and CI 95%: 0.46–0.95, P = 0.041 respectively]. Conclusions In a cohort of CS patients, continuous ECG monitoring with ICM revealed subclinical AF episodes in about one-third of patients. In such population, LA and LV strain analysis add predictive value for occurrence of AF over clinical and morpho-functional echocardiographic parameters. Impaired booster pump strain and LVLS strain are strong and independent predictors of AF.

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Does the volume overload exaggerate the severity of mitral regurgitation in patients with decompensated heart failure?

TURKISH JOURNAL OF MEDICAL SCIENCES ◽

10.3906/sag-2001-220 ◽

2020 ◽

Vol 50 (6) ◽

pp. 1552-1558

Author(s):

Göktuğ SAVAŞ ◽

Ömer ŞAHİN ◽

Mustafa YAŞAN ◽

Uğur KARABIYIK ◽

Nihat KALAY ◽

...

Keyword(s):

Heart Failure ◽

Mitral Regurgitation ◽

Volume Overload ◽

Integrated Approach ◽

Left Ventricular ◽

Functional Mitral Regurgitation ◽

Systolic Pulmonary Artery Pressure ◽

Vena Contracta ◽

Echocardiographic Parameters ◽

Echocardiographic Assessment

Background/aim: Diagnosing and managing functional mitral regurgitation (MR) is often challenging and requires an integrated approach including a comprehensive echocardiographic examination. However, the effects of volume overload on the echocardiographic assessment of MR severity are uncertain. The purpose of this study was to weigh the effects of volume overload in the echocardiographic assessment of MR severity among patients with heart failure (HF).Materials and methods: Twenty-nine patients with decompensated HF, who had moderate or severe MR, were included in the present study. The volume status and the N-terminal pro-B-type natriuretic peptide (proBNP) levels were recorded and the echocardiographic parameters were assessed. After the conventional treatment for HF, the proBNP levels and the echocardiographic parameters were assessed again.Results: The mean age of the patients was 72 ± 9 years and the average hospitalization time was 10.9 ± 5.9 days. Between the beginning and the end of the treatment, there were significant reductions in the effective regurgitant orifice area (EROA) (0.36 ± 0.09 cm2 to 0.29 ± 0.09 cm2, P < 0.001), vena contracta (VC) (P < 0.001), the regurgitant volume (RV) (P < 0.001), and systolic pulmonary artery pressure (sPAP) (P < 0.001). Conclusion: This is the first study to investigate the relationship of changes in severity of MR with volume-load by monitoring the proBNP levels among patients with HF. The present results demonstrated that volume reduction, as evidenced by a decline in the proBNP levels, was accompanied by a marked reduction in the EROA, VC, and the RV among patients with left ventricular dysfunction.

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

European Heart Journal ◽

10.1093/eurheartj/ehz746.0093 ◽

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.

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