scholarly journals Importance of Exercise Capacity in Predicting Outcomes and Determining Optimal Timing of Surgery in Significant Primary Mitral Regurgitation

2014 ◽  
Vol 3 (5) ◽  
Author(s):  
Peyman Naji ◽  
Brian P. Griffin ◽  
Tyler Barr ◽  
Fadi Asfahan ◽  
A. Marc Gillinov ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Exercise Capacity ◽  
Timing Of Surgery ◽  
Optimal Timing ◽  
Primary Mitral Regurgitation

Invasive and non-invasive quantification of myocardial fibrosis in primary mitral regurgitation: prognostic implications for post-operative remodelling, symptom burden and exercise capacity

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
B Liu ◽  
K.L.S Khin ◽  
D.A.H Neil ◽  
M Bhabra ◽  
R Patel ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Exercise Capacity ◽  
Myocardial Fibrosis ◽  
Nyha Class ◽  
Symptom Burden ◽  
Class I ◽  
Funding Source ◽  
Non Invasive ◽  
Primary Mitral Regurgitation ◽  
Free Status

Abstract   Chronic primary mitral regurgitation (MR) exposes the left ventricle (LV) to volume overload and is associated with evidence of fibrosis on non-invasive imaging. It is not known whether fibrosis predicts outcome from surgery. This study aimed to 1) quantify myocardial fibrosis on histology and non-invasive imaging, 2) investigate any association between fibrosis and LV size and function, 3) determine the impact of fibrosis on post-operative outcome. Methods In a prospective observational multicentre study, 105 patients with severe MR (N=65/32/8 NYHA Class I/II/III respectively; mean age 63.1±13.4 years; male 73%; VO2max 91.2±22.4%) had multiparametric cardiac magnetic resonance (CMR), symptom assessment (Minnesota Living with Heart Failure Questionnaire (MLHFQ)) and cardiopulmonary exercise testing before and at 9 months following repair. Patients consented for up to 3 intraoperative LV biopsies for histological collagen volume fraction (CVF) quantification. Results 234 LV biopsies were feasible from 86 patients with median CVF of 14.6% [IQR 7.4–20.3]. Fibrosis was present even in NYHA Class I patients (13.6% [6.3–18.8]), and was significantly higher than the 3.3% [2.6–6.1] obtained from 8 autopsy controls without cardiac disease (P<0.001). Pre-operatively, there was no relationship between CVF and LV size, systolic function, ECV, late gadolinium enhancement, although it did correlate with MLHFQ (R=0.23, P=0.034). Conversely, ECV (27.4±3.3%) correlated with systolic (LVEF Rho=−0.22, P=0.029; LVESVi Rho=0.22, P=0.025, GCS Rho=0.31, P=0.002) and diastolic function (E/e' R=0.25, P=0.022), exercise capacity (%VO2max R=−0.22, P=0.030), with borderline correlation to MLHFQ (R=0.19, P=0.058). Post-operatively, although LVEF remained normal (defined as >50%) in all but 6 patients (LVEF pre 69.1±8.0 vs post 63.3±8.3%, P<0.001), there was a reduction in ECV (27.4±3.3 vs 26.6±2.8%, P=0.027) that was proportionate to its pre-operative expansion (Figure1), suggesting that fibrosis was reversible within our patients. Neither histological CVF nor ECV predicted change in LVESVi, LVEF, symptom burden or exercise capacity following repair. GCS was an independent predictor of post-operative LVESVi and LVEF on multiple linear regression models. Whilst improvements in symptom burden and exercise capacity was observed in NYHA II-III patients, this sub-group of patients failed to achieve the same level of fitness and symptom-free status as NYHA I patients (VO2max 92.2±18.8% vs 102.9±21.1%, P=0.017; MLHFQ 12 [5–26] vs 3 [0–10], P<0.001). Conclusions Myocardial fibrosis is present in primary MR, before the onset of symptoms. Due to its patchy nature, ECV but not fibrosis on histology is a better marker of pre-operative myocardial function and symptom status. Despite ECV reduction following successful MR surgery, symptomatic patients fail to regain exercise fitness and symptom-free status – providing further support for the benefits of early surgery. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): British Heart Foundation

scholarly journals 6161Reduced myocardial ATP delivery in severe primary mitral regurgitation: a novel marker to guide timing of surgery?

2018 ◽  
Vol 39 (suppl_1) ◽  
Author(s):  
M A Peterzan ◽  
C A Lygate ◽  
H A Lake ◽  
J J Rayner ◽  
M J Hundertmark ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Timing Of Surgery ◽  
Primary Mitral Regurgitation

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.

scholarly journals Integrative characterization of asymptomatic vs. symptomatic patients with moderate-severe primary mitral regurgitation

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
EA Andrikopoulou ◽  
PB Pat ◽  
NSB Bajaj ◽  
PCP Powell ◽  
IA Aban ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Optimal Timing ◽  
P Value ◽  
Type I ◽  
Procollagen Type ◽  
National Budget ◽  
Funding Sources ◽  
Lv Remodeling ◽  
Primary Mitral Regurgitation ◽  
Public Grant

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by NHLBI and Specialized Centers of Clinically Oriented Research grant in cardiac dysfunction, by Department of Veteran Affairs for Merit Review and NIH Grant P01. Background Optimal timing for surgery in primary mitral regurgitation (PMR) is a subject of debate. Purpose Use a combination of imaging, circulating biomarkers and histology to define the transition from asymptomatic (asx) to symptomatic (sx) stage in moderate-severe PMR. Methods 57 controls, 82 sx and 47 asx patients with moderate to severe PMR underwent cardiac MR(CMR), plasma BNP, levels of xanthine oxidase (XO) activity, and circulating markers of collagen (Col) synthesis (propeptide of procollagen type I, PICP) and degradation (Col type I fibers, ICTP). Results A progressive worsening in the severity of adverse LV remodeling was noted based on CMR indices listed in Table 1. The 3D mid-wall LV endocardial curvature to wall thickness was lower in normal and similar in asx and sx patients.Plasma BNP was progressively higher in normal vs. asx vs sx (Figure 1A). The levels of XO activity were higher in sx vs. asx (Figure 1B,1C). Levels of PICP were similar among the three; levels of ICTP were significantly higher in the sx vs the asx (Figure 1D,1E). LV biopsies revealed large areas of patchy replacement fibrosis and areas devoid of interstitial Col (Figure 1F). From the subgroup of 56 patients who underwent CMR 6 months after surgery, 27% had LVEF &lt; 50%. The preoperative LVEF, LVESV, LVESD and LA emptying fraction were predictors of postoperative drop in LVEF. Conclusion Increased COl breakdown coupled with markers of oxidative stress and CMR-based LV remodeling characterize the transition from asx to sx PMR. Longitudinal studies are needed to define cutoff"s for patient selection and optimal timing for MV surgery. CMR indices in normal, asx and sx PMR. Normal (57) Moderate/Severe MR Asymptomatic (56) Pre-Surgery MR Symptomatic (81) P-value Age 48 (34, 55) 54 (46, 62) * 57 (50, 67) * &lt;0.0001 Female/Male 30(53%)/27(47%) 35(63%)/21(38%) 25(31%)/56(69%) LVEF (%) 64 (61, 67) 62 (59, 66) 63 (59, 67) 0.3482 LV EDV (mL/m2) 71 (61, 76) 89 (73, 103) * 100 (83, 123) *# &lt;0.0001 LV ESV (mL/m2) 24 (21, 29) 32 (26, 38) * 36 (28, 47) * &lt;0.0001 LVSV (mL/m2) 43 (37, 50) 54 (43, 66) * 60 (54, 77) *# &lt;0.0001 LVED Mass/Volume 0.7 (0.6, 0.8) 0.6 (0.5, 0.7) * 0.6 (0.6, 0.7) * 0.0012 LVED Mass/Vol x SI 1.29 (1.05, 1.50) 0.97 (0.77, 1.15) * 0.94 (0.77, 1.14) * &lt;0.0001 Regurgitant Volume (mL) ― 38 (26, 54) 57 (38, 83) # 0.001 Regurgitant Fraction (%) ― 39 (28, 50) 46 (36, 56) # 0.042 Table 1 shows the CMR indices of LV remodeling in normal, asymptomatic and symptomatic patients with moderate-severe PMR. p-values *vs. Normal; # vs. Asymptomatic. Kruskal-Wallis test or unpaired t-test Abstract Figure 1.

Novel staging classification of primary mitral regurgitation based on the presence of cardiac damage

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A.L Van Wijngaarden ◽  
Y.L Hiemstra ◽  
P Van Der Bijl ◽  
V Delgado ◽  
N Ajmone Marsan ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Kidney Function ◽  
Left Ventricular ◽  
Prognostic Impact ◽  
Cardiac Damage ◽  
Stage 4 ◽  
All Cause Mortality ◽  
Primary Mitral Regurgitation ◽  
Stage 1 ◽  
Staging Classification

Abstract Background The indication for surgery in patients with severe primary mitral regurgitation (MR) is currently based on the presence of symptoms, left ventricular (LV) dilatation and dysfunction, atrial fibrillation and pulmonary hypertension. The aim of this study was to evaluate the prognostic impact of a new staging classification based on cardiac damage including the known risk factors but also including global longitudinal strain (GLS), severe left atrial (LA) dilatation and right ventricular (RV) dysfunction. Methods In total 614 patients who underwent surgery for severe primary MR with available baseline transthoracic echocardiograms were included. Patients were classified according to the extent of cardiac damage (Figure): Stage 0-no cardiac damage, Stage 1-LV damage, Stage 2-LA damage, Stage 3-pulmonary vasculature or tricuspid valve damage and Stage 4-RV damage. Patients were followed for all-cause mortality. Results Based on the proposed classification, 172 (28%) patients were classified as Stage 0, 102 (17%) as Stage 1, 134 (21%) as Stage 2, 135 (22%) as Stage 3 and 71 (11%) as Stage 4. The more advanced the stage, the older the patients were with worse kidney function, more symptoms and higher EuroScore. Kaplan-Meier curve analysis revealed that patients with more advanced stages of cardiac damage had a significantly worse survival (log-rank chi-square 35.2; p&lt;0.001) (Figure). On multivariable analysis, age, male, chronic obstructive pulmonary disease, kidney function, and stage of cardiac damage were independently associated with all-cause mortality. For each stage increase, a 22% higher risk for all-cause mortality was observed (95% CI: 1.064–1.395; p=0.004). Conclusion In patients with severe primary MR, a novel staging classification based on the extent of cardiac damage, may help refining risk stratification, particularly including also GLS, LA dilatation and RV dysfunction in the assessment. Funding Acknowledgement Type of funding source: None

scholarly journals GCT-53. CASE OF INTRACRANIAL GROWING TERATOMA SYNDROME WITH DIFFICULTY IN TIMING OF RESECTION

2020 ◽  
Vol 22 (Supplement_3) ◽  
pp. iii339-iii339
Author(s):  
Hidenobu Yoshitake ◽  
Hideo Nakamura ◽  
Yuta Hamamoto ◽  
Yusuke Otsu ◽  
Jin Kikuchi ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Mature Teratoma ◽  
Timing Of Surgery ◽  
Optimal Timing ◽  
Third Ventriculostomy ◽  
Mixed Tumor ◽  
Gland Tumor ◽  
Growing Teratoma Syndrome

Abstract BACKGROUND Intracranial Growing teratoma syndrome(iGTS) is a phenomenon in which a tumor with a teratoma component grows during treatment, and its pathological tissue is often a mature teratoma. Here we report a case of iGTS in which the timing of surgery was determined by tumor markers and changes in tumor size on MRI images. CASE-REPORT: 11-year-old boy with a short stature. He developed a headache and we found a pineal gland tumor on MRI. Due to obstructive hydrocephalus, an endoscopic third ventriculostomy and biopsy were performed. The pathological diagnosis was mature teratoma, but AFP was elevated at 104.2 ng/mL. Considering NGGCT, we started chemoradiation immediately. Despite the declining AFP, it gradually increased, at which point we suspected iGTS. Resection was considered, but at some point tumor growth had stopped, so radiation therapy and a second course of ICE therapy preceded the resection. Thereafter, the tumor was completely removed, and a third course of ICE therapy was performed. DISCUSSION The onset mechanism of iGTS has not been elucidated, and its prediction is difficult. Early resection of the tumor is required, but discontinuation of radiation therapy and side effects of chemotherapy also need to be considered. In our case, resection was performed after normalization of AFP and recovery of myelosuppression. The patient followed an uneventful course, but the timing of resection was controversial. CONCLUSION We experienced a case of iGTS in NGGCT, a mixed tumor with mature teratoma. The optimal timing of the resection was discussed and literature was reviewed.

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