Mitral Regurgitation in Patients Undergoing Noncardiac Surgery

2021 ◽  
pp. 108925322110428
Author(s):  
Ellen W. Richter ◽  
Islam M. Shehata ◽  
Hamdy M. Elsayed-Awad ◽  
Matthew A. Klopman ◽  
Sujatha P. Bhandary
Keyword(s):  
Mitral Regurgitation ◽  
Anesthetic Management ◽  
Heart Association ◽  
Mitral Annulus ◽  
The United States ◽  
Cardiovascular Complications ◽  
Noncardiac Surgery ◽  
Surgical Patient ◽  
Increased Risk ◽  
Secondary Mr

Mitral regurgitation (MR) is one of the most frequently encountered types of valvular heart disease in the United States. Patients with significant MR (moderate-to-severe or severe) undergoing noncardiac surgery have an increased risk of perioperative cardiovascular complications. MR can arise from a diverse array of causes that fall into 2 broad categories: primary (diseases intrinsic to the valvular apparatus) and secondary (diseases that disrupt normal valve function via effects on the left ventricle or mitral annulus). This article highlights key guideline updates from the American College of Cardiologists (ACC) and the American Heart Association (AHA) that inform decision-making for the anesthesiologist caring for a patient with MR undergoing noncardiac surgery. The pathophysiology and natural history of acute and chronic MR, staging of chronic primary and secondary MR, and considerations for timing of valvular corrective surgery are reviewed. These topics are then applied to a discussion of anesthetic management, including preoperative risk evaluation, anesthetic selection, hemodynamic goals, and intraoperative monitoring of the noncardiac surgical patient with MR.

5942Clinical outcomes and prognostic implications of effective regurgitant orifice area. Defining severe mitral regurgitation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J M Monteagudo Ruiz ◽  
A Gonzalez Gomez ◽  
R Hinojar Baydes ◽  
E Casas Rojo ◽  
A Garcia Martin ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Cardiac Death ◽  
Cox Regression ◽  
Strong Predictor ◽  
Optimal Threshold ◽  
Orifice Area ◽  
End Point ◽  
Increased Risk ◽  
Secondary Mr ◽  
Regurgitant Orifice Area

Abstract Background Previous studies showed that the effective regurgitant orifice area (EROA) is a strong predictor of clinical outcomes. However, there is controversy over the optimal threshold that identifies patients at high-risk, especially in secondary mitral regurgitation (MR). Purpose To determine the optimal EROA threshold that identifies a subgroup patients with an increased risk of cardiac death and hospitalization for heart failure (HF), in both, primary and secondary MR. Methods A total of 6022 consecutive transthoracic echocardiograpic studies were analysed. Patients with significant MR were prospectively included. The EROA was calculated by the PISA method. Each patient was followed up for three years. Cox regression was performed to study predictors of the combined end-point. ROC curve analysis was performed to determine the optimal cut-off values of EROA. Results Significant primary MR was found in 115 patients (62%), whereas significant secondary MR was described in 71 studies (38%). In primary MR, the optimal threshold of EROA for predicting the combined end-point was 45mm2 (Sn=85.7%; Sp=82.2%). After adjusting for NYHA class, ejection fraction and chronic kidney disease, an EROA ≥45mm2 was strongly associated with cardiac death and admissions due to HF (HR 15.65, 95% CI 4.34–56.47, p<0.001). Regarding secondary MR, the optimal cut-off value was 21mm2 (Sn=75.0%; Sp=61.8%) and the adjusted HR was 2.57 (95% CI 1.03–6.37, p=0.042). Sensitivity and specificity curves Conclusions Our study demonstrates that an EROA of at least 45mm2 in primary MR or of at least 21mm2 in secondary MR is independently associated with a significantly increased risk of cardiac death and hospitalization for HF.

scholarly journals The Use of Sex-Specific Factors in the Assessment of Women’s Cardiovascular Risk

Circulation ◽  
2020 ◽  
Vol 141 (7) ◽  
pp. 592-599 ◽  
Author(s):  
Anandita Agarwala ◽  
Erin D. Michos ◽  
Zainab Samad ◽  
Christie M. Ballantyne ◽  
Salim S. Virani
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Primary Prevention ◽  
American Heart Association ◽  
American Heart ◽  
Heart Association ◽  
The United States ◽  
Cvd Risk Factors ◽  
Cvd Risk ◽  
Increased Risk

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. As compared with men, women are less likely to be diagnosed appropriately, receive preventive care, or be treated aggressively for CVD. Sex differences between men and women have allowed for the identification of CVD risk factors and risk markers that are unique to women. The 2018 American Heart Association/American College of Cardiology Multi-Society cholesterol guideline and 2019 American College of Cardiology/American Heart Association guideline on the primary prevention of CVD introduced the concept of risk-enhancing factors that are specific to women and are associated with an increased risk of incident atherosclerotic CVD in women. These factors, if present, would favor more intensified lifestyle interventions and consideration of initiation or intensification of statin therapy for primary prevention to mitigate the increased risk. In this primer, we highlight sex-specific CVD risk factors in women, stress the importance of eliciting a thorough obstetrical and gynecological history during cardiovascular risk assessment, and provide a framework for how to initiate appropriate preventive measures when sex-specific risk factors are present.

scholarly journals Clinical Implications for Exercise at Altitude Among Individuals With Cardiovascular Disease

2021 ◽  
Vol 10 (19) ◽  
Author(s):  
William K. Cornwell ◽  
Aaron L. Baggish ◽  
Yadav Kumar Deo Bhatta ◽  
Maria Joan Brosnan ◽  
Christoph Dehnert ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
American Heart ◽  
Oxygen Demand ◽  
Heart Association ◽  
The United States ◽  
Comprehensive Overview ◽  
Increased Risk ◽  
Scientific Statement ◽  
Number Of Individuals ◽  
Physiologic Responses

Abstract An increasing number of individuals travel to mountainous environments for work and pleasure. However, oxygen availability declines at altitude, and hypoxic environments place unique stressors on the cardiovascular system. These stressors may be exacerbated by exercise at altitude, because exercise increases oxygen demand in an environment that is already relatively oxygen deplete compared with sea‐level conditions. Furthermore, the prevalence of cardiovascular disease, as well as diseases such as hypertension, heart failure, and lung disease, is high among individuals living in the United States. As such, patients who are at risk of or who have established cardiovascular disease may be at an increased risk of adverse events when sojourning to these mountainous locations. However, these risks may be minimized by appropriate pretravel assessments and planning through shared decision‐making between patients and their managing clinicians. This American Heart Association scientific statement provides a concise, yet comprehensive overview of the physiologic responses to exercise in hypoxic locations, as well as important considerations for minimizing the risk of adverse cardiovascular events during mountainous excursions.

scholarly journals Cardiac Arrests and Deaths Associated with Malignant Hyperthermia in North America from 1987 to 2006

2008 ◽  
Vol 108 (4) ◽  
pp. 603-611 ◽  
Author(s):  
Marilyn Green Larach ◽  
Barbara W. Brandom ◽  
Gregory C. Allen ◽  
Gerald A. Gronert ◽  
Erik B. Lehman
Keyword(s):  
United States ◽  
Cardiac Arrest ◽  
Malignant Hyperthermia ◽  
Odds Ratio ◽  
Anesthetic Management ◽  
The United States ◽  
Exclusion Criterion ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Increased Risk

Background The authors determined associated cardiac arrest and death rates in cases from Canada and the United States as reported to The North American Malignant Hyperthermia (MH) Registry and analyzed factors associated with a higher risk of poor outcomes. Methods The authors searched the database for AMRA (adverse metabolic/musculoskeletal reaction to anesthesia) reports with inclusion criteria as follows: event date between January 1, 1987, and December 31, 2006; "very likely" or "almost certain" MH as ranked by MH Clinical Grading Scale; location in Canada or the United States; and one or more anesthetic agents given. The exclusion criterion was a pathologic condition other than MH independently judged by the authors. Severe MH outcomes were analyzed as regards clinical history and presentation, using Wilcoxon rank sum tests for continuous variables and Pearson exact chi-square tests for categorical variables. A Bonferroni correction adjusted for multiple comparisons. Results Of 291 events, 8 (2.7%) resulted in cardiac arrests and 4 (1.4%) resulted in death. The median age in cases of cardiac arrest/death was 20 yr (range, 2-31 yr). Associated factors were muscular build (odds ratio, 18.7; P = 0.0016) and disseminated intravascular coagulation (odds ratio, 49.7; P &lt; 0.0001). Increased risk of cardiac arrest/death was related to a longer time period between anesthetic induction and maximum end-tidal carbon dioxide (216 vs. 87 min; P = 0.003). Unrelated factors included patient or family history, anesthetic management, and the MH episode. Conclusions Modern US anesthetic practice did not prevent MH-associated cardiac arrest and death in predominantly young, healthy patients undergoing low- to intermediate-risk surgical procedures.

scholarly journals Racial Disparities in Cardiovascular Complications With Pregnancy-Induced Hypertension in the United States

Hypertension ◽  
2021 ◽  
Author(s):  
Anum S. Minhas ◽  
S. Michelle Ogunwole ◽  
Arthur Jason Vaught ◽  
Pensee Wu ◽  
Mamas A. Mamas ◽  
...  
Keyword(s):  
Black Women ◽  
Cardiovascular Events ◽  
Gestational Hypertension ◽  
The United States ◽  
Cardiovascular Complications ◽  
Pregnancy Induced Hypertension ◽  
Increased Risk ◽  
Induced Hypertension ◽  
Race Ethnicity ◽  
Asian Pacific

Women with pregnancy-induced hypertension, defined as gestational hypertension and preeclampsia/eclampsia, are at increased risk of long-term cardiovascular disease, but less is known about the spectrum of acute cardiovascular outcomes, especially across racial/ethnic groups. We evaluated the risk of cardiovascular events at delivery associated with gestational hypertension and preeclampsia/eclampsia, compared with no pregnancy-induced hypertension, overall and by race/ethnicity. We used the 2016 to 2018 National Inpatient Sample data. International Classification of Diseases , Tenth Revision , Clinical Modification codes identified delivery hospitalizations and clinical diagnoses. Using survey weights, cardiovascular events were examined using logistic regression by pregnancy-induced hypertension status, with subsequent stratification by race/ethnicity. Among 11 304 996 deliveries in 2016 to 2018, gestational hypertension occurred in 614 995 (5.4%) and preeclampsia in 593 516 (5.2%). Black women had higher odds for preeclampsia independent of underlying comorbidities (adjusted odds ratio, 1.45 [95% CI, 1.42–1.49]) and had the highest rates for several complications (peripartum cardiomyopathy, 506; heart failure, 660; acute renal failure, 953; and arrhythmias, 418 per 100 000 deliveries). After adjustment for socioeconomic factors and comorbidities, preeclampsia/eclampsia was associated with increased risk of cardiovascular events in women of all races/ethnicities. However, risk was highest among Asian/Pacific Islander women and lowest among Black women. In sum, while Black women were the most likely to experience preeclampsia, Asian/Pacific women were the most at risk for acute cardiovascular complications during delivery hospitalization.

scholarly journals Dynamic handgrip exercise for the evaluation of mitral valve regurgitation: an echocardiographic study to identify exertion induced severe mitral regurgitation

2020 ◽  
Author(s):  
Mhd Nawar Alachkar ◽  
Annemarie Kirschfink ◽  
Julian Grebe ◽  
Mohammad Almalla ◽  
Michael Frick ◽  
...  
Keyword(s):  
New York ◽  
Mitral Regurgitation ◽  
Stress Test ◽  
Nyha Class ◽  
Heart Association ◽  
Mitral Valve Regurgitation ◽  
Handgrip Exercise ◽  
Echocardiographic Parameters ◽  
Secondary Mr ◽  
Regurgitant Orifice Area

Abstract Handgrip exercise (HG) has been occasionally used as a stress test in echocardiography. The effect of HG on mitral regurgitation (MR) is not well known. This study aims to evaluate this effect and the possible role of HG in the echocardiographic evaluation of MR. 722 patients with MR were included (18% primary, 82% secondary disease). We calculated effective regurgitant orifice area (EROA) and regurgitant volume (RVOL) at rest and during dynamic HG. Increase in MR was defined as any increase in EROA or RVOL. We analyzed the data to identify possible associations between clinical or echocardiographic parameters and the effect of HG on MR. MR increased during dynamic HG in 390 of 722 patients (54%) (∆EROA = 25%, ∆RVOL = 27%). Increase of regurgitation occurred in 66 of 132 patients with primary MR (50%) and in 324 of 580 patients with secondary MR (55%). This increase was associated with larger baseline EROA and RVOL, but it was independent from other clinical or echocardiographic parameters. In secondary MR, dynamic HG led to a reclassification of regurgitation severity from non-severe at rest to severe MR during HG in 104 of 375 patients (28%). There was a significant association between this upgrade in MR classification and higher New York Heart Association (NYHA) class (OR 1.486, 95%-CI 1.138–1.940, p = 0.004). Dynamic HG exercise increases MR in about half of patients independent of the etiology. Dynamic HG may be used to identify symptomatic patients with non-severe secondary MR at rest but severe MR during exercise.

scholarly journals Cardiorespiratory Fitness in Youth: An Important Marker of Health: A Scientific Statement From the American Heart Association

Circulation ◽  
2020 ◽  
Vol 142 (7) ◽  
Author(s):  
Geetha Raghuveer ◽  
Jacob Hartz ◽  
David R. Lubans ◽  
Timothy Takken ◽  
Jennifer L. Wiltz ◽  
...  
Keyword(s):  
Cardiorespiratory Fitness ◽  
Temporal Trends ◽  
Heart Association ◽  
Cost Effective ◽  
The United States ◽  
Office Visits ◽  
Physical And Mental Health ◽  
Skeletal Muscle Mitochondria ◽  
Increased Risk ◽  
Important Marker

Cardiorespiratory fitness (CRF) refers to the capacity of the circulatory and respiratory systems to supply oxygen to skeletal muscle mitochondria for energy production needed during physical activity. CRF is an important marker of physical and mental health and academic achievement in youth. However, only 40% of US youth are currently believed to have healthy CRF. In this statement, we review the physiological principles that determine CRF, the tools that are available to assess CRF, the modifiable and nonmodifiable factors influencing CRF, the association of CRF with markers of health in otherwise healthy youth, and the temporal trends in CRF both in the United States and internationally. Development of a cost-effective CRF measurement process that could readily be incorporated into office visits and in field settings to screen all youth periodically could help identify those at increased risk.

Risk Assessment Before Noncardiac Surgery

2015 ◽  
Author(s):  
Wael AlJaroudi
Keyword(s):  
Risk Assessment ◽  
Preoperative Evaluation ◽  
A Priori ◽  
Cardiac Risk ◽  
Cardiovascular Complications ◽  
Noncardiac Surgery ◽  
Therapeutic Interventions ◽  
Increased Risk ◽  
History Of ◽  
Optimal Approach

Perioperative risk assessment is essential in screening patients before noncardiac surgery. Cardiovascular complications such as fatal and non-fatal myocardial infarction (MI), ventricular arrhythmia, pulmonary edema, and stroke are important in-hospital causes of morbidity and mortality intra and post-operatively. The optimal approach is to identify patients at increased risk so that appropriate testing and therapeutic interventions are undertaken a priori to minimize such risk. The initial preoperative evaluation includes identification of surgery-specific risk, patient exercise functional capacity and clinical risk profile. Patients with major predictors of events such as acute coronary syndromes, recent MI, unstable arrhythmia, and severe valvular disease warrant further management and optimization that often lead to delaying surgery. Those with three or more predictors (history of ischemic heart disease, compensated heart failure, diabetes, renal insufficiency, or history of cerebrovascular disease) undergoing high- risk surgery often require stress testing. Although data from randomized prospective trials are lacking, numerous studies have demonstrated the utility of myocardial perfusion imaging (MPI) for determination of perioperative cardiac risk. The goal of this chapter is to review the use of MPI for preoperative risk assessment and the recommendations from the current guidelines. The focus will be on short-term and long-term prognosis including special groups such as after coronary stenting and before vascular surgery, liver and renal transplantation.

scholarly journals Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association

Circulation ◽  
2021 ◽  
Author(s):  
Kurt Ruetzler ◽  
Nathaniel R. Smilowitz ◽  
Jeffrey S. Berger ◽  
P.J. Devereaux ◽  
Bradley A. Maron ◽  
...  
Keyword(s):  
Myocardial Injury ◽  
Clinical Symptoms ◽  
Heart Association ◽  
Cardiovascular Complications ◽  
Noncardiac Surgery ◽  
Reference Limit ◽  
Electrocardiographic Changes ◽  
Scientific Statement ◽  
Upper Reference Limit

Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.

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