scholarly journals Disproportionate Mitral Regurgitation Determines Survival in Acute Heart Failure

2021 ◽  
Vol 8 ◽  
Author(s):  
Max Berrill ◽  
Ian Beeton ◽  
David Fluck ◽  
Isaac John ◽  
Otar Lazariashvili ◽  
...  
Keyword(s):  
Heart Failure ◽  
Mitral Regurgitation ◽  
Acute Heart Failure ◽  
Volume Overload ◽  
Left Ventricular ◽  
Left Ventricular Volumes ◽  
Clinical Trial Registration ◽  
Proximal Isovelocity Surface Area ◽  
End Diastolic Volume ◽  
Lv Remodeling

Objectives: To assess the prevalence and impact of mitral regurgitation (MR) on survival in patients presenting to hospital in acute heart failure (AHF) using traditional echocardiographic assessment alongside more novel indices of proportionality.Background: It remains unclear if the severity of MR plays a significant role in determining outcomes in AHF. There is also uncertainty as to the clinical relevance of indexing MR to left ventricular volumes. This concept of disproportionality has not been assessed in AHF.Methods: A total of 418 consecutive patients presenting in AHF over 12 months were recruited and followed up for 2 years. MR was quantitatively assessed within 24 h of recruitment. Standard proximal isovelocity surface area (PISA) and a novel proportionality index of effective regurgitant orifice/left ventricular end-diastolic volume (ERO/LVEDV) >0.14 mm2/ml were used to identify severe and disproportionate MR.Results: Every patient had MR. About 331/418 (78.9%) patients were quantifiable by PISA. About 165/418 (39.5%) patients displayed significant MR. A larger cohort displayed disproportionate MR defined by either a proportionality index using ERO/LVEDV > 0.14 mm2/ml or regurgitant volumes/LVEDV > 0.2 [217/331 (65.6%) and 222/345 (64.3%), respectively]. The LVEDV was enlarged in significant MR−129.5 ± 58.95 vs. 100.0 ± 49.91 ml in mild, [p < 0.0001], but remained within the normal range. Significant MR was associated with a greater mortality at 2 years {44.2 vs. 34.8% in mild MR [hazard ratio (HR) 1.39; 95% CI: 1.01–1.92, p = 0.04]}, which persisted with adjustment for comorbid conditions (HR; 1.43; 95% CI: 1.04–1.97, p = 0.03). Disproportionate MR defined by ERO/LVEDV >0.14 mm2/ml was also associated with worse outcome [42.4 vs. 28.3% (HR 1.62; 95% CI 1.12–2.34, p = 0.01)].Conclusions: MR was a universal feature in AHF and determines outcome in significant cases. Furthermore, disproportionate MR, defined either by effective regurgitant orifice (ERO) or volumetrically, is associated with a worse prognosis despite the absence of adverse left ventricular (LV) remodeling. These findings outline the importance of adjusting acute volume overload to LV volumes and call for a review of the current standards of MR assessment.Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT02728739, identifier NCT02728739.

Abstract 216: Left Ventricular Enlargement and Heart Failure Events: Is Bigger Better?

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Farbod Raiszadeh ◽  
Neeraja Yedlapati ◽  
Ileana L Piña ◽  
Daniel M Spevack
Keyword(s):  
Heart Failure ◽  
New York ◽  
Cox Regression ◽  
Systolic Heart Failure ◽  
Heart Association ◽  
Left Ventricular ◽  
Left Ventricular Volumes ◽  
End Diastolic Volume ◽  
New York Heart Association ◽  
The Individual

Background: Since stroke volume (SV) is a function of ejection fraction (EF) and end-diastolic volume (EDV) (SV = EF x EDV), we hypothesized that increased EDV may be advantageous in systolic heart failure (HF), allowing the left ventricle to supply increased cardiac output. Methods: Echocardiograms from 968 consecutive patients seen in our hospital’s HF clinic were reviewed. Left ventricular volumes were measured both at end systole and end diastole using the bi-plane Simpson’s method and were indexed to body surface area. EF was calculated using (EDV-ESV)/EDV. Dates of subsequent HF events (death or admission for HF exacerbation) were obtained from our database. Results: Systolic HF (EF < 50%) was found in 649 of the study subjects. Increased SV index was associated with increased EDV index. The strength of this association varied with EF, Figure. In a bivariate Cox regression model, lower SV index and higher EDV index were each independent predictors of HF events. Increase in EDV by 50 cc was associated with a 20% increase in HF events, p<0.001. Decrease in SVI by 5 cc was associated with 5% increase in HF events, p<0.001. These associations were limited to those with systolic HF. The associations between both EDVI and SVI and HF events were not confounded by patient age, sex and New York Heart Association Class. Conclusion: Increased EDV index was independently associated with increased HF events, indicating that LV enlargement in HF is not favorable. These findings underscore the individual contributions of the components of EF (SV and EDV) in predicting HF outcomes.

scholarly journals Dissociation between cardiomyocyte function and remodeling with β-adrenergic receptor blockade in isolated canine mitral regurgitation

2008 ◽  
Vol 295 (6) ◽  
pp. H2321-H2327 ◽  
Author(s):  
Betty Pat ◽  
Cheryl Killingsworth ◽  
Thomas Denney ◽  
Junying Zheng ◽  
Pamela Powell ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Adrenergic Receptor ◽  
Volume Overload ◽  
Left Ventricular ◽  
Ultrastructural Changes ◽  
Receptor Blockade ◽  
Lv Mass ◽  
Lv Remodeling ◽  
Fractional Shortening ◽  
Adrenergic Receptor Blockade

The low-pressure volume overload of isolated mitral regurgitation (MR) is associated with increased adrenergic drive, left ventricular (LV) dilatation, and loss of interstitial collagen. We tested the hypothesis that β1-adrenergic receptor blockade (β1-RB) would attenuate LV remodeling after 4 mo of MR in the dog. β1-RB did not attenuate collagen loss or the increase in LV mass in MR dogs. Using MRI and three-dimensional (3-D) analysis, there was a 70% increase in the LV end-diastolic (LVED) volume-to-LV mass ratio, a 23% decrease in LVED midwall circumferential curvature, and a >50% increase in LVED 3-D radius/wall thickness in MR dogs that was not attenuated by β1-RB. However, β1-RB caused a significant increase in LVED length from the base to apex compared with untreated MR dogs. This was associated with an increase in isolated cardiomyocyte length (171 ± 5 μm, P < 0.05) compared with normal (156 ± 3 μm) and MR (165 ± 4 μm) dogs. Isolated cardiomyocyte fractional shortening was significantly depressed in MR dogs compared with normal dogs (3.73 ± 0.31 vs. 5.02 ± 0.26%, P < 0.05) and normalized with β1-RB (4.73 ± 0.48%). In addition, stimulation with the β-adrenergic receptor agonist isoproterenol (25 nM) increased cardiomyocyte fractional shortening by 215% ( P < 0.05) in β1-RB dogs compared with normal (56%) and MR (50%) dogs. In summary, β1-RB improved LV cardiomyocyte function and β-adrenergic receptor responsiveness despite further cell elongation. The failure to attenuate LV remodeling associated with MR could be due to a failure to improve ultrastructural changes in extracellular matrix organization.

Abstract 14952: Hemodynamic Comparison of Left Ventricular Function in Pressure Overload- versus Volume Overload-Induced Heart Failure Models by Invasive Pressure-Volume Analysis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Mihály Ruppert ◽  
Christian Karime ◽  
Alex A Sayour ◽  
Attila Oláh ◽  
Dávid Nagy ◽  
...  
Keyword(s):  
Heart Failure ◽  
Systolic Function ◽  
Pressure Overload ◽  
Volume Overload ◽  
Detailed Comparison ◽  
Left Ventricular ◽  
Lv Function ◽  
Arterial Elastance ◽  
Lv Remodeling ◽  
Av Shunt

Introduction: Both sustained left ventricular (LV) pressure overload (PO) and volume overload (VO) induces LV remodeling and eventually development of heart failure (HF). Using rat models, the present study aimed to provide a detailed comparison of distinct aspects of LV function in PO- and VO-induced HF. Methods: PO and VO was induced by transverse aortic constriction (TAC, n=12) and aortocaval shunt (AV-shunt, n=12) creation respectively. Controls underwent corresponding sham operations (n=11). LV remodeling was characterized by echocardiography, histology, qRT PCR, and western blot. LV function was assessed by invasive pressure-volume (P-V) analysis. Results: Both sustained PO and VO resulted in the development of HF, as evidenced by increased LV BNP mRNA expression, pulmonary edema, and characteristic symptoms. While the extent of LV hypertrophy was comparable between the HF models, PO induced concentric while VO evoked eccentric LV remodeling. P-V analysis revealed impaired systolic function in both HF models. Accordingly, decreased ejection fraction and impaired ventriculo-arterial coupling (calculated as the ratio of arterial elastance/LV contractility [VAC]: 0.38±0.05 vs. 1.30±0.13, ShamTAC vs. TAC and 0.52±0.08 vs. 1.17±0.13, ShamAV-Shunt vs. AV-shunt; p<0.05) was detected in both HF models. However, in case of VO the severely reduced LV contractility (slope of end-systolic P-V relationship: 1.79±0.19 vs. 0.52±0.06, ShamAV-Shunt vs. AV-shunt, p<0.05 and 2.14±0.28 vs. 2.03±0.21, ShamTAC vs. TAC p>0.05) underpinned the contractility-afterload mismatch, while in case of PO the increased afterload (arterial elastance: 0.77±0.07 vs. 2.64±0.28, ShamTAC vs. TAC and 0.80±0.07 vs. 0.54±0.05, ShamAV-Shunt vs. AV-shunt; p<0.05) was the main determinant. Furthermore, prolongation of active relaxation occurred to a greater extent in case of PO. In addition, increased myocardial stiffness was only observed in PO-induced HF. Conclusion: Systolic function was reduced in both HF models. However, different factors underpinned the impaired VAC in case of VO (reduced LV contractility) and PO (increased arterial elastance). Furthermore, although diastolic function deteriorated in both models, it occurred to a greater extent in case of PO.

scholarly journals Surgical treatment of secondary mitral regurgitation in heart failure: a present-day view

2021 ◽  
Vol 13 (1) ◽  
pp. 40-48
Author(s):  
E. G. Agafonov ◽  
M. A. Popov ◽  
D. I. Zybin ◽  
D. V. Shumakov
Keyword(s):  
Heart Failure ◽  
Mitral Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Volume Overload ◽  
Left Ventricular ◽  
Functional Class ◽  
Functional Mitral Regurgitation ◽  
Admission Rates ◽  
Replacement Surgery

Rationale. Secondary, or functional, mitral regurgitation is the most common complication of heart failure. Dysfunction of one or more mitral valve structures occurs in 39–74% of patients thus complicating the course of the disease and significantly worsening the prognosis in patients with left ventricle dilatation. An unfavorable prognosis in patients with the development of mitral regurgitation is conditioned by the progressive changes that form a vicious circle: the continuing volume overload and dilatation of the left ventricle cause its remodeling, leading to further dilatation of the mitral valve annulus. Dysfunctions of the papillary muscles lead to the increased tension of the left ventricle wall and increased mitral regurgitation. Clinically, this process is manifested by the congestive heart failure progression and worsened prognosis of the further course, which in the future may lead to considering the inclusion of this patient group on the waiting list for heart transplantation.Purpose. The purpose of this article is to review the role of surgical management in patients with heart failure complicated by mitral regurgitation.Conclusions. The main principles of the treatment for functional mitral regurgitation include the reverse left ventricular remodeling and mitral valve repair or replacement surgery which lead to an improved quality of life, the transition of patients to a lower functional class, reduced hospital admission rates, and also to a regression or slower progression of the heart failure and to an improved survival.

scholarly journals Left ventricular reverse remodeling after successful subannular mitral valve repair in end-stage heart failure: a case report

2020 ◽  
Vol 4 (3) ◽  
pp. 1-5
Author(s):  
Jonas Pausch ◽  
Tatiana Sequeira Gross ◽  
Hermann Reichenspurner ◽  
Evaldas Girdauskas
Keyword(s):  
Heart Failure ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Valve Repair ◽  
Left Ventricular ◽  
Papillary Muscles ◽  
Valve Repair ◽  
Lv Remodeling ◽  
End Stage Heart Failure ◽  
End Stage

Abstract Background Due to ongoing left ventricular (LV) remodeling and consecutive geometric displacement of both papillary muscles, end-stage heart failure is frequently associated with relevant functional mitral regurgitation (FMR) Type IIIb. Treatment strategies of FMR and their prognostic impact are still controversial. Case summary We present a case of an 80-year-old patient who suffered from recurrent symptoms of congestive heart failure due to dilated cardiomyopathy and concomitant severe FMR. To specifically address severe tethering of both mitral leaflets heart team decision was to perform minimally invasive mitral valve repair (MVR) including a subannular LV remodeling procedure, instead of an interventional edge-to-edge repair (MitraClip® procedure). In addition to mitral valve ring annuloplasty, standardized relocation of both papillary muscles was performed successfully, leading to a complete resolution of mitral leaflet tethering. There were no procedural complications and the patient was discharged with an excellent functional result without residual mitral regurgitation. Furthermore, after 12 and 24 months, he reported an increase of his functional exercise capacity and a remarkable reverse LV remodeling could be demonstrated. Discussion Novel subannular repair techniques, especially the relocation of both papillary muscles, specifically address severe leaflet tethering in FMR and have an obvious potential to improve long-term competence of MVR. Therefore, they could be considered as a viable therapeutic option even in elderly patients presenting with end-stage cardiomyopathy and severe leaflet tenting.

Volume overload hypertrophy in a closed-chest model of mitral regurgitation

1988 ◽  
Vol 254 (6) ◽  
pp. H1034-H1041 ◽  
Author(s):  
J. P. Kleaveland ◽  
W. G. Kussmaul ◽  
T. Vinciguerra ◽  
R. Diters ◽  
B. A. Carabello
Keyword(s):  
Cardiac Output ◽  
Mitral Regurgitation ◽  
Diastolic Pressure ◽  
Volume Ratio ◽  
Volume Overload ◽  
Canine Model ◽  
Left Ventricular ◽  
Closed Chest ◽  
Cardiac Decompensation ◽  
End Diastolic Volume

Chronic volume overload hypertrophy as seen in mitral regurgitation in humans eventually may cause left ventricular dysfunction. Longitudinal study of the mechanisms leading to such dysfunction is difficult in humans and more easily performed in an animal model. In this study, we describe a canine model of volume overload hypertrophy produced by mitral regurgitation. An arterially placed grasping forceps was used to disrupt mitral chordae or leaflets; thus mitral regurgitation was produced without the need for thoracotomy. Eleven of 22 dogs had severe mitral regurgitation (regurgitant fraction greater than 0.50) and survived for greater than or equal to 3 mo (average 9.2 +/- 6 mo) after the production of mitral regurgitation. At 3 mo, end-diastolic volume increased from 48 +/- 9 to 85 +/- 19 ml, P less than 0.01. Left ventricular mass increased from 71 +/- 13 to 90 +/- 10 g, P less than 0.01. Left ventricular end-diastolic pressure increased from 9 +/- 3 to 19 +/- 6 mmHg, P less than 0.01. Cardiac output decreased from 2.3 +/- 0.61 to 1.80 +/- 0.64 l/min, P less than 0.05. The mass-to-volume ratio decreased from 1.44 +/- 0.17 to 1.09 +/- 0.13, P less than 0.01. We conclude that this closed-chest model of chronic mitral regurgitation produces significant eccentric cardiac hypertrophy. Despite a doubling of end-diastolic volume, there was a fall in cardiac output and a rise in left ventricular end-diastolic pressure, suggesting cardiac decompensation.

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

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.

TNF-α and myocardial matrix metalloproteinases in heart failure: relationship to LV remodeling

2002 ◽  
Vol 282 (4) ◽  
pp. H1288-H1295 ◽  
Author(s):  
William S. Bradham ◽  
Gordon Moe ◽  
Katherine A. Wendt ◽  
Amelia A. Scott ◽  
Andrea Konig ◽  
...  
Keyword(s):  
Heart Failure ◽  
Matrix Metalloproteinases ◽  
Concomitant Administration ◽  
Left Ventricular ◽  
Myocardial Remodeling ◽  
End Diastolic Volume ◽  
Central Hypothesis ◽  
Tnf Α ◽  
Lv Remodeling ◽  
Cytokine Tumor Necrosis Factor

The cytokine tumor necrosis factor (TNF)-α has been causally linked to left ventricular (LV) remodeling, but the molecular basis for this effect is unknown. Matrix metalloproteinases (MMPs) have been implicated in cardiac remodeling and can be regulated by TNF-α. This study tested the central hypothesis that administration of a TNF-α blocking protein would prevent the induction of MMPs and alter the course of myocardial remodeling in developing LV failure. Adult dogs were randomly assigned to the following groups: 1) chronic pacing (250 beats/min, 28 days, n = 12), 2) chronic pacing with concomitant administration of a TNF-α blocking protein (TNF block) using a soluble p75 TNF receptor fusion protein (TNFR:Fc; administered at 0.5 mg/kg twice a week subcutaneously, n = 7), and 3) normal controls ( n = 10). LV end-diastolic volume increased from control with chronic pacing (83 ± 12 vs. 118 ± 10 ml, P < 0.05) and was reduced with TNF block (97 ± 9 ml, P < 0.05). MMP zymographic levels (92 kDa, pixels) increased from control with chronic pacing (36,848 ± 9,593 vs. 87,247 ± 12,912, P < 0.05) and was normalized by TNF block. Myocardial MMP-9 and MMP-13 levels by immunoblot increased with chronic pacing relative to controls (130 ± 10% and 118 ± 6%, P < 0.05) and was normalized by TNF block. These results provide evidence to suggest that TNF-α contributes to the myocardial remodeling process in evolving heart failure through the local induction of specific MMPs.

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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