Mitral Tissue Research Articles

Better diastolic function in CRT candidates is associated with improved survival after CRT implantation

The relationship between diastolic dysfunction (DD) and outcome after CRT is debated. The purpose of this study was to evaluate the role of DD in predicting all-cause mortality in heart failure patients undergoing CRT. One-hundred ninety-three patients (age: 67 ± 11 years, QRS width: 167 ± 21 ms, LVEF 28 ± 8%) were included in this multicentre prospective study. Mitral filling pattern, mitral tissue Doppler velocity, tricuspid regurgitation velocity, and indexed left atrial volume were used to classify DD from grade I to III according to the 2016 recommendations of the American Society of Echocardiography/European Association of Cardiovascular Imaging. A reduction of LV end-systolic volume > 15% at 6-month follow-up (FU) identified CRT-responders and was observed in 132 (68%) patients. During a median 35 months FU, 29 (15%) patients died. Through multivariable analysis, coronary artery disease [HR 2.21 (1.00–4.89) P = 0.05], NYHA [HR 2.92 (1.45–5.87), P = 0.003] and grade I DD [HR 0.34 (0.13–0.89)] were shown to be independent predictors of prognosis ( Table 1 ). Grade I DD was associated with a longer survival rate in both responders and non-responders ( Fig. 1 ). Non-responders with grade II-III DD had the worse outcome [HR 12.5 (3.56–44.04), P < 0.0001] Better diastolic function at baseline is associated with improved survival after CRT implantation, independently of CRT-response.

Assessment of the Impact of Percutaneous Coronary Intervention to Chronic Total Occlusion on the Ventricular Performance Using Different Echo-Doppler Modalities

Background: Chronic total occlusion (CTO) of coronary arteries represents one of the most challenging targets of lesion recanalization with percutaneous coronary intervention (PCI). The rationale for recanalization of CTO is the possible improvement of ventricular function. Different echo-Doppler modalities can be used for the assessment of ventricular performance with reported superiority of the newer modalities. Aim: To assess the impact of successful percutaneous coronary intervention for chronic totally occluded vessel on the ventricular performance using different echo-Doppler modalities. Methods: This study enrolled 30 patients with CTO for whom PCI was performed. Patients were subjected to thorough clinical assessment, Echo-Doppler evaluation of LV and RV functions before, within 48-hrs after successful PCI and one-month later, Echo-Doppler parameters included LV dimension, LV volumes, biplane and 3D-LV ejection fraction (LVEF), mitral Doppler-flow velocities (E, A & E/A), mitral valve early deceleration time (MV-EDT), mitral tissue Doppler systolic & diastolic annular velocities (Sa, Ea and Aa), LV global longitudinal strain (GLS). Results: There was no significant improvement of parameters reflecting LV function comparing the pre and 48-hrs post PCI. On the other hand, significant improvement was detected comparing the echo-Doppler measures of either the pre or 48-hours after PCI with those of one-month later. There was significant increase of biplane-LVEF (p

Abstract 16029: Patient Prosthesis Mismatch Post Transcatheter Aortic Valve Replacement is Associated With Lack of Improved Left Ventricular Diastolic Function

Background: Patient prosthesis mismatch (PPM) is a frequent problem after transcatheter aortic valve replacement (TAVR) that results in adverse cardiac remodeling. This study sought to evaluate the association between PPM and changes in diastolic function post-TAVR. Methods: 339 patients (79.3+8.8 y, 44.4% female) who underwent TAVR for severe aortic stenosis between 2015-2018 with an echocardiogram (echo) at baseline and at 1-year were studied. Echo measurements were performed according to ASE guidelines. Moderate PPM is defined by an indexed effective orifice area (iEOA) of &lt;0.85 to &gt;0.65 cm 2 /m 2 , and severe PPM by an iEOA &lt;0.65 cm 2 /m 2 . The aortic valve acceleration to ejection time ratio (AT/ET) was measured to further stratify patients with PPM and considered abnormal if &gt;0.35. Student’s t-tests were used to compare diastolic function at baseline and 1-year. Results: We found that 26.2% of subjects had moderate PPM, 11.8% had severe PPM, and 8.3% had an AT/ET &gt;0.35 (Table 1). Tissue velocity at both the medial and lateral mitral annulus was reduced at baseline and did not improve. Left atrial pressure (LAP) as assessed by E/e` improved in those without PPM (19.5+9.5 to 18.8+9.6, p=0.04) and those with moderate PPM (21+12.2 to 18.2+6.9, p=0.03), but not in those with severe PPM or with AT/ET&gt;0.35. Right ventricular systolic pressure (RVSP) decreased significantly in patients with no or moderate PPM (39.6+13.6 mmHg to 35.5+10.8 mmHg, p=0.02 and 41.2+13.9 mmHg to 36+10.8 mmHg, p=0.006; respectively), while there was no significant decrease for patients with severe PPM or with AT/ET&gt;0.35. Conclusion: We found that in patients undergoing TAVR, diastolic function was impaired as evidenced by low mitral tissue velocities, elevated LAP, and elevated RVSP. PPM resulted in less improvement of diastolic parameters including no improvement in LAP and RVSP. These findings suggest that severe PPM has an adverse effect on cardiac remodeling.

Identifying adolescent and young adult patients with sickle cell disease at highest risk of death.

Identifying adolescent and young adult patients with sickle cell disease at highest risk of death.

Better diastolic function in CRT candidates is associated with improved survival after CRT implantation

Abstract Background The relationship between diastolic dysfunction (DD) and outcome after CRT is debated. Purpose Purpose of this study was to evaluate the role of DD in predicting all-cause mortality in heart failure patients undergoing CRT. Methods One-hundred ninety-three patients (age: 67±11 years, QRS width: 167±21 ms, LVEF 28±8%) were included in this multicentre prospective study. Mitral filling pattern, mitral tissue Doppler velocity, tricuspid regurgitation velocity, and indexed left atrial volume were used to classify DD from grade I to III according to the 2016 recommendations of the American Society of Echocardiography/European Association of Cardiovascular Imaging. A reduction of LV end-systolic volume &amp;gt;15% at 6-month follow-up (FU) identified CRT-responders and was observed in 132 (68%) patients. Results During a median 35 months FU, 29 (15%) patients died. Through multivariable analysis, coronary artery disease, NYHA functional class and grade I DD were shown to be independent predictors of prognosis (Table 1). Grade I DD was associated with a longer survival rate in both responders and non responders (Figure 1). Non responders with grade II-III DD had the worse outcome (HR 12.5 [3.56–44.04], p&amp;lt;0.0001). Conclusions Better diastolic function at baseline is associated with an improved survival after CRT implantation, independently of CRT-response. Funding Acknowledgement Type of funding source: None

Left atrial myocardial function and compliance in pre-eclampsia with preserved left ventricular systolic and diastolic function.

Left atrial (LA) adaptive changes associated with pre-eclampsia (PE) have not been adequately addressed. This study aimed to evaluate the usefulness of LA myocardial function indices in detecting early cardiac alterations in PE. Using speckle tracking echocardiography (STE), LA volumetric and myocardial parameters were acquired in PE women with preserved left ventricular (LV) systolic and diastolic function based on standard criteria and normotensive controls. LA compliance was assessed by the ratio of reservoir strain (LASr) to the estimated LA pressure (E/e'). Subtle systolic and diastolic abnormalities were identified as LV global longitudinal strain < 17.8% and mitral tissue e' velocity < 7cm/s septal or < 10cm/s lateral, respectively. LASr/(E/e') was prior to other LA measurements in detecting early LA function changes in PE. The rate of LASr/(E/e') < 3 was significantly greater in the patients with subtle systolic impairments than those without (P < 0.05) in spite of similar proportion of LASr < 31% between them. Among PE women with subtle diastolic damages, the frequencies of anomaly and the values in both LASr/(E/e') and LASr were significantly different to those without (P < 0.05). Moreover, the rate of LASr/(E/e') < 3 was markedly higher than that of LASr < 31% in PE cases with subtle cardiac abnormalities (P < 0.05). In the setting of PE with preserved systolic and diastolic function, STE-derived LA strain and estimated LA compliance may be beneficial to identifying earlier cardiac alternations. LA compliance could outperform LASr in detecting cardiac anomalies earlier during a PE pregnancy with preserved LV performance.

Assessing the left atrium of childhood cancer survivors.

Survivors of childhood cancer are at risk of cancer therapy-related cardiac dysfunction (CTRCD) characterized by systolic impairment, with little known about diastolic function. Left atrial strain (LAS) is a surrogate measure of left ventricular filling. We hypothesized that survivors (1) have lower LAS versus controls, and (2) survivors exposed to higher anthracycline dosage have even lower LAS. Cross-sectional study of 45 survivors exposed to anthracyclines ≥ 1year after chemotherapy and 45 healthy controls. Echo variables included mitral spectral and tissue Doppler, left ventricular ejection fraction (LV EF), LV dimension, LA volume, LV global longitudinal strain (GLS), and LAS. Peak strain (Ɛ) and strain rate (SR) at three phases were obtained: atrial contraction (ac), reservoir (res), and conduit (con). Two sub-analyses of cancer survivors were performed: (1) those with anthracycline dosage ≥ 250mg/m2, and (2) those with Ɛres in the lowest quartile. On the whole, survivors had lower Ɛres and Ɛcon values. The majority of survivors had relatively normal LAS, while a subset had very low LAS values and were more likely to be older. Survivors exposed to ≥ 250mg/m2 anthracycline also had lower Ɛres than those < 250mg/m2. There were no differences in mitral spectral/tissue Doppler, LV dimension, left atrial volume, or GLS. A subset of childhood cancer survivors have lower LAS than their healthy counterparts, while most are essentially normal. Those exposed to higher anthracycline dosage have even lower Ɛres. Longitudinal study of LAS may prove useful in monitoring for CTRCD.

Potential mechanism of left ventricular spherical remodeling: association of mitral valve complex-myocardium longitudinal tissue remodeling mismatch.

Since mitral valve (MV) complex (MVC) longitudinally bridges left ventricular (LV) base end and its middle, insufficient MVC longitudinal tissue length (TL) elongation relative to whole LV myocardial longitudinal TL elongation could limit LV-base-longitudinal-TL elongation, leading to predominant LV-base-transverse-TL elongation, constituting LV spherical remodeling. In 30 patients with dilated cardiomyopathy (DCM), 30 with aortic regurgitation (AR), and 30 controls, LV sphericity, LV-apex- or base-transverse- and longitudinal-TL, MVC-longitudinal-TL, and whole-LV-longitudinal-TL were measured by three-dimensional (3D) echocardiography. Ratio of each measure versus mean normal value (i.e., LV-apex-transverse-TL ratio) was considered to express the directional and regional tissue elongation. [LV-base-longitudinal-TL ratio/global-LV-TL ratio] and [MVC-longitudinal-TL ratio/whole-LV-longitudinal-TL ratio] were obtained as the degree of LV-base-longitudinal-TL or MVC-longitudinal-TL elongation relative to the whole LV elongation. LV-apex-transverse-, LV-apex-longitudinal-, and LV-base-transverse-TL ratios were significantly increased (1.27 to 1.42, P < 0.01) in both DCM and AR, while the LV-base-longitudinal-TL ratio was not increased in DCM [1.04 ± 0.19, not significant (ns)] and only modestly increased in AR (1.12 ± 0.21, P < 0.01). Whole-LV-longitudinal-TL ratio was significantly increased in both DCM and AR (1.22 ± 0.18 and 1.20 ± 0.16, P < 0.01), while MVC-longitudinal-TL ratio was not or only modestly increased in both groups (1.07 ± 0.15, ns, and 1.12 ± 0.17, P = 0.02, respectively). Multivariable analysis revealed that LV sphericity was independently related to a reduced [LV-base-longitudinal-TL ratio/global-LV-TL ratio] (standard β = -0.42, P < 0.01), which was further related to a reduced [MVC-longitudinal-TL ratio/whole-LV-longitudinal-TL ratio] (standard β = 0.72, P < 0.01). These are consistent with the hypothesis that relatively less MVC-longitudinal-TL elongation in the process of primary LV myocardial tissue elongation may limit LV-base-longitudinal-TL elongation, contributing to LV spherical remodeling.NEW & NOTEWORTHY Left ventricular (LV) spherical remodeling is associated with poor prognosis and less-effective cardiac performance, which commonly develops in dilated cardiomyopathy. However, its mechanism remains unclear. We hypothesized and subsequently clarified that less mitral valve complex (MVC) tissue longitudinal elongation relative to whole LV myocardial tissue longitudinal elongation is related to disproportionately less LV base longitudinal versus transverse myocardial tissue elongation, constituting spherical remodeling. This study suggests modification of MVC tissue elongation could be potential therapeutic targets.

Wrinkle-induced tear in the mitral valve leaflet tissue: a computational model

In this study, we offer a numerical platform to detect the locations of high-stress zones in the prosthetic heart valve, in the mitral position, during the closing phase due to existing wrinkles. The intended prosthetic valves in this study have the same shape as the native mitral valve but made of synthetic biomaterials. We assume the most high-risk locations for ruptures to either initiate or propagate are at the base of existing wrinkles. We developed a finite element model for the human mitral valve. A mesh model was effectively created to account for the uneven stress distribution and high-stress concentration zones in the valve tissue structure. The constitutive material model used in this study is anisotropic and hyperelastic such that the membrane elements are used for the leaflets and spar elements are utilised for the mitral valve cords for which it was assumed flexural stiffness is insignificant for both sets of elements. We developed a novel and effective computational model for the simulation of wrinkles in the valve leaflet during the closing phase. The proposed numerical model provided a quick but precise assessment for the detection of locations of rips and tears on the leaflet tissue during the closing phase. The proposed model is an essential step for the design of material and geometry of leaflets of prosthetic heart valves made of polymers or tissue materials in the mitral position.

The role of pulmonary function in patients with heart failure and preserved ejection fraction: Looking beyond chronic obstructive pulmonary disease.

BackgroundThe prognostic value of chronic obstructive pulmonary disease (COPD) as a comorbidity in heart failure has been well documented. However, the role of pulmonary function indices in patients with heart failure and preserved ejection fraction (HFpEF) remains to be elucidated.MethodsSubjects with HFpEF received pulmonary function tests and echocardiogram. Total lung capacity (TLC), residual volume (RV), forced expiratory flow rate between 25% and 75% of vital capacity (FEF25-75), forced expiratory volume in the 1st second (FEV1), forced vital capacity (FVC), and vital capacity (VC) were measured. Echocardiographic indices, including pulmonary artery systolic pressure (PASP), the ratio of early ventricular filling flow velocity to the septal mitral annulus tissue velocity (E/e’), and left ventricular mass (LVM), were recorded. National Death Registry was linked for the identification of mortality.ResultsA total of 1194 patients (72.4±13.2 years, 59% men) were enrolled. PASP, E/e’ and LVM were associated with either obstructive (RV/TLC, FEV1 and FEF25-75) or restrictive (VC and TLC) ventilatory indices. During a mean follow-up of 23.0±12.8 months, 182 patients died. Subjects with COPD had a lower survival rate than those without COPD. While VC, FVC, RV/TLC, and FEV1 were all independently associated with all-cause mortality in patients without COPD, only FEF25-75 was predictive of outcomes in those with COPD.ConclusionsThe abnormalities of pulmonary function were related to the cardiac hemodynamics in patients with HFpEF. In addition, these ventilatory indices were independently associated with long-term mortality, especially in those without COPD.

Impairment of coronary flow and left ventricular function in patients with slow coronary flow phenomenon and other types of microvascular angina

Purpose: We aimed at assessing the impairment in coronary flow and left ventricular function in patients without obstructive coronary disease on anti-ischemic treatment admitted with diagnosis unstable angina. Material and methods: The epicardial coronary flow was evaluated in 71 patients with unstable angina in absence of coronary stenosis &gt;50% applying the methods the corrected TIMI frame count and systolic arrest of coronary flow at coronary angiography. The abnormalities in the diastolic function were assessed by echocardiography using PW-Doppler of the diastolic mitral flow and tissue Doppler imaging. Results: The early diastolic velocity of interventricular septum (E’sept) and left ventricular free wall (E’ lat) were reduced in the SFLVH group compared to SCFP and the patients with normal coronary flow. Significant difference was found in between the patients with SFLVH and SCFP regarding DT and A-wave velocity in sub-analysis. The epicardial coronary flow of the patients with SFLVH was as tendency impaired compared to SCFP. The therapy with β- blocker alone or combined with calcium channel blocker or nitrate did not influence either cardiac function or coronary flow in this analysis. Conclusion: Slower left ventricular relaxation is typical for the patients with microvascular angina and left ventricular hypertrophy associated with hypertension on treatment compared to SCFP and patients with normal coronary flow.

Real-time three-dimensional echocardiography predicts cardiotoxicity induced by postoperative chemotherapy in breast cancer patients.

BACKGROUNDThe anthracycline chemotherapeutic drugs are cardiotoxic. Studies have found some indicators related to cardiotoxicity. However, there is currently no accurate indicator that can predict cardiac toxicity early.AIMTo explore the diagnostic value of real-time three-dimensional echocardiography (RT3DE) in predicting cardiac toxicity in breast cancer patients undergoing chemotherapy.METHODSFemale breast cancer patients who underwent radical mastectomy and postoperative chemotherapy at the Affiliated Hanzhou First People’s Hospital, Zhejiang University School of Medicine were recruited. All patients were routinely administered with chemotherapy for four cycles (T1-T4) after surgery. Two-dimensional (2D) echocardiography, RT3DE, and serological examinations were performed after each cycle of chemotherapy. Patients were divided into a toxic group and a non-toxic group based on whether patients had Δ left ventricular ejection fraction > 10% after one year of chemotherapy. Repeated measurement analysis of variance was used to compare the changes in 2D echocardiographic indicators, serological indicators, and RT3DE indicators before and after chemotherapy. Multivariate logistic regression was used to identify independent predictive indicators for cardiac toxicity in postoperative chemotherapy patients. Receiver operating characteristics (ROC) curve analysis was performed to analyze the diagnostic value of potential indicators in the diagnosis of cardiotoxicity.RESULTSA total of 107 female breast cancer patients were included in the study. T4 maximum peak velocity in early diastole (E peak)/mitral annulus lateral tissue Doppler (e' peak) (E/e'), serological indicators [T4 cardiac troponin I (cTnI) and T4 pro-brain natriuretic peptide (Pro-BNP)], T3 minimum left atrial volume (LAV), T4 LAVmin, T3 LAV before the start of the P wave (LAVprep), and T4 LAVprep in the toxicity group were significantly higher than those in the non-toxic group. Multivariate logistic regression found that T4 cTnI, T4 Pro-BNP, T3 LAVmin, T4 LAVmin, T3 LAVprep, and T4 LAVprep had potential predictive value for cardiac toxicity (P < 0.05). ROC results showed that T4 LAVmin had the highest accuracy for diagnosing cardiac toxicity [area under the curve (AUC) = 0.947; sensitivity = 78.57%; specificity = 94.62%], followed by T4 LAVprep (AUC = 0.899; sensitivity = 100%; specificity = 66.67%). The accuracies of LAVprep and LAVprep in predicting cardiac toxicity were higher than those of T3 LAVmin and T3 LAVprep.CONCLUSIONRT3DE of left atrial volume can be used to predict the cardiotoxicity caused by chemotherapy, and it is expected to guide the clinical adjustment of dose and schedule in time.

The ventilatory abnormalities and prognostic values of H2 FPEF score in dyspnoeic patients with preserved left ventricle systolic function.

AimsHeart failure with preserved ejection fraction (HFpEF) is one of the major diagnoses in dyspnoeic subjects, and H2FPEF score enables robust differentiation of HFpEF. Given ventilatory abnormalities prevail in subjects with HFpEF, the associations between H2FPEF score and pulmonary function remain to be elucidated.Methods and resultsSubjects who presented with exertional dyspnoea and had left ventricular ejection fraction of >50% were eligible for this study. Total lung capacity, forced expiratory volume in the 1 s, and forced vital capacity (FVC) were obtained by pulmonary function tests. Pulmonary artery systolic pressure (PASP), the ratio of early ventricular filling flow velocity to the septal mitral annulus tissue velocity (E/e'), and left ventricular mass (LVM) were measured by echocardiogram. Among a total of 5849 participants (65.6 ± 6.4 years, 54% men), 2453 (41.9%) had low H2FPEF score (0 ~ 1) and 160 (2.7%) had high H2FPEF score,6~9 respectively. Subjects with high H2FPEF score were older and had higher proportion of restrictive and obstructive defect, more morbidities, poorer renal function, lower haemoglobin, higher LVM, E/e' ratio, and PASP. During a mean follow‐up duration of 30.0 ± 20.5 months, the H2FPEF score was significantly associated with mortality [hazard ratio and 95% confidence intervals, 1.063(1.010–1.18)], independent of sex, haemoglobin, renal function, LVM, and comorbidities.ConclusionsEither obstructive or restrictive ventilation defects prevail in subjects with high H2FPEF score, indicating chronic obstructive pulmonary disease (COPD) is commonly associated with HFpEF. In addition, H2FPEF score was correlated with long‐term survival in dyspnoeic subjects with or without concomitant diseases of HFpEF and COPD.

A New Role for the Aldosterone/Mineralocorticoid Receptor Pathway in the Development of Mitral Valve Prolapse.

Mitral valve prolapse (MVP) is one of the most common valvular disorders. However, the molecular and cellular mechanisms involved in fibromyxomatous changes in the mitral leaflet tissue have not been elucidated. Aldosterone (Aldo) promotes fibrosis in myocardium, and MR (mineralocorticoid receptor) antagonists (MRAs) improve cardiac function by decreasing cardiac fibrosis. We investigated the role of the Aldo/MR in the fibromyxomatous modifications associated with MVP. Aldo enhanced valvular interstitial cell activation markers and induced endothelial-mesenchymal transition in valvular endothelial cells, resulting in increased proteoglycan secretion. MRA blocked all the above effects. Cytokine arrays showed CT-1 (cardiotrophin-1) to be a mediator of Aldo-induced valvular interstitial cell activation and proteoglycan secretion and CD (cluster of differentiation) 14 to be a mediator of Aldo-induced endothelial-mesenchymal transition and proteoglycan secretion in valvular endothelial cells. In an experimental mouse model of MVP generated by nordexfenfluramine administration, MRA treatment reduced mitral valve thickness and proteoglycan content. Endothelial-specific MR deletion prevented fibromyxomatous changes induced by nordexfenfluramine administration. Moreover, proteoglycan expression was slightly lower in the mitral valves of MVP patients treated with MRA. These findings demonstrate, for the first time, that the Aldo/MR pathway regulates the phenotypic, molecular, and histological changes of valvular interstitial cells and valvular endothelial cells associated with MVP development. MRA treatment appears to be a promising option to reduce fibromyxomatous alterations in MVP.

Biventricular diastolic dysfunction, thrombocytopenia, and red blood cell macrocytosis in experimental pulmonary arterial hypertension.

Pulmonary arterial hypertension is a fatal disease, where death is associated with right heart failure and reduced cardiorespiratory reserve. The Sugen 5416, hypoxia and normoxia Fischer rat model mimics human pulmonary arterial hypertension, although the cause(s) of death remains incompletely understood. Here, we hypothesized that these animals develop biventricular diastolic dysfunction that contributes to tissue hypoperfusion coincident with severe pulmonary arterial hypertension. We performed comprehensive echocardiographic and hematologic assessments. Serial echocardiogram at 3–5 weeks was performed followed by blood sampling via aortic or cardiac puncture. Echocardiogram revealed pulmonary arterial hypertension in pulmonary artery Doppler waves, including notched wave envelopes, and decreased pulmonary artery acceleration time/pulmonary artery ejection time ratio and right ventricular outflow tract velocity time integral. Impaired right ventricular systolic function, assessed by decreased tricuspid annular plane systolic excursion and tricuspid tissue Doppler systolic positive wave velocity, was observed in pulmonary arterial hypertension. Tricuspid and mitral pulsed wave and tissue Doppler findings suggested biventricular diastolic dysfunction, with dynamic changes in early and late diastolic filling waves, their fusion patterns, and a decrease in e' velocity. Heart rate and ejection fraction did not change, but cardiac output, stroke volume, and end-diastolic volume were decreased, and inferior vena cava respiratory variation was decreased. Blood electrolyte values were suggestive of intravascular volume expansion early in the disease followed by volume contraction and tissue hypoperfusion in the latter stages of disease. Complete blood count showed thrombocytopenia and non-anemic macrocytosis with reticulocytosis and an increase in red blood cell distribution width. Thus, pulmonary, cardiac, and hematological findings in Fischer animals with pulmonary arterial hypertension are characteristic of humans and provide an insightful experimental platform to resolve mechanisms of disease progression.

Outcomes of Degenerative Mitral Valve Repair Surgery for Anterior, Posterior, and Bileaflet Pathology

Degenerative mitral valve disease involving anterior leaflet pathology is considered less favorable regarding durability of surgical repair than isolated posterior leaflet disease. We aimed to compare the outcomes of patients undergoing mitral valve repair for anterior, posterior, and bileaflet pathologies, and to investigate predictors for repair failure. Of the 760 consecutive patients with degenerative leaflet disease who underwent mitral valve repair, 485 (64%) had posterior, 223 (29%) had bileaflet, and 52 (7%) had anterior leaflet pathology. Mean age was 58 ± 12, 54 ± 14, and 58 ± 17 years, respectively (P= .001). Mean follow-up was 67 ± 47 months. There was no in-hospital or 30-day mortality. Freedom from reoperation was 97%, 95%, and 92%, respectively, and there were 25 (5%), 9 (4%), and 1 (2%) late deaths in the posterior, bileaflet, and anterior groups, respectively (not significant). Late echocardiography revealed that 94%, 97%, and 96% of patients (posterior, bileaflet, and anterior groups respectively) were free from moderate-severe or severe mitral regurgitation (P= .375). Postoperative residual mild mitral regurgitation emerged as the strongest predictor for recurrent mitral regurgitation (grade 3/4) at follow-up (hazard ratio= 2.36; 95% confidence interval, 1.30-4.29; P= .005). Unlike patients with excess mitral tissue, among patients with fibroelastic deficiency or those who underwent major leaflet resection, the use of larger ring annuloplasty was associated with recurrent mitral regurgitation (hazard ratio= 1.31/ring size increment; P < .001). Mitral valve repair can be achieved with excellent early and intermediate results across all valve pathologies. Further studies are required to determine the potential long-term impact of the underlying pathology on the rate of recurrent mitral regurgitation.

Tissue doppler imaging for estimation of left ventricular filling pressure in patients with systolic and diastolic heart failure: a comparative simultaneous doppler catheterization study

Background: Noninvasive assessment of diastolic filling by Doppler echocardiography provides important information about left ventricular (LV) status in selected subsets of patients. This study was designed to assess whether the lateral mitral annular velocity as assessed by tissue Doppler imaging is associated with invasive measures of diastolic LV performance in patients with diastolic and systolic heart failure. Aim of the study was to compare the diagnostic accuracy of lateral mitral annular E/E′ as an estimate of LV filling pressure with invasive LVEDP measurement in subjects with systolic or purely diastolic heart failure.Methods: Total 100 patients were studied, 50 patients with diastolic heart failure and 50 patients with systolic heart failure in patients undergoing diagnostic coronary angiogram. Detailed 2D Echocardiography, Trans mitral Doppler and Tissue Doppler velocities of lateral mitral annulus was obtained. The ratio of peak mitral velocity (E) to lateral mitral annular velocity (E′) by TDI (E/E′) was calculated.Results: The ratio of E/E′ in diastolic group was 13.4±4.9 and in systolic group it was 13.7±5.2. The mean LVEDP in diastolic heart failure patients was 14.3±4.5 and 14.2±4.9 in systolic heart failure patients. The ratio of E/E′ showed a better correlation with LVEDP. E/E′ &lt;8 accurately predicted normal LVEDP, and E/E′ &gt;15 identified increased LVEDP ≥15mmHg.Conclusions: E/E′ is a reliable estimate of LV filling pressures in subjects with systolic and diastolic heart failure. In subjects with diastolic heart failure, E/E′ seems helpful to identify those with truly elevated LV filling pressures. In patients with diastolic heart failure and normal E/E′, a search for other causes of symptoms (pulmonary disease, obesity and so forth) may be warranted.

Integration of polarized spatial frequency domain imaging (pSFDI) with a biaxial mechanical testing system for quantification of load-dependent collagen architecture in soft collagenous tissues

Collagen fiber networks provide the structural strength of tissues, such as tendons, skin and arteries. Quantifying the fiber architecture in response to mechanical loads is essential towards a better understanding of the tissue-level mechanical behaviors, especially in assessing disease-driven functional changes. To enable novel investigations into these load-dependent fiber structures, a polarized spatial frequency domain imaging (pSFDI) device was developed and, for the first time, integrated with a biaxial mechanical testing system. The integrated instrument is capable of a wide-field quantification of the fiber orientation and the degree of optical anisotropy (DOA), representing the local degree of fiber alignment. The opto-mechanical instrument''s performance was assessed through uniaxial loading on tendon tissues with known collagen fiber microstructures. Our results revealed that the bulk fiber orientation angle of the tendon tissue changed minimally with loading (median ± 0.5*IQR of 52.7° ± 3.3° and 51.9° ± 3.3° under 0 and 3% longitudinal strains, respectively), whereas on a micro-scale, the fibers became better aligned with the direction of loading: the DOA (mean ± SD) increased from 0.149 ± 0.032 to 0.198 ± 0.056 under 0 and 3% longitudinal strains, respectively, p < 0.001. The integrated instrument was further applied to study two representative mitral valve anterior leaflet (MVAL) tissues subjected to various biaxial loads. The fiber orientations within these representative MVAL tissue specimens demonstrated noticeable heterogeneity, with the local fiber orientations dependent upon the sample, the spatial and transmural locations, and the applied loading. Our results also showed that fibers were generally better aligned under equibiaxial (DOA = 0.089 ± 0.036) and circumferentially-dominant loading (DOA = 0.086 ± 0.037) than under the radially-dominant loading (DOA = 0.077 ± 0.034), indicating circumferential predisposition. These novel findings exemplify a deeper understanding of the load-dependent collagen fiber microstructures obtained through the use of the integrated opto-mechanical instrument. Statement of significanceIn this study, a novel quantitative opto-mechanical system was developed by combining a polarized Spatial Frequency Domain Imaging (pSFDI) device with a biaxial mechanical tester. The integrated system was used to quantify the load-dependent collagen fiber microstructures in representative tendon and mitral valve anterior leaflet (MVAL) tissues. Our results revealed that MVAL's fiber architectures exhibited load-dependent spatial and transmural heterogeneities, suggesting further microstructural complexity than previously reported in heart valve tissues. These novel findings were possible through the system's ability to, for the first time, capture the load-dependent collagen architecture in the mitral valve anterior leaflet tissue over a wide field of view (e.g., 10 × 10 mm for the MVAL tissue specimens). Such capabilities afford unique future opportunities to improve patient outcomes through concurrent mechanical and microstructural assessments of healthy and diseased tissues in conditions such as heart valve regurgitation and calcification.

A Rare Case of Left Ventricular Outflow Tract Obstruction 18 Years after a Mechanical Mitral Valve Replacement

Background: Left ventricular outflow tract (LVOT) obstruction is a serious complication that can occur after various mitral-valves, surgical or percutaneous, interventions.&#x0D; It was rarely described in mechanical mitral valve replacements.&#x0D; Aim: to describe a rare case of late LVOT obstruction after a mitral valve replacement by a low-profile mechanical prosthesis.&#x0D; Case Presentation: A 48-year woman, with a history of rheumatic mitral valve disease and mechanical mitral replacement by a hemi-disc valve 18 years ago, presented for a recent dyspnea. Echocardiography showed a narrowing of the LVOT, with anterior position of the mitral prosthesis, aorto-mitral annular angulation, septal thickening and remnant native sub-valvular tissue attached to the septum in the LVOT region. This resulted in LVOT obstruction with a peak gradient of 75 mmHg. The heart team opted for a redo surgery, but the surgical decision was refused by the patient.&#x0D; Discussion: This is a rare case of late LVOT obstruction after mitral valve replacement by mechanical low-profile prosthesis. Preserved native mitral valve tissue, which is the main described cause of LVOT obstruction after mechanical mitral valve replacements was not the unique cause of obstruction in this patient who had also a septal thickening and anterior prosthetic position. Aorto-mitral annular angulation that was identified as a risk factor of LVOT obstruction after trans-catheter mitral valve replacements, should be, probably, also took into account and assessed pre-operatively in patients undergoing surgical mitral replacements.&#x0D; Conclusion: LVOT obstruction can occur after mechanical mitral replacements event with low profile prosthesis. In patients with identified risk factors of LVOT obstruction, preservation mitral anterior leaflet should be avoided, and preservation of other native mitral tissue should be discussed.

DIAGNOSIS AND TREATMENT OF SEVERE AORTIC REGURGITATION IN A 14-YEAR-OLD PATIENT WITH CONNECTIVE TISSUE DISEASE: A CLINICAL CASE

Medical records of a patient presented with severe aortic and mitral regurgitation and connective tissue dysplasia were reviewed. Clinical, laboratory and instrumental findings were collected at baseline and after the surgery. Long-term outcomes, including quality of life, were estimated.