Moderate Secondary Mitral Regurgitation Research Articles

Prognostic value of left atrial and ventricular strain in moderate atrial and ventricular secondary mitral regurgitation

Abstract Background Secondary mitral regurgitation (SMR) is associated with increased morbidity and mortality. In these patients, left ventricular global longitudinal strain (LVGLS) and left atrial reservoir strain (LARS) have been proposed to improve risk stratification. However their prognostic value was shown to be inconsistent when considering the SMR etiology (i.e. atrial or ventricular), possibly due to be the influence of atrial fibrillation (AF) on these measures and specifically LARS. Moreover, data focusing on moderate SMR is lacking. Aim To investigate the prognostic value of LVGLS and LARS in patients with SMR stratified according to etiology, and to identify optimal threshold for both measures. Methods Patients (n=1061; age 68±11years , 59% male) with moderate SMR were retrospectively included and classified as ASMR or VSMR, and further subdivided into "sinus rhythm (SR) subgroup" (ASMR-SR: n=68 , VSMR-SR: n=435) or as "AF subgroup" (ASMR-AF: n=284 , VSMR-AF: n=274), if patients had history of AF. The endpoint was a composite of heart failure events and all-cause mortality. Threshold values for LVGLS and LARS were defined based on spline curve analysis. Results As compared to VSMR, ASMR patients were more frequently female (61% vs. 35%, p<0.001), had less comorbidities and were less symptomatic (i.e. NYHA functional class III-IV in 11% of ASMR vs. 24% of VSMR, p<0.001). For the echocardiographic characteristics, VSMR patients showed lower LV ejection fraction and LVGLS, as compared to ASMR patients. For both ASMR and VSMR, patients in the AF subgroups had larger LA volume index, lower LARS and more severe tricuspid regurgitation (Figure 1). During a median follow-up of 78 (IQR: 44-111) months, 27% of ASMR-SR, 37% of ASMR-AF, 50% of VSMR-SR and 72% of VSMR-AF group reached the combined endpoint. Separated multivariable cox regression analyses were performed in ASMR and VSMR patients (Table 1): for both etiologies, LARS and LVGLS were independently associated with the endpoint after correcting for other significant variables at the univariate analysis, including the SR or AF group and the interventions during follow-up. In addition, a stepwise addition of LVGLS and LARS to a basic model led to a significant difference in the likelihood ratio for both groups. The thresholds of LVGLS and LARS associated with an increased risk of the combined endpoint differed per etiology. For LVGLS the threshold was <16% for ASMR, and <12% for VSMR. When considering LARS assessment, different thresholds were identified according to the SR or AF group: <18% in ASMR-SR; <15% in ASMR-AF; <17% in VFMR-SR and <12% in VFMR-AF. Conclusion In moderate SMR patients, LVGLS and LARS are independently associated with outcomes both in ASMR and VSMR and could be considered to improve risk stratification. However, lower threshold for both parameters should be considered based on etiology and on the presence of AF.

Clinical and echocardiographic parameters associated with outcomes in patients with moderate secondary mitral regurgitation

BackgroundSignificant secondary mitral regurgitation (SMR) is known to be associated with worse prognosis. However, data focusing specifically on moderate SMR and associated risk factors are lacking. In the present study,...

Evaluating Mitral TEER in the Management of Moderate Secondary Mitral Regurgitation Among HeartFailurePatients.

Moderate secondary mitral regurgitation (SMR) represents a subgroup of heart failure (HF) patients with treatment restricted to medical therapy. Outcomes in patients with moderate SMR treated with mitral transcatheter edge-to-edge repair (M-TEER) are less well known. The aim of this study was to assess the safety and effectiveness of M-TEER in subjects with moderate SMR using the EXPANDed studies. One-year outcomes in subjects from the EXPANDed studies (EXPAND [A Contemporary, Prospective Study Evaluating Real-world Experience of Performance and Safety for the Next Generation of MitraClip Devices] and EXPAND G4 [A Post-Market Study Assessment of the Safety and Performance of the MitraClip G4 System] MitraClip studies) with baseline moderate SMR (2+), per echocardiographic core laboratory (ECL) assessment, were compared with subjects with baseline severe SMR (≥3+). There were 335 subjects with moderate SMR and 525 with severe SMR at baseline per ECL review. Baseline characteristics were similar between the 2 subgroups. After treatment with M-TEER, significant MR reduction was achieved in both groups. Significant left ventricular (LV) reverse remodeling was observed through 1 year, with a >20mL decrease in LV end-diastolic and end-systolic volumes on average in the moderate SMR group. Significant 1-year improvements in NYHA functional class (>78% NYHA functional class I or II) and quality of life (>20 points on the Kansas City Cardiomyopathy Questionnaire-Overall Summary) were observed in subjects with moderate SMR. Similarly, low rates of major adverse events, all-cause mortality, and HF hospitalizations were observed between the 2 subgroups through 1 year. In the EXPANDed studies, subjects with moderate SMR treated with M-TEER had improvements similar to subjects with severe SMR in quality of life and positive LV remodeling at 1 year. Future studies are needed to evaluate if M-TEER would be beneficial for HF patients with moderate SMR.

Cardiac function, haemodynamics, and valve competence with exercise in patients with heart failure with preserved ejection fraction and mild to moderate secondary mitral regurgitation.

This study aimed to evaluate the clinical significance of secondary mitral regurgitation (MR) in patients with heart failure with preserved ejection fraction (HFpEF). We conducted a prospective study enrolling consecutively evaluated patients with HFpEF undergoing invasive haemodynamic exercise testing with simultaneous echocardiography. Compared to HFpEF without MR (n = 145, 79.7%), those with mild or moderate MR (n = 37, 20.3%) were older, more likely to be women, had more left ventricular (LV) systolic dysfunction, and more likely to have left atrial (LA) myopathy reflected by greater burden of atrial fibrillation, more LA dilatation, and poorer LA function. Pulmonary artery (PA) wedge pressure was higher at rest in HFpEF with MR (17 ± 5 mmHg vs. 20 ± 5 mmHg, p = 0.005), but there was no difference with exercise. At rest, only 2 (1.1%) patients had moderate MR, and none developed severe MR. Pulmonary vascular resistance was higher, and right ventricular (RV)-PA coupling was more impaired in patients with HFpEF and MR at rest and exercise. LV and LA myocardial dysfunction remained more severe in patients with MR during stress compared to those without MR, characterized by greater LA dilatation during all stages of exertion, lower LA emptying fraction and compliance, steeper and rightward-shifted LA pressure-volume relationships, and reduced LV longitudinal contractile function. Patients with HFpEF and mild or moderate MR have more severe LV systolic dysfunction, LA myopathy, RV-PA uncoupling, and more severe pulmonary vascular disease. Mitral valve incompetence in this setting is a phenotypic marker of more advanced disease but is not a causal factor in development of HFpEF.

Identifying Patients With Secondary Mitral Regurgitation and Heart Failure who may Benefit From Transcatheter Edge-to-Edge Repair in the Wellington Region

As the New Zealand population ages, the incidence of heart failure and valvular disease increases. The Cardiovascular Outcomes Assessment of MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial showed decreased rates of hospitalisation for heart failure and all-cause mortality with transcatheter edge-to-edge repair (TEER) for clinically significant secondary mitral regurgitation (MR) within 24 months of follow-up compared with medical therapy. This retrospective observational study aimed to identify patients who may benefit from TEER in Wellington. This study retrospectively reviewed the electronic records of 337 consecutive patients aged ≥18 years who presented to Wellington Hospital from April to September 2022 with heart failure and identified those who met modified COAPT criteria: at least moderate secondary mitral regurgitation, left ventricular ejection fraction (LVEF) 20%–50% on echocardiography, and who did not meet criteria for cardiac surgery or other valve intervention. Forty patients met the modified COAPT criteria: 27 (68%) were male and 13 (33%) were female. The mean age was 71.7 years. Of them, 55% were New Zealand European, 23% were Pasifika, and 13% were New Zealand Māori. A total of 58% had moderate MR, 33% had moderate–severe MR, and 10% had severe MR; the median LVEF was 30%. The median survival was 309 days in those who met the modified COAPT criteria compared with 365 days in those who did not (non-statistically significant). Among patients who presented to Wellington Hospital with heart failure, a significant proportion (11.9%) had clinically significant secondary MR, who trend towards shorter survival times compared with those who present with heart failure in general. According to international guidelines and trial data such as COAPT, these patients would have potentially benefitted from TEER.

Fate of moderate secondary mitral regurgitation in patients undergoing aortic valve replacement for severe aortic regurgitation.

Moderate secondary mitral regurgitation is common in patients with severe aortic regurgitation, but whether it has to be addressed at the time of aortic valve surgery remains unclear. With this study, we evaluated the long-term fate of moderate secondary mitral regurgitation in this specific scenario. Between January 2004 and January 2018, in 154 patients admitted to our institution for treatment of severe aortic regurgitation, a moderate secondary mitral regurgitation was diagnosed. Ninety-four patients underwent isolated aortic valve replacement (group 1) and 60 patients underwent also concomitant mitral valve annuloplasty (group 2). One death (1.1%) occurred in group 1, whereas two deaths (3.3%) occurred in group 2 (p = .561). At 11 years, the cumulative incidence function of cardiac death, with noncardiac death as a competing risk was 11.5 ± 5.11% in group 1 and 8.3 ± 5.15% in group 2 (p = .731). The cumulative incidence function of mitral valve reintervention, with death as a competing risk, was 3.7 ± 2.61% in group 1 and 4.5 ± 4.35% in group 2 (p = .620) at 11 years. Secondary mitral regurgitation improved to ≤mild in 66% and 76% of the survivors of group 1 and group 2, respectively (p = .67). In our experience, in patients with moderate secondary mitral regurgitation undergoing aortic valve replacement for severe aortic regurgitation, concomitant mitral valve annuloplasty did not improve the long-term survival, the incidence of cardiac death and mitral valve reoperation or the evolution of the mitral valve disease.

November 2021 at a glance: focus on prevention, comorbidities, cardiogenic shock and novel devices.

November 2021 at a glance: focus on prevention, comorbidities, cardiogenic shock and novel devices.

Prognostic Implications of Left Ventricular Myocardial Work Indices in Patients With Secondary Mitral Regurgitation.

Assessment of left ventricular (LV) function in patients with secondary mitral regurgitation (SMR) remains challenging but is an important parameter for risk stratification. The association of LV myocardial work components (work index [GWI], constructive [GCW] and wasted [GWW] work, and work efficiency) derived from pressure-strain loops obtained with speckle tracking echocardiography, and all-cause mortality in patients with SMR was investigated. LV myocardial GWI, GCW, GWW, and global work efficiency were measured with speckle tracking strain echocardiography in 373 patients (72% men, median age 68 years) with various grades of SMR. All-cause mortality was the primary end point. Mild SMR was observed in 143 patients, 128 had moderate SMR, and 102 had severe SMR. Patients with severe SMR had the largest LV volumes and the worst LV ejection fraction and LV global longitudinal strain. In patients with severe SMR, LV GWI and GCW were more impaired (500 mm Hg% versus 680 mm Hg% P=0.024 and 678 mm Hg% versus 851 mm Hg% P=0.006, respectively), while GWW was lower (130 mm Hg% versus 260 mm Hg% P<0.001, respectively) and global work efficiency was significantly higher (82% versus 76%, P=0.001) compared with patients with mild SMR. After a median follow-up of 56 months, 161 patients died. LV GWI≤500 mm Hg%, LV GCW≤750 mm Hg%, and LV GWW<300 mm Hg% were independently associated with excess mortality. Patients with severe SMR had the worst LV GWI and LV GCW but better LV GWW and global work efficiency reflecting the unloading of the LV in the low-pressure left atrial chamber. These parameters were independently associated with worse long-term survival in patients with SMR.

Treating symptoms and reversing remodelling: clinical and echocardiographic 1-year outcomes with percutaneous mitral annuloplasty for mild to moderate secondary mitral regurgitation.

To determine the effects of percutaneous mitral annuloplasty on symptoms, walk distance and left ventricular (LV) structure and function in patients with mild or moderate secondary mitral regurgitation (SMR). This was a pooled analysis of patients (n= 68) who, despite guideline-directed medical therapy had symptomatic heart failure (HF) with mild (n= 25) or moderate (n= 43) SMR treated with percutaneous mitral annuloplasty as part of the TITAN, TITAN II, or REDUCE-FMR trials. Primary outcomes were changes in symptoms, 6-min walk distance, and quality of life assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ) after 1year. Secondary analyses included changes in LV structure and function. At 1 year, New York Heart Association class status was maintained (48%) or improved (46%) in most patients, mean KCCQ scores increased from baseline by 10units [95% confidence interval (CI) 3 to17; P< 0.01] and mean 6-min walk test distance increased by 34 m (95% CI 12 to 57; P< 0.01). SMR grade improved in 25% of patients and was maintained in 58% of patients with changes in mean regurgitant volume of -7mL (95% CI -11 to -3; P< 0.001), vena contracta -0.11 cm (95% CI -0.20 to -0.02; P< 0.05), and effective regurgitant orifice area -0.03 cm2 (95% CI -0.06 to -0.01; P< 0.05). There were non-significant improvements in LV ejection fraction and volumes. Survival over 1year was 89% with no difference between mild (96%) and moderate (86%) SMR (log-rank P= 0.22). Progression-free survival was 70% (82% in mild vs. 63% in moderate SMR; P= 0.16). Freedom from HF hospitalization was 73% (87% in mild SMR vs. 66% in moderate SMR; P= 0.07). Among patients with symptomatic HF and mild or moderate SMR on guideline-directed medical therapy, percutaneous mitral annuloplasty was associated with improvements in symptoms, SMR, a stabilization of LV structure and function, and high survival rates.

Prognostic value of global myocardial constructive work in patients with secondary mitral regurgitation

Abstract Background Left ventricular (LV) myocardial contractility evaluation is of crucial importance in patients with secondary mitral regurgitation (SMR). The most widespread echocardiographic tool, left ventricular ejection fraction (LVEF), might overestimate LV function, since it calculates the volume changes regardless of the flow direction. Global myocardial constructive work (GMCW) might be a more suitable tool, as LV myocardial work derived from pressure-strain loops obtained with speckle tracking echocardiography incorporates non-invasive blood pressure measurements. Purpose To evaluate the prognostic value of LV GMCW in patients with SMR. Methods 378 patients (72% men, median age 68 [range 60 to 74 years]) with various grades of SMR were retrospectively analysed. LV global myocardial constructive work, wasted work and work efficiency were measured with speckle tracking echocardiography. Results There were 145 patients with mild SMR, 130 with moderate SMR and 103 with severe SMR. Patients with severe SMR had larger LV volumes, lower LVEF and more impaired LV GLS. GMCW was more impaired in patients with severe SMR, compared with mild MR (678 mmHg% vs. 845 mmHg% p&amp;lt;0.001 respectively). After a mean follow-up of 59±37 months, 162 patients died. When dividing the population according to prognostically relevant cut offs derived by spline curve analysis, patients with a GMCW≤700 mmHg% had a worse prognosis, compared with their counterparts (Figure 1). Conclusion Global myocardial constructive work ≤700 mmHg% is associated with worse long-term survival in patients with SMR. Kaplan-Meier survival curves Funding Acknowledgement Type of funding source: None

Left ventricular myocardial work in patients with secondary mitral regurgitation

Abstract Background Assessment of left ventricular (LV) function in patients with secondary mitral regurgitation (SMR) remains challenging because LV ejection fraction (LVEF) reflects changes in LV volume without taking into account the direction of the blood flow. LV global longitudinal strain better reflects active LV myocardial deformation but does not incorporate afterload. LV myocardial work derived from pressure-strain loops integrates speckle tracking echocardiography with non-invasive blood pressure measurement. Purpose To evaluate LV myocardial work components to better characterize LV function in patients with SMR. Methods 378 patients (72% men, median age 68 [range 60 to 74 years]) with various grades of SMR were retrospectively analysed. LV myocardial constructive work, wasted work and work efficiency were measured with speckle tracking echocardiography. Results 145 patients had mild SMR, 130 moderate SMR and 103 severe SMR. Patients with severe SMR had larger LV volumes, lower LVEF and more impaired LV GLS (Table 1). While LV constructive work was more impaired in patients with severe SMR, wasted work was lower as compared to mild SMR (Table 1). Consequently, patients with severe SMR had better myocardial work efficiency than patients with mild MR. This could reflect, the regurgitant volume which is pumped into a low pressure chamber (the left atrium) resulting in less myocardial wasted work and preservation of myocardial efficiency. Conclusion In patients with severe SMR, LVEF, LV GLS and myocardial constructive work are more impaired when compared to mild SMR. However, myocardial wasted work is lower, resulting in higher better LV myocardial work efficiency. Funding Acknowledgement Type of funding source: None

P337 Edge-to-edge mitral valve repair in patients with secondary mitral regurgitation: impact of tethering pattern on clinical, echocardiographic and procedure-related characteristics

Abstract Edge-to-edge mitral valve repair (E2E-MVR) has emerged as a therapeutical option in patients with secondary mitral regurgitation (SMR). Two tethering patterns (TP) have been described in SMR: symmetric and asymmetric. However, information on the implications of these TP on E2E-MVR is limited. Our aim was to assess the impact of mitral valve TP on clinical, echocardiographic and procedure-related characteristics in patients undergoing E2E-MVR. We consecutively recruited 62 patients with at least moderate SMR who underwent E2E-MVR in our center between 2011 and 2019 and analysed clinical, echocardiographic and procedure-related characteristics according to TP, which we classified into symmetric and asymmetric considering jet direction and mitral valve leaflet position during systole by means of two-dimensional transesophageal echocardiography (Figure 1). In our series, 43 patients (69.3%) had symmetric TP and 19 (30.7%) had asymmetric TP. Asymmetric TP was associated with ischemic aetiology (52.6% vs 23.3%, p = 0.02) and a non-significant trend to higher frequency of male sex (89.5% vs 67.4%, p = 0.07), diabetes mellitus (52.6% vs 27.9%, p = 0.06), massive regurgitation (78.9% vs 58.1%, p = 0.11) and higher values of left ventricular ejection fraction (LVEF) (34 ± 9% vs 28 ± 11%, p = 0.06). There were no differences in procedure-related characteristic between groups, in particular in number of devices (1.63 [IQR 1-2] vs 1.52 [IQR 1-2], p = 0.27), number of graspings (3.21 [IQR 2-4] vs 2.78 [IQR 2-3], p = 0.16) and time of procedure (95 ± 38min vs 107 ± 43min, p = 0.29). Procedural success (defined as SMR severity reduction≥2) was high in both groups (89.5% vs 74.4%, p = 0.18). At discharge, there was a significant reduction in effective regurgitant orifice area (EROA) in (0.36 ± 0.16cm² vs 0.15 ± 0.10cm², p &amp;lt; 0.001) and pulmonary artery systolic pressure (PASP) (46 ± 12mmHg vs 40 ± 12mmHg, p = 0.004). LVEF was impaired in patients with asymmetric TP but not in patients with symmetric TP (difference in LVEF after procedure: -5 ± 9% vs -0 ± 8%, p = 0.03). In our study, asymmetric TP was related to the ischemic aetiology of left ventricular dysfunction. Procedural characteristics, and EROA and PASP reductions at discharge were similar regardless of TP. However, patients with asymmetric TP had a significantly impairment in LVEF, probably because of afterload mismatch phenomenon. Abstract P337 Figure 1: example of tethering patterns

SY2-1 - Assessment and Treatment for Secondary Mitral Regurgitation

The assessment and treatment for secondary mitral regurgitation (MR) are based on the concepts different from those for primary MR. The main etiology of traditional secondary MR is mitral leaflet tethering-tenting occurring from left ventricular dilatation and systolic dysfunction. The origin of secondary MR usually takes a transverse direction along the mitral leaflets' coaptation. Consequently, the Doppler-derived volumetric method should be selected for the echocardiographic quantitative analysis of the secondary MR rather than the proximal isovelocity surface area method. In general, the strong medical therapies are required in heart failure patients with significant secondary MR. Mitral valve surgery may be also considered for patients with severe secondary MR with heart failure symptoms despite the optimal medical therapies. Concomitant mitral valve surgery is more reasonable in patients with coronary artery disease and severe secondary MR at the time of coronary artery bypass grafting (CABG). It is still controversial whether concomitant mitral valve surgery should be performed in patients with coronary artery disease and moderate secondary MR at the time of CABG. Low-dose dobutamine stress echocardiography or exercise stress echocardiography may be helpful to address this issue. For secondary MR seen in patients with atrial fibrillation and left atrial dilatation despite havinf preserved left ventricular ejection fraction, mitral annuloplasty would be the primary treatment.

Correction of moderate secondary mitral regurgitation due to aortic valve disease: immediate results

To evaluate the impact of surgical strategy in concomitant mitral valve surgery or isolated aortic valve replacement (AVR) in patients with moderate secondary mitral regurgitation (MR), 1 574 patients underwent AVR over a period from January 2003 to December 2011. 241 patients had secondary MR 2+ and constituted the study population. Patients were stratified into two groups, those without concomitant mitral valve surgery (Group A, n = 113) and with it (Group B, n = 128). It was found out that AVR plastic correction of MI reduces its recurrence during short-term follow-up but increases the intervention time leading to an insignificant rise in lethality. In patients with aortic stenosis the age exceeding 70 years and the presence of atrial fibrillation are found to be the most significant predictors of preservation of residual mitral regurgitation in the early postoperative period, while more indicative for patients with aortic insufficiency is the presence of tricuspid regurgitation grade 2 or higher.

Imaging Challenges in Secondary Mitral Regurgitation

Chronic secondary mitral regurgitation (SMR) is a complex entity that is often clinically underappreciated.1 It complicates either ischemic heart disease or dilated cardiomyopathy; its prevalence varies among series but may reach ≤50% in patients with heart failure.2 When present, SMR may exhibit a broad range of severity and confers an adverse prognosis, which is worse with increasing severity of mitral regurgitation (MR).3,4 The management of SMR poses a unique set of challenges, based partly on the complexity of the valve disorder and the still-evolving adoption of the optimal therapeutic approach.5 Noninvasive imaging and, in particular, echocardiography, plays a critical role for the initial and longitudinal assessment, for individual risk stratification and outcome prediction, and for guiding intervention in patients with chronic SMR.6 SMR develops because of a combination of mitral leaflet tethering secondary to left ventricular (LV) dilatation/deformation with papillary displacement/discoordination, annular dilatation/dysfunction, insufficient LV-generated closing forces attributable to reduction of LV contractility, and global LV/papillary muscle dyssynchrony.1,5 Tethering of the mitral leaflets is the principal lesion of SMR and results in restriction of systolic leaflet motion, namely type IIIb of Carpentier’s classification. SMR does not typically occur in global LV dysfunction without tethering. However, once tethering occurs, leaflet closure is further impaired by LV dysfunction because there is decreased force opposing tethering.6–9 The key event in the pathogenesis of SMR is the distortion of normal LV geometry—regional and global LV remodeling—with subsequent apical and lateral displacement of papillary muscles, which, in turn, draws the chordae tendineae away from the line of coaptation.7,8 The extent of LV systolic dysfunction and dilatation is weakly correlated to the degree of SMR unless accompanied by geometric distortion in the region of the papillary muscles.1,9 …

Acute heart failure due to pheochromocytoma crisis after levosulpiride administration

A previously asymptomatic 32-year-old man was referred to our department because of palpitations, sweating, asthenia and effort dyspnea following levosulpiride assumption for dyspepsia. On admission, physical examination revealed a 3rd heart sound and a systolic apical murmur suggesting mitral regurgitation; blood pressure was 155/85mmHg. The ECG (Fig. 1) showed sinus tachycardia (130bpm), left atrial enlargement and marked left ventricular hypertrophy with striking secondary ST–T changes. At echocardiography, severe and diffuse impairment of left ventricular wall motion was evident with depressed ejection fraction (0.30) and moderate secondary mitral regurgitation, suggesting at first glance either acute/subacute myocarditis or acute decompensation of hypertrophic cardiomyopathy.

Stress Echocardiography in Regurgitant Valve Disease

Because of its wide availability, low cost, versatility, and clinical use, stress echocardiography has become increasingly recognized as a valuable tool in the assessment of patients with regurgitant valvular heart disease. Exercise testing is favored compared with pharmacological stress testing for risk stratification in asymptomatic patients and can identify what might otherwise be considered as a moderate valve disease. It has been shown to provide insights into exertional symptoms disproportionate to resting hemodynamics in these patients and to facilitate individual risk stratification. Aggravation of valvular regurgitation severity, exercise-induced pulmonary hypertension (PHT), impaired left ventricular (LV) contractile reserve, inducible ischemia, dynamic LV dyssynchrony, and altered exercise capacity, together with the development of symptoms during exercise echocardiography, provide the clinician with straightforward prognostic information, therefore enabling a more accurate definition of the optimal timing of intervention in patients with valvular regurgitation.1,2 In contrast, dobutamine stress echocardiography has little value in cases of valvular regurgitation. Dobutamine infusion is almost systematically associated with a decrease in the severity of regurgitation; however, it might be of interest in the detection of LV contractile reserve and inducible ischemia. The most common form of exercise used in conjunction with echocardiography is immediate postexercise imaging on a treadmill or upright bicycle ergometer. However, semisupine exercise testing on an appropriate tilted table allows continuous echocardiographic monitoring, which represents an advantageous tool for quantifying changes in valvular regurgitation severity, LV function, and pulmonary pressure (Table). This exercise stress echocardiography modality (ie, per-exercise echocardiography) is the most used in Europe, and we strongly suggest this approach in the setting of valvular heart disease to detect evanescent changes. A symptom-limited graded exercise test is recommended, and ≥80% of the age-predicted upper heart rate should be reached in the absence of symptoms. The test is adapted to the clinical conditions …

Management of moderate secondary mitral regurgitation at the time of aortic valve surgery†

To define the impact of surgical strategy [concomitant mitral valve surgery or isolated aortic valve replacement (AVR)] in patients with moderate secondary mitral regurgitation (MR) at the time of AVR. From January 1999 to December 2009, 3339 patients underwent AVR of whom 255 had secondary MR >2+ and constituted the study population. Patients were stratified into two groups, with (Group A, n = 94, 36.8%) and without concomitant mitral valve surgery (Group B, n = 161, 63.2%). Follow-up up to 12 years (1076 patient-years) was analysed for survival, valve-related events and persistent MR. Predictors of late mortality and persistent MR were further analysed. A case-match analysis [age, gender, New York Heart Association (NYHA) and left ventricular ejection fraction] was performed, excluding patients with coronary artery disease (CAD). The mean age of the population was 67.0 ± 11.7 years, 63.5% male and 64.7% in NYHA III-IV. Group B patients were significantly older and had higher incidence of coronary disease, hypertension and mitral calcification. They also had a higher ejection fraction and transaortic gradients, and lower MR grade (mean MR: 2.8 vs 3.2) and pulmonary artery pressure. Mitral surgery consisted mainly of annuloplasty procedures (96%). Only 2 patients from the entire cohort were reoperated on/for the mitral valve. Thirty-day mortality rate was 0.3%. There was no difference in long-term survival and valve-related complications, even after case-matched analysis. CAD, history of cerebrovascular accident, permanent atrial fibrillation, renal failure and persistence of MR emerged as independent predictors of late mortality (P < 0.05). MR improved in 67.4% of patients from Group B against 82.3% from Group A (P = 0.011). Atrial fibrillation (AF) and higher MR grade at discharge were the only independent predictors for persistent MR (P < 0.05). Patients with persistent MR early after AVR had decreased late survival (hazard ratio: 4.9, P = 0.001). Secondary MR improves after AVR even without mitral surgery. Concomitant mitral surgery was significantly associated with greater improvement of postoperative MR, but had no significant impact on survival. However, patients who did not improve immediately after AVR had compromised survival. Patients in AF should have mitral valve repair at the time of surgery.

Detection of left main coronary artery stenosis: utilization of transesophageal echocardiography in acute heart failure

A previously healthy 80-year-old male with a history of type II diabetes mellitus was referred to our emergency department because of severe dyspnoea. Physical examination revealed a diaphoretic man with a blood pressure of 105/65 mmHg, a low oxygen saturation of 85% and diffuse inspiratory crackles and rales on auscultation. The electrocardiogram showed a sinus tachycardia of 110 beats/min with a left bundle branch block. A chest X-ray of the lungs revealed pulmonary oedema. Arterial blood gas analysis indicated respiratory acidosis requiring intubation and ventilation. Immediate transoesophageal echocardiography (TEE) was performed to search for signs of suspected acute ischaemia. The echocardiogram pointed out a dilated left ventricle with severe hypokinesia of all wall segments. There was a moderate secondary mitral regurgitation due to the left ventricular dysfunction and annular dilatation. The aortic valve appeared normal without any signs of stenosis. The echocardiogram suggested the presence of chronic heart failure until colour Doppler analysis of the aortic valve revealed a mosaic flow pattern in the left main coronary artery suggesting a severe stenosis (Fig. 1a). Urgent cardiac catheterisation confirmed a pinpoint stenosis of the left main coronary artery (Fig. 1b). Subsequently, coronary artery bypass grafting was performed with maximum CK-MB of 55 μg/L, and the patient recovered uneventfully. Fig. 1 a Colour Doppler analysis reveals mosaic flow in the left main coronary artery suggestive of a severe stenosis with the aortic valve showing no signs of obstruction; b In the LAO view the pinpoint left main coronary artery stenosis is confirmed Transthoracic echocardiography can adequately assess coronary flow in approximately half of patients [1]. Normally, the colour flow pattern in the coronary artery is consistent with laminar flow. Diastolic mosaic flow caused by focal flow acceleration indicates significant left main coronary artery stenosis in 85% of patients. Peak diastolic velocities greater than 1.5 m/s are considered abnormal [1]. TEE can visualise haemodynamically significant stenosis of the left main as well as primarily proximal segments of the left anterior descending, circumflex and right coronary artery in the majority of patients [2]. Our case stresses the diagnostic power of a carefully performed TEE in haemodynamically unstable patients of unknown cause.

Subaortic dynamic obstruction: A contributing factor to hemodynamic instability in tako-tsubo syndrome?

We present a case of transient apical ballooning with haemodynamic instability in a female patient with normal coronaries and a history of poorly controlled systemic arterial hypertension. There was dynamic obstruction of the outflow tract and moderate secondary mitral regurgitation at presentation. These were due to systolic anterior motion of the mitral valve, which normalised gradually with the recovery of left ventricular function, and to a 'sigmoid' septum. Mid-cavity obstruction is potentially an important contributory factor to the haemodynamic instability sometimes encountered in this syndrome.