Moderate-severe Mitral Regurgitation Research Articles

The chance finding of echocardiographic complications of infective endocarditis

Fig. 1. Biatrial dilatation, a left ventricular dilatation, an interventricular septal hypertrophy, an anterior mitral leaflet abscess/perforation complication of infective endocarditis. Despite the progress in its knowledge and treatment, infective endocarditis [1–17] remains a therapeutic challenge [17]. We present a case of an infective endocarditis in a 62-year-old Italian man. A 62-year-old Italian man was admitted to the Cardiology Unit for a pre-operative cardiac risk assessment in colon cancer surgery. He reported a streptococcal infection two years ago. Echocardiographic evaluation revealed a biatrial dilatation and a left ventricular dilatationwith an interventricular septal hypertrophy. The semilunar aortic valves were markedly thickened with retraction of left and right cusps. A moderate–severe mitral regurgitation, a severe aortic regurgitation, a mild tricuspidal regurgitation, and an anterior mitral leaflet abscess/perforation complication of infective endocarditis were also observed. Also this case focuses attention on infective endocarditis.

Mitral regurgitation during a myocardial infarction – New predictors and prognostic significance at two years of follow-up

Ischemic Mitral Regurgitation (MR) has early prognostic impact in Myocardial Infarction (MI). Its medium-term importance, especially of mild MR, has not been established. to determine new clinical/analytical predictors of MR in MI-patients and establish its prognostic value during two-year follow-up [endpoints: mortality, decompensated heart failure (dHF)]. 796 patients admitted for MI (age 68.8±13.4, 63.2% males, 44.6% STEMI). Admission analytical study, risk scores, coronariography, pre-discharge echocardiogram. Patients followed for two years. Clinical/analytical predictors of pre-discharge MR assessed. Predictive model for presence of pre-discharge MR included GRACE for intra-hospital mortality [IHM](OR=1.008, p<0.001), glomerular filtration rate (GFR)[OR=0.993, p=0.048], admission haemoglobin (OR=0.84, p=0.003). In univariate analysis, moderate-severe MR predicted 2-year mortality (OR=3.32, p<0.001), but not dHF. Two year mortality rate was proportional to severity of pre-discharge MR. Mild MR (vs. no MR) associated with higher risk for 2-year mortality (OR=2.04, p=0.014) and re-admission for dHF (OR=2.55, p=0.001). Predictive model for 2-year mortality included MR severity (OR=1.42, p=0.033) and GRACE for IHM (OR=1.023, p<0.001). GRACE score for IHM, GFR and admission haemoglobin independently predicted risk for pre-discharge MR. MR, including its milder form, was an independent predictor of 2-year mortality, adding prognostic power to GRACE score.

Predictors of Pulmonary Hypertension in Patients With End‐Stage Heart Failure

Pulmonary hypertension (PH) is associated with a greater mortality rate in patients with heart failure (HF) and it is a risk factor for right ventricular failure after heart transplantation. This study was designed to explore risk factors for PH development in patients with advanced heart failure and left ventricular dysfunction. In a retrospective observational study of 419 patients evaluated for heart transplantation due to end stage HF, different variables were analyzed to find predictors of PH (defined as a mean pulmonary pressure >25 mmHg), reactive PH (defined as a transpulmonary gradient >12 mmHg) and severe PH (defined as a mean pulmonary pressure >40 mmHg and/or pulmonary vascular ressistance >3 WU) using a multivariate stepwise logistic regression analysis. Prevalence of PH, out of proportion and severe PH was 62.2%, 23.8%, and 18.8% respectively. The presence of moderate-severe mitral regurgitation [2.1 (1.2-3.7); P=0.006], moderate-severe tricuspid regurgitation [OR 2.9 (1.3-6.4); P=0.005] and a duration of disease >3 years [OR 1.7 (1.1-2.7); P=0.03] were independent risk factors associated with PH. Moreover, the presence of a moderate-severe mitral regurgitation and a duration of disease greater than 3 years, were independent predictors of out of proportion and severe PH.

Late gadolinium enhancement by cardiovascular magnetic resonance is complementary to left ventricle ejection fraction in predicting prognosis of patients with stable coronary artery disease.

BackgroundLate gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) predicts adverse prognosis in patients with stable coronary artery disease (CAD). However, the interaction with conventional risk factors remains uncertain. Our aim was to assess whether the extent of LGE is an independent predictor of adverse cardiac outcome beyond conventional risk factors, including left ventricle ejection fraction (LVEF).MethodsWe enrolled 376 patients (88% males, 64 ± 11 years) with stable CAD, who underwent LGE assessment and a detailed conventional evaluation (clinical and pharmacological history, risk factors, ECG, Echocardiography). During a follow-up of 38 ± 21 months, 56 events occurred (32 deaths, 24 hospitalizations for heart failure).ResultsLGE and LVEF showed the strongest univariate associations with end-points (HR: 13.61 [95%C.I.: 7.32-25.31] for LGE ≥ 45% of LV mass; and 12.34 [6.80-22.38] for LVEF ≤ 30%; p < 0.0001). Multivariate analysis identified baseline LVEF, loop diuretic therapy, moderate-severe mitral regurgitation and pulmonary hypertension as significant predictors among conventional risk factors. According to a step-wise approach, LGE showed strong association with prognosis as well (5.25 [2.64-10.43]; p < 0.0001). LGE significantly improved the model predictability (chi-square 239 vs 221, F-test p < 0.0001) with an additive effect on the prognostic power of LVEF, which however retained its prognostic power (4.89 [2.50-09.56]; p < 0.0001). Patients with LGE ≥ 45% and/or LVEF ≤ 30% had much worse prognosis compared to patients without risk factors (annual event rates of 43% vs 3%; p < 0.0001). Interestingly LGE was a significant predictor when all cause mortality was analyzed as the only endpoint.ConclusionsThis study demonstrates that LGE assessed by CMR is a robust independent non-invasive marker of prognosis in stable CAD patients. LGE can integrate the available metrics to substantially improve risk stratification.

Flow‐Mediated Vasodilation Measurements inCavalierKingCharlesSpaniels with Increasing Severity of Myxomatous Mitral Valve Disease

Cardiovascular disease is associated with endothelial dysfunction in humans and studies of plasma biomarkers suggest that dogs with myxomatous mitral valve disease (MMVD) might also have endothelial dysfunction. That progression of mitral regurgitation (MR) is associated with development of endothelial dysfunction. Forty-three Cavalier King Charles Spaniels (CKCS) with MR of varying severity. Privately owned CKCS were prospectively recruited and divided in 4 groups: (1) 12 CKCS with minimal MR; (2) 9 CKCS with mild MR; (3) 11 CKCS with moderate-severe MR; and (4) 11 CKCS with moderate-severe MR and clinical signs compatible with heart failure. Dogs underwent blood sampling, echocardiography, blood pressure (BP) recordings, and flow-mediated vasodilation (FMD) measurements. The effect of progressive MR on FMD was determined by multivariate analyses. Flow-mediated vasodilation decreased with progression of MR. Group 4 (4.79 ± 3.22%) had significantly lower FMD than groups 1 (10.40 ± 4.58%) and 2 (10.14 ± 3.67%) (P < .005) and group 3 (6.79 ± 3.98%) had a significantly lower FMD than group 1 (P = .03). Increasing left ventricular end-diastolic diameter (P = .0004, R(2) = 0.27) and the combination of age (P = .01) and body weight (P = .002) (R(2) = 0.31) were significantly associated with reduced FMD. FMD did not correlate with sex, BP, or plasma markers. Reduced FMD indicates that increased disease severity in CKCS with MMVD is associated with development of endothelial dysfunction which might be a future therapeutic and/or diagnostic target.

The significance of mild renal dysfunction in chronic heart failure.

Heart failure is a major public health concern. Prediction models in heart failure have employed echo-cardiography and other advanced laboratory parameters in predicting the risk of mortality. However, most of the patients in the resource poor economies still do not have easy access to these advanced technology. To determine the clinical and echocardiographic correlates of patients with chronic heart failure (CHF) in the presence or mild renal disease (MRD). One hundred CHF patients were categorized based on their estimated glomerular filtration rates into either normal renal function or MRD. The clinical and echocardiographic variables of both groups were compared. There were 38 females and 62 males with an overall mean age of 54 years. A significantly greater proportion of patients with mild renal disease presented in New York Heart Association classes 3 and 4 (82.9% vs 27.1%). Patients with MRD had echocardiographic findings of a significantly larger left atrial dimension, lower ejection fraction and fractional shortening and shorter deceleration time. A significantly greater proportion of patients with mild renal disease also had moderate-severe mitral and tricuspid regurgitation and grades 2-3 diastolic dysfunction compared to patients without mild renal disease. Patients with MRD also exhibited a significantly greater degree of deterioration in the fractional shortening and ejection fraction compared to non-MRD patients. Multivariate regression analysis indicated that a low ejection fraction and a low fractional shortening were significantly associated with MRD. Identification of MRD in chronic heart failure patients using the estimated glomerular filtration rate is valuable in resource poor countries. The presence of MRD in CHF is associated with poor left ventricular function and increased deterioration of ventricular function.

Evaluation of right ventricular function in patients with a previous episode of pulmonary embolism using tissue Doppler imaging

New echocardiographic techniques including tricuspid annular plane systolic excursion (TAPSE) and pulsed tissue Doppler imaging (TDI) of the right ventricular wall have been assessed to better define right ventricular dysfunction (RVD) during the acute phase of pulmonary embolism (PE) in patients without significant tricuspidal insufficiency. Their application in patients with a previous history of PE may provide a better estimation of the incidence and clinical significance of long-term functional impairment of the right ventricle. In a case-control study, we compared the prevalence of RVD in a cohort of consecutive patients with previous PE and in age and sex-matched controls without PE. Exclusion criteria were moderate-severe left heart failure, moderate-severe mitral valve regurgitation, severe tricuspid insufficiency, or other causes of chronic pulmonary hypertension. Systolic and diastolic right ventricular functions were evaluated by measuring TAPSE and TDI of the right ventricular wall. Twenty-five patients with a previous first episode of PE and 25 controls were enrolled. Mean value of TAPSE was similar between patients with previous PE and controls (2.58 ± 0.33 and 2.53 ± 0.35 cm, P = ns). In patients with PE, the mean value of E″/A″ was significantly lower than in controls (0.89 ± 0.24 vs. 1.30 ± 0.39, P < 0.001), with 14 out of 25 cases having diastolic dysfunction as compared to only 3 out of 25 controls (P < 0.002). A high proportion of patients with previous PE have echocardiographic signs of RV diastolic dysfunction 6 months after the acute phase, even in the absence of symptoms, and in the presence of normal pulmonary pressures.

Cardiac Resynchronization Therapy as a Therapeutic Option in Patients With Moderate-Severe Functional Mitral Regurgitation and High Operative Risk

Functional mitral regurgitation (MR) is a common finding in heart failure patients with dilated cardiomyopathy and has important prognostic implications. However, the increased operative risk of these patients may result in low referral or high denial rate for mitral valve surgery. Cardiac resynchronization therapy (CRT) has been shown to have a favorable effect on MR. Aims of this study were to (1) evaluate CRT as a therapeutic option in heart failure patients with functional MR and high operative risk and (2) investigate the effect of MR improvement after CRT on prognosis. A total of 98 consecutive patients with moderate-severe functional MR and high operative risk underwent CRT according to current guidelines. Echocardiography was performed at baseline and 6-month follow-up; severity of MR was graded according to a multiparametric approach. Significant improvement of MR was defined as a reduction ≥ 1 grade. All-cause mortality was assessed during follow-up (median 32 [range 6.0 to 116] months). Thirteen patients (13%) died before 6-months follow-up. In the remaining 85 patients, significant reduction in MR was observed in all evaluated parameters. In particular, 42 patients (49%) improved ≥ 1 grade of MR and were considered MR improvers. Survival was superior in MR improvers compared to MR nonimprovers (log rank P<0.001). Mitral regurgitation improvement was an independent prognostic factor for survival (hazard ratio 0.35, confidence interval 0.13 to 0.94; P=0.043). Cardiac resynchronization therapy is a potential therapeutic option in heart failure patients with moderate-severe functional MR and high risk for surgery. Improvement in MR results in superior survival after CRT.

Aortic valve replacement for aortic stenosis in patients with concomitant mitral regurgitation: should the mitral valve be dealt with?

Co-existent mitral regurgitation may adversely influence both morbidity and mortality in patients undergoing aortic valve replacement for severe aortic stenosis. Whilst it is accepted that concomitant mitral intervention is required in severe, symptomatic mitral regurgitation, in cases of mild-moderate non-structural mitral regurgitation, improvement may be seen following aortic valve replacement alone, avoiding the increased risk of double-valve surgery. The exact benefit of such a conservative approach is, however, yet to be adequately quantified. We performed a systematic literature review identifying 17 studies incorporating 3053 patients undergoing aortic valve replacement for aortic stenosis with co-existing mitral regurgitation. These were meta-analysed using random effects modelling. Heterogeneity and subgroup analysis were assessed. Primary end points were change in mitral regurgitation severity and 30-day, 3-, 5- and 10-year mortality. Secondary end points were end-organ dysfunction (neurovascular, renal and respiratory), and the extent of ventricular remodelling following aortic valve replacement. Our results revealed improvement in the severity of mitral regurgitation following aortic valve replacement in 55.5% of patients, whereas 37.7% remained unchanged, and 6.8% worsened. No significant difference was seen between overall data and either the functional or moderate subgroups. The overall 30-day mortality following aortic valve replacement was 5%. This was significantly higher in moderate-severe mitral regurgitation than nil-mild mitral regurgitation both overall (p=0.002) and in the functional subgroup (p=0.004). Improved long-term survival was seen at 3, 5 and 10 years in nil-mild mitral regurgitation when compared with moderate-severe mitral regurgitation in all groups (overall p<0.0001, p<0.00001 and p=0.02, respectively). The relative risk of respiratory, renal and neurovascular complications were 7%, 6% and 4%, respectively. Reverse remodelling was demonstrated by a significant reduction in left-ventricular end-diastolic diameter and left-ventricular mass (p=0.0007 and 0.01, respectively), without significant heterogeneity. No significant change was seen in left-ventricular end-systolic diameter (p=0.10), septal thickness (p=0.17) or left atrial area (p=0.23). We conclude that despite reverse remodelling, concomitant moderate-severe mitral regurgitation adversely affects both early and late mortality following aortic valve replacement. Concomitant mitral intervention should therefore be considered in the presence of moderate mitral regurgitation, independent of the aetiology.

Mitral Regurgitation After Anteroapical Myocardial Infarction

Background— Mitral regurgitation (MR) generally accompanies inferobasal myocardial infarction (MI), with leaflet tethering by displaced papillary muscles. Mitral regurgitation is also reported with anteroapical MI without global dilatation or inferior wall motion abnormalities. We hypothesized that anteroapical MI extending to the inferior apex displaces the papillary muscles, tethering the mitral leaflets to cause MR. Methods and Results— In the retrospective part of the study, consecutive anteroapical MI patients were studied. Moderate-severe MR occurred in 9% of 234 patients with only anteroapical MI versus 17% of 242 with inferoapical extension ( P &lt;0.001). Ejection fraction was only mildly different (41±4% versus 46±5%; P &lt;0.01). In the human mechanistic portion of the study, 60 anteroapical MI patients (20 with only 2 apical segments involved and 40 with involvement of all 4 apical segments; 20 with MR and 20 without MR) were compared with 20 normal controls. Those with MR (≥moderate) had higher systolic papillary muscle–to-annulus tethering length ( P &lt;0.01). Mitral regurgitation grade correlated most strongly with tethering length ( r =0.70) and its diminished systolic shortening ( r =−0.65). In the animal study, 9 sheep with left anterior descending coronary artery ligation were analyzed. Four sheep that developed MR had inferoapical MI extension with tethering length increasing over 1.5 months (2.1±0.4 to 2.9±0.4 cm, P &lt;0.001) versus no significant increase in 5 sheep without MR (2.0±0.4 to 2.1±0.3 cm, P not statistically significant). In MR sheep, the normal decrease in tethering length from diastole to systole was eliminated ( P &lt;0.01). Conclusions— Anteroapical MI with inferoapical extension can mechanically displace papillary muscles, causing MR despite the absence of basal and midinferior wall motion abnormalities. This suggests the possibility of repositioning treatments for this condition.

A Hybrid Approach to Cardiac Resynchronization Therapy

CRT (atrial-synchronized bi-ventricular pacing) has been shown to significantly improve the quality of life and exercise tolerance in patients with moderate-severe heart failure and an interventricular conduction delay (>120 msec) when compared to controls. Traditionally it has been performed by cardiologists in electrophysiology laboratories. In the event that the left ventricular lead cannot be positioned percutaneously the procedure is aborted and the cardiac surgeon consulted. The subsequent intervention by the surgeon, typically on another day, requires reexploration of the pocket, a thoracotomy, which results in an increase in length of stay (LOS), and an increase in infection risk. The objective of this study was to demonstrate that CRT could routinely be performed in a surgical operating room (OR) as a single rather than a staged procedure. Between 1/1/06 and 7/1/06 18 patients (17 male and 1 female) with an average age of 56 years (range 36-79) underwent CRT. Transthoracic echo (TTE) revealed that all had left ventricular ejection fractions (LVEF) <30% (range 8%-28%). Five of the 18 had moderate-severe mitral regurgitation (MR). The etiology of the cardiomyopathies was ischemia in 4 and non-ischemia in 14. All had QRS intervals >120 msec (range 120-200 msec) and all were maintained preoperatively on their conventional therapy for heart failure (B-blockers, ± diuretic, ± ACE-I or ARB) and all were either New York Heart Association (NYHA) functional class III or IV. Every case was performed under general anesthesia with an arterial line and Foley catheter in the semi right lateral decubitous position. Nine of the 18 patients underwent a left anterolateral mini-thoracotomy for epicardial left ventricular (LV) lead placement. All hardware included defibrillation technology (ICD). All 18 patients left the OR with successful bi-ventricular pacing in an average time of 170 minutes (range 140-200 min). The average epicardial lead pacing threshold was 0.9v (range 0.4-1.5v) while the average endocardial (transvenous) threshold was 0.4v (range 0.2-0.7v) at a pulse width of 0.5 msec. TTE at 1 month demonstrated an improvement in LVEF in 14/18 patients with an average increase of 5% (range 2%-9%). Four of the 5 patients with moderate-severe MR were reduced to mild. The average length of stay (LOS) following the procedure, in those patients who did not undergo a thoracotomy, was 4 days (range 3-6 days) while it was 7 days (range 6-10 days) in those who underwent a thoracotomy. These data clearly indicate that CRT can be successfully performed as a single-staged procedure in a cardiac OR. Although transvenous LV lead placement avoids a thoracotomy, the epicardial LV lead thresholds, in this series, are competitive with the transvenous results. We propose that in the spirit of cost containment, fee bundling, decreasing reimbursement, pay-for-performance, and infection control, these complex interventions should be performed in multipurpose interdisciplinary hybrid cardiac OR's, now available in most major medical centers, with designated time limitations and role assignments.

An isolated anterior mitral leaflet cleft: a case report

IntroductionThe anterior mitral leaflet cleft is an unusual congenital lesion most often encountered in association with other congenital heart defects. The isolated anterior leaflet cleft is quite a rare anomaly and is usually cause of mitral valve regurgitation. The importance of the lesion is that it is often correctable. When feasible, cleft suture and, eventually, annuloplasty are preferable to valve replacement. Echocardiography is the first choice technique in the evaluation of mitral valve disease, providing useful information about valve anatomy and hemodynamic parameters.Case presentationWe present a case of an isolated anterior mitral leaflet cleft producing moderate-severe mitral regurgitation correctly identified by echocardiography and successfully surgically corrected.ConclusionIsolated cleft is a rare aberration, that has to be known in order to be diagnosed. Transthoracic and transesophageal echocardiography is the most useful non invasive technique for cleft diagnosis and to indicate the right surgical correction.

The EVEREST II Trial: Design and rationale for a randomized study of the evalve mitraclip system compared with mitral valve surgery for mitral regurgitation

Mitral valve surgery is the standard of care for patients with symptomatic mitral regurgitation (MR) or asymptomatic MR with evidence of left ventricular dysfunction or dilation. Whether an endovascular approach to repair can offer comparable effectiveness with improved safety remains to be determined in randomized trials. The EVEREST II Trial is a multicenter, randomized controlled trial to evaluate the benefits and risks of endovascular mitral valve repair using the MitraClip device compared with open mitral valve surgery (control) in patients with moderate or severe MR. Using a 2:1 randomization ratio, the trial is enrolling up to 186 MitraClip-treated subjects and 93 control subjects. Trial end points include a primary efficacy end point: the proportion of patients free from death, surgery for valve dysfunction, and with moderate-severe (3+) or severe (4+) MR at 12 months; the primary safety end point includes the proportion of patients with death, myocardial infarction, reoperation, nonelective cardiovascular surgery, stroke, renal failure, deep would infection, ventilation >48 hours, gastrointestinal complication, new permanent atrial fibrillation, septicemia, or transfusion of >or=2 U at 30 days or hospital discharge, whichever is longer. This randomized controlled trial is designed to evaluate the performance of endovascular mitral repair in comparison to open mitral valve surgery in patients with significant MR.

Novel wall motion score-based method for estimating global left ventricular ejection fraction: validation by real-time 3D echocardiography and global longitudinal strain

To evaluate the reliability of a regional wall motion score index (WMSI)-based method for assessment of left ventricular (LV) ejection fraction (EF). Two-dimensional (2D) echocardiography was used to assess a LV 16-segment-based regional wall motion. Each segment received a score based on contractility status: 4, normal kinesis; 3, mild; 2.5, moderate; and 1.5, severe hypo-kinesis; 0, akinesis; -1, dyskinesis; 3.5 and 4.5 were used for low-normal and high-normal kinesis; 5 for hyper-kinesis. Hence, WMSI-based EF was derived by summing the score assigned to each segment. Contextually, EF was evaluated by real-time three-dimensional (3D) echocardiography and by traditional Simpson's method (2D). Global longitudinal strain (GLS) by speckle-tracking method was derived as a volume-independent indicator of LV chamber contractility sensitive to regional wall motion abnormalities. In 40 subjects with 3D-EF ranging from 14 to 80%, including clinically healthy hypertensive and patients with Stage B-D congestive heart failure with global or segmental wall motion abnormalities, on average, WMSI-EF did not differ from EF measured by 3D or 2D (all P > 0.5). By intraclass correlation coefficients, reliability of WMSI-EF vs. 3D method was as good as the reliability of 2D method vs. 3D method. GLS correlated with WMSI-EF as strongly as with 3D-EF (both r(2) = 0.90). Moderate-severe mitral regurgitation was associated with increased difference between WMSI-EF and 3D-EF, independent to potential confounders. Intra-observer and inter-observer reproducibility of WMSI-EF was comparable to the reproducibility of EF estimated by 3D echocardiography. Feasibility (WMSI, 3D, 2D, and GLS all available) was 78%; however, feasibility of WMSI per se was approximately 92% in clinical series. Trained readers may rapidly estimate EF by a novel WMSI system, which was found to be accurate compared with 3D method and GLS.

Late Echocardiographic and Clinical Outcomes after Mitral Valve Repair for Degenerative Disease

Mitral valve repair is the procedure of choice for severe degenerative mitral regurgitation (MR). The objective of this study was to review prospectively gathered echocardiographic and clinical results with mitral valve repair for degenerative disease. Between May 1995 and July 2004, 403 patients underwent mitral valve repair for degenerative disease (mean age 63 +/- 12 years, 72% males). Concomitant procedures included CABG (29%), radiofrequency left-sided maze procedure (8%), aortic valve replacement (6%), and tricuspid valve repair (4%). Thirty-day mortality was 0.4% for patients with isolated mitral valve repair and 5.1% for patients with mitral valve repair and concomitant procedure (p = 0.003). Five-year survival was higher for isolated mitral valve repair compared to mitral valve repair with a combined procedure (92 +/- 2% vs. 76 +/- 5%; p < 0.001). Pulmonary artery pressure and left atrial and left ventricular end-diastolic diameters were significantly improved following mitral valve repair (all p <or= 0.005) and this was sustained afterward. The freedom from severe (3+ or 4+) and moderate-severe (2+, 3+, or 4+) MR was 95% and 77% at 5 years, respectively, whereas the freedom from reoperation was 96 +/- 1% at 5 years. Significant predictors of moderate-severe MR recurrence were cardiac dilatation, anterior leaflet prolapse, and concomitant procedure, whereas mitral valve disease amenable to posterior leaflet resection had a lower risk of MR recurrence. Excellent clinical outcomes can be obtained using standard techniques of mitral valve repair of the degenerative valve. MR recurrence is low but nonnegligible, emphasizing the necessity for long-term postoperative echocardiographic follow-up in these patients.

Improvement in the Severity of Mitral Regurgitation after Direct Intramyocardial Injection of Angiogenic Cell Precursor

We reported a case of dilated cardiomyopathy and moderate-severe mitral regurgitation (MR) who we treated by surgical direct intramyocardial angiogenic cell precursors injection. The patient was a New York Heart Association functional class III-IV, 56 year old man, who presented with end-stage congestive heart failure, moderate/severe mitral regurgitation, and myocardial fibrosis with the left ventricular ejection fraction of 13%. After he underwent direct surgical intramyocardial cell implantation, the myocardial fibrosis was resolved at 3 months follow-up. The severity of MR reduced to moderate and mild at 3 and 9 months, respectively. The left ventricular function gradually improved up to 53% at 19 months. To our knowledge, this is one of the only reports of successful direct surgical intramyocardial peripheral blood stem cell implantation to treat MR in dilated cardiomyopathy patient.

Acute bioprosthetic thrombosis immediately after aortic valve replacement

We present the case of a 72-year-old woman referred for dyspnea and vertigo when admitted to the hospital with a diagnosis of aortic stenosis. She had hypertension with previous deep venous thrombosis with no known hypercoagulable diathesis. She underwent aortic valve replacement with a Carpentier-Magna bioprosthesis without intraoperative complications; selective cardioplegia before aortic wall suture confirmed that coronary ostia were free. After extracorporeal circulation weaning, an episode of ventricular fibrillation occurred; sinus rhythm was restored using 20 J shock. Considering new episodes of ventricular fibrillation, the increasing number of polymorph ectopic ventricular systoles and the worsening of patient condition despite the use of high doses of inotropes, an intra-aortic balloon pump 1: 1 was inserted via the right femoral artery. Echocardiography (ECG) did not show alteration of the bioprosthesis in the presence of severe left ventricular impairment (ejection fraction <30%) with ipokinesia of the anterior-lateral wall and moderate-severe mitral regurgitation. Considering the rapid decline of the patient's condition despite the use of high doses of inotropes and an intra-aortic balloon pump, the aortic wall was reopened to control bioprosthesis. The intraoperative finding was unexpected; a thrombus of length 3-4 cm was found, attached to the prosthetic annulus and protruding into the left main trunk. The thrombus was immediately sucked up to avoid coronary embolization and, after that, the prosthesis was replaced with a Mitroflow 19 (Sorin Group Inc, Mitroflow Division, Vancouver, Canada) bioprosthesis. Probably, an association between factors could induce thrombosis-like aortic sinuses: annulus dimensions, endothelium damage caused during decalcification, tears in the bioprosthetic sewing ring, unknown coagulation diathesis and the structure of the Carpentier-Magna support may have induced this very unusual complication. However, we do not have enough information to establish with certainty the causes of this complication, but discussion of this topic may be useful.

Abstract 3038: Influence Of Beta-blockade On Mitral Regurgitant Volume In Patients With Degenerative Mitral Valve Prolapse

Introduction: Beta-blockers may be indicated for treatment of hypertension or atrial arrhythmias in patients with degenerative mitral valve prolapse (MVP) and moderate-severe mitral regurgitation (MR). However the influence of beta-blockade on the mitral regurgitant volume is uncertain. Methods: The influence of metoprolol on regurgitant volume was studied in 25 asymptomatic patients with moderate-severe MR due to MVP in a randomized double-blind cross over study. Metoprolol or placebo were titrated by an independent investigator according to symptoms, blood pressure and resting heart rate (mean dose 119mg, range 23.75 to 195mg/day). Severity of MR was assessed by cardiac magnetic resonance imaging (MRI) and echo-Doppler after 10 –14 days on each treatment. Regurgitant fraction was calculated using MRI from the difference between stroke volume by LV volumetry and aortic forward flow by phase contrast analysis. Results. Conclusion: Although metoprolol decreased heart rate and systolic blood pressure it does not influence the mitral regurgitant volume in patients with degenerative mitral valve prolapse.

Afterload Reduction May Halt and Beta-Adrenergic Blockade May Worsen Progression of Left Ventricular Dysfunction in Patients With Chronic Compensated Mitral Regurgitation: A Retrospective Cohort Study

Severe chronic mitral regurgitation (MR) is associated with progressive left ventricular (LV) systolic dysfunction. Both afterload reduction and beta-adrenergic blockade have been suggested as methods for preventing LV dysfunction in asymptomatic patients with MR and normal LV function, who are therefore not yet candidates for surgical intervention. The objective of this study was to determine if afterload reduction reduces progression of LV dysfunction in patients with severe MR. The reports of echocardiographic studies performed 20 +/-14 months apart were compared in a retrospective cohort of 134 asymptomatic patients with moderate-severe chronic MR and baseline ejection fraction (LVEF) >50%. Groups were defined by exposure to any afterload-reducing drug: Group 0, no exposure; Group 1, exposure beginning after the first echocardiogram; and Group 2, drug exposure beginning before the baseline echocardiogram. The groups differed importantly only in treatment duration. In 72 patients not exposed to beta-adrenergic blockade, LVEF decreased by a relative -3.2% in Group 0, while Group 1 increased by 3.4% and Group 2 increased by 5.1%, p <0.01. Among 62 patients exposed to beta-adrenergic blockade, LVEF consistently worsened (Group 0, 4.8%; Group 1, -3.3%; Group 2, -1.7%; p = 0.71) compared to the 72 patients without beta-adrenergic blockade. In a multivariate model that included treatment duration and exposure to other medications, the beneficial effect of afterload reduction (p <0.03) and the deleterious effect of beta-adrenergic blockade (p < 0.02) were significant. Afterload reduction halted or reversed the progressive worsening of left ventricular function while beta-adrenergic blockade had a deleterious effect.

Mitral regurgitation in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: prognostic significance and relation to ventricular size and function

Mitral regurgitation (MR) confers independent risk in patients with acute myocardial infarction. We utilized data from the VALsartan In Acute myocardial iNfarcTion echo study to relate baseline MR to left ventricular (LV) size, shape, and function, and to assess the relationship between baseline MR and progression of MR and cardiovascular (CV) outcomes. We studied 496 patients with heart failure (HF) and/or systolic dysfunction after MI who underwent echocardiography at a median of 5 days after MI. MR severity, quantified as the regurgitant jet area/left atrial area ratio, was assessed at baseline, one and 20 months post-MI and related to LV size, shape, function, and clinical outcomes. Increased MR at baseline was associated with larger LV end-diastolic and end-systolic volumes, increased sphericity index, and reduced ejection fraction (P trend < 0.001). Moderate-severe MR was an independent predictor of total mortality [adjusted hazard ratio (HR) 2.4 (1.1-5.3)], CV mortality [adjusted HR 2.7 (1.2-6.1)], hospitalization for HF [adjusted HR 2.5 (1.1-5.5)], or death or HF hospitalization [adjusted HR 2.5 (1.4-4.6)]. Patients with progression of MR during the first post-MI month were substantially more likely to die or develop HF (adjusted HR per increased MR grade 3.0, 95% CI 1.8-4.9). Progression of MR over 20 months in survivors was associated with increased hospitalizations for HF (P < 0.001). Following high-risk myocardial infarction, baseline mitral regurgitant severity is associated with larger LV volumes and worse LV function. Both baseline MR severity and progression of MR are associated with an increased likelihood of adverse outcomes.