Papillary Muscle Displacement Research Articles

Echocardiographic quantification of mitral apparatus morphology and dynamics in patients with dilated cardiomyopathy.

Mitral regurgitation is among the most common valvular heart diseases. Mitral regurgitation in patients with dilated cardiomyopathy is a complex pathology involving annular dilatation, papillary muscle displacement, systolic leaflet tethering, and left ventricular remodeling. Quantification of mitral apparatus damage in these patients is essential for successful interventional and surgical therapy. Mitral regurgitation in the presence of dilated cardiomyopathy is classified as Carpentier type IIIB, with restricted leaflet mobility as a standard feature. Echocardiography allows accurate evaluation of the complex anatomy and function of the mitral apparatus. Updated guidelines recommend two-dimensional followed by systematic three-dimensional echocardiographic evaluation in patients with mitral regurgitation. New three-dimensional echocardiographic software packages provide many parameters that help identify the precise morphology and function of the various components of the mitral apparatus, helping to determine the etiology of mitral regurgitation and evaluate disease severity. This review provides the first point-by-point approach to the assessment of all old and new echocardiographic methods, from the simplest to the most complex, used to examine the components of the mitral valve apparatus in patients with dilated cardiomyopathy. Although these parameters are still under research, this information will be helpful for establishing therapeutic procedures in a disease with a poor prognosis.

Papillary muscle approximation in chronic ovine functional tricuspid regurgitation

ObjectiveIsolated tricuspid ring annuloplasty remains the surgical standard for functional tricuspid regurgitation repair but offers suboptimal results when right ventricular dilation and remodeling along with papillary muscle displacement is present. Addressing subvalvular remodeling with papillary muscle approximation may improve clinical outcomes. MethodsFunctional tricuspid regurgitation and biventricular dysfunction were induced in 8 healthy sheep by rapid ventricular pacing (200-240 bpm) for 27 ± 6 days. Subsequently, animals underwent cardiopulmonary bypass for implantation of sonomicrometry crystals on the tricuspid annulus, right ventricle, and papillary muscle tips. Papillary approximation sutures were anchored between anterior-posterior and anterior-septal papillary muscles and externalized through right ventricular free wall to epicardial tourniquets. After weaning from cardiopulmonary bypass, sequential papillary muscle approximations were performed. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were collected at baseline and after each papillary muscle approximation. ResultsWith rapid pacing, right ventricular fractional area change decreased from 59 ± 6% to 38 ± 8% (P < .001), whereas tricuspid annulus diameter increased from 2.4 ± 0.3 cm to 3.3 ± 0.6 cm (P = .003). Tricuspid regurgitation (0-4+) increased from +0 ± 0 to +3.3 ± 0.7 (P < .001). Both anterior–posterior and anterior–septal papillary muscle approximation significantly reduced functional tricuspid regurgitation from +3.3 ± 0.7 to +2 ± 0.5 and +1.9 ± 0.6, respectively (P < .001). Reduction of tricuspid insufficiency with both subvalvular interventions was associated with decreased distance of the anterior papillary muscle to the annular centroid. ConclusionsPapillary muscle approximations were effective in reducing severe ovine functional tricuspid regurgitation associated with right ventricular dilation and papillary muscle displacement. Further studies are needed to evaluate efficacy of this adjunct to ring annuloplasty in repair of severe functional tricuspid regurgitation.

Apical papillary muscle displacement is a prevalent feature and a phenotypic precursor of apical hypertrophic cardiomyopathy.

Papillary muscle (PM) abnormalities are considered part of the phenotypic spectrum of hypertrophic cardiomyopathy (HCM). The aim of this study was to evaluate the presence and frequency of PM displacement in different HCM phenotypes. We retrospectively analysed cardiovascular magnetic resonance (CMR) findings in 156 patients (25% females, median age 57 years). Patients were divided into three groups: septal hypertrophy (Sep-HCM, n = 70, 45%), mixed hypertrophy (Mixed-HCM, n = 48, 31%), and apical hypertrophy (Ap-HCM, n = 38, 24%). Fifty-five healthy subjects were enrolled as controls. Apical PM displacement was observed in 13% of controls and 55% of patients, which was most common in the Ap-HCM group, followed by the Mixed-HCM and Sep-HCM groups (respectively: inferomedial PM 92 vs. 65 vs. 13%, P < 0.001; anterolateral PM 61 vs. 40 vs. 9%, P < 0.001). Significant differences in PM displacement were found when comparing healthy controls with patients with Ap- and Mixed-HCM subtypes but not when comparing them with patients with the Sep-HCM subtype. T-wave inversion in the inferior and lateral leads was more frequent in patients with Ap-HCM (100 and 65%, respectively) when compared with Mixed-HCM (89 and 29%, respectively) and Sep-HCM (57 and 17%, respectively; P < 0.001 for both). Eight patients with Ap-HCM had prior CMR examinations because of T-wave inversion [median interval 7 (3-8) years], and in the first CMR study, none showed apical hypertrophy [median apical wall thickness 8 (7-9) mm], while all of them presented with apical PM displacement. Apical PM displacement is part of the phenotypic Ap-HCM spectrum and may precede the development of hypertrophy. These observations suggest a potential pathogenetic, mechanical link between apical PM displacement and Ap-HCM.

Abnormal Mechanics Relate to Myocardial Fibrosis and Ventricular Arrhythmias in Patients With Mitral Valve Prolapse.

The relation between ventricular arrhythmia and fibrosis in mitral valve prolapse (MVP) is reported, but underlying valve-induced mechanisms remain unknown. We evaluated the association between abnormal MVP-related mechanics and myocardial fibrosis, and their association with arrhythmia. We studied 113 patients with MVP with both echocardiogram and gadolinium cardiac magnetic resonance imaging for myocardial fibrosis. Two-dimensional and speckle-tracking echocardiography evaluated mitral regurgitation, superior leaflet and papillary muscle displacement with associated exaggerated basal myocardial systolic curling, and myocardial longitudinal strain. Follow-up assessed arrhythmic events (nonsustained or sustained ventricular tachycardia or ventricular fibrillation). Myocardial fibrosis was observed in 43 patients with MVP, predominantly in the basal-midventricular inferior-lateral wall and papillary muscles. Patients with MVP with fibrosis had greater mitral regurgitation, prolapse, and superior papillary muscle displacement with basal curling and more impaired inferior-posterior basal strain than those without fibrosis (P<0.001). An abnormal strain pattern with distinct peaks pre-end-systole and post-end-systole in inferior-lateral wall was frequent in patients with fibrosis (81 versus 26%, P<0.001) but absent in patients without MVP with basal inferior-lateral wall fibrosis (n=20). During median follow-up of 1008 days, 36 of 87 patients with MVP with >6-month follow-up developed ventricular arrhythmias associated (univariable) with fibrosis, greater prolapse, mitral annular disjunction, and double-peak strain. In multivariable analysis, double-peak strain showed incremental risk of arrhythmia over fibrosis. Basal inferior-posterior myocardial fibrosis in MVP is associated with abnormal MVP-related myocardial mechanics, which are potentially associated with ventricular arrhythmia. These associations suggest pathophysiological links between MVP-related mechanical abnormalities and myocardial fibrosis, which also may relate to ventricular arrhythmia and offer potential imaging markers of increased arrhythmic risk.

Subannular repair in secondary mitral regurgitation with restricted leaflet motion during systole

ObjectiveVentricular secondary mitral regurgitation (SMR) (Carpentier type IIIb) results from left ventricular (LV) remodelling, displacement of papillary muscles and tethering of mitral leaflets. The most appropriate treatment approach remains controversial....

Abstract 15014: Aberrant, Elevated Papillary Muscle and Left Ventricular Wall Forces Associated With Mitral Valve Prolapse Are Normalized by Surgical Neochordal Repair but Not by Transcatheter Edge-to-Edge Repair

Introduction: Recent studies have linked mitral valve prolapse (MVP) to localized myocardial fibrosis and ventricular arrhythmia, and early imaging work has shown altered ventricular motion with papillary muscle (PM) traction in MVP and MitraClip patients. We aimed to biomechanically compare MitraClip and neochordal repair for MVP on PM forces ex vivo . Methods: We developed a force transduction system to measure the forces exerted on the PMs throughout the cardiac cycle in a left heart simulator ( Fig A ) with consistent pressures. Using a randomized, paired procedure with porcine MVs (n=4), we measured the hemodynamics and forces for control, diseased (P2 prolapse via chordal rupture), MitraClip repair ( Fig B, C, D ) (single P2 clip), and neochordal repair (P2 primary neochord on each PM) conditions. Results: We found that MitraClip PM forces (7.19 ± 0.31 N) are higher by 9.34% compared with those of controls (6.58 ± 0.21 N, p&lt;0.001 ). This result is similar to MVP valves modeled by superior PM displacement, which showed 9.23% higher forces than those of controls (n=10, p&lt;0.001 ). Moreover, MitraClip repaired valves showed PM force increases of 6.4% compared with forces of neochordal repair (6.76 ± 0.22 N, p&lt;0.001 ), despite having similarly reduced regurgitation fractions (5.05% ± 1.98% vs. 4.25% ± 1.51%, respectively, p&gt;0.05 ) compared with those of the diseased state (16.96% ± 3.04%, p&lt;0.001 ) and controls (2.66% ± 0.87%). Additionally, neochordal repair valves had 2.79% higher forces compared to those of control valves ( p&lt;0.001 ). Conclusions: We discovered that MitraClip, while reducing regurgitation, does not restore aberrant forces on the PM induced in MVP to baseline or reduced levels, while neochordal repair does. Our work suggests that these elevated forces, associated with MVP and MitraClip, predisposes the MV to continued traction, which may present a long-term harm to patients by catalyzing localized fibrosis and ventricular arrhythmia.

Different mechanisms of mitral regurgitation in hypertrophic cardiomyopathy: A clinical case and literature review.

Abnormalities of the mitral valve (MV) apparatus are typical features of hypertrophic cardiomyopathy (HCM). These abnormalities include leaflet elongation, thick leaflets, displacement of papillary muscle, and systolic anterior motion (SAM) of the MV anterior leaflet. Mitral valve chordal rupture associated with HCM is a rare but serious issue capable of change the clinical apparence and the prognosis of the patient. A 57-year-old lady with a history of diabetes, dyslipidemia, and a previous single episode of atrial fibrillation (treated with pharmacological cardioversion), presented to the Emergency Department for worsening dyspnea (New York Heart Association Classification class IV). A trans-thoracic echocardiogram (TTE) showed a significant, septal, and asymmetric left ventricular hypertrophy (basal anteroseptal wall diastolic thickness of 19 mm) with normal left ventricle systolic function. A SAM of AML was evident together with a left ventricular outflow tract gradient of 56 mmHg at rest, rising to 136 mmHg during the Valsalva maneuver. In addition, there was evidence of moderate to severe mitral regurgitation (MR) with an anteriorly directed jet, not very typical of MR related to SAM. A 2D-3D trans-esophageal echocardiogram (2D-3D TEE) revealed a combined MR mechanism based on PML degenerative prolapse with P2-flail from ruptured chordae with related eccentric anteriorly directed regurgitant jet, together with a second regurgitant posteriorly directed jet, related to SAM of AML. The patient underwent MV repair together with septal myectomy, with a good final outcome. Pre-operative echocardiography (both TTE and 2D-3D TEE) is an essential tool in order to detect different MV abnormalities in patients with HCM. These types of patients should never be treated by septal reduction alone. Surgical MV repair or replacement, together with septal myectomy, may be the preferred approach.

ISCHEMIC MITRAL REGURGITATION - TO REPAIR OR REPLACE? LOOKING BEYOND THE VALVE.

Ischemic mitral regurgitation (IMR) is a frequent and serious complication of coronary artery disease, associated with considerable patient increased mortality and morbidity. While the benefits of optimal medical therapy and surgical revascularization, when indicated, are uncontested in moderate to severe cases, the ideal surgical approach to the valve, if any, is yet to be established. Mitral valve repair has established benefits over replacement in primary mitral regurgitation, but its superiority in the treatment of functional regurgitation has not been replicated. Differing outcomes likely stem from the distinct IMR pathophysiology. Unlike its degenerative counterparts, IMR does not derive from direct damage to the valve leaflets, but rather from dysfunction of its sub-valvular apparatus and the left ventricular wall, in the context of acute or chronic ischaemia. Echocardiographic data points to remodelling of the left ventricle, with subsequent papillary muscle displacement, increased leaflet tethering and inefficient coaptation, as the main responsible mechanism for ischemic mitral regurgitation. Neither mitral valve repair nor replacement directly address these issues, with the appearance of the first randomized trials supporting replacement as the more durable option. However, new subvalvular procedures are improving the stability of repair techniques and the debate is long from settled. The purpose of this review is to analyse the currently available data, couple it with our understanding of IMR's pathophysiology and compare the different outcomes for mitral valve repair and replacement.

Changes in Mitral Valve Apparatus with Continuous Flow LVAD

<h3>Purpose</h3> The purpose of this research was to study the changes in mitral valve apparatus after placement of continuous flow LVAD. These data can help determine if additional mitral valve intervention is needed at the time of LVAD placement. <h3>Methods</h3> A retrospective review of data of all the LVAD placed in the hospital from 2012 through March 31^st 2020 were done. Demographic, clinical variables and clinical outcomes were obtained from electronic medical records. The echocardiographic variables were obtained by two authors with standardized guidelines agreed upon before initiation of the study; this required review of all the images and identification of some unique variables dedicated to the study of mitral valve apparatus. The echocardiogram performed closest before LVAD placement and the last echocardiogram performed within one year after LVAD placement were evaluated to allow reflection of the worst pre-LVAD and the best post-LVAD state of the mitral valve apparatus. <h3>Results</h3> Of total of 145 patients who had LVAD during the study period, 88 patients were identified with pre-specified minimum available echocardiographic variables. 9 did not have significant pre-existing mitral regurgitation (MR). 69 patients had improvement from "moderate or severe" to "mild or none". 10 patients did not show any improvement in the severity of MR: 8 from mild and 2 from moderate MR. All severe MR improved. The changes in mitral valve apparatus included (all reduction): left ventricular end diastolic dimension by 9 (+/-14.98) mm; left atrial volume index by 16.2 (+/- 14.73) ml/m2; annulus size by 5 (+/- 7.94) mm; apical displacement by 2 (+/- 3.91) mm; posterior displacement by 2 (+/- 4.7) mm; tethering area by 85 (+/- 104.94) mm2 and papillary muscle displacement by 2 (+/- 9.55) mm. Changes in mitral valve apparatus were similar in those who had improvement of MR or not except the reduction in posterior displacement happened more in those who had improvement in MR severity. <h3>Conclusion</h3> Continuous flow LVAD favorably improves mitral valve apparatus and MR severity. Prevalence of clinically significant residual MR is low. More data is needed to understand the changes in mitral valve apparatus and guide if any concomitant mitral valve intervention is needed with LVAD placement.

Efficacy of a Novel Posterior Leaflet Repair Device to Treat Secondary Mitral Regurgitation Using an Ex Vivo Heart Model

Mitral regurgitation is one of the most prevalent valvular disorders. It has numerous etiologies grouped as primary typically because of underlying degenerative leaflet disease, or secondary mitral regurgitation (SMR), most commonly because of geometrical distortion of the left ventricle (LV) impacting the functional integrity of the valvular apparatus.1 Specifically for SMR, LV dilation and dysfunction lead to papillary muscle displacement, annular dilation, and apical tethering of the leaflets with restricted mobility, predominantly affecting the posterior leaflet.

Echocardiographic characteristics of non‐resectional ring‐only valve repair in mitral valve prolapse

AbstractBackgroundSimple mitral valve repair (MVR) using a ring‐only approach (ROA) was recently proposed for some complex forms of bileaflet myxomatous mitral valve prolapse (MVP). Nevertheless, few data are available concerning the characteristics of MVP patients that may benefit from this simple repair technique.MethodsBased on 39 consecutive patients (28 men; mean age 57 ± 15) with severe primary Mitral regurgitation (MR) caused by bileaflet MVP referred for MVR, we sought to identify the preoperative echocardiographic parameters associated with successful ROA repair.ResultsTwenty‐three patients (59%) underwent standard resectional MVR (SMVR) while 16 (41%) underwent ROA. Cardiopulmonary bypass and cross clamp times were lower in ROA than in SMVR (74 ± 27 min vs 99 ± 42 min and 49 ± 19 min vs 70 ± 25 min, respectively, p = 0.03 and p = 0.005). ROA patients were more frequently women (50% vs 13%, p = 0.027). Echocardiographic characteristics of successful ROA were mid‐late systolic MR, a paradoxical systolic papillary muscle displacement, and paradoxical systolic annulus expansion (PAE). A prolapsing depth &lt;10 mm, the absence of flail leaflet and ruptured chordae, the presence of multiple jets, more often in the central part of the valve were also associated with ROA. Non hemodynamic systolic anterior motion and residual trivial MR tended to be more frequent in ROA than in SMVR.ConclusionSimple and fast MVR using a ROA is feasible in 4/10 patients with complex forms of bileaflet MVP. Successful ROA patients were more frequently women, with mid‐late systolic central multiple jet, low prolapse depth, absence of chordal rupture or flail leaflet and PAE.

Geometric differences of the mitral valve apparatus in atrial and ventricular functional mitral regurgitation

BackgroundFunctional mitral regurgitation (FMR) occurs in patients with annular dilation (atrial, aFMR) or patients with left ventricular (LV) disease (ventricular, vFMR). Meticulous understanding of the mechanisms underpinning regurgitation is crucial to optimize therapeutic strategies. MethodsPatients with moderate-severe FMR were identified from a registry of patients referred for transcatheter mitral valve intervention. In addition, controls without cardiovascular disease were identified. Differences in the geometry of the LV and mitral valve apparatus (including leaflet and tenting geometry, papillary muscle displacement and movement, annular dimensions, and dynamism) between atrial and ventricular FMR, and control subjects, were assessed using multiphasic cardiac CT. ResultsOf 183 FMR patients, 18 patients (10%) were found to have aFMR. The remaining patients had either ischemic or non-ischemic ventricular FMR. In aFMR, both increasing LV end-systolic volume (rho 0.701, p ​< ​0.01) and left atrial volume (rho 0.909, p ​< ​0.01) were associated with larger annular area. By contrast, in vFMR larger annular area was most strongly associated with larger left atrial volume (rho 0.63, p ​< ​0.01). In controls, increased annular area was associated with larger LVEDV (rho 0.78, p ​< ​0.01) and LVESV (rho 0.824, p ​< ​0.01), but not left atrial size (rho 0.16, p ​= ​0.45).Ventricular FMR comprised apicolaterally displaced, akinetic posteromedial papillary muscles, resulting in pronounced leaflet tethering, leaflet elongation compared to controls, and only modest relative LA dilatation. Compared to vFMR, aFMR was characterised by marked relative annular dilation, smaller but discernible mitral valve tenting, shorter leaflet lengths when related to annular size, but normal papillary geometry. ConclusionFMR is characterised by multiple changes within the mitral valve complex. Atrial and ventricular FMR differ significantly in terms of the drivers of annular size, and geometry and function of the subvalvular apparatus. This highlights the need to consider these as separate disease entities.

Mitral Valve Translocation: Optimization of Patch Geometry in an Ex Vivo Model of Secondary Mitral Regurgitation.

Optimal translocation patch width for functional mitral regurgitation (FMR) treatment was evaluated in an air-filled ex vivo system. FMR was created in 19 isolated swine hearts by annular dilation and papillary muscle displacement. Frustum-shaped pericardial patches of varying widths (Group 1 = 0.5cm; Group 2 = 1.0cm; Group 3 = 1.5cm) were implanted and imaged via a 3D-structured light scanner. Median leaflet coaptation decreased (P < 0.001) from 5.5 ± 2.0mm at baseline to 2.4 ± 1.3mm following FMR creation. Translocation repair increased coaptation length over FMR levels by 2.2mm in Group 1 (P < 0.001), 4.6mm in Group 2 (P < 0.001), and 4.7mm in Group 3 (P < 0.001). After repair, no significant differences were found between groups for annular height, circularity index, tenting height, tenting area, and non-coapting surface area. The supranormal coaptation and minimal valve geometric changes support using a 1.0- or 1.5-cm translocation patch for FMR treatment. Implantation of a 1.0-cm or 1.5-cm circumferential pericardial patch (mitral valve translocation) increases leaflet coaptation length without significantly altering valve geometry.

Transcatheter mitral valve repair (TMVR) using MitraClip in patients younger than 65 years: a multicenter analysis of 2-years outcomes

Abstract Background TMVR using MitraClip became a well-established interventional therapy for severe MR. However, TMVR has been almost only applied to old aged patients rejected from surgical therapy. Objective To present 2-years outcomes of 36 patients younger than 65 years with no surgical options treated by TMVR. Methods A retrospective clinical and TEE study was conducted to evaluate 36 patients younger than 65 years treated by TMVR in 3 heart centers. Results Mean age of the 36 study patients was 56.3±6.6 years, male gender was 72.2%. High operative risk was estimated by STS score (mean = 8.73±2.97) and EuroSCORE (mean = 24.71±12.79). All patients were refused for surgery by heart team decision, therefore admitted to TMVR. Baseline severity of MR was assessed by 3D-TEE based biplane vena contracta width (mean = 8.35±1.87 mm). Baseline transmitral mean pressure gradient was 1.81±0.78 mmHg. 21 patients showed mitral annular dilatation as the main cause of MR, 8 patients had leaflet prolapse, 4 patients exhibited papillary muscle displacement leading to leaflet tethering and 3 patients showed mitral leaflet thickening and/or retraction due to fibrosis. Procedural success was achieved in all patients with 1/2/3 clips implanted in 52.8%/44.4%/2.8% of cases with a mean of 1.5 clip per case. Two grades or more reduction in severity of MR (MR grade ≤ II/IV) was accomplished in 88.9% of patients. Mean postprocedural MPG was 3.78±1.96 mmHg. Average follow-up (FU) period was 25,8 months and the median was 20 months (25th–75th percentile: 12–36 months). During 2-years FU, statistically significant difference (p value &amp;lt;0.002) was detected for NT-proBNP levels compared to baseline (mean = 9870±10819, median = 7748, 25th–75th percentile: 2702–14237 pg/ml) and at follow up visits (mean = 7645±11292, median = 3263, 25th-75th percentile: 883–8078 pg/ml). Furthermore, persistent symptomatic improvement during FU, defined as NYHA functional class improvement by 2 or more Grades, was achieved in 69% of patient in parallel with efficient reduction of MR in 34 patients so that a second intervention by reclipping was required in 2 patients to correct recurrent significant MR. Only two patients experienced procedure-related complications by large puncture site hematoma. No procedure-related mortality during the first 30 days was detected. However, mortality was recorded in 2 patients during the first month and was attributed to severe advanced heart failure in one case and septicemia after exclusion of infective endocarditis in another case. Over 2 years FU, other 5 patients passed away, 3 cases owing to advanced heart failure, one case due to multi-organ failure and one because of tumor disease. Conclusion TMVR in patients younger than 65 years refused from surgical repair provides satisfactory clinical and echocardiography outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hassan M.H. Mohammed received a scholarship grant from the Egyptian ministry of higher education and Minia University, Egypt.

Surgical Treatment of Left Ventricular Aneurysm Combined with Ischemic Mitral Regurgitation Using a Modified Technique

Background. Ischemic mitral regurgitation (IMR) is the second most common cause of mitral regurgitation (MR). IMR occurs in patients with myocardial infarction due to a rupture of the subvalvular apparatus. Pathological remodel-ing, dilatation and dysfunction of the left ventricle (LV) play a significant role in the development of IMR. The presence of a postinfarction LV aneurysm can lead to the development of MR due to dysfunction, relative and true shortening of the papillary muscles. There are various methods of surgical correction of IMR. The aim. To show the effectiveness of surgical treatment of left ventricular aneurysm combined with ischemic mitral regurgitation using a modified technique. Materials and methods. From January 2011 to December 2019, 20 patients with IMR combined with LV aneurysm underwent surgical intervention using a modified technique at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine. According to this technique, access to the mitral valve was performed through the left ventricle. The mean age of the patients was 61.2 ± 10.1 years. Among patients with IMR, the majority were men (60.0%). The overwhelming majority of patients (80.0%) had the history of hypertension. Diabetes mellitus was detected in 35.0% of patients. Mitral ring dilatation was observed in 25.0% (5) of the cases, papillary muscle displacement in 40.0% (8), chords rupture in 15.0% (3), papillary muscle infarction in 20.0% (4) of the cases. All the patients had reduced LV ejection fraction with a mean value of 34.5 ± 7.8%. Results. Aortic cross-clamp time through ventricular access was 112.9 ± 18.7 minutes. The duration of mechanical ventilation was 19.1 ± 20.6 hours. The length of stay of patients in the ICU was 99.2 ± 43.5 hours. There were no signs of acute heart failure in the early postoperative period in one in five patients (20.0%). The rate of degree III heart failure after intervention using the modified technique was 20.0% (4). The study of the incidence of cardiac arrhythmias after combined intervention showed that 85.0% (17) of patients operated using the modified technique had no cardiac arrhythmias. Conclusions. In patients who underwent surgery using the modified technique, the mortality rate was 5.0%. This is 1.6-2.8 times less than that in patients undergoing conventional operation. Postoperative occurrence of arrhythmias is much less common than that described in the literature.

Race, gender and clinical presentation in apical hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background The apical variant of hypertrophic cardiomyopathy (ApHCM) has male predominance and is a relatively rare phenotype in Western population. Characteristics of female and black patients diagnosed with ApHCM are very limited in the existing literature. Purpose We aimed to investigate whether gender and race are associated with a different clinical presentation and CMR findings in apical HCM. Methods We retrospectively analysed 150 patients (113 males and 37 females) with a diagnosis of apical HCM who have been followed in our inherited cardiac conditions (ICC) clinic between 2010 and 2020. Only patients with a CMR study and apical hypertrophy defined as ≥ 13mm at the time of diagnosis were included. Demographics and clinical characteristics were obtained from electronic records. Volumetric CMR data were taken from confirmed reports while other parameters were measured by standard protocol. "Pure" ApHCM was defined as isolated apical hypertrophy and "mixed" with both apical and septal hypertrophy but with the apex thickest (1). Apical displacement of papillary muscles (PM) was defined when the base of PM originated from the apical one-third of the left ventricle (LV) in the apical 4- or 2-chamber views. Giant T-wave inversion was defined as T-wave inversion that is equal or greater than 10 mm (1 mV) in any electrocardiogram lead. Results Our study population included patients of White (55, 37%), Black (37, 25%), Asian (36, 24%) and Mixed/Others (22, 15%) ethnicity. Black patients were more likely to have a diagnosis of hypertension at presentation when compared to White (70% vs 40%, p = 0.01) and to Asian and Mixed/Other patients (70% vs 48%, p = 0.03). Similarly, they were more likely to have "mixed" ApHCM than White (49% vs 20%, p = 0.003) and Asian and Mixed/Other (49% vs 26%, p = 0.02) patients. Females were diagnosed at an older age (63 ± 12 vs 52 ± 14, p &amp;lt; 0.001) and were less likely to have deep T-wave inversion on their ECG at presentation (14% vs 32%, p = 0.03) compared to their male counterparts. Females in this cohort also had higher representation of black ethnicity and were more likely to have hypertension (68% vs 47%, p = 0.03). Apart from the expected gender related differences in volumes and LV mass, there were no differences in cardiomyopathy-specific parameters we investigated. Conclusions In our cohort, females with ApHCM presented at an older age and were less likely to have giant T-wave inversion on ECG. Black patients with ApHCM were more likely to have hypertension and the "mixed" type of the disease.

STUDY OF CORRELATION BETWEEN SEVERITY OF ISCHEMIC MITRAL VALVE REGURGITATION BY ECHO DOPPLER AND ECG CHANGES IN ACUTE MYOCARDIAL INFARCTION

Background: Myocardial infarction (MI) accompanies with different mechanical complications including ischemic mitral regurgitation (IMR) which is correlated with increased risk of mortality and heart failure. IMR existence and its severity had significant prognostic effect on patients’ mortality following acute myocardial infarction (AMI). Echocardiography is the choice imaging modality for the diagnosis and assessment of IMR and establishing its etiology. IMR usually results from papillary muscle displacement, ventricular dilation and remodeling with reduced closing forces. Objective: Assessment of the correlation between echocardiographic severity of ischemic mitral valve regurgitation following acute myocardial infarction and its electrocardiographic location. Patients and methods: This was a prospective study that included 100 patients admitted to CCU OF Beni-Suief General Hospital in the period from October 2019 to May 2020 . Those patients were divided on two equal groups: Group I: patients with STEMI and no, trivial or mild MR and Group II: patients with STEMI and moderate or severe MR. Results: Mean age of group I involved in the study was 55.44 ± 7.23 years and 70% of them were males. Mean age of group II was 58.38 ± 7.8 and 56% were males. 70 % of the group II had inferolateral STEMI compared to group I who had more anterior STEMI. Group II were more smokers with hyperlipidemia. Group II was with higher previous stable and unstable angina, with less streptokinase treatment, with higher abnormal chest radiogrgh and higher killip class. Group II had significantly lower EF and higher LVEDD, LVESD, LA diameter, RV diameter, MV A velocity, tricuspid valve excursion TAPSI and pulmonary artery pressure and more diastolic dysfunction. Mechanism of IMR in case group was mono leaflet tethering in 43 cases, both leaflet tethering in 7 cases and ring dilation in 30 cases. MR jet direction was medial commissure posterior in 31 (62%), lateral commissure anterior in 12 (24%), and both commissures central in 7 (14%) cases. Conclusion: Mitral regurgitation is common after acute myocardial infarction, especially in cases with inferior mitral regurgitation. The echocardiographic findings are indicative of left ventricular remodeling and abnormality of mitral valve apparatus.

Assessment of mitral valve function in children and young adults with hypertrophic cardiomyopathy using three-dimensional echocardiography

ObjectiveThe objective of this study was to assess papillary muscle (PM) and mitral valve (MV) structure and function in children and young adults with mild and moderate hypertrophic cardiomyopathy (HCM) using real-time three-dimensional echocardiography (3DE) and to correlate them with HCM related adverse outcomes. MethodsTransthoracic research 3DE was performed in HCM patients and controls matched for age and gender. Anterolateral and posteromedial PM mass, apical displacement of anterolateral PM, and left ventricular (LV) mass were measured and indexed to body surface area. The MV annulus and leaflet structure and function were analyzed. Individual PMs were manually planimetered by tracing the endocardial borders on each mid systole frame, taking care to distinguish PMs as distinct from the LV wall. Apical PM displacement was expressed as ratio of the distance between the apex and the base of the anterolateral PM to the entire length of the LV lateral wall (APL index). All 3DE measurements were correlated to adverse outcomes. ResultsForty subjects were studied, including 20 HCM patients (age 18.1 ± 9.6 years, 16 male and 4 female), and 20 controls (18.2 ± 9.6 years, 16 male and 4 female). The indexed LV mass in HCM was 74.8 ± 25.8 g/m2 compared to 50.8 ± 12.4 g/m2 in controls (p = 0.001). The anterolateral, posteromedial and combined PM mass were 3.1 ± 2.2 g/m2, 1.7 ± 1.2 g/m2 and 4.9 ± 2.7 g/m2 in HCM, in contrast to respective measurements of 1.1 ± 0.6 g/m2, 1.2 ± 0.6 g/m2 and 2.3 ± 0.8 g/m2 in controls (p < 0.001, p = 0.062, and p < 0.001, respectively). The mitral valve annular parameters (annulus circumference, height and area) in HCM were not significantly different from controls. The APL index in HCM was less than in controls (0.44 ± 0.07 vs. 0.55 ± 0.04, p < 0.001). The LV lateral wall length and LV mass correlated with adverse HCM outcomes, while the APL index and PM total mass were not associated with adverse events. ConclusionIt is feasible to evaluate PM muscles and MV annulus geometry in children and young adults with HCM using 3DE. The morphologic and functional changes of anterolateral PM may occur in the absence of MV annulus changes. Prospective validation will be required to determine if LV lateral wall length and LV mass may be used as predictors of adverse events.

Mitral valve cleft gapping mechanism in functional mitral regurgitation: An in-vitro study

Background and aimGapping formation of the mitral valve cleft is unknown. The objective of this study was to quantify the geometry of mitral valve cleft coaptation in the asymmetric and symmetric papillary muscles (PMs) positions in a dilated annulus in order to reveal mitral valve gapping mechanism. MethodsNine fresh porcine mitral valves with the posterior leaflet clefts were sutured onto a saddle-shaped dilated annulus in an in-vitro experiment to simulate mitral valve closure at hydrostatic pressure. PMs were adjusted to the normal position, and subsequently to positions of asymmetric and symmetric PM displacement. Sonomicrometry was used to measure positions of the lateral and medial clefts. ResultsPM displacement tethered the leaflets. Both the opening angle and contact angle of the lateral cleft, but not of the medial cleft, increased in the asymmetric PM displacement. Neither the opening angle nor contact angle of both clefts increased in the symmetric PM displacement. ConclusionsDisplacement of the postero-medial PM moves the posterior leaflet medially and impairs coaptation of the lateral cleft, but not medial cleft, which suggest that the medial cleft displacement in the asymmetric PM position is another mechanism of gap formation in addition to leaflet tenting due to apical leaflet displacement. Symmetric PM displacement cause leaflet tenting, but doesn’t impair the leaflet cleft coaptation, which suggest that the asymmetric PM position is even worse than the symmetric PM position.

Hybrid transcatheter left ventricular reconstruction for the treatment of ischemic cardiomyopathy.

Left ventricular (LV) enlargement is a mechanical adaptation to accommodate LV systolic inefficiency following an acute damage or a progressive functional deterioration, which fails to correct the decline of stroke volume in the long term, leading to progressive heart failure (HF). Surgical ventricular reconstruction (SVR) is a treatment for patients with severe ischemic HF aiming to restore LV efficiency by volume reduction and LV re-shaping. Recently, a new minimally-invasive hybrid technique for ventricular reconstruction has been developed by means of the Revivent™ system (BioVentrix Inc., San Ramon, CA, USA). The device for ventricular reconstruction consists of anchor pairs that enable plication of the anterior and free wall LV scar against the right ventricular (RV) septal scar of anteroseptal infarctions to decrease cardiac volume without ventriculotomy in a beating-heart minimally-invasive procedure, consisting of a transjugular and left thoracotomy approach. Patients with severe (Grade 4) functional mitral regurgitation (FMR) or with previous cardiac surgery procedures were excluded. Outcome of the reconstruction procedure: from 2012 until 2019, it has been applied to 203 patients, with 5 (2.5%) in-hospital deaths. LV volume reduction varied according to experience gained along years: LV end-systolic volume index decreased from baseline 43% (post-market registry) vs. 27% (CE-mark study); left ventricular ejection fraction (LVEF) increased from baseline 25% (post-market registry) vs. 16% (CE-mark study). Clinical status (NYHA class, HF questionnaire, 6-minute walking test) improved significantly compared to baseline, and re-hospitalization rate was only 13% at 6-month follow-up (60% of patients in NYHA =3). FMR grade decreased at follow-up in 63%, while it was unchanged in 37% of patients. The hybrid ventricular reconstruction (HVR) seems a promising treatment for HF patients who may benefit from LV volume reduction, with reasonable mortality and good results at follow-up. A baseline less severe clinical profile was not associated to better outcome at follow-up, which makes the procedure feasible in patients with very large ventricles and depressed ejection fraction (EF). LV reshaping has no detrimental effect on FMR, that may, on the contrary, benefit owing to less papillary muscle displacement, partial recovery of torsion dynamics and of myofibers re-orientation. A controlled study on top of optimal medical treatment is warranted to confirm its role in the management of HF patients.