Significant Left Ventricular Reverse Remodeling Research Articles

Left Ventricular Reverse Remodeling after Surgical Aortic Valve Replacement for Aortic Regurgitation-An Explorative Study.

The timing of treatment for chronic aortic valve regurgitation (AR), especially in asymptomatic patients, is gaining attention since less invasive strategies have become available. The aim of the present study was to evaluate left ventricular reverse remodeling after aortic valve replacement (AVR) for severe AR. Patients (n = 25) who underwent surgical AVR for severe AR with left ventricular ejection fraction (LVEF) less than 55% were included in this study. Preprocedural and follow-up clinical and echocardiographic measurements of LVEF and left ventricular (LV) diameters were retrospectively analyzed. Mean LVEF increased significantly following surgical AVR (p < 0.0001). LV diameters showed a clear regression (p = 0.0088). Younger patients and those receiving a mechanical valve tended to have less improved LVEF on follow-up than patients over 60 years or the ones who were implanted with a biological prosthesis (p = 0.0239 and p = 0.069, respectively). Gender had no effect on the degree of LVEF improvement (p = 0.4908). We demonstrated significant LV reverse remodeling following AVR for AR. However, more data are needed on LV functional and geometrical improvement comparing the different types of valve prostheses to provide an optimal treatment strategy.

Effect of Ivabradine on Left Ventricular Reverse Remodeling in Relatively Stable Heart Failure Outpatients With Reduced Ejection Fraction.

Background: Elevations of resting heart rate (HR) in patients with heart failure (HF) with reduced ejection fraction (HFrEF) are often missed, resulting in some patients with an indication for ivabradine reportedly being missed. Methods and Results: We studied 30 relatively stable HFrEF outpatients, and ivabradine was administered when regular follow-up echocardiography showed a resting HR ≥75 beats/min. Significant left ventricular reverse remodeling was observed 10.1±3.9 months after administration of ivabradine. Conclusions: This finding may well make this procedure a potential new approach for preventing worsening of HF for relatively stable patients with HFrEF.

Left ventricular reverse remodeling following initiation of sacubitril/valsartan for heart failure with reduced ejection fraction and low blood pressure

Abstract Background Sacubitril/valsartan has become an important first-line drug for symptomatic heart failure (HF) patients, especially with left ventricular (LV) ejection fraction (LVEF) &amp;lt; 50%. Since sacubitril/valsartan was reported to be more potent than renin-angiotensin-aldosterone system inhibitors for lowering blood pressure, HF patients with low blood pressure were not included in most clinical studies as a result of sacubitril/valsartan administration, and average systolic blood pressure of most enrolled patients was around 120 mmHg. Thus, the effect of sacubitril/valsartan on cardiovascular outcomes, especially LV reverse remodeling for HF patients with LVEF &amp;lt; 50% and low blood pressure, remains uncertain. Purpose The aim of this study was to examine the effect of sacubitril/valsartan on LV reverse remodeling after initiation of the maximum tolerated dose of sacubitril/valsartan for HF patients with LVEF &amp;lt; 50% and systolic blood pressure ≤ 100 mmHg, and a comparison of its efficacy with that for patients with systolic blood pressure &amp;gt; 100 mmHg. Methods We retrospectively studied 164 HF patients with LVEF &amp;lt; 50% who were treated with sacubitril/valsartan from two institutions. Echocardiography was performed before and 9.5 ± 5.1 months after initiation of maximum tolerated dose of sacubitril/valsartan. Results sacubitril/valsartan was discontinued for 17 (10.4%) as decided by the attending physician mainly due to hypotension. The prevalence of discontinuation of sacubitril/valsartan for the low blood pressure group was higher than that for the non-low blood pressure group, but the difference was not statistically significant (16.0% vs. 9.4%, P = 0.32). No serious adverse events occurred during this study. The maximum tolerated dose of sacubitril/valsartan was lower for the low blood pressure group than for the non-low blood pressure group (165 ± 106 mg vs. 238 ± 124 mg, P = 0.017). As expected, significant LV reverse remodeling was observed in the non-low blood pressure group after initiation of sacubitril/valsartan. It was noteworthy that significant LV reverse remodeling was also observed in the low blood pressure group after initiation of sacubitril/valsartan (LV end-diastolic volume: 177.3 ± 66.0 mL vs. 137.7 ± 56.1 mL, P&amp;lt;0.001, LV end-systolic volume: 131.6 ± 60.3 mL vs. 94.6 ± 55.7 mL, P&amp;lt;0.001, LVEF: 26.8 ± 10.3% vs. 33.8 ± 13.6%, P = 0.015). Relative changes in LV volumes and LVEF after initiation of sacubitril/valsartan were similar for the two groups (Figure). Conclusions Significant LV reverse remodeling can occur after initiation of sacubitril/valsartan even in HF patients with LVEF &amp;lt; 50% and systolic blood pressure ≤ 100 mmHg if tolerated. This finding is expected to offer new insights for better management of HF patients.Figure

Left ventricular reverse remodeling following initiation of sacubitril/valsartan for heart failure with reduced ejection fraction and low blood pressure.

Sacubitril/valsartan has become an important first-line drug for symptomatic heart failure (HF) patients, especially with left ventricular (LV) ejection fraction (LVEF) < 50%. However, the impact of sacubitril/valsartan on cardiovascular outcomes, especially LV reverse remodeling for such patients with low blood pressure, remains uncertain. We retrospectively studied 164 HF patients with LVEF < 50% who were treated with sacubitril/valsartan from two institutions. Echocardiography was performed before and 9.5 ± 5.1months after initiation of maximum tolerated dose of sacubitril/valsartan. The maximum tolerated dose of sacubitril/valsartan was lower for the low blood pressure group (≤ 100mmHg in systole) than for the non-low blood pressure group (> 100mmHg in systole) (165 ± 106mg vs. 238 ± 124mg, P = 0.017). As expected, significant LV reverse remodeling was observed in the non-low blood pressure group after initiation of sacubitril/valsartan. It was noteworthy that significant LV reverse remodeling was also observed in the low blood pressure group after initiation of sacubitril/valsartan (LV end-diastolic volume: 177.3 ± 66.0mL vs. 137.7 ± 56.1mL, P < 0.001, LV end-systolic volume: 131.6 ± 60.3mL vs. 94.6 ± 55.7mL, P < 0.001, LVEF: 26.8 ± 10.3% vs. 33.8 ± 13.6%, P = 0.015). Relative changes in LV volumes and LVEF after initiation of sacubitril/valsartan were similar for the two groups. In conclusion, significant LV reverse remodeling occurred after initiation of sacubitril/valsartan, even in HF patients with LVEF < 50% and systolic blood pressure ≤ 100mmHg.

Long-term impact of angiotensin receptor-neprilysin inhibitor based on short-term treatment response in heart failure.

The long-term effect of angiotensin receptor-neprilysin inhibitor (ARNI) remains uncertain in patients who have experienced improvements in left ventricular (LV) systolic function or significant LV reverse remodelling following a certain period of treatment. It is also unclear how ARNI performs in patients who have not shown these improvements. This study aimed to assess the impact of prolonged ARNI use compared with angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) in patients with and without significant treatment response after 1year of heart failure (HF) treatment. The present study enrolled patients with HF with reduced ejection fraction (HFrEF) who were treated with either ARNI or ACEIs/ARBs within 1year of undergoing index echocardiography. After 1year of treatment, patients were reclassified into the following groups: (i) patients with HF with improved ejection fraction and persistent HFrEF and (ii) patients with and without LV reverse remodelling based on the follow-up echocardiography. The effect of ARNI versus that of ACEIs/ARBs in each group was assessed from the time of categorizing into new groups using the composite event of all-cause mortality and HF hospitalization. A total of 671 patients with HFrEF (age, 66.4±14.1years; males, 66.8%) were included, and 133 (19.8%) composite events of death and rehospitalization for HF were observed during the follow-up (median follow-up, 44 [interquartile range, 34-51] months). ARNI had a significantly lower event rate than ACEIs/ARBs in patients with HF with improved ejection fraction (7.0% vs. 30.4%, P=0.020) and those with persistent HFrEF (17.6% vs. 49.7%, P<0.001). Irrespective of whether patients exhibited LV reverse remodelling (15.8% vs. 31.1%, P=0.001) or not (15.0% vs. 54.9%, P<0.001), ARNIs were associated with a significantly lower event rate than ACEIs/ARBs. Regardless of significant treatment response measured by either LVEF or LV reverse remodelling after 1year of treatment, the extended utilization of ARNI demonstrated a more favourable prognosis than that of ACEIs/ARBs in patients with HFrEF.

Restrictive annuloplasty on remodeling and survival in patients with end-stage ischemic cardiomyopathy

ObjectivesTo elucidate the influence of concomitant restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) reverse remodeling and survival in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG). MethodsThis study comprised 157 patients with ischemic cardiomyopathy (LV ejection fraction ≤40%) who underwent CABG and completed echocardiographic examination at 1 year after surgery, with 84 (54%) undergoing concomitant RMA for clinically relevant ischemic mitral regurgitation. The primary end point was postoperative reduction in LV end-systolic volume index (LVESVI). The secondary end point was overall survival. Median follow-up was 5.1 years. ResultsAt baseline, patients who underwent CABG with RMA had a larger LVESVI (83 ± 23 vs 75 ± 24 mm; P = .046). One-year postoperatively, CABG with RMA reduced the LVESVI more than did CABG alone (37% vs 21% from baseline; P < .001), yielding nearly identical postoperative LVESVI (53 ± 27 vs 61 ± 26 mm; P = .065). In multivariable logistic regression analysis, concomitant RMA was associated with significant LV reverse remodeling (odds ratio, 2.79; 95% CI, 1.34-5.78; P = .006). The prevalence in moderate or severe mitral regurgitation was not different between the groups (7% vs 10%; P = .58). Survival rates were similar between the groups (5 years, 78% vs 83%; P = .35). ConclusionsIn patients with ischemic cardiomyopathy undergoing CABG, concomitant RMA was associated with significant reduction in LVESVI. The influence of LV reverse remodeling on survival remains undetermined.

Impact of baseline left ventricular volume on left ventricular reverse remodeling after cardiac resynchronization therapy.

Left ventricular (LV) dilatation may limit LV reverse remodeling after cardiac resynchronization therapy (CRT). The purpose of this study was to evaluate the impact of baseline LV volumes on LV reverse remodeling after CRT and whether this is associated with improved survival. Patients were stratified into quintiles according to baseline LV end-diastolic volume indexed for body surface area (LVEDVi). LV reverse remodeling was defined as ≥15% reduction in LV end-systolic volume at 6-month follow-up after CRT. Independent associates of LV remodeling were assessed and long-term mortality rates were compared between patients with and without LV reverse remodeling (across LVEDVi quintiles). A total of 864 patients were included (mean age 66 ± 10 years; 657 patients (76%) were male), of whom 101 (12%) were in quintile 1 (<65 mL/m2), 272 (32%) in quintile 2 (65-95 mL/m2), 247 (29%) in quintile 3 (95-125 mL/m2), 151 (18%) in quintile 4 (125-155 mL/m2), and 93 (11%) in quintile 5 (>155 mL/m2). Patients with larger baseline LVEDVi had worse survival after CRT (log-rank, P = .019). The cumulative 10-year survival was significantly better in patients with vs without LV reverse remodeling (48.7% vs 33.9%; P < .001). Significant LV reverse remodeling was observed in all LVEDVi quintiles. In addition, patients with LV reverse remodeling had superior survival than did patients without LV reverse remodeling, regardless of baseline LVEDVi quintile (log-rank, P < .05 for all). Many patients with larger baseline LV volumes still show significant LV reverse remodeling after CRT and had superior survival (regardless of baseline LV volumes) than did patients without LV reverse remodeling. Therefore, CRT should not be denied on the basis of severe LV dilatation.

Acute and chronic changes in LV performance in patients with secondary severe mitral regurgitation undergoing percutaneous mitral valve repair

Abstract Funding Acknowledgements Type of funding sources: None. Background The non-invasive assessment of myocardial work allows to evaluate left ventricular (LV) performance by considering the effect of LV load on LV deformation. Aim of this study is to evaluate the acute and chronic impact of percutaneous mitral valve repair (PMVR) on LV function, in patients with severe secondary mitral regurgitation (SMR). Methods and Results 41 patients (age: 69 ± 10 years, females: 29%) with severe SMR (effective regurgitant orifice: 0.42 ± 0.16 cm2, regurgitant volume: 65 ± 325 ml) underwent PMVR according to current recommendations. Myocardial work indices were evaluated before the procedure, 2 days after the procedure and at 1-year follow-up. PMVR was associated with an acute reduction in LV ejection fraction (LVEF), global longitudinal strain (GLS), and myocardial constructive work (MCW) and with a significant increase in myocardial wasted work (MWW). 1-year after the procedure, we did not observe significant LV reverse remodeling. GWE remained significantly impaired despite the small improvement in GCW, which can explain the absence of improvement in MWE and GLS. Interestingly, LVEF modestly increased compared with the post-procedural values, but remained significantly reduced compared to baseline values (Table1). Conclusions In patients severe SMR undergoing PMVR, the acute reduction in LV preload causes a significant impairment of all parameters of LV performance. After 1-year, the absence of LV reverse remodelling is associated a significant impairment in GWW, without substantial improvement in the remaining parameters of LV function. Abstract Figure.

Impact of valvuloarterial impedance on left ventricular reverse remodeling after aortic valve neocuspidization

BackgroundAortic valve neocuspidization (AVNeo) has emerged as a promising aortic valve procedure, and is expected to have a larger effective orifice area (EOA) than commercially available bioprostheses. It is, however, unclear which indices could facilitate left ventricular (LV) reverse remodeling after AVNeo. The aim of this study is to verify the impact of global left ventricular afterload on the LV reverse remodeling following AVNeo.MethodsData-available consecutive 38 patients (median age, 77; interquartile range, 72.8–82.0) undergoing AVNeo for severe aortic stenosis were enrolled in this study. Preoperative and the last follow-up echocardiographic data were retrospectively analyzed including the valvuloarterial impedance (Zva), a marker of global LV afterload. Reduction in LV geometry index (LVGI) and relative wall thickness (RWT) were used as an indicator for LV reverse remodeling.ResultsThe Zva reduced in 24 patients (63.2%) during the follow-up period (median, 12 months). Reduction in Zva significantly correlated to improvement of LV geometry (LVGI (r = 0.400, p = 0.013) and RWT (r = 0.627, p < 0.001)), whereas increase in EOA index did not significantly correlate to LVGI (r = 0.009, p = 0.957), or RWT (r = 0.105, p = 0.529)). The reduction in Zva was the multivariate predictor of LV reverse remodeling.ConclusionsLow global LV afterload led to significant LV reverse remodeling even after AVNeo, which could achieve better valve performance than the conventional bioprostheses.

Effects of trehalose on recurrence of remodeling after ventricular reconstruction in rats with ischemic cardiomyopathy.

Recurrence of left ventricular (LV) remodeling after surgical ventricular reconstruction (SVR) for ischemic cardiomyopathy has been reported to be partially attributed to autophagy. We aimed to examine the effects of trehalose, an autophagy inducer, on the recurrence of LV remodeling after SVR. After SVR in rats with ICM, trehalose was orally administered. The changes in LV end-diastolic dimension (LVEDD) and fractional shortening (FS) were evaluated. The activation of myocardial autophagy was also estimated by autophagy markers: microtubule-associated light chain 3 II (LC3-II) and p62; the former usually increases and the latter decreases if autophagy is activated. Significant LV reverse remodeling was observed early after SVR. On the other hand, the 28th postoperative day SVR + trehalose was associated with smaller LVEDD and better FS than SVR alone (LVEDD, P = 0.043; FS, P < 0.01). LC3-II increased comparably in both groups, while p62 was significantly lower in the SVR + trehalose group than in the SVR alone group (P < 0.01). In conclusion, trehalose attenuated the recurrence of LV remodeling and changed autophagy markers after SVR in rats with ICM. Trehalose may be a candidate for adjuvant therapy to retain the effects of SVR.

B-PO04-181 AN EVALUATION OF LEFT VENTRICULAR REVERSE REMODELING IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK AND QRS DURATION LESS THAN 150MS

The benefit of cardiac resynchronization therapy (CRT) for patients with left bundle branch block (LBBB) and QRS duration (QRSd) between 120 and 150 milliseconds (ms) remains contested. Left ventricular (LV) reverse remodeling may help identify the benefit of CRT in these patients. We hypothesized that patients with LBBB QRSd between 120 and 150ms would have significant LV reverse remodeling on echocardiography after initiation of CRT comparable to patients with LBBB QRSd > 150ms. We aimed to study the effects of CRT on LV reverse remodeling in patients with LBBB QRSd < 150ms compared to patients with QRSd > 150ms. From a cohort of 258 patients who initiated CRT between 2016 and 2019, we performed a retrospective case-control study comparing the reduction in LV end-systolic volume (LVESV) of 19 patients with New York Heart Association Class II-III symptoms on goal-directed medical therapy (GDMT) with LBBB and QRSd < 150ms who received CRT and 19 controls with QRSd > 150ms. LVESV was measured on echocardiography within 6 months prior to CRT implantation and at least 1 year after implantation. There was a significant reduction in LVESV (mL) in patients with QRSd < 150ms from 121.25 to 84.91 (p = 0.0399) and in patients with QRSd > 150ms from 162.2 to 140.1 (p = 0.019). There was no significant difference in the absolute or relative magnitude of the reduction in LVESV between the two groups (absolute: 25.74 vs 44.98 mL, p = 0.48, relative: 27.67% and 28.91%, p = 0.91). Spacing of the echocardiograms before and after CRT introduction did not significantly differ between cases and controls (432.4 vs 460.9 days, p = 0.579). LV reverse remodeling occurred significantly and comparably in both patients with LBBB and QRSd < 150ms and patients with LBBB and QRSd > 150ms. As reduction in LVESV is an important predictor of survival with biventricular pacing, CRT may provide benefit to patients with systolic dysfunction on GDMT with LBBB and QRSd < 150ms.

Left ventricular remodeling after mitral valve repair and papillary muscle approximation.

Mitral valve repair with papillary muscle approximation (MVr-PMA) for severe secondary mitral regurgitation (MR) decreases MR recurrence compared with MVr alone. This study assessed the effects of MVr-PMA on left ventricular (LV) remodeling and shape, systolic function and strain mechanics. Forty-eight patients who underwent MVr-PMA for severe secondary MR and had follow-up echocardiograms available for review were identified. Student's t-test, linear regression modeling, and receiver-operating characteristic curves were used in the statistical analyses. Median follow-up time was 14.9 months. MVr-PMA was associated with significant LV reverse remodeling with a smaller LV end-diastolic diameter, Systolic Sphericity Index, and interpapillary muscle distance at follow-up. Nine patients (18.8%) experienced moderate recurrent MR. When compared to recurrent MR patients at follow-up, those with durable MVr-PMA had a greater LV ejection fraction (32.8 vs. 22.0%, P=0.03), a smaller end-diastolic diameter (59.6 vs. 67.3 mm, P=0.03), Systolic Sphericity Index (0.35 vs. 0.47, P=0.03), and end-systolic interpapillary muscle distance (16.3 vs. 21.1 mm, P=0.03). A durable MVr-PMA also resulted in stable global longitudinal strain when compared with pre-operative values, while the recurrent MR group experienced a further decline (no recurrent MR: -8.4 vs. -7.5%; recurrent MR: -8.2 vs. -5.4%; P<0.05). A pre-operative LV end-diastolic diameter ≥ 64 mm was a discriminative predictor of MR recurrence (sensitivity=100%, specificity=51%, AUC=0.756, P=0.02). A durable MVr-PMA confers improved LV geometry and function, and stable LV mechanics. The extent of baseline LV remodeling identifies patients at risk for recurrent MR.

Should SGLT2i be used prior to transcatheter edge-to-edge repair for secondary mitral regurgitation?

Should SGLT2i be used prior to transcatheter edge-to-edge repair for secondary mitral regurgitation?

Long-term outcomes of etiology specific annuloplasty ring repair of ischemic mitral regurgitation.

Reductive annuloplasty repair of ischemic mitral regurgitation (IMR) is associated with high rates of recurrent MR, which may be improved with etiology-specific annuloplasty rings. From October 2005 to May 2015, 128 consecutive patients underwent repair of IMR with the GeoForm ring. Clinical data was extracted from our local Society of Thoracic Surgeons database and electronic medical records. Mortality data was obtained from the Michigan State Social Security Death Index. The average age of patients was 65±11 years with mean pre-op left ventricular ejection fraction (LVEF) of 30%±10% and MR grade of 3.1±0.9 (0-4+). Thirty-day mortality was 4.7%, rate of renal failure 7.9%, rate of atrial fibrillation 27.3%, and no strokes were observed. Of the surviving patients, 89% (109/122) had a follow-up echocardiogram beyond 1 month with a mean echocardiographic follow-up of 59±39 months. LVEF improved from 30%±10% to 38%±14%, P<0.001) while end-diastolic (5.9±0.0 to 5.3±0.9 cm, P<0.001) and end-systolic (5.0±1.0 to 4.4±1.1 cm, P<0.001) left ventricular (LV) diameters decreased, as compared to pre-operative values. Seven patients were found to have recurrent moderate or greater IMR in follow-up to 10 years with three being due to ring dehiscence. One-, 5-, and 10-year freedom from recurrent moderate or severe IMR was 98%, 94%, and 80% respectively. One-, 5-, and 10-year survival was 91%, 77%, and 44%, respectively. Overall, etiology-specific ring repair of IMR was associated with low rates of recurrent MR on long-term follow-up, coupled with significant LV reverse remodeling and improvement in ejection fraction.

Individual patient data meta-analysis of the effects of the CARILLON® mitral contour system.

AimsFunctional mitral regurgitation (MR) (FMR) is common in heart failure with reduced ejection fraction and worsens morbidity and mortality, even when mild. The CARILLON® mitral contour system (Cardiac Dimensions, Kirkland, WA, USA), a mitral annuloplasty device delivered percutaneously to the coronary sinus, is designed to reduce the mitral annular dimension by virtue of the close anatomic relationship between the coronary sinus and the posterior mitral annulus. We performed a comprehensive individual patient data meta‐analysis of all studies that used CARILLON® device vs. control that have measured mitral regurgitation severity, left ventricular (LV) remodelling, functional status, and heart failure‐related outcomes in heart failure with reduced ejection fraction patients.Methods and resultsThe Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched in July 2020. Primary outcomes of interest were measures of MR severity, LV remodelling, New York Heart Association functional class and heart failure‐related outcomes [mortality and heart failure hospitalization (HFH) during follow up]. All data were received as individual patient and individual time point data‐points. Mean differences and 95% confidence intervals (CIs) were calculated for continuous data using a fixed‐effects model. Three studies (REDUCE FMR, TITAN and TITAN II) enrolling 209 participants were identified and included. Pooled analysis showed that, compared with control, CARILLON® device significantly improved both MR volume (mean difference MD ‐9.20, 95% C.I. −16.11 to −2.29 mL, P = 0.009) and MR grade (MD ‐1.12, 95% CI −1.36 to −0.88, P < 0.00001) and this was associated with a significant reduction in LA volume, MD −7.54 mL, 95% CI −14.90 to − 0.18, P = 0.04. Significant LV reverse remodelling was also seen in terms of EDV (MD −16.53, 95% CI −28.61 to −44.4 mL, P = 0.007), and a trend in ESV (MD −8.68, 95% CI −18.69 to −1.34 mL, P = 0.09) but no significant effect on LVEF (MD 0.88, 95% CI −1.52% to 2.38%, P = 0.47), due presumably to the greater residual MR in the control patients falsely elevating the LVEF. In addition, the CARILLON® device significantly improved New York Heart Association functional Class (MD −0.22, 95% CI −0.24 to −0.16, P < 0.00001), associated with a lower rate of HFH compared with controls (45.3% vs. 64%, respectively, P = 0.04). As a sensitivity analysis we also restricted the analyses to those patients with Class 3+/4+ MR at baseline. In this cohort, the echocardiographic results were similar, and the reduction in HFH rates was even more marked (43.9% vs. 82.9%, respectively, P = 0.04).ConclusionsThis comprehensive meta‐analysis of individual patient data has shown that CARILLON® device provides statistically significant and clinically meaningful benefits on MR severity, LA and LV volumes, and remodelling and rates of subsequent heart failure hospitalization

Papillary muscle intervention vs mitral ring annuloplasty in ischemic mitral regurgitation.

Background and AimsThe main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering. For this reason, papillary muscle intervention (PMI) in combination with mitral ring annuloplasty (MRA) has recently been introduced into clinical practice to correct this displacement, and to reduce the recurrence of regurgitation.MethodsA meta‐analysis was conducted comparing the outcomes of PMI and MRA performed in combination vs MRA performed alone, in terms of MR recurrence and left ventricular reverse remodeling (LVRR). A meta‐regression was carried out to investigate the impact of the type of PMI procedure on the outcomes.ResultsMR recurrence in patients undergoing both PMI and MRA was lower than in those who only had MRA (log incidence rate ratio, −0.66; lower‐upper limits, −1.13 to 0.20; I 2 = 0.0%; p = .44; Egger's test: intercept 0.35 [−0.78 to 1.51]; p = .42).The group with both PMI and MRA and that with only MRA showed a slightly higher reduction in left ventricular diameters (−5.94%; −8.75% to 3.13%,). However, in both groups, LVRR was <10%. No difference was detected between PM relocation/repositioning and papillary muscle approximation in terms of LVRR (p = .33).ConclusionsUsing PMI and MRA together has a lower MR recurrence than using MRA alone. No significant LVRR was observed between the two groups nor between the PMI techniques employed.

CRT Pacing: Midterm Follow-Up in LV Only Pacing without RV Lead in Patients with Normal AV Conduction.

Background: The aim of our study was to assess the real life cardiac resynchronization therapy (CRT) fusion left ventricular (LV) only pacing in patients with normal AV conduction (NAVc) without right ventricular (RV) lead. Methods: Consecutive NAVc patients with CRT indication were implanted with a right atrium RA/LV DDD pacing system. Complete follow-up at 1, 3 and every 6 months thereafter included echocardiography and stress testing. Results: We analysed 55 patients (62 ± 11 years). All patients were responders with significant LV reverse remodelling (LV end-diastolic volume 193.7 ± 81 vs. 243.2 ± 82 mL at baseline, p < 0.002) and increased LV ejection fraction (38 ± 7.9% vs. 27 ± 5.2% at baseline, p < 0.001). Mitral regurgitation decreased in 38 patients (69%). During follow-up (35 ± 18 months), 20 patients (36%) needed reprogramming sensed/paced AV delay or maximum tracking rate (MTR) because of inadequate or lost LV capture at exercise test; personalized programming to achieve up to 100% fusion pacing was used in all patients. One patient developed Mobitz II second degree AV block and triple chamber CRT-P upgrade was performed; defibrillator upgrade was not necessary. Conclusions: LV only pacing CRT-P without RV lead showed a positive outcome in carefully selected patients.

Improved Left Ventricular Function and Remodeling After the David V for Significant Aortic Insufficiency

Valve-sparing root replacement is controversial in patients with significant aortic insufficiency (AI) because the aortic valve cusps often require repair, which may potentially jeopardize long-term valve function. The purpose of this study was to evaluate valve function and left ventricular reverse remodeling in patients undergoing valve-sparing root replacement in the setting of significant AI. A review of the Emory Aortic Surgery database between 2004 and 2012 identified 616 aortic root replacements. Of these procedures, 169 were performed for patients with 3+ or greater AI. Fifty-one patients (30%) underwent a David V procedure. Echocardiography was used to evaluate the degree of AI, left ventricular end-diastolic diameter, and left ventricular end-systolic diameter. The mean echocardiographic follow-up was 18 ± 21 months (range, 1 to 89). Patients undergoing valve-sparing root replacement had an increase in ejection fraction (preoperative 51% ± 7% versus postoperative 57% ± 6%, p < 0.01) and a reduction in left ventricular end-diastolic diameter (preoperative 58 ± 8 mm versus postoperative 48 ± 6 mm, p < 0.01) and left ventricular end-systolic diameter (preoperative 40 ± 8 mm versus postoperative 32 ± 6 mm, p < 0.01). During the follow-up period, freedom from greater than 1+ AI was 96%, and freedom from aortic valve replacement was 98%. The addition of cusp repair did not represent a significant risk factor for recurrent postoperative AI (p= 0.21). The David V technique produces significant left ventricular reverse remodeling and improved ventricular function in patients with chronic severe AI. Long-term data and close follow-up will be paramount in evaluating the durability of valve repair in this patient population.

Effect of isolated cabg on mild-to-moderate ischemic mitral regurgitation and cardiac remodeling

Results At follow-up 56 % of all survivors showed improvement in IMR grade, 32 % presented with the unchanged valve function and in only 12 % IMR grade was more severe than preoperative. Preoperative effective ejection fraction increased from 26 ± 8% to 32 ± 14% (p = 0.002) at the follow-up. Left ventricular end-systolic volume index (LVESVI) decreased from 35 ± 16 ml/m2 to 30 ± 14 ml/m2 (p = 0.001). Significant left ventricular reverse remodeling (≥ 15% reduction of LVESVI) was observed in 45 % of all survivors. In 21 % of all survivors significant left atrial reverse remodeling was present although mean left atrial volume index did not change significantly. Conclusions Isolated surgical revascularization improves the valve function in ischemic mitral regurgitation. It also triggers significant left ventricular reverse remodeling in half of the patients. It remains unclear how the persisting or advancing remodeling process seen in the other half changes the prognosis of these individuals.

Left heart chambers reverse remodeling after combined CABG and mitral repair

Results The mean effective ejection fraction increased from 18 ± 6% to 39 ± 13% (p << 0.05) at the follow-up. Left ventricular end-systolic volume index decreased from 44 ± 24 ml/m2 to 39 ± 26 ml/m2 (p = 0.002). Significant left ventricular reverse remodeling (≥ 15% reduction of LVESVI) was observed in 55 % of all survivors. Recurrent IMR was detected in only 2.8% (2/71) of the evaluated patients. Left atrial volume index decreased from 43 ± 15 ml/m2 to 36 ± 14 ml/m2 (p = 0.000003) and left atrial reverse remodeling was significant for 57 % of all survivors.