Mei mini maze procedure for atrial fibrillation patients with atrial functional mitral regurgitation / 中华胸心血管外科杂志

Objective:To study the influence of Mei mini maze procedure for atrial functional mitral regurgitation.Methods:The data of 33 patients with atrial fibrillation and atrial functional mitral regurgitation from January 2017 to June 2020 were retrospectively analyzed. All patients received Mei mini maze procedure for atrial fibrillation. The procedure is carried out thoracoscopically through the left thoracic approach. The ablation of atrial fibrillation includes bilateral circumferential pulmonary vein ablation, isolation of the left atrium posterior wall, left atrial appendage resection, ablation of Marshall's ligament and autonomic ganglion, etc. Follow-up was conducted by outpatient follow-up and telephone. Postoperative heart rhythm was recorded by the patient's symptoms, electrocardiogram, 24 h holter and other examinations. Postoperative mitral valve lesions were obtained by echocardiography.Results:33 patients successfully completed the operation. There was no conversion to thoracotomy and no perioperative death. Thirty patients(90.9%) maintained sinus rhythm at discharge. Before discharge, 16 patients had no mitral regurgitation in echocardiography, 8 patients had mild mitral regurgitation, and 9 patients had moderate mitral regurgitation. Follow-up was 1-4 years after discharge, with a mean of(2.6±1.1) years. Sinus rhythm was maintained in 23 patients(69.7%). 17 patients had no mitral regurgitation, 9 had mild mitral regurgitation, 6 had moderate, and 1 had severe mitral regurgitation. The degree of regurgitation in 25 patients was reduced compared with pre-operation, 5 patients remained unchanged, and 3 patients mitral regurgitation aggravated. Unreduced atrial functional mitral regurgitation was associated with recurrence of atrial fibrillation by Cox multivariate analysis.Conclusion:This study found a close relationship between atrial fibrillation rhythm and atrial functional mitral regurgitation. Most moderate atrial functional mitral regurgitation can be alleviated by effective treatment for atrial fibrillation. It is not recommended that patients with severe atrial functional mitral regurgitation only receive treatment for atrial fibrillation.

Clinical study on morphology and dynamics of mitral valve device in patients with different types of functional mitral regurgitation by real-time three-dimensional echocardiography / 中华超声影像学杂志

Objective:To quantitatively evaluate and compare the morphology and dynamics parameters of mitral valve devices in patients with atrial functional mitral regurgitation (AFMR) and ventricular functional mitral regurgitation (VFMR) by real-time three-dimensional ultrasound, in order to provide theoretical basis for diagnosis and clinical treatments of the two types of regurgitation patients.Methods:A retrospective study was conducted on 20 AFMR patients (AFMR group) and 20 VFMR patients (VFMR group) who underwent transesophageal echocardiography at Wuhan University People′s Hospital from May to November 2022. Additionally, 20 patients who underwent transesophageal echocardiography at our hospital during the same period due to patent foramen ovale or non cardiac surgery monitoring were selected as the control group. All subjects were measured mitral annulus anteroposterior diameter (AP diameter), anterolateral posteromedial diameter (ALPM diameter), anteroposterior diameter/anterolateral posteromedial diameter (AP/ALPM), commissural width (CW), annular area (AA), annular circumference (AC), annular height (AH), coaptation depth (CD), tenting volume (TV), non-planar angle (NPA) and posterior leaflet angle at isovolumic relaxation time, early diastole, mid diastole, late diastole, isovolumic contraction time, early systole, mid systole, and late systole. The total change rate and systolic change rate of the above parameters were calculated, the differences in structure and dynamic changes of the mitral valve device among three groups were compared, and the correlations between the change rate of mitral annular parameters and left ventricular long axis strain (GLS) were analyzed.Results:①The GLS of three groups were as follows: control group>AFMR group>VFMR group, and the differences between the groups were statistically significant (all P<0.05). ②Static structure: The AP diameter, ALPM diameter, AA, AC, and total leaflet area (TLA) of the AFMR group and VFMR group were significantly larger than those of the control group (all P<0.05), but there was no statistically significant difference between the AFMR group and VFMR group (all P>0.05). Compared with the other two groups, the TV, CD, and posterior leaflet angle of the VFMR group were significantly increased, exhibiting the mitral valve tethering; the control group had the largest AH/CW and the deepest saddle shape; the AFMR group had the smallest TLA/AA and the least mitral valve remodeling; there was no statistically significant difference in the junction area among the three groups (all P>0.05). ③Dynamic changes: AP diameter, ALPM diameter, AA and AC in the control group showed regular changes throughout the cardiac cycle, gradually decreased from isovolumic relaxation time to late diastole, and gradually increased from isovolumic contraction time to late systole; The changes in the above parameters in the AFMR and VFMR groups appeared more disordered. In addition, compared with the control group, the total change rate and systolic change rate of AP diameter in the AFMR group were significantly reduced, but the total change rate of ALPM diameter was significantly increased (all P<0.05). ④The total change rate of AA, ALPM diameter and AP diameter were moderately correlated with GLS ( r=0.353, P=0.006; r=-0.304, P=0.018; r=0.300, P=0.020), while the systolic change rate of posterior leaflet angle was weakly correlated with GLS ( r=0.267, P=0.039). Conclusions:There are differences in the morphology and dynamics parameters of mitral valve device in patients with AFMR and VFMR.Different clinical strategies can be used for the two kinds of functional mitral regurgitation.

Reparación valvular mitral transcatéter "borde a borde": influencia del sesgo en estudios aleatorizados / Transcatheter "edge-to-edge" mitral valve repair: influence of bias in randomized trials

Resumen La regurgitación valvular mitral funcional es el resultado de la desestructuración tridimensional de la válvula mitral debido a disfunción ventricular izquierda. La técnica quirúrgica de "borde a borde" ha dado lugar a la técnica transcatéter "borde a borde" percutánea (TEER) para tratar la regurgitación valvular mitral funcional; sin embargo, la falta de un anillo protésico por anuloplastia hace a la TEER solo parcialmente efectiva con resultados inciertos a largo plazo. Los estudios MITRA-FR (Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients with Severe Secondary Mitral Regurgitation) y COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation), en los cuales están basadas las recomendaciones actuales de la TEER, muestran resultados contradictorios. El posible sesgo de los resultados del COAPT ha influido en las recomendaciones actuales emitidas en las guías de práctica clínica a favor de la TEER en regurgitación valvular mitral funcional.

Abstract Functional mitral regurgitation (FMR) is the result of three-dimensional structural disruption of the mitral valve due to left ventricular dysfunction. The "edge-to-edge" surgical technique has given rise to the percutaneous transcatheter edge-to-edge repair (TEER) technique to treat FMR; however, the lack of a mitral annuloplasty ring makes TEER only partially effective, with uncertain long-term results. The MITRA-FR and COAPT trials, on which current TEER recommendations are based, show conflicting results. COAPT results possible bias has influenced current recommendations issued by clinical practice guidelines in favor of TEER in FMR.

Treatment of moderate functional mitral regurgitation during aortic valve replacement in patients with aortic valve disease: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective    To evaluate the impact of different surgical strategies for moderate functional mitral regurgitation (FMR) at the time of aortic valve replacement (AVR) on patients' prognosis. Methods    A total of 118 AVR patients, including 84 males and 34 females, aged 58.1±12.4 years, who were complicated with moderate FMR were retrospectively recruited. Patients were divided into three groups according to the treatment strategy of mitral valve: a group A (no intervention, n=11), a group B (mitral valve repair, n=51) and a group C (mitral valve replacement, n=56). The primary endpoint was the early and mid-term survival of the patients, and the secondary endpoint was the improvement of FMR. Results    The median follow-up time was 29.5 months. Five patients died perioperatively, all of whom were from the group C. Early postoperative FMR improvement rates in the group A and group B were 90.9% and 94.1% (P=0.694). The mid-term mortality in the three groups were 0.0%, 5.9% and 3.9%, respectively (P=0.264), while the incidences of major cardiovascular and cerebrovascular events were 0.0%, 9.8% and 17.7%, respectively (P=0.230). Improvements of FMR in the group A and group B were 100.0% and 94.3% at the mid-term follow-up (P>0.05). Conclusion    For patients receiving AVR with moderate FMR, conservative treatment or concurrent repair of mitral valve may be more reasonable, while mitral valve replacement may increase the incidence of early and mid-term adverse events.

Bridge to Left Ventricular Reconstruction and Mitral Valve Replacement with Pre- and Post-Operative IMPELLA 5.0 Support for Ischemic Cardiomyopathy and Functional Mitral Regurgitation / 日本心臓血管外科学会雑誌

A 76-year-old man with ischemic cardiomyopathy and functional severe mitral regurgitation, suffered from profound dyspnea. He displayed a very low ejection fraction (12%) and was diagnosed with cardiogenic shock. Initially, we inserted the IMPELLA 5.0 heart pump into the patient's left ventricle and began an optimal medical therapy regimen. Once hemodynamic stability was acquired, we performed left ventricular reconstruction, mitral valve replacement, and tricuspid annuloplasty. The patient was supported postoperatively with IMPELLA 5.0 and venoarterial extracorporeal membrane oxygenation. The patient was discharged on POD100. Overall, IMPELLA 5.0 may be a useful tool for perioperative support against cardiogenic shock.

Assessment of Mitral Valve Complex by Three-Dimensional Echocardiography: Therapeutic Strategy for Functional Mitral Regurgitation

The mitral valve complex is consisted of annulus, leaflets, chordae tendineae, papillary muscle (PMs) and surrounding left ventricle. Functional mitral regurgitation (MR) results from left ventricular remodeling such as dilatation or distortion, which displaces the PMs and then tethers the mitral leaflets, restricting leaflet coaptation. Undersized annuloplasty, which has been widely accepted as a simple and effective procedure for functional MR, sometimes worsens the tethering of posterior leaflet and induces recurrent MR. In order to overcome such problems, several additional procedures to the simple annuloplasty have been produced. Three dimensional echocardiography plays an essential role to understand the geometry of mitral valve complex and contributes greatly to decision making of the surgical strategy in functional MR and its postoperative assessment.

Outcome and predictive factor analysis of functional mitral regurgitation after aortic valve replacement in patients with severe aortic insufficiency / 中华胸心血管外科杂志

Objective Functional mitral regurgitation (FMR) refers to the systolic regurgitation of mitral valve secondary to compromised cardiac function or geometry abnormity with non-organic change of leaflets and ancillary parts of the valve.Severe aortic insufficiency (AI) with left ventricular dilation and dysfunction is clinically a complex heart disease and its postoperative complications and mortality are higher than usual valvular surgery.And such patients are often accompanied by FMR.It is generally acknowledged that FMR may improve after aortic valve replacement (AVR).This study follow up AI patients with left ventricular dilation and dysfunction and preoperative 2 + ＜ FMR ≤3 + to evaluate the outcome of FMR after AVR.Preoperative clinical data is assessed by regression analysis.Methods From January 2000 to April 2011,74 cases of patients were treated,who with severe aortic regurgitation combined with left ventricular dilation (left ventricle,LVEDD ≥ 70 mm) and dysfunction (left ventricle ejection fraction,LVEF ≤ 0.35) accompanied by 2 + ＜ FMR ≤3 +.Postoperative follow-up was performed.Calculation FMR preoperative/FMR postoperative ratio,the age,sex,weight,high blood pressure,ventricular arrhythmia,atrium fibrillation,LVEDD,LVEF,left atrium diameter(LAD),pulmonary artery pressure (PAH),mitral leaflet coaptation point and the mitral annular(CPMA).All factors for logistic multiple faotors regression analysis.Results The perioperative mortality rate was 8.1％.Average follow-up time was (14.9 ± 7.7) months and follow-up rate of 83.6％.5 patients died during follow-up.6 months after surgery,the average of FMR was 2.64 ± 1.17 (+),P ＞0.05 compared with preoperative data.LVEDD,LAD,CPMA,P ＞0.05 compared with the preoperative data.LVEF,PAH,both P ＜0.05 compared with preoperative data.3.Multiple regression analysis:FMR preoperative/FMR postoperative ratio is not correlated with age,gender,weight,LVEDD ≥75 mm,LVEF≤0.30,hypertension,ventricular arrhythmia and FMR postoperative improvement.However,PAH ≥50 mm Hg,LAD ≥50 mm,PAH ≥50 mm Hg,CPMA ≥ 15 mm,preoperative atrial fibrillation was negatively correlated with FMR postoperative improvement.Conclusion Severe AI with left ventricular dilation and dysfunction is a critical clinical heart disease and its postoperative complications and mortality were high.PAH ≥50 mm Hg,LAD ≥50 mm,PAH ≥50 mm Hg,CPMA ≥15 mm,preoperative atrial fibrillation was negatively correlated with FMR postoperative improvement.Since patients with 2 + ＜ FMR≤3 + usually do not improve or even worsen after AVR,those who have these above conditions preoperatively,should be treated on FMR during AVR.

Role of Dyssynchrony on Functional Mitral Regurgitation in Patients with Idiopathic Dilated Cardiomyopathy: A Comparison Study with Geometric Parameters of Mitral Apparatus

BACKGROUND: Functional mitral regurgitation (FMR) occurs commonly in patients with dilated cardiomyopathy (DCM). This study was conducted to explore the role of left ventricular (LV) dyssynchrony in developing FMR in patients with DCM in comparison with geometric parameters of the mitral apparatus. METHODS: Twenty patients without FMR and 33 patients with FMR [effective regurgitant orifice area (ERO) = 0.17 +/- 0.10 cm2] were enrolled. MR severity was estimated with ERO area. Dyssynchrony indices (DI) were measured using the standard deviations of time to peak myocardial systolic velocity between eight segments. Using real time 3D echocardiography, mitral valve tenting area (MVTa), anterior (APMD) and posterior papillary muscle distances (PPMD), LV sphericity, and tethering angle of anterior (Aalpha) and posterior leaflets (Palpha) were estimated. All geometrical measurements were corrected (c) by the height of each patient. RESULTS: The patient with FMR had significantly higher cDI, cMVTa, cAPMD and cPPMD, LV sphericity, Aalpha, and Palpha than the patients without FMR (all p < 0.05). With multiple logistic regression analysis, cMVTa (p = 0.017) found to be strongest predictor of FMR development. In patients with FMR, cMVTa (r = 0.868), cAPMD (r = 0.801), cPPMD (r = 0.742), Aalpha (r = 0.454), LV sphericity (r = 0.452), and DI (r = 0.410) showed significant correlation with ERO. On multivariate regression analysis, cMVTa and cAPMD (p < 0.001, p = 0.022, respectively) remained the strongest determinants of the degree of ERO and cAPMD (p < 0.001) remained the strongest determinant of the degree of cMVTa. CONCLUSION: Displacement of anterior papillary muscle and consequent mitral valve tenting seem to play a major role in developing FMR in DCM, while LV dyssynchrony seems to have no significant role.

Giant left ventricle complicated with severe aortic regurgitation in Marfan patients with functional mitral regurgitation: A clinical study / 第二军医大学学报

Objective: To analyze the incidence of functional mitral regurgitation (FMR),post-operation characteristics and operation indications of Marfan patients with severe aortic regurgitation and giant left ventricle. Methods: The clinical data and the follow-up data of 19 Marfan patients with severe aortic regurgitation (≥10 ml) and giant left ventricle (LVEDd≥7.0 cm), who were treated from Jan. 2000 to Dec. 2007,were analyzed retrospectively. Results: All patients received Bentall operation and there was no perioperation death. Follow-up was 72 patient-year (ranging 3 months-7 years). The degree of FMR decreased obviously after operation, with an improvement rate of 87.5%, and the FMR almost disappeared 6 months to 1 year later. Conclusion: Bentall achieves good outcome in Marfan patients with severe aortic regurgitation and giant left ventricle. Mild to moderate FMR(< 10 ml) disappears with the decrease of the left ventricle size. For patients with severe FMR (≥ 10 ml) complicated with dysfunction of left ventricle, managed ventricular pacing is suggested.

Echocardiographic Evaluation of the Functional Mitral Regurgitation

Functional mitral regurgitation (FMR) develops frequently in ischemic or dilated cardiomyopathy. It is clinically very important because it is strongly associated with the progression of the disease and its prognosis. Although the correct mechanism of the FMR is not fully understood, incomplete mitral leaflet closure area or tenting area is the most important determinant of the FMR. Regional or global remodeling, and the contractile dysfunction of the left ventricle could affect tenting area. However, there is still a debate about which is the most important factor among them to determine the tenting area. Also, new findings in histopathology of the mitral valve leaflets with the FMR suggest leaflet itself could be involved in the development of the FMR. For the treatment of the FMR, conventional mitral annuloplasty with or without ring is not always successful in some patients, and it may not prevent further remodeling of the left ventricle even in successfully repaired cases. Therefore, it needs more sophisticated and prospective study to evaluate the accurate mechanism of the FMR, and new treatment modality should be developed for the successful treatment of the functional mitral regurgitation.