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1.
J Multidiscip Healthc ; 16: 285-295, 2023.
Article in English | MEDLINE | ID: mdl-36741292

ABSTRACT

Artificial intelligence (AI) and machine learning (ML) is a promising field of cardiovascular medicine. Many AI tools have been shown to be efficacious with a high level of accuracy. Yet, their use in real life is not well established. In the era of health technology and data science, it is crucial to consider how these tools could improve healthcare delivery. This is particularly important in countries with limited resources, such as low- and middle-income countries (LMICs). LMICs have many barriers in the care continuum of cardiovascular diseases (CVD), and big portion of these barriers come from scarcity of resources, mainly financial and human power constraints. AI/ML could potentially improve healthcare delivery if appropriately applied in these countries. Expectedly, the current literature lacks original articles about AI/ML originating from these countries. It is important to start early with a stepwise approach to understand the obstacles these countries face in order to develop AI/ML-based solutions. This could be detrimental to many patients' lives, in addition to other expected advantages in other sectors, including the economy sector. In this report, we aim to review what is known about AI/ML in cardiovascular medicine, and to discuss how it could benefit LMICs.

2.
J Am Soc Echocardiogr ; 35(2): 165-175, 2022 02.
Article in English | MEDLINE | ID: mdl-34517112

ABSTRACT

BACKGROUND: The dynamic consequences of mitral annular disjunction (MAD) on the mitral apparatus and the left ventricle remain unclear and are crucial in the context of mitral surgery. Thus, the aim of this study was to assess mitral valvular, annular, and ventricular dynamics in mitral valve prolapse (MVP) stratified by presence of MAD. METHODS: In 61 patients (mean age, 62 ± 11 years; 25% women) with MVP and severe mitral regurgitation undergoing mitral surgery between 2009 and 2016, valvular and annular dimensions and dynamics by two-dimensional transthoracic and three-dimensional transesophageal echocardiography and left ventricular dimensions and dynamics were analyzed stratified by presence of MAD before and after surgery. RESULTS: MAD (mean, 8 ± 3 mm) was diagnosed in 27 patients (44%; with a mean effective regurgitant orifice area of 0.55 ± 0.20 cm2 and similar to patients without MAD), more frequently in bileaflet prolapse (52% vs 18% in patients without MAD, P = .004), consistently involving P2 (P = .005). Patients with MAD displayed larger diastolic annular areas (mean, 1,646 ± 410 vs 1,380 ± 348 mm2), circumferences (mean, 150 ± 19 vs 137 ± 16 mm), and intercommissural diameters (mean, 48 ± 7 vs 43 ± 6 mm) compared with those without MAD (P ≤ .008 for all). Dynamically, mid- and late systolic excess intercommissural diameter, annular area, and circumference enlargement were associated with MAD (P ≤ .01 for all). MAD was also associated with dynamically annular slippage, larger prolapse volume and height (P ≤ .007), and larger leaflet area (mean, 2,053 ± 620 vs 1,692 ± 488 mm2, P = .01). Although patients with MAD compared with those without MAD showed similar ejection fractions (mean, 65 ± 5% vs 62 ± 8%, respectively, P = .10), systolic basal posterior thickness was increased in patients with MAD (mean, 19 ± 2 vs 15 ± 2 mm, P < .001), with higher systolic thickening of the basal posterior wall (mean, 74 ± 27% vs 50 ± 28%) and higher ratio of basal wall thickness to diameter (P ≤ .01 for both). However, after mitral repair, MAD disappeared, and LV diameter, wall thickness, and wall thickening showed no difference between patients with MAD and those without MAD (P ≥ .10 for all). CONCLUSIONS: MAD in patients with MVP involves a predominant phenotype of bileaflet MVP and causes profound annular dynamic alterations with considerable expansion and excess annular enlargement in systole, potentially affecting leaflet coaptation. MAD myocardial and annular slippage simulates vigorous left ventricular function without true benefit after surgical annular suture. Thus, although MAD does not hinder the feasibility and quality of valve repair, it requires careful suture of ring to ventricular myocardium, lest it persist postoperatively.


Subject(s)
Echocardiography, Three-Dimensional , Mitral Valve Insufficiency , Mitral Valve Prolapse , Echocardiography, Transesophageal , Female , Humans , Male , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/surgery , Mitral Valve Prolapse/diagnostic imaging , Mitral Valve Prolapse/surgery
4.
J Am Coll Cardiol ; 76(3): 233-246, 2020 07 21.
Article in English | MEDLINE | ID: mdl-32674787

ABSTRACT

BACKGROUND: Etiology, mechanisms, and survival of mitral regurgitation (MR) plus hemodynamically-significant chronic aortic regurgitation (AR) are mostly unknown. OBJECTIVES: The purpose of this study was to investigate the prevalence, mechanisms, etiologies, and survival impact of coexistent ≥ moderate MR in AR patients. METHODS: Consecutive patients with ≥ moderate-severe AR were retrospectively identified between 2004 and 2019. RESULTS: Of 1,239 eligible patients (61 ± 18 years, 80% men), 1,072 (86%) had pure AR, and 167 (14%) had AR + MR (9% functional mitral regurgitation [FMR] [84% nonischemic] and 5% organic mitral regurgitation [OMR] [62% degenerative]). At baseline transthoracic echocardiogram, pure AR versus AR + OMR versus AR + FMR exhibited differences in age (59 ± 18, 62 ± 16, and 73 ± 14 years, respectively), female sex (18%, 27%, and 39%, respectively), symptoms (36%, 41%, and 64%, respectively), atrial fibrillation (5%, 17%, and 36%, respectively), left ventricular (LV) ejection fraction (59%, 58%, and 46%, respectively), LV end-systolic dimension and volume index, ≥ moderate tricuspid regurgitation (TR) (7%, 35%, and 53%, respectively), and right ventricular systolic pressure (32 ± 11, 45 ± 15, and 50 ± 14 mm Hg, respectively), all p < 0.0001. After a median follow-up of 5.2 years (interquartile range: 2.2 to 10.0 years) and adjusting for demographics, New York Heart Association functional class, aortic valve surgery, LV ejection fraction, LV end-systolic dimension and volume index, presence of FMR was independently associated with all-cause mortality (p ≤ 0.004). Compared with pure AR, AR + MR + TR exhibited the highest adjusted risk of death (2.4-fold; p < 0.0001). When compared with expected population survival, excess mortality risks of pure AR, AR + OMR, and AR + FMR were 1.25-fold, 1.76-fold, and 2.34-fold, respectively (all p ≤ 0.02). CONCLUSIONS: In hemodynamically significant AR, coexistent MR is not uncommon (approximately 14%) and mostly comprises FMR and less commonly OMR. As compared with pure AR, AR + MR + TR exhibit the largest mortality risk. Both AR + OMR and AR + FMR carry a survival penalty compared with the general population, but AR + FMR is associated with the largest excess mortality and represents an advanced stage within the AR clinical spectrum.


Subject(s)
Aortic Valve Insufficiency/epidemiology , Mitral Valve Insufficiency/epidemiology , Stroke Volume/physiology , Ventricular Function, Left/physiology , Aged , Aortic Valve Insufficiency/diagnosis , Aortic Valve Insufficiency/physiopathology , Chronic Disease , Comorbidity , Echocardiography , Female , Follow-Up Studies , Humans , Male , Middle Aged , Mitral Valve Insufficiency/diagnosis , Mitral Valve Insufficiency/physiopathology , Morbidity/trends , Retrospective Studies , Taiwan/epidemiology
5.
Ann Thorac Surg ; 110(5): 1595-1604, 2020 11.
Article in English | MEDLINE | ID: mdl-32289298

ABSTRACT

BACKGROUND: This study aims to investigate the association of wall shear stress (WSS) and aortic strain with circulating biomarkers including matrix metalloproteinases (MMP), tissue inhibitors of metalloproteinase (TIMP), and exosomal level of microRNA (miRNA) in ascending aortic aneurysms of patients with bicuspid or tricuspid aortic valve. METHODS: A total of 76 variables from 125 patients with ascending aortic aneurysms were collected from (1) blood plasma to measure plasma levels of miRNAs and protein activity; (2) computational flow analysis to estimate peak systolic WSS and time-average WSS (TAWSS); and (3) imaging analysis of computed tomography angiography to determine aortic wall strain. Principal component analysis followed by logistic regression allowed the development of a predictive model of aortic surgery by combining biomechanical descriptors and biomarkers. RESULTS: The protein activity of MMP-1, TIMP-1, and MMP-2 was positively correlated to the systolic WSS and TAWSS observed in the proximal ascending aorta (eg, R = 0.52, P < .001, for MMP-1 with TAWSS) where local maxima of WSS were found. For bicuspid patients, aortic wall strain was associated with miR-26a (R = 0.55, P = .041) and miR-320a (R = 0.69, P < .001), which shows a significant difference between bicuspid and tricuspid patients. Receiver-operating characteristics curves revealed that the combination of WSS, MMP-1, TIMP-1, and MMP-12 is predictive of aortic surgery (area under the curve 0.898). CONCLUSIONS: Increased flow-based and structural descriptors of ascending aortic aneurysms are associated with high levels of circulating biomarkers, implicating adverse vascular remodeling in the dilated aorta by mechanotransduction. A combination of shear stress and circulating biomarkers has the potential to improve the decision-making process for ascending aortic aneurysms to a highly individualized level.


Subject(s)
Aorta/physiopathology , Aortic Aneurysm, Thoracic/physiopathology , Aortic Valve/abnormalities , Stress, Mechanical , Adult , Aged , Aortic Aneurysm, Thoracic/blood , Aortic Aneurysm, Thoracic/surgery , Aortic Valve/physiopathology , Bicuspid Aortic Valve Disease/surgery , Biomarkers , Female , Humans , Logistic Models , Male , Matrix Metalloproteinase 1/blood , Matrix Metalloproteinase 12/blood , Mechanotransduction, Cellular , MicroRNAs/blood , Middle Aged , Tissue Inhibitor of Metalloproteinase-1/blood , Vascular Remodeling
7.
Catheter Cardiovasc Interv ; 96(6): 1323-1330, 2020 11.
Article in English | MEDLINE | ID: mdl-32180349

ABSTRACT

BACKGROUND: Transcatheter edge-to-edge repair with MitraClip is only approved for treatment of mitral regurgitation but is increasingly used to treat concomitant tricuspid regurgitation (TR) due to its common coexistence and association with poor outcomes. This study aimed to describe the learning curve associated with the challenge of off-label treatment of concomitant TR. METHODS: This is a retrospective review of initial and consecutive patients who underwent combined edge-to-edge repair of mitral and tricuspid valves (TVs) at our institution from August 2017 to October 2019. RESULTS: Repair of both valves with MitraClip was performed in 22 patients (median age 81.5 years, 32% female). Mean procedure time was 176 ± 47 min; mean fluoroscopy time was 65 ± 24 min. Procedure duration in the first tertile was significantly longer (223 ± 13 min) than in the third tertile (143 ± 23 min, p = .0003). Median number of total clips placed per case was 3; in 15 patients (68%), the anterior and septal leaflets of the TV were clipped. The average changes in mean right atrial (RA) and left atrial (LA) pressures were -1.7 ± 2.5 mmHg (p = .0080) and -3.2 ± 4.6 mmHg (p = .0045), respectively. The average changes in RA and LA V-wave heights were -3.3 ± 4.0 mmHg (p = .0009) and -8.1 ± 9.9 mmHg (p = .038), respectively. There was a significant trend toward decreasing residual TR over the course of the series (p = .046). At 30 days, survival was 100% and mean NYHA class decreased from 2.8 to 1.8 (p < .0001). CONCLUSIONS: Combined edge-to-edge tricuspid and mitral valve repair is safe and feasible. With experience, procedure duration and residual TR decreased.


Subject(s)
Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis , Learning Curve , Mitral Valve Insufficiency/surgery , Mitral Valve/surgery , Tricuspid Valve Insufficiency/surgery , Tricuspid Valve/surgery , Aged , Aged, 80 and over , Clinical Competence , Female , Heart Valve Prosthesis Implantation/adverse effects , Hemodynamics , Humans , Male , Middle Aged , Mitral Valve/diagnostic imaging , Mitral Valve/physiopathology , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/physiopathology , Operative Time , Prosthesis Design , Recovery of Function , Retrospective Studies , Time Factors , Treatment Outcome , Tricuspid Valve/diagnostic imaging , Tricuspid Valve/physiopathology , Tricuspid Valve Insufficiency/diagnostic imaging , Tricuspid Valve Insufficiency/physiopathology
9.
JACC Case Rep ; 2(8): 1135-1136, 2020 Jul.
Article in English | MEDLINE | ID: mdl-34317433

ABSTRACT

Unicuspid aortic valve (UAV) presented as predominant severe aortic regurgitation (AR) is rare (<1%) in pure AR cohort. We present a case with UAV that took more than 1 decade to achieve accurate diagnosis. Multimodality imaging showcased precise anatomy of UAV and mechanisms of AR, resembling exactly the surgical findings. (Level of Difficulty: Intermediate.).

11.
Echocardiography ; 36(11): 2099-2102, 2019 11.
Article in English | MEDLINE | ID: mdl-31693236

ABSTRACT

A rare case of a spontaneous coronary artery dissection (SCAD) in the postpartum of a 32-year-old woman is presented. Pregnancy-related SCAD is a potentially life-threatening condition. SCAD is triggered by nonatherosclerotic disease, typically affects young-aged women and is still often underdiagnosed. Cardiac magnetic resonance is crucial to demonstrate the ischemic origin of the disease. A conservative management is generally preferred in stable SCAD as most dissected segments will heal spontaneously over a few months. Additionally, the percutaneous coronary intervention is associated with high rate of complications and procedural failure. The aim of this case was to improve awareness of SCAD and to advise clinicians seeking aid with patient management.


Subject(s)
Coronary Angiography/methods , Coronary Vessel Anomalies/diagnosis , Coronary Vessels/diagnostic imaging , Magnetic Resonance Imaging, Cine/methods , Postpartum Period , Vascular Diseases/congenital , Adult , Diagnosis, Differential , Female , Humans , Pregnancy , Vascular Diseases/diagnosis
12.
J Mol Cell Cardiol ; 135: 31-39, 2019 10.
Article in English | MEDLINE | ID: mdl-31348923

ABSTRACT

BACKGROUND: Predictors of thoracic aorta growth and early cardiac surgery in patients with bicuspid aortic valve are undefined. Our aim was to identify predictors of ascending aorta dilatation and cardiac surgery in patients with bicuspid aortic valve (BAV). METHODS: Forty-one patients with BAV were compared with 165 patients with tricuspid aortic valve (TAV). All patients had LV EF > 50%, normal LV dimensions, and similar degree of aortic root or ascending aorta dilatation at enrollment. Patients with more than mild aortic stenosis or regurgitation were excluded. A CT-scan was available on 76% of the population, and an echocardiogram was repeated every year for a median time of 4 years (range: 2 to 8 years). Patterns of aortic expansion in BAV and TAV groups were analyzed by a mixed-effects longitudinal linear model. In the time-to-event analysis, the primary end point was elective or emergent surgery for aorta replacement. RESULTS: BAV patients were younger, while the TAV group had greater LV wall thickness, arterial hypertension, and dyslipidemia than BAV patients. Growth rate was 0.46 ±â€¯0.04 mm/year, similar in BAV and TAV groups (p = 0.70). Predictors of cardiac surgery were aorta dimensions at baseline (HR 1.23, p = 0.01), severe aortic regurgitation developed during follow-up (HR 3.49, p 0.04), family history of aortic aneurysm (HR 4.16, p 1.73), and history of STEMI (HR 3.64, p < 0.001). CONCLUSIONS: Classic baseline risk factors were more commonly observed in TAV aortopathy compared with BAV aortopathy. However, it is reassuring that, though diagnosed with aneurysm on average 10 years earlier and in the absence of arterial hypertension, BAV patients had a relatively low growth rate, similar to patients with a tricuspid valve. Irrespective of aortic valve morphology, patients with a family history of aortic aneurysm, history of coronary artery disease, and those who developed severe aortic regurgitation at follow-up, had the highest chances of being referred for surgery.


Subject(s)
Aorta , Aortic Valve Stenosis , Aortic Valve/abnormalities , Heart Valve Diseases , Tomography, X-Ray Computed , Tricuspid Valve , Aged , Aorta/diagnostic imaging , Aorta/physiopathology , Aorta/surgery , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/physiopathology , Aortic Valve Stenosis/surgery , Bicuspid Aortic Valve Disease , Dilatation, Pathologic/diagnostic imaging , Dilatation, Pathologic/physiopathology , Dilatation, Pathologic/surgery , Dyslipidemias/diagnostic imaging , Dyslipidemias/physiopathology , Dyslipidemias/surgery , Female , Follow-Up Studies , Heart Valve Diseases/diagnostic imaging , Heart Valve Diseases/physiopathology , Humans , Hypertension/diagnostic imaging , Hypertension/physiopathology , Hypertension/surgery , Male , Middle Aged , Tricuspid Valve/diagnostic imaging , Tricuspid Valve/physiopathology
13.
Mayo Clin Proc ; 94(1): 89-102, 2019 01.
Article in English | MEDLINE | ID: mdl-30611459

ABSTRACT

Recent innovations and advancements in 3-dimensional (3D) echocardiography allow for better understanding of anatomic relationships and improve communication with the interventional cardiologist for guidance of catheter-based interventions. The mitral valve lends itself best for imaging with transesophageal echocardiography (TEE). Consequently, the role of 3D TEE in guiding catheter-based mitral interventions has been evolving rapidly. Although several publications have reported on the advantages and role of 3D TEE in guiding one or more of the steps involved in percutaneous mitral valve repair using the MitraClip, none offer a comprehensive and practical user-friendly guide. This review article provides the reader with practical intraprocedural tips on use of 3D TEE to guide all relevant steps involved in the procedure including how to acquire the images needed and what to look for.


Subject(s)
Cardiac Catheterization/methods , Echocardiography, Three-Dimensional/methods , Echocardiography, Transesophageal/methods , Heart Valve Prosthesis Implantation/methods , Mitral Valve Insufficiency/surgery , Mitral Valve/surgery , Humans , Mitral Valve/diagnostic imaging , Mitral Valve Insufficiency/diagnosis , Practice Guidelines as Topic
14.
Eur Heart J Cardiovasc Imaging ; 20(6): 677-686, 2019 Jun 01.
Article in English | MEDLINE | ID: mdl-30445616

ABSTRACT

AIMS: Bicuspid aortic valve (BAV) and mitral valve prolapse (MVP) are common but the prevalence and significance of coexistent conditions are unknown. This study investigated the prevalence, phenotypic expression, and clinical significance of coexistent MVP-BAV. METHODS AND RESULTS: Retrospective comparison of MVP-BAV and MVP-tricuspid aortic valve (TAV) prevalence including de novo echocardiographic analysis of all MVP-BAV patients between 2005 and 2015 was performed. The community prevalence of MVP-BAV was 2.7% vs. 3.4% for MVP-TAV (P = 0.45). Posterior mitral leaflet (PML)-MVP was the most common phenotype in both BAV and TAV (P = 0.38), but anterior mitral leaflet (AML)-MVP was twice more prevalent in BAV (31% vs. 15%, P < 0.0001). Among 130 subjects with coexistent MVP-BAV (81% men, 51 ± 16 years old), 31 (24%) exhibited AML:PML length ratio ≥3:1, termed large-AML prolapse (LAP-BAV), who had predominant BAV regurgitation when compared with those with non-LAP-BAV (P ≤ 0.001). An extreme phenotype of LAP-BAV with giant-AML prolapse and diminutive PML (GAP-BAV) was identified in 18/130 (14%) subjects. Compared with posterior-MVP-BAV, GAP-BAV patients were younger (42 ± 15 vs. 64 ± 12 years, P < 0.0001), had larger aortic annulus (28 ± 3 vs. 26 ± 2 mm, P = 0.01), and 61% had ≥ moderate BAV regurgitation (vs. 16%, P = 0.0007). Mitral repair occurred in 37/130 (28%) subjects. After median follow-up 5.5 months (4-83), 4/5 (80%) GAP-BAV patients required redo surgery for recurrent mitral regurgitation vs. 2/31 (6%) for non-LAP-BAV (P = 0.001). CONCLUSION: The community prevalence of coexistent MVP-BAV is comparable to MVP-TAV and their most common phenotype is posterior-MVP. However, anterior-MVP is twice as prevalent in MVP-BAV. A large-AML phenotype (LAP-BAV) with predominant BAV regurgitation affects 24% of MVP-BAV patients. An extreme phenotype of anterior-MVP (GAP-BAV) affects 14% of BAV patients; characterized by exceptionally large AML, diminutive PML, high mitral and aortic regurgitation prevalence, and high mitral repair failure rate.


Subject(s)
Aortic Valve Insufficiency/diagnostic imaging , Aortic Valve Insufficiency/epidemiology , Aortic Valve/abnormalities , Heart Valve Diseases/diagnostic imaging , Heart Valve Diseases/epidemiology , Mitral Valve Prolapse/diagnostic imaging , Mitral Valve Prolapse/epidemiology , Adult , Age Distribution , Aged , Analysis of Variance , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Aortic Valve Insufficiency/surgery , Bicuspid Aortic Valve Disease , Cohort Studies , Comorbidity , Echocardiography/methods , Female , Heart Valve Diseases/surgery , Humans , Male , Middle Aged , Mitral Valve Prolapse/surgery , Phenotype , Prevalence , Prognosis , Retrospective Studies , Severity of Illness Index , Sex Distribution , Treatment Outcome
15.
Catheter Cardiovasc Interv ; 93(6): 1087-1094, 2019 05 01.
Article in English | MEDLINE | ID: mdl-30461167

ABSTRACT

OBJECTIVES: This study reports long-term outcomes percutaneous Melody valve (Medtronic, Minneapolis, Minnesota) valve-in-valve therapy in patients with prosthetic valve dysfunction. BACKGROUND: Repeat valve surgery is associated with high morbidity and mortality. Transcatheter mitral valve-in-valve is a promising alternative in patients at high-risk for cardiac surgery. METHODS: We conducted a retrospective cohort analysis of 13 patients who underwent Melody valve-in-valve for bioprosthetic dysfunction from July 2011 to October 2013. RESULTS: Mean age was 74.4 years, 46% male, and STS score 13.5 ± 6.8%. All patients had NYHA class 3 or 4 symptoms with improvement to class 1 or 2 in 82% post procedure. Median follow-up was 4.5 years with longest follow-up of 5.5 years. Thirty-day mortality was 15.4% with 1-year mortality of 25% and no other reported deaths until 4.5 years. 76.9% of patients had mitral gradient of 5 mmHg or less immediately postprocedure. One patient required repeat valve procedure for structural deterioration at 4.4 years. At 1, 3, and 5 year follow-ups 75% of patients were NYHA class 1 or 2, mean gradients were 4.5 ± 0.6, 6.8 ± 0.5, and 7.5 ± 0.7, respectively. Using 4-point scale, mitral regurgitation postprocedure was 0.8 ± 0.6. At 1, 3, and 5 years this increased to 1.0 ± 1.1, 1.3 ± 1.3, and 2.5 ± 2.1, respectively. CONCLUSIONS: Melody valve-in-valve therapy was effective with 1-year symptomatic improvement. Prosthesis deterioration requiring repeat intervention was observed in one patient. Larger cohorts with multicenter registries are needed to determine the role of this percutaneous valve-in-valve therapy as valve technology and procedural techniques improve.


Subject(s)
Bioprosthesis , Cardiac Catheterization/instrumentation , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis , Mitral Valve Insufficiency/surgery , Mitral Valve Stenosis/surgery , Mitral Valve/surgery , Prosthesis Failure , Aged , Aged, 80 and over , Cardiac Catheterization/adverse effects , Cardiac Catheterization/mortality , Female , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/mortality , Humans , Male , Middle Aged , Mitral Valve/diagnostic imaging , Mitral Valve/physiopathology , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/mortality , Mitral Valve Insufficiency/physiopathology , Mitral Valve Stenosis/diagnostic imaging , Mitral Valve Stenosis/mortality , Mitral Valve Stenosis/physiopathology , Prosthesis Design , Recovery of Function , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome
16.
Mayo Clin Proc ; 93(8): 1086-1095, 2018 08.
Article in English | MEDLINE | ID: mdl-30077202

ABSTRACT

OBJECTIVE: As invasive cardiovascular care has become increasingly complex, cardiac perforation leading to hemopericardium is a progressively prevalent complication. We sought to assess the frequency, etiology, and outcomes of hemorrhagic pericardial effusions managed through a nonsurgical echo-guided percutaneous strategy. PATIENTS AND METHODS: Over a 10-year period (January 1, 2007, to December 31, 2016), 1097 unique patients required pericardiocentesis for clinically important pericardial effusions. Of these 411 had drainage of hemorrhagic effusions (defined as a pericardial hemoglobin level >50% of serum hemoglobin or frank blood in the setting of cardiac perforation). Clinical characteristics, echocardiographic data, details of the procedure, and outcomes were determined. RESULTS: Median patient age was 67 years (interquartile range, 56-76 years), and 60% were men. The procedure was emergent in 83% and elective in 17%. The site of pericardiocentesis was determined by echo-guidance in all: 68% from the left para-apical region, 18% from the left or right parasternal areas, and 14% were subxyphoid. Half (n=215 [52%]) occurred after cardiac perforation with percutaneous interventional procedure (ablation, n=94; device lead implantation, n=65; percutaneous coronary intervention, n=22; other, n=34), whereas 30% followed cardiac or thoracic surgery. Pericardial fluid volume drained was 546±440 mL. In 94% of cases, echo-guided pericardiocentesis was the only treatment of the effusion needed, whereas definitive surgery was required in 25 (6%) cases for persistent bleeding or acute management of the underlying etiology. There was no procedural mortality. Late mortality was better for hemorrhagic effusions compared with a contemporary cohort with nonhemorrhagic effusions. CONCLUSION: Echocardiographic guidance allows rapid successful pericardiocentesis in the setting of hemopericardium related to microperforation with interventional procedures, malignancy, or pericarditis, with most not requiring surgical intervention. Surgery should remain the first-line approach for aortic dissection or myocardial rupture.


Subject(s)
Echocardiography , Pericardial Effusion/therapy , Pericardiocentesis/methods , Ultrasonography, Interventional , Aged , Cardiovascular Surgical Procedures/adverse effects , Female , Hemoglobins/analysis , Humans , International Normalized Ratio , Male , Middle Aged , Percutaneous Coronary Intervention/adverse effects , Pericardial Effusion/diagnostic imaging , Pericardial Effusion/mortality , Retrospective Studies , Thoracic Surgical Procedures/adverse effects
17.
Circulation ; 138(13): 1317-1326, 2018 09 25.
Article in English | MEDLINE | ID: mdl-29853518

ABSTRACT

BACKGROUND: Echocardiographic quantitation of degenerative mitral regurgitation (DMR) is recommended whenever possible in clinical guidelines but is criticized and its scalability to routine clinical practice doubted. We hypothesized that echocardiographic DMR quantitation, performed in routine clinical practice by multiple practitioners, predicts independently long-term survival and thus is essential to DMR management. METHODS: We included patients diagnosed with isolated mitral valve prolapse from 2003 to 2011 and any degree of mitral regurgitation quantified by any physician/sonographer in routine clinical practice. Clinical/echocardiographic data acquired at diagnosis were retrieved electronically. The end point was mortality under medical treatment analyzed by Kaplan-Meier method and proportional hazard models. RESULTS: The cohort included 3914 patients (55% male) mean age (±standard deviation) 62±17 years with left ventricular ejection fraction 63±8% and median after routinely-measured effective regurgitant orifice area (EROA) [interquartile range], 19 [0-40] mm2. During follow-up (6.7±3.1 years), 696 patients died under medical management, and 1263 underwent mitral surgery. In multivariate analysis, routinely-measured EROA was associated with mortality (adjusted hazard ratio, 1.19; 95% confidence interval, 1.13-1.24; P<0.0001 per 10 mm2) independently of left ventricular ejection fraction and end-systolic diameter, symptoms, and age/comorbidities. The association between routinely-measured EROA and mortality persisted with competitive risk modeling (adjusted hazard ratio, 1.15; 95% confidence interval, 1.10-1.20; P<0.0001 per 10 mm2), or in patients without guideline-based class I/II surgical triggers (adjusted hazard ratio, 1.19; 95% confidence interval, 1.10-1.28; P<0.0001 per 10 mm2) and in all subgroups examined (all P<0.01). Spline curve analysis showed that, compared with general population mortality, excess mortality appears for moderate DMR (EROA ≥20 mm2), becomes notable at EROA ≥30 mm2, and steadily increases with higher EROA levels (eg, higher EROA levels beyond the 40 mm2 threshold). CONCLUSIONS: Echocardiographic DMR quantitation is scalable to routine practice and is independently associated with clinical outcome. Routinely-measured EROA is strongly associated with long-term survival under medical treatment. Excess mortality versus the general population appears in the moderate DMR range and steadily increases with higher EROA. Hence, individual EROA values should be integrated into therapeutic considerations, in addition to categorical DMR grading.


Subject(s)
Echocardiography, Doppler , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Prolapse/diagnostic imaging , Mitral Valve/diagnostic imaging , Adult , Aged , Cardiac Surgical Procedures , Cardiovascular Agents/therapeutic use , Female , Hemodynamics , Humans , Male , Middle Aged , Mitral Valve/physiopathology , Mitral Valve Insufficiency/mortality , Mitral Valve Insufficiency/physiopathology , Mitral Valve Insufficiency/therapy , Mitral Valve Prolapse/mortality , Mitral Valve Prolapse/physiopathology , Mitral Valve Prolapse/therapy , Predictive Value of Tests , Retrospective Studies , Risk Assessment , Risk Factors , Stroke Volume , Time Factors , Treatment Outcome , Ventricular Function, Left
18.
Circ Cardiovasc Imaging ; 11(1): e005971, 2018 01.
Article in English | MEDLINE | ID: mdl-29321211

ABSTRACT

Despite its high prevalence, little is known about mechanisms of mitral regurgitation in degenerative mitral valve disease apart from the leaflet prolapse itself. Mitral valve is a complex structure, including mitral annulus, mitral leaflets, papillary muscles, chords, and left ventricular walls. All these structures are involved in physiological and pathological functioning of this valvuloventricular complex but up to now were difficult to analyze because of inherent limitations of 2-dimensional imaging. The advent of 3-dimensional echocardiography, computed tomography, and cardiac magnetic resonance imaging overcoming these limitations provides new insights into mechanistic analysis of degenerative mitral regurgitation. This review will detail the contribution of quantitative and qualitative dynamic analysis of mitral annulus and mitral leaflets by new imaging methods in the understanding of degenerative mitral regurgitation pathophysiology.


Subject(s)
Imaging, Three-Dimensional , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/physiopathology , Echocardiography, Three-Dimensional , Humans , Magnetic Resonance Imaging , Phenotype , Tomography, X-Ray Computed
19.
Circ Cardiovasc Interv ; 10(12)2017 Dec.
Article in English | MEDLINE | ID: mdl-29246914

ABSTRACT

BACKGROUND: Percutaneous closure of prosthetic mitral valve paravalvular leak (PVL) has emerged as an alternative to surgical treatment in high-risk patients. Limited data exist on the impact of successful percutaneous PVL closure on midterm outcomes. METHODS AND RESULTS: We examined consecutive patients who underwent percutaneous mitral PVL closure at Mayo Clinic, Rochester, MN, between January 2006 and January 2017. Procedural success, in-hospital outcomes, and midterm mortality were assessed. A total of 231 patients underwent percutaneous mitral PVL repair at a mean age of 67±12 years. Mean time from mitral valve replacement to percutaneous PVL repair was 1.25 (0.31-7.25) years. One hundred sixty-two patients (70%) had ≤mild PVL after the procedure. Compared with those who had >mild residual PVL, patients with ≤mild residual PVL had lower rates of repeat surgical interventions (6% versus 17%; P=0.004) and lower all-cause mortality at 30 days (1% versus 14%; P<0.001) and 1 year (15% versus 39%; P<0.001). Survival at 3 years was 61% in patients who had ≤mild residual leak and 47% in patients with higher grade of residual PVL (P=0.002). CONCLUSIONS: In a large consecutive cohort of patients undergoing percutaneous mitral PVL closure, successful percutaneous reduction of the PVL to mild or less was associated with significant midterm survival benefit.


Subject(s)
Bioprosthesis , Cardiac Catheterization , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis , Mitral Valve Insufficiency/therapy , Mitral Valve/surgery , Prosthesis Failure , Aged , Cardiac Catheterization/adverse effects , Cardiac Catheterization/instrumentation , Cardiac Catheterization/mortality , Female , Heart Valve Prosthesis Implantation/mortality , Humans , Male , Middle Aged , Mitral Valve/physiopathology , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/mortality , Mitral Valve Insufficiency/physiopathology , Prosthesis Design , Retrospective Studies , Risk Factors , Septal Occluder Device , Time Factors , Treatment Outcome
20.
JACC Cardiovasc Interv ; 10(19): 1946-1956, 2017 10 09.
Article in English | MEDLINE | ID: mdl-28982558

ABSTRACT

OBJECTIVES: The aim of this study was to report the use trends and immediate and long-term outcomes of a large cohort of patients who underwent redo surgery or transcatheter repair of paravalvular leaks (PVLs) at a tertiary referral center. BACKGROUND: Percutaneous treatment of mitral PVL has emerged as an alternative to surgical treatment in high-risk surgical candidates. There are limited data on the utilization trends, safety, and efficacy of both procedures in the management of mitral PVL. METHODS: Patients who underwent treatment of mitral PVL at the Mayo Clinic between January 1995 and December 2015 were enrolled. Utilization trends, procedural details, technical success, and in-hospital and long-term outcomes were assessed. RESULTS: Three hundred eighty-one patients underwent percutaneous (n = 195) or surgical (n = 186) treatment of mitral PVLs. The mean age was 66 ± 12 years, and 37% of patients had bioprosthetic valves. Technical success was higher in the surgical group (95.5% vs. 70.1%; p < 0.001). In-hospital major adverse events were more common after surgery (22.5% vs. 7.7%; p < 0.001). In-hospital death occurred in 3.1% and 8.6% of patients undergoing percutaneous and surgical treatment, respectively (p = 0.027). However, in a multivariate logistic regression analysis, only active endocarditis, chronic renal failure, and severe mitral annular calcifications were significant predictors of in-hospital mortality. Reintervention rates were similar (11.3% vs. 17.2% in the percutaneous and surgical groups, respectively; p = 0.10), with the majority of reinterventions in the percutaneous group occurring early because of residual leak or persistent hemolysis. After risk adjustment, there was no significant difference in long-term survival between patients who underwent surgical versus transcatheter treatment of PVLs. CONCLUSIONS: In contemporary practice, patients with symptomatic mitral PVLs are best treated with an integrated team approach incorporating both surgical and percutaneous techniques. Patient selection and timing of intervention are critical to achieve optimal results.


Subject(s)
Cardiac Catheterization , Device Removal , Mitral Valve Insufficiency/therapy , Mitral Valve/surgery , Aged , Bioprosthesis , Cardiac Catheterization/adverse effects , Cardiac Catheterization/mortality , Chi-Square Distribution , Device Removal/adverse effects , Device Removal/mortality , Female , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/mortality , Hospital Mortality , Humans , Logistic Models , Male , Middle Aged , Minnesota , Mitral Valve/diagnostic imaging , Mitral Valve/physiopathology , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/mortality , Mitral Valve Insufficiency/physiopathology , Multivariate Analysis , Odds Ratio , Proportional Hazards Models , Prosthesis Design , Prosthesis Failure , Reoperation , Risk Factors , Tertiary Care Centers , Time Factors , Treatment Outcome
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