Left ventricular dysfunction after mitral valve repair—the fallacy of “normal” preoperative myocardial function

Quintana, Eduard; Suri, Rakesh M.; Thalji, Nassir M.; Daly, Richard C.; Dearani, Joseph A.; Burkhart, Harold M.; Li, Zhuo; Enríquez-Sarano, Maurice; Schaff, Hartzell V.

doi:10.1016/j.jtcvs.2014.07.029

Cited by 110 publications

(103 citation statements)

References 31 publications

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“…This finding is consistent with previous study. 12 We do not consider that the postoperative reduction in LV ejection fraction and others express LV dysfunction caused by surgery. Preoperative ejection fraction or strain can be overestimated because of the presence of MR, and this overestimation disappears after surgery.…”

Section: Discussionmentioning

confidence: 98%

Basal Left Ventricular Dilatation and Reduced Contraction in Patients With Mitral Valve Prolapse Can Be Secondary to Annular Dilatation

Fukuda

Song

Mahara

et al. 2016

Circ: Cardiovascular Imaging

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Background— Prominent mitral valve (MV) annular dilatation with only modest left ventricular (LV) dilatation in patients with MV prolapse (MVP) suggests predominant dilatation in adjacent basal LV, which may augment regional wall tension and attenuate contraction by Laplace’s law. We hypothesized that MV annular dilatation in patients with MVP is associated with the basal predominance of LV dilatation and attenuated contraction, which can be altered by surgical MV plasty with annulus reduction. Methods and Results— Echocardiography with speckle-tracking analysis to assess regional cross-sectional short-axis area and longitudinal contraction (strain) of basal, middle, and apical LV was performed in 30 controls and 130 patients with MVP. The basal value/averaged middle and apical values (B/M·A ratio) of LV cross-sectional area and strain were obtained. Patients with MVP showed significantly greater MV annular area (6.4±1.6 versus 3.7±0.6 cm 2 /m 2 ), increased B/M·A LV area ratio (2.4±0.5 versus 1.8±0.2), and reduced B/M·A LV strain ratio (0.83±0.14 versus 0.96±0.09) than controls ( P <0.001). Multivariable analyses identified that MV annular dilatation was independently associated with increased B/M·A LV area ratio (β=0.60, P <0.001), which was associated with reduced B/M·A LV strain ratio (β=−0.32, P <0.001). In 35 patients with MVP, B/M·A LV area and strain ratio significantly altered after surgical MV plasty with annulus reduction (2.5±0.5–1.8±0.3 and 0.73±0.10–0.89±0.17, P <0.001, respectively). Conclusions— In patients with MVP, MV annular dilatation was associated with the basal predominance of LV dilatation and reduced contraction, which can be altered by surgical MV plasty with annulus reduction, suggesting unfavorable influence from MV annular dilatation on basal LV.

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Section: Discussionmentioning

confidence: 98%

Basal Left Ventricular Dilatation and Reduced Contraction in Patients With Mitral Valve Prolapse Can Be Secondary to Annular Dilatation

Fukuda

Song

Mahara

et al. 2016

Circ: Cardiovascular Imaging

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“…49,50,[52][53][54][55][56] In the PARTNER (Placement of Aortic Transcatheter Valve) IA trial of a balloon-expandable valve, 50,53 TAVR (n=348) was noninferior to surgical AVR (n=351) for all-cause death at 30 days, 1 year, 2 years, and 5 years (P=0.001). 53,54 The risk of death at 5 years was 67.8% in the TAVR group, compared with 62.4% in the surgical AVR group (hazard ratio [HR]: 1.04, 95% confidence interval [CI]: 0.86 to 1.24; P=0. 76).…”

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confidence: 99%

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Nishimura¹,

Otto²,

et al. 2017

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“…Previous reports have shown that outcome after MV surgery is impaired once preoperative LVEF is <60%, and, thus, an LVEF <60% is considered abnormal and a potential indication for surgery in severe MR. 3 Additionally, impaired LVEF postoperatively (<50%) has been shown to predict poorer long-term survival. 9 All of these challenges in MR management have led to the recognition of a need for parameters other than LV size and LVEF that may assist in the detection of the approach or onset of LV dysfunction and help optimize surgical timing. Brain natriuretic peptide (BNP) is a hormone secreted from myocardial cells in response to either diastolic stretch indicating volume overload, or wall stress indicating pressure overload, and is a marker of LV dysfunction.…”

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confidence: 99%

Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery

Alashi

Mentias

Patel

et al. 2016

Circ: Cardiovascular Imaging

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I n the developed world, myxomatous degeneration of the mitral valve (MV) is the most common cause of mitral regurgitation (MR).1,2 Surgical correction remains the cornerstone of management in severe primary MR because medical management alone does not improve the hemodynamic consequences of the regurgitant valve and its impact on outcome. 3,4 According to the most recent guidelines, indications for surgical intervention in patients with severe primary MR are development of symptoms, asymptomatic left ventricular (LV) systolic dysfunction, new-onset AF, or pulmonary arterial hypertension.5 However, appropriate timing of surgical intervention in asymptomatic severe primary MR is often challenging. Advances in MV repair have led to excellent long-term results with low morbidity and mortality at experienced centers 6,7 such that the threshold to recommend surgical intervention at these centers has been lowered by the guidelines when Background-In asymptomatic patients with ≥3+ mitral regurgitation and preserved left ventricular (LV) ejection fraction who underwent mitral valve surgery, we sought to discover whether baseline LV global longitudinal strain (LV-GLS) and brain natriuretic peptide provided incremental prognostic utility. Methods and Results-Four hundred and forty-eight asymptomatic patients (61±12 years and 69% men) with ≥3+ primary mitral regurgitation and preserved left ventricular ejection fraction, who underwent mitral valve surgery (92% repair) at our center between 2005 and 2008, were studied. Baseline clinical and echocardiographic data (including LV-GLS using Velocity Vector Imaging, Siemens, PA) were recorded. The Society of Thoracic Surgeons score was calculated. The primary outcome was death. Mean Society of Thoracic Surgeons score, left ventricular ejection fraction, mitral effective regurgitant orifice, indexed LV end-diastolic volume, and right ventricular systolic pressure were 4±1%, 62±3%, 0.55±0.2 cm 2 , 58±13 cc/m 2 , and 37±15 mm Hg, respectively. Forty-five percent of patients had flail. Median log-transformed BNP and LV-GLS were 4.04 (absolute brain natriuretic peptide: 60 pg/dL) and −20.7%. At 7.7±2 years, death occurred in 41 patients (9%; 0% at 30 days). On Cox analysis, a higher Society of Thoracic Surgeons score (hazard ratio 1.55), higher baseline right ventricular systolic pressure (hazard ratio 1.11), more abnormal LV-GLS (hazard ratio 1.17), and higher median log-transformed BNP (hazard ratio 2.26) were associated with worse longer-term survival (all P<0.01). Addition of LV-GLS and median log-transformed BNP to a clinical model (Society of Thoracic Surgeons score and baseline right ventricular systolic pressure) provided incremental prognostic utility (χ 2 for longer-term mortality increased from 31-47 to 61; P<0.001). Conclusions-In asymptomatic patients with significant primary mitral regurgitation and preserved left ventricular ejection fraction who underwent mitral valve surgery, brain natriuretic peptide and LV-GLS provided synergistic risk stratification, independent o...

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Left ventricular dysfunction after mitral valve repair—the fallacy of “normal” preoperative myocardial function

Cited by 110 publications

References 31 publications

Basal Left Ventricular Dilatation and Reduced Contraction in Patients With Mitral Valve Prolapse Can Be Secondary to Annular Dilatation

Basal Left Ventricular Dilatation and Reduced Contraction in Patients With Mitral Valve Prolapse Can Be Secondary to Annular Dilatation

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery

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