Repercussion of functional mitral regurgitation on reverse remodelling in cardiac resynchronization therapy

Cabrera-Bueno, Fernando; García‐Pinilla, José Manuel; Peña-Hernández, José; Jiménez-Navarro, Manuel F.; Gómez‐Doblas, Juan José; Barrera-Cordero, Alberto; Alzueta-Rodríguez, Javier; Teresa–Galván, Eduardo de

doi:10.1093/europace/eum122

Cited by 24 publications

(21 citation statements)

References 19 publications

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“…5 In studies including patients with systolic dysfunction of ischemic and nonischemic origins and significant LV asynchrony, LV remodeling at 6 months has been usually Ն70%. 14,25 In accordance with previous studies, our results suggest that in a population of patients with heart failure of ischemic origin, 12,23 LV remodeling at 6 months is less frequent (i.e., 58%) than in patients with other heart failure causes. Nonetheless, our study demonstrated that in the presence of significant asynchrony and viability in the region of the pacing lead, longterm LV remodeling in patients with ischemic cardiomyopathy is observed in 74% of patients.…”

Section: Discussionsupporting

confidence: 92%

“…Previous studies have shown that having heart failure from ischemic origin particularly if associated with severe MR is a predictor of lack of response to CRT. [12][13][14] In the same line Sutton et al 15 demonstrated that reverse remodeling after CRT occurred mainly in nonischemic patients. Conversely, Molhoek et al 21 showed that the underlying cause of heart failure was not related to CRT response.…”

Section: Discussionmentioning

confidence: 85%

“…Several investigators have suggested that extent of LV reverse remodeling could be lessened in patients with significant MR, particularly in the setting of ischemic cardiomyopathy. [12][13][14] This study investigated the potential impact of MR severity and myocardial contractile reserve on acute and long-term responses to CRT in patients with ischemic cardiomyopathy and significant LV dyssynchrony. …”

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confidence: 99%

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Impact of Mitral Regurgitation and Myocardial Viability on Left Ventricular Reverse Remodeling After Cardiac Resynchronization Therapy in Patients With Ischemic Cardiomyopathy

Sénéchal¹,

Lancellotti²,

Magné³

et al. 2010

The American Journal of Cardiology

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This study investigated the impact of ischemic mitral regurgitation (MR) severity and viability on left ventricular (LV) reverse remodeling after cardiac resynchronization therapy (CRT) in patients with ischemic cardiomyopathy. Severe MR and ischemic cardiomyopathy have been associated with lack of LV reverse remodeling after CRT. Fifty-seven consecutive patients with ischemic MR, LV ejection fraction <35%, QRS duration >120 ms, and intraventricular dyssynchrony >50 ms were prospectively included. Stress echocardiography was performed before CRT implantation. Viability in the region of the LV pacing lead was defined as the presence of viability in 2 contiguous segments. Response to CRT at 6 months was defined by evidence of >15% LV decrease in end-systolic volume. Severe MR was defined by an effective regurgitant orifice (ERO) area >20 mm 2 . Thirtythree patients (58%) were responders at follow-up. Baseline ERO area and prevalence of severe MR were not different between responders and nonresponders (19 ؎ 11 vs 21 ؎ 13 mm 2 , p ‫؍‬ 0.67; 52% vs 53%, p ‫؍‬ 0.84). In responders, MR was decreased by 58% (ERO 19 ؎ 12 to 8 ؎ 6 mm 2 ). In the presence of viability in the region of the pacing lead, 74% (n ‫؍‬ 29 patients) were responders (sensitivity 88%, specificity 58%); in the subgroup of patients with viability in the region of the pacing lead and severe MR, 83% (n ‫؍‬ 17 patients) were responders. In conclusion, LV remodeling is frequent and ischemic MR decrease important in patients with viability in the region of the pacing lead without regard to MR severity. © 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;106:31-37) Ischemic heart disease is the most common cause of systolic left ventricular (LV) dysfunction. The prognosis of these patients is particularly modulated by the extent of residual viable myocardium. Cardiac resynchronization therapy (CRT) improves LV function and geometry, exercise capacity, and outcomes of appropriately selected patients with heart failure.1-3 CRT leads to a decrease in mitral regurgitation (MR) severity at rest and during exercise by an increase of LV function and local synchronicity (decrease in mechanical activation delay of papillary muscles). 4 -11 Response to CRT largely depends on extent of LV dyssynchrony, severity of LV remodeling, extent of scar tissue, and possibility offered to the left ventricle to recruit function (contractile reserve). Whether the presence of MR and its severity could modulate the response to CRT is still controversial. Several investigators have suggested that extent of LV reverse remodeling could be lessened in patients with significant MR, particularly in the setting of ischemic cardiomyopathy. [12][13][14] This study investigated the potential impact of MR severity and myocardial contractile reserve on acute and long-term responses to CRT in patients with ischemic cardiomyopathy and significant LV dyssynchrony. MethodsFrom May 2005 to March 2008, 57 patients (mean age 71 Ϯ 8 years, 43 men, (75%) were prospectively enrolled in the Inst...

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 85%

mentioning

confidence: 99%

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Impact of Mitral Regurgitation and Myocardial Viability on Left Ventricular Reverse Remodeling After Cardiac Resynchronization Therapy in Patients With Ischemic Cardiomyopathy

Sénéchal¹,

Lancellotti²,

Magné³

et al. 2010

The American Journal of Cardiology

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“…Another known predictor is the presence of severe mitral regurgitation. Cabrera-Bueno et al (53) demonstrated that the presence of severe mitral regurgitation at baseline was associated with a lack of response in reverse remodeling in patients with nonischemic dilated cardiomyopathy, although there was significant improvement in FMR and intraventricular dyssynchrony. The presence of a significant volume overload due to severe FMR appears as a factor promoting further LV dilatation and blocking the LV reverse remodeling process.…”

Section: Cardiac Resynchronization Therapy and Functional Mitral Regumentioning

confidence: 99%

Functional mitral regurgitation and papillary muscle dyssynchrony in patients with left ventricular systolic dysfunction

Güler¹,

Dündar²,

Tigen³

2011

Anadolu Kardiyol Derg

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ÖZETSistolik fonksiyonları bozuk olan genişlemiş bir kalpte, mitral kapakta yapısal bir bozukluk olmasa bile fonksiyonel olarak yetersizlik meydana gelebilir. Fonksiyonel mitral yetersizliğinin gelişmesinde birçok mekanizma beraber rol alır. Bunlar, mitral kapağı kalbin apeksine doğru çeken kuvvetlerdeki artış, sistol sırasında kapağı kapayıcı kuvvetlerdeki azalma ve mekanik ve elektriksel dissenkronidir. Papiller adele dissenkronisi de fonksiyonel mitral yetersizliğine katkıda bulunan nedenlerden biridir. Sistolik kalp yetersizliği olan hastalarda -bazı durumlarda yanıt alına-mayabilirse de-kardiyak resenkronizasyon tedavisi ile fonksiyonel mitral yetersizliğinin gerilediği bilinir. Papiller adele dissenkronisi fonksiyonel mitral yetersizliğinin gerilemesi bakımından kardiyak resenkronizasyon tedavisine yanıtı tahmin edebilir ve koroner revaskülarizasyon, mitral onarım veya kardiyak resenkronizasyon tedavisi gibi farklı tedavilerden hangisinin seçileceği ya da beraber uygulanacağı konusunda yol göste-rici olabilir. Bu derlemede fonksiyonel mitral yetersizliğinin mekanizmaları, papiller adele dissenkronisi ve fonksiyonel mitral yetersizliği arasın-daki ilişki, papiller adele dissenkronisi ile kardiyak resenkronizasyon tedavisi sonrası fonksiyonel mitral yetersizliğindeki gerileme arasındaki ilişki incelenmiştir. ABSTRACTIn a dilated heart with impaired systolic functions, functional mitral regurgitation could be seen even in the presence of structurally normal mitral apparatus. A number of mechanisms play role in the development of functional mitral regurgitation. These are increased mitral tethering forces, reduction in closing forces and mechanical and electrical dyssynchrony. Papillary muscle dyssynchrony has also been shown to be related with functional mitral regurgitation. Cardiac resynchronization therapy is known to reduce the amount of functional mitral regurgitation in patients with left ventricular systolic failure although some may not respond to treatment with cardiac resynchronization therapy. Papillary muscle dyssynchrony may predict the response of cardiac resynchronization therapy on the regression of functional mitral regurgitation and may suggest the suitable therapeutic options, such as cardiac resynchronization therapy, mitral valve repair, coronary revascularization separately or in combination. In this review, the mechanisms of functional mitral regurgitation, papillary muscle dyssynchrony and its relationship with functional mitral regurgitation and the relationship of papillary muscle dyssynchrony with the improvement of functional mitral regurgitation after cardiac resynchronization therapy are focused. (Anadolu Kardiyol Derg 2011; 11: 450-5)

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“…1-7 In addition, CRT reverses LV remodeling. 8- 12 The implantation of a CRT system is recommended for heart failure patients who remain in symptomatic New York Heart Association (NYHA) functional class III or IV despite optimal medical treatment with low LV ejection fraction ≤35% and a QRS duration ≥120 ms (130 ms in Japan). Prolongation of the QRS duration on an electrocardiogram (ECG) served as an indirect marker to identify mechanical dyssynchrony.…”

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confidence: 99%

Limitations and Problems of Assessment of Mechanical Dyssynchrony in Determining Cardiac Resynchronization Therapy Indication - Is Assessment of Mechanical Dyssynchrony Necessary in Determining CRT Indication? (Con) -

Ishikawa¹

2011

Circ J

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Patients with left ventricular (LV) systolic dysfunction and dilation frequently have ventricular contraction delay. Prolonged QRS duration is associated with abnormal activation. The conduction abnormality is associated with delayed depolarization and contraction of the lateral LV free wall. Sometimes a left bundle branch block has been developed in patients with severe heart failure. Contraction delay of the lateral LV free wall is increased by a left bundle branch block. Contraction delay of the lateral LV free wall can be improved by biventricular pacing. CRT is based on the principle of resynchronizing un-uniformed contraction of the ventricle. CRT improves the cardiac function, heart failure hospitalization, quality of life, exercise capacity and overall prognosis of patients suffering from heart failure. 1-7 In addition, CRT reverses LV remodeling. 8-12 The implantation of a CRT system is recommended for heart failure patients who remain in symptomatic New York Heart Association (NYHA) functional class III or IV despite optimal medical treatment with low LV ejection fraction ≤35% and a QRS duration ≥120 ms (130 ms in Japan). Prolongation of the QRS duration on an electrocardiogram (ECG) served as an indirect marker to identify mechanical dyssynchrony. However, approximately 30% of the patients who met the criteria do not respond to CRT. 2-6 The multicenter InSymc randomized clinical evaluation (MIRACLE) trial demonstrated that 35% of patients receiving CRT experienced no improvement in the heart failure clinical composite score. 4 No reverse remodeling is observed up to 40% in recent studies based on echocardiographic observation. 9 As ventricular pacing, even biventricular pacing, reduces contractility, existence of dyssynchrony is essential for CRT. One possible explanation for the lack of response for CRT could be the absence of sufficient dyssynchrony to allow the therapy to have any impact. Direct assessments of mechanical dyssynchrony might better select responder patients for CRT. Presence of scar tissue have also great impacts on the effect of CRT. Prolongation of the QRS duration on an electrocardiogram served as an indirect marker to identify mechanical dyssynchrony. One of the greatest problems is approximately 30% of the patients who met the criteria do not respond for CRT. One possible explanation for the lack of response for CRT could be the absence of sufficient dyssynchrony to allow the therapy to have any impact. Direct assessments of mechanical dyssynchrony might better select responder patients for CRT. However, RethinQ study demonstrated that patients with heart failure and narrow QRS intervals might not benefit from CRT, even with dyssynchrony. Moreover, the results of the PROSPECT study suggest given the modest sensitivity and specificity in the multicenter setting, despite training and central analysis, no single echocardiographic measurement of dyssynchrony could be recommended to improve patient selection for CRT beyond current guidelines. At present, assessment of mechanical dyss...

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Repercussion of functional mitral regurgitation on reverse remodelling in cardiac resynchronization therapy

Abstract: CRT improved FMR, although the baseline presence of important mitral regurgitation, with a ROA > or = 0.20 cm(2), in patients undergoing CRT was associated with a lack of response in reverse remodelling.

Cited by 24 publications

References 19 publications

Impact of Mitral Regurgitation and Myocardial Viability on Left Ventricular Reverse Remodeling After Cardiac Resynchronization Therapy in Patients With Ischemic Cardiomyopathy

Impact of Mitral Regurgitation and Myocardial Viability on Left Ventricular Reverse Remodeling After Cardiac Resynchronization Therapy in Patients With Ischemic Cardiomyopathy

Functional mitral regurgitation and papillary muscle dyssynchrony in patients with left ventricular systolic dysfunction

Limitations and Problems of Assessment of Mechanical Dyssynchrony in Determining Cardiac Resynchronization Therapy Indication - Is Assessment of Mechanical Dyssynchrony Necessary in Determining CRT Indication? (Con) -

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