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Journal of Clinical Medicine Dec 2021Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full... (Review)
Review
Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full epicardial and tissue reperfusion but also with a very good immediate and long-term clinical outcome. However, the Achilles heel of MI treatment is its ensemble of complications, such as cardiogenic shock due to severe systolic and/or diastolic dysfunction or MI mechanical complications, including perforation of the left ventricular free wall, papillary muscle rupture with acute mitral regurgitation and ventricular septal rupture. They are associated with an increased or, sometimes, with an extremely high mortality rate, determining the overall mortality in an MI patient population. In this review we summarize the mechanisms of MI complications, current therapeutic management and alternative directions for overcoming their devastating consequences. Moreover, we have sought to indicate gaps in the evidence on current treatments as the potential targets for further clinical research. From the perspective of mortality trends that are not improving, the forthcoming therapeutic management of complicated MI will require an individualized and novel approach based on their thorough pathobiology.
PubMed: 34945202
DOI: 10.3390/jcm10245904 -
JACC. Clinical Electrophysiology Oct 2020
Topics: Humans; Catheter Ablation; Electrophysiology; Papillary Muscles; Ventricular Premature Complexes
PubMed: 33121668
DOI: 10.1016/j.jacep.2020.08.005 -
Surgical treatment of post-infarction papillary muscle rupture: systematic review and meta-analysis.Annals of Cardiothoracic Surgery May 2022Papillary muscle rupture (PMR) is a rare but potentially fatal complication following acute myocardial infarction (AMI). Surgical treatment is considered the standard of...
BACKGROUND
Papillary muscle rupture (PMR) is a rare but potentially fatal complication following acute myocardial infarction (AMI). Surgical treatment is considered the standard of care. This systematic review and meta-analysis aims to evaluate the early outcomes after surgical correction of post-AMI PMR.
METHODS
Electronic databases were searched from January 1990 to December 2020. Studies reporting patients undergoing mitral valve surgery for post-AMI PMR were analysed. The primary outcome assessed was operative mortality. Differences were expressed as risk ratio (RR) with 95% confidence interval (CI) to assess the relationships between predefined surgical variables and clinical prognosis.
RESULTS
A total of 1,851 adult patients, from 12 observational studies, were identified. Operative mortality was 21%. Meta-analysis revealed reduced operative risk in patients undergoing mitral valve repair (MVr) as compared to replacement (MVR) (RR, 0.33; 95% CI: 0.14 to 0.79; P=0.01), and an increased risk of operative mortality in patients with complete PMR (RR, 2.54; 95% CI: 1.12 to 5.74; P=0.03). No significant differences in terms of operative mortality were observed between patients with or without pre/peri-operative intra-aortic balloon pump (IABP) support and between subjects who underwent mitral valve surgery with or without concomitant coronary artery bypass grafting (CABG).
CONCLUSIONS
Mitral valve surgery for post-AMI PMR carries a high operative mortality. Patients with complete PMR and subjects undergoing MVR have increased risks of operative mortality. The preoperative use of IABP and concomitant CABG seem not to influence the early postoperative course in this context.
PubMed: 35733726
DOI: 10.21037/acs-2021-ami-15 -
Annals of Thoracic and Cardiovascular... Aug 2022In patients with obstructive hypertrophic cardiomyopathy, left ventricular outflow tract (LVOT) obstruction can be created by the hypertrophic interventricular septum... (Review)
Review
In patients with obstructive hypertrophic cardiomyopathy, left ventricular outflow tract (LVOT) obstruction can be created by the hypertrophic interventricular septum (IVS) as well as systolic anterior motion (SAM) of the anterior mitral leaflet (AML). Sufficient septal myectomy is a fundamental surgical technique to treat LVOT obstruction, however, direct surgical management for SAM is another key aspect. Besides the hypertrophic IVS, mitral valve, subvalvular apparatus, and papillary muscle may play important role for SAM and several surgical techniques have been proposed to treat SAM in literature. In this review, each surgical technique is classified by the anatomical structure on which the surgical procedure is applied. The AML is the main surgical site and is applied with plication (vertical plication, resection-plication-release strategy), extension (the AML extension, transverse incision of the AML), sutured (edge-to-edge repair, anterior leaflet retention plasty), or traction (floating stitch, papillary muscle-to-anterior annulus stitches, paradoxical stitches, transposition of a directed chorda tendinea to the AML). Height reduction of the posterior mitral valve leaflet and papillary muscle reorientation are other techniques. We should understand theoretical aspects of each technique on correction of anatomical and functional abnormalities of the structure and should apply them under proper indication.
Topics: Humans; Leukemia, Myeloid, Acute; Mitral Valve; Mitral Valve Insufficiency; Muscular Diseases; Treatment Outcome; Ventricular Outflow Obstruction
PubMed: 35851569
DOI: 10.5761/atcs.ra.22-00103 -
JACC. Cardiovascular Imaging Sep 2019This study sought to define interpapillary muscle dyssynchrony as a major contributing factor in functional mitral regurgitation (FMR) and prove the reversibility of FMR... (Observational Study)
Observational Study
OBJECTIVES
This study sought to define interpapillary muscle dyssynchrony as a major contributing factor in functional mitral regurgitation (FMR) and prove the reversibility of FMR by interpapillary muscle resynchronization.
BACKGROUND
Mechanistic features of FMR include papillary muscle displacement due to left ventricular remodeling. Intraventricular conduction delay might further augment this condition by introducing interpapillary muscle dyssynchrony.
METHODS
We enrolled 269 chronic heart failure with reduced ejection fraction patients with conduction delay and comprehensively assessed dyssynchrony by complementary echocardiographic techniques covering the entire spectrum of dyssynchrony.
RESULTS
Patients with severe FMR had markedly increased interpapillary longitudinal dyssynchrony (160 ms [interquartile range (IQR): 120 to 200 ms]) compared with those with moderate (70 ms [IQR: 40 to 110 ms]), no, or mild FMR (60 ms [IQR: 30 to 100 ms]; p < 0.001). Increased interpapillary muscle dyssynchrony was correlated with regurgitant volume (r = 0.50; p < 0.001) and vena contracta width (r = 0.49; p < 0.001). Restoration of longitudinal papillary muscle synchronicity by cardiac resynchronization therapy was correlated with FMR regression, as reflected by the reduction in regurgitant volume (r = 0.46; p < 0.001) and vena contracta width (r = 0.58; p < 0.001). Conversely, the improvement of FMR was associated with improved interpapillary radial (p = 0.006) and longitudinal (p < 0.001) dyssynchrony. The improvement of dyssynchrony-mediated FMR signified a better prognosis compared with no improvement in FMR during the 8-year follow-up period even after comprehensive adjustment by a bootstrap-selected confounder model (adjusted hazard ratio: 0.41; 95% confidence interval: 0.18 to 0.91; p = 0.028). The results remained virtually unchanged after adjustment for left bundle branch block.
CONCLUSIONS
Intraventricular dyssynchrony introduces unequal contraction by papillary muscle bearing walls, which has an adverse effect on FMR. Cardiac resynchronization therapy can effectively restore interpapillary balance and thus create a less tented leaflet configuration, resulting in a clinically meaningful reduction of FMR. The restoration of papillary muscle synchronicity in dyssynchrony-mediated FMR translates into a significantly better prognosis.
Topics: Aged; Cardiac Resynchronization Therapy; Chronic Disease; Female; Heart Failure; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Myocardial Contraction; Papillary Muscles; Recovery of Function; Stroke Volume; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left; Ventricular Remodeling
PubMed: 30121264
DOI: 10.1016/j.jcmg.2018.06.013 -
Cureus Feb 2022Introduction A normal atrioventricular valve complex of the heart consists of the atrioventricular (A-V) ring, cusps, chordae tendineae, and papillary muscles. The right...
Introduction A normal atrioventricular valve complex of the heart consists of the atrioventricular (A-V) ring, cusps, chordae tendineae, and papillary muscles. The right ventricle contains three while the left ventricle contains only two papillary muscles, which are named according to their location. A thorough understanding of the normal anatomy as well as possible variations can help surgeons in various corrective surgeries involving papillary muscles. Material & methods The study included 50 formalin-preserved hearts procured from human cadavers of unknown age and cause of death. The number of papillary muscles along with their shape, size, and pattern were noted separately for each ventricle. Data were analyzed using SPSS Version 21.0 (IBM Corp., Armonk, NY). Results The left and right ventricles contained two and three papillary muscles, respectively, in all the hearts. In the right ventricles, conical shape and the single base and divided apex (SBDA) pattern were found to be most prevalent. Anterior papillary muscles exhibited the mean length of 12.71±3.81 and 16.41±4.33 in the right and left ventricles, respectively. Similarly, posterior papillary muscles exhibited a mean length of 12.40±3.03 and 14.64±3.92 in the right and left ventricles, respectively. Both differences were found to be statistically significant Conclusion For the appropriate functioning of valves, both anatomical and mechanical coherence of the papillary muscles is required. A very keen understanding of this valvular complex is thus essential for anatomists, physiologists, and cardiologists to deal with normal as well as pathological valvular conditions.
PubMed: 35382408
DOI: 10.7759/cureus.22722 -
Diagnostics (Basel, Switzerland) Apr 2023: This study aimed to assess the value of radiomic features derived from the myocardium (MYO) and papillary muscle (PM) for left ventricular hypertrophy (LVH) detection...
: This study aimed to assess the value of radiomic features derived from the myocardium (MYO) and papillary muscle (PM) for left ventricular hypertrophy (LVH) detection and hypertrophic cardiomyopathy (HCM) versus hypertensive heart disease (HHD) differentiation. : There were 345 subjects who underwent cardiovascular magnetic resonance (CMR) examinations that were analyzed. After quality control and manual segmentation, the 3D radiomic features were extracted from the MYO and PM. The data were randomly split into training (70%) and testing (30%) datasets. Feature selection was performed on the training dataset. Five machine learning models were evaluated using the MYO, PM, and MYO+PM features in the detection and differentiation tasks. The optimal differentiation model was further evaluated using CMR parameters and combined features. : Six features were selected for the MYO, PM, and MYO+PM groups. The support vector machine models performed best in both the detection and differentiation tasks. For LVH detection, the highest area under the curve (AUC) was 0.966 in the MYO group. For HCM vs. HHD differentiation, the best AUC was 0.935 in the MYO+PM group. Comparing the radiomics models to the CMR parameter models for the differentiation tasks, the radiomics models achieved significantly improved the performance ( = 0.002). : The radiomics model with the MYO+PM features showed similar performance to the models developed from the MYO features in the detection task, but outperformed the models developed from the MYO or PM features in the differentiation task. In addition, the radiomic models performed better than the CMR parameters' models.
PubMed: 37174935
DOI: 10.3390/diagnostics13091544 -
The Forgotten, Not Studied or Not Valorized Tricuspid Valve: The Transcatheter Revolution Is Coming.Cardiology Research Aug 2019The tricuspid valve (TV) has been known as the forgotten valve. However, considering recent information from scientific studies, this nomenclature may need to be... (Review)
Review
The tricuspid valve (TV) has been known as the forgotten valve. However, considering recent information from scientific studies, this nomenclature may need to be adjusted for the valve, which also needs to be better studied and understood. For decades, tricuspid regurgitation (TR) was not fully appreciated and was never the priority. However, studies have revealed that such pathology is related to a possible negative impact on prognosis of patients. Severe TR is a predictor of higher mortality. For the treatment of TR, repair or valve replacement can be performed. Repair techniques can be performed on the annulus (suture annuloplasty or ring implant), on the leaflets (e.g. triangular resection), on the cords (transfers or new cords) and on the papillary muscles (e.g. sliding technique). The anatomical characteristics of the TV determine the repair technique to be used. In some cases, valve repair is not possible and/or not indicated and valve replacement is selected based on the strategy. Nowadays transcatheter therapies have been used and studied. The main transcatheter strategies for the treatment of TR are based on reduction of the annulus (Cardioband, Trialign, TriCinch, Millipede and TRAIPTA), improvement of the leaflet coaptation (Mitraclip, FORMA device, PASCAL system, and TV occluder), reduction of the reflux for the vena cava system (Tric valve and Sapien valve implant), and valve implants (Navigate, Trisol, Sapien, Melody). In this context, there are still other devices (such as Tricentro, Pasta, etc.) being developed and tested throughout several phases of research. In the future, improved knowledge of the TV and the evolution of transcatheter treatments will alter the history of the TV. The transcatheter revolution is coming!
PubMed: 31413775
DOI: 10.14740/cr874 -
Annals of Cardiothoracic Surgery May 2022The outcomes of patients with acute myocardial infarctions (AMI) have significantly improved with advances in early reperfusion strategies; however, patients with... (Review)
Review
The outcomes of patients with acute myocardial infarctions (AMI) have significantly improved with advances in early reperfusion strategies; however, patients with massive infarcts or those who do not receive timely revascularization may develop mechanical complications of AMI. The most common mechanical complications are ventricular septal rupture (VSR), acute mitral regurgitation (MR) due to papillary muscle rupture, and free-wall rupture. Each complication is associated with a high risk of morbidity and mortality, and requires a multidisciplinary approach for prompt diagnosis and hemodynamic stabilization. Surgery is the mainstay of therapy but is associated with poor outcomes if performed too early during the treatment course for VSR or if performed too late with MR and free wall rupture. Optimal timing for surgery in combination with temporary circulatory support may be a feasible strategy for better results.
PubMed: 35733711
DOI: 10.21037/acs-2021-ami-206 -
JTCVS Open Mar 2021The exact geometric pathogenesis of leaflet tethering in ischemic mitral regurgitation (IMR) and the relative contribution of each component of the mitral valve complex...
BACKGROUND
The exact geometric pathogenesis of leaflet tethering in ischemic mitral regurgitation (IMR) and the relative contribution of each component of the mitral valve complex (MVC) remain largely unknown. In this study, we sought to further elucidate mitral valve (MV) leaflet remodeling and papillary muscle dynamics in an ovine model of IMR with magnetic resonance imaging (MRI) and 3-dimensional echocardiography (3DE).
METHODS
Multimodal imaging combining 3DE and MRI was used to analyze the MVC at baseline, 30 minutes post-myocardial infarction (MI), and 12 weeks post-MI in ovine IMR models. Advanced 3D imaging software was used to trace the MVC from each modality, and the tracings were verified against resected specimens.
RESULTS
3DE MV remodeling was regionally heterogenous and observed primarily in the anterior leaflet, with significant increases in surface area, especially in A2 and A3. The posterior leaflet was significantly shortened in P2 and P3. Mean posteromedial papillary muscle (PMPM) volume was decreased from 1.9 ± 0.2 cm at baseline to 0.9 ± 0.3 cm at 12 weeks post-MI ( < .05). At 12 weeks post-MI, the PMPM was predominately displaced horizontally and outward along the intercommissural axis with minor apical displacement. The subvalvular contribution to tethering is a combination of unilateral movement, outward displacement, and degeneration of the PMPM. These findings have led to a proposed new framework for characterizing PMPM dynamics in IMR.
CONCLUSIONS
This study provides new insights into the complex interrelated and regionally heterogenous valvular and subvalvular mechanisms involved in the geometric pathogenesis of IMR tethering.
PubMed: 36003177
DOI: 10.1016/j.xjon.2020.10.007