-
Open Heart 2018To assess the association between cardiac morphology and function assessed with cardiac MRI (CMRI) and haemodynamics at rest and during exercise in patients with primary...
OBJECTIVE
To assess the association between cardiac morphology and function assessed with cardiac MRI (CMRI) and haemodynamics at rest and during exercise in patients with primary mitral regurgitation (MR).
METHODS
In an observational study, subjects with significant primary MR (N = 46) with effective regurgitant orifice ≥ 0.30 cm and left ventricular (LV) ejection fraction > 60% were examined with right heart catheterisation during rest and exercise and CMRI at rest. End-diastolic pressure volume relationship (EDPVR) was assessed using a single beat method using pulmonary capillary wedge pressure (PCWP) and end-diastolic volume. Patients were divided according to normal PCWP at rest (> 12 mm Hg) and with exercise (> 28 mm Hg). Results: Resting regurgitant volume correlated positively with resting PCWP, (r = 0.42, p = 0.002). However, with exercise no association between PCWP and regurgitant volume was seen (r = 0.09, p = 0.55). At rest left atrial (LA) maximal, minimal and volume index at atrial contraction correlated positively with PCWP (r = 0.60; r = 0.55; r = 0.58, all p < 0.001); in contrast none of these correlated with exercise PCWP (all p > 0.2). EDPVR in patients with high PCWP at rest was shifted towards higher volumes for the same pressures. The opposite was seen for patients with high PCWP during exercise where estimated volumes were smaller for the same pressure than patients with normal exercise PCWP.
CONCLUSION
In patients with significant MR the degree of regurgitation and LA dilatation is associated with resting PCWP. However, with exercise this association disappears. Estimation of EDPVR suggests lower LV compliance in patients where PCWP is increased with exercise.
CLINICAL TRIAL REGISTRATION
URL: https://clinicaltrials.gov/ct2/show/NCT02961647?term=HEMI&rank=1. ID: NCT02961647.
PubMed: 30613416
DOI: 10.1136/openhrt-2018-000919 -
Interventional Cardiology (London,... Feb 2019In 2018, the world of functional mitral regurgitation changed with the presentation of two trials - Multicentre Study of Percutaneous Mitral Valve Repair MitraClip... (Review)
Review
In 2018, the world of functional mitral regurgitation changed with the presentation of two trials - Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation (MITRA-FR) and Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT). The trials, which seemed to point in two different directions, raised significant questions for the field. This article looks at the differences in effective regurgitant area, guideline-directed medical therapy, patient selection, technical clues and other reasons why the trials had similar aims but very different findings.
PubMed: 30858892
DOI: 10.15420/icr.2018.40.1 -
Journal of Cardiovascular Magnetic... Dec 2008Cardiovascular magnetic resonance (CMR) is increasingly used to assess patients with mitral regurgitation. Its advantages include quantitative determination of... (Review)
Review
Cardiovascular magnetic resonance (CMR) is increasingly used to assess patients with mitral regurgitation. Its advantages include quantitative determination of ventricular volumes and function and the mitral regurgitant fraction, and in ischemic mitral regurgitation, regional myocardial function and viability. In addition to these, identification of leaflet prolapse or restriction is necessary when valve repair is contemplated. We describe a systematic approach to the evaluation of mitral regurgitation using CMR which we have used in 149 patients with varying etiologies and severity of regurgitation over a 15 month period. Following standard ventricular cine acquisitions, including 2, 3 and 4 chamber long axis views and a short axis stack for biventricular function, we image movements of all parts of the mitral leaflets using a contiguous stack of oblique long axis cines aligned orthogonal to the central part of the line of coaptation. The 8-10 slices in the stack, orientated approximately parallel to a 3-chamber view, are acquired sequentially from the superior (antero-lateral) mitral commissure to the inferior (postero-medial) commissure, visualising each apposing pair of anterior and posterior leaflet scallops in turn (A1-P1, A2-P2 and A3-P3). We use balanced steady state free precession imaging at 1.5 Tesla, slice thickness 5 mm, with no inter-slice gaps. Where the para-commissural coaptation lines curve relative to the central region, two further oblique cines are acquired orthogonal to the line of coaptation adjacent to each commissure. To quantify mitral regurgitation, we use phase contrast velocity mapping to measure aortic outflow, subtracting this from the left ventricular stroke volume to calculate the mitral regurgitant volume which, when divided by the left ventricular stroke volume, gives the mitral regurgitant fraction. In patients with ischemic mitral regurgitation, we further assess regional left ventricular function and, with late gadolinium enhancement, myocardial viability. Comprehensive assessment of mitral regurgitation using CMR is feasible and enables determination of mitral regurgitation severity, associated leaflet prolapse or restriction, ventricular function and viability in a single examination and is now routinely performed at our centre. The mitral valve stack of images is particularly useful and easy to acquire.
Topics: Humans; Image Interpretation, Computer-Assisted; Magnetic Resonance Imaging, Cine; Mitral Valve Insufficiency; Predictive Value of Tests; Severity of Illness Index; Ventricular Function, Left
PubMed: 19102740
DOI: 10.1186/1532-429X-10-61 -
Circulation. Cardiovascular... May 2024Acute aortic regurgitation is life-threatening with few nonsurgical options for immediate stabilization. We propose Trans-Aortic Balloon to Ease Regurgitation Applying...
BACKGROUND
Acute aortic regurgitation is life-threatening with few nonsurgical options for immediate stabilization. We propose Trans-Aortic Balloon to Ease Regurgitation Applying Counter-Pulsation (TABERNACL), a simple, on-table temporary valve using commercially available equipment to temporize acute severe aortic regurgitation.
METHODS
We hypothesize that an appropriately sized commercial balloon dilatation catheter-straddling the aortic annulus and connected to a counterpulsation console-can serve as a temporizing valve to restore hemodynamic stability in acute aortic regurgitation. We performed benchtop testing of valvuloplasty, angioplasty, and sizing balloons as counterpulsation balloons. TABERNACL was assessed in vivo in a porcine model of acute aortic regurgitation (n=8). We also tested a static undersized, continuously inflated transvalvular balloon as a spacer intended physically to obstruct the regurgitant orifice.
RESULTS
Benchtop testing identified that Tyshak II and PTS sizing (NuMed Braun) balloon catheters performed adequately as temporary valves (ie, complete inflation and deflation with each cycle) and resisted fatigue, in contrast to others. When TABERNACL was used in the acute severe regurgitation animals, there was immediate hemodynamic improvement, with a significant 35% increase in diastolic aortic pressure by 16 mm Hg ([95% CI, 7-25] =0.0056), 34% reduction in left ventricular end-diastolic pressure by -7 mm Hg ([95% CI, -10 to -5] =0.0006), improvement in the aortic diastolic index by 0.28 ([95% CI, 0.18-0.39] =0.0009), and reversal of electrocardiographic myocardial ischemia. As an alternative, static balloon inflation across the aortic valve stabilized regurgitation hemodynamics at the expense of a new aortic gradient and caused excessive ectopy from balloon movement in the left ventricular outflow tract.
CONCLUSIONS
TABERNACL improves hemodynamics and reduces coronary ischemia by electrocardiography in animals with acute severe aortic regurgitation. TABERNACL valves obstruct the diastolic regurgitant orifice without systolic obstruction. This may prove a lifesaving bridge to definitive valve replacement therapy.
Topics: Animals; Hemodynamics; Aortic Valve Insufficiency; Disease Models, Animal; Balloon Valvuloplasty; Sus scrofa; Aortic Valve; Equipment Design; Recovery of Function; Acute Disease; Cardiac Catheters; Time Factors; Severity of Illness Index; Ventricular Function, Left
PubMed: 38533653
DOI: 10.1161/CIRCINTERVENTIONS.123.013898 -
Journal of the American College of... Jul 2015Transcatheter therapies in structural heart disease have evolved tremendously over the past 15 years. Since the introduction of the first balloon-expandable valves for... (Review)
Review
Transcatheter therapies in structural heart disease have evolved tremendously over the past 15 years. Since the introduction of the first balloon-expandable valves for stenotic lesions with implantation in the pulmonic position in 2000, treatment for valvular heart disease in the outflow position has become more refined, with newer-generation devices, alternative techniques, and novel access approaches. Recent efforts into the inflow position and regurgitant lesions, with transcatheter repair and replacement technologies, have expanded our potential to treat a broader, more heterogeneous patient population. The evolution of multimodality imaging has paralleled these developments. Three- and 4-dimensional visualization and concomitant use of novel technologies, such as fusion imaging, have supported technical growth, from pre-procedural planning and intraprocedural guidance, to assessment of acute results and follow-up. A multimodality approach has allowed operators to overcome many limitations of each modality and facilitated integration of a multidisciplinary team for treatment of this complex patient population.
Topics: Aortic Valve Insufficiency; Cardiac Catheterization; Diagnostic Imaging; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Mitral Valve Insufficiency; Pulmonary Valve Insufficiency; Tricuspid Valve Insufficiency
PubMed: 26160633
DOI: 10.1016/j.jacc.2015.05.034 -
Journal of Magnetic Resonance Imaging :... Oct 2018In patients with mitral or tricuspid valve regurgitation, evaluation of regurgitant severity is essential for determining the need for surgery. While transthoracic...
BACKGROUND
In patients with mitral or tricuspid valve regurgitation, evaluation of regurgitant severity is essential for determining the need for surgery. While transthoracic echocardiography is widely accessible, it has limited reproducibility for grading inlet valve regurgitation. Multiplanar cardiac MRI is the quantitative standard but requires specialized local expertise, and is thus not widely available. Volumetric 4D flow MRI has potential for quantitatively grading the severity of inlet valve regurgitation in adult patients.
PURPOSE
To evaluate the accuracy and reproducibility of volumetric 4D flow MRI for quantification of inlet valvular regurgitation compared to conventional multiplanar MRI, which may simplify and improve accessibility of cardiac MRI.
STUDY TYPE
This retrospective, HIPAA-compliant imaging-based comparison study was conducted at a single institution.
SUBJECTS
Twenty-one patients who underwent concurrent multiplanar and 4D flow cardiac MRI between April 2015 and January 2017.
FIELD STRENGTH/SEQUENCES
3T; steady-state free-precession (SSFP), 2D phase contrast (2D-PC), and postcontrast 4D flow.
ASSESSMENT
We evaluated the intertechnique (4D flow vs. 2D-PC), intermethod (direct vs. indirect measurement), interobserver and intraobserver reproducibility of measurements of regurgitant flow volume (RFV), fraction (RF), and volume (RVol).
STATISTICAL TESTS
Statistical analysis included Pearson correlation, Bland-Altman statistics, and intraclass correlation coefficients.
RESULTS
There was high concordance between 4D flow and multiplanar MRI, whether using direct or indirect methods of quantifying regurgitation (r = 0.813-0.985). Direct interrogation of the regurgitant jet with 4D flow showed high intraobserver consistency (r = 0.976-0.999) and interobserver consistency (r = 0.861-0.992), and correlated well with traditional indirect measurements obtained as the difference between stroke volume and forward outlet valve flow.
DATA CONCLUSION
4D flow MRI provides highly reproducible measurements of mitral and tricuspid regurgitant volume, and may be used in place of conventional multiplanar MRI.
LEVEL OF EVIDENCE
4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1147-1158.
Topics: Adult; Aged; Aged, 80 and over; Blood Flow Velocity; Female; Humans; Image Enhancement; Image Interpretation, Computer-Assisted; Imaging, Three-Dimensional; Magnetic Resonance Imaging; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Observer Variation; Reproducibility of Results; Retrospective Studies; Stroke Volume; Time Factors; Tricuspid Valve; Tricuspid Valve Insufficiency; Young Adult
PubMed: 29638024
DOI: 10.1002/jmri.26040 -
Reviews in Cardiovascular Medicine Mar 2021Both Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) have well-established role in mitral regurgitation (MR) quantification for optimal...
Both Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) have well-established role in mitral regurgitation (MR) quantification for optimal management strategy. We assessed the correlation between TTE and CMR in the quantification of MR. Participants with isolated MR and echocardiographic mitral regurgitant volume (RVol) ≥ 30 mL/beat were included. A consecutive sample of 30 participants (Mean age 52.7 ± 19.3 years, 50% males) was selected and referred for indirect and direct CMR quantification of mitral RVol. There was a statistically significant strong positive correlation between the echocardiographic and indirect CMR quantification of the mitral RVol (r = 0.753, < 0.001) and a statistically significant moderate positive correlation between the echocardiographic and direct CMR quantification of the mitral RVol (r = 0.530, < 0.003). The inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant moderate agreement (κ = 0.502, = 0.0001) when the observers used the echocardiographic mitral RVol for grading of MR. On the other hand, the inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant faint agreement (κ = 0.251, = 0.024) when the observers used the echocardiographic regurgitant fraction (RF) for grading of MR. The positive reciprocal relationship between the CMR and the TTE highlights the potential role of the CMR as a concomitant imaging tool for quantification of the mitral RVol and grading of isolated MR, especially with limited or inconclusive TTE studies. This will enhance the management strategy and improve outcomes.
Topics: Adult; Aged; Echocardiography; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Mitral Valve Insufficiency; Reproducibility of Results; Severity of Illness Index
PubMed: 33792265
DOI: 10.31083/j.rcm.2021.01.20216 -
European Heart Journal Aug 1987Angiographic techniques have been used for the quantification of mitral or aortic and rarely tricuspid regurgitation. Mitral or aortic regurgitant volume per beat and... (Review)
Review
Angiographic techniques have been used for the quantification of mitral or aortic and rarely tricuspid regurgitation. Mitral or aortic regurgitant volume per beat and the regurgitation fraction (fao and fm, respectively) are obtained from the angiographic determination of total left ventricular stroke volume (TSV) and forward stroke volume (FSV) estimated by a different technique. Although this procedure is generally accepted as the gold standard for quantification of left heart regurgitations, there are several limitations: In the presence of mitral and aortic regurgitation no separate quantification of fao and fm is feasible; heart rate at the time of determination of FSV (from Fick or dye dilution cardiac output) and of TSV (angio) may be different; there is a tendency to consistently overestimate stroke volume by angio techniques; repeated estimations of TSV by angio are influenced by the circulatory effects of the contrast dye. In contrast indicator dilution techniques, where upstream and downstream sampling allow the simultaneous estimation of forward and regurgitant flow, the accuracy of the determination of FSV is well established and repeated estimations of fao and fm are possible because the indicators do not have cardiovascular effects. These methods are, however, crucially dependent on thorough mixing of the regurgitant volume with the blood in the upstream chamber. In 23 patients with isolated aortic regurgitation there was a positive correlation between fao evaluated by thermodilution and fao determined by the biplane angio-Fick method (r = 0.59). fao by thermodilution averaged 0.40 and fao by angio-Fick 0.46 (NS).(ABSTRACT TRUNCATED AT 250 WORDS)
Topics: Angiocardiography; Animals; Aortic Valve Insufficiency; Cineangiography; Heart Valve Diseases; Humans; Indicator Dilution Techniques; Mitral Valve Insufficiency; Stroke Volume; Thermodilution
PubMed: 3315666
DOI: 10.1093/eurheartj/8.suppl_c.1 -
Pediatric Gastroenterology, Hepatology... Jun 2016Regurgitation is a common physiological phenomenon in infants. The aim of the present study was to evaluate the efficacy of a new anti-regurgitation (AR) formula...
PURPOSE
Regurgitation is a common physiological phenomenon in infants. The aim of the present study was to evaluate the efficacy of a new anti-regurgitation (AR) formula (Novalac), thickened with an innovative complex including fibres, on the daily number of regurgitations and to assess its impact on stool consistency and frequency.
METHODS
Infants younger than five months, presenting at least 5 regurgitations per day were recruited in this trial. The efficacy of the new formula on regurgitation (daily number and Vandenplas score), stool frequency and consistency were assessed at day 14 and 90. Growth data were recorded at each study visit.
RESULTS
Ninety babies (mean age 9.6±5.8 weeks) were included in the full analysis data set. The mean number of regurgitation episodes at inclusion was 7.3±3.4. In all infants, regurgitations improved after 2 weeks. The daily number of regurgitations decreased significantly (-6.3±3.3, p<0.001) including in those previously fed a thickened formula (-6.2±3.0, p<0.001). There was no significant change in stool consistency at day 14. After 3 months, 97.5% of infants had formed or soft stools. Growth was appropriate with a slight increase of weight-for-age z-score (from -0.5±1.0 to -0.1±0.9) and no change of weight-for length z-score (-0.1±1.1 to -0.1±-1.1).
CONCLUSION
The new AR formula thickened with an innovative complex is very effective in reducing the daily number of regurgitations without having a negative impact on stools consistency.
PubMed: 27437186
DOI: 10.5223/pghn.2016.19.2.104