Perspectives on Secondary Mitral Regurgitation in Heart Failure.

Purpose Of The Review: This review focuses on broader perspectives of mitral regurgitation (MR) in patients with heart failure.

Recent Findings: The ratio of regurgitant volume to end-diastolic volume appears to help identify patients who may benefit from valve interventions. Secondary MR is not only attributed to geometric changes of the LV but also related to the structural changes in the mitral valve that include fibrosis of the mitral leaflets and changes in the extracellular matrix.

High-Output Heart Failure in a Patient With Klippel-Trénaunay Syndrome: A Case Report.

Klippel-Trénaunay syndrome (KTS) is a rare and complex congenital syndrome defined as the triad of cutaneous capillary malformation, bone and soft tissue hypertrophy, and venous and lymphatic malformations. KTS is thought to be due to a somatic mutation in phosphatidyl-inositol 3 kinase. It belongs to a group of syndromes termed the PI3CA-Related Overgrowth Spectrum (PROS) disorders.

Recurrent and Life-Threatening Peripartum Cardiomyopathy: Diagnosis, Delivery Considerations, and Management.

Peripartum cardiomyopathy is an idiopathic reduction in left ventricular systolic function (ejection fraction <45%) toward the end of pregnancy or in the months after delivery. A multidisciplinary approach to management with shock team support is key to identifying and adequately treating patients with refractory heart failure and peripartum cardiomyopathy. ().

An Appraisal of the Association of Clinical Outcomes With the Severity of Regurgitant Volume Relative to End-Diastolic Volume in Patients With Secondary Mitral Regurgitation.

Importance: Two randomized clinical trials of transcatheter edge-to-edge mitral valve repair in patients with secondary mitral regurgitation (the Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation [MITRA-FR] and the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation [COAPT]) report clinical outcome disparities that are largely unexplained. This appraisal sought to provide insight and an explanation for the differences in clinical outcomes (survival and hospitalization rates) in the 2 clinical trials. The mean echocardiogram Doppler results (and derived volume parameters) from each of the 2 clinical trials were compared and examined relative to the clinical outcomes.

Secondary mitral regurgitation (part 2): deliberations on mitral surgery and transcatheter repair.

Secondary mitral regurgitation (MR) develops as a consequence of postinfarction remodelling of the ventricle or other causes of left ventricular (LV) dilatation and dysfunction. The presence of MR amplifies the poor prognosis of the failing ventricle, but it has not been established whether the adverse outcomes stem from the MR or whether the MR is simply a marker of progressive LV dysfunction. In this article, an attempt will be made to clarify the clinical impact of mitral surgery and transcatheter repair in patients with secondary MR.

Secondary mitral regurgitation (part 1): volumetric quantification and analysis.

Secondary mitral regurgitation (MR) develops as a consequence of left ventricular (LV) dilatation and dysfunction, which complicates its evaluation and management. The goal of this article is to review the assessment of secondary MR with special emphasis on quantification and analysis of LV volume data. At the present time, the optimal method for making these measurements appears to be cardiac MRI.

Bioimpedance-Based Heart Failure Deterioration Prediction Using a Prototype Fluid Accumulation Vest-Mobile Phone Dyad: An Observational Study.

Background: Recurrent heart failure (HF) events are common in patients discharged after acute decompensated heart failure (ADHF). New patient-centered technologies are needed to aid in detecting HF decompensation. Transthoracic bioimpedance noninvasively measures pulmonary fluid retention.

Impedance to retrograde and forward flow in chronic mitral regurgitation and the physiology of a double outlet ventricle.

Objective: Mitral regurgitation (MR) is generally characterised as exhibiting a 'low impedance leak into the left atrium'. This notion is widely accepted without measured impedance data. The aim of this study was to define the impedance to retrograde and forward blood flow and to examine hydraulic (pressure-volume) and mechanical (stress-shortening) function in chronic severe MR.

Mitoxantrone-Induced Cardiotoxicity in Acute Myeloid Leukemia-A Velocity Vector Imaging Analysis.

Background: The purpose of this investigation was to: (1) determine incidence and predictors of mitoxantrone-induced early cardiotoxicity and (2) study left ventricular mechanics before and after receiving mitoxantrone.

Method And Results: We retrospectively analyzed 80 subjects diagnosed with acute myeloid leukemia (AML) who underwent chemotherapy with bolus high-dose mitoxantrone. Echocardiographic measurements were taken at baseline and at a median interval of 55 days after receiving mitoxantrone.

Creating and Maintaining a Successful Service Line in an Academic Medical Center at the Dawn of Value-Based Care: Lessons Learned From the Heart and Vascular Service Line at UMass Memorial Health Care.

The service line (SL) model has been proven to help shift health care toward value-based services, which is characterized by coordinated, multidisciplinary, high-quality, and cost-effective care. However, academic medical centers struggle with how to effectively set up SL structures that overcome the organizational and cultural challenges associated with simultaneously delivering the highest-value care for the patient and advancing the academic mission. In this article, the authors examine the evolution of UMass Memorial Health Care's heart and vascular service line (HVSL) from 2006 to 2011 and describe the impact on its success of multiple strategic decisions.

Decision-making under uncertainty in advanced heart failure.

The challenges managing advanced heart failure (AHF) are mounting, not least by the presence of multiple coexisting comorbidities, the lack of evidence of clinical benefit in many subsets of AHF, but also surrounding the uncertainty of the both short-term and long-term prognosis. Clinicians are highly variable in their interpretation of clinical data and are prone to considerable bias when it comes to treatment recommendations. This manuscript provides a critical appraisal of the uncertainties as it pertains to the natural history of AHF and management decisions.

Usefulness of pancreatitis-associated protein, a novel biomarker, to predict severity of disease in ambulatory patients with heart failure.

Pancreatitis-associated protein (PAP) is a novel cytokine with putative anti-inflammatory effects. PAP gene expression has been found to be increased in the myocardium of rats with decompensated pressure-overload hypertrophy. A prospective pilot study was performed to test the hypotheses that PAP is elevated in ambulatory patients with heart failure (HF) and that concentrations correlate with the severity of disease.

Systolic pulmonary and hepatic vein flow reversal due to pacemaker-induced retrograde ventriculoatrial conduction.

Systolic pulmonary and hepatic vein flow reversals can typically be seen with severe atrioventricular (AV) valve regurgitation and during atrial fibrillation (AF). We report the case of a 67-year-old woman who presented with recent-onset exertional dyspnea. Her pacemaker was near end-of-life and reverted to a VVI mode from the preset DDDR mode.

Alterations in early filling dynamics predict the progression of compensated pressure overload hypertrophy to heart failure better than abnormalities in midwall systolic shortening.

To evaluate whether the evolution of compensated pressure overload hypertrophy (POH) to overt heart failure (HF) is better predicted by systolic versus diastolic dysfunction, serial echocardiography was performed 1, 2, 4, 8, and 10 weeks after suprarenal aortic banding in 52 rats. One week after banding, at comparable extent of left ventricular hypertrophy and geometry, myocardial and chamber systolic performance, a restrictive filling pattern was well evident only in rats which eventually developed overt HF, according to postmortem lung weight. In experimental POH, early assessment of transmitral flow velocity allows to predict a faster progression toward HF.

Risk factors and comorbidities in a community-wide sample of patients hospitalized with acute systolic or diastolic heart failure: the Worcester Heart Failure Study.

Objectives: Few epidemiological studies have examined differences in the prevalence of risk factors and comorbidities in patients with systolic heart failure (HF), as compared with those with diastolic HF.

Methods: We analyzed data from 1426 residents of the Worcester (MA) metropolitan area hospitalized at all 11 greater Worcester medical centers for acute HF during 1995 and 2000 who had data available on ejection fraction (EF) findings during hospitalization. The analysis was conducted based on the presence of either normal (diastolic HF) as compared with reduced (systolic HF) EF, using an EF cutpoint of at least 50%.

Cardiac mechanics in mild hypertensive heart disease: a speckle-strain imaging study.

Background: We hypothesized that abnormalities in regional systolic strain (epsilon) might be present among hypertensive subjects with normal ejection fraction, and, if present, could be used to identify patients at high risk for heart failure. The aim of the current case-control study was to use speckle tracking imaging to identify subclinical global and regional systolic function abnormalities in hypertensive subjects with normal ejection fraction.

Methods And Results: Standard 2D Doppler echocardiography, tissue Doppler imaging, and 2D speckle strain imaging were performed in 52 hypertensive subjects with normal ejection fraction and 52 control subjects of similar age.

Prevalence and clinical characteristics of right ventricular dysfunction in transient stress cardiomyopathy.

Transient stress cardiomyopathy (TSC) is a cause of reversible left ventricular (LV) dysfunction that is increasingly recognized. Reports to date have focused primarily on LV involvement, with little attention paid to associated right ventricular (RV) dysfunction. With other forms of LV dysfunction, RV involvement has been shown to confer an adverse prognosis.

Mortality in diastolic heart failure: an update.

In 2003, the prevalence of heart failure in the United States was 5 million persons. Although historically at least one-third of these patients were considered to have diastolic heart failure (DHF) or "heart failure with preserved ejection fraction," contemporary cohort studies have shown that the prevalence of DHF in the community is not only higher than previously thought, but is actually rising. The increasing prevalence of this disorder has been attributed, in part, to the increasing mean age of the population and a progressive increase in the prevalence of associated risk factors, such as hypertension, obesity, and diabetes mellitus.

Direct ultrasound measurement of longitudinal, circumferential, and radial strain using 2-dimensional strain imaging in normal adults.

Current noninvasive techniques used to evaluate left ventricular systolic function are limited by dependence on the angle of insonation (tissue Doppler imaging/TDI) or limited by availability (MRI tagging). We utilized 2-dimensional speckle strain (epsilon) imaging (1) to establish normal values for all three epsilon vectors; (2) to compare circumferential epsilon values with circumferential shortening (midwall fractional shortening (FS(mw)); (3) to examine the relationship between left ventricular epsilon and wall stress; and (4) to compare 2D echocardiographic characteristics by gender. Echocardiography was performed in 60 normal subjects (mean 39 +/- 15 years).