1,720,974 research outputs found
Atrial Functional Mitral Regurgitation: Definition, Mechanisms, and Treatment Perspectives
No full textPurpose of ReviewThis review aims to explore the complex interplay between atrial functional mitral regurgitation (AFMR), atrial fibrillation (AF), and heart failure with preserved ejection fraction (HFpEF). The goal is to define these conditions, examine their underlying mechanisms, and discuss treatment perspectives, particularly addressing diagnostic challenges.Recent FindingsRecent research highlights the rising prevalence of AFMR, now accounting for nearly one-third of significant mitral regurgitation cases. Advances in percutaneous treatment options have improved management for vulnerable HFpEF patients, but long-term outcomes remain unclear, and symptom relief is inconsistent.SummaryAF and HFpEF share the left atrium as a common pathological substrate, with progressive LA remodeling contributing to AFMR. Diagnostic limitations hinder effective symptom management with current mitral valve interventions. Future research should focus on better diagnostic tools to determine the contributions of valvular disease, arrhythmia, or myocardial dysfunction to clinical outcomes, as we currently lack definitive tests to establish this connection.Fund for Scientific Research Flanders [FWO 11PGA24N
Acute valvular emergencies
No full textAbstract
Acute valvular emergencies represent an important cause of cardiogenic shock. However, their clinical presentation and initial diagnostic testing are often non-specific, resulting in delayed diagnosis. Moreover, metabolic disarray or haemodynamic instability may result in too great a risk for emergent surgery. This review will focus on the aetiology, clinical presentation, diagnostic findings, and treatment options for patients presenting with native acute left-sided valvular emergencies. In addition to surgery, options for medical therapy, mechanical circulatory support, and novel percutaneous interventions are discussed.</jats:p
The interaction between atrial fibrillation and mitral regurgitation: Insights from the CABANA randomized clinical trial
No full textAims Atrial fibrillation (AF) and mitral regurgitation (MR) frequently coexist. While catheter ablation is a key rhythm-control strategy in AF, its impact on MR severity remains uncertain. This study evaluates the effects of catheter ablation on AF recurrence, functional status, and MR progression in patients with AF and baseline MR. Methods and results This sub-analysis included 1423 patients (65% of the overall CABANA cohort) with available baseline echocardiography. Participants were randomized to catheter ablation or pharmacological therapy. The primary endpoint was the composite of all-cause mortality and cardiovascular hospitalization. Secondary endpoints included AF recurrence, changes in MR severity, and functional status. At baseline, 722 patients (52%) had MR, including 582 with mild and 140 with >= moderate MR, with characteristics suggestive of an atrial functional mechanism. Catheter ablation significantly reduced AF recurrence compared to pharmacological therapy (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.50-0.62, p < 0.001). The presence or absence of MR did not interact with randomization in terms of its neutral effect on all-cause mortality and cardiovascular hospitalization (p for interaction = 0.115). Baseline MR increased the risk of AF recurrence (OR 1.46, 95% CI 1.40-1.74, p < 0.001). However, the benefit of ablation on functional status was greater in patients with MR compared to those without (p for interaction < 0.001). Follow-up echocardiography (n = 248) showed a greater reduction in MR severity in the ablation group versus drug therapy (p for interaction = 0.040). Conclusion Catheter ablation was superior to pharmacological therapy in rhythm control and may reduce MR severity over time. These findings highlight ablation's potential structural and symptomatic benefits, pending specifically designed clinical trials.Sebastiaan Dhont is supported as predoctoral fundamental research fellow by the Fund for Scientific Research Flanders (FWO 11PGA24N). The Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC) is funded by the National Institutes of Health. Conflict of interest: W.H.W.T. is a consultant for Sequana Medical, Cardiol Therapeutics Inc, Genomics plc, Zehna Therapeutics, Boston Scientific, WhiteSwell, Intellia Therapeutics, CardiaTec Biosciences, Bristol Myers Squibb, Alleviant Medical, Alexion Pharmaceuticals, Salubris Biotherapeutics, BioCardia Inc, and has received honorarium from Springer, Belvoir Media Group, and American Board of Internal Medicine. All other authors have nothing to disclose
LA Mechanics in Decompensated Heart Failure Insights From Strain Echocardiography With Invasive Hemodynamics
No full textOBJECTIVES The aim of this study was to assess the effect of congestion and decongestive therapy on left atrial (LA) mechanics and to determine the relationship between LA improvement after decongestive therapy and clinical outcome in immediate or chronic heart failure with reduced ejection fraction (HFrEF).
BACKGROUND LA mechanics are affected by volume/pressure overload in decompensated HFrEF.
METHODS A total of 31 patients with HFrEF and immediate heart failure (age 64 15 years, 74% male, left ventricular ejection fraction 20 12%) underwent serial echocardiography during decongestive therapy with simultaneous hemodynamic monitoring. LA function was assessed by strain (rate) imaging. Patients were re-evaluated 6 weeks after discharge and prospectively followed up for the composite endpoint of heart failure readmission and all-cause mortality.
RESULTS LA reservoir function was markedly reduced at baseline and improved with decongestion (peak atrial longitudinal strain from 6.4 2.2% to 8.8 3.0% and strain rate from 0.29 0.11 s–1 to 0.38 0.13 s–1), independent of changes in left ventricular global longitudinal strain, LA end-diastolic volume, and mitral regurgitation severity (p < 0.001). Both measures continued to rise at 6 weeks (up to 13.4 6.1% and 0.50 0.19 s–1, respectively; p < 0.001). LA pump strain rate only increased 6 weeks after discharge (–0.25 0.12 s–1 to –0.55 0.29 s–1 ; p < 0.010). Changes in LA mechanics correlated with changes in wedge pressure (r ¼ –0.61; p < 0.001). Lower peak atrial longitudinal strain values after decongestion were associated with increased risk for the composite endpoint of heart failure and mortality (p < 0.019).
CONCLUSIONS LA reservoir and booster function, while severely impaired during immediate decompensation, significantly improve during and after decongestive therapy. Poor LA reservoir function after decongestion is associated with worse outcome
The Detrimental Effect of RA Pacing on LA Function and Clinical Outcome in Cardiac Resynchronization Therapy
No full textOBJECTIVES This study assessed the impact of right-atrial (RA) pacing on left-atrial (LA) physiology and clinical outcome.
BACKGROUND Data for the effects of RA pacing on LA synchronicity, function, and structure after cardiac resynchronization therapy (CRT) are scarce.
METHODS The effect of RA pacing on LA function, morphology, and synchronicity was assessed in a prospective imaging cohort of heart failure (HF) patients in sinus rhythm with a guideline-based indication for CRT. Additionally, in a retrospective outcome cohort of consecutive HF patients undergoing CRT implantation, the relationship to RA pacing was assessed using various outcome endpoints. High versus low atrial pacing burden was defined as atrial pacing above or below 50% in both cohorts.
RESULTS A total of 36 patients were included in the imaging cohort (68 11 years of age). Six months after CRT, patients with high RA pacing burden showed less improvement in LA maximum and minimum volumes and total emptying fraction (p < 0.05). Peak atrial longitudinal strain and reservoir and booster strain rates but not conduit strain rate improved after CRT in patients with low RA pacing burden but worsened in patients with high RA pacing burden (p < 0.05 for all). A high RA pacing burden induced significant intra-atrial dyssynchrony (maximum opposing wall delay: 44 13 ms vs. 97 17 ms, respectively; p ¼ 0.022). A total of 569 patients were included in the outcome cohort. After covariate adjustments were made, a high RA pacing burden was associated with reduced LV reverse remodeling (b ¼ 8.738; 95% confidence interval [CI]: 3.101 to 14.374; p ¼ 0.002) and new-onset or recurrent atrial fibrillation (41% vs. 22%, respectively, at a median of 31 months [range 22 to 44 months follow-up]; p < 0.001). There were no differences in time to first HF hospitalization or all-cause mortality (p ¼ 0.185) after covariate adjustment. However, in a recurrent event analysis, HF readmissions were more common in patients exposed to a high RA pacing burden (p ¼ 0.003).
CONCLUSIONS RA pacing in CRT patients negatively influences LA morphology, function, and synchronicity, which is associated with worse clinical outcome, including diminished LV reverse remodeling, increased risk for new-onset or recurrent AF and heart failure readmission. Strategies reducing RA pacing burden may be warranted.Dr. Martens is supported by Research Foundation-Flanders doctoral fellowship grant 1127917N.
Dr. Martens, Deferm, and Mullens are researchers for the Limburg Clinical Research Program, supported by Limburg Sterk Merk, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital
Left Atrial Mechanics Assessed Early during Hospitalization for Cryptogenic Stroke Are Associated with Occult Atrial Fibrillation: A Speckle-Tracking Strain Echocardiography Study
No full textBackground: Occult atrial fibrillation (AF) is an important contributor to cryptogenic stroke, yet remains difficult to unmask at presentation. This study investigated the predictive value of left atrial (LA) mechanics by strain echocardiography during stroke hospitalization for the presence of AF as detected on early 30-day monitoring and routine clinical follow-up. Methods: Left atrial mechanics were studied by strain echocardiography in a retrospective cohort of 191 patients with cryptogenic stroke and 30-day mobile cardiac outpatient telemetry poststroke to diagnose AF. After this, AF was diagnosed via routine clinical follow-up. The independent and incremental value of measures of LA size and mechanics (i.e., strain and strain rate in the reservoir, conduit, and booster pump phase) to predict AF on top of clinical characteristics was assessed. Results: Of 191 patients, 15% (n = 28) developed AF, of which 10 were observed during 30-day mobile cardiac outpatient telemetry and 18 were observed at a median follow-up of 25 (interquartile range, 10-43) months. Median time from embolic stroke to strain echocardiography was 1 day (interquartile range, 1-2 days). Left atrial mechanics were significantly worse in AF (P<.05 for all), despite largely similar baseline cardiovascular risk profile. Booster pump strain rate was the strongest predictor for AF, independent of age, LA volume index, E/e', and reservoir strain (odds ratio = 2.88 per SD increase; 95% confidence interval, 1.29-6.41; P = .010). Adding LA strain reservoir strain and booster pump function significantly enhanced a multivariate model to predict AF. Freedom from AF was significantly lower in subjects with a booster pump strain rate (at stroke presentation) worse than -0.67 sec(-1), as derived from receiver operator curve analysis (P<.001). Conclusions: Left atrial mechanics and particularly the LA booster pump function assessed early during hospitalization for cryptogenic stroke can identify patients at greater likelihood of future diagnosis of AF. These findings could in part relate to LA mechanical stunning after spontaneous cardioversion, which-when identified by early strain echocardiography-can inform further risk stratification and decision-making.Sanborn, DMY (corresponding author), Harvard Med Sch, Massachusetts Gen Hosp, Dept Med, Div Cardiol, 55 Fruit St,Yawkey 5E-5062, Boston, MA 02114 USA.
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Mitral Valve Dysfunction in Patients With Annular Calcification
No full textMitral annular calcification (MAC) is a common clinical finding and is associated with adverse clinical outcomes, but the clinical impact of MAC-related mitral valve (MV) dysfunction remains underappreciated. Patients with MAC frequently have stenotic, regurgitant, or mixed valvular disease, and this valvular dysfunction is increasingly recognized to be independently associated with worse prognosis. MAC-related MV dysfunction is a distinct pathophysiologic entity, and importantly much of the diagnostic and therapeutic paradigm from published rheumatic MV disease research cannot be applied in this context, leaving important gaps in our knowledge. This review summarizes the current epidemiology, pathophysiology, diagnosis, and classification of MAC-related MV dysfunction and proposes both an integrative definition and an overarching approach to this important and increasingly recognized clinical condition. (J Am Coll Cardiol 2022;80:739-751) (C) 2022 by the American College of Cardiology Foundation.This study was supported in part by a grant from the Ellison Foundation and by National Institutes of Health grant R01 HL141917 (Drs Levine and Hung). The authors have reported that they have no relationships relevant to the contents of this paper to disclose
Arrythmia-Mediated Valvular Heart Disease
No full textThe aging population is rising at record pace worldwide. Along with it, a steep increase in the prevalence of atrial fibrillation and heart failure with preserved ejection fraction is to be expected. Similarly, both atrial functional mitral and tricuspid regurgitation (AFMR and AFTR) are increasingly observed in daily clinical practice. This article summarizes all current evidence regarding the epidemiology, prognosis, pathophysiology, and therapeutic options. Specific attention is addressed to discern AFMR and AFTR from their ventricular counterparts, given their different pathophysiology and therapeutic needs.ERASMUS
Sodium loading in ambulatory patients with heart failure with reduced ejection fraction: Mechanistic insights into sodium handling
No full textAims Sodium restriction was not associated with improved outcomes in heart failure patients in recent trials. The skin might act as a sodium buffer, potentially explaining tolerance to fluctuations in sodium intake without volume overload, but this is insufficiently understood. Therefore, we studied the handling of an increased sodium load in patients with heart failure with reduced ejection fraction (HFrEF).Methods and results Twenty-one ambulatory, stable HFrEF patients and 10 healthy controls underwent a 2-week run-in phase, followed by a 4-week period of daily 1.2 g (51 mmol) sodium intake increment. Clinical, echocardiographic, 24-h urine collection, and bioelectrical impedance data were collected every 2 weeks. Blood volume, skin sodium content, and skin glycosaminoglycan content were assessed before and after sodium loading. Sodium loading did not significantly affect weight, blood pressure, congestion score, N-terminal pro-brain natriuretic peptide, echocardiographic indices of congestion, or total body water in HFrEF (all p > 0.09). There was no change in total blood volume (4748 ml vs. 4885 ml; p = 0.327). Natriuresis increased from 150 mmol/24 h to 173 mmol/24 h (p = 0.024), while plasma renin decreased from 286 to 88 mu U/L (p = 0.002). There were no significant changes in skin sodium content, total glycosaminoglycan content, or sulfated glycosaminoglycan content (all p > 0.265). Healthy controls had no change in volume status, but a higher increase in natriuresis without any change in renin.Conclusions Selected HFrEF patients can tolerate sodium loading, with increased renal sodium excretion and decreased neurohormonal activation. [GRAPHICS]Jeroen Dauw, Evelyne Meekers, Sebastiaan Dhont and Wilfried Mullens are researchers for the Limburg Clinical Research Center (LCRC) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk (LSM), province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg, and Jessa Hospital
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