Intermittent symptomatic functional mitral regurgitation illustrated by two cases

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Abstract

Functional mitral regurgitation may have different haemodynamic consequences, clinical implications and treatment options, such as surgical or percutaneous interventions or implanting a pacemaker. Here we present two cases with haemodynamically significant intermittent functional mitral regurgitation as the underlying mechanism of heart failure. The cases underline the importance of a high index of suspicion in patients with intermittent heart failure, and a careful analysis of echocardiographic images with simultaneous ECG, in order to delineate systolic and diastolic mitral regurgitation.

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Mitral regurgitation.

Maurice Enriquez-Sarano, Cary W Akins, Alec Vahanian (2009)

Mitral regurgitation affects more than 2 million people in the USA. The main causes are classified as degenerative (with valve prolapse) and ischaemic (ie, due to consequences of coronary disease) in developed countries, or rheumatic (in developing countries). This disorder generally progresses insidiously, because the heart compensates for increasing regurgitant volume by left-atrial enlargement, causes left-ventricular overload and dysfunction, and yields poor outcome when it becomes severe. Doppler-echocardiographic methods can be used to quantify the severity of mitral regurgitation. Yearly mortality rates with medical treatment in patients aged 50 years or older are about 3% for moderate organic regurgitation and about 6% for severe organic regurgitation. Surgery is the only treatment proven to improve symptoms and prevent heart failure. Valve repair improves outcome compared with valve replacement and reduces mortality of patient with severe organic mitral regurgitation by about 70%. The best short-term and long-term results are obtained in asymptomatic patients operated on in advanced repair centres with low operative mortality ( /=80-90%). These results emphasise the importance of early detection and assessment of mitral regurgitation.

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Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure.

Andreas Franke, M Sinha, Christoph Stellbrink … (2003)

We studied the acute effects of cardiac resynchronization therapy (CRT) on functional mitral regurgitation in heart failure (HF) patients with left bundle branch block (LBBB). Both an decrease [corrected] in left ventricular (LV) closing force and mitral valve tethering have been implicated as mechanisms for functional mitral regurgitation (FMR) in dilated hearts. We hypothesized that an increase in LV closing force achieved by CRT could act to reduce FMR. Twenty-four HF patients with LBBB and FMR were studied after implantation of a biventricular CRT system. Acute changes in FMR severity between intrinsic conduction (OFF) and CRT were quantified according to the proximal isovelocity surface area method by measuring the effective regurgitant orifice area (EROA). Results were compared with the changes in estimated maximal rate of left ventricular systolic pressure rise (LV+dP/dt(max)) and transmitral pressure gradients (TMP), both measured by Doppler echocardiography. Cardiac resynchronization therapy was associated with a significant reduction in FMR severity. Effective regurgitant orifice area decreased from 25 +/- 19 mm(2) (OFF) to 13 +/- 8 mm(2) (CRT). The change in EROA was directly related to the increase in LV+dP/dt(max) (r = -0.83, p < 0.0001). Compared with OFF, TMP increased more rapidly during CRT, and a higher maximal TMP was observed (OFF 73 +/- 24 mm Hg vs. CRT 85 +/- 26 mm Hg, p < 0.01). Functional mitral regurgitation is reduced by CRT in patients with HF and LBBB. This effect is directly related to the increased closing force (LV+dP/dt(max)). The results support the hypothesis that an increase in TMP, mediated by a rise in LV+dP/dt(max) due to more coordinated LV contraction, may facilitate effective mitral valve closure.

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Role of regional mechanical dyssynchrony as a determinant of functional mitral regurgitation in patients with left ventricular systolic dysfunction.

M Pisani, E Agricola, M Galderisi … (2006)

To assess regional mechanical dyssynchrony as a determinant of the degree of functional mitral regurgitation (FMR). Tertiary cardiology clinic. 74 consecutive patients with left ventricular (LV) dysfunction (ejection fraction < 40%, mean 32.2 (SD 7.3)%) were evaluated. Effective regurgitant orifice (ERO) area, indices of mitral deformation (systolic valvular tenting, mitral annular contraction) and of global LV function and remodelling (ejection fraction, end systolic volume, sphericity index) and local remodelling (papillary-fibrosa distance, regional wall motion score index), and tissue Doppler-derived dyssynchrony index (DI) (regional DI, defined as the standard deviation of time to peak myocardial systolic contraction of eight LV segments supporting the papillary muscles attachment) were measured. All the assessed variables correlated significantly with ERO. By multivariate analysis, systolic valvular tenting was the strongest independent predictor of ERO (R(2) = 0.77, p = 0.0001), with a minor influence of papillary-fibrosa distance (R(2) = 0.77, p = 0.01) and regional DI (R(2) = 0.77, p = 0.03). Local LV remodelling (regional wall motion score index: R(2) = 0.58, p = 0.001; papillary-fibrosa distance: R(2) = 0.58, p = 0.002) and global remodelling indices (sphericity index: R(2) = 0.58, p = 0.003) were the main determinants of systolic valvular tenting, whereas regional DI did not enter into the model. Regional DI was an independent predictor of ERO (R(2) = 0.56, p = 0.005) in patients with non-ischaemic LV dysfunction but not in patients with ischaemic LV dysfunction when these groups were analysed separately. The degree of FMR is associated mainly with mitral deformation indices. The regional dyssynchrony also has an independent association with ERO but with a minor influence; however, it is not a determinant of FMR in patients with ischaemic LV dysfunction.

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Author and article information

Contributors

Alper Aydin

Tayfun Gurol

Ozer Soylu

Bahadir Dagdeviren

Journal

Journal ID (nlm-ta): Cardiovasc J Afr

Journal ID (iso-abbrev): Cardiovasc J Afr

Journal ID (publisher-id): TBC

Title: Cardiovascular Journal of Africa

Publisher: Clinics Cardive Publishing

ISSN (Print): 1995-1892

ISSN (Electronic): 1680-0745

Publication date (Print): Jul-Aug 2015

Volume: 26

Issue: 4

Pages: e12-e14

Affiliations

Department of Cardiology, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey

Article

DOI: 10.5830/CVJA-2015-026

PMC ID: 4683338

PubMed ID: 26407328

SO-VID: b665f5a7-6f9c-4b88-89ff-4575b0a38ac1

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Intermittent symptomatic functional mitral regurgitation illustrated by two cases

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Abstract

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Functional role of amyloid

Most cited references 13

Mitral regurgitation.

Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure.

Role of regional mechanical dyssynchrony as a determinant of functional mitral regurgitation in patients with left ventricular systolic dysfunction.

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