1 Functional Significance of Elevated Mitral Gradients Following Repair for Degenerative Mitral Regurgitation Chan et al: Mitral Stenosis After Mitral Valve Repair Kwan Leung Chan, MD, FRCPC*; Shin-Yee Chen, MD, FRCPC*; Vincent Chan, MD, FRCSC*; Karen Hay, RDCS*; Thierry Mesana, MD, FRCSC*; Buu Khanh Lam, MD, FRCSC* *University of Ottawa Heart Institute Correspondence to Kwan Leung Chan, MD FRCP University of Ottawa Heart Institute 40 Ruskin Street, H3412 Ottawa, ON K1Y 4W7 Tel: 613-761-4189 Fax: 613-761-4170 Email: [email protected]DOI: 10.1161/CIRCIMAGING.112.000688 Journal Subject Codes: Cardiovascular (CV) surgery:[38] CV surgery: valvular disease, Diagnostic testing:[125] Exercise testing, Diagnostic testing:[31] Echocardiography M a 3 W M M M M MD D D D D FR R R RC CP CP C C a H H Heart Ins sti i itu u ute e e e 341 41 41 41 412 2 2 2 2 W7 by guest on May 22, 2018 http://circimaging.ahajournals.org/ Downloaded from
27
Embed
Functional Significance of Elevated Mitral Gradients ...circimaging.ahajournals.org/content/circcvim/early/2013/09/06/CIRC...1 Functional Significance of Elevated Mitral Gradients
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Functional Significance of Elevated Mitral Gradients Following Repair for
Degenerative Mitral Regurgitation
Chan et al: Mitral Stenosis After Mitral Valve Repair
ete mmmmmmmitititititititrarararararar l l l l l ll ananananananannununununununullo
o
n e
o
ooooociciciciciated wwwwwititititith hhhh EMEMEMEMEMG.G.G.G.G. GrGrGrGrGrououououo p ppp 2 22 paatttienenenenentstststss hhhhhadadadadad lllararararargegegeger r r r leleleleleftftftftft atatattatriririririalalalalal vvvvvo
tttususus. TTThehehe stststudududy y y yy prprprpp otototocococololol wwwasasas rrrevevevieieieweweweww ddd ananand d d apapappprprprpp ovovovededed bbbyyy thththeee RRR
of 25 Watts maintained for two minutes, the workload was stepwisely increased by 25 Watts
every two minutes. This was a symptom-limited exercise test and the patients were encouraged
to exercise to exhaustion.
Mitral Valve Hemodynamics:
The MV hemodynamics were measured by Doppler at rest and peak exercise. The peak and
mean transmitral pressure gradients were calculated using the modified Bernoulli equation, and
the MV area was calculated by the continuity equation by dividing the left ventricular outflow
tract stroke volume by the integral of the diastolic mitral transvalvular velocity.16 The
pulmonary systolic pressure was calculated based on the tricuspid regurgitant velocity and the
estimated right atrial pressure.17 Severity of MR was assessed according to the published
guidelines.18
We studied 20 patients with no structural heart disease who were referred for echocardiograms.
None had > mild MR. They were matched for age (60.0 4.3 years) and sex (14 men and 6
women), and they also had similar resting heart rate (72.0±12.5 beats per minute) compared to
the study patients. The resting mitral mean diastolic gradient was 1.24 0.52 mm Hg (range 0.62
to 2.70 mm Hg). Thus, in the analysis of MV repair patients, a resting mitral diastolic gradient >
3 mm Hg was used to indicate the presence of EMG.
6-minute Walk Test:
The 6-minute walk test was performed on the same day as the exercise echocardiogram, after the
patients rested for at least one hour.13,14
lvular velocitytyyyyyy.......
d regggggggurururururururgigigigigigigitatatatatatatantntntntntntnt vvvvvvvee
l pl ppppprrrer ssurrrre.e.ee 17 SeSeSeSeSeveveveveveririririritytytytyty ooooof ff ff MRMRMRMRR was aaaaasssssssssesesesesessesesesesed d d d acacacacaccocc rdrdrdrdrdinininnng gggg tototototo ttttthehehehehe p
pulmonary artery systolic pressure remained higher in Group 2 patients at rest and at peak
exercise (P=0.02), and correlated with resting mean diastolic MV gradient (r=0.47, P<0.0001;
r=0.46, P<0.0001 respectively).
Functional Assessment
The bicycle exercise test showed that Group 2 patients had lower exercise capacity with shorter
exercise durations and lower Watts and METS (Table 5). However, there was no significant
difference between the two groups in the 6-minute walk distance which is a submaximal exercise
test.
Both the baseline and post exercise BNP levels were higher in Group 2 patients.
The SF36 questionnaire showed significant differences between the 2 groups in three of the eight
domains: Physical Functioning, Vitality and General Health (Table 5).
Maximum exercise capacity in Watts correlated with age (r=-0.51, P<0.0001), MV mean
diastolic gradient at rest (r=-0.23, P=0.015) and at peak exercise (r=-0.22, P=0.02), MV area
(r=0.48, P<0.001), pulmonary artery systolic pressure at rest (r=-0.48, P<0.0001) and at peak
exercise (r=-0.21, P=0.03), and BNP at rest (r=-0.54, P<0.0001) and post exercise (r=-0.45,
P<0.0001). There was also association between maximum exercise capacity with gender
(125 28 Watts in men and 68 40 Watts in women, P=<0.0001) and 2 of the SF36 component
scales which were Physical Functioning (r=0.58, P<0.0001) and Vitality (r=0.31, P=0.0001).
Using multivariable regression analysis, we identified young age (P<0.0001), male gender
d
a t
d d d dd pppop st exexexexeercrcrcrcrcisssssee eee BNBNBNBNBNPPPPP lelelelelevevevevev lsssss wwwwerreee hihihiihighghghghghererererer iiiiin n n n GrGrGrGrGrouuuuppppp 22222 papapapapatitititit enenenenentststststs.
mamamamamay be aaaa ssssseeeeequuuuuelelelelela a aa a fofofofofollllllllllowowowowowininng gggg MVMVMM repepepepepaiaiaiaiair.rrrr ThThThThe ee e e prppp esesesesesenenennnt t ttt stststststudududududy y yy y is
in our controls provided further evidence that mean diastolic mitral gradient > 3 mm Hg was
abnormal and indicative of MS.
Clinical Significance of EMG
The functional significance of EMG in these patients has not been well recognized.4,5,11 Before
MV repair, many patients may have poor exercise endurance due to occult or overt heart failure
as a result of severe MR. They would experience improvement in their symptoms following MV
repair which drastically reduce MR, and thus may not recognize mild persistent limitation due to
the presence of MS which is mild in most instances. Furthermore, some of the patients are
elderly or sedentary, such that a mild or even moderate degree of limitation to their exercise
endurance may not be recognized. Without comprehensive assessment, mild limitation due to
incomplete recovery would be difficult to recognize by the patient or the physician.
Despite only mild EMG consistent with mild MS in the majority of cases, there was functional
and physiologic impact on the patients. Patients with functional MS had larger left atrial
volumes, and MV area was an independent predictor of exercise capacity. The physiological
importance of EMG is further supported by the higher levels of BNP indicative of elevated
intracardiac pressures, and higher pulmonary artery systolic pressures both at rest and at peak
exercise, consistent with the presence of functional MS in these patients. The adverse impact of
functional MS was further evidenced by the reduced exercise capacity demonstrated by the
exercise bicycle test, which is a better test for maximum exercise capacity than the 6-minute
walk test.
e, some of the e papppppp
f limmmmmmmititititititatatatatatatatioioioioioioon n n n n n n tototototototo tthh
b mbeeeee rrrrecognininininizezezezezed.d.d.d.d. WWWWWittttthohohohohoututututu cccommmmmprppp ehehhennnnnsisisisisivevvvev aaaasssssss esesesesessmsmsmsmenenenenent,t,t,t,t, mmmmmililililild dd d d lililililim
wowooooululuulu d dddd bebebebebe dddddifififififfiffiff cucucucc ltltlttt ttttooo oo recccccogogogogognininininizezezezeze bbbbby yyyy thththththeeee e papapapapatititititienenenee t tt orrrrr ttttthehehehehe ppppphyhyhyhyhysisisss cccicc
eeercrcrcisisiseee teteteststst aaandndnd ppprororovivividededesss a a a usususefefefululul iiindndnddicicici atatatioioion n n ofofof fffunununctctctioioionananaffffff lll cacacapapapa
surgical technique such as the avoidance of a complete ring may decrease the incidence of EMG
following MV repair.
Sources of Funding
Supported in part by the University of Ottawa Heart Institute Academic Medical Organization
Innovation Fund.
Disclosures
None.
References
1. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enqriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368:1005-11. 2. Enriquez-Sarano M, Tajik AJ, Schaff HV, Orszulak TA, McGoon MD, Bailey KR, Frye RL. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: Results and clinical implications. J Am Coll Cardiol. 1994;24:1536-1543. 3. Carpentier A, Chauvand S, Fabiani JN, Deloche A, Relland J, Lessana A, D’Alliances C, Blondeau P, Piwnica A, Dubost C. Reconstructive surgery of mitral valve incompetence: ten year appraisal. J Thorac Cardiovasc Surg. 1980;79:338-348. 4. Braunberger E, Deloche A, Berrebi A, Abdallah F, Celestin JA, Meimoun P, Chatellier G, Chauvaund S, Fabiani JN, Carpentier A. Very long-term results (more than 20 years) of valve repair with Carpentier’s techniques in nonrheumatic mitral valve insufficiency. Circulation 2001;104 (12 Suppl 1):I8-11 5. Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, Lytle BW, Smedira NG, Sabik JF, McCarthy PM, Loop FD. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg. 1998 ;116:734-43. 6. Enriquez-Sarano M, Schaff H, Orszulak T, Tajik AJ, Bailey KR, Frye RL. Valve repair improves the outcome of surgery for mitral regurgitation. Circulation 1995;91:1264-1265. 7. David TE, Armstrong S, Sun Z, Daniel L. Late results of mitral valve repair for mitral regurgitation due to degenerative disease. Ann Thorac Surg. 1993;56:7-14. 8. Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg. 2007;31:267-75.
G zheart diseases: a population-based study Lancet 2006;368:1
9. Lawrie GM. Mitral valve repair vs replacement. Current recommendations and long-term results. Cardiol Clin. 1998 ;16:437-48. 10. Carpentier A. Cardiac valve surgery: the French correction. J Thorac Cardiovasc Surg. 1983;86:323-337. 11. David TE, Ivanov J, Armstrong S, Rakowski H. Late outcomes of mitral valve repair for floppy valves: Implications for asymptomatic patients. J Thorac Cardiovasc Surg. 2003;125:1143-52. 12. Mesana T, Ibrahim M, Hynes M. A technique for annular plication to facilitate sliding plasty after extensive mitral valve posterior leaflet resection. Ann Thorac Surg. 2005;79:720-2.
13. American Thoracic Society Statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166:111-117. 14. Cahalin LP, Mathier MA, Semigran MJ, Dec GW, DiSalvo TG. The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure. Chest. 1996;110:325-32. 15. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellika PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Soloman SD, Spencer KT, Sutton MS, Stewart WJ; Chamber Quantification Writing Group; American Society of Echocardiography’s Guidelines and Standards Committee; European Association of Echocardiograph. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440-63. 16. Quinones MA, Otto CM, Stoddard M,Waggoner A, ZoghbiWA. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr. 2002;15:167-84. 17. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. . Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713. 18. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ; American Society of Echocardiography. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777-802. 19. Beaton DE, Hogg-Johnson S, Bombardier C, Evaluating changes in health status: reliability and responsiveness of five generic health status measures in workers with musculoskeletal disorders. J Clin Epidemiol. 1997;50:79–93. 20. Van Rijk-Zwikker G. Delemarre B, Husmans H. Mitral valve anatomy and morphology: Relevance to mitral valve replacement and valve reconstruction. J Card Surg. 1994;9:255. 21. Malkowski MJ, Boudoulas H, Wooley CF, Guo R, Pearson AC, Gray PG. Spectrum of structural abnormalities in floppy mitral valve echocardiographic evaluation. Am Heart J. 1996;132:145-151.
hocardiographhhhhhyyyyyyy. ReReReReReReRecococococococommmmmmmmmmmmmmenenenenenenendadadadadadadatititititiitigrappppppphyhyhyhyhyhyhy’s’sssss GGGGGGGuiuiuiuiuiuiuidededededdd l
e and the Chamber Quantifi ation Writing Group, developeds oc
O dDl fAm Soc Echocardiogr 2002;15:167-84
e annnnnd d d dd thththhheeeee ChChChChChamber Quantificattttioioioioion nnn Writing gggg GrGrGrGrGrouoooo p, developedssososososociationn nn ofofoofof EEEEEchchchchchocococococararararardidididdiogogogogo raaaaaphpp yy, a bbbbbrararararancncncncnchh h hh ofofofff tttttheheheheh EEEEEurururururopopopopopeaeaeaeaean n n n n SoSSSScc EEEEEchocardidiiogggrrr. 200000 5;188:1444440-6663.
Ottooooo CCCCCM,MMMM SSSSStototottoddddddddddarararaa d MM,MMM WaWaWaWaWaggggggggggonononononerereree AAAAA, ZoZoZoZoZoghghghghghbibibibibiWAWAWAWAWA. ReReReReRecocococc mmmmmmmmmmenenenenendDoppler echohohohohocacacacacardrdrdrdrdioioioioiogrgrgrgrgrapapapapaphyhyhyhyhy::::: a aa aa rerer popopopoportrtrtrtr fffrororoom m mm m thththththeee DoDoDoDoDopppppp ler Quantlllatatatururureee anananddd StStStananandadadardrdrdsss CoCoCommmmmmitititteteteeee ofofof ttttthehehe AAAmememeririricacacannn SoSoSocicicietetetyyy ofofof AmAm SSocococ EcEcEchohhohh cacacardrddddioiogrgrgr 20202000202020202;1;1115:5:5:1616161 77-7 8484844
22. Gillonov AM, Blackstone EH, Nowicki ER, Slisatkorn W, Al-Dossari G, Johnston DR, George KM, Houghtaling PL, Griffin B, Sabik JF 3rd, Svensson LG. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg. 2008;135:885-93, 893. 23. Magne J, Senechal M, Mathieu P, Dumesnil JG, Dagenais F, Pibarot P. Restrictive annuloplasty for ischemic mitral regurgitation may induce function mitral stenosis. J Am Coll Cardiol. 2008;51:1692-701. 24. Williams ML, Daneshmand MA, Jollis JG Horton JR, Shaw LK, Swaminathan M, Davis RD, Glower DD, Smith PK, Milano CA. Mitral gradients and frequency of recurrence of mitral regurgitation after ring annuloplasty for ischemic mitral regurgitation. Ann Thorac Surg. 2009;88:1197-201. 25. Kubota K, Otsuji Y, Ueno T, Koriyama C, Levine RA, Sakata R, Tei C.. Functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitaton : importance of subvalvular tethering in the mechanism and dynamic deterioration during exertion. J Thorac Cardiovasc Surg. 2010;140:617-623. 26. Kainuma S, Taniguchi K, Daimon T, Sakaguchi T, Funatsu T, Kondoh H, Miyagawa S, Takeda K, Shudo Y, Masai T, Fujita S, Nishino M, Sawa Y; Osaka Cardiovascular Surgery Research (OSCAR) Group. Does stringent restrictive annuloplasty for functional mitral regurgitation cause functional mitral stenosis and pulmonary hypertension? Circulation. 2011;124 (suppl1):S97-106. 27. Tanaka K, Makuuchi H, Naruse Y, Kobayashi T, Hayashi I, Takayama T, Namifusa Y. Mitral stenosis due to fibrous tissue overgrowth after mitral valve repair. J Cardiovasc Surg. (Torino). 2003;44:59-60. 28. Nishida H, Takahara Y, Takeuchi S, Mogi K. Mitral stenosis after mitral valve repair using the duran flexible annuloplasty ring for degenerative mitral regurgitation. J Heart Valve Dis. 2005;14:563-4. 29. Ibrahim MF, David TE. Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation. Ann Thorac Surg. 2002 ;73:34-6. 30. Okada Y, Shomura T, Yamaura Y, Yoshikawa J. Comparison of the Carpentier and Duran prosthetic rings used in mitral reconstruction. Ann Thorac Surg. 1995;59:658-62. 31. Garcia D, Kadem L. What do you mean by aortic valve area: geometric orifice area, effective orifice area, or Gorlin area? J Heart Valve Dis. 2006;15:601-8. 32. Hung J, Lang R, Flachskampf F, Shernan SK, McCulloch ML, Adams DB, Thomas J, Vannan M, Ryan T; ASE. 3D echocardiography: a review of the current status and future directions. J Am Soc Echocardiogr. 2007;20:213-233. 33. Verma S, Mesana TG. Mitral-valve repair for mitral valve prolapse. N Engl J Med. 2009;361:2261-9.
ka Cardiovasculululuuluu attttttty yyyyyy fofofofofofoforr r r rr r fufufufufufufuncncncncncncnctititititititionononononononalalalalalalalertennnnnnnsisisisisisiionononononono ??????? CCCCCCCiriririririrircuc
is online at: Circulation: Cardiovascular Imaging Information about subscribing to Subscriptions:
http://www.lww.com/reprints Information about reprints can be found online at: Reprints:
document. Permissions and Rights Question and Answer this process is available in the
located, click Request Permissions in the middle column of the Web page under Services. Further information aboutnot the Editorial Office. Once the online version of the published article for which permission is being requested is
can be obtained via RightsLink, a service of the Copyright Clearance Center,Circulation: Cardiovascular Imaging Requests for permissions to reproduce figures, tables, or portions of articles originally published inPermissions: