Marc Gillinov

Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation: real-time three-dimensional echocardiography study

Background—This study was conducted to elucidate the geometric differences of the mitral apparatus in patients with significant mitral regurgitation caused by ischemic cardiomyopathy (ICM-MR) and by idiopathic dilated cardiomyopathy (DCM-MR) by use of real-time 3D echocardiography (RT3DE). Methods and Results—Twenty-six patients with ICM-MR caused by posterior infarction, 18 patients with DCM-MR, and 8 control subjects were studied. With the 3D software, commissure-commissure plane and 3 perpendicular anteroposterior (AP) planes were generated for imaging the medial, central, and lateral sides of the mitral valve (MV) during mid systole. In 3 AP planes, the angles between the annular plane and each leaflet (anterior, A&agr;; posterior, P&agr;) were measured. In ICM-MR, A&agr; measured in the medial and central planes was significantly larger than that in the lateral plane (39±5°, 34±6°, and 27±5°, respectively;P <0.01), whereas P&agr; showed no significant difference in any of the 3 AP planes (61±7°, 57±7°, and 56±7°, P >0.05). In DCM-MR, both A&agr; (38±8°, 37±9°, and 36±7°, P >0.05) and P&agr; (59±6°, 58±5°, and 57±6°, P >0.05) revealed no significant differences in the 3 planes. Conclusions—The pattern of MV deformation from the medial to the lateral side was asymmetrical in ICM-MR, whereas it was symmetrical in DCM-MR. RT3DE is a helpful tool for differentiating the geometry of the mitral apparatus between these 2 different types of functional mitral regurgitation.

Incidence of atrial fibrillation post-cavotricuspid isthmus ablation in patients with typical atrial flutter: left-atrial size as an independent predictor of atrial fibrillation recurrence.

Introduction: Atrial fibrillation and atrial flutter often coexist. The long‐term occurrence of atrial fibrillation in patients presenting with atrial flutter alone is unknown. We report the long‐term follow‐up in patients who underwent cavotricuspid isthmus ablation for treatment of lone atrial flutter.

Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation

OBJECTIVES The Cardiothoracic Surgical Trials Network recently reported no difference in the primary end point of left ventricular end-systolic volume index at 1 year postsurgery in patients randomized to repair (n = 126) or replacement (n = 125) for severe ischemic mitral regurgitation. However, patients undergoing repair experienced significantly more recurrent mitral regurgitation than patients undergoing replacement (32.6% vs 2.3%). We examined whether baseline echocardiographic and clinical characteristics could identify those who will develop moderate/severe recurrent mitral regurgitation or die. METHODS Our analysis includes 116 patients who were randomized to and received mitral valve repair. Logistic regression was used to estimate a model-based probability of recurrence or death from baseline factors. Receiver operating characteristic curves were constructed from these estimated probabilities to determine classification cut-points maximizing accuracy of prediction based on sensitivity and specificity. RESULTS Of the 116 patients, 6 received a replacement before leaving the operating room; all other patients had mild or less mitral regurgitation on intraoperative echocardiogram after repair. During the 2-year follow-up period, 76 patients developed moderate/severe mitral regurgitation or died (53 mitral regurgitation recurrences, 13 mitral regurgitation recurrences and death, and 10 deaths). The mechanism for recurrent mitral regurgitation was largely mitral valve leaflet tethering. Our model (including age, body mass index, sex, race, effective regurgitant orifice area, basal aneurysm/dyskinesis, New York Heart Association class, history of coronary artery bypass grafting, percutaneous coronary intervention, or ventricular arrhythmias) yielded an area under the receiver operating characteristic curve of 0.82. CONCLUSIONS The model demonstrated good discrimination in identifying patients who will survive 2 years without recurrent mitral regurgitation after mitral valve repair. Although our results require validation, they offer a clinically relevant risk score for selection of surgical candidates for this procedure.

Prevalence and outcomes of unoperated patients with severe symptomatic mitral regurgitation and heart failure: comprehensive analysis to determine the potential role of MitraClip for this unmet need.

To the Editor: Mitral valve (MV) surgery is recommended in patients with severe symptomatic mitral regurgitation (MR) [(1)][1]. The role of MV surgery is unclear in patients with severe MR secondary to left ventricular (LV) dysfunction [(1)][1]. Many patients with severe MR are at high surgical

Accuracy of Wrist-Worn Heart Rate Monitors

Accuracy of Wrist-Worn Heart Rate Monitors Wrist-worn fitness and heart rate (HR) monitors are popular.1,2 While the accuracy of chest strap, electrode-based HR monitors has been confirmed,3,4 the accuracy of wrist-worn, optically based HR monitors is uncertain.5,6 Assessment of the monitors’ accuracy is important for individuals who use them to guide their physical activity and for physicians to whom these individuals report HR readings. The objective of this study was to assess the accuracy of 4 popular wrist-worn HR monitors under conditions of varying physical exertion.

Importance of ischemic and viable myocardium for patients with chronic ischemic mitral regurgitation and left ventricular dysfunction

The objective of this investigation is to determine the importance of ischemic viable myocardium for clinical outcomes in patients with severe chronic ischemic mitral regurgitation and severe left ventricular dysfunction undergoing surgical correction of mitral regurgitation. The study included 54 patients with left ventricular ejection fraction of 27 +/- 9%. Positron emission tomography was performed preoperatively for the identification of ischemic viable myocardium. The patients with a large amount of ischemic viable myocardium (> or =5 segments) had significantly lower 6-month mortality rates than those with less viable myocardium (0 to 4 segments) after the surgery.

Expert consensus guidelines: Examining surgical ablation for atrial fibrillation

From the Department of Cardiovascular and Thoracic Surgery, and WVU Heart and Vascular Institute, West Virginia University Morgantown, WVa; Washington Adventist Hospital, Adventist HealthCare, Takoma Park, Md; Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, Mo; Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Cardiothoracic Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands; Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan; Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany; Center for the Study of Chronic Illness and Disability, George Mason University, Fairfax, Va; and Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio. Received for publication Dec 21, 2016; revisions received Jan 27, 2017; accepted for publication Feb 1, 2017; available ahead of print April 5, 2017. Address for reprints: Niv Ad, MD, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, 1 Medical Center Drive, Morgantown, WV 26506 (E-mail: nivadmd14@gmail.com). J Thorac Cardiovasc Surg 2017;153:1330-54 0022-5223/

Association between obesity and postoperative atrial fibrillation in patients undergoing cardiac operations: A systematic review and meta-analysis

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.02.027 Forest plot: Improved perioperative survival (<30 days) with concomitant surgical ablation.

Early left and right ventricular response to aortic valve replacement

In a systematic review and random-effects meta-analysis, we evaluated whether obesity is associated with postoperative atrial fibrillation (POAF) in patients undergoing cardiac operations. We selected 18 observational studies until December 2011 that excluded patients with preoperative AF (n=36,147). Obese patients had a modest higher risk of POAF compared with nonobese (odds ratio, 1.12; 95% confidence interval, 1.04 to 1.21; p=0.002). The association between obesity and POAF did not vary substantially by type of cardiac operation, study design, or year of publication. POAF was significantly associated with a higher risk of stroke, respiratory failure, and operative death.

Hyperinsulinemic Normoglycemia Does Not Meaningfully Improve Myocardial Performance during Cardiac Surgery: A Randomized Trial.

BACKGROUND: The immediate effect of aortic valve replacement (AVR) for aortic stenosis on perioperative myocardial function is unclear. Left ventricular (LV) function may be impaired by cardioplegia-induced myocardial arrest and ischemia-reperfusion injury, especially in patients with LV hypertrophy. Alternatively, LV function may improve when afterload is reduced after AVR. The right ventricle (RV), however, experiences cardioplegic arrest without benefiting from improved loading conditions. Which of these effects on myocardial function dominate in patients undergoing AVR for aortic stenosis has not been thoroughly explored. Our primary objective is thus to characterize the effect of intraoperative events on LV function during AVR using echocardiographic measures of myocardial deformation. Second, we evaluated RV function. METHODS: In this supplementary analysis of 100 patients enrolled in a clinical trial (NCT01187329), 97 patients underwent AVR for aortic stenosis. Of these patients, 95 had a standardized intraoperative transesophageal echocardiographic examination of systolic and diastolic function performed before surgical incision and repeated after chest closure. Echocardiographic images were analyzed off-line for global longitudinal myocardial strain and strain rate using 2D speckle-tracking echocardiography. Myocardial deformation assessed at the beginning of surgery was compared with the end of surgery using paired t tests corrected for multiple comparisons. RESULTS: LV volumes and arterial blood pressure decreased, and heart rate increased at the end of surgery. Echocardiographic images were acceptable for analysis in 72 patients for LV strain, 67 for LV strain rate, and 54 for RV strain and strain rate. In 72 patients with LV strain images, 9 patients required epinephrine, 22 required norepinephrine, and 2 required both at the end of surgery. LV strain did not change at the end of surgery compared with the beginning of surgery (difference: 0.7 [97.6% confidence interval, −0.2 to 1.5]%; P = 0.07), whereas LV systolic strain rate improved (became more negative) (−0.3 [−0.4 to −0.2] s−1; P < 0.001). In contrast, RV systolic strain worsened (became less negative) at the end of surgery (difference: 4.6 [3.1 to 6.0]%; P < 0.001) although RV systolic strain rate was unchanged (0.0 [97.6% confidence interval, −0.1 to 0.1]; P = 0.83). CONCLUSIONS: LV function improved after replacement of a stenotic aortic valve demonstrated by improved longitudinal strain rate. In contrast, RV function, assessed by longitudinal strain, was reduced.