This thesis describes the additional value of advanced echocardiographic techniques in patients with primary cardiac disease, resulting in mitral regurgitation, and secondary cardiac disease caused... Show moreThis thesis describes the additional value of advanced echocardiographic techniques in patients with primary cardiac disease, resulting in mitral regurgitation, and secondary cardiac disease caused by a systemic disease. In this thesis we focussed on patients with mitral regurgitation, specifically primary MR and functional MR (FMR), and patients with Systemic Sclerosis (SSc). The general introduction provides a background of MR and cardiac involvement in SSc and how conventional 2-dimensional (2D) echocardiography is currently used. The potential role of 2D speckle tracking echocardiography and 3-dimensional (3D) echocardiography together with customized software to create 4-dimensional (4D) mitral valve models is introduced. This thesis aims to provide new insights in diagnosis, disease progression and risk stratification in patients with MR and patients with SSc with the implementation of advanced echocardiographic techniques. Show less
BackgroundSignificant (moderate or greater) mitral regurgitation (MR) could augment the hemodynamic effects of aortic valvular diseasein patients with bicuspid aortic valve (BAV), imposing a... Show moreBackgroundSignificant (moderate or greater) mitral regurgitation (MR) could augment the hemodynamic effects of aortic valvular diseasein patients with bicuspid aortic valve (BAV), imposing a greater hemodynamic burden on the left ventricle and atrium, possibly culminating in a faster onset of left ventricular dilation and/or symptoms. The aim of this study was to determine the prevalence and prognostic implications of significant MR in patients with BAV.MethodsIn this large, multicenter, international registry, a total of 2,932 patients (mean age, 48 ± 18 years; 71% men) with BAV were identified. All patients were evaluated for the presence of significant primary or secondary MR by transthoracic echocardiography and were followed up for the end points of all-cause mortality and event-free survival.ResultsOverall, 147 patients (5.0%) had significant primary (1.5%) or secondary (3.5%) MR. Significant MR was associated with all-cause mortality (hazard ratio [HR], 2.80; 95% CI, 1.91-4.11; P < .001) and reduced event-free survival (HR, 1.97; 95% CI, 1.58-2.46; P < .001) on univariable analysis. MR was not associated with all-cause mortality (adjusted HR, 1.33; 95% CI, 0.85-2.07; P = .21) or event-free survival (adjusted HR, 1.10; 95% CI, 0.85-1.42; P = .49) after multivariable adjustment. However, sensitivity analyses demonstrated that significant MR not due to aortic valve disease retained an independent association with mortality (adjusted HR, 1.81; 95% CI, 1.04-3.15; P = .037). Subgroup analyses demonstrated an independent association between significant MR and all-cause mortality for individuals with significant aortic regurgitation (HR, 2.037; 95% CI, 1.025-4.049; P = .042), although this association was not observed for subgroups with significant aortic stenosis or without significant aortic valve dysfunction.ConclusionsSignificant MR is uncommon in patients with BAV. Following adjustment for important confounding variables, significant MR was not associated with adverse prognosis in this large study of patients with BAV, except for the patient subgroup with moderate to severe aortic regurgitation. In addition, significant MR not due to aortic valve disease demonstrated an independent association with all-cause mortality. Show less
Assadi, H.; Grafton-Clarke, C.; Demirkiran, A.; Geest, R.J. van der; Nijveldt, R.; Flather, M.; ... ; Garg, P. 2022
Objectives: Mitral regurgitation (MR) and microvascular obstruction (MVO) are common complications of myocardial infarction (MI). This study aimed to investigate the association between MR in ST... Show moreObjectives: Mitral regurgitation (MR) and microvascular obstruction (MVO) are common complications of myocardial infarction (MI). This study aimed to investigate the association between MR in ST-elevation MI (STEMI) subjects with MVO post-reperfusion. STEMI subjects undergoing primary percutaneous intervention were enrolled. Cardiovascular magnetic resonance (CMR) imaging was performed within 48-hours of initial presentation. 4D flow images of CMR were analysed using a retrospective valve tracking technique to quantify MR volume, and late gadolinium enhancement images of CMR to assess MVO. Results: Among 69 patients in the study cohort, 41 had MVO (59%). Patients with MVO had lower left ventricular (LV) ejection fraction (EF) (42 +/- 10% vs. 52 +/- 8%, P < 0.01), higher end-systolic volume (98 +/- 49 ml vs. 73 +/- 28 ml, P < 0.001) and larger scar volume (26 +/- 19% vs. 11 +/- 9%, P < 0.001). Extent of MVO was associated with the degree of MR quantified by 4D flow (R = 0.54, P = 0.0003). In uni-variate regression analysis, investigating the association of CMR variables to the degree of acute MR, only the extent of MVO was associated (coefficient = 0.27, P = 0.001). The area under the curve for the presence of MVO was 0.66 (P = 0.01) for MR > 2.5 ml. We conclude that in patients with reperfused STEMI, the degree of acute MR is associated with the degree of MVO. Show less
Our understanding of the complexities of valvular heart disease (VHD) has evolved in recent years, primarily because of the increased use of multimodality imaging (MMI). Whilst echocardiography... Show moreOur understanding of the complexities of valvular heart disease (VHD) has evolved in recent years, primarily because of the increased use of multimodality imaging (MMI). Whilst echocardiography remains the primary imaging technique, the contemporary evaluation of patients with VHD requires comprehensive analysis of the mechanism of valvular dysfunction, accurate quantification of severity, and active exclusion extravalvular consequences. Furthermore, advances in surgical and percutaneous therapies have driven the need for meticulous multimodality imaging to aid in patient and procedural selection. Fundamental decision-making regarding whom, when, and how to treat patients with VHD has become more complex. There has been rapid technological advancement in MMI; many techniques are now available in routine clinical practice, and their integration into has the potential to truly individualize management strategies. This review provides an overview of the current evidence for the use of MMI in VHD, and how various techniques within each modality can be used practically to answer clinical conundrums. Show less
Functional mitral regurgitation (MR) – also referred to as secondary MR – is a disease condition which results from a combination of annular dilatation, papillary muscle displacement with increased... Show moreFunctional mitral regurgitation (MR) – also referred to as secondary MR – is a disease condition which results from a combination of annular dilatation, papillary muscle displacement with increased systolic leaflet tethering, and reduced closing forces, due to regional or global left ventricular (LV) remodelling.Functional MR is a common phenomenon and can be classified as either ischaemic or non-ischaemic, based on aetiology of LV remodelling. Regardless of aetiology, functional MR carries a poor prognosis.The primary step in the treatment of patients with functional MR consists of optimal medical and device therapy. In patients with persistence of MR despite optimal medical and device therapy, surgical treatment options can be considered. Over the past decades, many surgical treatment options have been developed, of which mitral valve repair by implantation of a restrictive mitral annuloplasty (RMA) ring forms the mainstay.In this thesis an integrated medico-surgical approach for patients with functional MR was examined, consisting of optimal medical and device therapy combined with RMA, and additional surgical interventions when indicated. The indication for each surgical intervention was determined after careful balancing of treatment options by the multidisciplinary Heart Team – consisting of heart failure specialists, interventional cardiologists, arrhythmia cardiologists and cardiac surgeons. Focus of this thesis was to determine (long-term) clinical and echocardiographic outcomes after this approach and to identify which patients are (un)likely to benefit from it. Show less
Tomsic, A.; Arabkhani, B.; Schoones, J.W.; Brakel, T.J. van; Takkenberg, J.J.M.; Palmen, M.; Klautz, R.J.M. 2018
In this thesis the surgical options for treatment of functional mitral regurgitation (MR) are described. In functional MR, the mitral valve has a normal anatomy, which distinguishes this type of... Show moreIn this thesis the surgical options for treatment of functional mitral regurgitation (MR) are described. In functional MR, the mitral valve has a normal anatomy, which distinguishes this type of insufficiency from organic MR. Regurgitation in functional MR is related to an abnormal geometry of the left ventricle, which can be the result of an infarction or ischaemia, or may be caused by another__intrinsic__disease of the myocardium. Based on aetiology, we can distinguish ischaemic and non-ischaemic functional MR. Patients with functional MR often present with signs and symptoms of heart failure. Current guidelines do not offer clear treatment algorithms for these patients, and an intervention on the mitral valve is often discouraged, mainly because of contradictory results from studies on surgical interventions on the valve. In this thesis, the role of surgery in the multidisciplinary treatment of patients with functional MR, typically associated with heart failure, is evaluated with regard to clinical and echocardiographic outcomes. The ultimate goal is to establish an individualised medico-surgical approach to this pathology. As such, this thesis results from close collaboration between the departments of Cardiothoracic Surgery and Cardiology of the Leiden University Medical Center. Show less
In recent years, a number of new cardiac interventional procedures have been introduced. Catheter ablation procedures for atrial fibrillation (AF) have been refined and are now considered a good... Show moreIn recent years, a number of new cardiac interventional procedures have been introduced. Catheter ablation procedures for atrial fibrillation (AF) have been refined and are now considered a good treatment option in patients with drug-refractory AF. In cardiac pacing, cardiac resynchronization therapy (CRT) is now standard of care for patients with drug-refractory heart failure. At the same time, CRT may also be beneficial in patients with heart failure after long-term right ventricular (RV) apical pacing. Finally, new percutaneous procedures for valvular heart disease have been introduced for patients that are deemed inoperable. At the same time, various imaging modalities have been further developed and important advances have been made in the integration of different imaging modalities. The aim of the present thesis was to explore the role of multimodality imaging in cardiac interventional procedures. In Part I, the integration of different imaging modalities during catheter ablation procedures for AF was studied. In addition, the effects of these procedures on left atrial and left ventricular (LV) size and function were investigated. Part II studied the effects of RV apical pacing on LV dyssynchrony and mechanics, and the effect of upgrade to CRT. Finally, in Part III the role of imaging in new percutaneous procedures for valvular heart disease was explored. Show less
