cardiovascular-agents and Mitral-Valve-Insufficiency

Acute mitral regurgitation (AMR) is a medical emergency which may lead to rapid clinical deterioration and is associated with high morbidity and mortality. The severity of the clinical presentation varies according to several factors, ranging from cardiogenic shock to a milder presentation. The medical management of AMR includes intravenous diuretics, vasodilators, inotropic support, and potentially mechanical support to stabilise patients. Patients persisting with refractory symptoms despite optimal medical therapy are considered for surgical intervention, but high-risk patients deemed to be inoperable frequently experience poor outcomes. This review highlights the variety of clinical presentations of AMR and the pitfalls in diagnosis and management. The emerging role of transcatheter edge-to-edge repair (TEER), particularly in high-risk patients early after myocardial infarction requiring urgent intervention, has demonstrated feasibility and promising efficacy. TEER is well tolerated and improves hemodynamic parameters in AMR. In a recent analysis, the in-hospital and 1-year mortality rates were significantly higher with surgical mitral interventions compared with TEER. The global TEER experience for treating AMR is encouraging, with reports indicating improved clinical outcomes in high-risk patients and its potential as a bridge to recovery. Early recognition of AMR, validated criteria for patient selection, optimal timing of the intervention as well as long-term outcomes and additional prospective data should be addressed in future studies.

Topics: Acute Disease; Cardiovascular Agents; Clinical Deterioration; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Prospective Studies; Treatment Outcome

Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR.. A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles.. A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009).. MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hospital Mortality; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Myocardial Ischemia; Patient Readmission; Postoperative Complications; Prosthesis Design; Recovery of Function; Reoperation; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

The benefit of percutaneous mitral valve repair (PMVR) in patients with secondary MR is still debated. We aimed to compare the outcome of PMVR with optimal medical therapy (OMT) versus OMT alone in patients with secondary mitral regurgitation (MR) and to assess the role of potential effect modifiers.. We performed a systematic review and meta-analysis of 2 randomized clinical trials (RCT) and 7 non-randomized observational studies (nROS). Hazard ratios (HR) and 95% confidence intervals (CI) were pooled through inverse variance random-effects model to compute the summary effect size for all-cause death, cardiovascular death and cardiac-related hospitalization. Subgroup and meta-regression analysis were also performed.. An overall population of 3118 individuals (67% men; mean age, 73 years) was included: 1775 PMVR+OMT and 1343 OMT patients, with mean follow-up of 24 ± 15 months. PMVR+OMT was associated with a lower risk of all-cause death (HR: 0.77; 95% CI: 0.68-0.87), cardiovascular death (HR: 0.55; 95% CI: 0.34-0.89) and cardiac-related hospitalization (HR:0.77; 95% CI: 0.64-0.92). Meta-regression analysis showed that larger left ventricular end-diastolic volume index (LVEDVI) portends higher risk of all-cause death, cardiovascular death and cardiac-related hospitalization after PMVR (p < 0.001 for all).. This study-level meta-analysis shows that PMVR+OMT is associated with reduced all-cause death, cardiovascular death and cardiac-related hospitalization when compared with OMT alone in secondary MR. LVEDVI is a predictive marker of efficacy, as patients with smaller LVEDVI have been shown to derive the largest benefit from PMVR.

Topics: Aged; Cardiac Catheterization; Cardiac Surgical Procedures; Cardiovascular Agents; Female; Heart Ventricles; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Observational Studies as Topic; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Ventricular Function, Left

Mitral regurgitation (MR) in heart failure (HF) notoriously carries a poor prognosis. While there are multiple interventional options for treatment, the optimal intervention remains controversial. Therefore, we aimed to evaluate the efficacy and safety of surgery, medical therapy, and transcatheter intervention in secondary MR.. A systematic database search was performed to identify all randomized controlled trials (RCTs) that evaluate various interventions for secondary MR. We performed a Bayesian network meta-analysis to calculate odd ratios (ORs) and 95% credible intervals (CIs). The primary endpoint was all-cause mortality. Secondary endpoints were moderate-severe MR, HF-hospitalizations, and freedom from severe HF symptoms.. We identified 12 RCTs (2316 total patients; age 67.6 ± 11; 63% males, and 74% with ischemic cardiomyopathy). There was a significant reduction of mortality at 24-months with transcatheter leaflet repair compared with medical therapy (OR = 0.57; 95% CI = 0.34-0.96). However, there were no significant differences among the competing treatments in all-cause mortality at the earlier time points of 30-days or 12-months (P > 0.05). Recurrent moderate-severe MR was significantly less with valvular interventions compared with medical therapy (P < 0.05), but there were no differences in the rates of HF-hospitalizations or persistent severe HF symptoms between the competing interventions (P > 0.05).. Among patients with HF and secondary MR, transcatheter leaflet repair was associated with significantly reduced 24-month mortality compared with medical therapy. Valvular interventions were associated with lower rates of recurrent moderate-severe MR, but non-significant improvements in clinical outcomes. Further long-term studies are needed to identify the best route of intervention for secondary MR.

Topics: Aged; Bayes Theorem; Cardiac Catheterization; Cardiovascular Agents; Cause of Death; Female; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Network Meta-Analysis; Randomized Controlled Trials as Topic; Recovery of Function; Recurrence; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

Functional mitral regurgitation (FMR) is a common finding among patients with heart failure (HF) and it is related to adverse events. Outcomes in patients undergoing transcatheter mitral valve repair (TMVR) are still a matter of debate. We performed a meta-analysis to assess mid- and long-term outcomes of patients with FMR treated with MitraClip® compared to medical management.. We conducted an electronic database search of all published data PubMed Central, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases. The primary end-point was all-cause mortality. The secondary end-points were hospitalizations for HF, need for heart transplantation or left ventricular assist device, unplanned mitral valve surgery, myocardial infarction and stroke.. Five studies (n = 1513 patients) were included in the analysis. The summary estimate including all the available studies showed a statistically significant reduction in all-cause mortality favoring MitraClip® (HR 0.56, CI 95% [0.38-0.84]) and HF hospitalizations (HR 0.65; CI 95% [0.46-0.92]). A significant reduction in the indication for advanced HF therapies (OR 0.48; CI 95% [0.25-0.90]) or the need for unplanned mitral valve surgery (OR 0.20; CI 95% [0.07-0.57]) was also found in the group of patients that underwent TMVR. No differences in the incidence of myocardial infarction or stroke were found between both groups of treatment. No publication bias was detected.. TMVR with MitraClip® system was related to a significant reduction in all-cause mortality, hospitalizations for HF and the need for HF transplant, left ventricular assist device or unplanned surgery beyond 1-year follow up.

Topics: Aged; Aged, 80 and over; Cardiac Catheterization; Cardiovascular Agents; Cause of Death; Female; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Prosthesis Design; Recovery of Function; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

To compare percutaneous mitral valve repair (PMVR) with optimal medical therapy (OMT) in patients with heart failure (HF) and severe functional mitral regurgitation (FMR).. Many patients with HF and FMR are not suitable for surgical valve replacement and remain symptomatic despite maximal OMT. PMVR has recently emerged as an alternative solution.. We performed a systematic review and a meta-analysis to address this question. Cochrane CENTRAL, MEDLINE, and Scopus were searched for randomized (RCT) and nonrandomized studies comparing PMVR with OMT in patients with HF and FMR. Primary endpoint was all-cause midterm mortality (at 1 and 2 years). Secondary endpoints were 30-day mortality and cardiovascular mortality and HF hospitalizations, at maximum follow-up. Studies including mixed cohort of degenerative and functional MR were allowed initially but were excluded in a secondary sensitivity analysis for each of the study's end points. This meta-analysis was performed following the publication of two RCTs (MITRA-FR and COAPT).. In comparison with OMT, PMVR significantly reduces 1-year mortality, 2-year mortality, and cardiovascular mortality in patients with HF and severe MR.

Topics: Cardiovascular Agents; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency

Topics: Cardiac Catheterization; Cardiovascular Agents; Clinical Decision-Making; Echocardiography; Heart Valve Prosthesis Implantation; Heart Ventricles; Humans; Mitral Valve; Mitral Valve Insufficiency; Predictive Value of Tests; Randomized Controlled Trials as Topic; Risk Factors; Severity of Illness Index; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left

Topics: Cardiac Catheterization; Cardiac Imaging Techniques; Cardiovascular Agents; Endovascular Procedures; Forecasting; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Patient Care Team; Patient Outcome Assessment; Risk Assessment

Percutaneous treatment of mitral regurgitation (MR) is a promising alternative for patients with functional MR (FMR) who are not appropriate for surgery and are not responding to optimal medical therapy and cardiac resynchronization therapy. Unlike degenerative MR, where repair therapy is clearly preferred, the optimal approach for FMR has not been defined. Challenges for novel mitral repair devices are to demonstrate safety and superior efficacy to medical management in higher risk patients. Transcatheter mitral valve replacement is emerging as a feasible therapy, but requires significant additional clinical trials to define its place in treating heart failure related to MR.

Topics: Cardiac Catheterization; Cardiac Resynchronization Therapy; Cardiovascular Agents; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Patient Selection; Risk Adjustment

Topics: Antihypertensive Agents; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Catheterization; Cardiology; Cardiovascular Agents; Disease Management; Echocardiography; Evidence-Based Medicine; Exercise Test; Heart Defects, Congenital; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Mitral Valve Insufficiency; Mitral Valve Stenosis; Patient Care Team; Pharyngitis; Referral and Consultation; Rheumatic Fever; Secondary Prevention; Severity of Illness Index; Streptococcal Infections; United States; Vasodilator Agents; Ventricular Dysfunction, Left

Topics: Cardiac Resynchronization Therapy; Cardiovascular Agents; Combined Modality Therapy; Echocardiography, Transesophageal; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency; Percutaneous Coronary Intervention; Postoperative Complications; Practice Guidelines as Topic; Prognosis; Risk Factors; Surgical Instruments; Survival Rate; Ventricular Dysfunction, Left

Myxomatous mitral valve disease (MMVD) causing mitral regurgitation is the most important disease of the heart in small animal cardiovascular medicine. Because MMVD is an example of a chronic disease that progresses from mild to severe over years, treatment strategies change with the stage of the disease. In this review the treatment options are compared and contrasted as they are discussed relative to the recently published ACVIM consensus statement regarding the treatment of MMVD. Results from clinical trials and evidence-based medicine are likely to provide significant improvements in the management of MMVD in the coming decades.

Topics: Animals; Cardiovascular Agents; Dog Diseases; Dogs; Mitral Valve Insufficiency

Despite significant improvements in pharmacological therapy heart failure is still one of the leading causes for death in the Western World. The gold standard treatment of end-stage heart failure remains cardiac transplantation, but there is a great excess of eligible candidates compared with the low number of suitable donor organs. The variety of surgical organ preserving treatment strategies has significantly increased during the last 20 years, intenting either to delay or even to prevent the need for cardiac transplantation. An individually tailored surgical concept should be considered as an alternative in any heart failure patient who has reached the limits of pharmacologic therapy. This article gives an overview about current and potential future therapeutic options in end-stage heart failure.

Topics: Cardiomyopathy, Dilated; Cardiomyoplasty; Cardiovascular Agents; Combined Modality Therapy; Heart Failure; Heart Transplantation; Heart Ventricles; Heart-Assist Devices; Humans; Mitral Valve; Mitral Valve Insufficiency; Myocardial Ischemia; Myocardial Revascularization

Topics: Cardiac Catheterization; Cardiac Resynchronization Therapy; Cardiovascular Agents; Echocardiography; Echocardiography, Three-Dimensional; Exercise Test; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency; Ventricular Dysfunction, Left

Mitral regurgitation (MR) is increasingly prevalent and poses an important public health problem. There are several mechanisms through which MR can occur. Primary (organic) MR is due to intrinsic valvular disease, whereas secondary (functional) MR is due to disruption of an otherwise normal mitral apparatus because of abnormal ventricular geometry. Identification of the causative mechanism is important as this will dictate management strategy and may influence subsequent outcome. Careful assessment of MR severity is important with the use of quantitative measures. There is currently no effective medical treatment for chronic MR. Careful follow-up is paramount in the management of MR to accomplish timely surgical intervention. Mitral valve repair is preferable to valve replacement. In chronic primary MR, conventional timing of surgery is based upon appearance of symptoms and hemodynamic consequences of chronic volume overload. Optimal timing of surgery for asymptomatic patients with chronic severe MR remains controversial although there is an increasing trend toward earlier surgery. In recent years there have been significant advances in percutaneous valve interventions for MR. Although initial results are promising, longer term evaluation will answer questions concerning efficacy, durability, and safety of these interventions.

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Diagnostic Techniques, Cardiovascular; Disease Progression; Hemodynamics; Humans; Mitral Valve; Mitral Valve Insufficiency; Risk Factors; Severity of Illness Index; Time Factors; Treatment Outcome; Ventricular Function

The edge-to-edge mitral valve repair, first described by Alfieri in 1995 treats mitral regurgitation when standard reparative techniques are difficult, unlikely to succeed, or have failed. This study examines one institution's medium-term experience with this procedure.. This study involved patients undergoing edge-to-edge mitral valve repair at a single institution from 1997 to 2003. Preoperative and postoperative echocardiograms were compared. Postoperative morbidity was examined including need for reoperation and long-term medical management. Thirty-day survival and long-term actuarial survival were also determined.. Seventy-one patients comprised this study. Mitral regurgitation on echocardiogram went from 3.43 +/- 0.86 to 0.39 +/- 0.61 (p < 0.001) following repair. Thirty-day mortality was 3 of 71 (4.2%) patients. Actuarial survivals at 24 and 60 months were 84.5% and 58.3%, respectively; adjusted excluding noncardiac death they were 89.5% and 82.3%, respectively. Forty (56.3%) patients had concomitant ring placement and experienced similar survival to those repaired with the bow-tie stitch alone. Home telephone follow-up was conducted, and current medical therapy was determined on 51 patients; 59% were on a beta-blocker, 31% were on an angiotensin-converting enzyme (ACE) inhibitor, 27% were on a diuretic, and 22% were on digoxin. All were New York Heart Association (NYHA) class I or II. Three patients (4.2%) underwent mitral valve reoperation after a mean of 299 +/- 429 days. In no case did the bow-tie suture rupture.. Edge-to-edge mitral valve repair is a valuable tool in the armamentarium available to treat complex cases of mitral insufficiency or as an adjunct to standard repair techniques that fail to achieve an acceptable result.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiac Surgical Procedures; Cardiovascular Agents; Coronary Artery Bypass; Female; Follow-Up Studies; Heart Atria; Heart Septal Defects, Atrial; Heart Septal Defects, Ventricular; Humans; Life Tables; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; New York City; Postoperative Complications; Reoperation; Retrospective Studies; Survival Analysis; Treatment Outcome

Topics: Aortic Valve Insufficiency; Aortic Valve Stenosis; Calcinosis; Cardiovascular Agents; Heart Valve Diseases; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Risk Factors

Topics: Adolescent; Cardiovascular Agents; Heart Function Tests; Heart Injuries; Hemodynamics; Humans; Male; Mitral Valve Insufficiency; Thoracic Injuries; Wounds, Nonpenetrating

There is no proven medical therapy that attenuates adverse left ventricular remodeling in patients with chronic primary mitral regurgitation (CPMR). Identification of molecular pathways important in the progression of left ventricular remodeling in patients with CPMR may lead to development of new therapeutic strategies.. We performed baseline echocardiographic, cardiac catheterization, and serum NT-pro-BNP analysis in patients with severe CPMR awaiting mitral valve surgery and stratified the study population into compensated or decompensated CPMR. We obtained left ventricular endomyocardial biopsies (n=12) for mRNA expression analysis, and compared baseline transcript levels of 109 genes important in volume-overload left ventricular remodeling with levels in normal hearts (n=5) and between patients with compensated (n=6) versus decompensated (n=6) CPMR. Patients were then randomized to treatment with and without carvedilol and followed until the time of surgery (mean follow-up 8.3 months) when repeat endomyocardial biopsies were obtained to correlate transcriptional dynamics with indices of adverse remodeling. CPMR was associated with increased. Transition to decompensated CPMR is associated with calcium dysregulation, increased expression of inflammatory, extracellular matrix and apoptotic genes, and downregulation of genes important in bioenergetics. These changes are not attenuated by carvedilol therapy and highlight the need for development of specific combinatorial therapies, targeting myocardial inflammation and apoptosis, together with urgent surgical or percutaneous valve interventions.

Topics: Adult; Cardiovascular Agents; Carvedilol; Chronic Disease; Gene Expression Profiling; Humans; Middle Aged; Mitral Valve Insufficiency; Ventricular Dysfunction, Left; Ventricular Function, Left; Ventricular Remodeling; Young Adult

Percutaneous mitral valve repair (PMVR) using the MitraClip System is feasible and entails clinical improvement even in patients with high surgical risk and severe functional mitral regurgitation (MR). The aim of this study was to assess survival rates and clinical outcome of patients with severe, functional MR treated with optimal medical therapy (OMT) compared with those who received MitraClip device. Sixty patients treated with OMT were compared with a propensity-matched cohort of 60 patients who underwent PMVR. Baseline demographics and echocardiographic variables were similar between the 2 groups. The mean age of patients was 75 years, and 67% were men. The median logistic EuroSCORE and EuroSCORE II were 17% and 6%, respectively, because of the presence of several co-morbidities. The mechanism of MR was functional in all cases with an ischemic etiology in 52% of patients. Median left ventricle ejection fraction was 34%. All the patients were symptomatic for dyspnea with 63% and 12% in the New York Heart Association class III and IV, respectively. In PMVR group, the procedure was associated with safety and very low incidence of procedural complications with no occurrence of procedural and inhospital mortality. After a median follow-up of 515 days (248 to 828 days), patients treated with PMVR demonstrated overall survival, survival freedom from cardiac death and survival free of readmission due to cardiac disease curves higher than patients treated conservatively (log-rank test p = 0.007, p = 0.002, and p = 0.04, respectively). In conclusion, PMVR offers a valid option for selected patients with high surgical risk and severe, functional MR and entails better survival outcomes compared with OMT.

Topics: Aged; Cardiac Catheterization; Cardiovascular Agents; Echocardiography; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; Male; Mitral Valve Insufficiency; Prospective Studies; Treatment Outcome; Ventricular Function, Left

Percutaneous mitral valve repair (pMVR) is a new therapeutic option for mitral valve regurgitation. Positive preliminary results in non-randomised studies have been published supporting the use of the MitraClip system in patients with secondary mitral regurgitation (MR) and poor left ventricular (LV) function contraindicated to surgery. The aim of the MITRA-FR study is to provide a higher level of evidence for the efficacy of the MitraClip device in this setting.. The MITRA-FR study is a national, multicentre, investigator-initiated, open-label, randomised trial to evaluate the benefits and safety of pMVR using the MitraClip system plus optimal medical therapy (OMT) compared with OMT alone (control) in patients with severe symptomatic secondary MR contraindicated to surgical repair. The trial aims to enrol 144 MitraClip-treated subjects and 144 control (OMT alone) patients. The primary endpoint is a composite of all-cause mortality and unplanned hospitalisations for heart failure at 12 months after randomisation. MITRA-FR is a randomised controlled national trial designed to evaluate the performance of pMVR in comparison to OMT in patients with severe symptomatic secondary MR contraindicated to cardiac surgery.

Topics: Aged; Aged, 80 and over; Cardiac Catheterization; Cardiomyopathy, Dilated; Cardiovascular Agents; Disease Management; Female; Humans; Male; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Severity of Illness Index; Treatment Outcome

The long-term benefits of the maze procedure in patients with chronic atrial fibrillation undergoing mechanical valve replacement who already require lifelong anticoagulation remain unclear.. We evaluated adverse outcomes (death; thromboembolic events; composite of death, heart failure, or valve-related complications) in 569 patients with atrial fibrillation-associated valvular heart disease who underwent mechanical valve replacement with (n=317) or without (n=252) a concomitant maze procedure between 1999 and 2010. After adjustment for differences in baseline risk profiles, patients who had undergone the maze procedure were at similar risks of death (hazard ratio, 1.15; 95% confidence interval, 0.65-2.03; P=0.63) and the composite outcomes (hazard ratio, 0.82; 95% confidence interval, 0.50-1.34; P=0.42) but a significantly lower risk of thromboembolic events (hazard ratio, 0.29; 95% confidence interval, 0.12-0.73; P=0.008) compared with those who underwent valve replacement alone at a median follow-up of 63.6 months (range, 0.2-149.9 months). The effect of superior event-free survival by the concomitant maze procedure was notable in a low-risk EuroSCORE (0-3) subgroup (P=0.049), but it was insignificant in a high-risk EuroSCORE (≥4) subgroup (P=0.65). Furthermore, the combination of the maze procedure resulted in superior left ventricular (P<0.001) and tricuspid valvular functions (P<0.001) compared with valve replacement alone on echocardiographic assessments performed at a median of 52.7 months (range, 6.0-146.8 months) after surgery.. Compared with valve replacement alone, the addition of the maze procedure was associated with a reduction in thromboembolic complications and improvements in hemodynamic performance in patients undergoing mechanical valve replacement, particularly in those with low risk of surgery.

Topics: Adult; Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Cryosurgery; Endocarditis; Female; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Kaplan-Meier Estimate; Male; Microwaves; Middle Aged; Mitral Valve Insufficiency; Postoperative Complications; Postoperative Hemorrhage; Prospective Studies; Thromboembolism; Treatment Outcome; Tricuspid Valve Insufficiency; Ultrasonography; Ventricular Dysfunction, Left

To evaluate the effects of treatment on respiratory rate, serum natriuretic peptide concentrations, and Doppler echocardiographic indices of left ventricular filling pressure in dogs with congestive heart failure (CHF) secondary to degenerative mitral valve disease (MVD) and dilated cardiomyopathy (DCM).. Prospective cohort study.. 63 client-owned dogs.. Physical examination, thoracic radiography, analysis of natriuretic peptide concentrations, and Doppler echocardiography were performed twice, at baseline (examination 1) and 5 to 14 days later (examination 2). Home monitoring of respiratory rate was performed by the owners between examinations.. In dogs with MVD, resolution of CHF was associated with a decrease in respiratory rate, serum N-terminal probrain natriuretic peptide (NT-proBNP) concentration, and diastolic functional class and an increase of the ratio of peak velocity of early diastolic transmitral flow to peak velocity of early diastolic lateral mitral annulus motion (E:Ea Lat). In dogs with DCM, resolution of CHF was associated with a decrease in respiratory rate and serum NT-proBNP concentration and significant changes in 7 Doppler echocardiographic variables, including a decrease of E:Ea Lat and the ratio of peak velocity of early diastolic transmitral flow to isovolumic relaxation time. Only respiratory rate predicted the presence of CHF at examination 2 with high accuracy.. Resolution of CHF was associated with predictable changes in respiratory rate, serum NT-proBNP concentration, and selected Doppler echocardiographic variables in dogs with DCM and MVD. Home monitoring of respiratory rate was simple and was the most useful in the assessment of successful treatment of CHF.

Topics: Animals; Cardiomyopathy, Dilated; Cardiovascular Agents; Cohort Studies; Dog Diseases; Dogs; Echocardiography, Doppler; Heart Failure; Mitral Valve Insufficiency; Natriuretic Peptides; Respiration

Resynchronization therapy by simultaneous pacing of the right and left ventricles has gained wide acceptance as a useful treatment for patients with severe congestive heart failure. Several short-term hemodynamic studies in humans and animals failed to demonstrate any benefit of biventricular pacing over left univentricular pacing, but long-term studies on this pacing mode are lacking. The objective of this study was to assess the outcome over a 1-year period of patients paced exclusively in the left ventricle.. Clinical, angiographic, echocardiographic, and ergometric data were collected at baseline and after 12 months in 22 patients (age, 69.3+/-6.5 years) with NYHA class III or IV (10 patients), sinus rhythm, left bundle-branch block, and no bradycardia indication for pacing. After 12 months, compared with baseline values, NYHA class improved significantly by 40% (P<0.0001), 6-minute walk distance by 30% (P=0.01), peak VO2 by 26% (P=0.01), left ventricular end-diastolic diameter by 5% (P=0.02), ejection fraction by 22% (P=0.07), mitral regurgitation area by 40% (P=0.01), and norepinephrine level by 37% (P=0.04).. In patients with severe congestive heart failure, sinus rhythm, and left bundle-branch block despite optimal pharmacological treatment, left univentricular pacing is feasible and results in significant midterm benefit in exercise tolerance and left ventricular function.

Topics: Aged; Bundle-Branch Block; Cardiac Pacing, Artificial; Cardiovascular Agents; Combined Modality Therapy; Coronary Angiography; Diuretics; Exercise Tolerance; Female; Follow-Up Studies; Heart Failure; Heart Ventricles; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Myocardial Ischemia; Norepinephrine; Oxygen Consumption; Prospective Studies; Stroke Volume; Treatment Outcome; Ultrasonography; Walking

Topics: Aged; Cardiovascular Agents; Female; Heart Failure; Humans; Male; Mitral Valve Insufficiency; Retrospective Studies; Severity of Illness Index; Stroke Volume; Treatment Outcome; United States

Topics: Aged; Cardiovascular Agents; Female; Heart Failure; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Prognosis; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke Volume; Time Factors; Ventricular Function, Left

Patients with severe secondary mitral regurgitation (MR) and normal ejection fraction are being excluded from clinical trials evaluating transcatheter mitral devices. We sought to evaluate the long-term mortality with medical management alone in this patient population.. We retrospectively evaluated patients diagnosed with ≥3+ MR at our institution over 15 years. Only patients with an ejection fraction ≥60% were included in the study. Those with degenerative mitral valve disease, papillary muscle dysfunction, or hypertrophic cardiomyopathy, and those who underwent mitral valve intervention were excluded. The study included 400 patients (age 71.1±14.8, 25.1% male, ejection fraction 62.5±3.6%). Mechanism of secondary MR was restricted valve motion, annular dilation and apical tethering in 91.5, 4.5 and 4%, respectively. One-year and three-year mortality were 19.1 and 26.3%, respectively. On multivariable Cox proportional regression analysis, older age, New York Heart Association functional Class III or IV, >3+ MR and larger left atrium were independent predictors of mortality.. Severe secondary MR with normal left ventricular systolic function has significant mortality with medical management alone. This initial observation needs to be confirmed in larger prospective studies. These patients should be included in future transcatheter clinical trials.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Female; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Ohio; Registries; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke Volume; Time Factors; Treatment Outcome; Ventricular Function, Left

: A 55-year-old gentleman with hypertrophic obstructive cardiomyopathy and heart failure symptoms underwent cardiac catheterization, which confirmed a significant pressure drop (60 mmHg) across the left ventricular outflow tract, a double-peaked pulse (pulsus bisferiens) and an absent postextrasystolic potentiation (Brockenbrough-Braunwald-Morrow sign) in the left ventricular outflow tract and the aorta. He was treated with medical therapy optimization and intracardiac defibrillator implantation. Cardiac catheterization may provide characteristic clues not only to diagnose obstructive hypertrophic cardiomyopathy, but also to understand its pathophysiological correlates.

Topics: Arrhythmias, Cardiac; Cardiac Catheterization; Cardiomyopathy, Hypertrophic; Cardiovascular Agents; Defibrillators, Implantable; Echocardiography; Electric Countershock; Electrocardiography; Hemodynamics; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Predictive Value of Tests; Treatment Outcome; Ventricular Function, Left; Ventricular Outflow Obstruction; Ventricular Pressure

Topics: Aneurysm; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Combined Modality Therapy; Continuous Positive Airway Pressure; Echocardiography, Transesophageal; Enterobacteriaceae Infections; Epoprostenol; Female; Humans; Hypertension, Pulmonary; Marfan Syndrome; Middle Aged; Mitral Valve Insufficiency; Oxygen Inhalation Therapy; Postoperative Complications; Pulmonary Artery; Pulmonary Valve Insufficiency; Respiratory Insufficiency

The indications for a concomitant mitral valve (MV) procedure remain controversial for patients with hypertrophic obstructive cardiomyopathy (HOCM). According to previous studies, a concomitant MV surgery was required in 11-20% of inpatient operations. Thus, we aimed to study the outcomes of an extended Morrow procedure without a concomitant MV procedure for HOCM patients who had no intrinsic abnormalities of the MV apparatus. We retrospectively reviewed 232 consecutive HOCM patients who underwent extended Morrow procedures from January 2010 to October 2014. Only 10 (4.31%) patients with intrinsic MV diseases underwent concomitant MV procedures. Of the 232 patients, 230 had no to mild mitral regurgitation (MR) postoperatively. We separated the 232 patients into two groups according to preoperative MR degree. One group is mild MR, and the other is moderate or severe MR. The three-month, one-year, and three-year composite end-point event-free survival rates had no difference between two groups (p = 0.820). When we separated the patients to postoperative no or trace MR group and mild MR group, there was also no difference on survival rates (p = 0.830). In conclusion, concomitant mitral valve procedures are not necessary for HOCM patients with MR caused by systolic anterior motion, even moderate to severe extent.

Topics: Adult; Cardiomyopathy, Hypertrophic; Cardiovascular Agents; China; Combined Modality Therapy; Disease-Free Survival; Female; Follow-Up Studies; Heart Septum; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Proportional Hazards Models; Retrospective Studies; Treatment Outcome; Ventricular Outflow Obstruction

Topics: Acute Coronary Syndrome; Anti-Bacterial Agents; Cardiobacterium; Cardiovascular Agents; Coronary Angiography; Dental Caries; Echocardiography, Transesophageal; Embolism; Endocarditis, Bacterial; Gram-Negative Bacterial Infections; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Mitral Valve Insufficiency; Treatment Outcome

Diastolic heart failure (DHF) remains unexplained in some patients with recurrent admissions after full investigation. A study was directed for screening SLE and systemic autoimmune connective tissue disorders in recurrent unexplained DHF patients admitted at a short-stay and intermediate care unit. It was found that systemic autoimmune conditions explained 11% from all of cases. Therapy also prevented new readmissions. Autoimmunity should be investigated in DHF.

Topics: Abortion, Habitual; Aged; Aged, 80 and over; Autoimmune Diseases; Cardiovascular Agents; Connective Tissue Diseases; Critical Care; Delayed Diagnosis; Female; Heart Failure, Diastolic; Humans; Lupus Erythematosus, Systemic; Male; Mass Screening; Middle Aged; Mitral Valve Insufficiency; Pregnancy; Prospective Studies; Recurrence; Spain

We prospectively applied the Surgical Treatment of Ischemic Cardiomyopathy trial entry criteria to an observational database to determine whether coronary artery bypass grafting (CABG) decreases mortality compared with medical therapy (MED) for patients with coronary artery disease and depressed left ventricular ejection fraction.. This was a retrospective, observational, cohort study of prospectively collected data from the Duke Databank for Cardiovascular Disease. Long-term mortality was the main outcome measure. Between January 1, 1995, and July 31, 2009, 86,874 patients underwent cardiac catheterization for suspected ischemic heart disease and were evaluated for inclusion in the analysis.. A total of 2,624 patients were found to have left ventricular ejection fraction less than 0.35, coronary artery disease amenable to CABG, and no left main stenosis of greater than 50%. After exclusions including ongoing Canadian Cardiovascular Society class III angina and acute myocardial infarction, 763 patients were included for propensity score analysis, including 624 who received MED and 139 who underwent CABG. Adjusted mortality curves were constructed for those patients in the three quintiles most likely to receive CABG. The curves diverged early, with risk-adjusted mortality rates at 5 years of 46% for MED versus 29% for CABG, and the survival benefit of CABG over MED continued through 10 years of follow-up (hazard ratio, 0.63; 95% confidence interval, 0.45 to 0.88).. Among a propensity-matched, risk-adjusted, observational cohort of patients with coronary artery disease, left ventricular ejection fraction less than 0.35, and no left main disease of greater than 50%, CABG is associated with a survival advantage over MED through 10 years of follow-up.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiac Catheterization; Cardiovascular Agents; Comorbidity; Coronary Artery Bypass; Databases, Factual; Female; Follow-Up Studies; Heart Failure; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Mitral Valve Insufficiency; Models, Cardiovascular; Myocardial Ischemia; North Carolina; Retrospective Studies; Risk Factors; Stroke Volume; Treatment Outcome

Coarctation of the aorta (CoA) is a common congenital anomaly that is usually treated in infancy or childhood. Adult patients with coarctation have a high incidence of associated cardiac disorders, including valve diseases, atrial fibrillation and ischemic heart disease. Most patients with uncorrected CoA die before reaching the age of 50 from complications such as myocardial infarction, intracranial hemorrhage, congestive heart failure (HF), infective endocarditis or aortic dissection. We report the case of a 65 year-old woman admitted to hospital with symptoms of heart failure NYHA class IV. She had been treated for several years for refractory arterial hypertension and concomitant stenocardia (II CCS). The symptoms of HF had been increasing over several months. Outpatient echocardiography examination revealed significant, increasing mitral and tricuspid valve regurgitation with progressive left ventricular dysfunction. The patient was referred for surgical repair of the mitral and tricuspid valves. In-hospital echocardiography and angiography revealed descending aorta discontinuity at the level of the aortic isthmus. This congenital disease revealed during hospitalization was determined to be the underlying cause of all the symptoms the patient presented. Due to the clinical status of the patient, she was discharged from surgical procedures and put on medication.

Topics: Aged; Aortic Coarctation; Aortography; Cardiac Catheterization; Cardiovascular Agents; Delayed Diagnosis; Echocardiography, Doppler; Female; Heart Failure; Humans; Mitral Valve Insufficiency; Predictive Value of Tests; Tricuspid Valve Insufficiency; Ventricular Dysfunction, Left

A 23-year-old male patient, who suffers from beta-thalassemia major, came to us for an endocrine-metabolic evaluation. Medical history showed a diagnosis of heart disease with heart failure since the age of 16, type 1 diabetes mellitus diagnosed at the age of 18, treated with an intensive insulin therapy with a poor glycometabolic control. Patient performed regular blood transfusions and iron chelation with deferasirox. An echocardiogram revealed an enlarged left ventricle. Patient had undergone a comprehensive study of buoyancy both basal and hormone-stimulated and it was therefore carried out a diagnosis of GH deficiency and hypogonadotropic hypogonadism. A recombinant GH replacement therapy was then prescribed. After six months of therapy, the patient reported a net improvement of asthenic symptoms. Physical examination showed a reduction in abdominal adiposity in waist and an increase of 5 cm in stature. Laboratory tests showed an amelioration of glycometabolic control, such as to justify a reduction in daily insulin dose. The stature observed was thought appropriate to begin the administration of testosterone. Moreover, the cardiological framework showed a reduction of left ventricular dilatation, good ventricular motility, global minimum persistent tricuspid but not mitral regurgitation and no alteration on ECG.

Topics: Asthenia; beta-Thalassemia; Blood Transfusion; Cardiovascular Agents; Chelation Therapy; Combined Modality Therapy; Diabetes Mellitus, Type 1; Dwarfism; Growth Hormone; Heart Failure; Human Growth Hormone; Humans; Hypogonadism; Insulin; Iron Chelating Agents; Iron Overload; Male; Mitral Valve Insufficiency; Testosterone; Tricuspid Valve Insufficiency; Young Adult

Topics: Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Valve Annuloplasty; Cardiovascular Agents; Combined Modality Therapy; Endovascular Procedures; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Tricuspid Valve Insufficiency; Tricuspid Valve Stenosis

We present analysis of a case history of a patient with rare congenital heart disorder - Bland-White-Garland syndrome. The 25 years old women was first diagnosed with this disorder during an examination in the cardiological department of the Moscow clinical hospital No83. The paper contains discussion of difficulties of diagnosis and peculiarities of management of adults with this pathology as well as of a problem of the choice of further therapeutic approaches.

Topics: Adult; Benzazepines; Cardiovascular Agents; Cardiovascular Surgical Procedures; Coronary Angiography; Coronary Vessel Anomalies; Coronary Vessels; Female; Heart Failure; Humans; Ivabradine; Metoprolol; Mitral Valve Insufficiency; Multidetector Computed Tomography; Prognosis; Pulmonary Artery; Syndrome; Treatment Outcome

Balloon atrial septostomy is ordinarily a safe palliative procedure for cyanotic congenital heart disease; however, if echocardiographic guidance is unavailable and fluoroscopy is used, distortions in the cardiac anatomy can invalidate the usual landmarks. Herein, we report iatrogenic mitral papillary muscle rupture during balloon atrial septostomy in a 4-day-old male neonate with total anomalous connection of the pulmonary veins. The anomalous connection and severe mitral regurgitation were emergently corrected, and the patient grew and developed normally. At age 24 years, he had only mild residual mitral regurgitation and was in New York Heart Association functional class I.In addition to describing the surgical treatment and positive late outcome of a rare complication, we highlight the importance of accurately evaluating balloon catheter location during atrial septostomy, especially in patients with a small left atrium.

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Catheterization; Cyanosis; Echocardiography, Transesophageal; Heart Defects, Congenital; Heart Failure; Heart Injuries; Humans; Iatrogenic Disease; Infant, Newborn; Male; Mitral Valve; Mitral Valve Insufficiency; Palliative Care; Severity of Illness Index; Time Factors; Treatment Outcome; Young Adult

A 71-year-old woman with idiopathic thrombocytopenic purpura (ITP), who had been treated with steroid and cyclosporine, was admitted in an emergency with fever and dyspnea. The diagnosis was mitral regurgitation due ton infective endocarditis. Although she received treatments for infection and cardiac failure, the cardiac failure could not be controlled. After high-dose γ-globulin therapy, an emergency operation was performed during the active phase of infective endocarditis. Rapid platelet transfusion was administered after weaning from extracorporeal circulation. She recovered and was discharged without postoperative bleeding and re-infection.The treatment course of elective cardiac surgery complicated with ITP has been established, but the course of emergency surgery has not been established because of the small number of cases reported. Since few patients have undergone emergency surgery for active infective endocarditis, we had difficulty in deciding the time of surgery and treatment for increasing the number of platelets before surgery, it was considered that the case provided us with useful suggestion for the future treatment for urgent surgery complicated with ITP.

Topics: Aged; Anti-Bacterial Agents; Cardiac Surgical Procedures; Cardiovascular Agents; Endocarditis; Extracorporeal Membrane Oxygenation; Female; gamma-Globulins; Heart Failure; Humans; Immunosuppressive Agents; Methicillin-Resistant Staphylococcus aureus; Mitral Valve Insufficiency; Platelet Transfusion; Purpura, Thrombocytopenic, Idiopathic; Staphylococcus epidermidis; Treatment Outcome

Isolated congenital cleft of the posterior leaflet of the mitral valve is a rare cause of mitral regurgitation (MR). This study describes the clinical, echocardiographic, and intraoperative findings as well as treatment options.. Adults with an isolated cleft of the posterior mitral valve leaflet diagnosed by transthoracic echocardiography were evaluated with respect to clinical, echocardiographic, preoperative and intraoperative findings, and different surgical strategies.. The prevalence of isolated cleft of the posterior mitral valve leaflet in all patients examined was 0.11% (n = 22 out of 19 320 evaluated echocardiograms); male gender was predominant (73%). Dyspnea on exertion was present in almost all patients with at least moderate regurgitation. The predominant localization of the cleft was within segment P2 (59%), followed by a cleft between P1/P2 (18%). An isolated cleft in segment P3 or segment P1 occurred twice in each segment (n = 2; 9%) and between P2/P3 once (n = 1; 5%). Regurgitation was severe in 50% (n = 11), moderate in 9% (n = 2), mild in 27% (n = 6), and only trivial in 14% (n = 3) of the patients. Surgical treatment involved reconstruction with ring annuloplasty in 45% (n = 10) and replacement in 4.5% (n = 1). A total of 11 patients (50%) with mostly mild or trivial mitral regurgitation were treated medically only.. Two-dimensional high-resolution cross-sectional echocardiography allows the distinct diagnosis of a clefted posterior leaflet, whereas clinical presentation, electrocardiogram, chest x-ray, and angiography are failing to identify the correct etiology of MR in patients with isolated posterior leaflet cleft mitral valve (IPLCMV). Patients with moderate to severe MR were treated surgically with excellent outcome.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Databases as Topic; Echocardiography, Doppler, Color; Female; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Severity of Illness Index; Time Factors; Treatment Outcome; Young Adult

Cogan's syndrome is a rare idiopathic chronic inflammatory disease of the eye and the inner ear in young adults. Cogan's syndrome can be associated with large vessel vasculitis. We report a young female, with a history of interstitial keratitis and audiovestibular disease, who presents with large vessel vasculitis with left main coronary artery occlusion and develops heart failure. Cogan's syndrome was diagnosed on the basis of the presence of large vessel vasculitis with the typical inner ear and ocular involvement.

Topics: Adult; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Cogan Syndrome; Combined Modality Therapy; Coronary Angiography; Coronary Artery Bypass; Coronary Occlusion; Cyclophosphamide; Electrocardiography; Female; Glucocorticoids; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Immunosuppressive Agents; Mitral Valve Insufficiency; Pulse Therapy, Drug; Treatment Outcome

Topics: Adult; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Cogan Syndrome; Combined Modality Therapy; Coronary Artery Bypass; Coronary Occlusion; Cyclophosphamide; Female; Glucocorticoids; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Immunosuppressive Agents; Mitral Valve Insufficiency; Pulse Therapy, Drug; Treatment Outcome

Topics: Acute Disease; Atrial Natriuretic Factor; Cardiovascular Agents; Heart Failure; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Treatment Outcome

A 67-year-old man was admitted to a coronary care unit for non-ST-segment elevation myocardial infarction with complicating acute heart failure. Severe mitral regurgitation was detected by echocardiography at presentation. Repeat echocardiography carried out during another ischemic episode revealed a marked reduction in the patient's mitral regurgitation that was related to decreased apical traction of the valve leaflets.. Physical examination, electrocardiography, laboratory tests, coronary angiography, chest radiography, echocardiography.. Mitral regurgitation associated with acute coronary syndrome.. Early revascularization by percutaneous coronary intervention, supported by pharmacological therapy to decrease left ventricular filling pressure.

Topics: Acute Disease; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Echocardiography, Doppler, Color; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Myocardial Contraction; Myocardial Ischemia; Papillary Muscles; Ventricular Function, Left

The management of asymptomatic severe mitral regurgitation remains controversial. The aim of this study was to evaluate the outcome of a watchful waiting strategy in which patients are referred to surgery when symptoms occur or when asymptomatic patients develop left ventricular (LV) enlargement, LV dysfunction, pulmonary hypertension, or recurrent atrial fibrillation.. A total of 132 consecutive asymptomatic patients (age 55+/-15 years, 49 female) with severe degenerative mitral regurgitation (flail leaflet or valve prolapse) were prospectively followed up for 62+/-26 months. Patients underwent serial clinical and echocardiographic examinations and were referred for surgery when the criteria mentioned above were fulfilled. Overall survival was not statistically different from expected survival either in the total group or in the subgroup of patients with flail leaflet. Eight deaths were observed. Thirty-eight patients developed criteria for surgery (symptoms, 24; LV criteria, 9; pulmonary hypertension or atrial fibrillation, 5). Survival free of any indication for surgery was 92+/-2% at 2 years, 78+/-4% at 4 years, 65+/-5% at 6 years, and 55+/-6% at 8 years. Patients with flail leaflet tended to develop criteria for surgery slightly but not significantly earlier. There was no operative mortality. Postoperative outcome was good with regard to survival, symptomatic status, and postoperative LV function.. Asymptomatic patients with severe degenerative mitral regurgitation can be safely followed up until either symptoms occur or currently recommended cutoff values for LV size, LV function, or pulmonary hypertension are reached. This management strategy is associated with good perioperative and postoperative outcome but requires careful follow-up.

Topics: Aged; Atrial Fibrillation; Cardiovascular Agents; Case Management; Comorbidity; Disease Progression; Disease-Free Survival; Female; Follow-Up Studies; Humans; Hypertension, Pulmonary; Hypertrophy, Left Ventricular; Life Tables; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Prospective Studies; Survival Analysis; Time Factors; Treatment Outcome; Ultrasonography; Ventricular Dysfunction, Left

Nesiritide is a recombinant brain-type natriuretic peptide (BNP), which decreases pulmonary arterial (PA) pressures and myocardial oxygen consumption while increasing coronary flow and urine output. Mitral valve (MV) surgery in patients with severe mitral regurgitation (MR), impaired left ventricular function, and pulmonary hypertension is associated with a high operative mortality. We hypothesized that the perioperative use of Nesiritide is safe, and may improve surgical outcomes.. From May 2003 to August 2004, 14 patients (11 male, 3 female; mean age, 64 years [23-87 years]; mean systolic PA, 63 mm Hg [48-94 mm Hg]; mean ejection fraction, 36% [10-50%]), undergoing MV surgery (10 repairs, 2 replacements, and 2 rereplacements) for severe MR, were treated for a median of 24 hours (13-55 hours) preoperatively with intravenous Nesiritide. Expected mortality by EuroSCORE was 26% (7.8-59%) (5 reoperations). Concomitant procedures included tricuspid valve repair (n = 7), coronary artery bypass grafting (n = 5), and left atrial maze procedure (n = 3). Eleven patients received Nesiritide postoperatively during a mean duration of 22 hours (2-80 hours).. Operative mortality was 0%. Prior to surgery after BNP treatment, mean systolic PA pressure dropped to 39 mm Hg (p = 0.0003), pulmonary capillary wedge pressure to 15 mm Hg (p = 0.001), central venous pressure to 6 mm Hg (p = 0.002), and weight by 3.7 kg (p = 0.006). Postoperative median ventilation time was 14 hours (4-48 hours). All other major hemodynamic parameters (systemic blood pressure, heart rate, and cardiac output) remained constant. The treatment was well-tolerated in all patients.. Perioperative use of Nesiritide is safe, and may contribute to improved early outcomes in high-risk patients undergoing MV surgery. This may be due to improved ventricular loading conditions (decreased PA pressures, more effective diuresis) and/or a direct myocardial effect of BNP. Further prospective evaluation of the role of BNP in cardiac surgery is warranted.

Topics: Adult; Aged; Aged, 80 and over; Cardiac Surgical Procedures; Cardiovascular Agents; Female; Hemodynamics; Humans; Hypertension, Pulmonary; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Natriuretic Peptide, Brain; Prospective Studies; Ventricular Dysfunction, Left