Chronic Mitral Regurgitation : Optimal time to Intervention

Chronic mitral regurgitation is commonly encountered valve disease. In this disease, there is volume overload on the left ventricle leading to left ventricle dilatation and dysfuction. Surgical or percutaneous intervention can improve prognosis, however optimal timing of intervention still controversial. In the past, timing of intervention was based solely on symptoms and left ventricle function. There have been recent advances in our knowledge, diagnosis, and treatment of mitral regurgitation. All of these advances have provided an incentive to change the indication for timing of operations in patients with mitral regurgitation, setting a new paradigm of an early operation before the onset of ventricular dysfunction. In this article we will outline these newer advances and provide recommendations regarding optimal timing of intervention for mitral regurgitation

Recent Echocardiography Parameters for Predicting Better Functional Result after Mitral Valve Correction Surgery in Patients with Primary Mitral Regurgitation

Abstract   Objectives We analyzed whether some echocardiographic parameters are good predictors of functional result after mitral valve correction surgery.    Background Ejection fraction was not the only parameter to decide optimal time for surgery, nor an indicator for a better functional result after surgery. Severity measurement being a main consideration in surgery decision. Reduced left ventricle dimension after surgery reflect a better functional result.   Methods In 2019, 67 patients was included in this analysis. Age 53 (17-67) years, male 52,2%. All patients are with severe primary mitral regurgitation and treated by mitral valve surgery (mitral valve repair or replacement). Retrospective echocardiographic analysis was performed, to find the best parameter for predicting better functional outcome after surgery.   Results Data was collected from January to December 2019. From 262 primary mitral valve surgery underwent in National Heart Center Harapan Kita, there was 67 patients included, the other was excluded due to probability of secondary mitral regurgitation mechanism, concomitant congenital heart disease and or other significant valves disease, missing post-surgery data due to referral flow to the prior hospital and less complete echocardiographic views for further analysis. In bivariate analysis, end-diastolic volume (EDV) and regurgitant volume (RV) were strong predictor of decreasing left ventricle diameter after surgery (p 0.0001 and p 0.05). End-diastolic volume 133,5 ml or more is predictive for decreasing left ventricle diameter if surgery was conducted (sensitivity 87.3%, sensitivity 66.7%).       Conclusions EDV and RV found to be good predictors for functional outcome of primary mitral valve surgery than other echocardiographic parameters. Measuring EDV before deciding timing of surgery will be helpful in targeting better functional result after surgery.   &nbsp

Clinical Outcome of Rheumatic Mitral Valve Repair and Replacement Surgery in Indonesia; A Comparison with Non-Rheumatic Aetiology

Introduction: Mitral valve repair (MVr) has been shown to achieve better outcomes than mitral valve replacement (MVR) in degenerative aetiology. However, that cannot be applied in rheumatic mitral valve disease. Therefore, this study aims to evaluate early and late clinical outcomes and mid-term survival in RHD compared to the non-RHD group and whether mitral valve repair is a better surgical approach in RHD patients. Methods: Patients who underwent mitral valve surgery with or without coronary artery bypass grafting were included in this study. All patients were divided into the RHD and non-RHD group by the type of mitral surgery performed. Early and late outcomes were evaluated, and mid-term cumulative survival was reported. Results: A total of 1382 patients post MV surgeries were included. The 30-day mortality was significantly higher in the RHD group compared to the non-RHD group (8.7% vs. 4.4%, p = 0.003). There was no difference in 30-day mortality between repair and replacement in each respective group. During follow-up (12–54 months), all-cause mortality between RHD and non-RHD groups (16.7% vs. 16.2%) was not different. In the RHD group, the survival of MVr was 85.6% (95% CI 82.0%–88.5%), and MVR was 78.3% (95% CI 75.8%–80.6%), p-value log rank 0.26 However, in the non-RHD group, patients who underwent MVr had better survival than MVR, with cumulative survival of 81.7% (95% CI 72.3%–88.2%) vs. 71.1% (95% CI 56.3%–81.7%) p-value log rank 0.007. Conclusion: Early mortality rate in rheumatic mitral valve surgery was higher than in non-rheumatic valve surgery. Although in rheumatic MV disease MV repair did not show a significant survival advantage over MV replacement, a trend towards more favourable survival in the repair group was observed

Global Left Ventricular Myocardial Work Efficiency in Patients With Severe Rheumatic Mitral Stenosis and Preserved Left Ventricular Ejection Fraction

BACKGROUND: Assessment of left ventricular (LV) function plays a pivotal role in the management of patients with valvular heart disease, including those caused by rheumatic heart disease. Noninvasive LV pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate global LV systolic function, integrating longitudinal strain by speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work. The aim of this study was to characterize global LV myocardial work efficiency in patients with severe rheumatic mitral stenosis (MS) with preserved ejection fraction (EF). METHODS: We retrospectively included adult patients with severe rheumatic MS with preserved EF (> 50%) and sinus rhythm. Healthy individuals without structural heart disease were included as a control group. Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements. RESULTS: A total of 45 individuals with isolated severe rheumatic MS with sinus rhythm and 45 healthy individuals were included. In healthy individuals without structural heart disease, the mean global LV myocardial work efficiency was 96% (standard deviation [SD], 2), Compared with healthy individuals, median global LV myocardial work efficiency was significantly worse in MS patients (89%; SD, 4; p < 0.001) although the LVEF was similar. CONCLUSIONS: Individuals with isolated severe rheumatic MS and preserved EF, had global LV myocardial work efficiencies lower than normal controls

Prediktor Mortalitas Dalam-Rumah-Sakit Pasien Infark Miokard ST Elevation (STEMI) Akut di RSUD Dr. Dradjat Prawiranegara Serang, Indonesia

Latar Belakang: ST-Elevation Myocardial Infarction (STEMI) adalah suatu sindrom klinis berupa kumpulan gejala iskemi miokard yang berhubungan dengan elevasi ST persisten dan pelepasan biomarker nekrosis miokard. Tujuan: Menentukan prediktor mortalitas pasien STEMI selama perawatan di rumah sakit berdasarkan data register SKA (Sindrom Koroner Akut) di RSUD dr. Dradjat Prawiranegara Serang tahun 2014. Metode: Studi cross-sectional menggunakan data sekunder. Variabel diadaptasi dari model prediktor TIMI, Killip, dan GRACE. Data disajikan dalam bentuk tabel dan diagram serta dianalisis menggunakan model regresi logistik untuk mengidentifikasi prediktor kematian selama perawatan di rumah sakit. Hasil: Terdapat 151 kasus SKA yang dianalisis pada tahun 2014. Sejumlah 63% kasus ST-elevation myocardial infarction (STEMI), 19% kasus non-ST-elevation myocardial infarction (NSTEMI), dan 18% kasus unstable angina pectoris (UAP). Mortalitas dalam rumah sakit adalah 20% untuk STEMI, 17% untuk NSTEMI, dan 0% untuk UAP. Dari 95 kasus STEMI, 42% pasien datang saat onset &lt;12 jam, hanya 20 pasien (50%) yang menjalani fibrinolisis. Delapan puluh tujuh persen pasien laki-laki dan 72% pasien berusia kurang dari 65 tahun. Pasien dengan Killip class 3 and 4, aritmia, STEMI anterior, gagal ginjal kronis, takikardia, onset &gt;12 jam, dan diabetes melitus memiliki mortalitas lebih tinggi (OR 95%: 3,375; 2,659; 2,656; 2,188; 1,905; 1,754; dan 1,484), pasien yang menjalani fibrinolitik memiliki mortalitas lebih rendah (OR 95%: 2,638). Mortalitas dalam-rumah-sakit lebih tinggi signifikan pada pasien STEMI anterior dibandingkan kelompok STEMI non-anterior (27% vs 12%; nilai p: 0,036). Di dalam kelompok non-fibrinolitik, pasien STEMI anterior memiliki mortalitas lebih tinggi dibandingkan dalam kelompok pasien STEMI nonanterior (31% vs 14%; nilai p: 0,105). Simpulan: Prediktor mortalitas dalam-rumah-sakit pasien ST-elevation myocardial infarction (STEMI) akut di RSUD dr. Dradjat Prawiranegara Serang adalah Killip kelas 3 dan 4, aritmia, STEMI anterior, penyakit ginjal kronis, takikardi, onset lanjut, diabetes, dan tanpa fibrinolisis

Insiden gejala menetap dan gambaran ekokardiografi pasca infensi COVID-19 ringan

Background: Survived from COVID-19 infection, some patients yet have residual symptoms. Multi-organ and mechanisms of disease can be involved. The data regarding echocardiographic dimension and function of the cardiac in the COVID-19 survivors remains scarce. Method: This was a descriptive cross-sectional study that involves a total of 63 subjects. Subjects were employees and medical residents at National Cardiovascular Center Harapan Kita, who previously get infected by COVID-19. Each subject was examined transthoracic echocardiography once at the time of recruitment. Echocardiographic parameters obtained in this study included dimension and systolic function of the left ventricle and right ventricle, global longitudinal strain by 2D speckle tracking echocardiography, and myocardial work index. Result: More than a half of the subjects experienced persistent symptoms after recovery from COVID-19 infection and mainly was fatigue (33.3%). The timing of data acquisition on the median was 32 days after the negative of the COVID-19 test result. 2D echocardiography measurement of left ventricle indicated mean of end-diastolic diameter and end-systolic diameter was 45 mm and 27 mm, respectively. The mean ejection fraction (EF) of the left ventricle by Simpson’s biplane method was 61%. The median of tricuspid annular plane systolic excursion (TAPSE) parameter was 23 mm and the fractional area change (FAC) parameter was 39%. The mean of global longitudinal strain (GLS) was -19.6%. &nbsp; Conclusion: After recovery from COVID-19 infection, some survivors may have post-acute infectious consequences of COVID-19 such as fatigue, dyspnea, and malaise. However, echocardiographic findings in those patients with mild symptoms, including 2D echocardiography, myocardial strain analysis, and myocardial work index, indicate normal dimension and systolic function in both left ventricle and right ventricle

Impact of Rheumatic Process in Left and Right Ventricular Function in Patients with Mitral Regurgitation

Background: Mitral regurgitation (MR) burdens the left and right ventricles with a volume or pressure overload that leads to a series of compensatory adaptations that eventually lead to ventricular dysfunction, and it is well known that in rheumatic heart disease (RHD) that the inflammatory process not only occurs in the valve but also involves the myocardial and pericardial layers. However, whether the inflammatory process in rheumatic MR is associated with ventricular function besides hemodynamic changes is not yet established. Purpose: Evaluate whether rheumatic etiology is associated with ventricular dysfunction in patients with chronic MR. Methods: The study population comprised patients aged 18 years or older included in the registry who had echocardiography performed at the National Cardiovascular Center Harapan Kita in Indonesia during the study period with isolated primary MR due to rheumatic etiology and degenerative process with at least moderate regurgitation. Results: The current study included 1,130 patients with significant isolated degenerative MR and 276 patients with rheumatic MR. Patients with rheumatic MR were younger and had a higher prevalence of atrial fibrillation and pulmonary hypertension, worse left ventricle (LV) ejection fraction and tricuspid annular plane systolic excursion (TAPSE) value, and larger left atrium (LA) dimension compared to patients with degenerative mitral regurgitation (MR). Gender, age, LV end-systolic diameter, rheumatic etiology, and TAPSE were independently associated with more impaired LV ejection fraction. Whereas low LV ejection fraction, LV end-systolic diameter, and tricuspid peak velocity (TR) peak velocity >3.4 m/s were independently associated with more reduced right ventricle (RV) systolic function (Table 3). Conclusions: Rheumatic etiology was independently associated with more impaired left ventricular function; however, rheumatic etiology was not associated with reduced right ventricular systolic function in a patient with significant chronic MR