New guidelines: do we have all the answers

    Authors

    Keywords

    mitral regurgitation, assessment of left ventricle dysfunction

    DOI

    https://doi.org/10.15836/ccar2018.204

    Full Text

    Background : Appropriate timing of surgery in asymptomatic severe primary mitral regurgitation (MR) remains challenging. According to the guidelines, surgery is recommended for patients with symptomatic severe primary MR or those with asymptomatic left ventricular (LV) systolic dysfunction, new-onset atrial fibrillation and pulmonary arterial hypertension ( 1 ). Case report : 40-year-old male came to our Echo Lab because of a heart murmur. He had no previous health problems and no disturbances in his daily activities. Myxomatous mitral valve degeneration with prolapse of the posterior leaflet and severe MR was found ( Figure 1 ). No additional echo findings that would indicate surgical intervention were detected (LVESD was 34 mm, LVEF 65%, RVSP 30 mmHg, no significant LA enlargement). He was in sinus rhythm. We also measured left ventricular global longitudinal strain (LV-GLS) and preformed an exercise stress testing to assess his functional capacity with addition of echocardiographic measurement of RVSP during peak stress. He achieved 100% of predicted METs with no worsening of RVSP and LV-GLS was -24% ( Figure 2 ). Based on the above-mentioned findings, we decided to follow-up the patient. Mitral regurgitation. Strain analysis. Discussion: Clinicians and patients often choose to postpone valve surgery as long as justified. This “watchful waiting” approach is dictated by a timely identification of LV dysfunction. Ejection fraction and end-systolic dimensions are affected by the altered loading conditions in MR and can remain falsely normal despite underlying myocardial dysfunction ( 2 ). New parameters capable of detecting onset of LV dysfunction earlier could help discriminate the higher risk patients. Current European guidelines state that the use of LV-GLS could be of potential interest and determination of functional capacity may be useful, but there are no exact recommendations ( 3 ). In the study of Mentias et al., reduced exercise capacity and worsening LV-GLS were associated with mortality providing additive prognostic utility ( 1 ). Maybe the detection of the relative change of GLS from baseline rather than an absolute cut-off value as in cardio-oncology could be helpful. Conclusion : We are still looking for an optimal timepoint when we should operate patients with asymptomatic severe primary MR. Further investigations are required.

    Cardiologia Croatica
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    New guidelines: do we have all the answers

    Extended Abstract
    Issue5-6
    Published
    Pages204
    PDF via DOIhttps://doi.org/10.15836/ccar2018.204
    mitral regurgitation
    assessment of left ventricle dysfunction

    Authors

    Petra Grubić Rotkvić*ORCIDUniversity Hospital „Sveti Duh“, Zagreb, Croatia
    Jozica ŠikićORCIDUniversity Hospital „Sveti Duh“, Zagreb, Croatia
    Edvard GalićORCIDUniversity Hospital „Sveti Duh“, Zagreb, Croatia
    Jasna Čerkez HabekORCIDUniversity Hospital „Sveti Duh“, Zagreb, Croatia
    Zrinka PlaninićORCIDUniversity Hospital „Sveti Duh“, Zagreb, Croatia

    Full Text

    Background : Appropriate timing of surgery in asymptomatic severe primary mitral regurgitation (MR) remains challenging. According to the guidelines, surgery is recommended for patients with symptomatic severe primary MR or those with asymptomatic left ventricular (LV) systolic dysfunction, new-onset atrial fibrillation and pulmonary arterial hypertension ( 1 ). Case report : 40-year-old male came to our Echo Lab because of a heart murmur. He had no previous health problems and no disturbances in his daily activities. Myxomatous mitral valve degeneration with prolapse of the posterior leaflet and severe MR was found ( Figure 1 ). No additional echo findings that would indicate surgical intervention were detected (LVESD was 34 mm, LVEF 65%, RVSP 30 mmHg, no significant LA enlargement). He was in sinus rhythm. We also measured left ventricular global longitudinal strain (LV-GLS) and preformed an exercise stress testing to assess his functional capacity with addition of echocardiographic measurement of RVSP during peak stress. He achieved 100% of predicted METs with no worsening of RVSP and LV-GLS was -24% ( Figure 2 ). Based on the above-mentioned findings, we decided to follow-up the patient. Mitral regurgitation. Strain analysis. Discussion: Clinicians and patients often choose to postpone valve surgery as long as justified. This “watchful waiting” approach is dictated by a timely identification of LV dysfunction. Ejection fraction and end-systolic dimensions are affected by the altered loading conditions in MR and can remain falsely normal despite underlying myocardial dysfunction ( 2 ). New parameters capable of detecting onset of LV dysfunction earlier could help discriminate the higher risk patients. Current European guidelines state that the use of LV-GLS could be of potential interest and determination of functional capacity may be useful, but there are no exact recommendations ( 3 ). In the study of Mentias et al., reduced exercise capacity and worsening LV-GLS were associated with mortality providing additive prognostic utility ( 1 ). Maybe the detection of the relative change of GLS from baseline rather than an absolute cut-off value as in cardio-oncology could be helpful. Conclusion : We are still looking for an optimal timepoint when we should operate patients with asymptomatic severe primary MR. Further investigations are required.