Jonathan D Kochav1, Jiwon Kim2, Robert Judd3, Katherine A Tak2, Emmad Janjua4, Abigail J Maciejewski2, Han W Kim3, Igor Klem3, John Heitner5, Dipan Shah6, William A Zoghbi6, Chetan Shenoy7, Afshin Farzaneh-Far8, Venkateshwar Polsani9, Pablo Villar-Calle2, Michele Parker3, Kevin M Judd10, Omar K Khalique11, Martin B Leon11, Richard B Devereux2, Robert A Levine12, Raymond J Kim3, Jonathan W Weinsaft2. 1. Division of Cardiology, Weill Cornell Medicine, New York, New York, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA. Electronic address: jww2001@med.cornell.edu. 2. Division of Cardiology, Weill Cornell Medicine, New York, New York, USA. 3. Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA. 4. Division of Cardiology, Weill Cornell Medicine, New York, New York, USA; Weill Cornell Medicine-Qatar, Doha, Qatar. 5. Division of Cardiology, New York Presbyterian Brooklyn Methodist Hospital, New York, New York, USA. 6. Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA. 7. Division of Cardiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA. 8. Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA. 9. Piedmont Atlanta Hospital, Atlanta, Georgia, USA. 10. Heart Imaging Technologies, Durham, North Carolina, USA. 11. Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA. 12. Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
Abstract
BACKGROUND: Left ventricular (LV) ischemia has been variably associated with functional mitral regurgitation (FMR). Determinants of FMR in patients with ischemia are poorly understood. OBJECTIVES: This study sought to test whether contractile mechanics in ischemic myocardium underlying the mitral valve have an impact on likelihood of FMR. METHODS: Vasodilator stress perfusion cardiac magnetic resonance was performed in patients with coronary artery disease (CAD) at multiple centers. FMR severity was confirmed quantitatively via core lab analysis. To test relationship of contractile mechanics with ischemic FMR, regional wall motion and strain were assessed in patients with inducible ischemia and minimal (≤5% LV myocardium, nontransmural) infarction. RESULTS: A total of 2,647 patients with CAD were studied; 34% had FMR (7% moderate or greater). FMR severity increased with presence (P < 0.001) and extent (P = 0.01) of subpapillary ischemia: patients with moderate or greater FMR had more subpapillary ischemia (odds ratio [OR]: 1.13 per 10% LV; 95% CI: 1.05-1.21; P = 0.001) independent of ischemia in remote regions (P = NS); moderate or greater FMR prevalence increased stepwise with extent of ischemia and infarction in subpapillary myocardium (P < 0.001); stronger associations between FMR and infarction paralleled greater wall motion scores in infarct-affected territories. Among patients with inducible ischemia and minimal infarction (n = 532), wall motion and radial strain analysis showed impaired subpapillary contractile mechanics to associate with moderate or greater FMR (P < 0.05) independent of remote regions (P = NS). Conversely, subpapillary ischemia without contractile dysfunction did not augment FMR likelihood. Mitral and interpapillary dimensions increased with subpapillary radial strain impairment; each remodeling parameter associated with impaired subpapillary strain (P < 0.05) independent of remote strain (P = NS). Subpapillary radial strain (OR: 1.13 per 5% [95% CI: 1.02-1.25]; P = 0.02) and mitral tenting area (OR: 1.05 per 10 mm2 [95% CI: 1.00-1.10]; P = 0.04) were associated with moderate or greater FMR controlling for global remodeling represented by LV end-systolic volume (P = NS): when substituting sphericity for LV volume, moderate or greater FMR remained independently associated with subpapillary radial strain impairment (OR: 1.22 per 5% [95% CI: 1.02-1.47]; P = 0.03). CONCLUSIONS: Among patients with CAD and ischemia, FMR severity and adverse mitral apparatus remodeling increase in proportion to contractile dysfunction underlying the mitral valve.
BACKGROUND: Left ventricular (LV) ischemia has been variably associated with functional mitral regurgitation (FMR). Determinants of FMR in patients with ischemia are poorly understood. OBJECTIVES: This study sought to test whether contractile mechanics in ischemic myocardium underlying the mitral valve have an impact on likelihood of FMR. METHODS: Vasodilator stress perfusion cardiac magnetic resonance was performed in patients with coronary artery disease (CAD) at multiple centers. FMR severity was confirmed quantitatively via core lab analysis. To test relationship of contractile mechanics with ischemic FMR, regional wall motion and strain were assessed in patients with inducible ischemia and minimal (≤5% LV myocardium, nontransmural) infarction. RESULTS: A total of 2,647 patients with CAD were studied; 34% had FMR (7% moderate or greater). FMR severity increased with presence (P < 0.001) and extent (P = 0.01) of subpapillary ischemia: patients with moderate or greater FMR had more subpapillary ischemia (odds ratio [OR]: 1.13 per 10% LV; 95% CI: 1.05-1.21; P = 0.001) independent of ischemia in remote regions (P = NS); moderate or greater FMR prevalence increased stepwise with extent of ischemia and infarction in subpapillary myocardium (P < 0.001); stronger associations between FMR and infarction paralleled greater wall motion scores in infarct-affected territories. Among patients with inducible ischemia and minimal infarction (n = 532), wall motion and radial strain analysis showed impaired subpapillary contractile mechanics to associate with moderate or greater FMR (P < 0.05) independent of remote regions (P = NS). Conversely, subpapillary ischemia without contractile dysfunction did not augment FMR likelihood. Mitral and interpapillary dimensions increased with subpapillary radial strain impairment; each remodeling parameter associated with impaired subpapillary strain (P < 0.05) independent of remote strain (P = NS). Subpapillary radial strain (OR: 1.13 per 5% [95% CI: 1.02-1.25]; P = 0.02) and mitral tenting area (OR: 1.05 per 10 mm2 [95% CI: 1.00-1.10]; P = 0.04) were associated with moderate or greater FMR controlling for global remodeling represented by LV end-systolic volume (P = NS): when substituting sphericity for LV volume, moderate or greater FMR remained independently associated with subpapillary radial strain impairment (OR: 1.22 per 5% [95% CI: 1.02-1.47]; P = 0.03). CONCLUSIONS: Among patients with CAD and ischemia, FMR severity and adverse mitral apparatus remodeling increase in proportion to contractile dysfunction underlying the mitral valve.
Authors: Burkhard Sievers; Michael D Elliott; Lynne M Hurwitz; Timothy S E Albert; Igor Klem; Wolfgang G Rehwald; Michele A Parker; Robert M Judd; Raymond J Kim Journal: Circulation Date: 2007-01-02 Impact factor: 29.690
Authors: Seth Uretsky; Linda Gillam; Roberto Lang; Farooq A Chaudhry; Edgar Argulian; Azhar Supariwala; Srinivasa Gurram; Kavya Jain; Marjorie Subero; James J Jang; Randy Cohen; Steven D Wolff Journal: J Am Coll Cardiol Date: 2015-03-24 Impact factor: 24.094
Authors: John F Heitner; Raymond J Kim; Han W Kim; Igor Klem; Dipan J Shah; Dany Debs; Afshin Farzaneh-Far; Venkateshwar Polsani; Jiwon Kim; Jonathan Weinsaft; Chetan Shenoy; Andrew Hughes; Preston Cargile; Jean Ho; Robert O Bonow; Elizabeth Jenista; Michele Parker; Robert M Judd Journal: JAMA Cardiol Date: 2019-03-01 Impact factor: 14.676
Authors: Simone Romano; Robert M Judd; Raymond J Kim; Han W Kim; Igor Klem; John F Heitner; Dipan J Shah; Jennifer Jue; Brent E White; Raksha Indorkar; Chetan Shenoy; Afshin Farzaneh-Far Journal: JACC Cardiovasc Imaging Date: 2018-01-17
Authors: R J Kim; E Wu; A Rafael; E L Chen; M A Parker; O Simonetti; F J Klocke; R O Bonow; R M Judd Journal: N Engl J Med Date: 2000-11-16 Impact factor: 91.245
Authors: Jonathan W Weinsaft; Han W Kim; Dipan J Shah; Igor Klem; Anna Lisa Crowley; Rhoda Brosnan; Olga G James; Manesh R Patel; John Heitner; Michele Parker; Eric J Velazquez; Charles Steenbergen; Robert M Judd; Raymond J Kim Journal: J Am Coll Cardiol Date: 2008-07-08 Impact factor: 24.094
Authors: Samuel C Volo; Jiwon Kim; Sergey Gurevich; Maya Petashnick; Polydoros Kampaktsis; Attila Feher; Massimiliano Szulc; Franklin J Wong; Richard B Devereux; Peter M Okin; Leonard N Girardi; James K Min; Robert A Levine; Jonathan W Weinsaft Journal: Am J Cardiol Date: 2014-05-16 Impact factor: 2.778