The mitral valve apparatus is a complex structure consisting of several coordinating components: the annulus, two leaflets, the chordae tendineae, and the papillary muscles. Due to the intricate ...interplay between the mitral valve and the left ventricle, a disease of the latter may influence the normal function of the former. As a consequence, valve insufficiency may arise despite the absence of organic valve disease. This is designated as functional or secondary mitral regurgitation, and it arises from a series of distortions to the valve components. This narrative review describes the normal anatomy and the pathophysiology behind the mitral valve changes in ischemic and non-ischemic dilated cardiomyopathies. It also explains the value of a complete multiparametric assessment of this structure. Not only must an assessment include quantitative measures of regurgitation, but also various anatomical parameters from the mitral apparatus and left ventricle, since they carry prognostic value and are predictors of mitral valve repair success and durability.
Anticoagulation therapy has undergone significant evolution, marked by the emergence of direct oral anticoagulants with distinct advantages. Despite these advancements, challenges persist in managing ...residual thrombotic and bleeding risks, particularly among vulnerable populations. The pursuit of alternative drugs has honed in on factor XI/XIa inhibitors. This comprehensive review delves into several key aspects regarding this new target: (i) the role of factor XI in the coagulation cascade; (ii) the genetic evidence and pathophysiologic rationale supporting factor XI inhibition as a therapeutic target; (iii) an exploration of the various types of factor XI/XIa inhibitors currently under investigation; (iv) potential applications of these medications, spanning thromboprophylaxis after orthopedic surgery, stroke prevention in atrial fibrillation, secondary prevention after acute coronary syndrome, non-cardioembolic stroke, thromboprophylaxis after foreign material implantation, end-stage renal disease, and patients with cancer; and (v) an overview of ongoing studies, recent findings, and the future trajectory of research into these drugs.
Left ventricular (LV) hypertrophy is a common finding in patients with severe aortic stenosis (AS). Cardiac magnetic resonance (CMR) is the gold-standard technique to evaluate LV remodeling. Our aim ...was to assess the prevalence and describe the patterns of LV adaptation in AS patients before and after surgical aortic valve replacement (AVR). Prospective study of 130 consecutive patients (71y IQR 68-77y, 48% men) with severe AS, referred for surgical AVR. Patterns of LV remodeling were assessed by CMR. Besides normal LV ventricular structure, four other patterns were considered: concentric remodeling, concentric hypertrophy, eccentric hypertrophy, and adverse remodeling. At baseline CMR study: mean LV indexed mass: 81.8 ± 26.7 g/m
; mean end-diastolic LV indexed volume: 85.7 ± 23.1 mL/m
and median geometric remodeling ratio: 0.96 g/mL IQR 0.82-1.08 g/mL. LV hypertrophy occurred in 49% of subjects (concentric 44%; eccentric 5%). Both normal LV structure and concentric remodeling had a prevalence of 25% among the cohort; one patient had an adverse remodeling pattern. Asymmetric LV wall thickening was present in 55% of the patients, with predominant septal involvement. AVR was performed in 119 patients. At 3-6 months after AVR, LV remodeling changed to: normal ventricular geometry in 60%, concentric remodeling in 27%, concentric hypertrophy in 10%, eccentric hypertrophy in 3% and adverse remodeling (one patient). Indexes of AS severity, LV systolic and diastolic function and NT-proBNP were significantly different among the distinct patterns of remodeling. Several distinct patterns of LV remodelling beyond concentric hypertrophy occur in patients with classical severe AS. Asymmetric hypertrophy is a common finding and LV response after AVR is diverse.
Chronic mitral regurgitation promotes left atrial (LA) remodeling. However, the significance of LA dysfunction in the setting of ventricular functional mitral regurgitation (FMR) has not been fully ...investigated. Our aim was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in patients with FMR and reduced left ventricular ejection fraction (LVEF).
Patients with at least mild ventricular FMR and LVEF < 50% under optimized medical therapy who underwent transthoracic echocardiography at a single center were retrospectively identified in the laboratory database. PALS was assessed by 2D speckle tracking in the apical 4-chamber view and the study population was divided in two groups according to the best cut-off value of PALS, using receiver operating characteristics (ROC) curve analysis. The primary endpoint-point was all-cause mortality.
A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 - 40%) and median effective regurgitant orifice area (EROA) was 15mm
(IQR: 9 - 22mm
). According to current European guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 - 6.6), 148 patients died. The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS. On multivariable analysis, PALS remained independently associated with all-cause mortality (adjusted hazard ratio 1.052 per % decrease; 95% CI: 1.010 - 1.095; P = 0.016), even after adjustment for several (n = 14) clinical and echocardiographic confounders.
PALS is independently associated with all-cause mortality in patients with reduced LVEF and ventricular FMR.
Cardiology has not been seen as an attractive specialty, and women have avoided it for many years. Some surveys have been performed in other countries, but in Portugal, the situation is largely ...unknown.
An online survey on perceptions of cardiology and professional preferences was sent to 1371 members of the Portuguese Society of Cardiology, of whom 18.2% completed the survey.
We included 219 cardiologists or cardiology trainees, of whom 50.2% were female, with decreasing proportions from younger to older age groups, in which males still predominate. Women are less often married and more frequently childless, particularly those working in an invasive subspecialty, where they represent only 16% of all respondents working in these areas. Men's perception is that women do not choose these areas due to family reasons, radiation concerns and difficult working conditions, but from the female perspective, male dominance, lack of female role models and restricted access are the main barriers. Women consider it is difficult for them to obtain a leadership role, but men do not think the same (75.5% vs. 27.5%).
In Portugal, females predominate in younger age groups, suggesting a paradigm change. Women are less frequently married and more frequently childless, particularly women working in invasive subspecialties. Women consider that it is more difficult for them to obtain a leadership role. Moreover, the barriers reported by women are substantially different from men regarding the reasons for not choosing an invasive subspecialty.
A cardiologia não tem sido uma especialidade atrativa, que as mulheres têm habitualmente evitado. Alguns questionários foram realizados na Europa, mas em Portugal esta realidade é desconhecida.
Foi enviado um questionário online sobre a perceção da cardiologia e preferências profissionais a 1371 membros da Sociedade Portuguesa de Cardiologia, tendo 18,2% respondido.
Incluíram-se no estudo 219 cardiologistas/internos de cardiologia, 50,2% mulheres, com aumentos progressivos da proporção de mulheres dos grupos etários mais jovens para os mais idosos, onde os homens ainda predominam. As mulheres são mais frequentemente solteiras e sem filhos, particularmente se trabalharem em áreas invasivas, onde elas representam apenas 16% dos respondedores que trabalham nessas áreas. A perceção masculina é de que as mulheres não escolhem as áreas invasivas por motivos familiares, preocupações com radiação e condições de trabalho difíceis. Contudo, a perspetiva feminina é de que as principais barreiras são a dominância masculina, ausência de role-models femininos e acesso restrito. As mulheres consideram também mais frequentemente que lhes é difícil chegar a lugares de liderança, não sendo essa a opinião global dos homens (75,5% versus 27,5%).
Em Portugal, as mulheres predominam nos grupos mais jovens, sugerindo uma mudança de paradigma. As mulheres são mais frequentemente solteiras e sem filhos, particularmente se trabalharem em áreas invasivas. Consideram que lhes é mais difícil atingir um lugar de liderança. As perspetivas femininas e masculinas relativas às barreiras colocadas às mulheres na escolha das áreas invasivas de subespecialização são substancialmente diferentes e até diametralmente opostas.
Increased collagen content of the myocardium modifies tissue reflectivity and integrated backscatter (IBS) indexes are suggested as markers of myocardial fibrosis (MF). We sought to assess the ...correlation between calibrated (c) IBS and bidimensional (2D) strain derived IBS with left ventricular (LV) MF in patients with severe aortic stenosis (AS).
We made a prospective observational cohort study including 157 patients with severe AS referred for surgical aortic valve replacement (AVR), with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of surgery. Two groups of 30 patients were specifically evaluated, with and without late gadolinium enhancement (LGE) at CMR. IBS was obtained at QRS peak from both parasternal long axis (PLAX) and apical-three-chamber (AP3C) views and measured in decibels (dB). Whole-cardiac cycle IBS at basal anterior septum was obtained from 2D longitudinal strain. Correlation analysis of reflectivity indexes was performed with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) (Masson´s Trichrome). IBS values were compared in both group of patients (LGE + vs. LGE -). 60 patients (74 36-74 years, 45% male) with high gradient (mean gradient: 63 ± 20mmHg), normal flow (45 ± 10mL/m
) AS and preserved left ventricular ejection fraction (60 ± 9%) were included. Basal septum cIBS was - 17.45 (-31.2-10.95) and - 9.17 ± 9.45dB from PLAX and A3C views, respectively. No significant correlations were found between IBS and both non-invasive CMR tissue characterization and CVF: median MF of 9.7(2.1-79.9)%. Acoustic indexes were not significantly different according to the presence of pre-operative LGE.
In this group of patients with classical severe AS, IBS reflectivity indexes are of no added value to discriminate the presence of MF.
Proportionality of secondary mitral regurgitation (sMR) may be a key factor in deciding whether a patient may benefit from mitral intervention. The aim of this study was to evaluate the prognostic ...value of two different concepts of proportionality and assess their ability to improve MR stratification proposed by the American Society of Echocardiography (ASE) guidelines.
We conducted a retrospective analysis in patients with reduced left ventricular ejection fraction (LVEF) (<50%) and at least mild sMR. Proportionality status was calculated using formulas proposed by a) Grayburn et al. – disproportionate sMR defined as EROALVEDV >0.14; b) Lopes et al. – disproportionate sMR whenever measured EROA>theoretical EROA (determined as 50%×LVEF×LVEDVMitralVTI). Primary endpoint was all-cause mortality.
A total of 572 patients (69±12 years; 76% male) were included. Mean LVEF was 33±9%, with a median left ventricular end-diastolic volume of 174 mL 136;220 and a median effective regurgitant orifice area of 14 mm2 8;22. During mean follow-up of 4.1±2.7 years, there were 254 deaths. There was considerable disagreement (p<0.001) between both formulas: of 96 patients with disproportionate sMR according to Lopes’ criteria, 46 (48%) were considered proportionate according to Grayburn's; and of 62 patients with disproportionate sMR according to Grayburn's, 12 (19%) were considered proportionate according to Lopes’ formula.
In multivariate analysis, only Lopes’ definition of disproportionate sMR maintained independent prognostic value (hazard ratio 1.5; 95% confidence interval 1.07–2.1, p=0.018) and improved the risk stratification of ASE sMR classification.
Of the two formulas available to define disproportionate sMR, Lopes’ model emerged as the only one with independent prognostic value while improving the risk stratification proposed by the ASE guidelines.
A proporcionalidade da regurgitação mitral secundária (sMR) pode ser um fator chave na decisão de que doentes podem beneficiar de intervenção mitral. O objetivo deste estudo foi de avaliar o valor prognóstico de dois modelos de proporcionalidade e aferir a sua capacidade para melhorar a estratificação da regurgitação mitral proposta pelas guidelines da ASE.
Realizamos um estudo retrospetivo com doentes com LVEF reduzida (<50%) e pelo menos sMR ligeira. O status de proporcionalidade foi calculado usando as fórmulas propostas por: a) Grayburn et al. – sMR desproporcional definida por EROALVEDV >0.14; b) Lopes et al. – sMR desproporcional quando o EROA medido>EROA teórico (determinado por 50%×LVEF×LVEDVMitralVTI). O endpoint primário foi mortalidade por qualquer causa.
Foram incluídos 572 pacientes (69±12 anos; 76% sexo masculino). LVEF média foi de 33±9%, com um LVEDV mediano de 174 mL 136;220 e um EROA mediano de 14 mm2 8;22. Após um follow-up médio de 4,1±2,7 anos, ocorreram 254 mortes. Verificou-se marcada discordância (p<0,001) entre ambas as fórmulas: de entre 96 doentes com sMR desproporcional pelo modelo de Lopes, 46 (48%) foram considerados proporcionais pela fórmula de Grayburn; de entre os 62 doentes com sMR desproporcional pelo modelo de Grayburn, 12 (19%) foram considerados proporcionais pelo modelo de Lopes.
Em análise multivariável, apenas a definição de desproporcionalidade descrita por Lopes manteve valor prognóstico independente (HR 1,5; 95%CI 1,07–2,1, p=0,018) e melhorou a estratificação de risco pela classificação da sMR da ASE.
De entre as duas fórmulas disponíveis para definição sMR desproporcional, apenas o modelo de Lopes demonstrou valor prognóstico independente e melhorou a estratificação de risco proposta pelas guidelines da ASE.
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