Dynamics of functional mitral regurgitation during dobutamine therapy in patients with severe congestive heart failure: A Doppler echocardiographic study

doi:10.1016/0002-8703(89)90588-7

American Heart Journal

Volume 118, Issue 4, October 1989, Pages 748-754

https://doi.org/10.1016/0002-8703(89)90588-7 Get rights and content

Abstract

Functional mitral regurgitation plays a major role in determining the therapeutic response to vasodilators in patients with severe congestive heart failure. Its role in the response to inotropic therapy has not been studied in these patients. Ten patients with stage 3 or 4 congestive heart failure (New York Heart Association class) and secondary mitral regurgitation were studied before and during intravenous administration of dobutamine (mean dose, 7.4 μg/kg/min). Hemodynamic measurements were obtained invasively. Echo and Doppler cardiography were used to determine cardiac volumes. Mitral regurgitation was calculated as the difference between total stroke volume by echo and forward stroke volume by Doppler. Mitral regurgitation area was calculated from a modified hemodynamic formula. Dobutamine caused a marked rise in mean forward stroke volume (43 to 61 ml), with a decrease in mitral regurgitation volume from 20 to 10 ml/beat and a drop in pulmonary capillary wedge pressure from 21 to 13 mm Hg. Since the pressure gradient between the left ventricle and atrium increased significantly during dobutamine therapy, only a marked decrease in the orifice of regurgitation could explain the changes in regurgitant volume. Indeed, the end-diastolic volume decreased from 254 to 234 ml and the orifice of mitral regurgitation was reduced from 0.25 to 0.12 cm².

References (31)

C Yoran et al.
Mechanism for reduction of mitral regurgitation with vasodilator therapy
Am J Cardiol
(1979)
G Keren et al.
Noninvasive quantification of mitral regurgitation in dilated cardiomyopathy: correlation of two Doppler echocardiographic methods
Am Heart J
(1988)
RH Strauss et al.
Predictability of mitral regurgitation detected by Doppler echocardiography in patients referred for cardiac transplantation
Am J Cardiol
(1987)
G Keren et al.
Dynamics of mitral regurgitation during nitroglycerin therapy: a Doppler echocardiographic study
Am Heart J
(1986)
LW Stevenson et al.
Effects of afterload reduction (diuretics and vasodilators) on left ventricular volume and mitral regurgitation in severe congestive heart failure secondary to ischemic or congestive cardiomyopathy
Am J Cardiol
(1987)
DS Weiland et al.
Contribution of reduced mitral regurgitant volume to vasodilator effect in severe left ventricular failure secondary to coronary artery disease or idiopathic dilated cardiomyopathy
Am J Cardiol
(1986)
I Schnittger et al.
Limitations of comparing left ventricular volumes by two dimensional echocardiography. Myocardial markers and cineangiography
Am J Cardiol
(1982)
EP Gordon et al.
Reproducibility of left ventricular volumes by two dimensional echocardiography
J Am Coll Cardiol
(1983)
R Grose et al.
Systemic and coronary effects of intravenous milrinone and dobutamine in congestive heart failure
J Am Coll Cardiol
(1986)
TB Levine et al.
Activity of the sympathetic nervous system and the renin angiotensin system assessed by plasma hormone levels and their relation to hemodynamic abnormalities in congestive heart failure
Am J Cardiol
(1982)

M Packer et al.

Physiologic and pharmacologic determinants of vasodilator response: a conceptual framework for rational drug therapy for chronic heart failure

Prog Cardiovasc Dis

(1982)

JN Cohn et al.

Neurohumoral control mechanism in congestive heart failure

Am Heart J

(1981)

MJ Likoff et al.

Comparison of acute hemodynamic effects of dobutamine and intravenous MDL 17,043 in severe congestive heart failure secondary to ischemic or dilated cardiomyopathy

Am J Cardiol

(1986)

C Yoran et al.

Dynamic aspects of mitral regurgitation: effects of ventricular volume, pressure and contractility on the effective regurgitant orifice area

Circulation

(1979)

DM Borgenhagen et al.

The effects of left ventricular load and contractility on mitral regurgitant orifice size and flow in the dog

Circulation

(1976)

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Pharmacologic management of myxomatous mitral valve disease in dogs
2012, Journal of Veterinary Cardiology
Citation Excerpt :
High-dose pimobendan (0.3 mg/kg TID); (see Class C1 discussion) In one of the author’s (CEA) clinic, high-dose pimobendan is frequently used and the experience is that it is both safe and effective in refractory heart failure. Intravenous inotropic support, using dobutamine at 2–15 ug/kg/min) as an alternative, more rapidly acting inotrope (also a lusitropic and afterload-reducing agent, which means it has the potential to reduce the mitral valve orifice size,59 thereby reducing MR). Class D2 denotes dogs which have developed signs of CHF and/or low output signs (e.g., exercise intolerance, weakness, syncope) and which have been treated and relapsed or failed to respond to initial treatment (thereby, are refractory).
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.
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Pre-ejection annular area reduction is an important mechanism for mitral valve leaflet competency.27 It is also known that inotropically induced mitral area reduction abolishes mitral insufficiency in functional mitral regurgitation.28 Measuring the dynamic mitral annular area, however, is challenging.
The mitral annulus is a dynamic, saddle-shaped structure consisting of fibrous and muscular regions. Normal physiologic mechanisms of annular motion are incompletely understood, and more complete characterization is needed to provide rational basis for annuloplasty ring design and to enhance clinical outcomes.
Seventeen sheep had radiopaque markers implanted; 16 around the annulus and 2 on middle anterior and posterior leaflet edges. Four-dimensional marker coordinates were acquired with biplanar videofluoroscopy at 60 Hz. Hinge angle was quantified between fibrous and muscular annular planes, with 0° defined at end diastole, to characterize its contribution to alterations in mitral septal–lateral dimension and 2-dimensional total annular area throughout the cardiac cycle.
During isovolumic contraction (pre-ejection), hinge angle abruptly increased, reaching maximum (steepest saddle shape, change 18° ± 13°) at peak left ventricular pressure. During ejection, hinge angle did not change; it then decreased during early filling (change 2° ± 2°). Septal–lateral dimension and total area paralleled hinge angle dynamics and leaflet distance (anterior to posterior marker). Pre-ejection septal–lateral reduction was 13% ± 7% (3.3 ± 1.5 mm) from 9% muscular dimension fall and 18° ± 13° hinge angle increase.
Pre-ejection increase in hinge angle contributes substantially to septal–lateral and total area reduction, facilitating leaflet coaptation. Semirigid annuloplasty rings or partial bands may preserve hinge motion, but possible recurrent annular dilatation could result in recurrent mitral regurgitation. Long-term clinical studies are required to determine who might benefit most from preserving intrinsic hinge motion without compromising repair durability.
Clinical value of exercise Doppler echocardiography in patients with cardiac-valvular disease
2008, Archives of Cardiovascular Diseases
Besides its usefulness for the detection of exercise-induced ischemia, conventional exercise testing may help to predict the onset of clinical events and the need for surgery in asymptomatic patients with cardiac-valvular disease. Doppler echocardiography examination during exercise recently emerged as a new stress testing modality that may add useful information regarding dynamism of LV function, valve disease severity and pulmonary circulation. Few studies have demonstrated a correlation between the results of exercise Doppler echocardiography and clinical outcome. Preliminary experience needs to be confirmed to warrant routine use of Doppler echocardiography examination during exercise in the evaluation of patients with cardiac-valve disease.
Au-delà de son utilité dans la détection d’une ischémie induite par l’effort, le test d’effort conventionnel réalisé chez des patients porteurs de valvulopathies, asymptomatiques, pourrait contribuer à prédire la survenue d’évènements cliniques et aider à poser les indications opératoires. L’échographie doppler pendant un exercice physique apparaît comme une nouvelle modalité d’évaluation pour ces patients apportant des informations complémentaires concernant la dynamique de la fonction ventriculaire gauche, la sévérité de l’atteinte valvulaire et la circulation pulmonaire. Peu d’études ont, à ce jour, établi une corrélation entre les données obtenues par échographie doppler à l’effort et le devenir des patients. Les études préliminaires nécessitent confirmation avant d’utiliser en pratique clinique l’échodoppler cardiaque d’effort pour les patients porteurs de valvulopathies.
Exercise does not enhance the prognostic value of Doppler echocardiography in patients with left ventricular systolic dysfunction and functional mitral regurgitation at rest
2008, American Heart Journal
Functional mitral regurgitation (MR) is a powerful predictor of poor prognosis in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD). However, severity of MR varies with dynamic exercise. Accordingly, we sought to assess the prognostic value of exercise-induced changes in functional MR in patients with LVSD and functional MR at rest.
One hundred four patients with chronic heart failure due to LVSD (ejection fraction [EF] <45%) and functional MR at rest underwent conventional continuous 2-dimensional Doppler echocardiography at rest and during maximal symptom-limited exercise. The primary end point of the study was all-cause mortality. The median follow-up period was 20 months.
Fifty-six patients (54%) had ischemic cardiomyopathy. When feasible, all 56 patients with ischemic cardiomyopathy had undergone revascularization procedures before enrollment into the study. In the whole patient cohort, resting LV end-diastolic volume was 205 ± 76 mL and EF was 26% ± 9%. Univariate predictors of death were functional class (New York Heart Association), LV EF, LV end-diastolic volume, resting mitral effective regurgitant orifice, mitral E deceleration time, tricuspid annular plane systolic excursion ≤14 mm, systolic blood pressure, LV EF, and trans-tricuspid pressure gradient response to exercise. Exercise-induced change in mitral effective regurgitant orifice did not predict survival (HR 0.99, 95% CI 0.94-1.04, P = .63). By Cox multivariate analysis, resting LV end-diastolic volume and tricuspid annular plane systolic excursion ≤14 mm were the independent predictors of death.
Exercise Doppler echocardiography does not refine the predictive value of resting Doppler echocardiography in patients with LVSD and functional MR at rest.
Functional valvular incompetence in decompensated heart failure: Noninvasive monitoring and response to medical management
2005, American Journal of the Medical Sciences
We hypothesized that functional mitral and tricuspid valvular incompetence (MR and TR, respectively) are reversible causes of reduced cardiac output in decompensated heart failure (DF) that accompanies systolic dysfunction in ischemic or nonischemic cardiomyopathy.
DF, defined as signs and symptoms of heart failure at rest, is rooted in a salt-avid state transduced by neurohormonal activation secondary to impaired renal perfusion. Functional MR and TR are reversible causes of reduced systemic blood flow. Their impact on cardiac output, thoracic fluid content, cardiac chamber dimensions, and valvular apparatus function can be monitored noninvasively, before and after optimized medical management.
Fourteen male subjects (66 ± 8 years old) with reduced ejection fraction (24 ± 5%) secondary to ischemic (71%) or nonischemic (29%) cardiomyopathy, who developed DF with clinical evidence of mitral (MR) and tricuspid (TR) valvular incompetence, were each assessed by bioimpedance and echocardiography before and 1 week after optimized medical management restored compensated failure.
Pharmacologic elimination of DF was accompanied by a reduction in body weight (P < 0.01). Hemodynamic improvements included a rise in cardiac index (2.1 to 2.6 L/min/m²; P < 0.01) and a reduction in predicted pulmonary artery systolic pressure (58 to 35 mm Hg; P < 0.001), thoracic fluid content (39 to 32 kOhm; P < 0.001), and systemic vascular resistance (1633 to 1209 dynes/sec/cm⁵; P < 0.001). Improvements in functional MR and TR included reductions in left and right atrial areas (27 to 24 cm² and 26 to 23 cm², respectively; P < 0.001), color-flow grading of MR and TR severity (P < 0.01), mitral regurgitant volume (105 to 65 mL; P < 0.001), and effective MR orifice size (0.8 to 0.6 cm²; P < 0.01).
In DF, functional MR and TR contribute to reduced cardiac output, increased thoracic fluid content, and systemic vascular resistance, together with enlarged atria and valvular orifice size, which can be improved by medical management. Bioimpedance and echocardiography provide for serial noninvasive assessments of hemodynamic status and valvular function in such cases.
Influence of inotropy and chronotropy on the mitral valve sphincter mechanism
2004, Annals of Thoracic Surgery
This study was designed to isolate and quantify the effects of ventricular inotropic and chronotropic state on the normal mitral valve annular sphincter mechanism.
Sonomicrometry tansducers were placed around the mitral annulus in six sheep; atrial pacing wires were also placed. One week later, esmolol was titrated to produce a baseline hemodynamic state with a heart rate of 90 bpm; hemodynamic and sonomicrometry data were recorded. Then animals were paced at 120 bpm and 150 bpm; data were recorded at each heart rate. Isoproterenol infusion was titrated to achieve a heart rate, without pacing, of 120 and 150 bpm; again, data were recorded. Annular area was calculated at end diastole (ED) and end systole (ES) for all experiments using sonomicrometry array localization. Analysis of variance was used to assess the independent effects of heart rate and inotropic state on annular area.
Atrial pacing at 120 bpm produced ES and ED annular areas of 777 ± 150 mm² and 748.8 ± 140.1 mm², respectively. At the same heart rate, isoproterenol-treatment resulted in significantly smaller ES and ED areas: 699 ± 160 mm² and 641.9 ± 156.5 mm², respectively. Atrial pacing at 150 bpm produced ES and ED annular areas of 745.2 ± 131.3 mm² and 723.7 ± 141.3 mm², respectively. At the same heart rate, isoproterenol-treatment resulted in significantly smaller ES and ED areas: 652.8 ± 146.4 mm² and 569.7 ± 155.9 mm², respectively.
The inotropic state of the left ventricle directly affects the mitral valve annular orifice area, independent of heart rate. This inotropic effect on valve size is more pronounced at ED than at ES in the sheep.

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Dynamics of functional mitral regurgitation during dobutamine therapy in patients with severe congestive heart failure: A Doppler echocardiographic study☆

Abstract

Am J Cardiol

Am Heart J

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Prog Cardiovasc Dis

Am Heart J

Am J Cardiol

Dynamic aspects of mitral regurgitation: effects of ventricular volume, pressure and contractility on the effective regurgitant orifice area

Circulation

The effects of left ventricular load and contractility on mitral regurgitant orifice size and flow in the dog

Circulation