Background Percutaneous mitral repair with the MitraClip device (Evalve, Menlo Park, CA) has been reported. Preserving conventional surgical options in the event of percutaneous treatment failure is ...important. We describe surgical treatment at varying intervals after the MitraClip procedure in 32 patients. Methods One hundred seven patients with moderate-to-severe or severe mitral regurgitation who were either symptomatic (91%) or, if asymptomatic (9%), had evidence of left ventricular dysfunction were enrolled as part of the Endovascular Valve Edge-to-Edge REpair STudy (EVEREST) phase I registry study or as “roll-in” subjects in the EVEREST II study. Thirty-two of the 107 patients (30%) underwent surgery after an attempted MitraClip procedure. Results Of the 32 patients undergoing post-clip mitral valve surgery, 23 patients (72%) had one or more clips implanted and 9 patients (28%) received no clip implant. The indications for mitral valve surgery in the 23 patients with a clip included partial clip detachment (n = 10), residual or recurrent mitral regurgitation greater than 2+ (n = 9), and other (atrial septal defect n = 2, device malfunction n = 1, and incorrectly diagnosed mitral stenosis n = 1). Twenty-seven of 31 patients (87%) underwent the surgical procedure planned before surgery (planned procedure unknown in 1 patient). Four of 25 patients (16%) with planned repair underwent mitral valve replacement. Conclusions Standard surgical options were preserved in patients who had surgery after percutaneous repair with the MitraClip device. Successful repair was feasible in the majority of patients after the MitraClip procedure, with repair performed as late as 18 months after clip implantation.
Septal to Posterior Wall Motion Delay Fails to Predict Reverse Remodeling or Clinical Improvement in Patients Undergoing Cardiac Resynchronization Therapy
Emily Rose, Gregory M. Marcus, Esperanza M. ...Viloria, Jill Schafer, Teresa De Marco, Leslie A. Saxon, Elyse Foster, for the VENTAK CHF/CONTAK-CD Biventricular Pacing Study Investigators
This study was designed to test the hypothesis that longer septal-to-posterior wall motion delay (SPWMD) would predict reverse remodeling and clinical response in a cohort of heart failure patients with predominantly ischemic cardiomyopathy randomized to cardiac resynchronization therapy in the CONTAK-CD trial. The SPWMD failed to reliably predict beneficial ventricular remodeling or clinical response.
The aim of this study was to test the hypothesis that a longer septal-to-posterior wall motion delay (SPWMD) would predict greater reverse remodeling and an improved clinical response in heart failure patients randomized to cardiac resynchronization therapy (CRT) in the CONTAK-CD trial.
The SPWMD predicted clinical benefit with CRT in two previous studies from the same center.
In this retrospective analysis of the CONTAK-CD trial, SPWMD was measured from the baseline echocardiogram of 79 heart failure patients (ejection fraction 22 ± 7%, QRS duration 159 ± 27 ms, 72% ischemic, 84% male) randomized to CRT and compared with six-month changes in echocardiographic and clinical parameters. Patients with a left ventricular end-systolic volume index (LVESVI) reduction of at least 15% were considered responders.
The feasibility and reproducibility of performing the SPWMD measurements were poor. Larger values for SPWMD did not correlate with six-month changes in left ventricular end-diastolic volume index (p = 0.26), LVESVI (p = 0.41), or left ventricular ejection fraction (p = 0.36). Responders did not have a significantly different SPWMD than non-responders (p = 0.26). The SPWMD did not correlate with measures of clinical improvement. At a threshold of SPWMD >130 ms, the test characteristics to predict reverse remodeling or a clinical response were inadequate.
The previous findings that SPWMD predicts reverse remodeling or clinical improvement with CRT were not reproducible in patients randomized in the CONTAK-CD trial.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Whites have an increased risk of atrial fibrillation (AF) compared to Blacks. The mechanism underlying this association is unknown. Left atrial (LA) size is an important AF risk factor, and studies ...in older adults suggest Whites have larger LA diameters. However, because AF itself causes LA dilation, LA size differences may be due to greater subclinical AF among older Whites. We therefore assessed for racial differences in LA size among young adults at low AF risk. The Coronary Artery Risk Development in Young Adults (CARDIA) study enrolled White and Black participants between 18 and 30 years of age. LA diameter was measured in a subset of participants using echocardiography at Year 5 (n = 4,201) and Year 25 (n = 3,373) of follow up. LA volume was also assessed at Year 5 (n = 2,489). Multivariate linear regression models were used to determine the adjusted association between race and LA size. In unadjusted analyses, mean LA diameter was significantly larger among Blacks compared to Whites both at Year 5 (35.5 ± 4.8 mm versus 35.1 ± 4.5 mm, p = 0.01) and Year 25 (37.4 ± 5.1 mm versus 36.8 ± 4.9 mm, p = 0.002). After adjusting for demographics, comorbidities, and echocardiographic parameters, Whites demonstrated an increased LA diameter (0.7 mm larger at Year 5, 95% CI 0.3-1.1, p<0.001; 0.6 mm larger at Year 25, 95% CI 0.3-1.0, p<0.001). There was no significant association between race and adjusted Year 5 LA volume. In conclusion, in a young, well-characterized cohort, the larger adjusted LA diameter among White participants suggests inherent differences in atrial structure may partially explain the higher risk of AF in Whites. The incongruent associations between race, LA diameter, and LA volume suggest that LA geometry, rather than size alone, may have implications for AF risk.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Percutaneous mitral repair is rapidly developing as an alternative to cardiac surgery in select patients. The Evalve percutaneous E2E system uses the MitraClip to replicate the surgical suture-based ...approach. This procedure requires real-time echocardiographic guidance in a unique and significant collaboration between echocardiographer and interventionalist. transesophageal echocardiography (TEE) is used as the primary imaging modality to guide this procedure and is essential to its success.
In EVEREST I, the US multicenter phase I safety and feasibility trial, 47 patients with 3 or 4+ mitral regurgitation (MR) were enrolled. The trial involved a standardized echocardiographic imaging protocol with a standardized anatomic-based vocabulary, predetermined standard TEE views, preprocedural strategy meetings, and display of echocardiographic aids to optimize communication and procedural efficiency during placement of the clip.
TEE guidance facilitated the creation of a double-orifice mitral valve in all 47 patients enrolled (100%), and 40 patients were discharged with 1 or more clips (85%). At discharge, successful placement of a clip and <or= 2+ MR was present in 34 patients (74%). The standardized approach contributed to a reduction in the time to perform the procedure over the course of the trial at both initial and new sites.
TEE is essential to the guidance of percutaneous MitraClip E2E repair. A streamlined approach to echocardiographic guidance, using predetermined standardized views, a common anatomic-based vocabulary, preprocedural strategy meetings, and a display of echocardiographic aids in the catheterization laboratory shortens the procedure time and allows for efficient percutaneous repair.
A 44-year-old man presents with dyspnea and new atrial fibrillation. He received a diagnosis of mild mitral regurgitation at 28 years of age but has not seen a physician in many years. Physical ...examination reveals a holosystolic murmur and a soft S
3
. Repeat echocardiography shows a flail posterior leaflet and moderately severe mitral regurgitation. How should this case be managed?
A 44-year-old man presents with dyspnea and new atrial fibrillation. He received a diagnosis of mild mitral regurgitation at 28 years of age but has not seen a physician in many years. Echocardiography shows a flail posterior leaflet and moderately severe mitral regurgitation. How should this case be managed?
Foreword
This
Journal
feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.
Stage
A 44-year-old man presents with dyspnea and new atrial fibrillation. He received a diagnosis of mitral regurgitation at 28 years of age, after physical examination revealed a midsystolic click and late-systolic murmur; echocardiography performed at that time showed mitral-valve prolapse with mild late-systolic mitral regurgitation and normal left ventricular size and function. He has not seen a physician in many years. Physical examination reveals a holosystolic murmur and a soft S
3
sound. Repeat echocardiography shows a flail posterior leaflet and moderately severe mitral regurgitation. How should this case be managed?
The Clinical Problem
Degenerative disease is the most . . .
While percutaneous closure is preferred in adults with a patent ductus arteriosus (PDA), the extent of cardiac remodeling following percutaneous PDA closure in adults is not well understood. We ...performed a meta-analysis to characterize cardiac remodeling following percutaneous PDA closure in adults.
MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (24 h), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included data from patients >18 years of age that underwent percutaneous PDA closure between January 2015–December 2019 at our centre. Weighted averages were calculated for parameters with sufficient data. Pooled differences were presented as weighted mean differences (WMD).
After screening 278 abstracts, 5 studies were identified. When combined with our cohort, our meta-analysis encompassed 244 patients. Immediately post-procedure, LVEF was the only parameter to change significantly (64 vs 52%, WMD -8.64 95%, CI -14.04 to −3.25). All parameters significantly decreased from baseline to follow-up: LVEF: 64 vs 60% (WMD -3.95, CI -5.80 to −2.09), LVEDD: 62 vs 53 mm (WMD -8.79, CI -12.78 to −4.81) LVEDVI 172 vs 123 mL/m2 (WMD -26.60, CI -45.4 to −7.85), LVESD 42 vs 36 mm (WMD -4.64, CI -9.10 to −0.17) and LA dimension: 42 vs 37 mm (WMD -5.87, CI -9.85 to −1.90).
As compared to the baseline values, left ventricular and left atrial sizes decreased. The LVEF decreased immediately following PDA closure and, while it recovers, it remained lower on follow-up testing.
Abbreviations: CI: Confidence interval; LA: left atrium, LVEDD: left ventricular end-diastolic dimension, LVEDVI: left ventricular end-diastolic index, LVEF: left ventricular ejection fraction. LVESD: left ventricular end-systolic dimension, LVESVI: left ventricular end-systolic index, WMD: weighted mean difference. Display omitted
•Left atrial and left ventricular sizes decrease after percutaneous PDA closure.•LVEF decreases acutely after percutaneous PDA closure.•LVEF improves however remains lower on follow-up testing than the baseline LVEF.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The primary objective of this study was to test whether an elevated systolic pulmonary artery (PA) pressure or an elevated pulmonary dead space fraction (Vd/Vt) in early acute lung injury (ALI) is ...associated with poor clinical outcomes in the era of lung-protective ventilation.
Prospective observational cohort study.
ICUs of a university hospital.
Forty-two patients with ALI receiving mechanical ventilation.
PA pressure was measured noninvasively using transthoracic echocardiography. Vd/Vt was measured by volumetric capnography (NICO Cardiopulmonary Management System; Novametrix; Wallingford, CT).
There was no difference in the mean systolic PA pressure in patients who died compared to those who survived (43 ± 9 mm Hg vs 41 ± 9 mm Hg, p = 0.54) mean ± SD. In contrast to the PA systolic pressure, Vd/Vt was significantly higher in patients who died compared to those who survived (0.61 ± 0.09 vs 0.53 ± 0.10, p = 0.02). Similarly, Vd/Vt was higher in patients with < 7 ventilator-free days during the first 28 days after enrollment compared to those with > 7 ventilator-free days (0.61 ± 0.08 vs 0.52 ± 0.11, p = 0.008).
In the era of lung-protective ventilation, systolic PA pressure early in the course of ALI is elevated but not predictive of outcome. However, elevated Vd/Vt in early ALI is associated with increased mortality and with fewer ventilator-free days.
Although the anteroposterior dimension of the left atrium is universally used in clinical practice and research, we hypothesized that it may be an inaccurate surrogate for volume because its use is ...based on the unlikely assumption that there is a constant relation among atrial dimensions. The following measurements of the left atrium were made at end ventricular systole: (1) M-mode–derived anteroposterior linear dimension from the parasternal long-axis view; (2) digitized planimetry of the left atrial (LA) cavity from the apical 4-chamber view; and (3) digitized planimetry of the LA cavity from the apical 2-chamber view. The following volume calculations were obtained from these digital measurements: (1) volume derived from the M-mode dimension assuming a spherical shape; (2) volume derived from the single plane area-length of apical 4-chamber view, which assumes that LA geometry can be generalized from a single 2-dimensional plane; and (3) volume derived from the biplane method of discs. The correlation coefficient between the M-mode and biplane methods of determining LA volume was r = 0.76. The mean difference (±2 SDs) between these methods is −25 ± 33 ml. The correlation coefficient between the single plane apical 4-chamber and biplane methods of determining LA volume is r = 0.97. The mean difference (±2 SDs) between these methods was −5.0 ± 12 ml, indicating good agreement. The M-mode measure of the left atrium is an inaccurate representation of its size. Two-dimensional–derived LA volumes provide a more accurate measure of the true size of the left atrium and are more sensitive to changes in LA size. When an echocardiographic measure of LA size is made either in an individual patient or as a variable in a research study, the M-mode measure should be avoided.
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IJS, IMTLJ, KILJ, KISLJ, NUK, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background In EVEREST II (Endovascular Valve Edge-to-Edge Repair Study), treatment of mitral regurgitation (MR) with a novel percutaneous device showed superior safety compared with surgery, ...but less effective reduction in MR at 1 year. Objectives This study sought to evaluate the final 5-year clinical outcomes and durability of percutaneous mitral valve (MV) repair with the MitraClip device compared with conventional MV surgery. Methods Patients with grade 3+ or 4+ MR were randomly assigned to percutaneous repair with the device or conventional MV surgery in a 2:1 ratio (178:80). Patients prospectively consented to 5 years of follow-up. Results At 5 years, the rate of the composite endpoint of freedom from death, surgery, or 3+ or 4+ MR in the as-treated population was 44.2% versus 64.3% in the percutaneous repair and surgical groups, respectively (p = 0.01). The difference was driven by increased rates of 3+ to 4+ MR (12.3% vs. 1.8%; p = 0.02) and surgery (27.9% vs. 8.9%; p = 0.003) with percutaneous repair. After percutaneous repair, 78% of surgeries occurred within the first 6 months. Beyond 6 months, rates of surgery and moderate-to-severe MR were comparable between groups. Five-year mortality rates were 20.8% and 26.8% (p = 0.4) for percutaneous repair and surgery, respectively. In multivariable analysis, treatment strategy was not associated with survival. Conclusions Patients treated with percutaneous repair more commonly required surgery for residual MR during the first year after treatment, but between 1- and 5-year follow-up, comparably low rates of surgery for MV dysfunction with either percutaneous or surgical therapy endorse the durability of MR reduction with both repair techniques. (EVEREST II Pivotal Study High Risk Registry; NCT00209274 )
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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