Background Mitral regurgitation (MR) is frequent in patients with aortic stenosis (AS). Although primary MR is an established negative prognostic factor, whether different mechanisms of MR have ...different effects on outcome is currently unknown. The aim of this study was to evaluate the impact of the MR mechanism in patients undergoing transcatheter aortic valve replacement (TAVR). Methods and Results This is a retrospective observational study of patients who underwent TAVR for severe aortic stenosis in a high‐volume tertiary care center. Echocardiographic comprehensive MR assessment was performed at baseline and within 3 months post TAVR. The study population was divided into 4 groups according to MR mechanism: Group I: fibro‐calcific leaflet degeneration; Group II: prolapse/flail; Group III: ventricular secondary MR (functional MR); and Group IV: atrial functional MR. The study end point was a combination of death from cardiovascular cause and heart failure–related hospitalization. The study population included 427 patients (mean age 81.7±6.5 years; 71% primary MR; 62% ≥moderate MR). At 3‐year follow‐up, survival free from the composite end point significantly differs according to MR mechanism: it was higher in group IV (atrial functional MR, 96.6%) compared with group I (80.4%, P =0.002) and group II patients (60.7%, P =0.001), and group III (84.8%, P =0.037); patients with MR due to leaflet prolapse showed poorer prognosis compared with patients with functional MR (group III, P =0.023 and group IV, P =0.001) and with group I ( P =0.040). Overall, severe MR after TAVR identified patients with poorer prognosis and was significantly more frequent in group II (46.4%, P =0.001). Conclusions In patients undergoing TAVR, preprocedural identification of MR mechanism and mechanism provides prognostic insights.
We demonstrate that in patients with stress cardiomyopathy the type of triggering event is associated with different clinical, instrumental, and laboratory features that characterize the phenotype at ...presentation.
COAPT-trial entry criteria are useful to identify patients with better outcomes after transcatheter edge-to-edge repair (TEER). However, up to one-half of real-world patients with secondary mitral ...regurgitation (SMR) undergoing TEER do not meet these highly selective criteria and no study has formally investigated them. The aim of this study was to evaluate the predictors of good outcome after TEER in COAPT-ineligible patients.
All consecutive patients with SMR and heart failure (HF) treated with MitraClip at 3 European centres were retrospectively screened. The presence of at least 1 COAPT exclusion criterion was used to define a COAPT-ineligible profile, allowing the inclusion in the study population. Freedom from all-cause death or HF hospitalisation was evaluated at 2-year follow-up (primary end point).
A total of 305 patients (47%) had a COAPT-ineligible profile. An overall 58% rate of all-cause death or HF hospitalisation was detected at 2 years. Patients with a single COAPT exclusion criterion experienced fewer adverse events than those with multiple criteria (55% vs 69%). At multivariable Cox regression analysis, New York Heart Association functional class II, younger age (< 75 years), lower serum creatinine (< 2 mg/dL), lower left ventricular end-diastolic volume (< 240 mL), and the absence of hemodynamic instability, atrial fibrillation, and chronic obstructive pulmonary disease were independently associated with good outcome.
In this real-world series of patients with SMR undergoing TEER, a COAPT-ineligible profile was common. The presence of only 1 COAPT exclusion criterion or the absence of hemodynamic instability were associated with the most favourable outcomes.
Les critères d’admission à l’étude COAPT (CardiovascularOutcomesAssessment of the MitraClipPercutaneousTherapy for Heart Failure Patients With Functional Mitral Regurgitation) sont utiles pour identifier les patients susceptibles d’obtenir de meilleurs résultats après une réparation mitrale percutanée bord à bord (RMPBB). Cependant, en contexte réel, jusqu’à la moitié des patients atteints d'insuffisance mitrale secondaire (IMS) qui subissent une RMPBB ne répondent pas à ces critères hautement sélectifs et aucune étude formelle ne les a formellement étudiés. La présente étude visait à évaluer les prédicteurs d’une issue favorable à la suite d’une RMPBB chez les patients non admissibles selon les critères de l’étude COAPT.
Tous les patients consécutifs atteints d'IMS et d’insuffisance cardiaque (IC) traités au moyen d’un dispositif MitraClip dans trois centres européens ont été choisis de façon rétrospective. La présence d’au moins un critère d’exclusion de l’étude COAPT a été utilisée pour définir un profil non admissible selon les critères COAPT, et admettre les patients dans la population de la présente étude. L’absence de décès toutes causes confondues et d’hospitalisation pour IC a été évaluée après un suivi de deux ans (critère d’évaluation principal).
Au total, 305 patients (47 %) présentaient un profil non admissible selon les critères COAPT. Un taux global de 58 % de décès toutes causes confondues ou d’hospitalisation pour IC a été observé après un suivi de deux ans. Chez les patients présentant un seul critère d’exclusion de l’étude COAPT, la fréquence de manifestations indésirables a été plus faible que chez les patients présentant plus d’un critère d’exclusion (55 % vs 69 %). Dans une analyse de régression de Cox multivariée, la classe II de la classification de la NYHA, un âge moins avancé (< 75 ans), un taux sérique de créatinine faible (< 2 mg/dl), un volume télédiastolique faible dans le ventricule gauche (< 240 ml), et l’absence d’instabilité hémodynamique, de fibrillation auriculaire et de maladie pulmonaire obstructive chronique ont été des variables associées de façon indépendante à une issue favorable.
Chez cette série de patients traités en contexte réel qui étaient atteints d'IMS et qui ont été soumis à une RMPBB, un profil non admissible selon les critères de l’étude COAPT était une ca- ractéristique courante. La présence d’un seul critère d’exclusion de l’étude COAPT ou l’absence d’instabilité hémodynamique ont été associées aux issues les plus favorables.
Renin-angiotensin-aldosterone (RAAS) is a hormone system which acts on multiple physiologic pathways primarily by regulating blood pressure and fluid balance, but also by local autocrine and ...paracrine actions. In pathophysiologic conditions RAAS also contributes to the development of atherosclerosis and its various manifestations, both directly and indirectly through the actions on other systems. RAAS mainly acts as a promoter of atherosclerosis by its action on vessels, and by promoting the development of hypertension, insulin resistance and diabetes, obesity, vascular and systemic inflammation. As RAAS plays a key role in the pathogenesis of cardiovascular diseases, RAAS genes have been extensively studied as candidate genes for atherosclerosis and coronary artery disease. Several polymorphisms of its genes have been found to be in relationship with atherosclerosis and cardiovascular diseases. In this review we will discuss these issues and present the most recent advances about this topic.
Atrial fibrillation (AF) is the most common clinically relevant cardiac arrhythmia. AF poses patients at increased risk of thromboembolism, in particular ischemic stroke. The CHADS2 and CHA2DS2-VASc ...scores are useful in the assessment of thromboembolic risk in nonvalvular AF and are utilized in decision-making about treatment with oral anticoagulation (OAC). However, OAC is underutilized due to poor patient compliance and contraindications, especially major bleedings. The Virchow triad synthesizes the pathogenesis of thrombogenesis in AF: endocardial dysfunction, abnormal blood stasis, and altered hemostasis. This is especially prominent in the left atrial appendage (LAA), where the low flow reaches its minimum. The LAA is the remnant of the embryonic left atrium, with a complex and variable morphology predisposing to stasis, especially during AF. In patients with nonvalvular AF, 90% of thrombi are located in the LAA. So, left atrial appendage occlusion could be an interesting and effective procedure in thromboembolism prevention in AF. After exclusion of LAA as an embolic source, the remaining risk of thromboembolism does not longer justify the use of oral anticoagulants. Various surgical and catheter-based methods have been developed to exclude the LAA. This paper reviews the physiological and pathophysiological role of the LAA and catheter-based methods of LAA exclusion.
Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust ...evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called “functional isolated” TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.
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