Over the past two decades interest in mitral valve regurgitation has increased as a result of the development of new technologies that have expanded the number of patients who can potentially benefit ...from mitral regurgitation treatments. To develop new devices for the treatment of mitral regurgitation, the focus has been placed on the functional anatomy and pathophysiology of the mitral valve, with the use of the most advanced methods of cardiac imaging that allow the best visualization of the mitral valve and a perfect understanding of the complexity of a specific disease. Mitral regurgitation is still underdiagnosed and undertreated in a substantial number of patients who have poor survival. Therefore, the priority should be to identify and treat these patients to increase their survival and quality of life. To achieve this goal, general physicians and cardiologists must be aware of all the treatment options that are currently available in dedicated centres of excellence. Patients referred to these centres can benefit from a tailored heart team-based approach. The aim of this Review is to analyse the basic principles of mitral regurgitation, discussing new concepts on the pathophysiology of the mitral valve that have been developed to facilitate the selection of patients for transcatheter procedures. We also describe the indications and timing of treatment, contemporary surgical and transcatheter techniques and the heart team approach, and highlight the need for centres of excellence.
Balloon predilation is historically considered a requirement before performing transcatheter aortic valve implantation (TAVI). As the procedure has evolved, it has been questioned whether it is ...actually needed, but data are lacking on mid-term outcomes. The aim of this study was to evaluate the effect of balloon predilation before TAVI. A total of 517 patients who underwent transfemoral TAVI from November 2007 to October 2015 were analyzed. The devices implanted included the Medtronic CoreValve (n = 216), Medtronic Evolut R (n = 30), Edwards SAPIEN XT (n = 210), and Edwards SAPIEN 3 (n = 61). Patients were divided into 2 groups depending on whether pre-implantation balloon aortic valvuloplasty (pre-BAV) was performed (n = 326) or not (n = 191). Major adverse cardiac and cerebrovascular events (MACCE) were primarily evaluated. Propensity score matching was used to adjust for differences in baseline characteristics and potential confounders (n = 113 pairs). In the overall cohort, patients without pre-BAV had a significantly higher MACCE rate at 30 days, driven by a higher incidence of stroke (0.3% pre-BAV vs 3.7% no-pre-BAV, p <0.01). MACCE and mortality at 1 year were, however, similar in both groups. Independent predictors of MACCE at 1 year included serum creatinine, NYHA class 3 to 4, logistic European System for Cardiac Operative Risk Evaluation, and postdilation. Of note, the postdilation rate was higher in the no-pre-BAV group (21.5% pre-BAV vs 35.6% no-pre-BAV, p <0.001). After propensity score matching, there were no differences in MACCE between the 2 groups. In conclusion, this study showed that, in selected patients and with specific transcatheter valves, TAVI without pre-BAV appears to be associated with similar mid-term outcomes compared with TAVI with pre-BAV, but it may increase the need for postdilation.
Nowadays, the necessity of having a cardioplegia circuit capable of being adapted in order to administer different types of cardioplegia is strategically fundamental, both for the perfusionist and ...for the cardiac surgeon. This allows to avoid cutting tubes, guarantees sterility and, most of all, limits the number of cardioplegia circuits for the different strategies of cardiac arrest. The novel “ReverseTWO cardioplegia circuit system” is the development of the precedent “Reverse system” where mainly the 4:1 and crystalloid cardioplegia were used, It has the advantage of allowing immediate change of cardioplegia set-up versus four types of cardioplegia technique, when the strategy is unexpectedly changed before the beginning of cardiopulmonary bypass (CPB), is safe and enables the perfusionist to use one single custom pack of cardioplegia. Two pediatric roller pumps are usually used in our centre for cardioplegia administration; they have a standardized calibration (the leading with ¼ inch and the follower with 1/8 inch) and the circuit consequently has two different tube diameters for the two different pumps. The presence in the circuit of two different shunts coupled with two different coloured clamps allows the immediate set-up for different cardioplegia administration techniques utilizing a colour-coding mechanism The aim of this manuscript is to present the new ReverseTWO Circuit. This novel system allows to administer four different cardioplegic solutions (4:1, 1:4, crystalloid, ematic) based on multiple tubes, which can be selectively clamped, identified through a color-coding method. The specificity of this circuit is the great versatility, which leads to numerous advantages, such as reduced risk of perfusion accident and reduced costs related not only to the purchase of different cardioplegia kits but also to the storage. https://youtu.be/ovJBE4ok2Ds
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.
The purpose of this study was to evaluate the impact of surgical timing on survival in patients with left-sided infective endocarditis (IE). This was a retrospective study including 313 patients with ...left-sided IE between 2009 and 2017. Surgery was defined as urgent (US) or early (ES) if performed within 7 or 28 days, respectively. A multivariable Cox regression analysis including US and ES as time-dependent variables was performed to assess the impact on 1-year mortality. ES was associated with a better survival (aHR 0.349, 95% CI 0.135–0.902), as US (aHR 0.262, 95% CI 0.075–0.915). ES and US were associated with a better prognosis in patients with left-sided IE.
The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) for surgically recognized mitral valve (MV) prolapse ...anatomy compared to 2-dimensional transthoracic echocardiography (2D-TTE), 2D-transesophageal echocardiography (2D-TEE), and real-time 3D-transthoracic echocardiography (RT3D-TTE). We preoperatively analyzed 222 consecutive patients undergoing repair for prolapse-related mitral regurgitation using RT3D-TEE, 2D-TEE, RT3D-TTE, and 2D-TTE. Multiplanar reconstruction was added to volume-rendered RT3D-TEE for quantitative prolapse recognition. The echocardiographic data were compared to the surgical findings. Per-patient analysis of RT3D-TEE identified prolapse in 204 patients more accurately (92%) than 2D-TEE (78%), RT3D-TTE (80%), and 2D-TTE (54%). Even among those 60 patients with complex prolapse (>1 segment localization or commissural lesions), RT3D-TEE correctly identified 58 (96.5%) compared to 42 (70%), 31 (52%), and 21 (35%) detected by 2D-TEE, RT3D-TTE, and 2D-TTE (p < 0.0001). Multiplanar reconstruction enabled RT3D-TEE to differentiate dominant (≥5-mm displacement) and secondary (2 to <5-mm displacement) prolapsed segments in agreement with surgically recognized dominant lesions (100%), but with a low predictive value (34%) for secondary lesions. In addition, owing to the identification of clefts and subclefts (indentations of MV tissue that extended ≥50% or <50% of the total leaflet height, respectively), RT3D-TEE accurately characterized the MV anatomy, including that which deviated from the standard nomenclature. In conclusion, RT3D-TEE provided more accurate mapping of MV prolapse than 2D imaging and RT3D-TTE, adding quantitative recognition of dominant and secondary lesions and MV anatomy details.
The COVID-19 pandemic has required reorganization of the cardiac surgery system in the Italian region of Lombardy during early 2020. As a consequence, the hub-and-spoke (H&S) model was introduced to ...manage emergent/urgent cardiac surgery cases. In this challenging scenario, in which thousands of people were affected by the novel coronavirus, we present the case of a successful treatment of a middle-aged patient affected by both COVID-19 pneumonia and subacute aortic endocarditis. Learning objective: How to treat endocarditis during the COVID-19 pandemic.
Background The purpose of this study was to evaluate the safety and clinical results of aortic valve replacement performed with minimally invasive closed circuit extracorporeal circulation technique ...(MECC system) versus standard cardiopulmonary bypass. Methods Forty consecutive patients undergoing isolated aortic valve replacement at a single institution were randomly assigned to either miniaturized closed circuit cardiopulmonary bypass with the Maquet-Cardiopulmonary (Rastatt, Germany) minimal extracorporeal circulation (MECC) system (study group B, n = 17) or standard cardiopulmonary bypass (control group A, n = 23). The MECC system is a low priming circuit without blood-air interface. Technical feasibility, in particular the potential entry of air in the circuit, and clinical results were prospectively evaluated. Results Demographic characteristics and surgical data were similar in both groups. Patients in the study group showed reduced chest tube drainage (217 ± 62 mL vs 420 ± 219 mL, p < 0.05) and blood transfusion requirements (5.1% vs 43.4%, p < 0.02) compared with patients in the control group. Moreover, the study group showed significantly higher time course of hematocrit at all time points during the operation and longer hospital stay ( p < 0.02) than the control group; similarly, in the study group patients’ platelet count in intensive care unit admission was significantly higher than the control group (140 ± 29 × 109 /L vs 119 ± 37 × 109 /L, p < 0.05). Peak postoperative troponin C release was significantly lower in the study group (4.74 ± 2.82 vs 8.43 ± 6.25 ng/dL, p < 0.033). One patient undergoing the MECC system operation showed a major neurologic event on postoperative day four, which was probably secondary to severe aortic calcification. Conclusions The MECC system is suitable for aortic valve replacement and provides better clinical results than standard cardiopulmonary bypass as regards blood transfusion requirements, platelets consumption, and myocardial damage.
The aim of this retrospective study is to show medium-long-term results in terms of cardiac death and aortic events in patients undergoing reduction ascending aortoplasty between 1997 and 2009 in our ...hospital. The Fine and Grey model for competing risk analysis was performed for time to cardiac death, with non-cardiac death as the competing risk, and time to recurrence of both re-dilation (aortic diameter > 45 mm) and re-operation with overall death as the competing risk. Paired t-test was used to evaluate the change in aortic diameter from the post-operative values to follow-up. The population included 142 patients. The mean pre-operative aortic diameter and the diameter at follow-up were respectively 46.5 ± 5.11 mm vs. 41.4 ± 5.55 mm (p-value < 0.001). At a mean follow-up of 11.6 ± 4.15 years, 11 patients (7.7%) required re-operation on the ascending aorta. At 16 years, the CIF of aortic-related events was 29.4 ± 7.2%; the freedom from cardiac death was 89.2 ± 3.7%. Ten patients (7%) died from cardiac causes but no one was aortic-related. The Fine and Grey analysis did not identify any significant predictors. This procedure is safe but might be justified only in high-risk patients or in those with advanced age/short life expectancy.
Transcatheter aortic valve implantation (TAVI) is now the treatment of choice for patients with symptomatic aortic stenosis who are inoperable or with high surgical risk. Data with regards to ...contemporary clinical practice and long-term outcomes are sparse. To evaluate temporal changes in TAVI practice and explore procedural and long-term clinical outcomes of patients in a contemporary “real-world” population, outcomes of 829 patients treated from November 2007 to May 2015, at the San Raffaele Scientific Institute, Milan, Italy, were retrospectively analyzed. Median follow-up was 568 days, with the longest follow-up of 2,677 days. Overall inhospital mortality was 3.5%. During the study period, there was a trend toward treating younger, lower risk patients. Overall mortality rates were 3.5% (30 days), 14% (1 year), 22% (2 years), 29% (3 years), 37% (4 years), 47% (5 years), 53% (6 years), and 72% (7 years). The survival probability at 5 years was significantly higher in patients treated through the transfemoral (TF) route compared to other vascular access sites (log rank p <0.001). Non-TF vascular access and residual paravalvular leak ≥2 (after TAVI) were identified as independent predictors for both all-cause and cardiovascular mortality. No patient required further aortic valve intervention for TAVI prosthesis degeneration. In conclusion, there is a trend toward treating younger, lower-risk patients. Non-TF vascular access approach and ≥2 PVL after TAVI were identified as independent predictors for both overall and cardiovascular mortality with no cases of prosthesis degeneration suggesting acceptable durability.
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