Background Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or ...cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. Method From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. Results Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. Conclusions Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.
Abstract Objective To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy ...influenced clinical outcome. Methods Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 ± 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). Results No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. Conclusions Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial.
What is a “good” result after transcatheter mitral repair? Impact of 2+ residual mitral regurgitation Buzzatti, Nicola, MD; De Bonis, Michele, MD; Denti, Paolo, MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
2016, January 2016, 2016-Jan, 2016-01-00, 20160101, Letnik:
151, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Abstract Objective The study objective was to assess the impact on follow-up outcomes of residual mitral regurgitation 2+ in comparison with ≤1+ after MitraClip (Abbott Vascular Inc, Santa Clara, ...Calif) repair. Methods We compared the outcomes of mitral regurgitation 2+ and mitral regurgitation ≤1+ groups among a population of 223 consecutive patients with acute residual mitral regurgitation ≤2+ who underwent MitraClip implantation at San Raffaele Scientific Institute (Milan, Italy) between October 2008 and December 2014. Results Residual mitral regurgitation 2+ was found in 64 patients (28.7%). Overall actuarial survival was 63.1% ± 4.4% at 48 months. Cumulative incidence functions of cardiac death in patients with mitral regurgitation 2+ was significantly higher (Gray test P < .001) compared with the mitral regurgitation ≤1+ group. The adjusted hazard ratio was 5.28 (95% confidence interval, 2.41-11.56, P < .001). Cumulative incidence function of mitral regurgitation ≥3+ recurrence in patients with residual mitral regurgitation ≤1+ and mitral regurgitation 2+ at 48 months was 13.3% ± 3.8% and 45.2% ± 6.8%, respectively (Gray test P < .001). Multivariate model showed that mitral regurgitation 2+ was the only factor associated with the development of mitral regurgitation ≥3+ at follow-up (adjusted hazard ratio, 6.71; 95% confidence interval, 3.48-12.90; P < .001). Mitral regurgitation cause was not associated with cardiac death and recurrence of mitral regurgitation ≥3+ at follow-up. No relationship between New York Heart Association class and follow-up time after MitraClip implant was found (odds ratio, 1.07; 95% confidence interval, 0.98-1.15; P = .11), and factors related to postoperative New York Heart Association also included residual mitral regurgitation 2+ ( P = .07). Conclusions Residual 2+ mitral regurgitation after MitraClip implantation was associated with worse follow-up outcomes compared with ≤1+ mitral regurgitation, including survival, symptom relief, and mitral regurgitation recurrence. Better efficacy should be pursued by transcatheter mitral repair technologies.
Objectives The aim of this study is to report the long-term outcomes (median follow-up time, 7 years; range, 1 month to 14 years) of patients who underwent surgery for paravalvular leak in our ...single-center experience. Methods From October 2000 to November 2007, 122 consecutive patients underwent surgery for symptomatic paravalvular leak (40 patients with aortic paravalvular leak; 82 with mitral paravalvular leak). In 7 patients (5.7%, all mitral), surgery was performed on the beating heart through a right thoracotomy. In 35% of patients, multiple paravalvular leaks were present. Results The mean age of patients was 62 ± 11 years, and European System for Cardiac Operative Risk Evaluation II was 7.2% ± 6%. Most of the patients were in New York Heart Association functional class III or IV (60%). Symptomatic hemolysis was present in 31% of the patients, and 41% of the patients had more than 1 previous cardiac operation. Paravalvular leak repair was feasible in 79 patients (65%), whereas in 43 patients (35%) prosthesis re-replacement was required. Thirty-day mortality was 10.7% (13/122 patients; 5% for aortic paravalvular leak and 13% for mitral paravalvular leak; P = .1); 2 patients (1.6%) with residual severe mitral paravalvular leak underwent successful redo surgery before discharge. Median length of stay was 7 days. Overall actuarial survival was 39% ± 6% at 12 years; freedom from cardiac death was 54% ± 7% at 12 years. Only 1 patient underwent redo surgery during follow-up. Multivariable analysis identified preoperative chronic renal failure (hazard ratio, 2.6; 95% confidence interval, 1.4-4.9; P = .03) and more than 1 previous cardiac reoperation (hazard ratio, 2.3; 95% confidence interval, 1.3-4; P = .03) as independent predictors of death at follow-up. Conclusions The operative mortality of surgical treatment of paravalvular leak is still high. Long-term outcomes remain suboptimal in these challenging patients, especially in the presence of multiple previous cardiac operations and associated co-pathologies. These results support the importance of alternative therapeutic options.
Objective Weaning from venoarterial extracorporeal membrane oxygenation (VA ECMO) usually is performed without clear guidelines; yet, patients still die after removal of extracorporeal circulation ...because of inadequate heart or end-organ recovery. The aim of the study was to address the weaning procedure, analyzing the hemodynamic and echocardiographic picture of patients weaned and to identify predictors of poor outcome among this population. Design Observational study. Setting University hospital. Participants One hundred twenty-nine VA ECMO cases. Interventions None. Measurements and Main Results Forty-nine patients (38%) were weaned, 7 (5.4%) were bridged to a ventricular assist device, and 6 (5.2%) were listed for heart transplantation. Weaned patients showed a significant increase of pulse pressure (35 0-50 mmHg before ECMO, 59 53–67 mmHg at weaning, 61 51–76 mmHg after ECMO (p<0.001) and reduction of dose of inotropes (inotropic score as defined in the text 20 14–40 before ECMO, 10 3–15 at weaning, and 10 5–15 after ECMO, p<0.001). Left ventricular ejection fraction (LVEF) increased from 19 (0-22.5)% before ECMO to 35 (22-55)% after ECMO (p<0.001). A significant improvement of right ventricular (RV) function was observed in weaned patients (RV dysfunction from 52% to 21%, p<0.001). Among weaned patients, 15 (31%) died. Patients who died after weaning had longer ECMO duration compared to discharged patients (8 5–11 v 4 2–6 days, p = 0.01) and more transfusions (22 10–37 v 7 0.5-15 units, p = 0.02); survival was lower in patients with central ECMO (postcardiotomy) compared to peripheral ECMO (p = 0.045). Mortality was higher in those with persistence of RV failure, continuous venovenous hemofiltration, higher inotropic score, lower systolic pressure, or higher leucocyte count at weaning. Conclusions Successful weaning from ECMO is a multifaceted process, which encompasses consistent recovery of myocardial and end-organ function; LVEF, though improved, is still low at weaning. Hospital survival is correlated significantly to the duration of ECMO support and to bleeding complications.
Objective Heparin-based anticoagulation for patients undergoing extracorporeal membrane oxygenation has many limitations, including a high risk of heparin-induced thrombocytopenia. However, little ...experience with other anticoagulants in these patients has been described. The aim of this study was to compare bivalirudin-based anticoagulation with heparin-based protocols in a population of patients treated with venovenous or venoarterial extracorporeal membrane oxygenation. Design In this case-control study, 10 patients received bivalirudin (cases) and 10 heparin (controls). The target activated partial thromboplastin time (aPTT) was 45 to 60 seconds. Interventions None. Measurements and Main Results aPTT variations >20% of the previous value were much more frequent in patients treated with heparin than in patients receiving bivalirudin (52 v 24, p < 0.001). The number of corrections of the anticoagulant dose was higher in the heparin group compared with the bivalirudin group (58 v 51), although it did not reach statistical significance. Bleeding, thromboembolic complications, extracorporeal membrane oxygenation (ECMO) support duration, mortality, and the number of episodes of aPTT >80 seconds were not different between the 2 groups. A further analysis was performed in the bivalirudin group according to the presence of acute renal failure requiring continuous venovenous hemofiltration. The median bivalirudin dose in patients with or without hemofiltration was 0.041 (0.028-0.05) mg/kg/h and 0.028 (0-0.041) mg/kg/h, respectively ( p = 0.2). Conclusions Bivalirudin-based anticoagulation may represent a new method of anticoagulation for reducing thromboembolic and bleeding complications, which still jeopardize the application of extracorporeal membrane oxygenation. Moreover, bivalirudin is free from the risk of heparin-induced thrombocytopenia. Higher doses of bivalirudin may be needed in patients undergoing hemofiltration.
Abstract Objective We sought to investigate the clinical outcomes of patients with isolated severe aortic stenosis and an intermediate- to high-risk profile treated by means of conventional surgery ...(surgical aortic valve replacement), sutureless valve implantation, or transcatheter aortic valve replacement in a multicenter evaluation. Methods Among 991 consecutive patients with isolated severe aortic stenosis and an intermediate- to high-risk profile (Society of Thoracic Surgeons score >4 and logistic European System for Cardiac Operative Risk Evaluation I >10), a propensity score analysis was performed on the basis of the therapeutic strategy: surgical aortic valve replacement (n = 204), sutureless valve implantation (n = 204), and transcatheter aortic valve replacement (n = 204). Primary end points were 30-day mortality and overall survival at 24-month follow-up; the secondary end point was survival free from a composite end point of major adverse cardiac events (defined as cardiac-related mortality, myocardial infarction, cerebrovascular accidents, and major hemorrhagic events) and periprosthetic regurgitation greater than 2. Results Thirty-day mortality was significantly higher in the transcatheter aortic valve replacement group (surgical aortic valve replacement = 3.4% vs sutureless = 5.8% vs transcatheter aortic valve replacement = 9.8%; P = .005). The incidence of postprocedural was 3.9% in asurgical aortic valve replacement vs 9.8% in sutureless vs 14.7% in transcatheter aortic valve replacement ( P < .001) and peripheral vascular complications occurred in 0% of surgicalaortic valve replacement vs 0% of sutureless vs 9.8% transcatheter aortic valve replacement ( P < .001). At 24-month follow-up, overall survival (surgical aortic valve replacement = 91.3% ± 2.4% vs sutureless = 94.9% ± 2.1% vs transcatheter aortic valve replacement = 79.5% ± 4.3%; P < .001) and survival free from the composite end point of major adverse cardiovascular events and periprosthetic regurgitation were significantly better in patients undergoing surgical aortic valve replacement and sutureless valve implantation than in patients undergoing transcatheter aortic valve replacement (surgical aortic valve replacement = 92.6% ± 2.3% vs sutureless = 96% ± 1.8% vs transcatheter aortic valve replacement = 77.1% ± 4.2%; P < .001). Multivariate Cox regression analysis identified transcatheter aortic valve replacement as an independent risk factor for overall mortality hazard ratio (hazard ratio, 2.5; confidence interval, 1.1-4.2; P = .018). Conclusions The use of transcatheter aortic valve replacement in patients with an intermediate- to high-risk profile was associated with a significantly higher incidence of perioperative complications and decreased survival at short- and mid-term when compared with conventional surgery and sutureless valve implantation.
Objective To assess the very long-term clinical and echocardiographic results of the edge-to-edge repair for mitral regurgitation (MR) due to isolated prolapse or flail of the anterior leaflet. ...Methods From 1991 to 2004, 139 patients (age, 54 ± 14.4 years; left ventricular ejection fraction 56% ± 7.8%, New York Heart Association class I-II in 68.9%, atrial fibrillation in 20.1%) with severe degenerative MR due to isolated segmental prolapse or flail of the anterior leaflet were treated with the EE technique combined with annuloplasty. MR had resulted from prolapse or flail of the central scallop of the anterior leaflet (A2) in 105 patients (75.5%) and scallops A1 or A3 in 34 (24.4%). Results No hospital deaths occurred. At hospital discharge, MR was absent or mild in 130 patients (93.5%) and moderate (2+/4+) in 9 (6.4%). The clinical and echocardiographic follow-up data were 97.1% complete (mean length, 11.5 ± 3.73 years; median, 11; longest duration, 21.5). At 17 years, the actuarial survival was 72.4% ± 7.89%, freedom from cardiac death was 90.8% ± 4.77%, and freedom from reoperation was 89.6% ± 2.74%. At the last echocardiographic examination, recurrence of MR grade ≥3+ was documented in 17 patients (17 of 135, 12.5%). Freedom from MR grade ≥3+ at 17 years was 80.2% ± 5.86%. At multivariate analysis, the predictors of MR recurrence grade ≥3+ were residual MR greater than mild at hospital discharge (hazard ratio, 7.4; 95% confidence interval, 2.5-21.2; P = .0001) and the use of posterior pericardial rather than prosthetic ring annuloplasty, which was very close to statistical significance (hazard ratio, 2.8; 95% confidence interval, 0.9-8.7; P = .06). Conclusions In patients with MR due to segmental anterior leaflet prolapse, the very long-term results of the edge-to-edge repair combined with annuloplasty were excellent.
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.
Background The aim of this study was to assess the occurrence of reverse left ventricular (LV) remodeling after effective mitral valve repair in advanced dilated cardiomyopathy and its impact on ...clinical outcome and repair durability. Methods Of 111 patients undergoing mitral valve repair in ischemic or idiopathic dilated cardiomyopathy, 79 patients with no or trivial residual mitral regurgitation (MR) at discharge and with a follow-up length of at least 6 months were included in this study. Preoperatively they had 3 to 4+ functional MR, an ejection fraction of 0.28 ± 0.055, an indexed LV end-diastolic volume of 113 ± 33.0 mL/m2 , an indexed LV end-systolic volume of 80.8 ± 26.3 mL/m2 , a tenting area of 2.7 ± 0.9 cm2 , and a coaptation depth of 1.1 ± 0.3 cm. Sixty-three patients (79.8%) were in New York Heart Association class III or IV. A complete, rigid or semirigid undersized ring annuloplasty (with or without “edge-to-edge”) was used. Concomitant procedures were coronary artery bypass grafting (49 of 79 patients, 62%), tricuspid valve repair (11 of 79 patients, 13.9%), and ablation of permanent atrial fibrillation (13 of 79 patients, 16.4%). Results At a mean follow-up of 2 ± 1.3 years (median, 1.8 years), LV reverse remodeling was documented in 41 patients (51.8%), whereas in 38 patients (48.1%) LV dimensions remained unchanged or increased compared with preoperative values. The persistence or progression of LV remodeling paralleled the recurrence of MR and worsening of symptoms. Recurrence of MR of 3+ or greater was 0% in the “reverse remodeling” group and 18.4% in the “no reverse remodeling” one ( p = 0.008). At 3 years, freedom from recurrence of MR of 2+ or greater was 74% ± 11.7% and 62% ± 9.2% ( p = 0.004) and New York Heart Association class was 1.5 ± 0.61 and 2 ± 0.72 ( p < 0.0001), respectively. Predictors of reverse remodeling were ischemic etiology ( p = 0.04), concomitant coronary artery bypass grafting ( p = 0.02), successful ablation of atrial fibrillation ( p = 0.05), and shorter history of congestive heart failure ( p = 0.06). The use of the edge-to-edge showed a trend toward favoring reverse remodeling compared with isolated annuloplasty ( p = 0.08). Conclusions In patients with functional MR undergoing effective repair, the occurrence of reverse LV remodeling is associated with longer repair durability and a better clinical outcome compared with those with persistence or progression of the remodeling process.
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