This study sought to assess the impact of right ventricular dysfunction (RVD) as defined by impaired right ventricular-to-pulmonary artery (RV-PA) coupling, on survival after edge-to-edge ...transcatheter mitral valve repair (TMVR) for severe secondary mitral regurgitation (SMR).
Conflicting data exist regarding the benefit of TMVR in severe SMR. A possible explanation could be differences in RVD.
Using data from the EuroSMR (European Registry on Outcomes in Secondary Mitral Regurgitation) registry, this study compared the characteristics and outcomes of SMR patients undergoing TMVR, according to their RV-PA coupling, assessed by tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure (TAPSE/sPAP) ratio.
Overall, 817 patients with severe SMR and available RV-PA coupling assessment underwent TMVR in the participating centers. RVD was present in 211 patients (25.8% with a TAPSE/sPAP ratio <0.274 mm/mm Hg). Although all patients demonstrated significant improvement in their New York Heart Association (NYHA) functional class, there was a trend toward a lower rate of NYHA functional class I or II among patients with RVD (56.5% vs. 65.5%, respectively; p = 0.086) after TMVR. Survival rates at 1 and 2 years were lower among patients with RVD (70.2% vs. 84.0%, respectively; p < 0.001; and 53.4% vs. 73.1%, respectively; p < 0.001). On multivariate analysis, a reduced TAPSE/sPAP ratio was a strong predictor of mortality (odds ratio: 1.62; 95% confidence interval: 1.14 to 2.31; p = 0.007).
RVD, as shown by impairment of RV-PA coupling, is a major predictor of adverse outcome in patients undergoing TMVR for severe SMR. The often neglected functional and anatomic RV parameters should be systematically assessed when planning TMVR procedures for patients with severe SMR.
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Protocols for "Enhanced recovery after surgery (ERAS)" are on the rise in different surgical disciplines and represent one of the most important recent advancements in perioperative medical care. In ...cardiac surgery, only few ERAS protocols have been described in the past. At University Heart Center Hamburg, Germany, we invented an ERAS protocol for patients undergoing minimally invasive cardiac valve surgery. In this retrospective single center study, we aimed to describe the implementation of our ERAS program and to evaluate the results of the first 50 consecutive patients. Our ERAS protocol was developed according to a modified Kern cycle by an expert group, literature search, protocol creation and pilot implementation in the clinical practice. Data of the first 50 consecutive patients undergoing minimally invasive cardiac valve surgery were analysed retrospectively. The key features of our multidisciplinary ERAS protocol are physiotherapeutic prehabilitation, minimally invasive valve surgery techniques, modified cardiopulmonary bypass management, fast-track anaesthesia with on- table extubation and early mobilisation. A total of 50 consecutive patients (mean age of 51.9±11.9 years, mean STS score of 0.6±0.3) underwent minimally-invasive mitral or aortic valve surgery. The adherence to the ERAS protocol was high and neither protocol related complications nor in-hospital mortality occurred. 12% of the patients developed postoperative atrial fibrillation, postoperative delirium emerged in two patients and reintubation was required in one patient. Intensive care unit stay was 14.0±7.4 hours and total hospital stay 6.2±2.9 days. Our ERAS protocol is feasible and safe in minimally-invasive cardiac surgery setting and has a clear potential to improve patients outcome.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The aim of this study was to assess the impact of residual mitral regurgitation (resMR) on mortality with respect to left ventricular dilatation (LV-Dil) or right ventricular dysfunction (RV-Dys) in ...patients with secondary mitral regurgitation (SMR) who underwent mitral valve transcatheter edge-to-edge repair (TEER).
The presence of LV-Dil and RV-Dys correlates with advanced stages of heart failure in SMR patients, which may impact the outcome after TEER.
SMR patients in a European multicenter registry were evaluated. Investigated outcomes were 2-year all-cause mortality and improvement in New York Heart Association functional class with respect to MR reduction, LV-Dil (defined as LV end-diastolic volume ≥159 ml), and RV-Dys (defined as tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure ratio of <0.274 mm/mm Hg).
Among 809 included patients, resMR ≤1+ was achieved in 546 (67%) patients. Overall estimated 2-year mortality rate was 32%. Post-procedural resMR was significantly associated with mortality (p = 0.031). Although the improvement in New York Heart Association functional class persisted regardless of either LV-Dil or RV-Dys, the beneficial treatment effect of resMR ≤1+ on 2-year mortality was observed only in patients without LV-Dil and RV-Dys (hazard ratio: 1.75; 95% confidence interval: 1.03 to 3.00).
Achieving optimal MR reduction by TEER is associated with improved survival in SMR patients, especially if the progress in heart failure is not too advanced. In SMR patients with advanced stages of heart failure, as evidenced by LV-Dil or RV-Dys, the treatment effect of TEER on symptomatic improvement is maintained, but the survival benefit appears to be reduced.
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Aims
Guideline‐directed medical therapy (GDMT), based on the combination of beta‐blockers (BB), renin–angiotensin system inhibitors (RASI), and mineralocorticoid receptor antagonists (MRA), is known ...to have a major impact on the outcome of patients with heart failure with reduced ejection fraction (HFrEF). Although GDMT is recommended prior to mitral valve transcatheter edge‐to‐edge repair (M‐TEER), not all patients tolerate it. We studied the association of GDMT prescription with survival in HFrEF patients undergoing M‐TEER for secondary mitral regurgitation (SMR).
Methods and results
EuroSMR, a European multicentre registry, included SMR patients with left ventricular ejection fraction <50%. The outcome was 2‐year all‐cause mortality. Of 1344 patients, BB, RASI, and MRA were prescribed in 1169 (87%), 1012 (75%), and 765 (57%) patients at the time of M‐TEER, respectively. Triple GDMT prescription was associated with a lower 2‐year all‐cause mortality compared to non‐triple GDMT (hazard ratio HR 0.74; 95% confidence interval CI 0.60–0.91). The association persisted in patients with glomerular filtration rate <30 ml/min, ischaemic aetiology, or right ventricular dysfunction. Further, a positive impact of triple GDMT prescription on survival was observed in patients with residual mitral regurgitation of ≥2+ (HR 0.62; 95% CI 0.44–0.86), but not in patients with residual mitral regurgitation of ≤1+ (HR 0.83; 95% CI 0.64–1.08).
Conclusion
Triple GDMT prescription is associated with higher 2‐year survival after M‐TEER in HFrEF patients with SMR. This association was consistent also in patients with major comorbidities or non‐optimal results after M‐TEER.
Triple guideline‐directed medical therapy (GDMT) prescription was associated with a lower 2‐year mortality compared to non‐triple GDMT prescription (A). Such association was observed in patients with concomitant comorbidities (B). CI, confidence interval; CKD, chronic kidney disease; CMP, cardiomyopathy; HR, hazard ratio; MRA, mineralocorticoid receptor antagonists; M‐TEER, mitral valve transcatheter edge‐to‐edge repair; RAS, renin–angiotensin system; ResMR, residual mitral regurgitation; RV‐Dys, right ventricular dysfunction; SMR, secondary mitral regurgitation.
We sought to assess the impact of tricuspid regurgitation (TR) severity on patient outcome in a collective with relevant mitral regurgitation undergoing MitraClip implantation..
From August 2010 to ...July 2013, 766 patients (age 75.3±8.5 years, 61% male, median EuroSCORE 24.3%±18.4) were prospectively enrolled in the TRAMI registry and stratified by echocardiography into no/mild, moderate and severe TR. Overall, the mean number of implanted MitraClips was higher in patients with severe TR but increasing TR severity was not associated with procedural success. In-hospital and one-year mortality as well as MACE and MACCE (death, myocardial infarction±stroke) rates were higher with increasing TR severity. Kaplan-Meier curves indicated a significant difference for mortality (p<0.0001), but not for rehospitalisation for heart failure. After multivariate Cox regression, severe TR proved to be a predictor for one-year mortality (HR 2.01, 95% CI: 1.25-3.26, p=0.004). Higher rates of severe bleeding were more frequent with increasing TR grades.
In patients with MitraClip implantation, increasing TR severity is associated with adverse outcome, higher bleeding rates and decreased survival rates.
Patients with established cardiovascular (CV) disease remain at dramatic residual risk for subsequent events, despite growing evidence in secondary prevention and wider dissemination of intensive ...treatment. This review focuses on new options in secondary risk prevention as presented by these five major randomized controlled trials (RCT): PEGASUS-TIMI 54, COMPASS, FOURIER, ODYSSEY and CANTOS. Three main therapeutic targets are addressed: residual cholesterol, residual inflammatory and residual thrombotic risk. All of the trials reviewed included patients with stable CV disease on optimal medical treatment with a surprising similar mortality. As of now, evolocumab, alirocumab and ticagrelor are on the market, while rivaroxaban and canakinumab are not yet licensed for the treatment of secondary prevention in CV disease. Although life-style modifications and better utilization of established medical treatment options will remain first-line strategy, new medication is just about to enter the market. Secondary prevention in coronary artery disease (CAD) holds a strong potential to reduce subsequent CV events, even CV death. It seems that a combination of an aggressive lipid-lowering treatment in combination with antithrombotic therapy could improve prognosis significantly (at least for distinct subgroups). Against this background, individual efficacy, risk, and costs have to be considered when identifying patients for each new regime.
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