This study was designed to assess hemodynamic changes in response to transcatheter tricuspid valve edge-to-edge repair (TTVR) and to identify hemodynamic predictors associated with mortality.
Severe ...tricuspid regurgitation (TR) is associated with high mortality. TTVR effectively alleviates heart failure symptoms, but comprehensive hemodynamic characterization of patients undergoing TTVR is currently lacking.
This international, multicenter study included 236 patients undergoing TTVR. Data from clinical assessment, echocardiography, intraprocedural right heart catheterization, and noninvasive cardiac output measurement were analyzed. Hemodynamic predictors for mortality were identified using linear Cox regression analysis and were used for stratification of patients with subsequent analysis of survival time.
Patients (median age 78 years, 53% women) were symptomatic (89% in New York Heart Association functional class III or IV) because of severe TR (grade ≥3+ in 100%). TTVR significantly reduced TR at discharge (grade ≥3+ in 16%; p < 0.001), with a corresponding 19% reduction of the right atrial v wave (21 mm Hg vs. 16 mm Hg; p < 0.001) and an improvement in cardiac output (from 3.5 to 4.0 l/min; p < 0.01). Invasive mean pulmonary artery pressure, transpulmonary gradient, pulmonary vascular resistance, and right ventricular stroke work were significant predictors of 1-year mortality (p < 0.05 for all). Hemodynamic stratification by mean pulmonary artery pressure and transpulmonary gradient best predicted 1-year survival (p < 0.001). Although patients with pre-capillary dominant pulmonary hypertension showed an unfavorable prognosis (1-year survival 38%), patients without or with post-capillary pulmonary hypertension had favorable outcome (1-year survival 92% or 78%, respectively).
Invasive assessment of cardiopulmonary hemodynamic status predicts survival after TTVR. Invasive hemodynamic characterization may help identify patients profiting most from TTVR.
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The aim of this study was to assess the value of echocardiographic right ventricular (RV) and systolic pulmonary artery pressure (sPAP) assessment in predicting transcatheter tricuspid edge-to-edge ...valve repair (TTVR) outcome.
RV dysfunction and pulmonary hypertension are associated with poor prognosis and are systematically sought during tricuspid regurgitation evaluation. The value of echocardiographic assessment in predicting TTVR outcome is unknown.
Data were taken from the TriValve (Transcatheter Tricuspid Valve Therapies) registry, which includes patients undergoing TTVR at 14 European and North American centers. The primary outcome was 1-year survival free from hospitalization for heart failure, and secondary outcomes were 1-year survival and absence of hospital admission for heart failure at 1 year.
Overall, 249 patients underwent TTVR between June 2015 and 2018 (mean tricuspid annular plane systolic excursion TAPSE 15.8 ± 15.3 mm, mean sPAP 43.6 ± 16.0 mm Hg). Tricuspid regurgitation grade ≥3+ was found in 96.8% of patients at baseline and 29.4% at final follow-up; 95.6% were in New York Heart Association functional class III or IV initially, compared with 34.3% at follow-up (p < 0.05). Final New York Heart Association functional class did not differ among TAPSE and sPAP quartiles, even when both low TAPSE and high sPAP were present. Rates of 1-year survival and survival free from hospitalization for heart failure were 83.9% and 78.7%, respectively, without significant differences according to baseline echocardiographic RV characteristics (TAPSE, fractional area change, and end-diastolic area) and sPAP (p > 0.05 for all).
TTVR provides clinical improvement, with 1-year survival free from hospital readmission >75% in patients with severe tricuspid regurgitation. Conventional echocardiographic parameters used to assess RV function and sPAP did not predict clinical outcome after TTVR.
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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.
Intraprocedural transesophageal echocardiography (TEE) guidance plays an essential role in transcatheter repair therapy of the tricuspid valve (TV). So far, several different imaging concepts are in ...use. We propose an imaging protocol that fully addresses the morphological complexity of the TV and further offers efficacious workarounds for the frequently occurring restrictions of TV imaging in edge‐to‐edge repair of the TV. As a tertiary referral center with a large experience of more than 250 cases of transcatheter edge‐to‐edge repair (TEER) of the TV performed at the Heart Valve Center in Mainz/Germany, we have constantly adapted our peri‐interventional echocardiographic approach to accomplish both. As a key measure for success, we intensely rely on the transgastric acoustic windows that not only deliver high‐resolution information on the morphology of the TV and all relevant procedural steps but also help to avoid the frequent shadowing artifacts experienced in transesophageal imaging.
Objectives
Transcatheter mitral valve repair (TMVR) by edge‐to‐edge therapy is an established treatment for severe mitral valve regurgitation (MR).
Background
Symptomatic and prognostic benefit in ...functional MR has been shown recently; nevertheless, data on long‐term outcomes are sparse.
Methods and results
We analyzed survival of patients treated with isolated edge‐to‐edge repair from June 2010 to March 2018 (primarily combined edge‐to‐edge repair with other mitral valve interventions was excluded) in a retrospective monocentric study. Overall, 627 consecutive patients (47.0% females, 78.6 years in mean) were included. Leading etiology was functional MR (57.4%). Follow‐up regarding survival was available in 97.0%. While 97.6% were discharged alive, 75.7% were alive after a 1‐year, 54.5% after 3‐year, 37.6% after 5‐year and 21.7% after 7‐year follow‐up. Higher logistic Euroscores and comorbidities such as COPD and renal insufficiency were associated with higher in‐hospital and 1‐year mortality. Importantly, in‐hospital survival increased over the years.
Conclusions
With the present study we established high survival rates at discharge and after 1 year of patients treated with TMVR. This goes along with high implantation numbers, increased interventional experience and a better in‐hospital survival over the years. Long‐term mortality in turn was substantially influenced by comorbidities.
Systemic inflammation can occur after transcatheter aortic valve replacement (TAVR) and correlates with adverse outcome. The impact of remote ischemic preconditioning (RIPC) on TAVR associated ...systemic inflammation is unknown and was focus of this study.
We performed a prospective controlled trial at a single center and included 66 patients treated with remote ischemic preconditioning (RIPC) prior to TAVR, who were matched to a control group by propensity score. RIPC was applied to the upper extremity using a conventional tourniquet. Definition of systemic inflammation was based on leucocyte count, C-reactive protein (CRP), procalcitonin (PCT) and interleukin-6 (IL-6), assessed in the first 5 days following the TAVR procedure. Mortality was determined within 6 months after TAVR. RIPC group and matched control group showed comparable baseline characteristics.
Systemic inflammation occurred in 66% of all patients after TAVR. Overall, survival after 6 months was significantly reduced in patients with systemic inflammation. RIPC, in comparison to control, did not significantly alter the plasma levels of leucocyte count, CRP, PCT or IL-6 within the first 5 days after TAVR. Furthermore, inflammation associated survival after 6 months was not improved by RIPC. Of all peri-interventional variables assessed, only the amount of the applied contrast agent was connected to the occurrence of systemic inflammation.
Systemic inflammation frequently occurs after TAVR and leads to increased mortality after 6 months. RIPC neither reduces the incidence of systemic inflammation nor improves inflammation associated patient survival within 6 months.
Background: Mitral annular dilation has been shown to challenge successful edge-to-edge therapy with earlier MitraClip generations. Recently, third-generation MitraClip-XTR with extended clip arm ...length was introduced. We assessed the impact of annular dilation on residual mitral regurgitation (MR) after MitraClip-XTR repair and sought to identify cutoffs associated with suboptimal MR reduction. Methods: We included 107 patients (78.9±6.7 years; 40.2% female) with symptomatic severe MR (46.7% primary MR; 53.3% secondary MR) undergoing MitraClip-XTR repair. Annular dimensions were retrospectively assessed by 2-dimensional and 3-dimensional-transesophageal echocardiography including a semiautomated analysis. Impact of annular diameters and area on suboptimal reduction defined as ≥2+MR on transthoracic echocardiography at discharge was assessed and predictive cutoff values identified. Previously identified predictors of suboptimal outcome after MitraClip therapy were included in multivariable analysis. Results: Technical success was achieved in 93%, 1-year mortality was 23%. Suboptimal MR reduction was observed in 26% and associated with higher 1-year mortality (odds ratio, 4.5 1.5–14.1). End-systolic anteroposterior and intercommissural annular diameters, annular area and further vena-contracta width, effective regurgitant orifice area and left atrial volume were associated with suboptimal outcomes. Independent predictors of suboptimal reduction were end-systolic annular area (odds ratio, 1.36 1.08–1.71 per cm 2 ) and vena-contracta width (odds ratio, 1.47 1.04–2.09 per mm). On receiver operating characteristic analysis, 3-dimensional-transesophageal echocardiography end-systolic anteroposterior diameter >40.5 mm, intercommisural diameter >40.5 mm, and annular-area >12.50 cm 2 were the most predictive thresholds for suboptimal reduction. If all 3 annular measurements exceeded the determined threshold values, the risk for suboptimal reduction increased by 17-fold. Conclusions: Annular dilation was found to challenge successful edge-to-edge therapy also with extended-reach MitraClip-XTR. Our proposed thresholds for preprocedural annular dimensions may serve as guidance for improved patient selection in edge-to-edge repair.
Background
The number of MitraClip® implantations increased significantly in recent years. Data regarding the impact of weight class on survival are sparse.
Hypothesis
We hypothesized that weight ...class influences survival of patients treated with MitraClip® implantation.
Methods
We investigated in‐hospital, 1‐year, 3‐year, and long‐term survival of patients successfully treated with isolated MitraClip® implantation for mitral valve regurgitation (MR) (June 2010–March 2018). Patients were categorized by weight classes, and the impact of weight classes on survival was analyzed.
Results
Of 617 patients (aged 79.2 years; 47.3% females) treated with MitraClip® implantation (June 2010–March 2018), 12 patients were underweight (2.2%), 220 normal weight (40.1%), 237 overweight (43.2%), and 64 obesity class I (11.7%), 12 class II (2.2%), and 4 class III (0.7%). Preprocedural Logistic EuroScore (21.1 points IQR 14.0–37.1; 26.0 18.5–38.5; 26.0 18.4–39.9; 24.8 16.8–33.8; 33.0 25.9–49.2; 31.6 13.1–47.6; p = .291) was comparable between groups. Weight class had no impact on in‐hospital death (0.0%; 4.1%; 1.5%; 0.0%; 7.7%; 0.0%; p = .189), 1‐year survival (75.0%; 72.0%; 76.9%; 75.0%; 75.0%; 33.3%; p = .542), and 3‐year survival (40.0%; 36.8%; 38.2%; 48.6%; 20.0%; 33.3%; p = .661). Compared to normal weight, underweight (hazard ratio HR: 1.35 95% confidence interval CI: 0.65–2.79, p = .419), obesity‐class I (HR: 0.93 95% CI: 0.65–1.34, p = .705), class II (HR: 0.39 95% CI: 0.12–1.24, p = .112), and class III (HR: 1.28 95% CI: 0.32–5.21, p = .726) did not affect long‐term survival. In contrast, overweight was associated with better survival (HR: 1.32 95% CI: 1.04–1.68, p = .023).
Conclusion
Overweight affected the long‐term survival of patients undergoing MitraClip® implantation beneficially compared to normal weight.
Long‐term survival stratified for weight classes illustrated by Hazard plot for patients treated with MitraClip® implantation stratified for weight classes. Association of weight class compared to normal‐weight with long‐term survival (adjusted for Logistic EuroScore). Survival rate at discharge, 1‐year follow‐up, and 3‐year follow‐up stratified for weight classes.
Background:LV twist has a key role in maintaining left ventricular (LV) contractility during exercise. The purpose of this study was to investigate LV torsion instead of twist as a surrogate marker ...of peak oxygen uptake (peak V̇O2) assessed by cardiopulmonary exercise testing (CPET) in patients with non-ischemic dilated cardiomyopathy (DCM).Methods and Results:We evaluated 45 outpatients with DCM (50±12 years, 24% females) with 3D speckle-tracking electrocardiography prior to CPET. LV torsion, LV ejection fraction (EF), LV diastolic function, LV global longitudinal (GLS) and circumferential (GCS) strain were quantified. A reduced functional capacity (FC) was defined as a peak V̇O2<20 mL/kg/min. LV torsion correlated most strongly with peak V̇O2(r=0.76, P<0.001). LV torsion instead of twist was an independent predictor of peak V̇O2(B: 0.59 to 0.71, P<0.001) in multivariable analyses. Impaired LV torsion <0.61 degrees/cm was able to predict a reduced FC with higher sensitivity and specificity (0.91 and 0.81; area under the curve (AUC): 0.88, P<0.001) than LV EF, GLS or GCS (AUC 0.64, 0.63 and 0.66; P<0.05 for differences in AUC).Conclusions:Peak V̇O2correlated more strongly with LV torsion than with LV diastolic function, LV EF, GLS or GCS. LV torsion had high accuracy in identifying patients with a reduced FC.
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