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
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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.
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.
Abstract
OBJECTIVES: A single MitraClip implant is often considered enough to achieve adequate mitral regurgitation (MR) reduction. The aim of this study was to compare MR recurrence in patients with ...an initial optimal result treated with a single clip versus those treated with two clips.
METHODS: From October 2008 to May 2016, 322 patients were treated with the MitraClip procedure at our institution. We retrospectively selected all patients treated for functional MR (FMR) and degenerative MR (DMR) aetiologies with residual MR ≤1+, excluding patients who required >2 clips. FMR and DMR were analysed separately.
RESULTS: In FMR, a single clip was used in 45 patients and 2 clips in 99 patients. The single clip group had smaller coaptation depth (1.1 ± 0.3 vs 1.3 ± 0.3 mm, P = 0.022) and jet extension (10.5 ± 2.1 vs 13.0 ± 3.6 mm, P = 0.026) as well as left ventricular end-diastolic diameter (64.4 ± 7.3 vs 69.0 ± 7.9 mm, P = 0.001). Freedom from MR ≥ 3+ after 4 years was 71.9 ± 8.9% in patients receiving a single clip vs 88.0 ± 5.2% in those receiving 2 clips, single clip use being an independent predictor of MR recurrence (HR 3.48, CI 1.24–9.81, P = 0.018). In DMR, a single clip was deployed in 24 patients and 2 clips in 30 patients. The single clip group had a smaller flail gap (3.6 ± 0.7 vs 6.8 ± 2.5, P = 0.002). Freedom from MR ≥ 3+ after 2 years was 82.5 ± 8% in patients with a single clip vs 100% in those with 2 clips, P = 0.014. The residual mitral area was reduced in patients with 2 clips compared with those with single clip, both in FMR (P = 0.015) and DMR (P = 0.039), but it was not associated with increased death rate during the follow-up period (all P > 0.05).
CONCLUSIONS: Despite favourable anatomical characteristics and an optimal initial result, implantation of a single clip was associated with an increased recurrence of MR compared with that of 2 clips, both in FMR and in DMR. Caution should be exercised with the implantation of a single clip.
Objectives
The aim of the present study was to evaluate the prognostic impact and late evolution of associated tricuspid regurgitation (TR) 2/4+ after aortic valve replacement (AVR).
Methods
We ...evaluated 61 patients who underwent AVR between 2003 and 2012 (35 for aortic stenosis AS, 26 for aortic regurgitation AR) with associated untreated TR 2/4+. Patients with concomitant mitral disease were excluded. Median follow‐up was 3.2 years. Serial echocardiographic and clinical data were collected and analyzed.
Results
Mean age was 65 ± 13 years; 26% of the patients were in NYHA class III–IV. Left ventricular ejection fraction was 53 ± 11%. Comorbidity included: chronic obstructive pulmonary disease in 5%, chronic renal failure in 13%, coronary artery disease in 20%, history of stroke/TIA in 8%. Thirty‐day mortality was 1.6%. Overall actuarial survival was 83 ± 6% at 6.5 years, with a freedom from cardiac death of 90 ± 5%. Freedom from TR ≥3+ was 86 ± 6% at 6.5 years. At last follow‐up, 82% of the patients had TR 0–1/4+, 9% had TR 2/4+, 4.5% had TR 3/4+ and 4.5% had TR 4/4+. Occurrence of TR ≥ 3+ at follow‐up was associated with increased cardiac mortality (HR 10.5; p = 0.009).
Conclusions
preoperative untreated TR 2/4+ improves or remains stable in the majority of patients. The poor outcomes associated with TR > 2+ suggest the need for better methods to identify subjects at risk for TR progression. doi: 10.1111/jocs.12656 (J Card Surg 2016;31:9–14)
Aims
Acute mitral regurgitation (MR) in the setting of myocardial infarction (MI) may be the result of papillary muscle rupture (PMR). This condition is associated with high morbidity and mortality. ...We aim to evaluate the feasibility of transcatheter edge‐to‐edge mitral valve repair (TEER) in this acute setting.
Methods and results
We analysed data from the International Registry of MitraClip in Acute Mitral Regurgitation following acute Myocardial Infarction (IREMMI) of 30 centres in Europe, North America, and the middle east. We included patients with post‐MI PMR treated with TEER as a salvage procedure, and we evaluated immediate and 30‐day outcomes. Twenty‐three patients were included in this analysis (9 patients suffered complete papillary muscle rupture, 9 partial and 5 chordal rupture). The patients' mean age was 68 ± 14 years. Patients were at high surgical risk with median EuroSCORE II 27% (IQR 16, 28) and 20 out of 23 (87% were in cardiogenic shock). All patients were treated with vasopressors, and 17 out of 23 patients required mechanical support. TEER procedure was performed on the median 6 days after the index MI date IQR (3, 11). Procedural success was achieved in 87% of patients. The grade of MR was significantly decreased after the procedure. MR reduction to 0 or 1 + was achieved in 13 patients (57%), to 2 + in 7 patients (30%), P < 0.01. V‐Wave was reduced from 49 ± 8 mmHg to 26 ± 10 mmHg post‐procedure, P < 0.01. Sixteen out of 23 patients (70%) were discharged from hospital and 5 of them required reintervention with surgical mitral valve replacement. No additional death at 1 year was documented.
Conclusions
TEER is a feasible therapy in critically ill patients with PMR due to a recent MI. TEER may have a role as salvage treatment or bridge to surgery in this population.
The aim of this study was to report the long-term results of the clover and edge-to-edge repair techniques for complex tricuspid regurgitation (TR).
This was a single-center observational study. A ...competing risks proportional-hazards regression model, using the Fine and Gray model, was performed to analyze the time to TR ≥2+, considering death as a competing risk.
A total of 145 consecutive patients (57% female) with severe or moderately severe TR secondary to leaflet prolapse or flail (115 patients), tethering (27 patients), or mixed (3 patients) lesions underwent clover (110 patients) or edge-to-edge repair(35 patients). The TR origin was degenerative in 75% of cases, posttraumatic in 8%, and secondary to dilated cardiomyopathy in 17%. Ring (64%) or suture (31%) annuloplasty was performed in 95% of patients. Concomitant procedures (mainly mitral surgery) were performed in 80% of cases. Hospital death was 5.5%. Follow-up was 98% complete, and median was 15 years (interquartile range, 14-17 years). The 16-year overall survival was 56% ± 5%. Previous cardiac surgery (hazard ratio HR, 2.83; 95% CI, 1.15-6.93; P = .023) and right ventricular dysfunction (HR, 2.24; 95% CI, 1.01-4.95; P = .046) were identified as predictors of death. The 16-year cumulative incidence function (CIF) of cardiac death with noncardiac death as a competing risk was 19.6%, and previous cardiac surgery (HR, 3.44; 95% CI, 1.23-9.65; P = .019) was detected as the only predictor of the event. At 16 years, the CIF of TR ≥2+ with death as a competing risk was 23.8%. In particular, TR ≥3+ was detected in 4 patients (3%).
When TR could not be treated by annuloplasty alone, concomitant leaflet repair with the clover or edge-to-edge technique effectively restored valve competence with very satisfactory long-term results and a low rate of moderate or greater TR recurrence.
Abstract
OBJECTIVES
The aim of this study was to assess the long-term outcomes of different surgical strategies in patients with hypertrophic obstructive cardiomyopathy (HOCM) with septal thickness ...≤18 mm and systolic anterior motion (SAM)-related moderate-to-severe mitral regurgitation (MR).
METHODS
Seventy-six HOCM patients with septal thickness 17 16; 18 mm, resting left ventricle outflow tract gradient 60 41; 85 mmHg and SAM-related MR ≥2+/4+, underwent septal myectomy alone (54%) or mitral valve (MV) surgery ± myectomy (46%).
RESULTS
No hospital death and no ventricular septal defect occurred. Patients undergoing MV surgery ± myectomy had longer cardiopulmonary bypass and X-clamp times (77 60–106 vs 51 44–62 min, P < 0.001 and 56 45–77 vs 32 28–41 min, P < 0.001) and higher incidence of low output syndrome (11% vs 0%, P = 0.04). Follow-up was 98.6% complete, median 8 years 3–11. There were no statistically significant differences in overall survival (P = 0.069) with survival rates at 9 years of 96 ± 4% in the myectomy alone group and 81 ± 8% in the MV surgery ± myectomy one. At 9 years, cumulative incidence function of cardiac death was 12 ± 6% in the MV surgery ± myectomy group vs 0% in the myectomy one, P = 0.06. Multivariable analysis identified age and previous septal alcoholization as predictors of cardiac death (hazard ratio (HR) = 1.1, 95% confidence interval (CI) 1.0–1.1, P = 0.004 and HR = 2.9, 95% CI 1.0–8.3, P = 0.042). The 9-year cumulative incidence function of recurrence of MR ≥2+, with death as competing risk, was 3 ± 2.8% in the MV surgery ± myectomy group vs 25 ± 6.9% in the myectomy one, P = 0.005.
CONCLUSIONS
In HOCM patients with moderate septal thickness and SAM-related MR, as the degree of septal hypertrophy decreases, addressing the abnormalities of the MV apparatus may become necessary to provide a durable resolution of left ventricle outflow tract obstruction and SAM-related MR. However, performing myectomy alone, whenever possible, seems to be associated to a better postoperative course and a trend towards lower cardiac mortality at follow-up, despite a higher rate of residual moderate MR.
Abstract
OBJECTIVES
This study aimed at assessing mid-term outcomes of patients undergoing isolated tricuspid valve (TV) surgery based on a preoperative baseline clinical and functional ...classification.
METHODS
All patients treated with isolated TV repair or replacement from March 1997 to May 2020 at a single institution were retrospectively reviewed and assessed for mid-term postoperative outcome according to a novel classification stages 1–5 related to the absence or presence and extent of right heart failure (RHF). Kaplan–Meier survival curves were used to estimate mid-term survival. Competing risk analysis for time to cardiac death and hospitalizations for RHF were also carried out.
RESULTS
Among the 172 patients included, 129 (75%) underwent TV replacement and 43 (25%) TV repair. At follow-up (median 4.2 years 2.1–7.5), there were 23 late deaths. At 5 years, overall survival was 100% in stage 2, 88 ± 4% in stage 3 and 60 ± 8% in stages 4–5 (P = 0.298 and P = 0.001, respectively). Cumulative incidence function of cardiac death at 5 years was 0%, 8.6 ± 3.76% and 13.2 ± 5% for stages 2, 3 and 4 and 5, respectively. At follow-up, cumulative incidence function of re-hospitalizations for RHF was 0% for stage 2, 20 ± 5% for stage 3 and 20 ± 6.7% for stages 4 and 5 (P = 0.118 and P = 0.039, respectively).
CONCLUSIONS
Both short- and mid-term outcomes support early referral for surgery in isolated TV disease, with excellent survival at 5 years and no further hospitalizations for RHF.
Tricuspid regurgitation (TR) has been identified as an independent prognostic factor associated with excess mortality and morbidity, regardless of left ventricular (LV) function and pulmonary hypertension 1–3.
To compare the outcomes of MitraClip and surgical mitral repair in low-intermediate risk elderly patients affected by degenerative mitral regurgitation (DMR).
We retrospectively selected patients ...aged ≥75 years, with Society of Thoracic Surgeons Predicted Risk Of Mortality (STS-PROM) <8%, submitted to MitraClip (n = 100) or isolated surgical repair (n = 206) for DMR at 2 centers between January 2005 and May 2017. To adjust for baseline imbalances, we used a propensity score model for average treatment effect on survival.
After weighting, MitraClip showed fewer postoperative complications (P < .05) but increased residual mitral regurgitation (MR) ≥2 (27.0% vs 2.8%, P < .001) compared with surgery. One-year survival was greater after MitraClip compared with surgery (97.6% vs 95.3%, hazard ratio HR, 0.09; confidence interval CI, 0.02-0.37, P = .001), whereas 5-year survival was lower (34.5% vs 82.2% respectively, HR, 4.12; CI, 2.31-7.34, P < .001). Greater STS-PROM (HR, 1.18; CI, 1.12-1.24, P < .001) and MR ≥3+ recurrence (HR, 2.18; CI, 1.07-4.48, P = .033) were associated with reduced survival. 5-year MR ≥3+ was more frequent after MitraClip compared with surgery: 36.9% versus 3.9%, odds ratio, 11.4; CI, 4.40-29.68, P < .001.
In elderly patients affected by DMR and STS-PROM <8%, the average effect of MitraClip resulted in lower acute postoperative complications and improved 1-year survival compared with surgery. However, MitraClip was associated with greater MR recurrence and reduced survival beyond 1 year. Long-term survival was impaired by patients' greater risk profile and MR recurrence. Early results are promising, but in the setting of operable patients with life expectancy beyond 1 year, the quality bar for transcatheter mitral repair needs to be raised.
ATE-weighted Kaplan–Meier survival estimates after MitraClip or surgical repair for DMR. Display omitted
Abstract
OBJECTIVES
With the expanding use of cardiac implantable electronic devices (CIEDs), lead interference with the tricuspid valve (TV) causing significant tricuspid regurgitation (TR) has ...gained increasing recognition. However, current knowledge about the long-term results of the surgical treatment of TR in this setting is scanty. Therefore, increasing this information was the goal of this study.
METHODS
A retrospective review of our institutional database was carried out to select all patients with previously implanted CIEDs who underwent tricuspid valve repair and replacement from 2000 through 2019. Kaplan–Meier methods were used to analyse long-term survival. To describe the time course of TR, we performed a longitudinal analysis using generalized estimating equations.
RESULTS
A total of 151 patients were identified. Mechanical interference with leaflet mobility and coaptation was detected in 103 patients (68%) (CIED-induced group); in the remaining 48 patients (32%), the lead was associated with TR without being the cause of it (CIED-associated group). A total of 105 patients underwent TV repair; in the remaining 46, a TV replacement was necessary. In patients who underwent TV repair, no significant difference in moderate TR recurrence rate was highlighted between CIED-induced and CIED-associated TR.
CONCLUSIONS
In patients with CIEDs and surgically treated tricuspid regurgitation, TR is CIED-induced in about two-thirds of the cases and CIED-associated in one-third of them. In our experience, TV repair was still possible in 63% of the cases, with good long-term results and no significant durability difference between CIED-induced and CIED-associated TR.
Old trials focusing on the safety and efficacy of the implantable cardioverter defibrillator demonstrated a significant decrease in the rate of sudden death 1, 2.
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