Percutaneous left atrial appendage (LAA) exclusion is an evolving treatment to prevent embolic events in patients with nonvalvular atrial fibrillation. In the past few years multiple percutaneous ...devices have been developed to exclude the LAA from the body of the left atrium and thus from the systemic circulation. Two- and 3-dimensional transesophageal echocardiography (TEE) is used to assess the LAA anatomy and its suitability for percutaneous closure to select the type and size of the closure device and to guide the device implantation procedure in conjunction with fluoroscopy. In addition, 2- and 3-dimensional TEE is also used to assess the effectiveness of device implantation acutely and on subsequent follow-up examination. Knowledge of the implantation options that are currently available along with their specific characteristics is essential for choosing the appropriate device for a given patient with a specific LAA anatomy. We present the currently available LAA exclusion devices and the echocardiographic imaging approaches for evaluation of the LAA before, during, and after LAA occlusion.
Mitral regurgitation (MR) is the most prevalent valvular heart disease and, when left untreated, results in reduced quality of life, heart failure, and increased mortality. Mitral valve transcatheter ...edge-to-edge repair (M-TEER) has matured considerably as a non-surgical treatment option since its commercial introduction in Europe in 2008. As a result of major device and interventional improvements, as well as the accumulation of experience by the interventional cardiologists, M-TEER has emerged as an important therapeutic strategy for patients with severe and symptomatic MR in the current European and American guidelines. Herein, we provide a comprehensive up-do-date overview of M-TEER. We define preprocedural patient evaluation and highlight key aspects for decision-making. We describe the currently available M-TEER systems and summarise the evidence for M-TEER in both primary mitral regurgitation (PMR) and secondary mitral regurgitation (SMR). In addition, we provide recommendations for device selection, intraprocedural imaging and guiding, M-TEER optimisation and management of recurrent MR. Finally, we provide information on major unsolved questions and "grey areas" in M-TEER.
Abstract
Interventricular septum defects are a known complication after an aortic valve replacement, but not after mitral surgery. We present a case of a 65-year-old female who underwent unsuccessful ...mitral valvuloplasty through port-access surgery, followed by uneventful mechanical bioprosthesis replacement. Postoperatively, the patient experienced multiple arrhythmias and recovered poorly. A systolic murmur led to echocardiography, showing an interventricular septum rupture. This was closed with 2 polypropylene pledgeted mattress sutures, via the right atrium and tricuspid valve through midsternal access. The authors believe that the most likely cause is tearing of 2 deeply placed adjacent sutures in the septum, creating localized weakening of the septum susceptible to further rupture. We therefore underline the importance of adequate exposure, especially at the notorious anterior annulus.
Known complications after mitral valvuloplasty or valve replacement are death, resternotomy for bleeding/tamponade, myocardial infarction, stroke, infection, atrial fibrillation, prosthetic endocarditis, thromboembolism, paravalvular leak (PVL) and prosthesis failure 1.
Aims
To assess the feasibility, short‐term durability and clinical outcomes of MitraClip® therapy for mitral regurgitation (MR) in patients with end‐stage heart failure and a severely reduced left ...ventricular (LV) ejection fraction.
Methods and results
We analysed retrospectively collected data from seven European centres. Included in the study were 50 heart failure patients mean age 70 ± 11 years, 38 men (76%) with a LV ejection fraction ≤25% and MR of at least grade 3+. All patients had functional MR, were in New York Heart Association (NYHA) functional class III or IV, and their mean logistic EuroSCORE was 34%. The patients underwent a total of 53 MitraClip® procedures; one or more clips were implanted in 50 procedures (48 patients), for an acute procedural success rate of 94%. Severity of MR was reduced in all successfully treated patients, 44 (92%) were discharged with MR ≤2+. Thirty‐day mortality was 6%; cumulative survival at 6 months was 81.2%. Clinical and echocardiographic 6‐month follow‐up data were obtained from 32 and 31 successfully treated patients, respectively. At 6 months, MR ≤2+ was present in 27 (87%) of 31 patients, and 23 (72%) of 32 patients were in NYHA functional class I or II. Six‐minute walk distance improved significantly, and significant reductions in LV volumes indicative of reverse LV remodelling were concordant with significant reductions in N‐terminal pro‐brain natriuretic peptide plasma levels.
Conclusion
MitraClip® therapy reduces functional MR in patients with end‐stage heart failure and marked LV dysfunction and entails clinical benefit at 6 months.
The work-up for transcatheter aortic valve replacement (TAVR) currently uses computed tomography to evaluate the annulus diameter and peripheral vascular access plus invasive coronary angiography ...(ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of coronary computed tomography angiography (CCTA). Prior studies found an improvement of the diagnostic accuracy of CCTA with the use of computed tomography–derived fractional flow reserve (CT-FFR).
The aim of this study was to assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVR.
Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVR work-up between 2015 and 2019 were included in this retrospective cross-sectional study. All patients underwent CCTA and ICA within 3 months, and the diagnostic performance of both CCTA and CT-FFR was assessed using ICA as the reference.
Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis on ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per patient were 76.9%, 64.5%, 34.0%, 92.1%, and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0%, and 87.6% for CT-FFR. The area under the receiver-operating characteristic curve was significantly different between CCTA and CT-FFR (0.84 vs 0.90, P = 0.02). A CT-FFR–guided approach could avoid ICA in 57.1% versus 43.6% of patients using CCTA.
CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided. It has the potential to be integrated in the current clinical work-up for TAVR for diagnosing stable CAD requiring treatment.
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Functional mitral regurgitation (FMR) can be subclassified on the basis of its proportionality relative to left ventricular (LV) volume and function, indicating potential differences in underlying ...etiology. The aim of this study was to evaluate the association of FMR proportionality with FMR reduction, heart failure hospitalization and mortality after transcatheter edge-to-edge mitral valve repair (TEER).
This multicenter registry included 241 patients with symptomatic heart failure with reduced LV ejection fraction treated with TEER for moderate to severe or greater FMR. FMR proportionality was graded on preprocedural transthoracic echocardiography using the ratio of the effective regurgitant orifice area to LV end-diastolic volume. Baseline characteristics, follow-up transthoracic echocardiography, and 2-year clinical outcomes were compared between groups.
Median LV ejection fraction, effective regurgitant orifice area and LV end-diastolic volume index were 30% (interquartile range IQR, 25%–35%), 27 mm2, and 107 mL/m2 (IQR, 90–135 mL/m2), respectively. Median effective regurgitant orifice area/LV end-diastolic volume ratio was 0.13 (IQR, 0.10–0.18). Proportionate FMR (pFMR) and disproportionate FMR (dFMR) was present in 123 and 118 patients, respectively. Compared with patients with pFMR, those with dFMR had higher baseline LV ejection fractions (median, 32% IQR, 27%–39% vs 26% IQR, 22%–33%; P < .01). Early FMR reduction with TEER was more pronounced in patients with dFMR (odds ratio, 0.45; 95% CI, 0.28–0.74; P < .01) than those with pFMR, but not at 12 months (odds ratio, 0.93; 95% CI, 0.53–1.63; P = .80). Overall, in 35% of patients with initial FMR reduction after TEER, FMR deteriorated again at 1-year follow-up. Rates of 2-year all-cause mortality and heart failure hospitalization were 30% (n = 66) and 37% (n = 76), with no differences between dFMR and pFMR.
TEER resulted in more pronounced early FMR reduction in patients with dFMR compared with those with pFMR. Yet after initial improvement, FMR deteriorated in a substantial number of patients, calling into question durable mitral regurgitation reductions with TEER in selected patients. The proportionality framework may not identify durable TEER responders.
•Transcatheter treatment of FMR is a subject of debate.•Proportionality of EROA to LV volumes could influence the outcome of TEER.•Disproportionate mitral regurgitation showed greater reduction after TEER.•A substantial part of initial FMR reduction deteriorated during follow-up.•Clinical outcomes at 2 years did not differ between different proportionality groups.
A new collagen-based MANTA vascular closure device (VCD) was developed for closing large-bore arteriotomies after transfemoral transcatheter aortic valve implantation (TAVI).
We evaluated safety and ...feasibility at 30-day follow-up in terms of vascular and bleeding complications and mortality of the collagen-based MANTA VCD compared with the suture-based Prostar XL VCD in a cohort of 366 patients who underwent transfemoral TAVI between January 2015 and April 2018. The MANTA VCD was used in 168 patients and the Prostar XL VCD in 198 patients, with successful closure of 98.8% and 98.5%, respectively. VARC-2 defined as major vascular and bleeding complications was similar in both groups (MANTA vs Prostar XL): 0.6% versus 1.0% (p = 0.661) and 0.6% versus 1.5% (p = 0.102). Minor vascular and bleeding complications, were significantly more frequent (10.7 vs 18.8 %, p = 0.003 and 13.7 vs 19.7%, p = 0.080, respectively) in the Prostar XL cohort. Thirty-day all-cause mortality was 2.7%, without significant difference between the groups (p = 0.278). The MANTA device is a safe and feasible option for vascular access closure in patients undergoing transfemoral TAVI.
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