Objectives
To assess the value of effective regurgitant orifice (ERO) in predicting outcome after edge-to-edge transcatheter mitral valve repair (TMVR) for secondary mitral regurgitation (SMR) and ...identify the optimal cut-off for patients’ selection.
Methods
Using the EuroSMR (European Registry of Transcatheter Repair for Secondary Mitral Regurgitation) registry, that included patients undergoing edge-to-edge TMVR for SMR between November 2008 and January 2019 in 8 experienced European centres, we assessed the optimal ERO threshold associated with mortality in SMR patients undergoing TMVR, and compared characteristics and outcomes of patients according to baseline ERO.
Results
Among 1062 patients with severe SMR and ERO quantification by proximal isovelocity surface area method in the registry, ERO was < 0.3 cm
2
in 575 patients (54.1%), who were more symptomatic at baseline (NYHA class ≥ III: 91.4% vs. 86.9%, for ERO < vs. ≥ 0.3 cm
2
;
P
= 0.004). There was no difference in all-cause mortality at 2-year follow-up according to baseline ERO (28.3% vs. 30.0% for ERO < vs. ≥ 0.3 cm
2
,
P
= 0.585). Both patient groups demonstrated significant improvement of at least one NYHA class (61.7% and 73.8%,
P
= 0.002), resulting in a prevalence of NYHA class ≤ II at 1-year follow-up of 60.0% and 67.4% for ERO < vs. ≥ 0.3 cm
2
, respectively (
P
= 0.05).
Conclusion
All-cause mortality at 2 years after TMVR does not differ if baseline ERO is < or ≥ 0.3 cm
2
, and both groups exhibit relevant clinical improvements. Accordingly, TMVR should not be withheld from patients with ERO < 0.3 cm
2
who remain symptomatic despite optimal medical treatment, if TMVR appropriateness was determined by experienced teams in dedicated valve centres.
Sudden Cardiac Arrest in Young Women Weizman, Orianne; Sharifzadehgan, Ardalan; Bougouin, Wulfran ...
Circulation (New York, N.Y.),
02/2021, Letnik:
143, Številka:
7
Journal Article
Atrioventricular regurgitation is frequent in the setting of heart failure. It is due to atrial and ventricular remodelling, as well as rhythmic disturbances and loss of synchrony. Once ...atrioventricular regurgitation develops, it can aggravate the underlying heart failure, and further participate and aggravate its own severity. Its presence is therefore concomitantly a surrogate of advance disease and a predictor of mortality. Heart failure management, including medical therapy, cardiac resynchronization therapy, and restoration of sinus rhythm, are the initial steps to reduce atrioventricular regurgitation. In the current review, we analyse the current data assessing the epidemiology, pathophysiology, and impact of non-valvular intervention on atrioventricular regurgitation including medical treatment, cardiac resynchronization and atrial fibrillation ablation.
Valvular heart disease (VHD) is encountered in approximately 1% of pregnancies, significantly increasing both maternal and foetal risk. Rheumatic VHD remains the most common form in non-Western ...countries, whereas congenital heart disease dominates in the Western world. The risk of complications varies according to the type and severity of the underlying VHD. Moreover, pregnancy is a hypercoagulable state associated with increased risk of thromboembolism. The authors review the main VHDs encountered during pregnancy, and suggest management strategies based on the 2018 European Society of Cardiology recommendations for the management of pregnant women with VHD, providing an overview of classical and new transcatheter structural therapeutic options with a special focus on radiation exposure and anticoagulation drug management.
Aortopathy is common in patients with bicuspid aortic valve (BAV).
To evaluate the fate of unreplaced Valsalva sinuses in patients with BAV, 10 years after aortic valve replacement (AVR) with or ...without replacement of the ascending aorta (RAA).
We retrospectively reviewed all surgical patients with BAV who were operated on between January 2005 and December 2007. Patients who underwent AVR with or without RAA were included. Surgical data were entered prospectively. Ten-year clinical and echocardiographic follow-up data as well as survival data were collected by contacting the patients and their personal cardiologists, and by consulting the French national mortality registry. Overall, 25% of the patients had computed tomography angiographic assessment of the aortic root at follow-up.
A total of 133 patients with BAV were operated on within the selected period. Thirty-two patients did not meet the inclusion criteria, and had primary Valsalva sinus surgery. Twenty-four patients underwent AVR with RAA and 77 patients had isolated AVR; all of these 101 patients were included in the study. The median follow-up was 9 years (up to 12 years). During follow-up, eight patients (7.9%) underwent late reoperation; two of them (2.0%) required root surgery. Ten-year freedom from reoperation was 86.2±4.7%. Ten-year freedom from dilatation of the Valsalva sinuses (>45mm) was 86.6±5.2%. Ten-year cumulative survival was 83.5±4%.
Ascending aorta and Valsalva sinuses seem to have different fates after AVR in BAV disease. When the Valsalva sinuses are not dilated at the initial surgery, the risk of secondary dilatation at 10 years is low. Preservation of the sinuses is therefore justified in patients with BAV with a non-dilated root. In BAV with isolated aortic insufficiency, a more aggressive approach may be justified, especially in young patients.
L’atteinte de la paroi aortique est fréquente chez les patients ayant une valve aortique bicuspide. Nous avons évalué le devenir des sinus de Valsalva non remplacés chez les patients porteurs de bicuspidie aortique 10 ans un remplacement de la valve aortique (RVA), avec ou sans remplacement de l’aorte ascendante (RAA).
Nous avons examiné rétrospectivement tous les patients ayant une bicuspidie, opérés entre janvier 2005 et décembre 2007. Les patients qui ont bénéficié d’un RVA avec ou sans RAA ont été inclus. Les données chirurgicales ont été entrées prospectivement. Les données de suivi clinique et échocardiographique à dix ans ainsi que les données de survie ont été collectées en contactant les patients, leurs cardiologues et en consultant le Répertoire national français d’identification des personnes physiques (RNIPP) respectivement. Un quart des patients avaient un suivi de la racine aortique par angioscanner.
Cent trente-trois patients avec bicuspidie aortique ont été opérés durant cette période. Trente-deux malades ne répondaient pas au critères d’inclusion. Vingt-quatre patients ont été opérés de RVA avec RAA et 77 patients ont bénéficiés de RVA isolé. Le temps de suivi médian était de 9 ans et le suivi maximal de 12 ans. Durant le suivi, 8 patients (7,9 %) ont été réopérés dont deux pour dilatation du culot aortique (1,9 %). L’absence de réopération et l’absence de dilatation des sinus de Valsalva (> 45mm) à 10 ans était de 86.2±4.7 % et 86.6±5.2 % respectivement. La survie cumulée à 10 ans était de 83.5±4 %.
L’aorte ascendante et les sinus de Valsalva semblent avoir un destin différent après remplacement de la valve aortique dans la bicuspidie. Lorsque les sinus de Valsalva ne sont pas dilatés au moment de la chirurgie initiale, le risque de dilatation secondaire à 10 ans est faible. La conservation des sinus de Valsalva est donc justifiée chez les patients ayant une valve aortique bicuspide sans dilatation du culot aortique. Dans le cas de valve bicuspide avec insuffisance aortique isolée, une approche plus agressive pourrait être justifiée, notamment chez les patients jeunes.
Aims
The impact of the cardio‐hepatic syndrome (CHS) on outcomes in patients undergoing mitral valve transcatheter edge‐to‐edge repair (M‐TEER) for relevant mitral regurgitation (MR) is unknown. The ...objectives of this study were three‐fold: (i) to characterize the pattern of hepatic impairment, (ii) to investigate the prognostic value of CHS, and (iii) to evaluate the changes in hepatic function after M‐TEER.
Methods and results
Hepatic impairment was quantified by laboratory parameters of liver function. In accordance with existing literature, two types of CHS were distinguished: ischaemic type I CHS (elevation of both transaminases) and cholestatic type II CHS (elevation of two out of three parameters of hepatic cholestasis). The impact of CHS on 2‐year mortality was evaluated using a Cox model. The change in hepatic function after M‐TEER was assessed by laboratory testing at follow‐up. We analysed 1083 patients who underwent M‐TEER for relevant primary or secondary MR at four European centres between 2008 and 2019. Ischaemic type I and cholestatic type II CHS were observed in 11.1% and 23.0% of patients, respectively. Predictors for 2‐year all‐cause mortality differed by MR aetiology. While in primary MR cholestatic type II CHS was independently associated with 2‐year mortality, ischaemic CHS type I was an independent mortality predictor in secondary MR patients. At follow‐up, patients with MR reduction ≤2+ (obtained in 90.7% of patients) presented with improved parameters of hepatic function (median reduction of 0.2 mg/dl, 0.2 U/L and 21 U/L for bilirubin, alanine aminotransferase and gamma‐glutamyl transferase, respectively, p < 0.01).
Conclusions
The CHS is frequently observed in patients undergoing M‐TEER and significantly impairs 2‐year survival. Successful M‐TEER may have beneficial effects on CHS.
Cardio‐hepatic syndrome (CHS) in patients with primary or secondary mitral regurgitation undergoing transcatheter edge‐to‐edge repiar M‐TEER, mitral valve transcatheter edge‐to‐edge repair.
Aims
Right ventricular dysfunction (RVD), as expressed by right ventricular to pulmonary artery coupling, has recently been identified as a strong outcome predictor in patients undergoing mitral ...valve edge‐to‐edge repair (M‐TEER) for secondary mitral regurgitation (MR). The aim of this study was to define RVD in patients undergoing M‐TEER for primary MR (PMR) and to evaluate its impact on procedural MR reduction, symptomatic development and 2‐year all‐cause mortality.
Methods and results
This multicentre study included patients undergoing M‐TEER for symptomatic PMR at nine international centres. The study cohort was divided into a derivation (DC) and validation cohort (VC) for calculation and validation of the best discriminatory value for RVD. A total of 648 PMR patients were included in the study. DC and VC were comparable regarding procedural success and outcomes at follow‐up. Sensitivity analysis identified RVD as an independent predictor for 2‐year mortality in the DC (hazard ratio HR 2.37, 95% confidence interval CI 1.47–3.81, p < 0.001), which was confirmed in the VC (HR 2.06, 95% CI 1.36–3.13, p < 0.001). Procedural success (MR ≤2+) and symptomatic improvement at follow‐up (New York Heart Association NYHA class ≤II) were lower in PMR patients with RVD (MR ≤2+: 82% vs. 93%, p = 0.002; NYHA class ≤II: 57.3% vs. 66.5%, p = 0.09 for with vs. without RVD). In all PMR patients, the presence of RVD significantly impaired 2‐year survival after M‐TEER (HR 2.23, 95% CI 1.63–3.05, p < 0.001).
Conclusions
Mitral valve edge‐to‐edge repair is an effective treatment option for PMR patients. The presence of RVD is associated with less MR reduction, less symptomatic improvement and increased 2‐year mortality. Accordingly, RVD might be included into pre‐procedural prognostic considerations.
RVD predicts outcome after M‐TEER for PMR. CI, confidence interval; HR, hazard ratio; PMR, primary mitral regurgitation; RVD, right ventricular dysfunction.
Aims
To investigate the role of left atrial volume index (LAVi) in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge‐to‐edge mitral valve repair (TEER).
Methods and ...results
Outcomes were evaluated in SMR patients of a European multicentre registry according to baseline LAVi. Main analysis was performed for all‐cause mortality; residual mitral regurgitation (MR) and New York Heart Association (NYHA) class improvement were analysed for patients available. A total of 1074 patients were included with a median LAVi (interquartile range) of 58 ml/m2 (46–73). Postprocedural reduction of MR grade to ≤2+ was similar across LAVi quintiles, ranging 91%–96% (p = 0.26). Symptomatic benefit (≥1 NYHA class improvement) also did not differ by LAVi quintiles (61%–68% of patients) (p = 0.66). The risk of mortality increased by 23%–42% in the four upper quintiles compared to the bottom quintile (LAVi <42 ml/m2). The hazard ratio (HR) of mortality was 1.35 (95% confidence interval CI 1.02–1.78, p = 0.035) associated with a LAVi >42 ml/m2, which was attenuated after multivariable adjustment (HR 1.18, 95% CI 0.83–1.67, p = 0.36). A significant interaction was found for MR severity and pulmonary hypertension, with an increased risk of death associated with enlarged LAVi in patients with inframedian effective regurgitant orifice area (HR 1.99, 95% CI 1.06–3.74, p = 0.032) and in patients with systolic pulmonary pressure ≤50 mmHg (HR 1.67, 95% CI 1.02–2.75, p = 0.042) in multivariable analysis.
Conclusion
Procedural success and symptomatic benefit were high throughout the whole range of LAVi. The prognostic impact of left atrial enlargement was relevant in patients with less severe SMR and without pulmonary hypertension, reinforcing the need to identify patients in the early course of backward congestion to achieve good long‐term outcome after TEER.
IntroductionExtracellular Vesicles (EV) recapitulate the benefits of cell therapy for heart repair. Their mechanism of action remains unsettled.HypothesisEV may contribute to heart repair by de novo ...cardiogenesis.MethodsTo answer this question, we used 2 bi-transgenic mouse modelsthe fate-mapping MerCreMer/ZEG and the Mosaic Analysis With Double Markers (MADM). Myocardial infarction was induced by permanent coronary artery ligation. Those with a LVEF ≤ 45% were treated 3 weeks later with EV (from human iPS-derived cardiovascular progenitor cells; 10x10 particles) or PBS, injected under echo guidance in the peri-infarcted area (MerCreMer/ZEGn=15/group and MADMn=6/group). To track endogenous cardiomyocyte (CM) proliferation, we used EdU labeling in MerCreMer/ZEG delivered by osmotic pumps implanted for 7-10 days post-injection and biphoton microscopy in MADM models. Cardiac function was assessed 4-6 weeks after injection by echocardiography and MRI, blinded to treatment group. Hearts were then subjected to histological and transcriptomic analyses (qPCR and genome-wide microarray).ResultsIn PBS controls, EF remained stable over time in MerCreMer/ZEG mice and decreased from 34.5% ± 6.0% to 30.7% ± 7.5% in MADM mice by the end of the study. Conversely, EV injections increased EF from 32.1% ± 9.5% to 36.1% ± 7.45 % in MerCreMer/ZEG and from 36.2 %± 8.7% to 40.5% ± 8.9% in MADM mice. A significant difference in the change from baseline was found between EV and controls20.7% ± 10.5 % (p=0.048) and 28.0% ± 11.0 %, (p=0.045) for MerCreMer/ZEG and MADM groups, respectively. This improvement was confirmed by MRI in MerCreMer/ZEG mice (p=0.05). Improvement in EF was unrelated to the appearance of new CM, as shown by the absence of difference in TnT+/EdU+/GFP+ cell numbers and the lack of activation of the YAP/TAZ pathway between control and EV groups. However, EV reduced infarct size by 11.9% ± 5.75% (p=0.04), which was accompanied by decreased expression of 4 pro-fibrotic genes (Col1a2, Col3a1, Lox, Col1a2 by qPCR) in heart tissue and a 2.13X overexpression of the anti-fibrotic miRNA 133a-1 compared to controls (n=3/group; p=0.001).ConclusionsEV likely improve cardiac function by modulation of fibrosis rather than by de novo cardiogenesis.
•Trend to fewer periprocedural complications over the years.•Significant decrease of thromboembolic and haemorrhagic events post procedure.•Almost half of haemorrhagic events occur during the first 3 ...months.
Percutaneous left atrial appendage closure may be considered in selected patients with atrial fibrillation at significant risk of both thromboembolism and haemorrhage.
To report the experience of a tertiary French centre in percutaneous left atrial appendage closure and to discuss the outcomes compared with previously published series.
This was a retrospective observational cohort study of all patients referred for percutaneous left atrial appendage closure between 2014 and 2020. Patient characteristics, procedural management and outcomes were reported, and the incidence of thromboembolic and bleeding events during follow-up were compared with historical incidence rates.
Overall, 207 patients had left atrial appendage closure (mean age 75.3±8.6 years; 68% men; CHA2DS2-VASc score 4.8±1.5 ; HAS-BLED score 3.3±1.1), with a 97.6% (n=202) success rate. Twenty (9.7%) patients had at least one significant periprocedural complication, including six (2.9%) tamponades and three (1.4%) thromboembolisms. Periprocedural complication rates decreased from earlier to more recent periods (from 13% before 2018 to 5.9% after; P=0.07). During a mean follow-up of 23.1±20.2 months, 11 thromboembolic events were observed (2.8% per patient-year), a 72% risk reduction compared with the estimated theoretical annual risk. Conversely, 21 (10%) patients experienced bleeding during follow-up, with almost half of the events occurring during the first 3 months. After the first 3 months, the risk of major bleeding was 4.0% per patient-year, a 31% risk reduction compared with the expected estimated risk.
This real-world evaluation emphasizes the feasibility and benefit of left atrial appendage closure, but also illustrates the need for multidisciplinary expertise to initiate and develop this activity.
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