Numerous patients are treated with the MitraClip, although they do not fulfill the stringent inclusion criteria of the Endovascular Valve Edge-to-Edge Repair Study (EVEREST) trials. The outcome of ...those patients is not well known. Therefore, we compared the long-term outcome after MitraClip treatment between patients who matched (group 1) and did not match (group 2) the EVEREST criteria. One hundred thirty-four consecutive patients were treated from September 2009 to July 2012: 59 patients (44%) in group 1 versus 75 patients (56%) in group 2. Investigated end points were acute procedural success (for group 1 vs 2: 97% vs 95%; p = 0.694), all-cause mortality (28% vs 27%; p = 0.656), reintervention (RI) rate (11% vs 37%; p = 0.010), and improvement in mitral regurgitation (MR) (−1.3 ± 1 vs −1.5 ± 1, p = 0.221) and in New York Heart Association functional class (−0.7 ± 1 vs −0.9 ± 0.8, p = 0.253) during the follow-up of 33 months (27.9 to 38.3). The morphologic extent of a flail leaflet was an independent predictor for RI. In conclusion, although the overall outcome was comparable between both groups, recurrent symptomatic MR with need for RI was higher in group 2, mainly because of complex valve pathologies: especially flail width >15 mm and gap ≥10 mm. Improvements in the interventional strategy are warranted for reducing the need for RI in patients with primary MR.
The clinical outcome of patients with severe primary and secondary mitral regurgitation (MR) and heart failure or significantly reduced left ventricular ejection fraction (LVEF) who underwent ...percutaneous mitral valve repair (pMVR) is yet not well known. This study compares midterm outcome of patients with severe left ventricular dysfunction (EF ≤30%) versus patients with slightly or moderately reduced or normal LVEF (EF >30%) after pMVR. One hundred thirty-six consecutive patients were enrolled: 42 patients displayed severe left ventricular dysfunction, group 1 (logistic EuroSCORE I 27.7 ± 21.8%; secondary MR in 37 patients), and 94 patients displayed slightly or moderately reduced or normal LVEF, group 2 (logistic EuroSCORE I 17 ± 18.2%; secondary MR in 21 patients). The primary efficacy endpoint was death of any cause, repeat mitral valve intervention, and/or New York Heart Association class ≥III, which was reached in 31% of patients in group 1 versus 40% in group 2 (p = 0.719) at a median follow-up of 371 days. MR, graded by transthoracic echocardiography, was reduced in both groups (p <0.001) and New York Heart Association class improved in each group (p <0.001), with no differences between groups (p >0.05). In conclusion, at midterm follow-up, the pMVR provided significant clinical benefits with comparable results achieved both in patients with significantly reduced and in patients with moderately reduced to normal LVEF. Thus, pMVR represents a feasible and effective treatment in high-risk patients who otherwise have limited therapeutic options and no safe option to reduce MR.
Background Schizophrenia has been defined as a dysconnection syndrome characterized by aberrant functional brain connectivity. Using task-based fMRI, we assessed to what extent the nature of the ...cognitive context may further modulate abnormal functional brain connectivity. Methods We analyzed data matched for motion in patients with schizophrenia and healthy controls who performed 3 different tasks. Tasks 1 and 2 both involved emotional processing and only slighlty differed (incidental encoding v. memory recognition), whereas task 3 was a much different mental rotation task. We conducted a connectome-wide general linear model analysis aimed at identifying context-dependent and independent functional brain connectivity alterations in patients with schizophrenia. Results After matching for motion, we included 30 patients with schizophrenia and 30 healthy controls in our study. Abnormal connectivity in patients with schizophrenia followed similar patterns regardless of the degree of similarity between cognitive tasks. Decreased connectivity was most notable in the medial prefrontal cortex, the anterior and posterior cingulate, the temporal lobe, the lobule IX of the cerebellum and the premotor cortex. Limitations A more circumscribed yet significant context-dependent effect might be detected with larger sample sizes or cognitive domains other than emotional and visuomotor processing. Conclusion The context-independence of functional brain dysconnectivity in patients with schizophrenia provides a good justification for pooling data from multiple experiments in order to identify connectivity biomarkers of this mental illness.
In idiopathic dilated cardiomyopathy (IDC), myocardial deformational parameters and their mutual relationships remain incompletely characterized.
Thirty-seven patients with IDC underwent ...two-dimensional speckle-tracking echocardiography (2D-STE) to assess left ventricular rotation, torsion, and longitudinal, circumferential, and radial systolic and diastolic strains and strain rates. Additionally, 2D-STE was performed in 14 controls.
All deformational parameters on 2D-STE were significantly lower in patients with IDC compared with controls. Seven patients exhibited opposite basal (positive, counterclockwise) and 11 patients exhibited opposite apical (negative, clockwise) rotation at end-systole. Circumferential, radial, and longitudinal early diastolic strain rates were correlated most strongly with the corresponding spatial components of systolic deformation.
In patients IDC, all torsional, systolic, and diastolic deformational parameters were decreased. Corresponding three-dimensional components of systolic and diastolic deformations were closely coupled. Considerable variation in the direction of basal and apical rotation exists in a subset of patients with IDC.
The development and progression of cardiac allograft vasculopathy documented by coronary angiography (CAV
) after heart transplantation (HTx) has prognostic relevance. Yet there are limited data ...regarding the role of concomitant intracoronary imaging in the presence CAV
. In particular, atherosclerotic plaques might represent a potential target for prevention, but their impact on stenosis is understudied.
We used high-resolution intracoronary optical coherence tomography (OCT) to quantify and compare findings of intimal hyperplasia (IH) and plaque morphologies in HTx patients (fibrotic plaque, lipid plaque, and calcified plaque). OCT findings were related to the presence of CAV
as well as to the severity of stenosis.
We included 65 consecutive patients into analysis (66% with CAV
, posttransplant interval 9.9 ± 7.6 y). Fibrotic, lipid, and calcified plaques were present in 41 (63.1%), 39 (60%), and 18 (27.7%) patients, respectively. In addition to IH, the presence of fibrotic, lipid, and calcified plaques was found to be associated with CAV
. The prevalence of lipid plaque and quantitative measurements of fibrotic plaque increased with stenosis severity (lipid plaque,
< 0.001, maximal and mean fibrotic arc,
= 0.05 and
= 0.001, respectively). Receiver operating characteristic analysis showed that area under the curve of the fibrotic plaque parameter mean fibrotic arc (0.87, 95% confidence interval 0.76-0.99;
= 0.002) was superior to area under the curve of intima parameters regarding CAV
. The effect of mean fibrotic arc (
= 0.52,
< 0.001) was relevant regarding stenosis severity.
After a longer posttransplant interval, CAV findings in OCT included a combination of IH and atherosclerotic plaques. In addition to IH, the presence of fibrotic, lipid, and calcified plaques is associated with CAV
. Further studies are warranted to evaluate if the in vivo screening for plaque progress, particularly of fibrotic plaque, could improve individual secondary prevention and outcome in HTx patients.
Abstract Background Aspirin administration, as part of a dual antiplatelet treatment regimen, is essential for patients undergoing percutaneous coronary intervention (PCI). Although the correlation ...between high on-clopidogrel treatment platelet reactivity (HCPR) and clinical outcome is well established, data for high on-aspirin treatment platelet reactivity (HAPR) are conflicting. Objectives The aim of the ISAR-ASPI (Intracoronary Stenting and Antithrombotic Regimen—ASpirin and Platelet Inhibition) registry was to assess the value of HAPR as a possible prognostic biomarker in PCI-treated patients with regard to clinical outcome. Methods From February 2007 to May 2013, we identified 7,090 consecutive PCI-treated patients with measured on-aspirin treatment platelet aggregation values directly before PCI. Platelet function was assessed with a Multiplate analyzer. The primary endpoint was death or stent thrombosis (ST) at 1 year. Results The upper quintile of patients (n = 1,414), according to Multiplate measurements, was defined as the HAPR cohort. Compared with non-HAPR patients (n = 5,676), HAPR patients showed a significantly higher risk of death or ST at 1 year (6.2% vs. 3.7%, respectively; odds ratio OR: 1.78; 95% confidence interval CI: 1.39 to 2.27; p < 0.0001). HAPR was found to be an independent predictor of the primary outcome (adjusted hazard ratio HRadj : 1.46; 95% CI: 1.12 to 1.89; p = 0.005). Conclusions HAPR, measured at the time point of the PCI, is associated with a higher risk for death or ST during the first year after PCI. Present data are in support of the addition of HAPR to a panel of prognostic biomarkers in PCI-treated patients.
Reply Mayer, Katharina, MD; Bernlochner, Isabell, MD; Braun, Siegmund, MD ...
Journal of the American College of Cardiology,
2015, Volume:
65, Issue:
19
Journal Article
Venoarterial extracorporeal membrane oxygenation treatment in patients with severe cardiogenic shock can cause or aggravate acute lung injury. In our retrospective analysis, we aimed at identifying ...markers for acute lung injury after arrival on ICU, which predict mortality of those patients. DESIGNObservational, monocentric, retrospective analysis. SETTINGCardiac ICU of Ludwig Maximilian University Hospital, Munich, Germany. PATIENTSTwo-hundred eleven patients undergoing venoarterial extracorporeal membrane oxygenation treatment for severe cardiogenic shock were included into this analysis. Patients who died within 24 hours after venoarterial extracorporeal membrane oxygenation implantation were excluded. INTERVENTIONSNone. MEASUREMENTS AND MAIN RESULTSTo determine lung injury, we investigated the influence of Pao2/Fio2 ratio (Horowitz index). The lowest Horowitz index was measured on ICU 6-12 hours after venoarterial extracorporeal membrane oxygenation implantation. An optimal cutoff value of less than 126 for Horowitz index to predict mortality was identified via receiver operating characteristic analysis (area under the curve, 0.62). Patients with Horowitz index less than 126 had a 30-day mortality rate of 67.5% compared to 37.5% with a Horowitz index greater than or equal to 126 (p < 0.001). Multivariate analysis identified Horowitz index less than 126 as an independent risk factor of ICU mortality (odds ratio, 3.6; 95% CI, 1.8-7.3; p < 0.001). CONCLUSIONSIn this hypothesis-generating analysis, a Horowitz index less than 126 is associated with increased mortality in patients with cardiogenic shock and venoarterial extracorporeal membrane oxygenation, which may serve as a threshold for further therapeutic interventions.
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