To address the mechanisms responsible for the increase in LV filling pressures induced by acute hypertension transients in patients with heart failure with preserved ejection fraction (HFpEF).
...Multiple-beat pressure-volume loops were recorded during inferior vena cava occlusion in 39 HFpEF patients and 20 controls during handgrip and atrial pacing. We measured the contribution of relaxation, elastic recoil, and stiffness to instantaneous diastolic pressure using a novel processing method. Fibrosis was quantified from endomyocardial biopsies. HFpEF patients showed higher diastolic pressures and stiffness constant than controls (P < 0.05 for all). As opposed to controls, all intrinsic global diastolic properties were sensitive to acute changes in systolic pressure in the HFpEF group. In fact, the stiffness constant increased by more than 50% during handgrip in HFpEF patients (P < 0.05), tightly related to changes in systolic pressure (fixed-effect = 0.26 mm Hg per mm Hg 95% CI = 0.15-0.37; P < 0.0001). Incomplete relaxation contributed to increasing pressure before atrial contraction, but changes in end-diastolic pressure was mostly caused by the increase in stiffness. The degree of pressure-sensitivity of stiffness correlated with myocardial collagen volume and crosslinking (R = 0.40 to 0.82 for all).
Acute chamber stiffening is the main mechanism responsible for rising late-diastolic pressures when HFpEF patients undergo hypertension transients. This stiffening behaviour is related to impaired dynamic systolic-diastolic interactions and correlates with matrix remodelling. Ventricular-vascular relationships are a promising target in HFpEF and should be taken into account when assessing diastolic function.
Optimal timing for percutaneous mitral regurgitation (MR) treatment using MitraClip (Abbott Vascular) remains unclear. We evaluated the outcome after MitraClip in patients with moderate resting MR, ...progressing to severe exercise- induced MR (MR2+) compared to patients with severe resting MR (MR3).
We retrospectively investigated 221 patients undergoing MitraClip. All-cause deaths and heart failure (HF) hospitalizations were assessed as the combined primary endpoint.
We identified 55 MR2+ and 166 MR3 patients. At baseline, MR3 patients showed higher STS scores (6.7 ± 7.3 vs 4.4 ± 5.5; P<.01), more HF hospitalizations in the 2 years prior to the procedure (51% vs 29%; P<.01), worse left ventricular ejection fraction (44.9 ± 16.5% vs 52.5 ± 14.3%; P<.01), larger left ventricular end-diastolic diameter (LVEDd; 57.0 ± 9.3 mm vs 51.7 ± 8.2 mm; P<.001), and larger left atrial volumes (118.3 ± 55.8 mL vs 98.6 ± 35.2 mL; P=.02). Long-term outcome according to the combined endpoint was significantly worse in MR3 patients (P=.01). HF hospitalizations significantly declined in both groups 2 years after MitraClip (P<.001 in MR3 patients, P=.03 in MR2+ patients). Multivariate Cox regression analysis revealed LVEDd (hazard ratio, 1.035; 95% confidence interval, 1.005-1.066; P=.02) and previous HF hospitalizations (hazard ratio, 1.813; 95% confidence interval, 1.016-3.234; P=.04) as strong outcome predictors.
Symptomatic patients with moderate resting and severe exercise-induced MR during handgrip echocardiography may represent an MR cohort at an earlier disease stage with improved treatment response following MitraClip implantation compared to individuals with severe resting MR. Larger left ventricular diameters and preprocedural HF hospitalizations were identified as independent adverse outcome predictors.
Aims
Hepatitis C virus (HCV) has been associated with cardiomyopathies. Former anti-HCV therapies employing interferon could have serious side effects in patients with advanced heart failure since ...interferon may adversely impact upon cardiac function. We, therefore, examined whether the novel, interferon-free and highly virus-selective anti-HCV combination therapy might be applicable even in advanced or end-stage heart failure.
Methods and results
In a retrospective series of HCV-positive patients admitted to our institution with suspected cardiac disease, coronary, valvular or hypertensive heart disease was diagnosed in 70/146 (47.9%). Among the others, 36/76 (47.4%) had myocardial disease: LV (32.9%)/RV (13.2%) hypertrophy, RV dysfunction (13.2%)/dilation (6.6%), severe diastolic dysfunction (7.9%), pulmonary hypertension (22.4%). One critically ill patient listed for heart transplantation (HTX) had previously not tolerated an interferon-based protocol. To still improve her chance of enduring transplant survival, we attempted an interferon-free virus-selective antiviral combination drug protocol under careful monitoring of possible side effects. Regarding clinical status she tolerated this treatment well, with the exception of transient severe hyponatremia requiring substitution. Her NYHA functional class improved from II–IV before to class II immediately after successful complete HCV elimination.
Conclusions
Whereas prevalence of cardiac dysfunction and potential benefit from antiviral treatment was reported previously, there is lack of data regarding the response of patients with advanced heart failure. Since the highly HCV-selective drugs used above do not eliminate other cardiotropic viruses and have no direct effect on inflammation, massive improvement in such critically ill patients indicates a
causal
role of HCV in their cardiac failure, and of HCV elimination in their functional recovery.
High surgical risk patients presenting with severe mitral valve regurgitation (MR) and concomitant aortic valve disease are frequently a challenge for the interdisciplinary heart team meeting. If ...open-heart surgery for severe MR is performed, aortic stenosis (AS) or regurgitation (AR) is corrected during the same procedure if at least moderate severity of AS or AR has been confirmed. In patients with prohibitive surgical risk, optimal management strategies in the light of available transcatheter interventions still needs to be established.
In this retrospective single center Study, we aimed to investigate the impact of coincident moderate aortic valve disease on the outcome of patients undergoing MitraClip for severe MR. In 286 MitraClip procedures performed in our institution, 21 patients (7,3%) were identified to suffer from concomitant moderate AS and 28 patients had moderate AR (9,8%). Patients with AS were found to have a higher incidence of >moderate MR following the procedure when compared to patients without aortic valve disease (14,3% vs. 8,9%, p = 0.001). No differences between the groups were found regarding a combined endpoint of all cause deaths and heart failure hospitalizations after 1 year follow up (no aortic-valve disease vs. moderate AS: 19% vs 18%; p = 0,881 and no aortic valve disease vs moderate AR: 19% vs. 25%; p = 0.477). However, mortality was significantly higher in patients with coincidental moderate AR (3.8% patients without aortic valve disease, 5% in patients with AS, 17,9% in patients with AR; p = 0.006).
According to our analysis coincidental Aortic valve stenosis may be associated with worse technical results regarding residual MR after MitraClip. Although our results regarding a combined endpoint of all-cause mortality and heart failure hospitalizations within one year of follow up were comparable between the groups, patients with moderate AR had significantly higher mortality rates. Due to the limited number of patients, our study is only hypothesis generating. Larger trials are necessary to confirm our result.
Objectives
The present study aimed to evaluate the outcome and potential limitations of a repeated MitraClip procedure (ReClip).
Background
The MitraClip procedure has emerged as a treatment option ...in high surgical risk patients suffering from severe mitral regurgitation (MR). However, despite successful initial repair a significant number of patients develops severe recurrent MR.
Methods
Patients undergoing a ReClip procedure in our institution were retrospectively identified. Baseline data and the procedural outcome were assessed to identify potential limitations of such procedures.
Results
Fifteen out of 234 patients undergoing a mitral‐valve repair with the MitraClip device (Abbott Vascular) underwent a ReClip due to recurrent MR. In 11 patients, a MR reduction of at least one degree without causing mitral valve stenosis (trans‐mitral mean gradient ≥5 mmHg) was achieved by performing a ReClip. After 1 year, two patients developed severe recurrent MR again. Pulmonary artery pressures significantly decreased after the procedure in individuals with successful repair (MR reduction of at least one degree and mitral valve mean gradient <5 mmHg).
Conclusion
A ReClip procedure may be feasible in patients with recurrent MR but the risk benefit ratio should be carefully balanced against other treatment options.
Abstract Background Conventional echocardiography has limited accuracy in detecting diastolic dysfunction and NT-proBNP is known to be a reliable biomarker to rule out heart failure. Therefore ...NT-proBNP on top to conventional mitral flow Doppler might improve the diagnostic of diastolic dysfunction in patients with heart failure despite normal EF (HFNEF) without using tissue Doppler. Methods and results Diastolic function of 46 patients with HFNEF was determined by pressure–volume loop obtained by conductance-catheter measurements. LV stiffness correlated with the amount of collagen types I and III analyzed from endomyocardial biopsies (EMBs). NT-proBNP plasma levels correlated with LV stiffness, LVEDP and the collagen amount from EMBs ( p < 0.01). In another set of patients with HFNEF ( n = 107, 53 45–62 years), diastolic dysfunction was confirmed by left and/or right heart catheterization. Their Doppler indices and plasma marker NT-proBNP values were compared with those of 73 controls (186 70–342 vs 5430–75 pg/ml, p < 0.001). Mitral flow Doppler was impaired in 70/107 (65%) of the HFNEF. When additional criterium NT-proBNP > 125 pg/ml was used 96/107 (90%) patients with impaired diastolic function were recognized. Sensitivity of tissue Doppler indices E ′/ A ′ and E / E ′ were improved by 4–6% using NT-proBNP on top. NT-proBNP recognized HFNEF patients with higher hospitalization rate indicated by phone questionnaire, whereas Doppler indices alone did not. Conclusion Plasma NT-proBNP levels are associated with increased LV stiffness and cardiac collagen content. On top measurements of plasma NT-proBNP improve the echocardiography diagnostic of diastolic function and prognostic of rehospitalization in HFNEF.
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