Elevated Pressure Gradient Research Articles

Elevated mitral valve pressure gradient following transcatheter edge-to-edge repair is independently associated with inferior outcomes in atrial, but not in ventricular secondary mitral regurgitation

Abstract Background In transcatheter mitral valve edge-to-edge repair (M-TEER), the goal of optimizing post-procedural residual mitral regurgitation inadvertently carries the risk of generating relevant mitral stenosis, resulting in an elevated mean mitral valve pressure gradient (MPG). In patients with primary mitral regurgitation, an elevated post-procedural MPG has been found to independently predict impaired outcomes. However, the effect of elevated post-procedural MPG on outcome after M-TEER in patients with secondary mitral regurgitation (SMR) has yet to be fully elucidated. This study investigated the impact of elevated MPG on outcome in the EuroSMR registry, a large, multi-center real-world cohort of patients with SMR. Methods This retrospective study included patients who underwent M-TEER for SMR between 2009 and 2021 in 12 centers. Patients were stratified into two groups based on SMR etiology: (1) ventricular SMR (vSMR), and (2) atrial SMR (aSMR). The etiology was considered as vSMR in patients with a left ventricular ejection fraction (LV-EF) <50% and aSMR in subjects with preserved left ventricular function (LV-EF ≥50%) and a markedly dilated left atrium (Left Atrial Volume Index [LAVi] ≥40ml/m2). According to the proposed M-VARC threshold, post-procedural MPG was assessed by discharge transthoracic echocardiography and was considered elevated if >5 mmHg. The primary endpoint was all-cause mortality after 5 years, with statistical analysis conducted using Kaplan-Meier and uni- and multivariable Cox Regression analysis. Results Among the 1703 patients in the study (vSMR: n=1420; aSMR: n=283), elevated post-procedural MPG was observed in 9.4% (n=133) of vSMR and 19.1% (n=54) of aSMR patients. Atrial fibrillation was significantly more prevalent in aSMR (78.4% vs. 57.1%, p<0.001). Patients with vSMR had a higher median surgical risk assessed by the EuroScore II (aSMR vs. vSMR: 7.0% [IQR 4.0, 13.1] vs. 4.9% [IQR 2.9, 8.5], p<0.001). Kaplan-Meier analyses for all-cause mortality after 5 years demonstrated significant differences in aSMR patients (low vs. elevated MPG: 48.9% vs. 69.8%, log-rank p<0.01), while there was no difference in vSMR patients (55.7% vs. 60.8%, log-rank p=0.66) (Figure 1). This observed effect remained significant even after accounting for common confounding factors: elevated MPG was an independent predictor for all-cause mortality in aSMR patients (HR=1.86; 95%-CI: 1.14-3.02, p=0.013) but not in vSMR patients (HR=1.00; 95%-CI: 0.74-1.35, p=0.99). Conclusion Our findings suggest that elevated post-procedural MPG is an independent predictor of adverse outcomes in patients with aSMR, but not in those with vSMR. This effect may partially be explained by a reduced left atrial function and higher rates of atrial fibrillation.Figure 1.Study flowchart

A propensity score matched analysis of transcatheter aortic valve replacement in failed bioprosthetic valves

Abstract Introduction While recently published data indicate similar long-term results of transcatheter aortic valve replacement (TAVR) compared to surgical procedures, surgical aortic valve replacement (SAVR) remains the standard of care in low-risk patients. However, since life expectancy increases, a non-negligible number of patients experience bioprosthetic valve dysfunction with the need for reintervention, but long-term data of TAVR in failed bioprosthetic valves is scarce. Purpose The aim of the study was to analyse long-term data of patients with TAVR in failed bioprosthetic valves compared to patients with native valve TAVR. The primary endpoint was 6-year all-cause mortality and the main secondary endpoint was echocardiographic valve function. Methods Patients undergoing TAVR for severe aortic valve disease between December 2012 and December 2020 were retrospectively analysed. Prior TAVR or aortic valve homografts led to exclusion from the study. A 2:1 propensity score matching by the optimal neighbor matching algorithm was performed to overcome differences in baseline characteristics. Results Between December 2012 and December 2020, 3,423 patients received TAVR for severe aortic valve disease and met inclusion criteria for the study. Of those, 3,287 patients underwent native valve TAVR, whereas 136 patients experienced bioprosthetic valve dysfunction and were treated with TAVR-in-SAV. After 2:1 propensity score matching, baseline characteristics without any relation to prior SAVR were similar between both groups. Concerning postprocedural echocardiographic function, a less pronounced gradient reduction (57.0 vs. 71.0 %, p < 0.01, Figure 1) and a higher number of patients with elevated mean pressure gradient > 20 mmHg could be found after prior SAVR (19.4 vs. 3.0 %, p < 0.01). However, there was no difference regarding 6-year all-cause mortality between both groups (log rank test p = 0.8, Figure 2). Conclusions Besides a less pronounced gradient reduction and higher mean aortic pressure gradients after TAVR-in-SAV compared to patients with native valve TAVR, no differences in 6-year all-cause mortality could be observed in a propensity score matched analysis.Reduction of mean pressure gradient6-year all-cause mortality

Elevated Trans-mitral Pressure Gradient Predicts Surgery in Young People with Moderate-Severe Rheumatic Mitral Regurgitation.

Mitral regurgitation (MR) is the most common lesion in children with rheumatic heart disease (RHD). Progression of RHD results in the need for surgical intervention, the timing of which is dictated by left ventricular dilatation and the onset of heart failure symptoms. We sought to determine whether elevation in trans-mitral pressure gradient (TMPG) in those with moderate or severe rheumatic MR without significant mitral stenosis (MS) could predict the need for future surgical intervention. Echocardiographic studies were reviewed for 116 children and young people with moderate or severe rheumatic MR. Those with significant mitral stenosis or concurrent aortic valve disease were excluded. Trans-mitral pressure gradient was measured at baseline and details of mitral valve surgical intervention were retrieved from a registry database. Time to future surgery (up to six years) was compared between those with TMPG < 5mmHg and TMPG ≥ 5mmHg. Survival curves demonstrated an increased risk of surgery for those with TMPG ≥ 5mmHg with Cox proportional regression analysis providing a hazard ratio of 5.8. The proportion free from mitral valve surgery at one year for the TMPG < 5mmHg group was 0.94 (95% CI 0.86-0.97), compared to 0.62 (95% CI 0.42-0.77) in the ≥ 5mmHg group. Trans-mitral pressure gradient is a strong predictor of future mitral valve surgery in children and young people with significant rheumatic MR without MS. This non-invasive measure could be used to signal the need for more aggressive monitoring in order to optimize the timing of intervention.

Analysis of cerebral venous sinus stenosis by flat panel angiographic CT (FP-CT) to guide treatment for idiopathic intracranial hypertension.

Cerebral venous sinus stenting (CVSS) is an effective treatment for idiopathic intracranial hypertension (IIH) secondary to dural venous sinus stenosis. Traditional selection of patients for CVSS has been made by microcatheter manometry, but pressure measurements are often equivocal. Here we present the results of a series of cases in which venous flat-panel CT (FP-CT) was used as an adjunct to microcatheter manometry to improve decision making and precise stent placement during CVSS. Ten consecutive patients with IIH underwent angiography with microcatheter manometry and venous FP-CT, with CVSS if indicated by the results. Cross-sectional measurements of the narrowed sinus were obtained on FP-CT before and after stenting. After the procedure, clinical outcomes were tracked. Follow-up with quantitative MRA with sinus flow measurements was also performed, when available. There was an exponential correlation between measured pressure gradient and degree of stenosis calculated using venous FP-CT. All patients with both a high degree of stenosis measured by FP-CT and a high pressure gradient across the stenosis showed a clinical benefit from stenting. True measurement of the cross-sectional area of the dural sinus, made by venous phase FP-CT, has a high degree of correlation with elevated venous pressure gradient across the point of stenosis. Even in a limited series of cases, we found an exponential decrease in flow with increasing severity of stenosis. Furthermore, patients with both an elevated venous pressure gradient and critical stenosis of the sinus on FP-CT showed symptomatic improvement after stenting.

Echocardiographic Profiling Predicts Clinical Outcomes After Mitral Transcatheter Edge-to-Edge Repair.

Prior studies investigating the impact of residual mitral regurgitation (MR), tricuspid regurgitation (TR), and elevated predischarge transmitral mean pressure gradient (TMPG) on outcomes after mitral transcatheter edge-to-edge repair (TEER) have assessed each parameter in isolation. We sought to examine the prognostic value of combining predischarge MR, TR, and TMPG to study long-term outcomes after TEER. We reviewed the records of 291 patients who underwent successful mitral TEER at our institution between March 2014 and June 2022. Using well-established outcomes-related cutoffs for predischarge MR (≥moderate), TR (≥moderate), and TMPG (≥5 mm Hg), 3 echo profiles were developed based on the number of risk factors present (optimal: 0 risk factors, mixed: 1 risk factor, poor: ≥2 risk factors). Discrimination of the profiles for predicting the primary composite end point of all-cause mortality and heart failure hospitalization at 2 years was examined using Cox regression. Overall, mean age was 76.7±10.6 years, 43.3% were women, and 53% had primary MR. Two-year event-free survival was 61%. Predischarge TR≥moderate, MR≥moderate, and TMPG≥5 mm Hg were risk factors associated with the primary end point. Compared with the optimal profile, there was an incremental risk in 2-year event-rate with each worsening profile (optimal as reference; mixed profile: hazard ratio (HR), 2.87 [95% CI, 1.71-5.17], P<0.001; poor profile: HR, 3.76 [95% CI, 1.84-6.53], P<0.001). Echocardiographic profile was statistically associated with the 2-year mortality end point (optimal as reference; mixed profile: HR, 3.55 [95% CI, 1.81-5.96], P<0.001; poor profile: HR, 3.39 [95% CI, 2.56-7.33], P=0.02). The echocardiographic profile integrating predischarge TR, MR, and TMPG presents a novel prognostic stratification tool for patients undergoing mitral TEER.

Determinants of trans-prosthetic gradients after isolated surgical aortic valve replacement and effect on survival

Abstract Background Surgical aortic valve replacement (sAVR) remains the primary therapeutic approach for severe symptomatic aortic stenosis. Patient-prosthetic mismatch (PPM) occurs when the implanted valve is too small for the patient and is characterized by a small orifice area and elevated trans-valvular pressure gradient identified on post-operative transthoracic echocardiography (TTE). PPM is thought to be associated with adverse clinical outcomes, especially when severe, however data is conflicting. Purpose We sought to determine the impact of patient- and prosthesis-related parameters on post-operative trans-valvular pressure gradient, as a surrogate of PPM, and identify its influence on survival in a large single centre study. Methods This was a retrospective study of patients who underwent isolated sAVR between June 2003 and February 2017 at our tertiary cardiothoracic centre. Patients were excluded if their clinical and surgical records were incomplete, they hadn’t attended post-operative follow up or they had undergone valve replacement with anything other than a conventional stented tissue or mechanical prosthesis. All patients underwent postoperative follow up at eight weeks, six months and annually thereafter in keeping with local guidelines. TTE was performed between six and 12 months after surgery. Peak trans-valvular gradient was calculated using the continuity equation based upon continuous wave doppler assessment through the aortic valve. The highest value obtained from multiple views was recorded. Independent predictors of post-operative gradient were determined using a cox-proportional hazards model. Survival analysis was evaluated by Kaplein-Meier curves and log-rank test. Results One thousand seven hundred and ninety patients underwent isolated SAVR during the study period, of which 604 patients satisfied the inclusion and exclusion criteria. Mean age was 69.5 (±11.4) years and 346 (59%) were male. Mean peak pressure gradient was 29.96 (±12.4) mmHg. Independent predictors of increased post-operative gradients were: smaller valve size, postoperative diuretic use, age, gender and operating surgeon (p&amp;lt;0.001) (Table 1). Seventy-two patients (12%) died during follow-up. Mean survival was 12.1 years. After adjusting for confounders, post-operative pressure gradient was identified as a significant predictor of mortality (HR 1.02, p=0.001), alongside age (HR 1.06, p=0.001) and diabetes mellitus (HR 2.18, p=0.007) (Figure 1). Conclusion In a large cohort of patients undergoing sAVR at a single centre in the UK, valve size was the biggest determinant of postoperative pressure gradient alongside sex, diabetes, diuretic use and operating surgeon. Postoperative pressure gradient was a significant predictor of all-cause mortality. Accordingly, implanting the largest possible valve size should be considered the single most effective way of reducing the post-operative gradient and long-term mortality in patients undergoing sAVR.Table 1:Multivariate linear regressionFigure 1:K-M curve

Noninvasive, patient-specific computational fluid dynamics simulations of dural venous sinus pressures in idiopathic intracranial hypertension

BackgroundThe pathophysiology of Idiopathic Intracranial Hypertension (IIH) is poorly understood, making the disease difficult to properly diagnose and treat. Endovascular venous stenting has emerged as an effective non-invasive treatment option for a select cohort of IIH patients with venous sinus stenosis and elevated venous sinus pressure gradient. Unfortunately, current methods of determining patient eligibility for stenting treatment depend on highly invasive and insufficient measurement methods such as venous manometry, which can only measure pressure gradients and not other components of the complex 3D hemodynamic environment. Thus, there is a need for a non-invasive methodology for determining the 3D flow environment of the dural venous sinuses. ObjectiveTo develop a novel method of non-invasive, patient-specific computational fluid dynamic (CFD) simulation of venous sinus hemodynamics for evaluating stenting eligibility. MethodA patient with IIH and elevated sinus pressure gradient underwent MR venography, phase-contrast MR venography, and venous manometry. Patient-specific dural venous anatomy was segmented from the MR venography to construct 3D models of the venous sinuses. 3D transient patient-specific computational fluid dynamic simulations were conducted using flow velocities measured with phase-contrast MR venography as boundary conditions. ResultsSuccessful computational simulations were completed, allowing for the calculation of the spatio-temporal evolution of blood flow through the dural venous sinuses, and the quantitative examination of pressure gradients. Calculated pressure gradients from CFD were validated against venous manometry with an error of only ∼5%. ConclusionsWe have successfully developed time-resolved, patient-specific 3D computational simulations of the dural venous sinuses without assumptions at the boundary conditions for the first time. The methodology can accurately and non-invasively measure venous pressure gradients. This preliminary study serves as a proof of concept for our method to be used as a diagnostic tool for determining venous stenting eligibility, as well as a tool for advancing the general understanding of IIH pathophysiology. Statement of SignificanceThe pathophysiology of Idiopathic Intracranial Hypertension (IIH) is poorly understood making the disease difficult to properly diagnose and treat. Endovascular venous stenting has emerged as an effective non-invasive treatment option for a select cohort of IIH patients with venous sinus stenosis and elevated venous sinus pressure gradient. Our work provides a method for noninvasively determining eligibility for venous sinus stenting, avoiding costly and invasive venous manometry.

Electromagnetic turbulence simulation of tokamak edge plasma dynamics and divertor heat load during thermal quench

The edge plasma turbulence and transport dynamics, as well as the divertor power loads during the thermal-quench phase of tokamak disruptions, are numerically investigated with BOUT++’s flux-driven six-field electromagnetic turbulence model. Here, transient yet intense particle and energy sources are applied at the pedestal top to mimic the plasma power drive at the edge induced by a core thermal collapse, which flattens the core temperature profile. Interesting features, such as surging of divertor heat load (up to 50 times) and broadening of heat-flux width (up to four times) on the outer-divertor target plate, are observed in the simulation, in qualitative agreement with experimental observations. The dramatic changes in divertor heat load and width are due to the enhanced plasma turbulence activities inside the separatrix. Two cross-field transport mechanisms, namely, the E × B turbulent convection and the stochastic parallel advection/conduction, are identified to play important roles in this process. First, an elevated edge pressure gradient drives instabilities and subsequent turbulence in the entire pedestal region. The enhanced turbulence not only transports particles and energy radially across the separatrix via the E × B convection, which causes the initial divertor heat-load burst, but it also induces amplified magnetic fluctuation . Once themagnetic fluctuation is large enough to break the magnetic flux surface, magnetic flutter effect provides an additional radial transport channel. In the late stage of our simulation, reaches to 10−4 level that completely breaks magnetic flux surfaces such that stochastic field lines are directly connecting pedestal top plasma to the divertor target plates or first wall, further contributing to the divertor heat-flux width broadening.

Risk factors and outcomes with surgical bioprosthetic mitral valve dysfunction

BackgroundThere are insufficient data regarding the risk factors associated with valve dysfunction of bioprosthetic valves in the mitral position This study aimed to investigate the factors associated with bioprosthetic mitral...

Monte Carlo Simulations of Shear‐Thinning Flow in Geological Fractures

AbstractThe hydraulic behavior of fractured rocks under shear‐thinning flow is a challenging topic of interest in several fields, related either to environmental remediation or to natural resources recovery. The compound effect of fluid rheology and medium heterogeneity strongly affects flow and transport in fractured geological formations. Here, a stochastic analysis is conducted via Monte Carlo simulations to investigate the flow of shear‐thinning fluids in fractures subjected to both natural and forced flow, considering different fracture dimensions, for a spatial correlation of the fracture that is an intrinsic parameter of the geological formation, independent of the fracture size. Considering the lubrication approximation, a generalized Reynolds equation for shear‐thinning fluids is solved using an ad hoc, finite volume‐based, numerical scheme. The influence of the rheology and aperture field heterogeneity on ensemble statistics of the velocity components and magnitude, as well as apparent fracture‐scale transmissivity, is quantified over 103 fracture realizations. The probability density functions (PDFs) and relative confidence intervals, obtained by averaging over the statistics, are analyzed to characterize the apparent transmissivity transition from Newtonian to shear‐thinning regime. The autocorrelation functions of velocity components are computed to understand the impact of rheology on spatial correlations the flow. Velocity components exhibit narrow PDFs with nearly exponential decay. More elevated pressure gradients emphasize the shear‐thinning behavior, inducing a more pronounced flow localization, under otherwise identical conditions. This translates at the scale of the fracture into a larger apparent transmissivity as compared to the same configuration with Newtonian rheology, by orders of magnitude.

Portal Hypertension: Current Surgical Management

AbstractPortal hypertension occurs due to multiple disorders of the liver and its circulation. It is defined as an elevated pressure gradient between the portal circulation and the systemic circulation. The primary clinical consequences of portal hypertension are ascites and the development of portosystemic varices, which may cause life threatening hemorrhage. Modern management of portal hypertension includes medical, endoscopic therapy and transjugular intrahepatic portosystemic shunt placement by interventional radiology. Historically, portal hypertension was treated through the creation of surgical portosystemic shunts. In this chapter, the physiology of portal hypertension and the approaches to its management will be discussed. Specifically, the chapter will focus on indications, technical considerations, and types of surgical shunts used to treat portal hypertension, as well as literature supporting these procedures. Three case reports describing recent successful surgical shunt creation will be presented. Although portosystemic surgical shunt creation is performed far less frequently as medical, endoscopic and radiologic interventions have improved, this chapter illustrates that this procedure is a vital tool to be used in the treatment of portal hypertension.

Long-Term Outcomes of Patients With Elevated Mitral Valve Pressure Gradient After Mitral Valve Edge-to-Edge Repair

The aim of this study was to investigate the adverse impact of elevated postprocedural mitral valve pressure gradient (MPG) on outcome in a real-world population of patients with severe mitral regurgitation (MR) who underwent transcatheter mitral valve edge-to-edge repair (TEER). TEER has become a routine treatment alternative for patients with severe MR at high surgical risk. The consequences of elevated MPG after TEER have been subject to controversial debates. All consecutive patients undergoing TEER for either severe degenerative MR (DMR) or functional MR (FMR) at a high-volume center between September 2008 and January 2020 were prospectively included and followed periodically. Postprocedural MPG by discharge transthoracic echocardiography was considered elevated at≥5mmHg. The primary combined endpoint was death or heart failure rehospitalization after 5 years. A total of 713 patients undergoing TEER (DMR, n=265; FMR, n=445) were included. Elevated postprocedural MPG was present in 37.0% of those with DMR (n=98) and 22.0% of those with FMR (n=98). In contrast to patients with FMR, 6-minute walk distance did not improve in patients with DMR with elevated MPG. Kaplan-Meier analyses did not demonstrate significant differences for the primary endpoint in patients with DMR (low vs elevated MPG, 67.3% vs 74.4%; P=0.06) and those with FMR (78.6% vs 74.8%; P=0.54). After adjustment, elevated MPG was an independent predictor of the primary endpoint in patients with DMR (HR: 1.59; 95%CI: 1.03-2.45; P=0.034) but not in those with FMR (HR: 0.87; 95%CI: 0.63-1.22; P=0.43). Elevated postprocedural MPG is an independent predictor of adverse clinical and functional outcomes in patients with DMR but not in those with FMR.

508 Incidence and determinants of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted indexed effective orifice area

Abstract Aims A small effective orifice area (EOA) by body surface area (BSA), defined as prosthesis–patient mismatch (PPM), is associated with elevated transprosthetic pressure gradients, less ventricular remodelling, and a worse prognosis. Calculating PPM by dividing the normal reference value of EOA for the model and size of the prosthetic valve (predicted PPM), instead of using the continuity equation has been recently confirmed as more accurate after trans catheter aortic valve intervention (TAVI), providing a stronger association with post-procedural haemodynamic outcomes. However, current evidence using this new definition is still limited, thus impairing generalizability. Accordingly, this analysis aims to extend such evidence providing incidence, and determinants of predicted PPM (PPMp) in an all-comers population undergoing TAVR with a high prevalence of self-expandable devices. Methods 395 patients who underwent TAVI at our Institution from September 2008 to November 2020 were included in this analysis. PPMp was then classified as moderate if ≤ 0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 as well as moderate if ≤ 0.70 cm2/m2 and severe if ≤ 0.55 cm2/m2 for patients with a body mass index &amp;gt; 30, as recommended by the Valve Academic Research Consortium-3 definition. The independent association between baseline clinical and procedural variables and the presence of moderate or severe PPMp was investigated with cross-sectional logistic regression analysis. Results 11 patients (2.78%) had severe and 33 (8.35%) moderate PPMp. Patients with moderate or severe PPMp (m/s PPMp) were younger, female, with a higher prevalence of hypercholesterolaemia, prior aortic valve implantation and balloon expandable device and lower prevalence of chronic obstructive disease (COPD). Post-procedural mean gradient was higher in patients with m/s PPMp. The independent clinical and procedural correlates associated with higher likelihood of m/s PPMp were valve in valve procedure (ViV) and the use of a balloon-expandable device. Conclusions Moderate or severe PPMp was observed only in a small part of patients underwent TAVI, leading, however, a higher post-procedural mean gradient compared to those without PPMp. Balloon expandable devices and ViV were the strongest determinant of moderate or severe PPM.

Long-Term survival and functional status in patients with elevated mitral valve pressure gradient after transcatheter mitral valve repair

Abstract Background A growing number of patients are currently treated for severe mitral regurgitation (MR) using a transcatheter mitral valve repair (TMVr). In clinical routine, the potential risk of elevated post-procedural mitral valve pressure gradient (MPG) may prohibit optimal MR reduction driven by the avoidance of additional clip implantations. Thus, the unfavorable impact on survival and functional outcome of increased MPG in patients undergoing TMVr is currently debatable. Methods In this single-center, prospective study, survival and functional outcome of 780 consecutive patients with severe MR undergoing TMVr between September 2008 and January 2020 were investigated. After exclusion of patients with unsuccessful procedure and those lost to follow-up, data of 676 patients with a median follow-up time of 5.26 (5.11, 5.51) years were analyzed. MPG was determined by transthoracic echocardiography at discharge and considered elevated in excess of 4.5 mmHg. Kaplan-Meier analysis as well as multivariable Cox regression models were performed for the impact on elevated MPG on 5-year outcomes for the subgroups of functional MR (FMR) and degenerative MR (DMR). The primary outcome measure was a combined endpoint of death or rehospitalization for congestive heart failure. Results Among 676 patients undergoing TMVr (mean age 74.6±8.5 years, 59.0% male, median STS Score 3.9 [interquartile range 2.5; 6.0]), 179 (26.4%) patients had elevated MPG &amp;gt;4.5 mmHg. FMR was present in 426 (63.0%) patients. In the overall patient cohort, Kaplan-Meier and Cox Regression analyses could not demonstrate significant differences for the combined endpoint (p=0.99). In contrast, subgroup analysis according to MR etiology indicated a significant adverse influence of elevated MPG on the combined endpoint as well as functional outcome in patients with DMR, but not with FMR (Figure 1). After adjustment, multivariate Cox Regression analysis showed an inferior prognosis in patients with DMR and elevated MVPG &amp;gt;4.5 mmHg (hazard ratio 1.79 [1.17, 2.72], p=0.0069, Figure 2). Conclusions TMVr-patients with DMR and measurable elevated post-procedural MVPG face an inferior prognosis and reduced functional outcomes compared to patients with FMR. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Factors determining mitral valve dysfunction in patients who underwent surgical mitral valve replacement with bio-prosthetic valves

Abstract Background There is increasing Interest in bio-prosthetic MVD as recent advances in transcatheter MV interventions, but there is limited data. Objectives The aim of this study was to identify the factors determining mitral valve (MV) dysfunction (MVD) in patients who underwent MV replacement with bio-prosthetic valves. Also, we sought to investigate clinical outcomes in patients with bio-prosthetic MVD. Methods A total of 233 patients underwent surgical bio-prosthetic MV replacement between June 1996 and May 2015. Finally, 226 patients (mean age 66.9±11.5 years, 74.3% of women) were analyzed, excluding patients who followed-up for less than 5 years and patients whose baseline or follow-up echocardiography could not be analyzed. Clinical, echocardiographic, and laboratory data were collected early after the surgery and during follow-up. MVD was defined as an increase in mean gradient ≥5 mmHg with leaflet motion limitation and/or newly developed MV regurgitation during follow-up. Clinical outcome was defined as a composite of cardiovascular death, redo MV surgery or intervention, and hospitalization for heart failure. Results During a median of 102.0 months (interquartile range 72.0 to 132.0 months), 65 patients (28.8%) revealed MVD. 8 (12.3%) patients revealed predominant MV obstruction, and 57 (87.7%) showed predominant MV regurgitation. Factors associated with bio-prosthetic MVD by multivariate regression analysis were young age at operation (hazard ratio 0.97, 95% CI 0.95–0.99, p=0.001), end-stage renal disease (hazard ratio 4.29, 95% CI 1.45–12.71, p=0.007), elevated mean diastolic pressure gradient&amp;gt;5.5 mmHg across the bio-prosthetic MV early after operation (hazard ratio 1.86, 95% CI 0.97–3.74, p=0.063) and anemia after operation (hazard ratio 0.84, 95% CI 0.74–0.95, p=0.007). However, the presence of hypertension, dyslipidemia, or porcine bio-prosthesis was not related to the bio-prosthetic MVD. Kaplan-Meier curves revealed significant differences in event-free survivals for the occurrence of bio-prosthetic MVD according to each factor (Figure 1). Patients with bio-prosthetic MVD showed significantly poor clinical outcomes compared with those without bio-prosthetic MVD (event-free survival 43.1% vs. 91.9%, log-rank p&amp;lt;0.001) during the follow-up. Conclusions Young age at operation, end-stage renal disease, elevated mean pressure gradient early after the operation, and anemia after operation were associated with bio-prosthetic MVD in patients who underwent bio-prosthetic MV replacement. Funding Acknowledgement Type of funding sources: None.

Prevalence, echocardiographic profile and clinical outcomes of patients with paradoxical low-gradient rheumatic mitral stenosis

Abstract Introduction Rheumatic mitral stenosis (MS) has been conventionally defined by the mitral valve area (MVA), and associated with an elevated mean pressure gradient (PG) across the valve. However, there may be discrepancies between MVA and PG. We compared the clinical and echocardiographic parameters, as well asoutcomes of those with consistent (normal-gradient, NG) versus discrepant (Low-gradient, LG) grading between MVA and PG. Methods Consecutive patients (n=452) with index echocardiographic diagnosis of rheumatic MS (MVA &amp;lt;1.5cm2) were examined. Patients were matched by MVA and divided based on mean PG (LG &amp;lt;10mmHg or HG ≥10mmHg). The groups were compared using appropriate univariable, multivariable and survival analyses. Patients were followed up prospectively for clinical outcomes (admission for congestive heart failure, stroke or death). Results There were 226 patients (50.0%) with LGMS despite MVA&amp;lt;1.5cm2. They had similar age and body mass index. The LG group had higher prevalence of atrial fibrillation (62.4% vs 45.1%, p&amp;lt;0.001), hypertension (31.4% vs 18.8%, p&amp;lt;0.001) and lower heart rate during echocardiography (74.3±16.6 vs 82.5±20.2 beats per minute, p&amp;lt;0.001). LG MS patients had lower incidence of adverse events (log-rank 4.62, p=0.032). On multivariable Cox regression adjusting for age, left ventricular ejection fraction, MVA, pulmonary artery systolic pressure and mitral valve procedure, LG MS remained protective for adverse events (adjusted HR 0.58, 95% CI 0.38–0.89, p=0.013). Conclusions There was significant prevalence of paradoxical LG MS. Despite similar MVA, these patients had lower PASP and had fewer adverse outcomes on follow-up. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Dr Jan Stassen is supported by an ESC Training Grant (Appehab724.169164741)

Direct Flow Medical vs. Edwards Sapien 3 Prosthesis: A Propensity Matched Comparison on Intermediate Safety and Mortality.

Aims: To compare intermediate performance and mortality rates in patients, who underwent transcatheter aortic valve implantation (TAVI) with two different types of prostheses: Edwards Sapien 3 (ES3) and Direct Flow Medical (DFM).Methods and Results: 42 consecutive patients implanted with a DFM prosthesis for severe aortic stenosis were matched 1:1 with an equal number of patients, who received an ES3 during the same period. Primary endpoint was mortality. MACE, as a composite of all-cause death, stroke, and re-do-procedure (valve-in-valve), was defined as secondary endpoint. Moreover, we compared NYHA class, NT-proBNP-levels and the extent of restenosis. Patients were followed for 2 years. DFM patients showed echocardiographic elevated mean pressure gradients compared to ES3 patients before discharge (11.2 mmHg ± 5.3 vs. 3.5 mmHg ± 2.7; p < 0.001) and upon 6-months follow-up (20.3 mmHg ± 8.8 vs. 12.3 mmHg ± 4.4; p < 0.001). ES3 candidates showed superior NYHA class at follow-up (p = 0.001). Kaplan-Meier analysis revealed significantly worse survival in patients receiving a DFM prosthesis compared to ES3 (Breslow p = 0.020). MACE occurred more often in DFM patients compared to ES3 (Breslow p = 0.006).Conclusions: Patients receiving DFM valve prostheses showed worse survival and higher rates in MACE compared to ES3. Prosthesis performance regarding mean pressure gradients and patients' NYHA class also favored ES3.

A Double-Envelope Mitral Inflow Spectral Doppler Profile After MitraClip

A Double-Envelope Mitral Inflow Spectral Doppler Profile After MitraClip

Rectal\u2013vaginal pressure gradient in patients with pelvic organ prolapse and symptomatic rectocele

ObjectiveThe aim of this study is to examine the relationship between rectal–vaginal pressure and symptomatic rectocele in patients with pelvic organ prolapse (POP).MethodPatients with posterior vaginal prolapse staged III or IV in accordance with the POP Quantitation classification method who were scheduled for pelvic floor reconstructive surgery in the years 2016–2019 were included in the study. Rectocele was diagnosed using translabial ultrasound, and obstructed defecation (OD) was diagnosed in accordance with the Roma IV diagnostic criteria. Both rectal and vaginal pressure were measured using peritron manometers at maximum Vasalva. To ensure stability, the test was performed three times with each patient.ResultsA total of 217 patients were enrolled in this study. True rectocele was diagnosed in 68 patients at a main rectal ampulla depth of 19 mm. Furthermore, 36 patients were diagnosed with OD. Symptomatic rectocele was significantly associated with older age (p < 0.01), a higher OD symptom score (p < 0.001), and a lower grade of apical prolapse (p < 0.001). The rectal–vaginal pressure gradient was higher in patients with symptomatic rectocele (37.4 ± 11.7 cm H2O) compared with patients with asymptomatic rectocele (16.9 ± 8.4 cm H2O, p < 0.001), and patients without rectocele (17.1 ± 9.2 cm H2O, p < 0.001).ConclusionThe rectal–vaginal pressure gradient was found to be a risk factor for symptomatic rectocele in patients with POP. A rectal–vaginal pressure gradient of > 27.5 cm H2O was suggested as the cut-off point of the elevated pressure gradient.

Predictors for Reintervention after Surgical Coarctation Repair through Left Thoracotomy

Background: Recoarctationof the aorta may occur in infants after the primary surgical repair. Several risk factors were suggested in the literature, with controversial results among the studies. Objective: This study was conducted to evaluate the predictors for reintervention after surgical coarctation repair by different techniques through left thoracotomy. Patients and Methods: A retrospective analysis was performed for patients who underwent isolated surgical coarctation repair or with pulmonary artery band between Sep 2014 and December 2018. All primary intervention was through thoracotomy. Reintervention was defined as the need for balloon angioplasty or reoperation. Results: A total of 47 patients with median age at repair of 7 days. The median duration of follow-up was 18 months (95% CI=14 to 22 months). Only 7 (14.9%) patients required reintervention. No mortality was recorded during the follow-up period. Cox proportional hazard analysis showed that only postoperative pressure gradient was an independent risk factor for reintervention. Receiver operating characteristic curve showed that postoperative pressure gradient was an excellent indicator (AUC = 0.948, 95% CI: 0.841 to 0.992, p 25, sensitivity of 100% and specificity of 80%. Conclusions: Repair of aortic coarctation through thoracotomy has an overall good outcome. However, reintervention is required in some patients and elevated pressure gradient on echocardiographic assessment <25 can exclude recoarctation