Reduction Of Mitral Regurgitation Research Articles

Transapical Coaptation Plate for Functional Mitral Regurgitation: An In Vitro Study.

A novel transapical coaptation plate (TCP) device was developed and anchored by sutures in the mitral valve to treat functional mitral regurgitation. The objective of this study was to test efficacy of the TCP in an in vitro model. Eight fresh porcine mitral valves were mounted in a left heart simulator to simulate functional mitral regurgitation by means of annular dilatation and asymmetrical or symmetrical papillary muscle (PM) displacement. Six polyurethane TCPs in thickness of 6.4(#1), 4.8(#2), 3.2(#3) mm and hardness of durometer 30 A (H) and 30 OO(S),were fabricated and labeled as H1, H2, H3 and S1, S2, S3, respectively. These TCPs were anchored by the sutures in the mitral annulus and left ventricle apex, and tested. Steady backward flow leakage in a hydrostatic condition and regurgitant volume in a pulsatile flow were measured before and after implantation of the TCPs. Mean regurgitant volume fractions in the asymmetric PM displacement were reduced significantly from 59.1 to 37.2% for H1, 43.2% for H2, 35.9% for S1 and 34.2% for S2 (p<0.021), after implantation of the TCPs. No significant reduction in mitral regurgitation was seen for H3 and S3 (p>0.067). Mitral regurgitation was mild in the symmetric PM displacement, and was not significantly reduced after implantation of the TCPs. In conclusion, the TCP anchored by the sutures in the mitral annulus and left ventricle apex functions successfully as a plug in the mitral valve leaflet gap. The TCP with thickness equal to or greater than 4.8mm is effective to reduce functional mitral regurgitation. The TCP hardness has no effect on difference in reduction of functional mitral regurgitation.

Balloon aortic valvuloplasty as a bridge-to-decision in high risk patients with aortic stenosis: a new paradigm for the heart team decision making.

BackgroundWhilst the majority of the patients with severe aortic stenosis can be directly addressed to surgical aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI), in some instances additional information may be needed to complete the diagnostic workout. We evaluated the role of balloon aortic valvuloplasty (BAV) as a bridge-to-decision (BTD) in selected high-risk patients.MethodsBetween 2007 and 2012, the heart team in our Institution required BTD BAV in 202 patients. Very low left ventricular ejection fraction, mitral regurgitation grade ≥ 3, frailty, hemodynamic instability, serious comorbidity, or a combination of these factors were the main drivers for this strategy. We evaluated how BAV influenced the final treatment strategy in the whole patient group and in each specific subgroup.ResultsMean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 23.5% ± 15.3%, age 81 ± 7 years. In-hospital mortality was 4.5%, cerebrovascular accident 1% and overall vascular complications 4% (0.5% major; 3.5% minor). Of the 193 patients with BTD BAV who survived and received a second heart team evaluation, 72.6% were finally deemed eligible for definitive treatment (25.4% for AVR; 47.2% for TAVI): 96.7% of patients with left ventricular ejection fraction recovery; 70.5% of patients with mitral regurgitation reduction; 75.7% of patients who underwent BAV in clinical hemodynamic instability; 69.2% of frail patients and 68% of patients who presented serious comorbidities.ConclusionsBalloon aortic valvuloplasty can be considered as bridge-to-decision in high-risk patients with severe aortic stenosis who cannot be immediate candidates for definitive transcatheter or surgical treatment.

Impact of mitral geometry and global afterload on improvement of mitral regurgitation after trans-catheter aortic valve implantation.

ObjectiveTo assess the impact of mitral geometry, left ventricular (LV) remodelling and global LV afterload on mitral regurgitation (MR) after trans-catheter aortic valve implantation (TAVI).MethodsIn this study, 60 patients who underwent TAVI were evaluated by 3D echocardiography at baseline, 1 month and 6 months after procedure. The proportional change in MR following TAVI was determined by examining the percentage change in vena contracta (VC) at 6 months. Patients having a significant reduction of at least 30% in VC were defined as good responders (GR) and the remaining patients were defined as poor responders (PR).ResultsAfter 6 months of TAVI, 27 (45%) patients were GR and 33 (55%) were PR. There was a significant decrease in 3DE-derived mitral annular diameter and area (P = 0.001), mitral valve tenting area (TA) (P = 0.05), and mitral papillary muscle dyssynchrony index (DSI) (P = 0.05) in the GR group. 3DE-derived LVESV (P = 0.016), LV mass (P = 0.001) and LV DSI, (P = 0.001) were also improved 6 months after TAVI. In addition, valvulo-arterial impedance (ZVA) was significantly higher at baseline in patients with PR (P = 0.028). 3DE-derived mitral annular area (β: 0.47, P = 0.04), mitral papillary DSI (β: −0.65, P = 0.012) and ZVA (β: 0.45, P = 0.028) were the strongest independent parameters that could predict the reduction of functional MR after TAVI.ConclusionGR patients demonstrate more regression in mitral annulus area and diameter after significant decrease in high LVEDP and trans-aortic gradients with TAVI. PR patients appear to have increased baseline ZVA, mitral valve tenting and restriction in mitral valve coaptation. These factors are important for predicting the impact of TAVI on pre-existing MR.

Baseline Echocardiographic Features Associated With Improvement in Significant Mitral Regurgitation After Cardiac Resynchronization Therapy—START Study Sub-Analysis

Background: The aim of this study was to investigate baseline parameters associated with improvement in significant mitral regurgitation (MR) after CRT in advanced heart failure patient. Methods: We prospectively studied 180 consecutive CRT patients with NYHA class III/IV. Quantitative echocardiography was performed before and 6 months after CRT. MR was quantified by jet area to left atrial area ratio. Results: Of 150 patients met the inclusion criteria, 75 patients had significant MR at baseline. After CRT, 26 patients of them had an improvement in MR after CRT. There was a significant difference in baseline LV dimensions and volumes in end-diastole and end-systole, deceleration time of early diastole wave in transmitral flow, previous myocardial infarction (MI), maximum time delay of radial strain (RS-TD) between patients groups with and without significant MR after CRT. Logistic multivariate analysis revealed LV end-systolic volume (ESV), previous MI, and RS-TD were independent predictors of. The novel scoring system which put 1 point for each: the absence of previous MI, LVESV less than 121 ml, and RS-TD more than 280ms, was strongly predictive for the improvement in significant MR after CRT (Odds ratio: 0.26, P = .0001). Conclusion: The absence of previous MI, not too much dilated LV and definite radial dyssynchrony associated with improvement in MR have the potential to predict MR reduction following CRT.

Transapical Beating-Heart Mitral Valve Repair With an Expanded Polytetrafluoroethylene Cordal Implantation Device: Initial Clinical Experience.

Degenerative mitral valve (MV) disease is a common cause of severe mitral regurgitation (MR) and accounts for the majority of MV operations. Conventional MV surgery requires cardiopulmonary bypass, aortic cross-clamping, cardioplegia, and a thoracotomy or sternotomy and, therefore, is associated with significant disability, risks, and unpredictable rates of MV repair. Transesophageal echocardiography-guided beating-heart MV repair with expanded polytetrafluoroethylene cordal insertion has the potential to significantly reduce surgical morbidity. We report the first-in-human clinical experience with a novel preformed expanded polytetrafluoroethylene knot implantation device (Harpoon TSD-5) designed to treat degenerative MR. Through a small left thoracotomy, the device was inserted into the heart and guided by transesophageal echocardiography to the ventricular surface of the prolapsed leaflet. Multiple expanded polytetrafluoroethylene cords were anchored in the leaflet and then adjusted to the correct length to restore MV leaflet coaptation and secured at the epicardium. Eleven patients with posterior leaflet prolapse and severe MR, with mean±SD age of 65±13 years and mean ejection fraction of 69±7%, were treated with 100% procedural success. Immediate postprocedural mean MR grade was trace. At 1 month, the mean MR grade was mild with significant decreases in end-diastolic volume (139 to 107 mL; P=0.03) and left atrial volume (118 to 85 mL; P=0.04). A novel device used for beating-heart image-guided MV repair demonstrates a significant reduction in MR with favorable left ventricular and left atrial reverse remodeling. This approach has the potential to decrease invasiveness and surgical morbidity. Further follow-up is necessary to assess long-term efficacy. URL: https://clinicaltrials.gov. Unique identifier: NCT02432196.

Prognostic implications of mitral regurgitation in patients after cardiac resynchronization therapy

Mitral regurgitation (MR) is a common finding in patients with heart failure with debatable effects on prognosis. Reduction in MR is one of the mechanisms by which cardiac resynchronization therapy (CRT) exerts its beneficial effects. We investigated the prognostic impact of baseline MR and MR persistence after CRT on outcomes of treated patients. We prospectively followed 1122 CRT patients (66.4 ± 10.3 years, 78% male) who were stratified according to baseline MR severity as having MR- (degree 0-1; n = 508, 45%) or MR+ (degrees 2-3-4; n = 614, 55%). In 916 patients (82%) with MR severity data available at 1-year follow-up, the annual mortality rate was 3.4 and 6.0 per patient-year in the MR- and MR+ group, respectively, with a 1-year incidence rate ratio (IRR) of 1.76 (P < 0.001). Similar results were observed for cardiovascular mortality (1-year IRR 1.72, P = 0.002). When considering survival according to MR severity after CRT, all-cause and cardiovascular mortality were lower in the improved than in the worsened group (1-year IRR 1.87 and 2.33, respectively; both P < 0.001). Regression analysis showed that absence of MR improvement at follow-up was a significant independent predictor of both all-cause and cardiovascular mortality. Baseline significant MR and absence of MR improvement after CRT are strongly predictive of less favourable long-term survival.

141 Eclampsia as the first presentation of peripartum cardiomyopathy

Introduction In some cases eclampsia (which is the main cause of mortality during pregnancy) may be associated with peripartum cardiomyopathy (the main cause of serious complications during pregnancy and postpartum period). Case report Female patient 36 years old, in the 30th week of gestational (the first pregnancy), previously completely healthy, was admitted to hospital due to syncope, convulsion and hypertension (160/100 mmHg). The caesarean delivery was performed immidiately. ECG and echocardiography were without pathological findings, but because of elevated troponin I (0,19) and NT pro BNP (1500), CT coronary angiography was performed. The finding on coronary arteries was completely normal. After improvement in clinical symptoms, values of blood pressure and laboratory findings, patient was discharged. Three months later (in the meantime she didn’t come on the routine clinical folow-up) she was again admitted to hospital due to dyspnoea, peripheral edema and palpitations. Symptoms had begun ten days before that. Physical examination indicated systolic murmur at the apex, signs of left and right heart failure. Laboratory analysis showed leukocytosis, anemia, increased liver ensymes AST (62), LDH (531), uric acid (548), CRP (7,5) and significant increase of NT pro BNP (20975). Electrocardiogram pointed to tachycardia and T-wave inversion in standard and precordial leads. Chest X-ray demonstrated enlarged heart shadow without pathological changes in the lungs. The patient underwent an echocardiography exam which showed dilated left ventricle, global hypokinetic, with low ejection fraction (25%) and with large thrombus in the apex, with very high embolic potential. It also demonstrated moderate mitral regurgitation. The patient was treated according to guidelines on acute and chronic heart failure with ACE inhibitors, beta blockers, diuretics, mineralocorticoid receptor antagonists, also with anticoagulant therapy and supstitution therapy of folic acid and iron, with addition of bromocriptine. Two months later she was symptomless, while echocardiography showed improvement in ejection fraction (45–50%), reduction of mitral regurgitation and completely resolution of the left ventricle thrombus. Finally, about twelve months later, coming to a complete clinical, laboratory, ECG and echocardiography restitution. Conclusion In case of presentation of eclampsia it is necessary to follow up the patient frequently not to miss the beginning of sytolic disfunction due to peripartum cardiomyopathy, which may be coused by eclampsia. It is also important to be aware that some cases need more time (not only six months) for complete restitution.

Percutaneous Transluminal Mitral Valve Repair (Mitraclip): A First Successful Case in the Philippines

INTRODUCTION: Mitral regurgitation (MR) is a common valvular disease. The major causes of MR include mitral valve prolapse (MVP), rheumatic heart disease, infective endocarditis, annular calcification, cardiomyopathy and ischemic heart disease. MR is classified as primary MR (or degenerative), which is caused by intrinsic disease of the mitral leaflets, and secondary MR which is caused by diseases of the left ventricle and/or mitral annulus. Surgical treatment should be considered for patients with functional disability and/or for patients with no symptoms or only mild symptoms but with progressively deteriorating left ventricular (LV) function or progressively increasing LV dimensions. Without surgical treatment, the prognosis for patients with MR and heart failure is poor, so mitral valve repair or replacement is indicated for symptomatic patients. However, in patients with MR due to primary abnormality of the mitral apparatus (degenerative MR) who are deemed high risk for mitral valve surgery, MitraClip Clip Delivery System provides an alternative option in reducing significant symptomatic MR (MR ≥ 3+). THE CASE: We present the case of a 59-year-old female, hypertensive, with a history of progressive easy fatigability. Echocardiography revealed the presence of MVP with severe MR. The patient was initially offered surgical treatment but she refused and opted for percutaneous mitral valve repair (Mitraclip). The patient underwent minimally invasive percutaneous mitral valve repair which resulted in a marked reduction of mitral regurgitation. Two months after the treatment, the patient had significant clinical improvement. CONCLUSION: Percutaneous mitral valve repair using the Mitraclip Delivery System provides a novel and promising approach to select patients with severe MR as an alternative to open heart surgery. This paper describes a patient with MVP with severe MR who was treated successfully with this latest technique.

Long-term echocardiographic evaluation of valvular lesions in a patient with nonbacterial thrombotic endocarditis associated with advanced uterine cancer

Nonbacterial thrombotic endocarditis (NBTE) is characterized by the deposition of thrombi on previously undamaged heart valves in the absence of bacteremia and predominantly affects patients with hypercoagulable state. Although the diagnosis is usually based on transthoracic echocardiography, little is known about the serial changes of the vegetation in response to treatment. We experienced a 42-year-old woman with advanced uterine cancer and asymptomatic cerebral embolization. Plasma d-dimer level was markedly elevated and echocardiography showed highly mobile masses attached to the anterior and posterior mitral leaflets with moderate regurgitation. Based on these findings, she was diagnosed as having NBTE associated with uterine cancer and intravenous administration of heparin and chemotherapy were performed. Follow-up echocardiography revealed the disappearance of the vegetation and reduction of mitral regurgitation. Uterine cancer was successfully treated by surgery and recurrence of the valvular lesion did not occur.<Learning objective: Echocardiographic follow-up of valvular lesions could be a useful guide of the response to the treatment in patients with nonbacterial thrombotic endocarditis. Accordingly, anticoagulation therapy with careful follow-up echocardiography before the removal of the original cancer could be a reasonable approach in these patients.>

First Experience With Percutaneous Mitral Valve Plication as Primary Therapy for Symptomatic Obstructive Hypertrophic Cardiomyopathy

BackgroundFew therapeutic options exist for patients with severe heart failure due to obstructive hypertrophic cardiomyopathy (HCM) who are at unacceptable surgical risk. We hypothesized that percutaneous plication of the mitral valve could reduce left ventricular outflow tract (LVOT) obstruction and associated mitral regurgitation, thereby leading to amelioration of heart failure symptoms. ObjectivesThis study sought to evaluate the potential effectiveness of percutaneous mitral valve plication as a therapy for patients with symptomatic, obstructive HCM. MethodsSix patients (age 83 ± 8 years; 5 women), judged as not optimal candidates for septal myectomy, were referred for management of severe, drug-refractory heart failure symptoms due to obstructive HCM (New York Heart Association functional class III). Each underwent percutaneous mitral valve leaflet plication to reduce systolic anterior motion (SAM) and mitral regurgitation using the transcatheter mitral clip system. ResultsThe procedure was completed in 5 patients with placement of a single clip at the A2-P2 segments of the mitral valve. One other patient experienced cardiac tamponade, leading to termination of the procedure. Among the 5 treated patients, percutaneous plication with the eliminated SAM and consequently decreased the intraoperative LVOT gradient (91 ± 44 mm Hg to 12 ± 6 mm Hg; p = 0.007), left atrial pressure (29 ± 11 mm Hg to 20 ± 8 mm Hg; p = 0.06), and mitral regurgitation grade (3.0 ± 0 vs. 0.8 ± 0.4; p = 0.0002) associated with improved cardiac output (in n = 4; 3.0 ± 0.6 l/min to 4.3 ± 1.2 l/min; p = 0.03). Over follow-up of 15 ± 4 months, symptom improvement to New York Heart Association functional class I or II occurred in all patients. Follow-up echocardiography after 15 ± 4 months demonstrated continued absence of SAM and significant reduction in mitral regurgitation, although high systolic LVOT velocities (i.e., >4 m/s) were evident in 3 of the 5 treated patients. ConclusionsThis is a report of percutaneous mitral valve plication as a primary therapy in the management of severely symptomatic, obstructive HCM patients. This initial experience suggests that percutaneous mitral valve plication may be effective for symptom relief in such patients via reduction of SAM and mitral regurgitation. The significance of persistent elevations of LVOT velocities in some patients requires further study.

Transcatheter Procedure for ResidualMitral Regurgitation After MitraClip Implantation Using AmplatzerDuct Occluder II.

This study reports a novel transcatheter procedure for residual mitral regurgitation (MR) after MitraClip implantation using the Amplatzer Duct Occluder II (ADO II). Although the MitraClip procedure is a transcatheter treatment option for patients at high surgicalrisk with severe MR, management of significant residual MR after MitraClip implantation is still challenging. We describe a case series of 9 consecutive patients who underwent transcatheter deployment of the ADO II plug for significant residual MR after MitraClip implantation from April to October2015. The mean age was 79.3 ± 11.4 years. The deployment of the ADO II plug was performed at the initial MitraClip procedure in 7 patients and at the second procedure for recurrent symptoms in 2 patients. There were 2 types of residual MR seen after MitraClip implantation: residual commissural MR (n = 3) and residual intraclip MR (n = 6). The ADO II was successfully deployed with significant reduction of MR flow and left atrial pressure in all patients. The ADO II plug was retrieved in 1 patient because of device embolization to the ostial right coronary artery. However, all patients were discharged 1.8 ± 1.2 days after the procedure, with no significant MR on pre-discharge transthoracic echocardiography. In 8 patients who underwent 1-month symptomatic assessment, clinical symptoms were diminished to New York Heart Association functional class I or II. Transcatheter deployment of the ADO II plug was effective for the reduction of residual commissuralMR and intraclip MR after MitraClip implantation. The potential role of this technique should be established for challenging cases.

Treatment of Chronic Functional Mitral Valve Regurgitation With a Percutaneous Annuloplasty System

BackgroundCurrent surgical and medical treatment options for functional mitral regurgitation (FMR) are limited and additional interventional approaches are required. ObjectivesThis study sought to report the safety and performance data from the feasibility study with a novel direct annuloplasty system. MethodsSeventy-one patients with moderate to severe FMR (mean 67.7 ± 11.3 years of age, left ventricular [LV] ejection fraction 34.0 ± 8.3%), on stable medical heart failure medication were prospectively enrolled. ResultsDevice success rate was 70.4% (n = 50 of 71). No intraprocedural death occurred. In patients receiving implants, 4 patients (8.9%) experienced cardiac tamponade. Thirty-day (n = 45) and 6-month (n = 41) rates for all-cause mortality, stroke, and myocardial infarction were 4.4%, 4.4%, and 0.0% and 12.2%, 4.9%, and 0%, respectively. At 6 months, nonurgent mitral surgery was performed in 1 patient (2.4%) and nonurgent percutaneous repair in 7 patients (17.1%). Echocardiographic core analysis after 6 months showed mitral regurgitation reduction in 50% of treated patients by a mean of 1.3 grades. Concerning mitral valve (MV) annular geometry, we found significant reduction of anterior-posterior (–0.31 ± 0.4 cm) and septal-lateral dimensions (–0.21 ± 0.3 cm), a decreased MV-tenting area (–0.57 ± 1.1 cm2) and increase in MV coaptation length (0.13 ± 0.2 cm). Transthoracic echocardiography indicated reverse LV remodeling with reduction of LV end-diastolic diameter (–0.20 ± 0.4 mm) and volume (–22 ± 39 ml). Treatment was associated with significant improvement in 6-min walking distances (56.5 ± 92.0 m) and improvements in New York Heart Association functional class III/IV at 6 months from 53.3% to 23.3%. ConclusionsPercutaneous direct annuloplasty is feasible and safe in high-risk FMR patients. This treatment initiates LV reverse remodeling, and provides clinical improvement during 6 months after treatment. (Mitralign Percutaneous Annuloplasty First in Man Study; NCT01852149).

Multislice computed tomography-guided surgical repair of acquired posterior left ventricular aneurysms: demonstration of mitral valve and left ventricular reverse remodelling.

Involvement of the mitral valve (MV) apparatus represents a challenge in surgical ventricular repair (SVR) of posterior left ventricular (LV) aneurysms. This study sought to investigate whether multislice computed tomography (MSCT) assessment can be used to optimize the surgical procedure for posterior LV aneurysms. Thirty patients (m : w = 24 : 6, age 38-78, median 66 years; mean New York Heart Association class 2.98) with posterior LV aneurysm were operated upon. MSCT was performed in 24 patients before and after surgery. End-diastolic and end-systolic volumes of LV and aneurysm were indexed to body surface area (LVEDVI/LVESVI, AEDVI/AESVI). The MV apparatus was characterized by coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), MV annulus area (MVAA) and interpapillary muscle distance (IMD). Thirty-day mortality was 10% and 5-year survival rate was 83%. After surgery, LVEDVI decreased from 151.2 ± 84.1 to 85.7 ± 28.3 ml/m(2) (P = 0.001) and LVESVI from 110.6 ± 88.8 to 50.2 ± 22.9 ml/m(2) (P = 0.001). LV ejection fraction increased from 31.5 ± 15.1 to 43.4 ± 9.9% (P = 0.001). Preoperative MSCT showed significantly higher values of MVAA, CD and TA in patients who needed MV repair or replacement. Postoperative reduction of mitral regurgitation in patients without MV surgery corresponded with significant reduction in intercommissural diameter, anteroposterior diameter, MVAA, TA, CD, MVCA and IMD. MSCT represents an excellent diagnostic tool for the assessment of MV and LV geometry. MSCT-guided SVR of submitral LV aneurysms leads to excellent mid-term results. On the basis of the MSCT assessment, we propose an algorithm for surgical planning in posterior LV aneurysms.

Effects of Mitral Annulus Remodeling Following MitraClip Procedure on Reduction of Functional Mitral Regurgitation

Introduction and objectivesThe percutaneous mitral valve repair procedure (MitraClip) appears to reduce mitral annulus diameter in patients with functional mitral regurgitation, but the relationship between this and regurgitation severity has not been demonstrated. The aim of this study was to determine the effect of mitral annulus remodeling on the reduction of mitral regurgitation in patients with functional etiology. MethodsThe study included all patients with functional mitral regurgitation treated with MitraClip at our hospital until January 2015. Echocardiogram (iE33 model, Philips) was performed in all patients immediately after device positioning. Changes in the mitral annulus correlated with mitral regurgitation severity, as assessed using the effective regurgitant orifice area. ResultsThe study included 23 patients (age, 65±14 years; 74% men; left ventricular ejection fraction, 31%±13%; systolic pulmonary artery pressure, 47±10 mmHg). After the procedure, the regurgitant orifice area decreased by 0.30 cm2±0.04 cm2 (P<.0005), from a baseline of 0.49 cm2±0.09 cm2. Anteroposterior diameter decreased by 3.14 mm±1.01 mm (P<.0005) from a baseline of 28.27 mm±4.9 mm, with no changes in the intercommissural diameter (0.50 mm±0.91 mm vs 40.68 mm±4.7 mm; P=.26). A significant association was seen between anteroposterior diameter reduction and regurgitant orifice area reduction (r=.49; P=.020). ConclusionsIn patients with functional mitral regurgitation, the MitraClip device produces an immediate reduction in the anteroposterior diameter. This remodeling may be related to the reduction in mitral regurgitation.

Impacto del remodelado del anillo mitral tras el procedimiento MitraClip en la reducción de la insuficiencia mitral funcional

Introduction and objectivesThe percutaneous mitral valve repair procedure (MitraClip) appears to reduce mitral annulus diameter in patients with functional mitral regurgitation, but the relationship between this and regurgitation severity has not been demonstrated. The aim of this study was to determine the effect of mitral annulus remodeling on the reduction of mitral regurgitation in patients with functional etiology. MethodsThe study included all patients with functional mitral regurgitation treated with MitraClip at our hospital until January 2015. Echocardiogram (iE33 model, Philips) was performed in all patients immediately after device positioning. Changes in the mitral annulus correlated with mitral regurgitation severity, as assessed using the effective regurgitant orifice area. ResultsThe study included 23 patients (age, 65±14 years; 74% men; left ventricular ejection fraction, 31%±13%; systolic pulmonary artery pressure, 47±10 mmHg). After the procedure, the regurgitant orifice area decreased by 0.30 cm2±0.04 cm2 (P<.0005), from a baseline of 0.49 cm2±0.09 cm2. Anteroposterior diameter decreased by 3.14 mm±1.01 mm (P<.0005) from a baseline of 28.27 mm±4.9 mm, with no changes in the intercommissural diameter (0.50 mm±0.91 mm vs 40.68 mm±4.7 mm; P=.26). A significant association was seen between anteroposterior diameter reduction and regurgitant orifice area reduction (r=.49; P=.020). ConclusionsIn patients with functional mitral regurgitation, the MitraClip device produces an immediate reduction in the anteroposterior diameter. This remodeling may be related to the reduction in mitral regurgitation.Full English text available from: www.revespcardiol.org/en

Relato de Caso: manejo perioperatório para implante de dispositivo percutâneo MitraClip

Percutaneous mitral repair using the MitraClip system decreased mitral regurgitation (MR) severity and improved NYHA functional class in patients with symptomatic severe MR. Hence, it became an alternative to conventional surgical repair for patients at high risk due to its comorbidities. The purpose of this report is to present the first case of percutaneous repair of MR with the MitraClip device in a patient with severe MR in the state of Rio Grande do Sul, Brazil, as well as the anesthetic implications involved. Female patient, 81 years old, ASA III due to symptomatic severe mitral MR (NYHA functional class III), anemia, atrial fibrillation and anxiety disorder. The patient underwent venous general anesthesia induction and balanced maintenance, monitored with invasive arterial pressure, cardioscope, pulse oximetry, capnography, temperature probe and transesophageal echocardiography (TEE). Throughout the procedure, after multiple transseptal punctures, cardiac tamponade was diagnosed. Subsequent hemodynamic instability was controlled with pericardial drainage, autotransfusion and heterologous transfusion as well as by use of vasoactive drugs. MitraClip placement guided by TEE performed successfully on the first attempt. Immediate reduction of MR (from baseline grade 3 to 1 immediate post procedural), without additional clipping. Postoperative care provided in cardiac intensive care unit. Bleeding in the femoral vein puncture site, previously closed with Perclose Proglide® device, was presented in the immediate postoperative period. After intensive care management, patient progressed to clinical stability and was discharged from hospital on the fourth postoperative day. Since this was the first MitraClip implantation held at the institution, it was decided to be performed under general anesthesia and invasive monitoring. This has truly improved diagnostic and anesthetic management. The reported perioperative complications were diagnosed and managed promptly owing to the intensive care provided and TEE played a critical role in it. Knowledge of the steps involved, in order to anticipate possible complications, and multidisciplinary teamwork were paramount to the procedure success, which is a feasible alternative in high risk patients with symptomatic severe MR.

Native Electrocardiographic QRS Duration after Cardiac Resynchronization Therapy: The Impact on Clinical Outcomes and Prognosis

BackgroundWe investigated whether reversed electrical remodeling (RER), defined as narrowing of the native electrocardiographic QRS duration after cardiac resynchronization therapy (CRT), might predict prognosis and improvement in echocardiographic outcomes. Methods and ResultsA total of 110 CRT recipients were retrospectively analyzed for the end points of death and hospitalization during 18 ± 3 months. Native QRS durations were recorded at baseline and 6 months after CRT (when pacing was switched off to obtain an electrocardiogram) to determine RER. CRT response and mitral regurgitation (MR) improvement were defined as ≥15% reduction in left ventricular end-systolic volume and absolute reduction in regurgitant volume (RegV) at 6 months, respectively. Overall, 48 patients (44%) had RER, which was associated with functional improvement (77% vs 34%; P < .001) and CRT response (81% vs 52%; P < .001) compared with those without RER. The change in the intrinsic QRS duration correlated with the reduction in RegV (r = 0.51; P < .001) and in tenting area (r = 0.34; P < .001). RER was a predictor of MR improvement (P = .023), survival (P = .043), and event-free survival (P = .028) according to multivariate analyses. ConclusionsNarrowing of the intrinsic QRS duration is associated with functional and echocardiographic CRT response, reduction in MR, and favorable prognosis after CRT.

Intraprocedural assessment of mitral regurgitation during the mitraclip procedure: Impact of continuous left atrial pressure monitoring.

Intraprocedural assessment of mitral regurgitation (MR) is a challenging issue during the MitraClip procedure, which might influence not only the position but also the number of MitraClips implanted. Though transesophageal echocardiography (TEE) is the predominant tool used during the MitraClip procedure, MR assessment might be facilitated by a multimodality approach including continuous and simultaneous determination of left atrial and left ventricular (LV) pressure. 86 consecutive patients (76.5 ± 8 years) who qualified for the MitraClip procedure were included into the study. In all patients, the multimodal assessment of MR (TEE, LV angiogram, TEE bubble evaluation, left atrial (LA) pressure => MitraScore) was performed after introducing the MitraClip guide catheter. In the first 42 patients (group A, no CAP), left atrial (LA) pressure (peak pressure of V-wave) was determined only before and after MitraClip implantation, whereas, in the subsequent 44 patients (group B, with CAP), continuous left atrial pressure monitoring (CAP) was performed. Patients with CAP (group B) had similar total procedural durations and no increase in the complication rate. MitraScore decreased from 10.5 to 3.5 in group A compared to 10.7 to *2.8 in group B (*P = 0.021 vs. group B). Whether the significant improvement of intraprocedural MR in group B translated into superior MR reduction in the conscious patient, was analyzed by transthoracic echocardiography (TTE) in a blinded fashion. Again MR reduction was significantly greater (P = 0.03) in group B (MR grade 2.8 to 0.9) as compared to group A (MR grade 2.8 to 1.3) and 2D vena contracta decreased from 0.54 ± 0.15 cm to 0.17 ± 0.10 in group B compared to group A (0.56 ± 0.19 cm to *0.23 ± 0.12; *P = 0.01 vs. group B). Multimodality assessment of intraprocedural MR supported by continuous left atrial pressure monitoring was associated with superior intraprocedural results translating into improved MR reduction also at the end of the hospital stay. © 2016 Wiley Periodicals, Inc.

A META-ANALYSIS OF CONTROLLED STUDIES COMPARING MITRACLIP VERSUS SURGERY FOR SEVERE MITRAL REGURGITATION: IS THERE A MORTALITY BENEFIT?

The MitraClip is a transcatheter device for percutaneous edge-to-edge mitral valve (MV) repair. Registries have shown safety and efficacy of MitraClip in the reduction of mitral regurgitation (MR) severity. Studies comparing MitraClip to MV surgery have shown conflicting results. We aimed to

THE EFFICACY OF PERCUTANEOUS TRANS-VENOUS MITRAL ANNULOPLASTY FOR THE TREATMENT OF FUNCTIONAL MITRAL REGURGITATION: PREDICTIVE VALUE OF ECHOCARDIOGRAPHIC PARAMETERS

Implantation of Carillon device into the coronary venous system was shown to result in the reduction in functional mitral regurgitation (FMR), but it is not clear which patient would benefit the most. We investigated which echo parameters may help in prediction of the efficacy of percutaneous mitral