P43673D analysis of mitral annular reshape with third generation MitraClip XTr in functional and degenerative mitral regurgitation

The 3rd generation Mitraclip XTr was recently introduced to improve device performance, through longer clip arms that should allow better grasping of the mitral leaflets, thus improving coaptation and results eventually. Several studies have demonstrated additional effects such as the reshape of the mitral annulus immediately after clip implantation.

The aim of our study was to evaluate the mitral valve (MV) annular remodelling with MitraClip XTr.

Between March 2018 and November 2018, 75 consecutive patients were enrolled. The population was divided in two groups: functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR).

The 3D MV datasets at baseline and immediately after the procedure were acquired and then analysed with semiautomatic MVQ software (QLAB Cardiac 3DQ v.10.0; Philips Medical Systems).

The software provides the following parameters: annular diameters (antero-posterior, AP, and inter-commissural, IC), circumference, area, height and ellipsicity (IC/AP ratio as percentage); saddle-index, defined as annular height to IC diameter ratio was derived.

The 3D post-processing was feasible in 54 patients (108 3D datasets): 28 had FMR (52%) and 26 had DMR (48%).

An average of 1.8 clips per patient were implanted: 2 clips in 38 (70%), 1 clip in 14 (26%) and 3 clips in 2 (4%) patients. The position was central in 93% of the procedures.

Results are reported in table 1. In the FMR group, a reduction in the AP diameter (p=0.001), an increase in both IC diameter (p=0.001) and annular ellipsicity (p<0.001) were observed.

In the DMR group, an increase in annular ellipsicity (p=0,008) and in saddle-index (p<0.05) were observed.

Table 1 Functional mitral regurgitation (N=28) Degenerative mitral regurgitation (N=26) Pre-clip Post-clip P-value Pre-clip Post-clip P-value IC diameter (mm) 39.3±4.2 41.9±4.1 0.001 40.9±6.5 41.8±5.8 0.257 AP diameter (mm) 32.8±4.6 30.4±3.2 0.001 32.6±4.8 31.7±4.5 0.199 Annular Height (mm) 5.1±1.8 5.4±1.8 0.336 4.8±1.9 5.7±2.2 0.026 3D circumference (mm) 122.7±15.1 123.5±11 0.718 123.5±19.0 124.0±17.1 0.812 3D area (mmq) 1128.0±280 1113.7±206 0.752 1160±346.7 1156.8±318.0 0.926 Annular ellipsicity (%) 121.5±12.2 138.5±11.8 0.0005 125.9±9.6 132.4±10.7 0.008 Saddle index 13.0±4 13.0±4 0.957 11.8±4.2 13.6±4.2 0.048

Our study demonstrates that the XTr implantation produces a MV annular remodelling both in FMR and DMR probably with different mechanisms. In FMR the MV annulus resulted more elliptical, wheras in DMR the geometrical modifications involve both the ellipsicity and the saddle-shape morphology.

P4728Prognostic implications of the relationship between effective regurgitant orifice area and left ventricle end diastolic volume in patients with functional mitral regurgitation treated with MitraClip

Background

The distinction between proportionate and disproportionate functional mitral regurgitation (FMR), based on the relationship between effective regurgitant orifice area (EROA) and left ventricle end diastolic volume (LVEDV), has recently been proposed as a possible new clinical and physiopathological concept to identify patients that could likely benefit from transcatheter mitral repair.

Purpose

The aim of our study was to explore the possible prognostic implications of the EROA/LVEDV ratio in patients with FMR treated with MitraClip.

Methods

Baseline EROA/LVEDV ratio was calculated in 72 patients with moderate-to-severe, symptomatic FMR treated with MitraClip. All patients underwent clinical, biochemichal and echocardiographic evaluation before MitraClip. EROA was calculated using PISA method. The primary outcome was a composite end-point of all-cause death or re-hospitalization for heart failure (HF).

Results

The median follow-up was 1 year. The primary outcome occurred in 25 patients (34.7%). The cut-off value of EROA/LVEDV ratio for primary outcome, identified by receiver operating characteristic curve, was 0.15 (p=0.007) with a sensitivity and specificity of 72 and 68%, respectively. Patients were divided in two groups according to the identified cut-off. Patients with higher ratio (Group I, n=35) presented a less dilated LV (LVEDVi: 113.2±33.4 mL vs 129.3±29.3 mL, p=0.033; LVESV: 140.7±49.0 mL vs 171.1±47.4 mL, p=0.010), a better LV systolic function (LVEF: 31.9±9.5% vs 27.8±5.8%, p=0.028) and a more severe MR (EROA: 44.5±12.9 mm2 vs 24.5±6.8 mm2, p<0.001; vena contracta: 7.4±1.5 mm vs 6.7±1.0 mm, p=0.045). Patients with lower ratio (Group II, n=37) showed a reduced prevalence of MV annular dilation (57.1% vs 91.7%, p=0.005) and a worse RV function (s'TDI: 9.2±2.2 cm/s vs 10.5±2.9 cm/s, p=0.039). At univariate analysis, EROA/LVEDV ratio >0.15 (HR = 2.467, 95% CI 1.017–5.982, p=0.046) and severe pulmonary hypertension (HR = 2.481, 95% CI 1.030–5.976, p=0.043) were associated with a worse clinical outcome. At multivariate Cox-regression analysis, both EROA/LVEDV ratio >0.15 and severe pulmonary hypertension were identified as independent predictors (HR 3.203, 95% CI 1–310–7.832, p=0.011; HR = 3.280, 95% CI 1.326–8.116, p=0.010, respectively).

Figure 1

Conclusion

Our data show that EROA/LVEDV ratio was an independent predictor of adverse clinical outcome in FMR patients treated with MitraClip. This preliminary experience shows that this index could help to identify subgroups of patients with potential different clinical benefits from MitraClip therapy. However, further and extended data are needed to provide more precise evidence.

Acknowledgement/Funding

None

P4385Diaphragm dysfunction following cardiac surgery: role of ultrasound imaging for initial and follow-up assessment during cardiac rehabilitation

Background

Diaphragm dysfunction is a common complication of cardiac surgery, often underdiagnosed. Ultrasonography (US) is a promising technique for diaphragmatic assessment. Few trials have been conducted using US after heart surgery and no clear data exist on the recovery of diaphragm function after cardiovascular rehabilitation (CR).

Purpose

The aim of this study is to evaluate post-cardiac surgery diaphragm dysfunction using US and to assess the impact of an inpatient CR programme on its functional recovery.

Methods

In a single-centre prospective cohort study 97 consecutive patients hospitalised in our CR Unit were enrolled. 14 patients underwent aortic valve replacement, 38 mitral valve repair or replacement, 14 coronary artery bypass grafting (CABG), 22 combined surgery, and 9 other surgical interventions. We performed diaphragm US at admission and after 10 rehabilitative sessions. The following parameters were assessed: thickening fraction (TF) in B-mode on the right intercostal projections, and excursion, time of inspiration, time of a respiratory cycle and contraction velocity in M-mode on right anterior subcostal projections.

Results

After cardiac surgery, the incidence of diaphragm dysfunction and paralysis were 60% and 1%, respectively. Patients with TF <20% at admission showed a significant improvement in TF (13.30%, IQR 8.69–17.39 vs 27.27%, IQR 21.05–31.58; p<0.001), excursion (1.67cm, IQR 1.3–2.1 vs 2.23cm, IQR 1.9–2.7; p<0.001), time of inspiration (0.9s, IQR 0.9–1.07 vs 1.01s, IQR 0.87–1.13; p=0.005), time of a respiratory cycle (2.67s, IQR 2.38–3.05 vs 3.07s, IQR 2.68–3.35; p<0.001) and velocity (1.81cm/s, IQR 1.14–2.33 vs 2.24cm/s, IQR 1.92–2.76; p<0.001). On the contrary, in patients with a TF>20%, no additional improvement was observed. In both groups, there was a significant improvement in the parameters of physical performance.

In particular, in the group with a TF<20%, the distance covered during the 6MWT (300m, IQR 205–370 vs 555m, IQR 450–612; p<0.001) and the energy cost of physical activity (2.60, IQR 2.13–2.92 vs 4.09, IQR 3.44–4.50; p<0.001) increased while the perception of exertion (Borg Scale 11, IQR 11–13 vs 13, IQR 12–13; p=0.011) was reduced. At the 10th day assessment, 51.5% of the total population had a recovery of diaphragm function, whilst 48.5% had a failure of recovery (TF relative change between admission and discharge <60%). The multivariate analysis identified CABG as an independent predictor of failure of diaphragm recovery (OR 5.44; CI 1.10–26.84, p=0.037).

Conclusion

US might be a valuable part of routine clinical practice for initial and follow-up assessment of patients after open-heart surgery. CR showed to be an effective strategy to improve diaphragm parameters in patients with post-surgical dysfunction. Progressive evaluation of diaphragm function may drive personalised rehabilitation programmes.

P2522A new scoring system to stratify post-surgical valvular patients during cardiovascular rehabilitation: derivation and validation study

Background

Guidelines underline the importance of Cardiovascular Rehabilitation (CR) in post-surgical valvular patients both for the functional recovery and the monitoring of complications. However, there are no established indicators to better categorise their risk and to identify the real probability of recovery.

Purpose

The aim of this study is to propose and validate a scoring system to appropriately stratify post-surgical valvular patients in order to individualise CR programmes.

Methods

A retrospective study was conducted on 1480 post-surgical valvular patients hospitalized in our CR Unit (902 M – 578 F; median age of 64 years, IQR 53–73). 485 patients underwent single heart valve repair, 408 single heart valve replacement, 237 single heart valve surgery and additional interventions, 249 multiple valve interventions and 101 multiple heart valves and additional interventions. Subjects were randomised in two groups for data analysis: a Derivation (D; n=1000) and a Validation (V; n=480) group. Initially, in group D we assessed the predictive value of anamnestic, clinical and laboratory variables for major complications and functional recovery. We created two scoring systems for these outcomes and, subsequently, we validated them on group V. Finally, we interlaced them in an operative algorithm.

Results

Chronic kidney disease (OR 2.588; 95% CI 1.232–5.436; p=0.012), sternal surgical re-synthesis (OR 7.757; 95% CI 2.042–29.471; p=0.003), post-surgical transfusions (OR 2.419; 95% CI 1.407–4.161; p=0.001) and Troponin T peak >1400 μg/L (OR 2.441; 95% CI 1.418–4.200; p=0.001) were independent predictors for the occurrence of major complications in group D. Age (OR 0.958; 95% CI 0.9339–0.977; p<0.001), post- surgical transfusions (OR 1.981; 95% CI 1.160–3.380; p<0.001) and METS at admission (OR 0.032; 95% CI 0.017–0.061; p<0.001) were independent predictors of a higher functional recovery in group D. When the two scoring systems were validated on group V, we obtained a z score of 0.07 (p=0.941) for the major complications risk score and a z score of 1.23 (p=0.219) for the functional recovery stratification system, respectively, indicating a very reliable model. We proceeded to build an operative algorithm to stratify patients and propose personalised CR strategies.

Conclusions

We identified predictors to stratify the risk of complications and to define the probability of recovery in post-surgical valvular patients undergoing CR. The proposed final operative algorithm may be a unique tool to support the cardiologist to tailor rehabilitation programmes. This may lead to better outcomes and reduction of healthcare expenditure with optimisation in the use of available resources.

Acknowledgement/Funding

None

Loss of Leaflet Insertion After Percutaneous Mitral Valve Repair Requiring Left Ventricular Assist Device Implantation: Usefulness of 3D Multiplanar Reconstruction

Three-dimensional multiplanar reconstruction was used to diagnose recurrence of mitral regurgitation after MitraClip implantation in a 71-year-old man. Subsequent mitral valve surgery in such a case is high risk, and repeat MitraClip intervention could be feasible but is technically challenging. This imaging series demonstrates that LVAD implantation may be a solution to address MitraClip failure.

Intra-procedural monitoring protocol using routine transthoracic echocardiography with backup trans-oesophageal probe in transcatheter aortic valve replacement: a single centre experience

Aim

The aim of this study is to describe our 9-year experience in transcatheter aortic valve replacement (TAVR) using transthoracic echocardiography (TTE) as a routine intra-procedural imaging modality with trans-oesophageal echocardiography (TEE) as a backup.

Methods and results

From January 2008 to December 2017, 1218 patients underwent transfemoral TAVR at our Institution. Except the first 20 cases, all procedures have been performed under conscious sedation, with fluoroscopic guidance and TTE imaging monitoring. Once the TTE resulted suboptimal for final result assessment or a complication was either suspected or identified on TTE, TEE evaluation was promptly performed under general anaesthesia. Only 24 (1.9%) cases required a switch to TEE: 6 cases for suboptimal TTE prosthetic valve leak (PVL) quantification; 12 cases for haemodynamic instability; 2 cases for pericardial effusion without haemodynamic instability; 4 cases for urgent TAVR. The 30-days and 1-year all-cause mortality were 2.1% and 10.2%, respectively. Cardiac mortality at 30-days and 1-year follow-up were 0.6% and 4.1%, respectively. Intra-procedural and pre-discharge TT evaluation showed good agreement for PVL quantification (k agreement: 0.827, P = 0.005).

Conclusion

TTE monitoring seems a reasonable imaging tool for TAVR intra-procedural monitoring without delay in diagnosis of complications and a reliable paravalvular leak assessment. However, TEE is undoubtedly essential in identifying the exact mechanism in most of the complications.

[New therapeutic options for the treatment of tricuspid regurgitation]

Tricuspid regurgitation is a common finding in patients with left-sided heart disease with prognostic implications. In addition, isolated tricuspid valve surgery is associated with high mortality and is infrequently performed. Hence, a largely unmet clinical need exists and less invasive therapeutic options are emerging: multiple percutaneous therapies have been developed, including tricuspid valve repair or replacement. This review aims to provide an overview with diagnostic and clinical perspectives, potential challenges and future directions.

Mycobacterium chimaera in heater-cooler units: new technical approach for treatment, cleaning and disinfection protocol

Mycobacterium chimaera infections have mainly been associated with the heater-cooler unit (HCU) and, ultimately, linked to contaminated aerosols in the operation room. The contamination status of HCUs seems to be influenced by the maintenance, therefore, according to the manufacturer's recommendations, peracetic acid (Puristeril) was introduced to increase HCU cleaning and disinfection protocol maintenance. Aerosol dispersion from Puristeril during maintenance can cause adverse effects to nearby workers. We aim to describe our technique to reduce the impact of Puristeril on operating room staff and to limit dispersion of its aerosol in the environment by performing the cleaning procedure through a closed circuit.

Surgical Techniques for Tricuspid Valve Disease

Tricuspid valve disease affects millions of patients worldwide. It has always been considered less relevant than the left-side valves of the heart, but this “forgotten valve” still represents a great challenge for the cardiac surgeons, especially in the most difficult symptomatic scenarios. In this review we analyze the wide spectrum of surgical techniques for the treatment of a diseased tricuspid valve.

Recent advances in managing tricuspid regurgitation

Isolated tricuspid valve surgery is usually carried out with very high morbidity and mortality given the complexity of the affected patients. In light of this, trans-catheter tricuspid valve interventions have been emerging as an attractive alternative to surgery over the last few years. Although feasibility has been shown with a number of devices, clinical experience remains preliminary and associated with significant clinical and technical challenges. Here we describe currently available trans-catheter treatment options for severe tricuspid regurgitation implanted in different locations.

Ventricular septal defect and left ventricular outflow tract obstruction after transcatheter aortic valve implantation

: Ventricular septal defect (VSD) has been reported as a rare complication after transcatheter aortic valve implantation (TAVI), presenting with signs of heart failure. Furthermore, left ventricular outflow tract obstruction (LVOTO) may worsen after TAVI, especially in cases of severe left ventricular hypertrophy and small cavity. However, the simultaneous appearance of VSD and LVOT after TAVI has not been reported before. We report a case of combined VSD and LVOTO after TAVI.

Five-year evolution of mild aortic regurgitation following transcatheter aortic valve implantation: early insights from a single-centre experience

OBJECTIVES

To assess the follow-up evolution and impact of mild aortic regurgitation (1 + AR) following transcatheter aortic valve implantation (TAVI).

METHODS

We evaluated the follow-up outcomes and AR evolution of 558 patients affected by native aortic stenosis who underwent TAVI with residual AR ≤ 1+.

RESULTS

No residual AR was found in 294 (52.7%) patients, whereas 1 + AR was found in 264 (47.3%) patients. At 5.5 years, freedom from all-cause mortality (56.9% vs 53.5%), cardiac mortality (75.0% vs 74.3%) and heart failure (70.0% vs 63.9%) were similar between no-AR and 1 + AR groups, respectively (all P  > 0.05). New York Heart Association Class I-II was found in 88.9% vs 82.4% of patients respectively ( P  = 0.013). Freedom from AR ≥3+ at 5.5 years was 98.6% in the no-AR group vs 82.5% in the 1 + AR group (log-rank <0.001). Residual 1 + AR was found to be an independent predictor of increased follow-up AR ≥3+ ( P  = 0.012). In 1 + AR group, higher left ventricle mass index independently predicted increased cardiac death [hazards ratio (HR) 1.01, confidence interval (CI) 1.00-1.02, P  = 0.036] and heart failure rate (HR 1.01, CI 1.00-1.02, P  = 0.002), while larger native aortic annulus perimeter predicted follow-up AR ≥ 3+ (HR 1.12, CI 1.02-1.22, P  = 0.016).

CONCLUSIONS

5 years after TAVI, a higher progression of paravalvular AR to Grade ≥3+ together with worse symptoms were found in patients with residual 1 + AR compared with no-AR, although no marked difference in survival was observed. These findings raise further concerns about 1+ residual AR after TAVI, especially in the perspective of expanding indications to younger low-risk patients. Mechanisms that cause progression of paravalvular AR after TAVI remain to be clarified.

Mitral valve annuloplasty

Mitral valve prosthetic ring annuloplasty represents a key milestone in the history of mitral valve repair, delivering restoration of annular shape and size. Increased leaflet coaptation, together with significant reduction in stress on sutures, has ensured predictability and immediate stability for valve repair, both of which were lacking with previous techniques. Long-term durability of repair seems to be positively affected by placement of an annuloplasty ring, and by following the well-established, standardized approach described in our tutorial, this procedure can be performed with a very low surgical risk.

[Superior Cava Vein stenosis in a hemodialysis patient with long-term central venous catheter and vascular graft: a case report]

Recently, the use of central venous catheters (CVC) as a vascular access in patients undergoing hemodialysis is significantly increased, mainly because of the aging of this population and the presence of several comorbidities. However, the implantation and the long stay of CVC are associated with many complications. Among them, central venous stenosis represents one of the most common problems that, if not properly diagnosed, could lead to vascular thrombosis and consequent vascular access malfunction. Here, we report a case of a 38-year-old patient, who underwent hemodialysis firstly by a CVC long-term into right jugular vein and then by a prosthetic fistula in the ipsilateral limb. The patient presented many episodes of vascular access thrombosis that required endovascular interventions. The ultrasound screening and CT-angiography revealed an asymptomatic stenosis of the superior cava vein, which treatment with the implantation of vascular stent resulted in an initial improvement of vascular access performance. However, in the following months, a restenosis was observed that required new interventions to reestablish a satisfactory vascular access function. This case highlights that patients on hemodialysis should undergo proper clinical and instrumental follow-up in order to prevent or early recognize vascular access complications.