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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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Javadikasgari H, McGurk S, Newell PC, Awtry JA, Sabe AA, Kaneko T. Evolving Concept of Aortic Valve Replacement in Asymptomatic Patients With Severe Aortic Stenosis. Ann Thorac Surg 2024; 117:796-803. [PMID: 37660965 DOI: 10.1016/j.athoracsur.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/06/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Surgical treatment of asymptomatic severe aortic stenosis (AS) has been gaining attention ever since the results of the Early Surgery Versus Conventional Treatment in Very Severe Aortic Stenosis (RECOVERY) and Aortic Valve replacement versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trials showed survival benefits with early surgical aortic valve replacement (SAVR). This study analyzed the long-term clinical and echocardiographic outcomes of SAVR in asymptomatic severe AS. METHODS Between 2002 and 2020, 272 patients with asymptomatic severe AS and a left ventricular ejection fraction ≥50% underwent SAVR with or without concomitant aortic surgery and met the study criteria. The median follow-up was 8.5 years (interquartile range, 6-12.8 years), for a total of 2584 patient-years. The time course of the left ventricular mass index (LVMI) and the average E/E' (ratio of the Doppler-derived E wave to the tissue Doppler-derived E' wave) were assessed using 594 postoperative echocardiograms. The association of preoperative LVMI and average E/E' with survival was assessed using Cox proportional hazards. RESULTS There was no operative mortality. On longitudinal analyses, LVMI improved in patients who presented with moderate or severe preoperative left ventricular hypertrophy (LVH). However, after the early decline in average E/E', there was a late increase to greater than upper limit normal, particularly in patients with a preoperative average E/E'≥14. Postoperative survival was 100%, 94%, 84%, and 76% at 1, 5, 10, and 15 years, respectively, comparable to age- and sex-matched expected survival on the basis of the US general population. On adjusted Cox survival analysis, only moderate to severe LVH was associated with a survival penalty (hazard ratio], 2.32; 95% CI, 1.02-5.27; P = .045). CONCLUSIONS In asymptomatic patients with AS, SAVR restores survival and improves LVH, but patients with diastolic dysfunction are left with persistent dysfunction. Presentation with moderate or severe LVH at the time of surgery translated to a survival penalty. This observational study supports early SAVR in this population before development of LVH, although further investigation is needed.
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Affiliation(s)
- Hoda Javadikasgari
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paige C Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jake A Awtry
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashraf A Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Tsuyoshi Kaneko
- Mary Culver Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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Kumbhani DJ, Manandhar P, Bavry AA, Chhatriwalla AK, Giri J, Mack M, Carroll J, Pandey A, Kosinski A, Peterson ED, Kaneko T, de Lemos JA, Vemulapalli S. National Variation in Hospital MTEER Outcomes and Correlation With TAVR Outcomes: STS/ACC TVT Registry Analysis. JACC Cardiovasc Interv 2024; 17:505-515. [PMID: 38340102 DOI: 10.1016/j.jcin.2023.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A single, multitiered valve center designation has been proposed to publicly identify centers with expertise for all valve therapies. The correlation between transcatheter aortic valve replacement (TAVR) and mitral transcatheter edge-to-edge repair (MTEER) procedures is unknown. OBJECTIVES The authors sought to examine the relationship between site-level volumes and outcomes for TAVR and MTEER. We further explored variability between sites for MTEER outcomes. METHODS Using the STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) national registry, TAVR and MTEER procedures at sites offering both therapies from 2013 to 2022 were examined. Sites were ranked into deciles of adjusted in-hospital and 30-day outcomes separately for TAVR and MTEER and compared. Stepwise, hierarchical multivariable models were constructed for MTEER outcomes, and the median OR was calculated. RESULTS Between 2013 and 2022, 384,394 TAVRs and 53,274 MTEERs (median annualized volumes: 93.6 and 18.8, respectively) were performed across 453 U.S. sites. Annualized TAVR and MTEER volumes were moderately correlated (r = 0.48; P < 0.001). After adjustment, 14.3% of sites had the same decile rank for TAVR and MTEER 30-day composite outcome, 50.6% were within 2 decile ranks; 35% had more discordant outcomes for the 2 procedures (P = 0.0005). For MTEER procedures, the median OR for the 30-day composite outcome was 1.57 (95% CI: 1.51-1.64), indicating a 57% variability in outcome by site. CONCLUSIONS There is modest correlation between hospital-level volumes for TAVR and MTEER but low interprocedural correlation of outcomes. For similar patients, site-level variability for mortality/morbidity following MTEER was high. Factors influencing outcomes and "centers of excellence" as a whole may differ for TAVR and MTEER.
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Affiliation(s)
- Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Pratik Manandhar
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Anthony A Bavry
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jay Giri
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Mack
- Baylor Scott and White Heart Hospital, Plano, Texas, USA
| | - John Carroll
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrzej Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri, USA
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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Duggal NM, Engoren M, Chadderdon SM, Rodriguez E, Morse MA, Vannan MA, Yadav PK, Morcos M, Li F, Reisman M, Garcia-Sayan E, Raghunathan D, Sodhi N, Sorajja P, Chen L, Rogers JH, Calfon MA, Kovach CP, Gill EA, Zahr FE, Chetcuti SJ, Yuan Y, Mentz GB, Lim DS, Ailawadi G. Mortality Associated With Proportionality of Secondary Mitral Regurgitation After Transcatheter Mitral Valve Repair: North American Mitraclip for Functional Mitral Regurgitation Registry. Am J Cardiol 2024; 213:99-105. [PMID: 38110022 DOI: 10.1016/j.amjcard.2023.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/17/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
The association, if any, between the effective regurgitant orifice area (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients who undergo mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip system (Abbott Vascular, Santa Clara, CA). This study's objective was to determine the association between EROA/LVEDV and 1-year mortality in patients who undergo m-TEER with MitraClip. In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. We studied 525 patients with secondary MR who underwent m-TEER. Most patients were male (63%) and were New York Heart Association class III (61%) or IV (21%). Mitral regurgitation was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely, with median = 0.19 mm2/ml, interquartile range [0.12,0.28] mm2/ml, and 187 patients (36%) had values <0.15 mm2/ml. Postprocedural mitral regurgitation severity was substantially alleviated, being 1+ or less in 74%, 2+ in 20%, 3+ in 4%, and 4+ in 2%; 1-year mortality was 22%. After adjustment for confounders, the logarithmic transformation (Ln) of EROA/LVEDV was associated with 1-year mortality (odds ratio 0.600, 95% confidence interval 0.386 to 0.933, p = 0.023). A higher Society of Thoracic Surgeons risk score was also associated with increased mortality. In conclusion, lower values of Ln(EROA/LVEDV) were associated with increased 1-year mortality in this multicenter registry. The slope of the association is steep at low values but gradually flattens as Ln(EROA/LVEDV) increases.
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Affiliation(s)
- Neal M Duggal
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan.
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Scott M Chadderdon
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Evelio Rodriguez
- Department of Cardiothoracic Surgery, Ascension Saint Thomas Heart, Nashville, Tennessee
| | - M Andrew Morse
- Division of Cardiology, Ascension Saint Thomas Heart, Nashville, Tennessee
| | - Mani A Vannan
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Pradeep K Yadav
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Michael Morcos
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Flora Li
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | - Enrique Garcia-Sayan
- Division of Cardiovascular Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Deepa Raghunathan
- Division of Cardiovascular Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Nishtha Sodhi
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute, Abbott Northwestern Medical Center, Minneapolis, Minnesota
| | - Lily Chen
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California
| | - Jason H Rogers
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California
| | - Marcella A Calfon
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | | | - Edward A Gill
- Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Firas E Zahr
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Stanley J Chetcuti
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Yuan Yuan
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Graciela B Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - D Scott Lim
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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Bansal K, Pawar S, Gupta T, Gilani F, Khera S, Kolte D. Association Between Hospital Volume and 30-Day Readmissions After Transcatheter Mitral Valve Edge-to-Edge Repair. Am J Cardiol 2023; 203:149-156. [PMID: 37499594 DOI: 10.1016/j.amjcard.2023.06.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
Data on the association between hospital procedural volume and 30-day readmissions after mitral valve transcatheter edge-to-edge repair (mTEER) are limited. We used the 2019 Nationwide Readmissions Database to identify hospitals that performed at least 5 mTEERs. Hospitals were categorized based on tertiles of annual mTEER volume as low-volume (5 to 13), medium-volume (14 to 28), and high-volume (29 to 171). Multivariable hierarchical logistic regression models and restricted cubic spline analyses were used to examine the association between hospital mTEER volume and 30-day readmissions. Median (interquartile range) annual hospital mTEER volume was 20 (11.5 to 34). Of 234 hospitals included in the study, 77 (32.9%), 77 (32.9%), and 80 (34.2%) were categorized as low-volume, medium-volume, and high-volume. Of 5,574 index mTEER procedures included in this study, 634 (11.4%), 1,353 (24.3%), and 3,587 (64.3%) were performed at low-volume, medium-volume, and high-volume centers, respectively. In the overall study cohort, rates of 30-day all-cause readmissions after mTEER were 13.2%. In multivariable analyses, there was no significant association between hospital mTEER volume (as a categorical variable) and 30-day all-cause or cause-specific (cardiac, non-cardiac, heart failure) readmissions. Similarly, no significant relation was observed between hospital mTEER volume as a continuous variable and 30-day all-cause or cause-specific readmissions in restricted cubic spline analysis. In conclusion, in a nationally representative sample of 234 hospitals with >5,500 mTEER procedures, we found no association between annual hospital mTEER volume and 30-day all-cause or cause-specific readmissions.
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Affiliation(s)
- Kannu Bansal
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Shubhadarshini Pawar
- Department of Medicine, Shree Vighanaharta Superspeciality Hospital, Dhule, India
| | - Tanush Gupta
- Division of Cardiology, Department of Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Fahad Gilani
- Division of Cardiovascular Medicine, Catholic Medical Center, Manchester, New Hampshire
| | - Sahil Khera
- Division of Interventional Cardiology, Mount Sinai Hospital, New York, New York
| | - Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM, Mendes LA, Arrighi JA, Breinholt JP, Day J, Dec GW, Denktas AE, Drajpuch D, Faza N, Francis SA, Hahn RT, Housholder-Hughes SD, Khan SS, Kondapaneni MD, Lee KS, Lin CH, Hussain Mahar J, McConnaughey S, Niazi K, Pearson DD, Punnoose LR, Reejhsinghani RS, Ryan T, Silvestry FE, Solomon MA, Spicer RL, Weissman G, Werns SW. 2023 ACC/AHA/SCAI advanced training statement on interventional cardiology (coronary, peripheral vascular, and structural heart interventions): A report of the ACC Competency Management Committee. J Thorac Cardiovasc Surg 2023; 166:e73-e123. [PMID: 37269254 DOI: 10.1016/j.jtcvs.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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7
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Romano LR, Scalzi G, Malizia B, Aquila I, Polimeni A, Indolfi C, Curcio A. Impact of Percutaneous Mitral Valve Repair on Left Atrial Strain and Atrial Fibrillation Progression. J Cardiovasc Dev Dis 2023; 10:320. [PMID: 37623333 PMCID: PMC10456079 DOI: 10.3390/jcdd10080320] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/26/2023] Open
Abstract
Transcatheter edge-to-edge repair (TEER) currently represents a valuable therapeutic option for patients with severe mitral regurgitation (MR) considered at high surgical risk. Besides symptoms and left ventricular (LV) echocardiographic improvements upon TEER, it has been postulated that left atrial (LA) function plays a prognostic role. The aims of our study were to evaluate LA changes after TEER, measured by two-dimensional speckle-tracking echocardiography analysis (2D-STE), their association with atrial fibrillation (AF) occurrence, and relative arrhythmic burden. We considered in a single-center study 109 patients affected by symptomatic severe MR undergoing TEER from February 2015 to April 2022. By 2D-STE, LA reservoir (R_s), conduct (D_s), and contractile (C_s) strains were assessed along with four-chamber emptying fraction (LAEF-4CH) before, 1, 6, and 12 months following TEER. Statistical analysis for comparison among baseline, and follow-ups after TEER was carried out by ANOVA, MANOVA, and linear regression. Successful TEER significantly improved LV dimensions and LA performances, as indicated by all strain components, and LAEF-4CH after 1 year. Strikingly, a significant reduction in arrhythmic burden was observed, since only one case of subclinical AF detected by a previously implanted cardiac electronic device was found in the cohort of sinus rhythm patients (n = 48) undergone TEER; in addition, ventricular rate was reduced in the AF cohort (n = 61) compared to baseline, together with few episodes of nonsustained ventricular tachycardias (5/61, 8.2%) after MR improvement. Overall, TEER was associated with improved cardiac performance, LA function amelioration, and reduced arrhythmic burden.
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Affiliation(s)
- Letizia Rosa Romano
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Giuseppe Scalzi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Biagio Malizia
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Iolanda Aquila
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87100 Cosenza, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Antonio Curcio
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
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8
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. JACC Cardiovasc Interv 2023; 16:1239-1291. [PMID: 37115166 DOI: 10.1016/j.jcin.2023.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. J Am Coll Cardiol 2023; 81:1386-1438. [PMID: 36801119 DOI: 10.1016/j.jacc.2022.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Little SH, Rigolin VH, Garcia-Sayan E, Hahn RT, Hung J, Mackensen GB, Mankad S, Quader N, Saric M. Recommendations for Special Competency in Echocardiographic Guidance of Structural Heart Disease Interventions: From the American Society of Echocardiography. J Am Soc Echocardiogr 2023; 36:350-365. [PMID: 36841670 DOI: 10.1016/j.echo.2023.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Transcatheter therapies for structural heart disease continue to grow at a rapid pace, and echocardiography is the primary imaging modality used to support such procedures. Transesophageal echocardiographic guidance of structural heart disease procedures must be performed by highly skilled echocardiographers who can provide rapid, accurate, and high-quality image acquisition and interpretation in real time. Training standards are needed to ensure that interventional echocardiographers have the necessary expertise to perform this complex task. This document provides guidance on all critical aspects of training for cardiology and anesthesiology trainees and postgraduate echocardiographers who plan to specialize in interventional echocardiography. Core competencies common to all transcatheter therapies are reviewed in addition to competencies for each specific transcatheter procedure. A core principle is that the length of interventional echocardiography training or achieved procedure volumes are less important than the demonstration of procedure-specific competencies within the milestone domains of knowledge, skill, and communication.
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Affiliation(s)
- Stephen H Little
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Vera H Rigolin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rebecca T Hahn
- Columbia University Irving College of Medicine, New York, New York
| | - Judy Hung
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | - Muhamed Saric
- New York University Langone Health, New York, New York
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Huie LC, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. Circ Cardiovasc Interv 2023; 16:e000088. [PMID: 36795800 DOI: 10.1161/hcv.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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12
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Abstract
BACKGROUND Risk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR). METHODS A novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately. RESULTS Event rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4746; 8.88%), and CONV (n = 3399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (interquartile range: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality. CONCLUSIONS This etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100575. [PMID: 39129804 PMCID: PMC11307585 DOI: 10.1016/j.jscai.2022.100575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
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Badhwar V, Chikwe J, Gillinov AM, Vemulapalli S, O'Gara PT, Mehaffey JH, Wyler von Ballmoos M, Bowdish ME, Gray EL, O'Brien SM, Thourani VH, Shahian DM, Habib RH. Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation. J Am Coll Cardiol 2023; 81:636-648. [PMID: 36669958 DOI: 10.1016/j.jacc.2022.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/31/2022] [Accepted: 11/10/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Risk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. OBJECTIVES The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR). METHODS A novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately. RESULTS Event rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4,746; 8.88%), and CONV (n = 3,399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (IQR: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality. CONCLUSIONS This etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.
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Affiliation(s)
- Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA.
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sreek Vemulapalli
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Patrick T O'Gara
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA
| | | | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elizabeth L Gray
- STS Analytic and Research Center, The Society of Thoracic Surgeons, Chicago, Illinois, USA
| | - Sean M O'Brien
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Vinod H Thourani
- Department of Cardiac Surgery, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - David M Shahian
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert H Habib
- STS Analytic and Research Center, The Society of Thoracic Surgeons, Chicago, Illinois, USA
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15
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Delling FN, Noseworthy PA, Adams DH, Basso C, Borger M, Bouatia-Naji N, Elmariah S, Evans F, Gerstenfeld E, Hung J, Le Tourneau T, Lewis J, Miller MA, Norris RA, Padala M, Perazzolo-Marra M, Shah DJ, Weinsaft JW, Enriquez-Sarano M, Levine RA. Research Opportunities in the Treatment of Mitral Valve Prolapse: JACC Expert Panel. J Am Coll Cardiol 2022; 80:2331-2347. [PMID: 36480975 PMCID: PMC9981237 DOI: 10.1016/j.jacc.2022.09.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/31/2022] [Accepted: 09/12/2022] [Indexed: 12/10/2022]
Abstract
In light of the adverse prognosis related to severe mitral regurgitation, heart failure, or sudden cardiac death in a subset of patients with mitral valve prolapse (MVP), identifying those at higher risk is key. For the first time in decades, researchers have the means to rapidly advance discovery in the field of MVP thanks to state-of-the-art imaging techniques, novel omics methodologies, and the potential for large-scale collaborations using web-based platforms. The National Heart, Lung, and Blood Institute recently initiated a webinar-based workshop to identify contemporary research opportunities in the treatment of MVP. This report summarizes 3 specific areas in the treatment of MVP that were the focus of the workshop: 1) improving management of degenerative mitral regurgitation and associated left ventricular systolic dysfunction; 2) preventing sudden cardiac death in MVP; and 3) understanding the mechanisms and progression of MVP through genetic studies and small and large animal models, with the potential of developing medical therapies.
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Affiliation(s)
- Francesca N Delling
- Department of Medicine (Cardiovascular Division), University of California-San Francisco, San Francisco, California, USA.
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | | | - Sammy Elmariah
- Department of Medicine (Cardiovascular Division), University of California-San Francisco, San Francisco, California, USA; Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Frank Evans
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Edward Gerstenfeld
- Department of Medicine (Cardiovascular Division), University of California-San Francisco, San Francisco, California, USA
| | - Judy Hung
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thierry Le Tourneau
- Nantes Université, CHU Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - John Lewis
- Heart Valve Voice US, Washington, DC, USA
| | - Marc A Miller
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Russell A Norris
- Department of Regenerative Medicine and Cell Biology, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Muralidhar Padala
- Department of Surgery (Cardiothoracic Surgery Division), Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Dipan J Shah
- Department of Cardiology, Houston Methodist, Weill Cornell Medical College, Houston, Texas, USA
| | | | | | - Robert A Levine
- Massachusetts General Hospital Cardiac Ultrasound Laboratory, Boston, Massachusetts, USA
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16
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Young MN, Kearing S, Albaghdadi MA, Latib A, Iribarne A. Trends in Transcatheter vs Surgical Mitral Valve Repair Among Medicare Beneficiaries, 2012 to 2019. JAMA Cardiol 2022; 7:770-772. [PMID: 35507335 PMCID: PMC9069336 DOI: 10.1001/jamacardio.2022.0775] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Michael N Young
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephen Kearing
- The Dartmouth Institute, Dartmouth College, Lebanon, New Hampshire
| | - Mazen A Albaghdadi
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Azeem Latib
- Interventional Cardiology and Structural Heart Interventions, Montefiore Medical Center, New York, New York
| | - Alexander Iribarne
- The Dartmouth Institute, Dartmouth College, Lebanon, New Hampshire.,Division of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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17
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Sazzad F, Hon JKF, Ramanathan K, Nah JH, Ong ZX, Ti LK, Foo R, Tay E, Kofidis T. Design Variation, Implantation, and Outcome of Transcatheter Mitral Valve Prosthesis: A Comprehensive Review. Front Cardiovasc Med 2022; 8:782278. [PMID: 35284498 PMCID: PMC8907442 DOI: 10.3389/fcvm.2021.782278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/31/2021] [Indexed: 11/26/2022] Open
Abstract
The transcatheter mitral valve prosthesis is ideally suited for patients with inoperable mitral etiology. The transcatheter mitral valve implantation (TMVI) procedure has closely followed the evolution of transcatheter aortic procedures. There are considerable design variations amongst the limited TMVI prostheses currently available, and the implantation profiles of the devices are notably different. This comprehensive review will provide an overview of the current clinically tried TMVI devices with a focused outcome analysis. In addition, we have discussed the various design characteristics of TMVI and its associated failure mode, implantation technology, delivery methods, first-in-man trials, and pivotal trial summary for the synthesis of recent evidence. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255241, identifier: CRD42021255241.
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Affiliation(s)
- Faizus Sazzad
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore, Singapore
- Cardiovascular Disease Translational Research Programme, Centre for Translational Medicine, National University of Singapore, Singapore, Singapore
| | - Jimmy Kim Fatt Hon
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore, Singapore
- National University Heart Centre, National University Health System, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore, Singapore
- National University Heart Centre, National University Health System, Singapore, Singapore
| | - Jie Hui Nah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Zhi Xian Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Heart Centre, National University Health System, Singapore, Singapore
| | - Roger Foo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cardiovascular Disease Translational Research Programme, Centre for Translational Medicine, National University of Singapore, Singapore, Singapore
- National University Heart Centre, National University Health System, Singapore, Singapore
| | - Edgar Tay
- National University Heart Centre, National University Health System, Singapore, Singapore
- Asian Heart & Vascular Centre (AHVC), Mount Elizabeth Medical Centre, Singapore, Singapore
| | - Theo Kofidis
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore, Singapore
- Cardiovascular Disease Translational Research Programme, Centre for Translational Medicine, National University of Singapore, Singapore, Singapore
- National University Heart Centre, National University Health System, Singapore, Singapore
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19
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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20
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Gómez Vidal MA. ¿Quién y cómo deberíamos iniciar un programa TAVI o transcatéter? CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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21
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60:727-800. [PMID: 34453161 DOI: 10.1093/ejcts/ezab389] [Citation(s) in RCA: 316] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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22
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Davies A, Roberts-Thompson R, Puri R, Psaltis P. Position Statements for Transcatheter Valve Therapies in Australia: Accreditation Standards and Heart Team Opportunities. Heart Lung Circ 2021; 30:1787-1789. [PMID: 34627671 DOI: 10.1016/j.hlc.2021.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Allan Davies
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.
| | - Ross Roberts-Thompson
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | | | - Peter Psaltis
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia; Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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23
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2021; 43:561-632. [PMID: 34453165 DOI: 10.1093/eurheartj/ehab395] [Citation(s) in RCA: 2318] [Impact Index Per Article: 772.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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24
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Kawsara A, Alqahtani F, Rihal CS, Alkhouli M. Lack of Association Between the Recommended Annual Volume Thresholds for Transcatheter Mitral Programs and Safety Outcomes of MitraClip Implantation. JACC Cardiovasc Interv 2021; 13:2822-2824. [PMID: 33303127 DOI: 10.1016/j.jcin.2020.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/04/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022]
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25
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Ranganath P, Moore A, Guerrero M, Collins J, Foley T, Williamson E, Rajiah P. CT for Pre- and Postprocedural Evaluation of Transcatheter Mitral Valve Replacement. Radiographics 2021; 40:1528-1553. [PMID: 33001784 DOI: 10.1148/rg.2020200027] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Transcatheter mitral valve replacement (TMVR) is a catheter-based interventional technique for treating mitral valve disease in patients who are at high risk for open mitral valve surgery and with unfavorable anatomy for minimally invasive edge-to-edge transcatheter mitral valve repair. There are several TMVR devices with different anchoring mechanisms, delivered by either transapical or transseptal approaches. Transthoracic echocardiography is the first-line imaging modality used for characterization and quantification of mitral valve disorders. CT is complementary to echocardiography and has several advantages, including high isotropic spatial resolution, good temporal resolution, large field of view, multiplanar reconstruction capabilities, and rapid turnaround time. CT is essential for multiple aspects of preprocedural planning. Accurate and reproducible techniques to prescribe the mitral annulus at CT have been described from which important measurements such as the area, perimeter, trigone-trigone distance, intercommissural distance, and septolateral distance are obtained. The neo-left ventricular outflow tract (LVOT) can be simulated by placing a virtual prosthesis in the CT data to predict the risk of TMVR-induced LVOT obstruction. The anatomy of the landing zone and subvalvular apparatus as well as the relationship of the virtual device to adjacent structures such as the coronary sinus and left circumflex coronary artery can be evaluated. CT also stimulates procedural fluoroscopic angles. CT can be used to evaluate the chest wall for transapical access and the atrial septum for transseptal access. Follow-up CT is useful in identifying complications such as LVOT obstruction, paravalvular leak, pseudoaneurysm, and valve embolization. Online supplemental material is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Praveen Ranganath
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath); Department of Radiology, Baylor University Medical Center, Dallas, Tex (A.M.); and Department of Cardiology (M.G.) and Department of Radiology (J.C., T.F., E.W., P. Rajiah), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Alastair Moore
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath); Department of Radiology, Baylor University Medical Center, Dallas, Tex (A.M.); and Department of Cardiology (M.G.) and Department of Radiology (J.C., T.F., E.W., P. Rajiah), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Mayra Guerrero
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath); Department of Radiology, Baylor University Medical Center, Dallas, Tex (A.M.); and Department of Cardiology (M.G.) and Department of Radiology (J.C., T.F., E.W., P. Rajiah), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Jeremy Collins
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath); Department of Radiology, Baylor University Medical Center, Dallas, Tex (A.M.); and Department of Cardiology (M.G.) and Department of Radiology (J.C., T.F., E.W., P. Rajiah), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Thomas Foley
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath); Department of Radiology, Baylor University Medical Center, Dallas, Tex (A.M.); and Department of Cardiology (M.G.) and Department of Radiology (J.C., T.F., E.W., P. Rajiah), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Eric Williamson
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath); Department of Radiology, Baylor University Medical Center, Dallas, Tex (A.M.); and Department of Cardiology (M.G.) and Department of Radiology (J.C., T.F., E.W., P. Rajiah), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Prabhakar Rajiah
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath); Department of Radiology, Baylor University Medical Center, Dallas, Tex (A.M.); and Department of Cardiology (M.G.) and Department of Radiology (J.C., T.F., E.W., P. Rajiah), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
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26
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Operator and Institutional Requirements for Transcatheter Mitral Valve Therapies in Australia: a CSANZ and ANZSCTS Position Statement. Heart Lung Circ 2021; 30:1805-1810. [PMID: 34266762 DOI: 10.1016/j.hlc.2021.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/15/2021] [Accepted: 07/05/2021] [Indexed: 11/21/2022]
Abstract
The expert Position Statement is a description of the requirements for Accreditation for transcatheter mitral valve therapy (TMVT) in Australia. The requirements include the need for a multidisciplinary Heart Team review of individual cases, mandatory reporting of outcome data to a national TMVT Registry, and accreditation of individuals and institutions by the Conjoint Accreditation Committee, the assigned accreditation authority.
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27
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Barker CM, Reynolds MR, Reardon MJ, Van Houten JL, Murphy SM, Mollenkopf SA, Feldman TE. Relation of Institutional Mitral Valve Surgical Volume to Surgical and Transcatheter Outcomes in Medicare Patients. Am J Cardiol 2021; 147:94-100. [PMID: 33662328 DOI: 10.1016/j.amjcard.2021.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/15/2022]
Abstract
There are limited data to support proposed increases to the minimum institutional mitral valve (MV) surgery volume required to begin a transcatheter mitral valve repair (TMVr) program. The current study examined the association between institutional MV procedure volumes and outcomes. All 2017 Medicare fee-for-service patients who received a TMVr or MV surgery procedure were included and analyzed separately. The exposure was institutional MV surgery volume: low (1 to 24), medium (25 to 39) or high (40+). Outcomes were in-hospital mortality and 1-year postdischarge mortality and cardiovascular rehospitalization. For MV surgery patients, in-hospital mortality rates were 6.4% at low-volume, 8.7% at medium-volume and 9.8% at high-volume facilities. Rates were significantly higher for low-volume [OR = 1.50, 95% CI (1.23 to 1.84)] and medium-volume [OR = 1.33, 95% CI (1.06 to 1.67)] compared with high-volume facilities. There was no statistically significant relationship between institutional MV surgery volume and in-hospital mortality for TMVr patients, either at low-volume [OR = 1.52, 95% CI (0.56, 4.13)] or medium-volume [OR = 1.58, 95% CI (0.82, 3.02)] facilities, compared with high-volume facilities. Across all volume categories, in-hospital mortality rates for TMVr patients were relatively low (2.3% on average). For both cohorts, the rates of 1-year mortality and cardiovascular rehospitalizations were not significantly higher at low- or medium-volume MV surgery facilities, as compared with high-volume. In conclusion, among Medicare patients, there was a relation between institutional MV surgery volume and in-hospital mortality for MV surgery patients, but not for TMVr patients.
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28
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Kolte D, Butala NM, Kennedy KF, Wasfy JH, Jena AB, Sakhuja R, Langer N, Melnitchouk S, Sundt TM, Passeri JJ, Palacios IF, Inglessis I, Elmariah S. Association between hospital cardiovascular procedural volumes and transcatheter mitral valve repair outcomes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:27-33. [PMID: 33903039 DOI: 10.1016/j.carrev.2021.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/17/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Cardiovascular procedural volumes can serve as metrics of hospital infrastructure and quality, and are the basis for thresholds for initiating transcatheter mitral valve repair (TMVr) programs. Whether hospital volumes of TMVr, surgical mitral valve replacement or repair (SMVRr), and percutaneous coronary intervention (PCI) are indicators of TMVr quality of care is not known. METHODS We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TMVr procedures. Hospitals were divided into quartiles of TMVr volume. Associations of hospital TMVr, SMVRr, and PCI volumes, as well as SMVRr and PCI outcomes with TMVr outcomes were examined. Outcomes studied were risk-standardized in-hospital mortality rate (RSMR) and 30-day readmission rate (RSRR). RESULTS The study included 3404 TMVr procedures performed across 150 hospitals in the US. The median hospital TMVr volume was 17 (IQR 10, 28). The mean hospital-level RSMR and RSRR for TMVr were 3.0% (95% CI 2.5%, 3.4%) and 14.8% (95% CI 14.5%, 15.0%), respectively. There was no significant association between hospital TMVr volume (as quartiles or as a continuous variable) and TMVr RSMR or RSRR (P > 0.05). Similarly, there was weak or no correlation between hospital SMVRr and PCI volumes and outcomes with TMVr RSMR or RSRR (Pearson correlation coefficients, r = -0.199 to 0.269). CONCLUSION In this study, we found no relationship between hospital TMVr, SMVRr, and PCI volume and TMVr outcomes. Further studies are needed to determine more appropriate structure and process measures to assess the performance of established and new TMVr centers.
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Affiliation(s)
- Dhaval Kolte
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neel M Butala
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Rahul Sakhuja
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathaniel Langer
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Serguei Melnitchouk
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thoralf M Sundt
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan J Passeri
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Igor F Palacios
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ignacio Inglessis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sammy Elmariah
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Henning RJ. The current diagnosis and treatment of high-risk patients with chronic primary and secondary mitral valve regurgitation. Future Cardiol 2021; 18:67-87. [PMID: 33840221 DOI: 10.2217/fca-2020-0189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Mitral valve regurgitation (MR) is due primarily to either primary degeneration of the mitral valve with Barlow's or fibroelastic disease or is secondary to ischemic or nonischemic cardiomyopathies. Echocardiography is essential to assess MR etiology and severity, the remodeling of cardiac chambers and to characterize longitudinal chamber changes to determine optimal therapies. Surgery is recommended for severe primary MR if persistent symptoms are present or if left ventricle dysfunction is present with an EF <60% or a left ventricle end-systolic diameter ≥40 mm. For secondary MR, therapy of heart failure with vasodilators and diuretics improves forward cardiac output. Coronary artery bypass grafts (CABG) or percutaneous coronary intervention (PCI) should be considered for severe MR due to ischemia. This review summarizes the pathophysiology, the characteristics, the management and the different interventions for high risk patients with chronic primary and secondary MR.
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Affiliation(s)
- Robert J Henning
- University of South Florida, Tampa, FL 33612, USA.,James A Haley Hospital, Tampa, FL 33612, USA
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30
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Alkhouli M, Alqahtani F, Kawsara A, Guerrero M, Eleid MF, Nkomo VT, Rihal CS, Crestanello JA. Association of Transcatheter Mitral Valve Repair Availability With Outcomes of Mitral Valve Surgery. J Am Heart Assoc 2021; 10:e019314. [PMID: 33754835 PMCID: PMC8174333 DOI: 10.1161/jaha.120.019314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Transcatheter mitral valve repair (TMVr) is currently offered at selected centers that meet certain operator and institutional requirements. We sought to explore the hypothesis that the availability of TMVr is associated with improved outcomes of MV surgery. Methods and Results We used the Nationwide Readmissions Database to identify patients who underwent MV surgery at centers with or without TMVr capabilities between January 1 and December 31, 2017. The primary end point was in‐hospital mortality. Secondary end points were postoperative complications, resource use, and 30‐day readmissions. A total of 24 477 patients from 595 centers (446 TMVr, 149 non‐TMVr) were included. There were modest but statistically significant differences in the prevalence of comorbidities between the groups. Patients at non‐TMVr centers had higher unadjusted in‐hospital mortality than those at TMVr centers (5.6% versus 3.6%, P<0.001). They also had higher rates of postoperative complications, longer hospitalizations, higher cost, and fewer home discharges but similar 30‐day readmission rates. After propensity matching, mortality remained higher at non‐TMVr centers (5.5% versus 4.0%, P<0.001). Rates of postoperative complications, prolonged hospitalizations, and nonhome discharges also remained higher. Postoperative mortality was consistently higher at non‐TMVr centers in multiple risk‐adjustment analyses incrementally accounting for differences in risk factors, surgical volume, availability of surgical repair, and excluding concomitant procedures. In the most comprehensive model, surgery at non‐TMVr centers was associated with higher odds of death (odds ratio, 1.41; 95% CI, 1.14–1.73; P=0.002). Conclusions Mitral valve surgery at TMVr centers is associated with improved in‐hospital outcomes compared with non‐TMVr centers.
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Affiliation(s)
| | - Fahad Alqahtani
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Division of Cardiology Department of Medicine University of Kentucky Lexington KY
| | - Akram Kawsara
- Division of Cardiology Department of Medicine West Virginia University Morgantown WV
| | - Mayra Guerrero
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Mackram F Eleid
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | - Juan A Crestanello
- Department of Cardiovascular Surgery Mayo Clinic School of Medicine Rochester MN
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Patterson JH, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2021; 77:772-810. [DOI: 10.1016/j.jacc.2020.11.022] [Citation(s) in RCA: 233] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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32
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Workup and Management of Primary Mitral Regurgitation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00868-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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33
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Shreenivas S, Abraham WT, Lilly S. The National Coverage Decision for MitraClip in Functional Mitral Regurgitation: Missing the Mark. JAMA Cardiol 2020; 6:9-10. [PMID: 33052372 DOI: 10.1001/jamacardio.2020.4762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Satya Shreenivas
- Lindner Research Center, The Christ Hospital Heart and Vascular Center, Cincinnati, Ohio
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34
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Donatelle M, Ailawadi G. Transcatheter Mitral Valve Repair and Replacement: What's on the Horizon? Semin Thorac Cardiovasc Surg 2020; 33:291-298. [PMID: 32980535 DOI: 10.1053/j.semtcvs.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/06/2020] [Accepted: 09/13/2020] [Indexed: 11/11/2022]
Abstract
There are more than 4 million people affected by mitral regurgitation in both the United States and Europe. Prior to the last decade the only options for treatment of MR were medical therapy and open-heart surgery which left many high risk patients with little option once medically optimized. However, we saw a flood in innovative transcatheter mitral valve interventions. As the technologies are refined these new approaches are considerably less invasive and for some high-risk patients may represent a superior option to conventional open-heart surgery. There are 3 main approaches currently being considered for transcatheter mitral valve repair, edge to edge repair, indirect annuloplasty and direct annuloplasty. There have also been large advancements in recent years in transcatheter replacement of the mitral valve. Although many of these devices are under investigation still, we sought to examine the current state of innovative transcatheter mitral valve technologies.
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Affiliation(s)
- Marissa Donatelle
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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35
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Chen SW, Chen CY, Chien-Chia Wu V, Chou AH, Cheng YT, Chang SH, Chu PH. Mitral valve repair versus replacement in patients with rheumatic heart disease. J Thorac Cardiovasc Surg 2020; 164:57-67.e11. [PMID: 32994098 DOI: 10.1016/j.jtcvs.2020.07.117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/31/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rheumatic heart disease remains a major cause of cardiovascular death worldwide. Limited real-world nationwide data are available to compare the long-term outcomes between mitral valve repair and replacement in rheumatic heart disease. METHODS We identified adult patients with rheumatic heart disease who underwent mitral valve repair or replacement surgery between 2000 and 2013 from Taiwan's National Health Insurance Research Database. Outcomes of interest included operation-related complications, all-cause mortality, and mitral valve reoperation rate. Propensity score matching at a 1:1 ratio was conducted to mitigate possible confounding factors. RESULTS A total of 5086 patients with rheumatic heart disease who underwent mitral valve surgery were identified. Of those, 489 (9.6%) and 4597 (90.4%) underwent mitral valve repair and mitral valve replacement, respectively. After propensity score matching was applied, each group had 467 patients. No difference in risk of in-hospital mortality was observed between groups. With a mean follow-up of 6 years, the mitral valve repair group had comparable risks of all-cause mortality with the mitral valve replacement group (33.4% vs 32.5%; hazard ratio, 1.01; 95% confidence interval, 0.81-1.25). However, higher risks of mitral valve reoperation were observed in the mitral valve repair group (subdistribution hazard ratio, 4.32; 95% confidence interval, 2.02-9.23). Previous percutaneous transvenous mitral commissurotomy was identified as a risk factor of mitral valve reoperation in the repair group. CONCLUSIONS Among patients with rheumatic heart disease, mitral valve repair is not associated with superior long-term outcomes. Patients should be carefully selected for mitral valve repair because of its higher reoperation rate, particularly those with previous percutaneous transvenous mitral commissurotomy.
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Affiliation(s)
- Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.
| | - Cheng-Yu Chen
- Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Ting Cheng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Shang-Hung Chang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan; Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
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36
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A novel case of transcatheter mitral valve-in-valve replacement using Mi-thos™ system. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 17:229-233. [PMID: 32362923 PMCID: PMC7189260 DOI: 10.11909/j.issn.1671-5411.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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37
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Tamburino C, Capranzano P. Balancing the expansion of transcatheter interventions for heart valve disease. EUROINTERVENTION 2020; 15:e1567-e1569. [PMID: 32234690 DOI: 10.4244/eijv15i18a287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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