Clinical outcomes of conventional surgery versus MitraClip® therapy for moderate to severe symptomatic mitral valve regurgitation in the elderly population: an institutional experience

Cardiogeriatrics: the current state of the art

It is estimated that by 2050, 17% of the world's population will be greater than 85 years old, which, combined with cardiovascular disease (CVD) being the leading cause of death and disability, sets an unprecedented burden on our health and care systems. This perfect storm will be accompanied by a rise in the prevalence of CVD due to increased survival of patients with pre-existing CVD and the incidence of CVD that is associated with the process of ageing. In this review, we will focus on the diagnosis and management of common CVD conditions in old age, namely: heart failure (HF), coronary artery disease (CAD), atrial fibrillation (AF) and valvular heart disease (VHD). Despite limited evidence, clinical guidelines are increasingly considering the complexity of management of these conditions in the older person, which often coexist, for example, AF and HF or CAD and VHD. Furthermore, they, in turn, need specific consideration in the context of comorbidities, polypharmacy, frailty and impaired cognition found in this age group. Hence, the emerging role of the geriatric cardiologist is therefore vital in performing comprehensive geriatric assessment, attending multidisciplinary team meetings and ultimately considering the patient and the sum of their diseases in their totality. There have been recent advances in CVD management but how we apply these to deliver integrated care to the elderly population is key. This review article aims to bring together emerging studies and guidelines on assessment and management of CVD in the elderly, summarising latest definitions, diagnostics, therapeutics and future challenges.

Surgical outcomes of patients at prohibitive risk who are reconsidered for surgery

Objectives

Transcatheter treatment of advanced mitral and tricuspid valve disease is largely limited to patients at prohibitive surgical risk, although many are not candidates for transcatheter treatment. Here, we describe surgical outcomes of patients at prohibitive risk who were ineligible for transcatheter therapies to guide surgeons in management of this unique population.

Methods

Patients at prohibitive risk, defined per surgeon or cardiologist discretion, who were initially referred for a transcatheter mitral or tricuspid intervention in a multidisciplinary atrioventricular valve clinic, were identified from 2019 to 2022. Preoperative risk, operative outcomes, and long-term mortality were evaluated.

Results

A total of 337 patients at prohibitive risk were referred for evaluation in a multidisciplinary atrioventricular valve clinic. Of those, 161 underwent transcatheter therapy, 130 patients underwent continued medical management, and 45 were reevaluated and had high-risk surgery. Among surgical patients, 51% were women with a median age of 76 years (quartile 1-quartile 3, 65-81 years). Most patients presented in heart failure (83%; n = 37 out of 45), and 73% were in New York Heart Association functional class III or IV. Most patients (94%; n = 43) had a mitral valve intervention, of whom 56% (24 out of 43) had a mitral valve replacement. The 30-day mortality rate was 4% (2 out of 45) and major morbidity occurred in 33% (15 out of 45). By Kaplan-Meier analysis, 1-year survival was 86% ± 9%.

Conclusions

Select patients at prohibitive risk who were ineligible for transcatheter mitral or tricuspid valve intervention underwent surgery with overall low operative mortality and excellent 1-year survival. Patients a prohibitive risk whose anatomy is not amenable to transcatheter devices should be reconsidered for surgery.

Variables that enhance the development of resilience in young gay people affected by the COVID-19 pandemic

AIMS

Sexual and gender minorities are more likely to suffer from depression and anxiety caused by COVID-19. However, they also have specific variables that have been little studied but which may protect them from this adverse situation. The aim of this study was to find out whether there were differences in socio-demographic and psychosocial variables in two groups of Spanish gay young people (high and low resilience), and predictors of risk and protective factors were examined.

METHODS

Nine hundred and seventy-nine young homosexuals (389; 39.73% self-reported as women) aged between 18 and 26 years old who experienced mandatory confinement due to COVID-19, completed an anonymous online questionnaire. Hope, perceived self-efficacy, reappraisal index, coping humour, anxiety, depression were assessed along with socio-demographic information. Data were collected between 15 and 26 April 2020.

RESULTS

Socio-demographic variables that were predictive of highly resilient behaviour included being between 24 and 26 years old, living with LGBTI+ peers and living in big cities, protective psychosocial variables included reframing in reappraising the confinement situation, humour as coping, social support from significant others and self-efficacy.

CONCLUSION

This is one of the first studies on this subject of compulsory COVID-19 confinement on young homosexuals in Spain. Mental health professionals and organizations should also include work on psychosocial protective factors, not just risk factors, to enhance resilient outcomes in this group.

Edge-to-Edge Transcatheter Mitral Valve Repair Using PASCAL vs. MitraClip: A Systematic Review and Meta-Analysis

BACKGROUND

Transcatheter edge-to-edge repair (TEER) of the mitral valve (MV) can be performed using the PASCAL or MitraClip devices. Few studies offer a head-to-head outcome comparison of these two devices.

MATERIAL AND METHODS

PubMed, EMBASE, Cochrane Library, Clinicaltrials.gov and WHO's International Clinical Trials Registry Platform, from 1 January 2000 until 1 March 2023, were searched. Study protocol details were registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42023405400). Randomized Controlled Trials and observational studies reporting head-to-head clinical comparison of PASCAL and MitraClip devices were eligible for selection. Patients with severe functional or degenerative mitral regurgitation (MR) who had undergone TEER of the MV with either PASCAL or MitraClip devices were included in the meta-analysis. Data from six studies (five observational and one randomized clinical trial) were extracted and analyzed. The main outcomes were a reduction in MR to 2+ or less, improvement of New York Heart Association (NYHA) and 30-day all-cause mortality. Peri-procedural mortality, success rate and adverse events were also compared.

RESULTS

Data from 785 and 796 patients that underwent TEER using PASCAL and MitraClip, respectively, were analyzed. Thirty-day all-cause mortality (Risk ratio [RR] = 1.51, 95% CI 0.79-2.89), MR reduction to maximum 2+ (RR = 1.00, 95% CI 0.98-1.02) and NYHA improvement (RR = 0.98, 95% CI 0.84-1.15) were similar in both device groups. Both devices had high and similar success rates (96.9% and 96.7% for the PASCAL and MitraClip group, respectively, p value = 0.91). MR reduction to 1+ or less at discharge was similar in both device groups (RR = 1.06, 95% CI 0.95-1.19). Composite peri-procedural and in-hospital mortality was 0.64% and 1.66% in the PASCAL and MitraClip groups, respectively (p value = 0.094). Rates of peri-procedural cerebrovascular accidents were 0.26% in PASCAL and 1.01% in MitraClip (p value = 0.108).

CONCLUSIONS

Both PASCAL and MitraClip devices have high success and low complication rates for TEER of the MV. PASCAL was not inferior to MitraClip in reducing the MR level at discharge.

Clinical predictors of improvement in left ventricular ejection fraction in U.S. veterans with heart failure

Background

Our understanding of the factors associated with improvement of LVEF and a heart failure with improved EF (HFimpEF) phenotype remains incomplete.

Methods

We conducted a retrospective study using a national database of patients followed in the Veterans Affairs (VA) health system with serial assessment of left ventricular ejection fraction (LVEF) by echocardiography. We identified US veterans with a new diagnosis of heart failure with: (i) LVEF of <40 % in the 12 months prior to diagnosis, and (ii) follow-up LVEF assessment at least 6 months after their diagnosis. We defined HFimpEF as a final LVEF of ≥40 %.

Results

Among the 106,414 US veterans with an initial LVEF of <40 % in this analysis, 39,994 (37.6 %) had a final EF of >40 % after a median follow up of 5 years. Multivariate regression analysis identified several factors that were independently associated with LVEF improvement including female sex, younger age, higher BMI, and a history of specific comorbid conditions such as hypertension, valve disease, atrial fibrillation, connective tissue disease, liver disease, and malignancy (p < 0.001). Conversely, a history of ischemic heart disease and peripheral arterial disease, as well as specific racial backgrounds (Black and Hispanic) were associated with lower rates of LVEF improvement. The model c-statistic for predicting LVEF improvement was 0.70.

Conclusions

This large, detailed dataset facilitated an analysis of a large number of variables that significantly associated with HFimpEF; however, their combined discriminatory value for LVEF improvement remained modest, underscoring the complexity of the gene-environment-treatment interactions that govern LV function.

Mortality and morbidity of surgical and transcatheter mitral valve repair in octogenarians: A systematic review

BACKGROUND

Valvular heart disease (VHD) is a prominent problem in healthcare today with mitral regurgitation (MR) being the leading cause of VHD in the elderly population. While mitral valve repair (MVr) surgery is one of the only options for the end-stage disease, octogenarians are often denied MVr due to concerns with operative mortality and postoperative morbidity. To provide information on this underrepresented group of surgical patients, a systematic approach was taken to review the mortality and morbidity rates of octogenarians who received MVr.

METHODS

Pubmed and Medline were searched for articles containing outcomes of octogenarians receiving surgical mitral valve repair (SMVr) or transcatheter mitral valve repair (TMVr) published after 2000. Ten articles met the inclusion criteria for a total of 7968 patients included in the analysis using Microsoft Excel, Version 2105.

RESULTS

Short-term mortality rates for SMVr and TMVr were 2.6% and 1.4% for in-hospital, and 7.8% and 3.3% for 30 days, respectively. The average incidence of stroke, acute kidney injury, infection, and major bleeding for SMVr were 3.2%, 11.2%, 7.7%, and 24%, respectively, and 0.3%, 6.7%, 2.7%, and 7.9% for TMVr, respectively.

CONCLUSION

Octogenarians receiving SMVr or TMVr experienced similar rates of short-term mortality and morbidity as younger populations, and when considering life expectancy, midterm mortality was also similar. With these results, denying octogenarians MVr operations based on age alone should be reconsidered. Depending on risk factors and comorbidities, either SMVr or TMVr is a viable and relatively safe option for octogenarians with severe MR.

Impact of COPD on Outcomes After MitraClip for Secondary Mitral Regurgitation: The COAPT Trial

OBJECTIVES

The aim of this study was to examine the relationship between chronic obstructive pulmonary disease (COPD) and outcomes after transcatheter mitral valve repair (TMVr) for severe secondary mitral regurgitation.

BACKGROUND

TMVr with the MitraClip improves clinical and health-status outcomes in patients with heart failure and severe (3+ to 4+) secondary mitral regurgitation. Whether these benefits are modified by COPD is unknown.

METHODS

COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) was an open-label, multicenter, randomized trial of TMVr plus guideline-directed medical therapy (GDMT) versus GDMT alone. Patients on corticosteroids or continuous oxygen were excluded. Multivariable models were used to examine the associations of COPD with mortality, heart failure hospitalization (HFH), and health status and to test whether COPD modified the benefit of TMVr compared with GDMT.

RESULTS

Among 614 patients, 143 (23.2%) had COPD. Among patients treated with TMVr, unadjusted analyses demonstrated increased 2-year mortality in those with COPD (hazard ratio [HR]: 2.08; 95% confidence interval [CI]: 1.33 to 3.26), but this association was attenuated after risk adjustment (adjusted HR: 1.48; 95% CI: 0.87 to 2.52). Although TMVr led to reduced 2-year mortality among patients without COPD (adjusted HR: 0.47; 95% CI: 0.33 to 0.67), for patients with COPD, 2-year all-cause mortality was similar after TMVr versus GDMT alone (adjusted HR: 0.94; 95% CI: 0.54 to 1.65; p_int = 0.04), findings that reflect offsetting effects on cardiovascular and noncardiovascular mortality. In contrast, TMVr reduced HFH (adjusted HR: 0.48 [95% CI: 0.28 to 0.83] vs. 0.46 [95% CI: 0.34 to 0.63]; p_int = 0.89) and improved both generic and disease-specific health status to a similar extent compared with GDMT alone in patients with and without COPD (p_int >0.30 for all scales).

CONCLUSIONS

In the COAPT trial, COPD was associated with attenuation of the survival benefit of TMVr versus GDMT compared with patients without COPD. However, the benefits of TMVr on both HFH and health status were similar regardless of COPD. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] [COAPT]; NCT01626079).

Characteristics and outcomes of MitraClip in octogenarians: Evidence from 1853 patients in the GIOTTO registry

BACKGROUND

We aimed at appraising features and outcomes of patients undergoing MitraClip treatment according to their age.

METHODS

We queried the prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) multicenter registry dataset including 19 Italian centers performing MitraClip implantation, distinguishing patients <80 vs ≥80 years of age.

RESULTS

In total, 1853 patients were included, 751 (40.5%) octogenarians and 1102 (59.5%) non-octogenarians. Several baseline and procedural features were significantly different, including gender, regurgitation etiology, and functional class (all p < 0.05). In-hospital outcomes were similarly satisfactory, with death occurring in 18 (2.4%) and 32 (2.9%, p = 0.561), respectively, and improvement in mitral regurgitation in 732 (97.4%) and 1078 (97.8%, p = 0.746), respectively. After a mean follow-up of 15 months, death occurred in 152 (20.2%) and 264 (24.0%), and cardiac death in 85 (11.3%) and 138 (12.5%), respectively (both p > 0.05). Rehospitalization for heart failure and the composite of cardiac death or rehospitalization for heart failure were significantly less common in octogenarians: 63 (8.4%) vs 156 (14.2%, p < 0.001), and 125 (16.6%) vs 242 (22.0%, p = 0.005), respectively. Multivariable analysis showed that these differences were largely due to confounding features, as after adjustment for baseline, clinical and imaging characteristics no significant difference was found for the above clinical endpoints.

CONCLUSIONS

Transcatheter mitral valve repair with the MitraClip in carefully selected octogenarians appears feasible and safe, and is associated with favorable clinical outcomes at mid-term follow-up.

Mitral valve repair for mitral regugitation in the elderly: Yes, we have to, but look at the etiologies!

The meta-analysis by Di Tommaso et al. demonstrated as elderly patients with mitral regurgitation (MR) undergoing mitral valve repair had lower short-term mortality and higher long-term survival with respect to patients undergoing mitral valve replacement. The benefit of repair is such, that initial surgical strategy is advisable in the elderly even in case of mild symptoms if compared with conservative management. However, even if repair can be performed in presence of some specific etiologies, as degenerative MR or secondary MR, there are always cases where a replacement can be an acceptable solution compared to a repair with uncertain future, regardless of our believes and our technical ability.

Effect of Operator Experience on Transcatheter Mitral Valve Repair Outcomes

Transcatheter mitral valve repair with MitraClip is a novel, intricate therapy for mitral regurgitation that improves survival and quality of life. Similar to other medical procedures, there is a relationship between procedural experience and clinical outcomes. MitraClip results and the efficiency and safety of the procedure all improved with increasing experience at both the institutional and operator level in two large studies from the Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapy Registry. Patient selection was also found to have a significant role in procedure success. The old adage of “See one, do one, teach one” does not necessarily apply to complex interventions, such as MitraClip, given that the learning curve does not appear to plateau even as operators approach a 150-case experience.

Residual versus recurrent mitral regurgitation after transcatheter mitral valve edge-to-edge repair

BACKGROUND

The number of MtraClip procedures is increasing, and consequently, the number of patients with residual or recurrent mitral regurgitation (MR). We aimed to characterize patients who had residual versus recurrent MR after MitraClip and report the outcomes of different treatment strategies.

METHODS

From 2012 to 2020, 167 patients had MitraClip. Out of them, 16 patients (9.5%) had residual mitral regurgitation (MR), and 27 patients (16.2%) had recurrent MR.

RESULTS

The median age in patients with residual MR was 67.5 (59-73) years versus 69 (61-78) years in patients with recurrent MR (p = .87). The etiology of mitral valve disease was functional in 13 patients (81.3%) and 22 patients (84.6%) in residual versus recurrent MR patients (p > .99). Cardiac resynchronization therapy-defibrillator implantation was higher in patients with residual MR (p = .02). Survival was 93.7% at 1 year, 76.4% at 3 years versus 92.5% at 1 year, and 84.5% at 3 years in residual versus recurrent MR (p = .69). Two patients in the residual MR group had re-clip, and three had surgery, and in the recurrent MR group, one patient had re-clip, and two patients had surgery (p = .23). Patients who had re-clip were older (p = .09). Surgery was associated with 100% survival at 5 years, 63% after medical therapy and the worst survival was reported in re-clip patients (p = .007).

CONCLUSION

The outcomes of patients with residual versus recurrent mitral regurgitation after MitraClip were comparable. Survival could be improved with surgery compared with medical therapy and re-clip.

Comparison of percutaneous MitraClip versus mitral valve surgery for severe mitral regurgitation: a meta-analysis: Mitraclip and mitral valve surgery meta-analysis

AIMS

Mitral valve surgery (MVS) is the gold-standard treatment for severe symptomatic mitral regurgitation. Percutaneous mitral valve interventions such as the MitraClip procedure offer another dimension to its management particularly in high-risk patients. We meta-analysed the outcomes of MitraClip and MVS.

METHODS AND RESULTS

PubMed, MEDLINE, Embase, Cochrane and Scopus from 1980/01-2019/06 were searched for eligible studies. Data were extracted and pooled using random-effects models. After screening 959 studies and reviewing 21 full-text articles, nine studies totalling 640 MitraClip and 531 MVS (91% valve repair) procedures were included in the meta-analysis. MitraClip patients were older, with a higher prevalence of previous cardiac surgery, coronary disease and a higher EuroSCORE (all p<0.05) than MVS patients. Pooled operative mortality was similar for MitraClip, 3%, versus MVS, 5%, odds ratio (OR): 0.58, 95%, CI: 0.28-1.19, as well as at 1 year mortality, OR: 1.09, CI: 0.71-1.68 and 3-year mortality, OR: 1.08, CI: 0.72-0.163. MitraClip patients had higher rates of early and late significant mitral regurgitation (MR) and more cardiovascular readmissions, while MVS had higher rates of in-hospital bleeding and pacemaker implantation (all p<0.05).

CONCLUSIONS

MitraClip patients had a higher baseline risk than MVS, but there were no significant differences in short- and long-term mortality. MitraClip patients had higher rates of cardiovascular admissions and significant MR post-operatively, while MVS patients had more procedural complications.

Kidney transplantation in valvular heart disease and pulmonary hypertension: Consensus in waiting

Kidney transplantation induces a lesser anesthetic, surgical, and physiological alterations than other solid organ transplantation. Concomitant valvular pathologies expose these patients to poor postoperative outcome. There is a critical gap in knowledge and lack of coherence in the guidelines related to the management in patients with end-stage renal disease with valvular heart disease. The individualized diagnostic and management plan should be based on the assessment of perioperative outcomes. Similarly, pulmonary hypertension in end-stage renal disease poses a unique challenge, it can manifest in isolation or may be associated with other cardiac lesions, namely left-sided valvular heart disease and left ventricular systolic and diastolic dysfunction. Quantification and stratification according to etiology are needed in pulmonary hypertension to ensure an adequate management plan to minimize the adverse perioperative outcomes. Lack of randomized controlled trials has imposed hindrance in proposing a unified approach to clinical decision-making in these scenarios. In this review, we have described the magnitude of the problems, pathophysiologic interactions, impact on clinical outcomes and have also proposed a management algorithm for both the scenarios.

Stroke after transcatheter edge-to-edge mitral valve repair: a systematic review and meta-analysis

AIMS

The aim of this study was to assess the stroke rate after transcatheter mitral valve repair (TMVR) with the MitraClip, comparing it with surgical mitral valve repair (SMVR) and optimal medical treatment (OMT).

METHODS AND RESULTS

In December 2018, we systematically searched PubMed, Embase and Cochrane Controlled Register of Trials for studies comparing TMVR with SMVR and/or OMT for the treatment of severe mitral regurgitation. Random-effects and cumulative meta-analysis was performed. Ten studies were included (seven of TMVR versus SMVR and three of TMVR versus OMT), providing a total of 1,881 patients and 61 pooled strokes (16 in TMVR versus SMVR and 45 in TMVR versus OMT). There was no difference in stroke incidence between TMVR and SMVR (pooled OR 0.49 [0.17, 1.42], p=0.19). However, there was a trend towards a lower stroke risk in TMVR. For TMVR versus OMT, no difference in stroke rate was identified (pooled OR 1.09 [0.60, 1.97], p=0.79). Post-procedure de novo atrial fibrillation was more frequent in SMVR when compared with TMVR.

CONCLUSIONS

Despite both a low number of pooled stroke events and the failure to reach the pre-specified statistical significance, there was a trend for a lower post-procedure stroke rate in TMVR when compared with SMVR and a similar one between TMVR and OMT alone.

Trends in MitraClip, mitral valve repair, and mitral valve replacement from 2000 to 2016

OBJECTIVE

The dissemination of mitral valve repair as the first-line treatment and the introduction of MitraClip for patients who have a prohibitive risk for surgery have changed the landscape of mitral valve intervention. The aim of this study is to provide current and generalizable data regarding the trend of mitral valve interventions and outcomes from 2000 to 2016.

METHODS

Patients ≥18 years of age who underwent mitral-valve interventions were identified using the National Inpatient Sample database. National estimates were generated by means of discharge weights; comorbid conditions were identified using Elixhauser methods. All trends were analyzed with JoinPoint software.

RESULTS

A total of 656,030 mitral valve interventions (298,102 mitral valve replacement, 349,053 mitral valve repair, and 8875 MitraClip) were assessed. No changes in rate of procedures (per 100,000 people in the United States) were observed over this period (annual percent change, -0.4; 95% confidence limit, -1.1 to 0.3; P = .3). From 2000 to 2010, the number of replacements decreased by 5.6% per year (P < .001), whereas repair increased by 8.4% per year from 2000 to 2006 (P < .001). MitraClip procedures increased by 84.4% annually from 2013 to 2016 (P < .001). The burden of comorbidities increased throughout the study for all groups, with the greatest score for MitraClip recipients. Overall, length of stay has decreased for all interventions, most significantly for MitraClip. In-hospital mortality decreased from 8.5% to 3.7% for all interventions, with MitraClip having the most substantial decrease from 3.6% to 1.5%.

CONCLUSIONS

Over a 17-year period, mitral-valve interventions were associated with improved outcomes despite being applied to an increasingly sicker population.

Usefulness of Age (≥85 Years) and Residual Mitral Regurgitation (>1+/4+) for the Prediction of Adverse Outcomes in Patients Receiving the MitraClip

The goal of this study was to determine the predictors of adverse clinical outcomes in patients treated with the MitraClip for significant mitral regurgitation (MR) with a focus on acute changes in hemodynamics and cardiac function. This retrospective study included 63 patients (mean age 82 ± 8 years, 48% male) with moderate to severe or severe MR. Cardiac catheterization was performed before and immediately after MitraClip repair. Volumetric and functional changes were assessed in both ventricles. A major adverse cardiac event was defined as a composite of cardiac death and readmission for heart failure. Patients were followed up on average for 380 days. MR was improved in 92% of patients after MitraClip therapy from an average grade of 4+ to <2+ (p <0.001). The pulmonary capillary wedge pressure decreased from 22 ± 7 mm Hg to 19 ± 6 mm Hg (p <0.001), and the cardiac stroke volume increased by 28% from 102 ± 53 ml to 131 ± 54 ml (p <0.001). The left ventricular end-diastolic volume was significantly reduced 24 hours after MitraClip therapy compared to that at baseline (p = 0.001). In the multivariate Cox proportion hazard regression model, an age ≥85 years (p <0.001) and residual MR >1+ (p <0.048) were predictors of an adverse prognosis at follow-up. In conclusion, a reduced left ventricular end-diastolic volume and improved hemodynamics occurred early after MitraClip therapy. An advanced age (≥85 years) and residual MR >1+ were associated with an increased risk of mortality and heart failure.

Valvular Heart Disease in Patients ≥80 Years of Age

In the United States, the octogenarian population is projected to triple by 2050. With this aging population, the prevalence of valvular heart disease (VHD) is on the rise. The etiology, approach to treatment, and expected outcomes of VHD are different in the elderly compared with younger patients. Both stenotic and regurgitant lesions are associated with unfavorable outcomes if left untreated. Surgical mortality remains high due to multiple co-morbidities, and long-term survival benefit is dependent on many variables including valvular pathology. Quality of life is an important consideration in treatment decisions in this age group. Increasingly, octogenarian patients are receiving transcatheter therapies, with transcatheter aortic valve replacement having the greatest momentum. Numerous transcatheter devices for management of other valve lesions are currently in early clinical trials. This review will describe the epidemiology, etiology, diagnosis, and therapeutic options for VHD in the oldest old, with a focus on transcatheter technologies.

Failed MitraClip therapy: surgical revision in high-risk patients

Background

MitraClip implantation is a valid interventional option that offers acceptable short-term results. Surgery after failed MitraClip procedures remains challenging in high-risk patients. The data on these cases are limited by the small sample numbers.

Aim

The aim of our study is to show, that mitral valve surgery could be possible and more advantageous, even in high-risk patients.

Methods

Between 2010 and 2016, nine patients underwent mitral valve surgery after failed MitraClip therapy at our institution.

Results

The patients’ ages ranged from 19 to 75 years (mean: 61.2 ± 19.6 years). The median interval between the MitraClip intervention and surgical revision was 45 days (range: 0 to 1087 days). In eight of nine patients, the MitraClip intervention was initially successful and the  mitral regurgitation was reduced. Only one patient had undergone cardiac surgery previously.

Intra-operatively, leaflet perforation or rupture, MitraClip detachment, and chordal or papillary muscle rupture were potentially the causes of recurrent mitral regurgitation.

There were three early deaths. One year after surgery, the six remaining patients were alive.

Conclusions

Mitral valve surgery can be successfully performed after failed MitraClip therapy in high-risk patients. The initial indication for MitraClip therapy should be considered carefully for possible surgical repair.

Changing clinical profiles and in-hospital outcomes of octogenarians undergoing cardiac surgery over 18 years: a single-centre experience†

OBJECTIVES

With an ageing population, increasing numbers of octogenarians are undergoing high-risk cardiac surgery. We examine the changing characteristics and in-hospital outcomes for octogenarians over an 18-year period.

METHODS

Clinical data from our prospective database for all octogenarians who had cardiac surgery from March 1999 through May 2016 were reviewed. We examined trends, risk profiles and in-hospital outcomes over 3 eras, namely early (1999-2004), middle (2005-2010) and late (2011-2016). A multivariable analysis was performed to identify independent predictors for adverse outcomes.

RESULTS

There were 1022 patients aged 80-94 years in our study cohort. The octogenarian population increased progressively from early to late eras (4.5%, n = 255 vs 7.1%, n = 321 vs 9.3%, n = 446), as the average logistic EuroSCORE predicted mortality (9% vs 9.7% vs 10.1%, P < 0.01). On the contrary, observed mortality declined substantially (9.4% vs 7.8% vs 4.7%, P = 0.04) over this period. While cardiac morbidity and respiratory comorbidities were more prevalent in the late era, chronic renal failure was more frequent in the early era. Over time, more procedures were performed electively (P = 0.05). Common operations across all eras were coronary artery bypass grafting (CABG), aortic valve replacement and CABG + aortic valve replacement. Emergency operation [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.51-16.35; P < 0.01], poor ejection fraction (OR 3.38, 95% CI 1.80-6.32; P < 0.01) and bypass time (OR 1.01, 95% CI 1.00-1.02; P < 0.01) were predictors of in-hospital mortality. The late era of surgery (OR 0.41, 95% CI 0.23-0.73; P < 0.01) was associated with reduced mortality risk.

CONCLUSIONS

The operative outcome in this growing surgical population is steadily improving despite the increasing prevalence of comorbidities, and surgery should be performed electively as much as possible.

Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team

Background

Although decision-making using the heart-team approach is apparently intuitive and has a class I recommendation in most recent guidelines, supportive data is still lacking. The current study aims to demonstrate the individualised clinical pathway for mitral valve disease patients and to evaluate the outcome of all patients referred to the dedicated mitral valve heart team.

Methods

All patients who were evaluated for mitral valve pathology with or without concomitant cardiac disease between 1 January 2016 and 31 December 2016 were prospectively followed and included. Patients were evaluated, and a treatment strategy was determined by the dedicated mitral valve heart team.

Results

One hundred and fifty-eight patients were included; 67 patients were treated surgically (isolated and concomitant surgery), 20 by transcatheter interventions and 71 conservatively. Surgically treated patients had a higher 30-day mortality rate (4.4%), which decreased when specified to a dedicated surgeon (1.7%) and in primary, elective cases (0%). This was also observed for major adverse events within 30 days. Residual mitral regurgitation >grade 2 was more frequent in the catheter-based intervention group (23.5%) compared to the surgical group (4.8%).

Conclusion

In conclusion, the implementation of a multidisciplinary heart team for mitral valve disease is a valuable approach for the selection of patients for different treatment modalities. Our research group will focus on a future comparative study using historical cohorts to prove the potential superiority of the dedicated multidisciplinary heart-team approach.

Degenerative Mitral Regurgitation After Nonmitral Cardiac Surgery: MitraClip Versus Surgical Reconstruction

BACKGROUND

Surgical mitral valve repair is the conventional treatment for severe degenerative mitral regurgitation (MR). MitraClip therapy has emerged as a viable option in high-risk surgical patients. We sought to compare conventional surgery to MitraClip therapy in patients with severe degenerative mitral valve prolapse (MVP) and previous cardiac interventions.

METHODS

From January 2012 to May 2016, 131 patients with previous cardiac surgery and subsequent intervention for degenerative MVP were included in this analysis: 75 (57.3%) underwent surgical repair and 56 (42.7%) underwent MitraClip placement. Follow-up was available in all early survivors at median of 11 (interquartile range, 0 to 32) months for surgery and 11 (interquartile range, 3 to 21) months for MitraClip patients.

RESULTS

MitraClip patients were older (75.7 ± 8.6 years of age versus 68.6 ± 13.1 of age; p < 0.001), and had higher Society of Thoracic Surgeons risk scores (5.8 ± 2.4 versus 2.7 ± 2.3; p < 0.001). Median length-of-stay was 7 (interquartile range, 5 to 11) days for surgery and 2 (interquartile range, 2 to 4) days for MitraClip patients (p < 0.001), but 30-day mortality was comparable between the 2 groups (2.7% versus 3.6%; p = 0.77). Recurrent MR (moderate or severe) was significantly higher for MitraClip patients, both at discharge (43.1% versus 5.4%; p < 0.001) and at 1-year follow-up (66.7% versus 33.3%; p = 0.02). At 1 year postintervention, freedom from mitral reintervention was significantly higher for surgical patients (100.0% versus 87.5%; p = 0.006).

CONCLUSIONS

In patients with previous cardiac interventions and severe degenerative MVP, a repeat conventional surgery is safe and durable. Percutaneous MitraClip repair is effective but associated with higher risk of residual MR, and should only be considered in selected patients. Careful patient selection using a heart team approach is recommended.

Comparison of Transcatheter Mitral Valve Repair Versus Surgical Mitral Valve Repair in Patients With Advanced Kidney Disease (from the National Inpatient Sample)

Transcatheter mitral valve repair (TMVR) is an emerging treatment modality that has been reserved for high-risk patients with multiple co-morbidities. We hypothesize that TMVR is a safe and effective procedure for patients with moderate to severe mitral regurgitation who are not surgical candidates. The National Inpatient Sample (2012 to 2014) using the International Classification of Diseases, 9th Revision, Clinical Modification procedure codes 35.97 for TMVR and 35.12 for surgical mitral valve repair (SMVR) were used. Patients with chronic kidney disease stage IV, Stage V, and end-stage renal disease (ESRD) were considered as patients with advanced kidney disease. A total of 2,123 patients were treated with SMVR and 74 patients were treated with TMVR. There were notably fewer patients treated with TMVR compared with patients treated with SMVR. The mean age was higher with the TMVR group (72.4 vs 61.7 years, p = <0.001). After performing multivariate regression analysis, the primary outcome of in-hospital mortality (13.8% vs 1.3%, adjusted p = 0.003) and all secondary outcomes, excluding dialysis requirement, cardiogenic shock, and cardiac arrest, were significantly lower with the TMVR approach. The average length of stay was lower with TMVR compared with SMVR (22.8 vs 12.6 days, adjusted p = <0.001), with reduced in-hospital costs ($98,165 vs $52,646, adjusted p = <0.001). This large, national study suggests TMVR is associated with significantly lower in-patient morbidity and mortality, with significant cost savings in patients with advanced kidney disease compared with SMVR. Hence, TMVR could be a safe and effective alternative for patients with advanced kidney disease who are not surgical candidates.