Global Longitudinal Strain Predicts Outcomes in Patients with Reduced Left Ventricular Function Undergoing Transcatheter Edge-to-Edge Mitral Repair

BACKGROUND

The timing and selection of optimal candidates for mitral transcatheter edge-to-edge valve repair remains to be fully determined, especially in cases with severely depressed left ventricular ejection fraction (LVEF). The objective of this study is to evaluate the prognostic value of myocardial strain (LVGLS) in this setting.

METHODS

Retrospectively, 172 consecutive patients with LVEF ≤40% and severe MR treated with MitraClip were included. Four groups were generated according to the LVEF (<30% or ≥30%) and median LVGLS. The primary end-point was cardiovascular mortality.

RESULTS

Procedural success was high (96.5%) and complications were rare. At one-year follow-up, 82.5% of patients maintained MR grade ≤2, 79.2% were at a NYHA class ≤II and a reduction of 80% in heart failure admissions was observed in all groups. Interestingly, among patients with a more depressed LVEF, LVGLS was found to be an independent predictor for cardiovascular mortality (HR: 3.3; 95% CI: 1.1-10, p = 0.023).

CONCLUSIONS

Mitral valve repair with MitraClip is safe and it improves the mid-term functional class of patients regardless of LVEF. LVGLS can help in the selection of optimal candidates and timing for this procedure, as well as in the recognition of those patients with worse prognoses.

Temporal trend and potential impact of angiotensin receptor neprilysin inhibitors on transcatheter edge-to-edge mitral valve repair

INTRODUCTION AND OBJECTIVES

Transcatheter edge-to-edge repair (TEER) should be considered in patients with heart failure and secondary mitral regurgitation (MR). Angiotensin receptor-neprilysin inhibitors (ARNIs) have been demonstrated to improve prognosis in heart failure. We aimed to evaluate the impact ARNIs on patient selection and outcomes.

METHODS

The population of the Spanish TEER prospective registry (March 2012 to January 2021) was divided into 2 groups: a) TEER before the ARNI era (n=450) and b) TEER after the recommendation of ARNIs by European Guidelines (n=639), with further analysis according to intake (n=52) or not (n=587) of ARNIs.

RESULTS

A total of 1089 consecutive patients underwent TEER for secondary MR. In the ARNI era, there was a reduction in left ventricle dilation (82mL vs 100mL, P=.025), and better function (35% vs 38%, P=.011). At 2 years of follow-up, mortality (10.6% vs 17.3%, P <.001) and heart failure readmissions (16.6% vs 27.8%, P <.001) were lower in the ARNI era, but not recurrent MR. In the ARNI era, 1- and 2-year mortality were similar irrespective of ARNI intake but patients on ARNIs had a lower risk of readmission+mortality at 2 years (OR, 0.369; 95%CI, 0.137-0.992; P=.048), better NYHA class, and lower recurrence of MR III-IV (1.9% vs 14.3%, P=.011).

CONCLUSIONS

Better patient selection for TEER has been achieved in the last few years with a parallel improvement in outcomes. The use of ARNIs was associated with a significant reduction in overall events, better NYHA class, and lower MR recurrence.

Ventricular arrhythmias in patients with functional mitral regurgitation and implantable cardiac devices: implications of mitral valve repair with Mitraclip®

Background

Limited information has been reported regarding the impact of percutaneous mitral valve repair (PMVR) on ventricular arrhythmic (VA) burden. The aim of this study was to address the incidence of VA and appropriate antitachycardia implantable cardiac defibrillator (ICD) therapies before and after PMVR.

Methods

We retrospectively analyzed all consecutive patients with heart failure with reduce left ventricular ejection fraction (LVEF), functional mitral regurgitation (FMR) grade 3+ or 4+ and an active ICD or cardiac resynchronizer who underwent PMVR in any of the eleven recruiting centers. Only patients with complete available device VA monitoring from one-year before to one year after PMVR were included. Baseline clinical and echocardiographic characteristics were collected before PMVR and at 12-months follow-up.

Results

Ninety-three patients (68.2±10.9 years old, male 88.2%) were enrolled. PMVR was successfully performed in all patients and device success at discharge was 91.4%. At 12-month follow-up, we observed a significant reduction in mitral regurgitation severity, NT-proBNP and prevalence of severe pulmonary hypertension and severe kidney disease. Patients also referred a significant improvement in NYHA functional class and showed a non-significant trend to reserve left ventricular remodeling. After PMVR a significant decrease in the incidence of non-sustained ventricular tachycardia (VT) (5.0±17.8 vs. 2.7±13.5, P=0.002), sustained VT or ventricular fibrillation (0.9±2.5 vs. 0.5±2.9, P=0.012) and ICD antitachycardia therapies (2.5±12.0 vs. 0.9±5.0, P=0.033) were observed.

Conclusions

PMVR was related to a reduction in arrhythmic burden and ICD therapies in our cohort.

Previously diagnosed cancer and mortality after ST-segment elevation acute myocardial infarction treated with primary angioplasty

OBJECTIVE

We investigated if a previous cancer diagnosis influences the outcome of patients with STEMI treated with primary coronary intervention (PCI).

BACKGROUND

ST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both have a high incidence and prevalence.

METHODS

Prospective cohort observational study, The primary end-point was total mortality.

RESULTS

We included 917 patients, 53 of them (5.8%) were cancer survivors. During follow-up (median, 643 days [interquartile range, 258 to 1,015 days]), 100 patients died, 88 (10.2%) patients without a cancer diagnosis and 12 (22.6%) patients with a previous cancer diagnosis, which was significantly different (log-rank test = 8.4, p = .004). Cancer patients were older (73.4 (11.5) vs. 65.2 (13.8) years, p < .001), with a lower prevalence of previous stroke (1.1% vs. 2.2%, p = .002). Their hemoglobin concentration was also lower (13.4 (2.1) vs. 14.4 (1.7) g/L, p = .001). A trend towards a lower use of coronary stents in cancer survivors was noted (p = .061). Cancer was associated with a high probability of death (HR = 2.37, 95% confidence interval [CI] 1.30-4.34, p = .005). When confounding variables were included, this association was no longer significant (HR = 1.63, 95% CI 0.84-3.18, p = .150).

CONCLUSIONS

Patients with a previous cancer diagnosis who had an acute STEMI treated by primary PCI did not seem to have a worse prognosis. The difference in the crude mortality rate can be explained by the baseline differences between both groups. Previous cancer diagnosis should not be included in the clinical decision process when a patient is having an acute STEMI.

Scaling Echocardiographic Cardiac Dimensions to Body Size: A Bayesian Analysis in Healthy Men and Women

BACKGROUND

Proper scaling of cardiac dimensions is of paramount importance in making correct decisions in clinical cardiology. The usual normalization of cardiac dimensions to overall body size assumes an isometric relationship. We sought to investigate these relationships to obtain the best allometric coefficient (AC) for scaling.

METHODS

Ninety-seven healthy volunteers were included. The dimensions to be scaled were the left atrial volume, the end-diastolic and end-systolic left ventricular volumes, and the diameter of the tricuspid annulus. A Bayesian statistical analysis was applied with isometric coefficients as priors.

RESULTS

The linear correlations between cardiac dimensions and body size were modest, ranging from 0.12 (-0.10–0.32) for the left atrial volume and height to 0.70 (0.58–0.80) for the end-diastolic volume and height. The ACs varied across the different cardiac dimensions and body size measurements. For the best linear relationships, the isometric coefficients were outside the 95% highest density interval of the posterior distribution for the left atrial volume-weight (AC: 0.7; 0.4–0.9) and end-diastolic volume-height (AC: 2.3; 1.7–2.9), whereas they were different from 1 for the left atrial volume-weight, end-diastolic volume, and diameter of the tricuspid annulus-body surface area (AC: 0.6; 0.3–0.8). Not scaling the cardiac dimensions to their corresponding ACs can lead to important errors in size estimations of cardiac structure.

CONCLUSIONS

The ACs found in this study are somewhat different from the corresponding isometric coefficients and often different from 1. This finding should be considered when normalizing cardiac structures to body size when making clinical decisions.

Percutaneous Mitral Valve Repair Vs. Stand-Alone Medical Therapy in Patients with Functional Mitral Regurgitation and Heart Failure

BACKGROUND

Functional mitral regurgitation (FMR) is a common finding among patients with heart failure (HF) and it is related to adverse events. Outcomes in patients undergoing transcatheter mitral valve repair (TMVR) are still a matter of debate. We performed a meta-analysis to assess mid- and long-term outcomes of patients with FMR treated with MitraClip® compared to medical management.

METHODS

We conducted an electronic database search of all published data PubMed Central, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases. The primary end-point was all-cause mortality. The secondary end-points were hospitalizations for HF, need for heart transplantation or left ventricular assist device, unplanned mitral valve surgery, myocardial infarction and stroke.

RESULTS

Five studies (n = 1513 patients) were included in the analysis. The summary estimate including all the available studies showed a statistically significant reduction in all-cause mortality favoring MitraClip® (HR 0.56, CI 95% [0.38-0.84]) and HF hospitalizations (HR 0.65; CI 95% [0.46-0.92]). A significant reduction in the indication for advanced HF therapies (OR 0.48; CI 95% [0.25-0.90]) or the need for unplanned mitral valve surgery (OR 0.20; CI 95% [0.07-0.57]) was also found in the group of patients that underwent TMVR. No differences in the incidence of myocardial infarction or stroke were found between both groups of treatment. No publication bias was detected.

CONCLUSION

TMVR with MitraClip® system was related to a significant reduction in all-cause mortality, hospitalizations for HF and the need for HF transplant, left ventricular assist device or unplanned surgery beyond 1-year follow up.

Survival Advantage of MitraClip® Over Medical Treatment in Patients with Mitral Regurgitation: A Meta-Analysis

BACKGROUND

The MitraClip® system is a percutaneous treatment for mitral regurgitation (MR) that has shown promising results in patients who are inoperable or at high risk for mitral surgery. Data on the efficacy of the system over optimal medical therapy, above all in patients with functional MR, are scarce. The study aim was to assess the effect of MitraClip on the survival of patients with moderate/severe or severe MR compared to medical therapy, using meta-analytical techniques.

METHODS

Independently, reviewers searched electronically for relevant articles based on predefined criteria and end-points. Only articles with a comparison between MitraClip and conservative therapy were included. Standard meta-analysis techniques were used. The primary outcomes were 30-day and one-year mortalities.

RESULTS

Five observational reports were included that enrolled a total of 1,271 patients: 720 patients underwent percutaneous mitral valve repair (PMVR) with the MitraClip device, and 551 were managed conservatively. A total of 49 all-cause mortality events was reported at 30 days: 3.05% (22/720) in the PMVR arm, and 4.90% (27/510) in the conservative group, with no significant differences in all-cause mortality (OR 0.64; 95% CI 0.36-1.14). A total of 269 all-cause mortality events at one year was reported: 15.14% (109/720) in the PMVR arm, and 29.04% (160/551) in the conservative group. A significant difference favoring PMVR with the MitraClip system over medical therapy alone was observed (OR 0.44; 95% CI 0.30-0.64, p <0.0001). Neither significance between study heterogeneity (p = 0.18) nor publication bias was detected (p = 0.3).

CONCLUSIONS

PMVR with the MitraClip system may be associated with an improvement in one-year survival compared to stand-alone medical management.

Trileaflet Mitral Valve Treated with the MitraClip® System

A 79-year-old woman with a history of ischemic dilated cardiomyopathy, severely depressed left ventricular ejection fraction and significant mitral regurgitation (MR) was admitted to the authors´ institution for percutaneous mitral valve repair. Transesophageal echocardiography (TEE) revealed the presence of a posterior mitral cleft at the P2 level, causing a trileaflet mitral valve that contributed significantly to the regurgitant jet. The procedure was performed under general anesthesia and guided by real-time three-dimensional TEE. Three MitraClip® devices (Abbott Vascular, Santa Clara, CA, USA) were implanted, which reduced the MR to grade 1+.

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II)

Background:

Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area.

Methods:

From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22–92), 443 type A (70.4%) and 186 type B (29.6%).

Results:

Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th–75th percentiles, 2.7–15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1–3, 2.5–11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment.

Conclusion:

Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.

A Simple Technique for Aortic Root Dissection and Massive Aortic Regurgitation Repair after Blunt Chest Trauma

Aortic regurgitation due to valve injury after blunt chest trauma is a rare condition that may be caused by leaflet or commissural rupture, aortic dissection, or a combination of both. The case is presented of a 48-year-old male patient with an aortic dissection and aortic valve commissural detachment and massive aortic regurgitation after a 12-meter vertical free fall and secondary thoracic blunt trauma. The aortic root tear and dissection was repaired with a continuous polypropylene 5/0 suture and subcommissural annuloplasty that restored the aortic valve geometry and resulted in a normally functioning aortic valve.

Third CoreValve™ insertion for treatment of a severe paravalvular leak after a failed valve-in-valve procedure

An 83-year-old high-risk gentleman diagnosed with severe symptomatic aortic stenosis was scheduled for TAVR. A 31 mm CoreValve was implanted but severe paravalvular leak was noted. A valve-in-valve procedure was performed. However, the valve frame was partially dislodged into de ascending aorta. We report our strategy to solve this severe leak after a failed valve-in-valve procedure.

Contribution of right ventricular dysfunction to heart failure mortality: a meta-analysis

Right ventricular systolic dysfunction (RVSD) has been related to prognosis in patients with heart failure (HF) and/or left ventricular systolic dysfunction. However, most of the studies addressing this issue are not large enough, have different inclusion criteria, and use different methods to evaluate RV function to draw definite conclusions. We sought to investigate the association between RVSD and outcomes in patients with left ventricular dysfunction. Eleven studies of 40 (27.5%), with 4732 patients, were included in the meta-analysis. RVSD was present in 2234 patients (47.2%). Four of the studies had admission for HF as an endpoint. We found a significant association between RVSD and overall mortality with significant between-studies heterogeneity and presence of publication bias (funnel plot). A significant association was found between RVSD and admission for HF. RVSD is associated with overall mortality and admission for HF during follow-up. Significant between-studies heterogeneity and publication bias must be taken into account when interpreting this information.

Emergency Nontraumatic Chest Pain: Use of Stress Echocardiography to Detect Significant Coronary Artery Stenosis

OBJECTIVE

We sought to assess the usefulness of stress echocardiography in a chest pain department.

METHODS

Consecutive patients (n = 487) with nontraumatic chest pain, with no signs of myocardial ischemia on arrival to the emergency department, 6 and 12 hours later, were recruited.

RESULTS

The sensitivity and specificity of stress echocardiography in the biased sample were 74% (95% confidence interval [CI] 63-85%) and 65% (95% CI 44-86%). After application of the method of Begg and Greenes to debias the sample, the calculated sensitivity was 24% (95% CI 19-29%) and specificity was 94% (95% CI 91-97%). After application of Diamond's method, sensitivity was 32% (95% CI 21-44%) and specificity (normalcy rate) was 99% (95% CI 88-100%).

CONCLUSIONS

Stress echocardiography is an insensitive test when used to detect significant coronary artery stenosis in patients presenting with nontraumatic chest pain with no objective signs of myocardial ischemia.

Preinfarction angina limits myocardial infarction size in nondiabetic patients treated with primary coronary angioplasty

OBJECTIVE

To evaluate myocardial necrosis extent after myocardial infarction (MI) and reperfusion with primary coronary angioplasty in nondiabetic patients and the relationship with unstable preinfarction angina (PA).

DESIGN

Prospective cohort study.

SETTING

Studies suggest PA limits infarct size. This effect is questioned in patients treated with primary coronary angioplasty.

PATIENTS

Seventy-eight, nondiabetic, consecutive MI patients.

INTERVENTIONS

Primary coronary angioplasty and scintigraphic study to assess the myocardial infarct size.

MAIN OUTCOME MEASURES

Scintigraphic myocardial infarct size.

RESULTS

There were 32 patients with PA (PA +) and 46 without PA (PA -) in the 24-h period prior to MI onset. There were no significant differences in the baseline characteristics between the two groups. The scintigraphy indicated myocardial infarct size significantly smaller in PA + patients: mean, 18.0% (SD, 14.7) vs 27.0% (SD, 20.1) [p = 0.033]. This occurs even though Thrombolysis in Myocardial Infarction grade 3 flow achieved in both groups was similar (84.8% vs 84.4%, p = 1.000). We found a higher percentage of ST-segment resolution (>/= 70%) in PA + patients (65.6% vs 45.7%, p = 0.082) together with a lower incidence of left ventricular systolic dysfunction (3.2% vs 18.6%, p = 0.071).

CONCLUSIONS

PA exerts a beneficial effect in nondiabetic patients with ST-segment elevation acute MI even when treated with primary PCI. The infarct size is limited, and left ventricular systolic function is preserved. The effects may be related to a better preservation of tissue reperfusion in patients with PA.

[Tricuspid stenosis after pacemaker implantation without evidence of bacterial endocarditis. A case report]

Tricuspid stenosis related to endocardial pacemaker leads is uncommon. We report the case of a patient with severe tricuspid stenosis documented 15 years after the implantation of a permanent DDD pacemaker for symptomatic congenital heart block. The atrial and ventricular leads both had a loop at the level of the tricuspid valve that may have caused endothelial damage and, eventually, tricuspid stenosis.

Pre-infarction angina elicits greater myocardial viability on reperfusion after myocardial infarction: a dobutamine stress echocardiographic study

OBJECTIVES

We sought to evaluate myocardial viability (inotropic reserve) after myocardial infarction (MI) and its relationship with the presence of unstable pre-infarction angina (PIA).

BACKGROUND

Several studies have suggested that PIA can limit infarct size, but it is not known whether PIA can elicit myocardial viability after an acute MI, with left ventricular function improvement.

METHODS

Before discharge from the hospital, 91 patients with a reperfused MI (either fibrinolysis or primary coronary angioplasty) had low-dose dobutamine echocardiography performed to assess the myocardial inotropic reserve of the infarct-related area.

RESULTS

Twenty-nine patients (31.9%) had PIA in the 24-h period before the onset of MI. Nine patients were treated with primary coronary angioplasty: five (8.1%) in the group with PIA and four (13.8%) in the group without PIA. There were no other significant differences in the baseline characteristics of the patients. There were more viable segments in patients with PIA (44.9% vs. 30.7%, p = 0.007), and the number of patients with significant viability was higher in the PIA group (73.9% vs. 46.3%, p = 0.026). This occurred despite a similar number of segments with segmental wall abnormalities at baseline in both groups (46.1% vs. 46.9%, p = NS).

CONCLUSIONS

The presence of previous unstable PIA induces greater myocardial viability of the infarct-related area upon reperfusion and, as such, could have considerable therapeutic and clinical implications.

[Antiphospholipid syndrome and cardiovascular disease]

Recurrent thrombosis, abortion and thrombocytopenia are the most frequent manifestation of antiphospholipid syndrome, which usually presents antibodies against some anionic phospholipids. A few years ago, this syndrome was considered as a manifestation of systemic lupus erythematosus; nowadays it is classified as an isolated systemic lupus erythematosus; nowadays it is classified as an isolated autoimmune disease. Hypotheses have been proposed to explain the origin of antiphospholipid antibodies, including infectious and autoimmune diseases with high titles of anticardiolipin antibodies. Genetic factors have also been involved. Laboratory tests of choice for the detection of anticardiolipin antibodies are RIA and ELISA tests; there are some structural differences among them depending on the underlying disease. Hypercoagulability and recurrent thrombosis are the main features of this entity; ischemic heart disease is in this context of outmost importance. Despite the lack of any clinically demonstrated association between antiphospholipid syndrome and ischemic heart disease, there are many "in vitro" studies that support this possibility.