Mitral regurgitation severity assessment after percutaneous edge-to-edge mitral valve repair: guidelines-recommended integration versus volumetric assessment

Background

Percutaneous edge-to edge mitral valve repair (PMVr) using the MitraClip device is a common method for treating mitral regurgitation (MR) when mitral valve operation is contra-indicated or deemed too risky. The evaluation of residual MR post PMVr is crucial for understanding the benefit and prognostic effect on patients. The common methods used today, based on color flow Doppler and the appearance of the color Doppler jet, may be misguiding because of the multiple jets created by the PMVr technique. Also, flow acceleration induced by the reduced systolic orifice may exaggerate systolic flow acceleration and thus jet area.

Purpose

We hypothesized that the guidelines-recommended method to assess MR may underestimate the effect of PMVr in reducing MR.

Methods

Patients undergoing PMVr in a large-volume PMVr centre were recruited between 2015–2019. Post procedural MR was evaluated using the integrated qualitative approach as recommended by the guidelines. In addition, MR volume for each patient was calculated by subtracting the forward stroke volume (calculated by multiplying LVOT area with the velocity time integral of LVOT systolic flow) from the total stroke volume (using the biplane method of discs), We compared the two methods for concordance.

Results

Overall, 112 cases were enrolled. In 59% of cases, the calculated volumetric residual MR was lower than the MR assessed by the integrated method. In 25.1% of patients the grade of MR was identical in both methods. In 16.2% the MR was more severe when calculated by the volumetric method (p<0.001, Kappa measure of agreement = 0.053–0.074). The reduction in residual MR degree using the volumetric approach was mostly observed in patients classified as “moderate” by the integrated qualitative approach. When considering basic characteristics and cardiac function of the patients, we did not find any sub-group of patients in whom the tendency for this mistake was higher.

Conclusion

Because of multiple jet origins and clip-induced flow acceleration, the integrated method to assess MR severity, based mainly on color Doppler, is not ideal in patients after PMVr. In most cases, MR severity after MitraClip is over-estimated by the integrated, guideline-recommended integrative method when compared with a volumetric method. This is especially relevant for patients classified with “moderate” MR. This study suggests that quantitative methods, not based on colour Doppler, should be used to assess MR severity after PMVr

Funding Acknowledgement

Type of funding sources: None.

MitraClip therapy in patients with acute severe mitral regurgitation

Background

There is a lack of data to support the optimal management of high-risk patients with acute severe mitral regurgitation (MR). The role of the MitraClip implantation in treatment of acute severe mitral regurgitation (MR) is undetermined.

Methods

We screened all patients who underwent MitraClip implantation at the Hadassah Medical Center between October 2015 and December 2019. We evaluated immediate, 30-day and 1-year outcomes after the procedure. We evaluated patients with severe MR due to ruptured cord because of degenerative disease and acute-on-chronic functional MR due to ischemic (after a recent myocardial infarction (MI)) or non-ischemic etiology (secondary to decompensated HF).

Results

From a cohort of 151 patients, who underwent MitraClip implantation in our center, we identified 35 patients (23.2%) with acute severe mitral regurgitation (4+) and decompensated refractory heart failure. Patients' mean age was 74.15 years, 66.9% - were males. One, 2, or 3 clips were implanted. Reduction of MR from 4+ to 1+ was achieved in 34 patients (66.7%). Twenty-eight patients (80%) had acute-on-chronic severe MR and refractory heart failure including 6 cases after recent MI, other 7 patients presented with heart failure and acute severe MR secondary to ruptured cord due to degenerative disease. After MitraClip implantation, reduction of MR severity was achieved in all patients. Seven patients were withdrawn from intravenous therapy and intra-aortic balloon pump 2–3 days after the procedure. Four patients died during hospitalization, three of them due to sepsis. 30-day follow-up showed improvement of NYHA functional class and a tendency toward improvement in left ventricle systolic function with signs of reverse remodeling. Nevertheless, we observed high 30-day and 1-year mortality rate (11.4 and 23.8% respectively).

Conclusions

MitraClip therapy could be an alternative option for treatment of patients with acute and acute-on-chronic severe MR of ischemic and non-ischemic etiology.

Funding Acknowledgement

Type of funding source: None

Echocardiographic and clinical outcomes of MitraClip therapy in patients with severe mitral regurgitation

Background

MitraClip implantation improves mitral regurgitation (MR), however its impact on pulmonary hypertension (PHT) is not fully elucidated. Our hypothesis was that changes in pulmonary pressure after MitraClip implantation might predict outcomes.

Methods

We studied a cohort of 149 consecutive patients who underwent MitraClip implantation between August 2015 and September 2019. We compared echocardiographic and clinical variables between a group with not-severe PHT and a group with severe PHT according to Pulmonary artery systolic pressure (PASP) >55 mmHg.

Results

Mean age of the cohort was 73±10 years, 75% were men, and 80% had functional MR. There are no differences in baseline characteristics between the two groups. There was a significant reduction of 13.6 mmHg in PASP at the severe PHT group from 68.2±10.9 mmHg before the procedure to 54.6±14.9 after (P=0.001) compared to the absence of a significant change in the second group. This reduction was maintained in the 6 months follow-up. Although PHT is considered a poor prognostic measure, and the severe PHT group had a baseline PASP higher than the not-severe group (P<0.001), however the Kaplan Meier curve did not show any significant difference in overall survival (p=0.468), and there is also no difference in one-year survival.

Conclusions

MitraClip therapy improves PASP in patients with severe MR and severe PHT. These patients showed the same survival as patients with not-severe PHT. MitraClip is a safety and effective procedure even for patients with severe PHT, that should not be excluded.

Funding Acknowledgement

Type of funding source: None

Transcatheter embolization of renal artery aneurysm in Behçet’s disease

A 20-year-old man with Behç et’s disease presented with a ruptured renal artery aneurysm. This patient had previously had aneurysms of the coronary arteries and coronary vein thrombosis that were treated with immunosuppression. A selective transcatheter embolization of the renal artery branch was done successfully and treatment with corticosteroids and methotrexate was added. Presented here is a rare complication of Behçet’s disease, with discussion on the pathophysiology, differential diagnosis, and the advantages and disadvantages of the angiographic treatment. This paper is supplemented with a comprehensive review of the literature.

PAPP-A levels as an early marker of idiopathic preterm birth: a pilot study

OBJECTIVE

To evaluate late PAPP-A levels as predictive of preterm birth in symptomatic women.

STUDY DESIGN

Prospective cohort study of singleton gestations, 23 to 34 weeks, and symptoms of preterm labor. PAPP-A, IGF-I and IGF-III analysis were performed. Primary end point was delivery < or =7 days. Accuracy and optimally predictive PAPP-A values were based on receiver operator characteristic (ROC) curves.

RESULT

In all, 26 women (51%) delivered < or =7 days post-admission (Group 1); 25 women (49%) >7 days (Group 2). Group 1 mean PAPP-A=38 000 vs 55 333 for Group 2 (P<0.04). Group 1 mean gestational age at delivery=29 weeks vs 37 weeks for Group 2 (P<0.00014). PAPP-A level < or =30,000 mU l(-1) had highest specificity (88%), sensitivity (50%), and positive predictive (81%) and negative predictive (62%) values for delivery < or =7 days. ROC area under curve=0.703.

CONCLUSION

PAPP-A levels < or =30,000 mU l(-1) at admission was associated with increased risk for preterm birth < or =7 days, supporting active management and therapeutic approach in these women.

Transcatheter embolization of renal artery aneurysm in Behçet's disease

A 20-year-old man with Behçet's disease presented with a ruptured renal artery aneurysm. This patient had previously had aneurysms of the coronary arteries and coronary vein thrombosis that were treated with immunosuppression. A selective transcatheter embolization of the renal artery branch was done successfully and treatment with corticosteroids and methotrexate was added. Presented here is a rare complication of Behçet's disease, with discussion on the pathophysiology, differential diagnosis, and the advantages and disadvantages of the angiographic treatment. This paper is supplemented with a comprehensive review of the literature.