Target-controlled infusion during MitraClip procedures in deep-sedation with spontaneous breathing

OBJECTIVE

Percutaneous mitral valve repair with the MitraClip system is an alternative procedure for high-risk patients not suitable for conventional surgery. The MitraClip can be safely performed under general anesthesia (GA) or deep sedation (DS) with spontaneous breathing using a combination of propofol and remifentanil. This study aimed to evaluate the benefits of target-controlled infusion (TCI) of remifentanil and administration of propofol during DS compared with manual administration of total intravenous anesthesia (TIVA) medication during GA in patients undergoing MitraClip. We assessed the impact of these procedures in terms of remifentanil dose, hemodynamic profile, adverse events, and days of hospital stay after the process.

PATIENTS AND METHODS

From March 2013 to June 2015 (mean age 73.5 ± 9,54), patients underwent transcatheter MitraClip repair, 27 received DS via TCI and 27 GA with TIVA.

RESULTS

Acute procedural success was 100%. DS-TCI group, in addition to a significant reduction of remifentanil dose administrated (249 µg vs. 2865, p < 0.01), resulted in a decrease in vasopressor drugs requirement for hemodynamic adjustments (29.6% vs. 63%, p = 0.03) during the procedure and a reduction of hypotension (p = 0.08). The duration of postoperative hospitalization did not differ between the two groups (5.4 days vs. 5.8 days, p = 0.4).

CONCLUSIONS

Administration of remifentanil by TCI for DS in spontaneously breathing patients offers stable anesthesia conditions, with a lower amount of drugs, higher hemodynamic stability, and decreased side effects.

P299 Acute effects of Levosimendan on myocardial function in patients with severe mitral regurgitation and left ventricular dysfunction undergoing MitraClip repair

Background

MitraClip system has developed as a valid therapeutic option in patients affected by moderate to severe and severe mitral regurgitation, low left ventricular ejection fraction (LVEF) and high surgical risk. Often, after the procedure occurs afterload mismatch, an acute and transient worsening of LVEF. Inotropic drugs can improve hemodynamic values at the prize of severe side effects. Levosimendan increases myocardial contractility without an elevation of intracellular calcium concentration, tachyarrhythmia and cardiomyocytes necrosis.

Purpose

Aim of our study was to assess the acute Levosimendan effects on LVEF of patients who underwent MitraClip procedure

Methods

Among 160 patients who underwent MitraClip procedure in our institute, 99 patients, with LVEF ≤35%, were included in the study. Transthoracic echocardiogram was performed in all patients, at moment of hospital admission and at discharge; transesophageal echocardiogram was performed during the procedure. We recorded the LVEF by modified Simpson’s rule. Periprocedural hemodynamic parameters were also recorded. 59 patients received Levosimendan during and early after the procedure (L-group) and 40 patients did not (no-L-group). Levosimendan perfusion was started at 0.01 μg/kg/min 1 h before the procedure without a loading dose, and maintained for 12h, according to hemodynamics.

Results

In the overall population, patients suffered from a severe reduction of LVEF (29.5 ± 5.3%) and high systolic pulmonary arterial pressure (sPAP) (51 ± 14.2 mmHg), without significant difference between the two groups. Acute procedural success was achieved in 98% of the study population, with 2 procedural failures in no-L-group (p = 0.16). During the procedure we observed a significant improvement of LVEF compared to baseline values only in L-group (from 29.6 ± 5.7% to 32.1 ± 7.6%, p = 0.046); in no-L-group the LVEF improved from 29.4 ± 5% to 30.2 ± 4.9% (p = 0.47); at discharge the LVEF was 31.3 ± 4.9% and 30.8 ± 5.7%, in L-group and no-L-group, respectively (p = ns compared to baseline and procedure). At discharge the sPAP significantly reduced in the overall population to 46.3 ± 12.7 mmHg (p 0.015): from 50.8 ± 12.3 mmHg vs 48.7 ± 11.9 in L-group (p = 0.35); from 51.2 ± 16 to 44.3 ± 13.2 mmHg (p = 0.04) in no-L-group. In-hospital mortality was 1.7% in L-group (1 patient die) and 0% in no-L-group. No relevant arrhythmias were reported in any patient during the hospital recovery.

Conclusion

In MitraClip patients with severe reduction of LVEF, Levosimendan has proven to improve hemodynamic outcome, increasing myocardial contractility during and early after procedure.

P1362 Echocardiographic findings and BNP levels in patients with valve-in-valve implantation in small failed mitroflow aortic prosthesis

BACKGROUND

Early structural valve deterioration (SVD) frequently occurs in Mitroflow aortic bioprosthesis, especially for small sizes (19-mm and 21-mm), and it is associated with reduced overall survival. Treatment by percutaneous valve-in-valve (ViV) implantation is considered a challenging procedure. This is mainly due to an elevated risk of coronary ostia obstruction and high residual post-procedural mean gradients (mG), particularly when severe pre-existing patient-prosthesis mismatch (PPM) is present.

PURPOSE

Aim of our study was to assess the feasibility of transfemoral ViV in small Mitroflow aortic valves using supra-annular self-expanding valves, named CoreValve and Evolut R and Acurate neo and report the midterm clinical results by comparing serum natriuretic peptide type B levels (BNP) before the procedure and at a mean follow-up of 2 years.

METHODS

This is an observational study including 11 patients with stenotic-type SVD of small Mitroflow aortic valves, considered at high/prohibitive risk for surgical reoperation, who underwent ViV implantation between July 2012 and March 2018. We performed echocardiographic assessment of valve hemodynamics (according to VARC-2 definitions) before and after the procedure and during the follow-up. We used the BNP ratio (the ratio between measured serum BNP/NT-proBNP level and maximal normal level) to compare BNP results before the procedure and at follow-up. All-cause mortality during the hospitalization and follow-up was also reported.

RESULTS

The Mitroflow size was 19-mm in 4 patients and 21-mm in 7 patients. Pre-existing severe PPM was present in 4 patients and moderate PPM in 7. CoreValve 26 was implanted in 2 patients, EvolutR 23 in 5 and Acurate neo S in 4 patients. We reported no coronary obstruction, deaths or other major events during the hospitalization. At a mean follow-up of 2 years one patient died. The baseline aortic mG of 56 ± 19 mmHg has significantly reduced after the procedure to 16,6 ± 8 mmHg (p &lt; 0.0001) and follow-up 29,6 ± 16 mmHg (p = 0.008). A post-procedural mG≥20, but &lt;40 mmHg, was observed in 3 patients. BNP ratio at baseline was 14,6 ± 12; only one patient had a BNP ratio &lt;3. At follow-up (n = 7 patients), BNP ratio was significantly lowered to 1,5 ± 1,08 (p = 0.01) with only one patient with a BNP ratio &gt;3. Patients with mPG ≥20 mmHg did not show differences in terms of mortality and reduction of serum BNP levels.

CONCLUSIONS

In our experience the ViV procedure on small degenerated aortic Mitroflow bioprosthesis appears to be technically feasible and provides good midterm clinical results with a net reduction in serum BNP levels, although an increase in mG was observed. Even though a post-procedural mG ≥20 mmHg is considered indicative of suboptimal aortic valve hemodynamics (according to VARC-2 criteria), its correlation with worse outcomes remains unclear and deserves further investigations.

P748 Three-year echocardiographic outcomes in MitraClip patients with chronic kidney disease

Background

Chronic kidney disease (CKD) has been shown to impact negatively the prognosis of patients with heart failure, coronary artery or valvular heart disease and emerged as predictor of poor outcomes in mitraclip population.

Purpose

Aim of our study was to evaluate three-year echocardiographic outcomes in CKD patients with severe mitral regurgitation (MR) treated with mitraclip.

Methods

This in an observational study including patients treated with mitraclip in our institution, who completed three years of follow up. Patients population was divided into two groups according to basal creatinine clearance (CrCl): group A, including patients with normal/mild decline of renal function (CrCl &gt; 60 ml/min) and group B, including patients with CKD (CrCl &lt; 60 ml/min). Demographic and procedural characteristics were compared, as well as echocardiographic data, including grade of MR, left ventricular ejection fraction (LVEF), mean transmitral gradient and systolic pulmonary artery pressure (sPAP). Kaplan-Meier survival curves were obtained.

Results

The study population consists of 107 patients (mean age 71 ± 9 years, 69% male): 57 belonging to group A and 50 to group B. Patients of group B had higher values of LogEuroScore (22 ± 10 vs.15 ± 9 p = 0,0002), systemic hypertension (92% vs. 74%, p = 0,026), complicated diabetes (46% vs. 24% p = 0,034) and NYHA IV before the procedure (24% vs 9 %, p = 0,059). Additionally, patients of group B had lower baseline LVEF (35 ± 11 vs. 41 ± 13; p = 0,012). Procedural success was similar between the two groups without significant difference in degree of MR reduction after mitraclip implantation. Echocardiographic follow-up showed that in group B, the LVEF did not improve after the treatment (more than 50% had LVEF &lt; 35% at 1,2 and 3 years) while in the group A it improved significantly (LVEF &lt; 35% from 47,6% at discharge to 29%, 32% and 31% at 1, 2 and 3 years, respectively). In comparison to group A, in group B a progressive increase in residual MR grade was observed (moderate-to-severe MR from 2% at discharge to 14%, 15%, and 27% at 1, 2 and 3 years, respectively) as well as in the mean transmitral gradient (from 3,90 ±1,6 mmHg after the mitraclip implantation to 5,28 ± 1,7; 5,73 ± 1,75; 6,06 ±1,75 at 1, 2 and 3 years, respectively) and sPAP (from 47 ± 12 mmHg at discharge to 49 ± 21; 51 ± 20; 48 ± 22 at 1, 2 and 3 years, respectively). Kaplan Meier estimate of survival free from in-hospital readmission was 77% in group A and 61% in group B (Log-Rank 4.563, p = 0,033) and survival free from cardiovascular death was 95% and 81,5%, in group A and B, respectively (Log-Rank 4.806, p = 0,028).

Conclusion

Our results suggest that CKD patients have poorer outcomes after mitraclip implantation with worsening of some echocardiographic parameters, particularly for residual MR degree, mean transmitral gradient and sPAP, without improvement in LVEF at one, two and three years of follow-up.

Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study

BACKGROUND

The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined.

METHODS

Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed.

RESULTS

Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001).

CONCLUSIONS

Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.