Echocardiography and computed tomography predictors of successful transcatheter direct annuloplasty for mitral regurgitation

Background

Secondary mitral regurgitation (SMR) is associated with adverse outcomes and the optimal treatment modality remains challenging due to extensive variety in the pathology of SMR. Percutaneous direct annuloplasty using the Cardioband system emerged as a promising treatment in selected patients. However, success predictors of this intervention and their association with prognosis remain unclear.

Purpose

To investigate the role of echocardiographic and computed tomography (CT) data in patients with SMR undergoing percutaneous direct annuloplasty.

Methods

We retrospectively analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband system for SMR at five tertiary centres in Germany and Switzerland between 2013 and 2020. Patients with procedural success (defined as postprocedural MR grade ≤2+) were compared to those with MR >2+ with respect to baseline echocardiographic data and outcome.

Results

We included 130 patients (median age 75.5 [71–79], 37% female). Most patients were severely symptomatic (NYHA class III/IV 86.9%), had a median EF of 39 (29–52) with an ischaemic etiology in 39%. Procedural success was achieved in 68%. Procedural time was 178.5 (147.5–214.5) minutes. Patients with and without procedural success differed significantly in measures of MR severity (defined as postprocedural SMR severity (grade, vena contracta (VC), effective regurgitation orifice area and regurgitation volume), annular dilatation (leaflet length, LA sphericity index at end-systole and CT-derived intercommissural distance) and leaflet tethering (tenting area, regurgitation jet direction). In multivariable analysis of echocardiographic parameters including significant measures of annular dilatation and leaflet tethering, predictors of procedural treatment success were tenting area (OR 0.54; 95% CI 0.33–0.98 per mm2, p=0.016) and central regurgitation jet direction (OR 2.96; 95% CI 1.06–8.25, p=0.038). After adding CT data in the multivariable model, intercommissural distance proved to be the most significant predictor (OR 0.96; 0.92–0.99, p=0.009), whereas VC was the only echo predictor (OR 0.84; 0.73–0.98, p=0.03).

NYHA class III/IV at last follow up was significantly different between groups, with 34.1% vs. 55.2% of patients with vs. without procedural success, respectively (p=0.04). The combined endpoint of mortality or reintervention at 1 year was significantly lower in patients with procedural success (27% vs. 63%, p=0.002), whereas the association of procedural success with 1-year mortality was of borderline significance (13% vs. 32%, p=0.05).

Conclusion

Two thirds of patients undergoing transcatheter direct annuloplasty for SMR had procedural success. Careful patient selection by assessment of mitral valve anatomy is helpful to predict procedural success, which translates into less symptom burden and better clinical outcome.

Funding Acknowledgement

Type of funding sources: None.

P6491Predictive effect of mitral annular size on persistent mitral valve dysfunction after transcatheter edge-to-edge mitral valve repair for functional mitral regurgitation

Background

In patients with functional mitral regurgitation (FMR), deformation of the mitral valve (MV) apparatus leads to deteriorating coaptation of both leaflets. The MV geometry is essential to predict procedural success of using the MitraClip™ for FMR patients. Persistent such mitral regurgitation (MR) and post-procedural mitral stenosis (MS) are parameters for an increasing mortality rate after MitraClip implantation. The anterior-to-posterior mitral annulus diameter (MAD) is simple to evaluate with a high reproducibility rate. However, the predictive effect has not been determined to date.

Purpose

We evaluated the predictive effect of baseline anterior-to-posterior MAD on persistent MV dysfunctions after MitraClip™ implantation.

Methods

We investigated the prevalence of procedural failure (MR at discharge > grade 2+) and post-procedural MS (mean transmitral gradient (mTMG) at discharge ≥6 mmHg) in a patient cohort with FMR (n=190), who underwent MitraClip™ implantation. We measured the MV apparatus geometry on mid-systole using transoesophageal echocardiography before the index procedure. The MAD was stratified by interquartile ranges (IQR) in the comparison. (≤34 mm, 35 to 37 mm, 38 to 40 mm, and ≥41 mm, respectively)

Results

The mean age was 75±9 years, and 63 patients (33%) were female. The mean left ventricular ejection fraction was 34±14%. Moderate-to-severe (3+) or severe MR (4+) were documented in all patients before the procedure. Transthoracic echocardiography at discharge revealed residual MR (>2+) in 10 patients (5%) and post-procedural MS in 13 patients (7%), in which one patient presented with both residual MR and MS.

After stratification by the IQRs of MAD, there were significant differences in body weight (p<0.001), height (p<0.001), and body surface area (p<0.001), but no significant differences in the other baseline characteristics. Notably, significant differences in the prevalence of procedural failure (p=0.004) and post-procedural MS (p=0.022) were observed among the groups. (Figure) Specifically, in the cohort with the 4th IQR (MAD ≥41 mm, n=44), procedural failure was observed in 7 patients (16%), although the prevalence was only 2% in the other IQR groups. Moreover, the cohorts with the 1st and 2nd IQR presented with higher prevalence of post-procedural MS (6 of 46 patients (13%) in the 1st IQR group, and 6 of 51 (12%) in the 2nd IQR group) than those with the 3rd and 4th IQRs. (1 of 49 patients (2%) in the 3rd IQR, and none of 44 patients in the 4th IQR)

Figure 1

Conclusion

In this analysis we showed that the mitral annulus size affected MV dysfunction after MitraClip™. Anterior-to-posterior MAD was useful to predict the procedural result. For FMR candidates with dilated mitral annulus larger than 40 mm, new-generation MitraClip-XTR™ system or other therapeutic concept such as annuloplasty may be reasonable to obtain satisfactory MV function.

[Future interventional procedures for valve diseases]

BACKGROUND

Percutaneous valve therapies represent one of the most innovative areas within interventional cardiology in the past 10 years.

AIM

The aim of this work is to give an overview of current and upcoming therapeutic options.

MATERIALS AND METHODS

In this manuscript, the results of a retro- and prospective literature research are summarized.

RESULTS AND DISCUSSION

With the introduction of percutaneous therapies for valvular heart disease, patients who were previously considered too ill for surgery can now be treated. The percutaneous treatment of aortic or mitral valve disease has become standard therapy. Likewise, promising results have been obtained for percutaneous treatment options for pathologies of the tricuspid valve, which are still under intense investigation.

Validity of ultrasonography for postoperative monitoring in pediatric urology

PURPOSE

We studied the validity of ultrasonography for short-term followup in pediatric urology.

MATERIALS AND METHODS

The study group comprised 137 children (187 urinary tracts) undergoing surgery at our hospital for congenital urological pathology between February 1982 and July 1992. The study protocol designed to evaluate urinary tract dilation postoperatively and monitor its progress, included ultrasound at discharge from the hospital, and repeat ultrasound between days 20 and 30, and days 45 and 60. Diuretic renography or excretory urography was indicated when urinary tract dilatation showed no signs of regressing or had increased on 2 consecutive evaluations. Ultrasound of the urinary tract was done to evaluate variations in the grade of dilatation of the pelves, calices, infundibula and ureters, and grade of hydronephrosis.

RESULTS

Variations in the grade of dilatation of the infundibula and ureters were early sensitive indicators of the absence of obstruction. Using this protocol only 15 of the 187 urinary tracts (8%) corrected surgically needed further evaluation for suspected iatrogenic stenosis, including 3 with obstruction that required reoperation. No other cases of obstruction were detected during long-term followup.

CONCLUSIONS

A series of sonographic evaluations performed within a short period and the greater significance attributed to more specific parameters, such as grade of dilatation of the infundibula and ureters, make ultrasound a valid means of monitoring urological cases postoperatively.

[Multiple splenic and renal abscesses caused by Candida albicans: a new diagnostic and therapeutic method using intraoperative echography and closure of the residual cavities with biological glue]

The Candida albicans infection represents a rather frequent complication in immunodeficient patients, while the evolution towards the growth of multiple intraparenchymal abscesses constitutes a very rare event. The authors describe the diagnostic-therapeutic pathway chosen in a case regarding a young patient in treatment for leukemia , who was affected by multiple splenic and renal abscesses caused by Candida albicans. After a preoperative diagnosis through ultrasonography and C.A.T., a splenectomy was undertaken. Next the only healthy part of the spleen was removed and grafted into the omentum. By using the intraoperative ultrasonography on both kidneys, the abscess cavities were precisely located, aspirated and finally stuck with a human fibrin glue.

[Hepatic hemangioma in the neonate: description of a case treated surgically with favorable outcome]

The authors describe a case of hepatic hemangioma in a newborn, treated by successful surgical resection. Neonatal hepatic hemangioma is able to produce congestive heart failure with high output, thrombocitopenia, spontaneous rupture with peritoneal hemorrhage and sudden death. The major symptoms are a palpable anterior abdominal mass, tachicardia, and congestive heart failure unrespansive to medical treatments; sometimes there are cutaneus hemangiomas. When diagnosis is made, surgical resection is necessary in the solitar hemangioma; for diffuse or multinodular hemangiomatosis radiotherapy, corticosteroids and hepaticartery ligation have been employed with some good results.