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Jansen R, Urgel K, Cramer MJ, van Aarnhem EEHL, Zwetsloot PPM, Doevendans PA, Kluin J, Chamuleau SAJ. Reference Values for Physical Stress Echocardiography in Asymptomatic Patients after Mitral Valve Repair. Front Surg 2018. [PMID: 29516004 PMCID: PMC5826059 DOI: 10.3389/fsurg.2018.00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Clinical decision-making in symptomatic patients after mitral valve (MV) repair remains challenging as echocardiographic reference values are lacking. In native MV disease intervention is recommended for mean transmitral pressure gradient (TPG) >15 mmHg or systolic pulmonary artery pressure (SPAP) >60 mmHg at peak exercise. Insight into standard stress echo parameters after MV repair may therefore aid to clinical decision-making during follow-up. Hypothesis Stress echocardiography derived parameters in asymptomatic patients after successful MV repair differ from current guidelines for native valves. Material and methods In 25 patients (NYHA I) after MV repair stress echocardiography was performed on a semi-supine bicycle. Doppler flow records and MV related hemodynamics at rest and peak were obtained. Linear regression analysis was performed for mean TPG and SPAP at peak, using predetermined variables and confounders. Results Mean TPG at rest (3.2 ± 1.4 mmHg) significantly increased at peak (15.0 ± 3.4 mmHg) but was always <25 mmHg. Mean SPAP at rest (21.4 ± 3.8 mmHg) significantly increased at peak (41.8 ± 8.9 mmHg) but was never >57 mmHg. Only the indexed MV ring diameter was inversely correlated to mean TPG at peak in a multivariable model. Conclusion In contrast to current recommendations in native MV disease, our data indicate that the standard value for mean TPG during stress echocardiography in asymptomatic patients after successful MV repair was above the guideline threshold of 15 mmHg in >50%, but always <25 mmHg. For SPAP, patients never reached the guideline cutoff (60 mmHg). Long-term follow-up data are needed to provide insight in clinical consequences. Baseline stress echocardiography may indicate individual reference values to compare with during follow-up. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02371863?term=chamuleau+AND+Mitral&rank=1.
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Affiliation(s)
- Rosemarijn Jansen
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Kim Urgel
- Department of Cardiology, St Antonius Hospital Woerden, Woerden, Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Peter P M Zwetsloot
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
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Jeyhani M, Shahriari S, Labrosse M. Experimental Investigation of Left Ventricular Flow Patterns After Percutaneous Edge-to-Edge Mitral Valve Repair. Artif Organs 2017; 42:516-524. [DOI: 10.1111/aor.13020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/07/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Morteza Jeyhani
- Department of Mechanical and Industrial Engineering; Ryerson University; Toronto Ontario Canada
- Department of Mechanical and Industrial Engineering; Concordia University; Montreal Quebec Canada
| | - Shahrokh Shahriari
- Department of Mechanical and Industrial Engineering; University of Toronto; Toronto Ontario Canada
| | - Michel Labrosse
- Department of Mechanical Engineering; University of Ottawa; Ottawa Ontario Canada
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Paranskaya L, D'Ancona G, Bozdag-Turan I, Kische S, Akin I, Turan GR, Ortak J, Schuetz J, Nienaber CA, Ince H. Mitral valve repair using multiple MitraClips®: a dobutamine stress echocardiography evaluation. EUROINTERVENTION 2013; 8:1372-8. [PMID: 23360653 DOI: 10.4244/eijv8i12a210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The haemodynamic effect of mitral valve (MV) repair using multiple MitraClips® (MC) has not been investigated. The aim of the study was to evaluate the stress performance of MV repair with MC. METHODS AND RESULTS Twenty consecutive patients (77±7 years, 13 men [65%]) after implantation of >2 MitraClips® were subsequently evaluated with dobutamine stress echocardiography (DSE). After MC implantation, mean transmitral pressure gradient (TPG) (3.3±0.8 mmHg vs. 4.0±0.6 mmHg; p<0.001) and mitral valve orifice area (2.9±0.3 cm2 vs. 3.9±0.4 cm2; p<0.001) were significantly increased during DSE showing a physiological behaviour effect of the MV. LVEF (41±18% vs. 46±21%; p<0.001) and systolic pulmonary artery pressure (42±11 mmHg vs. 44±12 mmHg; p=0.014) increased significantly. The degree of MR was stable during stress (p=0.68). At linear regression, only baseline peak TPG was related to stress mean TPG (p<0.001; Beta 0.816; 95% CI: 0.368-0.918). CONCLUSIONS MV repair using MitraClips® should be performed with the aim of maximal reduction of MR degree. MV repair using MC may not lead to pathological degrees of MV stenosis. Although the TPG is significantly increased during stress, it never reaches pathological levels and is always accompanied by a significant increase in MVOA. The degree of residual MR remains unchanged during maximal pharmacological stress.
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Mitral inflow patterns after MitraClip implantation at rest and during exercise. J Am Soc Echocardiogr 2013; 27:24-31.e1. [PMID: 24161483 DOI: 10.1016/j.echo.2013.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND MitraClip implantation reduces mitral regurgitation effectively but decreases mitral valve area, creating iatrogenic mitral stenosis. Evaluation with transesophageal echocardiography intraprocedurally is necessary to measure mitral regurgitation and mitral valve pressure gradient (MVPG) to determine whether it is necessary and safe to place more clips. The aim of this study was to investigate whether these intraprocedural hemodynamics represent postprocedural measurements and whether exercise is affected by the stenosis. METHODS In this retrospective single-center study, 51 patients who underwent MitraClip implantation were included. Measurements were performed intraprocedurally using transesophageal echocardiography and postprocedurally using transthoracic echocardiography. In 23 of these patients, exercise echocardiography was performed at follow-up. RESULTS Intraprocedural mean MVPG was 3.0 ± 1.6 mm Hg and increased to 4.3 ± 2.2 mm Hg postprocedurally (P < .001). During exercise, mean MVPG increased significantly compared with rest conditions (from 3.6 ± 1.7 to 6.3 ± 2.7 mm Hg, P < .001). Six patients had mean resting MVPGs ≥ 5 mm Hg at follow-up and had higher systolic pulmonary artery pressure (sPAPs) than patients with mean MVPGs < 5 mm Hg (47 ± 7 vs 35 ± 12 mm Hg, P = .035). Higher MVPG and sPAP did not lead to more symptoms of heart failure. Receiver operating characteristic curve analysis showed an estimated cutoff point for intraprocedural pressure half-time of 91 msec to identify patients with mitral stenosis and sPAP ≥ 50 mm Hg postprocedurally. CONCLUSIONS Mean MVPG during MitraClip implantation measured by TEE underestimates the hemodynamics in daily life, of which operators should be aware when deciding on placing one or more clips. Pressure half-time seems to be the most robust parameter compared with mean and maximum MVPG and may contribute to this decision. Patients with higher mean MVPGs after MitraClip implantation have higher sPAPs at follow-up. However, more symptoms of heart failure were not detected at follow-up.
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Kische S, Nienaber C, Ince H. Use of four MitraClip devices in a patient with ischemic cardiomyopathy and mitral regurgitation: "zipping by clipping". Catheter Cardiovasc Interv 2012; 80:1007-13. [PMID: 22120912 DOI: 10.1002/ccd.23431] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 10/10/2011] [Indexed: 01/13/2023]
Abstract
Severe mitral regurgitation (MR) as a consequence of underlying left ventricular dysfunction substantially contributes to morbidity and mortality. A variety of percutaneous treatment options for mitral valve repair have been developed; however, most of these techniques are still at an early stage of clinical evaluation. Today, percutaneous edge-to-edge mitral valve repair using the MitraClip® system is the only endovascular approach that demonstrated noninferiority when compared with standard surgical repair in a randomized trial. However, a considerable number of patients with functional MR will present with extensive annulus dilatation and minimal vertical leaflet coaptation that potentially preclude them from this beneficial technology for anatomical reasons. In this report, we portray a 72-year-old man presenting with end-stage systolic heart failure and severe functional MR as a consequence of long-standing coronary artery disease. Recently, his clinical course was complicated by intractable hemodynamic instability and recurrent pulmonary edema. High predicted mortality and progressive physical decay rendered this moribund patient a candidate for salvage percutaneous mitral valve repair. During the endovascular procedure, a central systolic coaptation gap of 7 mm proved to be too wide for adequate simultaneous grasping of both leaflets. Consideration was given to an alternative approach by means of our novel "zipping technique." Through the trans-septal route, medial to lateral approximation of the tethered leaflets was successfully achieved by intentional deployment of four MitraClip® devices. With the first in-human application of four mechanical implants, a profound reduction of MR grade has been accomplished by the creation of a lateral neo-orifice with apparent acute clinical success. However, it needs to be determined whether successful application of the zipping technique leads to sustained reverse ventricular remodeling and will translate into an improved long-term prognosis.
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Affiliation(s)
- Stephan Kische
- Medical Faculty, Department of Cardiology at the University Hospital Rostock, Rostock School of Medicine, Rostock, Germany
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Herrmann HC, Kar S, Siegel R, Fail P, Loghin C, Lim S, Hahn R, Rogers JH, Bommer WJ, Wang A, Berke A, Lerakis S, Kramer P, Wong SC, Foster E, Glower D, Feldman T. Effect of percutaneous mitral repair with the MitraClip device on mitral valve area and gradient. EUROINTERVENTION 2009; 4:437-42. [PMID: 19284064 DOI: 10.4244/eijv4i4a76] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Percutaneous repair of mitral regurgitation (MR) by leaflet apposition using a clip deployed via transseptal catheterisation is undergoing evaluation. METHODS AND RESULTS In order to detect the potential for clinically significant left ventricular inflow obstruction after percutaneous repair, we measured mitral valve area (MVA) and mean transmitral gradient (MVG) echocardiographically in 96 patients implanted with a clip followed for up to 24 months. By planimetry, the mean MVA decreased from 6.0 +/- 1.3 cm2 to 3.6 +/- 1.2 cm2 (p < 0.05) (range 1.9 to 7.6 cm2) after clip placement, and remained unchanged after 24 months of follow-up (3.5 +/- 0.8 cm2). The mean MVG increased after clip placement from 1.7 +/- 0.9 mmHg to 4.1 +/- 2.2 mmHg (p < 0.05), and did not increase further to 24 months (3.8 +/- 1.9 mmHg). There were no differences in MVA or MVG between patients who received 1-clip (69%) and those receiving 2-clips (31%). Patients with functional MR (23%) had a slightly smaller MVA, both at baseline and after clip placement, but did not differ from degenerative MR patients at later follow-up. After 2 years of follow-up, no patient required surgery for LV inflow obstruction. CONCLUSIONS Mitral repair with the MitraClip device for MR decreases MVA without significant mitral obstruction. After 2 years of follow-up, no patient required surgery for LV inflow obstruction, and these results were not influenced by the use of more than 1 clip or the aetiology of MR.
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Affiliation(s)
- Howard C Herrmann
- Interventional Cardiology and Cardiac Catheterization Laboratories, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9038 Gates Building, Philadelphia, PA 19104, USA.
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Minardi G, Manzara C, Pulignano G, Luzi G, Maselli D, Casali G, Musumeci F. Rest and Dobutamine stress echocardiography in the evaluation of mid-term results of mitral valve repair in Barlow's disease. Cardiovasc Ultrasound 2007; 5:17. [PMID: 17386112 PMCID: PMC1845153 DOI: 10.1186/1476-7120-5-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 03/26/2007] [Indexed: 11/10/2022] Open
Abstract
Background Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up. Methods and Results Twenty patients selected for the study (12 men and 8 women, mean age 60 ± 9 years) underwent pre- and post-operative transthoracic echocardiography (TTE) and intra-operative transesophageal echocardiography (TEE). At mid-term follow-up (20 ± 5 months) all patients underwent rest TTE and DSE (3 min. dose increments up to 40 microg/Kg/min protocol). Pre-discharge and one-month TTE showed absence of MR in 11 pts., trivial or mild MR in 9 pts. and normal mitral valve area and gradients. Mid-term TTE showed decrease in left atrial and ventricular dimension, in pulmonary artery pressure (sPAP) and grade of MR. During DSE a significant increase in mitral valve area, maximum and mean gradients, sPAP, heart rate and cardiac output and a decrease in systolic annular diameter and left ventricular volume were found; in 6 pts. a transient left ventricular outflow tract obstruction was observed. Conclusion Basal and Dobutamine stress echocardiography proved to be valuable tools for evaluation of mid-term results of mitral valve repair. In our study population, the surgical technique employed had a favourable impact on several cardiac parameters, evaluated by these methods.
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Affiliation(s)
- Giovanni Minardi
- Division of Cardiology, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Carla Manzara
- Division of Cardiology, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Giovanni Pulignano
- Division of Cardiology, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Giampaolo Luzi
- Division of Cardiovascular Surgery, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Daniele Maselli
- Division of Cardiovascular Surgery, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Giovanni Casali
- Division of Cardiovascular Surgery, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Francesco Musumeci
- Division of Cardiovascular Surgery, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
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Herrmann HC, Rohatgi S, Wasserman HS, Block P, Gray W, Hamilton A, Zunamon A, Homma S, Di Tullio MR, Kraybill K, Merlino J, Martin R, Rodriguez L, Stewart WJ, Whitlow P, Wiegers SE, Silvestry FE, Foster E, Feldman T. Mitral valve hemodynamic effects of percutaneous edge-to-edge repair with the MitraClip™ device for mitral regurgitation. Catheter Cardiovasc Interv 2006; 68:821-8. [PMID: 17080467 DOI: 10.1002/ccd.20917] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The Endovascular Valve Edge-to-Edge REpair STudies (EVEREST) are investigating a percutaneous technique for edge-to-edge mitral valve repair with a repositionable clip. The effects on the mitral valve gradient (MVG) and mitral valve area (MVA) are not known. METHODS Twenty seven patients with moderate to severe or severe mitral regurgitation (MR) were enrolled. Echocardiography was performed preprocedure, at discharge, and at 1, 6, and 12 months. Mean MVG was measured by Doppler and MVA by planimetry and pressure half-time, and evaluated in a central core laboratory. Pre- and postclip deployment, simultaneous left atrial/pulmonary capillary wedge and left ventricular pressures were obtained in eight patients. RESULTS Three patients did not receive a clip, six patients had their clip(s) explanted by 6 months (none for mitral stenosis), and four were repaired with two clips. Results are notable for a slight increase in mean MVG by Doppler postclip deployment (1.79 +/- 0.89 to 3.31 +/- 2.09 mm Hg, P < 0.01) and an expected decrease in MVA by planimetry (6.49 +/- 1.61 to 4.46 +/- 2.14 cm(2), P < 0.001) and by pressure half time (4.35 +/- 0.98 to 3.01 +/- 1.42 cm(2), P < 0.05). There were no significant changes in hemodynamic parameters postclip deployment by direct pressure measurements. There was no change in MVA by planimetry from discharge to 12 months (3.90 +/- 1.90 to 3.79 +/- 1.54 cm(2), P = 0.78). CONCLUSIONS Echocardiographic and hemodynamic measurements after percutaneous mitral valve repair with the MitraClip show an expected decrease in mitral valve area with no evidence of clinically significant mitral stenosis either immediately after clip deployment or after 12 months of follow-up.
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Affiliation(s)
- Howard C Herrmann
- Cardiac Catheterization Laboratories, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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