'Just the two of us': single-operator interventional left atrial appendage closure-a case report

Background

Different procedural strategies have been published targeting to facilitate transcatheter left atrial appendage closure (LAAc). We demonstrate feasibility of a procedural set-up allowing single-operator LAAc in a selected patient.

Case summary

A 87-year-old male with persistent Afib (CHA²DS²VASc, five; HASBLED, three) was referred to our hospital for LAAc. Pre-procedural planning and device sizing with three-dimensional transesophageal echocardiography (3DTEE) confirmed a non-complex anatomy of the essential anatomical structures predicting suitability for LAAc. Therefore, the procedure was performed with a simplified single-operator interventional approach. Intraprocedural TEE guidance, device preparation, and LAAc were accomplished by the interventionalist himself. For procedural guidance, the TEE probe was arranged and handled in a technique comparable to the use of intracardiac echocardiography (ICE). Procedure time (skin-to-skin) was 21 min, left atrial access time 9 min, and fluoroscopy time was 4:28 min without the use of contrast dye. The patient was discharged the following day in good medical conditions.

Discussion

To the best of our knowledge, this is the first report on successful single-operator LAAc in a selected patient. The intervention, pre-procedural screening, and intraprocedural 3D TEE were performed by one single experienced interventionalist. This simplified technique is based on a standardized pre-procedural imaging-protocol with 3D echocardiography. According to our experience, this streamlined approach is a valuable option in non-complex LAAc cases. In the growing field of structural cardiac interventions, this approach might be an interesting option for centres with limited personal and technical resources.

3D-speckle-tracking echocardiography correlates with cardiovascular magnetic resonance imaging diagnosis of acute myocarditis – An observational study

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Regional changes in myocardial texture (as diagnosed by CMR) were significantly associated with regional impairment of circumferential, longitudinal, and radial strain, as well as regional 3D displacement and total 3D strain.

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3D and 2D global longitudinal strain (GLS) showed higher diagnostic performance than well-known parameters associated with myocarditis, such as LVEF and LVEDV in our patient collective.

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3D-speckle-tracking echocardiography offers a promising diagnostic tool in the diagnosis of myocarditis.

Background

The diagnostic importance of three-dimensional (3D) speckle-tracking strain-imaging echocardiography in patients with acute myocarditis remains unclear. The aim of this study was to test the diagnostic performance of 3D-speckle-tracking echocardiography compared to CMR (cardiovascular magnetic resonance imaging) for the diagnosis of acute myocarditis.

Methods and results

45 patients with clinically suspected myocarditis were enrolled in our study (29% female, mean age: 43.9 ± 16.3 years, peak troponin I level: 1.38 ± 3.51 ng/ml). 3D full-volume echocardiographic images were obtained and offline 2D as well as 3D speckle-tracking analysis of regional and global LV deformation was performed. All patients received CMR scans and myocarditis was diagnosed in 29 subjects based on original Lake-Louise criteria. The 16 patients, in whom myocarditis was excluded by CMR, served as controls. Regional changes in myocardial texture (diagnosed by CMR) were significantly associated with regional impairment of circumferential, longitudinal, and radial strain, as well as regional 3D displacement and total 3D strain. Interestingly, the 2D and 3D global longitudinal strain (GLS) showed higher diagnostic performance than well-known parameters associated with myocarditis, such as LVEF (as obtained by echocardiography and CMR) and LVEDV (as obtained by CMR).

Conclusions

In this study, we examined the use of 3D-speckle-tracking echocardiography in patients with acute myocarditis. Global longitudinal strain was significantly impaired in patients with acute myocarditis and correlated with CMR findings. Therefore, 3D echocardiography could become a useful diagnostic tool in the primary diagnosis of myocarditis.

TAVR outcome after reclassification of aortic valve stenosis by using a hybrid continuity equation that combines computed tomography and echocardiography data

BACKGROUND

In the continuity equation, assumption of a round-shaped left ventricular outflow tract (LVOT) leads to underestimation of the true aortic valve area in two-dimensional echocardiography. The current study evaluated whether inclusion of the LVOT area, as measured by computed tomography (CT), reclassifies the degree of aortic stenosis (AS) and assessed the impact on patient outcome after transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

Four hundred and twenty-two patients with indexed aortic valve area index (AVAi) of <0.6 cm² /m² , assessed by using the classical continuity equation (mean age: 81.5 ± 6.1 years, 51% female, mean left ventricular ejection fraction: 53.2 ± 13.6%), underwent TAVR and were included. After inclusion of the CT measured LVOT area into the continuity equation, the hybrid AVAi led to a reclassification of 30% (n = 128) of patients from severe to moderate AS. Multivariate predictors for reclassification were male sex, lower mean aortic gradient, and lower annulus/LVOT ratio (all p < .01). Reclassified patients had significantly higher sST2 at baseline and higher NT-proBNP values at baseline and 6 months follow-up compared to non-reclassified patients. Acute kidney injury was experienced more frequently after TAVR by reclassified patients, but no significant mortality difference occurred during 2 years of follow-up.

CONCLUSION

The hybrid AVAi reclassifies a significant portion of low-gradient severe AS patients into moderate AS. Reclassified patients showed increased fibrosis and heart failure markers at baseline compared to non-reclassified patients. But reclassification had no significant impact on mortality up to 2 years after TAVR. Routine assessment of hybrid AVAi seems not to improve further risk stratification of TAVR patients.

Left atrial global function in chronic heart failure patients with functional mitral regurgitation after MitraClip

BACKGROUND

Left atrial (LA) volumes and function are believed to improve following interventional reduction of mitral regurgitation (MR) with MitraClip. However, exact LA alterations after MitraClip in patients with functional MR and functional mitral regurgitation (FMR) are unknown.

OBJECTIVES

We aimed to evaluate the effect of MitraClip on LA volumes and global function in patients with FMR and its importance for patients' prognosis.

METHODS

All patients underwent three-dimensionally transthoracic echocardiography with an offline evaluation of LA geometry and strain analysis at baseline and follow-up (FU). FU examinations were planned for 6 and 12 months after MitraClip.

RESULTS

We prospectively included 50 consecutive surgical high-risk (logistic EuroSCORE: 17.2 ± 13.9%) patients (77 ± 9 years, 22% female) with symptomatic moderate-to-severe to severe functional MR without atrial fibrillation. Echocardiographic evaluation showed that the E/E' ratio was significantly higher at FU (15.6 ± 7.3, 24.1 ± 13.2, p = .05) without relevant changes in systolic left ventricle (LV) function (p = .5). LA volumes (end-diastolic volume [LA-EDV] and end-systolic volume [LA-ESV]) (LA-EDV: 83.1 ± 39.5 ml, 115.1 ± 55.3 ml, p = .012; LA-ESV: 58.4 ± 33.4 ml, 80.1 ± 43.9 ml, p = .031), muscular mass (105.1 ± 49.3 g, 145.4 ± 70.6 g, p = .013), as well as LA stroke volume (24.6 ± 12.5 ml, 34.9 ± 19.1 ml, p = .016) significantly increased after the procedure. LA ejection fraction (LA-EF: 31.7 ± 12.8%, 31.1 ± 12.3%, p = .8) and atrial global strain (aGS: -10.8 ± 5.4%, -9.7 ± 4.45%, p = .4) showed no significant changes at FU. Despite no relevant changes during FU, the baseline aGS was found to be the strongest predictor for mortality and adverse interventional outcome.

CONCLUSION

MitraClip increases atrial stroke volume, atrial volumes, and muscular mass in patients with FMR. We found that the baseline aGS the strongest predictor for mortality, rehospitalization, and higher residual MR at FU.

Prognostic Impact of Redo Transcatheter Mitral Valve Repair for Recurrent Mitral Regurgitation

There is little known about the prognostic impact of a redo transcatheter mitral valve repair (TMVR) for residual or recurrent mitral regurgitation (MR). From January 2011 to March 2019, we identified 43 consecutive patients who underwent a redo TMVR procedure with the MitraClip system. A control cohort was treated medically for MR ≥2+ after the first TMVR and was propensity score 1:1 matched using age, gender, MR severity, trans-mitral pressure gradient, and etiology of MR. To investigate the association of redo TMVR with 1-year mortality, we fitted a Cox proportional hazard model. The technical success rate of redo TMVR was 95%. A reduction in MR to ≤2+ was achieved in 79% of patients, with a significant decline of tricuspid regurgitation pressure gradient and improvement of the New York Heart Association class. After matching was performed, 43 well-matched pairs of patients were analyzed. Redo TMVR patients showed lower 1-year mortality (10.5% vs 37.6%, p = 0.01) compared with the control patients. Redo TMVR was associated with better survival (hazard ratio [HR] 0.26, 95% confidence interval [CI] 0.08 to 0.79, p = 0.02) and lower risk of the composite end point (mortality and rehospitalization due to HF: HR 0.34, 95% CI 0.15 to 0.78; p = 0.01) at 1-year follow-up. The association with the primary end point remained significant after accounting for the New York Heart Association class III/IV, TR ≥severe, the type of MR (i.e., recurrent or residual MR), or the type of previous implanted TMVR device. In conclusion, redo TMVR in selected patients with residual or recurrent MR may be associated with lower 1-year mortality than medical therapy alone.

Comparison of different imaging modalities for the quantification of tricuspid valve geometry and regurgitation: a retrospective, single-center study

BACKGROUND AND AIMS

Tricuspid regurgitation (TR) is a frequent valvular heart disease with relevant adverse impact on patients' prognosis. Adequate TR imaging and evaluation is challenging. In this study, we aimed to compare different imaging modalities (echocardiography and multi-slice computed tomography) for the assessment of tricuspid valve (TV) function and geometry.

METHODS

We retrospectively investigated patients that presented to University Hospital Bonn, Germany, between September 2018 and March 2019, who underwent comprehensive echocardiography and multi-slice computed tomography (MSCT) to evaluate TR. MSCT was considered the reference approach for dimensional assessment of TV anatomy and echocardiography (transthoracic echocardiography + transesophageal echocardiography) for functional assessment of TV. We used Spearman's Rank order correlation, Bland-Altman analysis, and intra-class correlation to compare the different imaging modalities.

RESULTS

Forty patients (Mean Age ± SD: 77.5 ± 7.1 years; 35% female) with high grade TR (effective regurgitant orifice area, EROA: 0.49 ± 0.3 cm2, RegVol: 49.5 ± 13.4 mL) were included. There was a statistically significant but moderate correlation between 2D-TEE and MSCT for anteroposterior (AP) (r = 0.68, 95% confidence interval [CI]: 0.44-0.93, P = .05; intraclass correlation [ICC]: 0.77, P = .03) and septolateral (SL) diameters (r = 0.71, 95% CI: 0.33-0.93, P = .03; ICC = 0.76, P = .05). MSCT and 3D-TEE showed a strong correlation for determination of TV annulus area (r = 0.94, 95% CI: 0.57-0.98, P = .002; ICC = 0.95, P = .4), perimeter (r = 0.9, 95% CI: 0.6-0.98, P = .002; ICC = 0.97, P = .3) and diameters (AP-Diameter: r = 0.73, 95% CI: 0.06-0.94, P = .03; ICC = 0.83, P = .09; SL-Diameter: r = 0.86, 95% CI: 0.47-0.97, P = .02; ICC = 0.95, P = .1). Only 3D-TEE allowed for direct measurement of planimetric EROA, which exhibited a significant difference from calculated EROA (0.49 ± 0.4 cm2, 0.67 ± 0.17 cm2, P = .05; r = 0.93, 95% CI: 0.5 to 0.99, P = .006). According to Bland-Altman analysis, we found a relevant agreement between MSCT and 3D-TEE only for TV area (bias: -1.95, 95% limits of agreement -3.6 to -0.1).

CONCLUSION

Only 3D-TEE allowed for sufficient simultaneous functional and dimensional assessment of TR in our cohort.

42 Comparison of different imaging modalities for the quantification of tricuspid valve geometry and regurgitation

Objectives

Tricuspid regurgitation (TR) is a frequent valvular heart disease with relevant adverse impact on patients´ prognosis. Imaging of tricuspid valve and tricuspid Regurgitation is through anatomical circumstances is challenging. In this study, we aimed to compare the ability of different imaging modalities to visualize and quantify tricuspid valve (TV) function and annular dimensions.

Methods and Results

We prospectively included 40 consecutive patients (Age: 77.5 ± 7.1 years) with high surgical risk (EuroSCORE II: 8.8 ± 12.1%) and significant TR, who underwent transesophageal echocardiography (TEE) and multislice computed tomography (MSCT) to evaluate TR, TV function, and dimensions. In general, 2D-TEE showed lower diameters than MSCT with a significant but weak correlation between both imaging modalities for AP diameters (41.4 ± 7.8 mm, 47.2 ± 8.9 mm, r = 0.68, p = 0.05correlation, p = 0.03difference) and for SL diameters (41.6 ± 5.3 mm, 46.6 ± 4.6 mm, r = 0.71correlation, p = 0.05difference, p = 0.03). We found no significant correlation, however significant difference agreement, between MSCT and 2D-TEE on measures for annulus perimeter (117.6 ± 18.9 mm, 130.3 ± 21.5 mm, r = 0.3, p = 0.4correlation, p = 0.03difference) and annulus area (10.1 ± 3.3 cm2, 13.4 ± 4.1 cm2, r = 0.5, p = 0.4correlation, p = 0.04difference).

When comparing 3D-TEE with MSCT, we found a strong correlation between both imaging modalities concerning TV annulus areas (12.9 ± 2.6 cm2, 13.4 ± 4.1 cm2, r = 0.94, p = 0.0017correlation, p &lt; 0.001difference), and perimeter (130.1 ± 12.4 mm, 130.3 ± 21.5 mm, r = 0.9, p = 0.002correlation, p = 0.005difference), as well as for AP (43.8 ± 3.2 mm, 47.2 ± 8.9 mm, r = 0.73, p = 0.03correlation, p = 0.008difference) and SL diameters (44.5 ± 3.6 mm, 46.6 ± 4.6 mm, r = 0.86, p = 0.02correlation, p = 0.1difference). MSCT was not useful for TR grading and determination of TV function. In addition to conventional 2D echocardiography, only 3D-TEE allowed for direct measurement of effective regurgitant orifice area (EROA), which differed significantly from calculated EROA (p &lt; 0.05).

Conclusion

3D-TEE is highly comparable to MSCT and superior to 2D imaging for the determination of TV geometry and diameters. In contrast to MSCT, 3D-TEE allows sufficient grading and functional assessment of TR.

P1374 Clinical outcomes of patients with solid left atrial appendage thrombi. Predictors of thrombus resolution and impact of anticoagulation regimens

OBJECTIVE

Current guidelines recommend vitamin k antagonist (VKA) therapy with a therapeutic international normalized ratio of 2.0 to 3.0 for at least 3 weeks upon detection of an LA/LAA thrombus in patients with atrial fibrillation (AF). Reported thrombus resolution rates with VKAs vary between approximately 50% and 90%. Data on thrombus resolution after a therapy with a direct-acting oral anticoagulant (DOAC) are scarce but efficacy data on DOAC indicate on potential favorable outcomes.

METHODS

We analyzed 78 patients diagnosed with a solid LA thrombus by transesophageal echocardiography and compared baseline characteristics, the anticoagulatory regime and the clinical outcomes of patients with and without thrombus resolution.

RESULTS

Mean age of the population was 76 ±8 years old. Patients were male in 61.5% and presented with a high risk for thromboembolism (CHA2DS2-VASc 4.3 ± 1.1). At the time of thrombus diagnosis 44,9% (35/78) patients were treated with a DOAC, 47,4% (37/78) were under therapy with a VKA and only 14,1% (11/78) of the patients had no prior DOAC or VKA treatment. Mean thrombus size was 1,63 ± 0,61cm x 0,98 ± 0,31cm. Complete thrombus resolution was achieved after a mean 116 ± 79 days in a total of 48,2% (40/78) of patients. There was no statistically significant difference in the rate of LAA thrombus resolution between VKA and DOACs (41,2% vs. 57,1%), but in cases in which therapy with a DOAC led to a complete thrombus resolution, the time needed for the resolution was significantly shorter than with VKA (81 ± 38 days vs. 129 ± 46 days, p = 0,03).

CONCLUSIONS

There was difference in the rate of LAA thrombus resolution between VKA and DOACs, the resolution time was shorter in patients prescribed a DOAC. In clinical practice the individual risk for thrombus persistence can not be predicted. 80,1% of patients were prescribed, what would be considered, an appropriate anticoagulant regimen, but only 48,2% had thrombus resolution at any point of follow up documented via TEE. Switching to DOAC after prior VKA therapy is an effective and valid alternative to patients presenting with LAA thrombi.

422 Single-center five-year outcomes after interventional edge-to-edge repair of the mitral valve

The MitraClip procedure is established as a therapeutic alternative to mitral valve surgery for symptomatic patients with severe mitral regurgitation (MR) at prohibitive surgical risk. In this study, we aimed to evaluate five-year outcomes after MitraClip.

265 patients (Age: 81.4 ± 8.1 years, 46.7% female, logistic EuroSCORE: 19.7 ± 16.7%) with symptomatic MR (60,5% secondary MR: sMR) undergoing MitraClip were included. Despite procedural success of 91.3%, patients with primary MR (pMR) had a higher rate of procedural failure (sMR: 3.1%, pMR: 8.6%; p = 0.04).

Five years after MitraClip, the majority of patients presented with reduced symptoms, sustained MR reduction (≤ grade 2) and improved functional capacity (Functional NYHA class: p = 0.0001; six minutes walking test: p = 0.04) and right ventricular (RV) function.

Systolic pulmonary artery pressure (sPAP) was significantly reduced during FU only in sMR patients, (p = 0.05, p = 0.3). Despite a pronounced clinical and echocardiographical amelioration and low interventional failure, five-year mortality was significantly higher in patients with sMR (p = 0.05). The baseline level of creatinine (HR: 0.695), sPAP (HR: 0.96) and mean mitral valve gradient (HR: 0.82) were found to be independent predictors for poor functional outcome and mortality.

MitraClip showed low complication rates and sustained MR reduction with improved RV function and sPAP five years after the procedure, which was found in all patients, predominantly in patients with sMR. Despite pronounced functional amelioration with low procedure failure, sMR patients had higher five-year mortality and worse outcomes. Baseline creatinine, MVG, and sPAP were found to be independent predictors of poor functional outcomes and five-year mortality.

425 Alterations in left atrial structure and function in chronic heart failure patients with functional mitral regurgitation after MitraClip

Backround

The MitraClip procedure has been increasingly performed as an established treatment alternative for symptomatic patients with moderate to severe mitral regurgitation (MR) at prohibitive surgical risk. Left ventricular (LV) reverse remodelling following MitraClip has been shown in different studies. Left atrial (LA) volumes are believed to decrease following interventional reduction of MR. However, effects of MitraClip on LA function are not well understood.

Objectives

In this study we aimed to evaluate the effect of MitraClip on LA structure, volumes and function in chronic heart failure patients with functional MR.

Methods

All patients underwent 3D transthoracic echocardiography prior to the MitraClip procedure and at follow-up (FU) with offline evaluation of LA function and geometry using dedicated software (TomTec Image Arena, 4D LV-Analysis, Munich, Germany). FU examinations were performed 10 ± 3.4 months after the procedure.

Results

We prospectively included 75 consecutive surgical high risk (Logistic EuroScore: 17.2 ± 13.9%) patients (Age: 77 ± 9years, 22% female) with symptomatic moderate to severe MR without atrial fibrillation. All patients underwent MitraClip following heart team decision without periinterventional major complications.

Baseline echocardiography showed impaired left ventricular function (Ejection fraction (EF): 32,6 ± 11.2%), moderate to severe MR , increased systolic right ventricle pressure (RVSP: 46.1 ± 10.5 mmHg) and elevation in estimated left ventricle enddiastolic pressure (E/E´ ratio: 15.6 ± 7.3) in the patient cohort.

There was no relevant mitral stenosis after the procedure (MPG: 3.3 ± 0.5 mmHg), however the MPG increased significantly after the procedure (p = 0.05). The E/E´ ratio significantly increased at FU (15.6 ± 7.3, 24.1 ± 13.2, p = 0.05) as well. The left atrial (LA) volumes and LA-muscular mass (End-diastolic volume [LA-EDV] and end-systolic volume [LA-ESV]) significantly increased at FU (LA-EDV: 83.1 ± 39.5ml, 115.1 ± 55.3ml, p = 0.012; LA-ESV: 58.4 ± 33.4ml, 80.1 ± 43.9ml, p = 0.031; 105.1 ± 49.3gr, 145.4 ± 70.6gr, p = 0.013). LA stroke volume significantly increased after the procedure (24.6 ± 12.5ml, 34.9 ± 19.1ml, p = 0.016). LA-EF and atrial global longitudinal strain (LA-GLS) showed no significant changes at FU (LA-EF: 31.7 ± 12.8%, 31.1 ± 12.3%, p= 0.8; LA-GLS: -10.8 ± 5.4%, -9.7 ± 4.45%, p = 0.4).

Despite no relevant changes during FU, baseline E/E´ ratio (AUC: 0.652) and baseline aGLS (AUC: 0.694) were found to be independent predictors for mortality.

Conclusion

Transcatheter MV repair (TMVR) with the MitraClip procedure improves atrial stroke volume, increases atrial volumes and muscular mass acutely after the procedure. It might be explained by the acutely increased MPG and LVEDP after the MitraClip procedure. Baseline aGLS and E/E´ ratio were found to be independent predictors for mortality.

P1002Echocardiographic assessment of optimal device position after percutaneous left atrial appendage occlusion - introduction of a novel classification and its impact on outcome

Background

Left atrial appendage occlusion (LAAo) is an established therapy in patients with atrial fibrillation. However, criteria regarding optimal device position are not well defined making comparability of procedural results virtually impossible. We therefore sought to a) introduce a classification describing optimal vs. suboptimal device-position by assessing predefined parameters in transoesophageal echocardiography (TEE) and to b) analyze the impact of device-position on outcome in patients treated with different LAAo devices.

Methods and results

We retrospectively analyzed 120 patients who were treated by LAAo and had undergone follow-up TEEs after 3 or 6 months. Patients were at mean age: 76±8 years; female 40% and presented an increased CHADS-VASC- (4.6±1.4) and HAS-BLED-score (3.7±1). TEE-guidance was performed in all cases.

In 62.5% (75/120) pacifier occluders (PO) (ACP/Amulet, Lambre, Ultraseal) were used, whereas 37.5% (45/120) were treated with non-pacifier occluders (NPO) (Watchman, Wavecrest, Occlutech). To assess device position, TEE images in a commissural view (60–90°) were analyzed and characterised by 1) implantation depth in the left atrial appendage, 2) peridevice flow (PF) and 3) the angle between occluder disc and pulmonal ridge (LUPV). For the purpose of this study, optimal device position was defined as a) ostial (LUPV length <10mm) or slightly subostial position (LUPV length ≤15mm, angle ≥100°) with b) the absence of major PF (>3mm).

Overall, occluders were implanted at a depth of 12±7.8 mm with ostial positioning being achieved in 47.5% (57/120). Major PF was seen in 7.5% (9/120). NPOs were implanted deeper than POs (depth: 15.6±7.1 vs. 9.8±7.4 mm, p<0.01; ostial position: 31.1% vs. 57.3%, p<0.01) and were associated with a higher incidence of major PF (15.6% vs. 2.7%, p=0.01). Also, the depth/angle ratio was higher (i.e. “worse”) in NPOs (18.3±9 vs. 14.6±8, p<0.04). As a result, optimal device position was achieved in 48.3% (58/120) of all patients, with lower rates in NPOs than in POs (26.7% vs. 61.3%, p<0.01). Procedural aspects revealed slight differences in occluder size (optimal: 23.7±3.2 vs. suboptimal: 24.5±3.7 mm, p=0.3), need for repositioning (10.3% vs. 17.7%, p=0.25) and procedural duration (48±36 vs. 52±34 min, p=0.3).

Of interest, device related thrombi (DRT) occurred less frequently in optimally implanted devices (3.4% vs. 12.9%, p=0.06). Hereby, implantation depth and depth/angle ratio were found to be predictors for DRT in ROC-analysis, respectively (AUC: 0.7, 95% Confidence interval [CI]: 0.56–0.84, p=0.05 and AUC: 0.72, 95% CI: 0.58–0.86, p=0.03).

Optimal vs. suboptimal position

Conclusion

Echocardiographic classification of device-position is warranted to provide comparability and appears to be feasible. Based on the novel classification provided, optimal device-position is achieved in 50% and is found more often with the use of POs. DRT appeared to occur more often in suboptimal device-position.

Single-center five-year outcomes after interventional edge-to-edge repair of the mitral valve

BACKGROUND

The MitraClip procedure was established as a therapeutic alternative to mitral valve surgery for symptomatic patients with severe mitral regurgitation (MR) at prohibitive surgical risk. In this study, the aim was to evaluate 5-year outcomes after MitraClip.

METHODS

Consecutive patients undergoing the MitraClip system were prospectively included. All patients underwent clinical follow-up and transthoracic echocardiography.

RESULTS

Two hundred sixty-five patients (age: 81.4 ± 8.1 years, 46.7% female, logistic EuroSCORE: 19.7 ± 16.7%) with symptomatic MR (60.5% secondary MR [sMR]). Although high procedural success of 91.3% was found, patients with primary MR (pMR) had a higher rate of procedural failure (sMR: 3.1%, pMR: 8.6%; p = 0.04). Five years after the MitraClip procedure, the majority of patients presented with reduced symptoms and improved functional capacity (functional NYHA class: p = 0.0001; 6 minutes walking test: p = 0.04). Sustained MR reduction (≤ grade 2) was found in 74% of patients, and right ventricular (RV) function was significantly increased (p = 0.03). Systolic pulmonary artery pressure (sPAP) was significantly reduced during follow-up only in sMR patients (p = 0.05, p = 0.3). Despite a pronounced clinical and echocardiographical amelioration and low interventional failure, 5-year mortality was significantly higher in patients with sMR (p = 0.05). The baseline level of creatinine (HR: 0.695), sPAP (HR: 0.96) and mean mitral valve gradient (MVG) (HR: 0.82) were found to be independent predictors for poor functional outcome and mortality.

CONCLUSIONS

Transcatheter mitral valve repair with the MitraClip system showed low complication rates and sustained MR reduction with improved RV function and sPAP 5 years after the procedure was found in all patients, predominantly in patients with sMR. Despite pronounced functional amelioration with low procedure failure, sMR patients had higher 5-year mortality and worse outcomes. Baseline creatinine, MVG, and sPAP were found to be independent predictors of poor functional outcomes and 5-year mortality.

Bildgebende Diagnostik bei Rechtsherzerkrankungen

Erkrankungen des rechten Herzens wurden über viele Jahre hinweg nicht als prognostisch relevant erachtet. Die Erkenntnis über den progressiven Verlauf unterschiedlicher Pathologien mit einem direkten Einfluss auf das Outcome der betroffenen Patienten rückt moderne, teils experimentelle Therapieverfahren aktuell zunehmend in den Fokus der medizinischen Aufmerksamkeit. Basis für die Entwicklung neuer therapeutischer Ansätze ist ein grundlegendes Verständnis und die adäquate Darstellung der Anatomie des rechten Herzens und der komplexen Zusammenhänge mit der pulmonalen Hämodynamik. Unterschiedliche bildgebende Verfahren werden bereits eingesetzt für die Beurteilung der Anatomie und pathologischer Veränderungen des rechten Herzens.

Left Ventricular Longitudinal Contractility Predicts Acute-on-Chronic Liver Failure Development and Mortality After Transjugular Intrahepatic Portosystemic Shunt

Acute deterioration of liver cirrhosis (e.g., infections, acute-on-chronic liver failure [ACLF]) requires an increase in cardiac contractility. The insufficiency to respond to these situations could be deleterious. Left ventricular global longitudinal strain (LV-GLS) has been shown to reflect left cardiac contractility in cirrhosis better than other parameters and might bear prognostic value. Therefore, this retrospective study investigated the role of LV-GLS in the outcome after transjugular intrahepatic portosystemic shunt (TIPS) and the development of ACLF. We included 114 patients (48 female patients) from the Noninvasive Evaluation Program for TIPS and Their Follow-Up Network (NEPTUN) cohort. This number provided sufficient quality and structured follow-up with the possibility of calculating major scores (Child, Model for End-Stage Liver Disease [MELD], Chronic Liver Failure Consortium acute decompensation [CLIF-C AD] scores) and recording of the events (development of decompensation episode and ACLF). We analyzed the association of LV-GLS with overall mortality and development of ACLF in patients with TIPS. LV-GLS was independently associated with overall mortality (hazard ratio [HR], 1.123; 95% confidence interval [CI],1.010-1.250) together with aspartate aminotransferase (HR, 1.009; 95% CI, 1.004-1.014) and CLIF-C AD score (HR, 1.080; 95% CI, 1.018-1.137). Area under the receiver operating characteristic curve (AUROC) analysis for LV-GLS for overall survival showed higher area under the curve (AUC) than MELD and CLIF-C AD scores (AUC, 0.688 versus 0.646 and 0.573, respectively). The best AUROC-determined LV-GLS cutoff was -16.6% to identify patients with a significantly worse outcome after TIPS at 3 months, 6 months, and overall. LV-GLS was independently associated with development of ACLF (HR, 1.613; 95% CI, 1.025-2.540) together with a MELD score above 15 (HR, 2.222; 95% CI, 1.400-3.528). Conclusion: LV-GLS is useful for identifying patients at risk of developing ACLF and a worse outcome after TIPS. Although validation is required, this tool might help to stratify risk in patients receiving TIPS.

Left atrial thrombus resolution in non-valvular atrial fibrillation or flutter: biomarker substudy results from a prospective study with rivaroxaban (X-TRA)

BACKGROUND

Non-vitamin K antagonist oral anticoagulants including rivaroxaban are widely used for stroke prevention in patients with atrial fibrillation (AF). We investigated the relationship between plasma biomarkers (indicative of thrombogenesis, fibrinolysis and inflammation) and left atrial thrombus resolution after rivaroxaban treatment.

METHODS

This was an ancillary analysis of the X-TRA study, which was a prospective interventional study evaluating the use of rivaroxaban for left atrial/left atrial appendage (LA/LAA) thrombus resolution in AF patients. We assessed various biomarkers of thrombogenesis/fibrinolysis [D-dimer, plasminogen activator inhibitor-1 (PAI-1), prothrombin fragment 1 + 2 (F1,2), thrombin-antithrombin (TAT) complexes, von Willebrand factor (vWF)] and inflammation [high-sensitivity interleukin-6 (hsIL-6), and high-sensitivity C-reactive protein (hsCRP)], measured at baseline and after 6 weeks' of rivaroxaban treatment.

RESULTS

There was a significant decrease in the mean levels of hsCRP, D-dimer, vWF, and TAT from baseline to end of treatment with rivaroxaban. Although none of the thrombogenesis/fibrinolysis biomarkers showed a significant relationship with thrombus resolution, high inflammatory biomarkers at baseline were significantly associated with an increased chance of the thrombus being completely resolved (hsIL-6) or reduced/resolved (hsCRP).

CONCLUSIONS

Biomarkers of inflammation are significantly associated with LA/LAA thrombus outcomes in AF patients prospectively treated with rivaroxaban.

Increased myocardial contractility identifies patients with decompensated cirrhosis requiring liver transplantation

Late allocation of organs for transplant impairs post-liver transplantation (LT) survival. Cardiac dysfunction, especially diastolic and autonomic dysfunction, is frequent and plays an important role in the prognosis of patients with cirrhosis. However, the role of myocardial contractility is unexplored, and its prognostic value is controversially discussed. This study analyses the role of myocardial contractility assessed by speckle tracking echocardiography in LT allocation. In total, 168 patients with cirrhosis (training cohort, 111; validation cohort [VC], 57) awaiting LT in 2 centers were included in this retrospective study. Also, 51 patients from the training and all patients from the VC were transplanted, 36 patients of the training and 38 of the VC were alive at the end of follow-up, and 21 nontransplanted patients died. Contractility of the left ventricle (LV) increased with severity of the Child-Pugh score. Interestingly, higher LV contractility in the training cohort patients, especially in those with Child-Pugh C, was an independent predictor of reduced transplant-free survival. In male patients, the effects on survival of increased left and right ventricular myocardial contractility were more pronounced. Notably, competing risk analysis demonstrated that increased contractility is associated with earlier LT, which could be confirmed in the VC. Importantly, LV myocardial contractility had no impact on survival of patients not receiving LT or on post-LT survival. In conclusion, this study demonstrates for the first time that increased myocardial contractility in decompensated patients identifies patients who require LT earlier, but without increased post-LT mortality. Liver Transplantation 24 15-25 2018 AASLD.

Bridging of oral anticoagulation with low-molecular-weight heparin: Experience in 373 patients with renal insufficiency undergoing invasive procedures

If surgery or another intervention is planned, current guidelines recommend bridging oral anticoagulation (OAC) with heparins in patients at elevated thromboembolic (TE) risk. While patients with renal impairment have a higher risk of bleeding and dosing of heparins is more difficult, there are no specific recommendations for bridging the latter patients. Hence, we aimed to investigate the efficacy and tolerability of using reduced low-molecular-weight heparin (enoxaparin) dosages for bridging of OAC. Three hundred twenty-two hospitalised and 51 ambulatory adult patients at moderate to high TE risk were enrolled. Patients with renal insufficiency (n=274 with creatinine clearance [CrCl] 30–50 ml/min and n=99 with CrCl 20–29 ml/min) received after discontinuation of OAC therapy enoxaparin 1mg/ kg once daily. Surgery was performed at international normalised ratio (INR) <1.5. Mean time between the last enoxaparin dose and procedure was 26.8 ± 2.7 hours. Within 30 days of individual follow-up, no case of TE was observed (0 %; 95 % confidence interval [CI] 0– 0.9). A total of 30 bleeding events (8.0 %; CI 5.5–11.3) occurred (3 major [0.8 %; CI 0.2–2.3] and 27 minor [7.2 %; CI 4.8–10.4]). Bleeding events occurred in 6.5% (CI 3.9–10.2) of patients with CrCl 30–50 ml/min and in 12.1% (CI 6.4–20.2) of patients with CrCl 20–29 ml/min (p between groups =0.08). Logistic regression analysis identified the CHADS2 score as the only independent haemorrhagic risk factor (p= 0.03). No heparin-induced thrombocytopenia (HIT-II) was reported. Bridging therapy could be performed in 51 (13.7%) ambulatory patients. In renally impaired patients undergoing bridging of OAC, the use of a priori reduced dosage of enoxaparin was not compromised by any TE events. It appeared well tolerated as the rate of major bleeds was low.

How useful is determination of anti-factor Xa activity to guide bridging therapy with enoxaparin?

Low-molecular-weight heparins (LMWH) are commonly used as peri-procedural bridging anticoagulants. The usefulness of measurement of anti-factor Xa activity (anti-Xa) to guide bridging therapy with LMWH is unknown. It was the objective of this study to determine levels of anti-Xa during standard bridging therapy with enoxaparin, and to examine predictors for residual anti-Xa. Consecutive patients receiving enoxaparin at a dosage of 1 mg/kg body weight/12 hours for temporary interruption of phenprocoumon were prospectively enrolled to the study. Blood-samples were obtained 14 hours after LMWH-application immediately pre- procedurally. Procedural details, clinical and demographic data were collected and subsequently analyzed. Seventy patients were included (age 75.2 ± 10.8 years, Cr Cl 55.7 ± 21.7ml/min, body mass index [BMI] 27.1 ± 4.9). LMWH- therapy was for a mean of 4.2 ± 1.6 days; overall anti-Xa was 0.58 ± 0.32 U/ml. In 37 (52.8%) of patients anti-Xa was ≥0.5 U/ml, including 10 (14.3%) patients with anti-Xa > 1U/ml. Linear regression analysis of single variables and logistic multivariable regression analysis failed to prove a correlation between anti-Xa and single or combined factors. No major bleeding, no thromboembolism and four (5.7%) minor haemorrhages were observed. When bridging OAC with therapeutic doses of enoxaparin a high percentage of patients undergo interventions with high residual anti-Xa. The levels of anti-Xa vary largely and are independent of single or combined clinical variables. Since the anti-Xa-related outcome of patients receiving bridging therapy with LMWH is not investigated, no firm recommendation on the usefulness of monitoring of anti-Xa can be given at this stage.

The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation

Patients who receive long-term oral anticoagulant (OAC) therapy often require interruption of OAC for an elective invasive procedure. Current guidelines allow bridging therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Apart from the risk of embolism, bleeding is an important complication in this setting and the optimal perioperative management of such patients is still under discussion. The aims of this prospective, observational, multicentre registry of patients treated by cardiologists were: 1) to evaluate current practice of perioperative management of OAC in a large outpatient cohort, 2) to document embolic and haemorrhagic events, and 3) to identify risk factors predicting adverse events. In the years 2009 and 2010, 1,000 invasive procedures (cardiac catheterisation n=533, pacemaker implantation n = 128, surgery n = 194, other n = 145) were performed in patients with OAC. Sixty- one (6.1%) of those patients did not receive bridging therapy during interruption of OAC, 937 (93.7%) patients were treated with LMWH, two patients (0.2%) received UFH. In 22 patients (2.2%) LMWHs were given in prophylactic dose, 727 patients (72.7%) were treated with halved therapeutic (i.e. weight-adapted) LMWH doses and 188 (18.8%) received full therapeutic LMWH doses. Four thromboembolic complications were observed during 30 days of follow-up (two retinal embolisms, one stroke, one myocardial infarction; 0.4%). One major bleeding (0.1%) and 35 clinically relevant bleedings (3.5%) occurred. Rehospitalisation after bleedings was necessary in 20 patients. Independent predictors for bleedings were history of mechanical heart valve replacement (MVR) (p=0.0002) and the HAS-BLED score (<0.0001), with a cut off value ≥3 being the most predictive variable for haemorrhage (hazard ratio 11.8, 95% confidence interval 5.6–24.9, p<0.0001). A total of 527 patients with atrial fibrillation and a CHADS2 score ≤2 received halved therapeutic or full therapeutic dosages of LMWH despite a low embolic risk, whereas 49 of the patients with heart valve replacement (51%) did not receive dosages of bridging therapy as recommended in guidelines. In conclusion, in this registry of patients treated by cardiologists, 94% of patients who required interruption of OAC before invasive procedures received LMWH as a bridging therapy, of whom 73% were treated with halved therapeutic LMWH-dosages. Guideline recommendations were followed in only 31% of cases. Importantly, 69% of patients with AF were over-treated while 51% of patients with heart valve replacement were under-treated with LMWHs. A HASB-BLED score ≥3 was highly predictive of bleeding events.

[Echocardiographic imaging of the tricuspid valve]

Pathologies of the right heart and the tricuspid valve were not recognized to be of prognostic relevance for many years. Available evidence showing the progressive nature of right heart diseases with direct impact on patient survival have changed current understanding of its clinical importance. Visualization and a profound understanding of the right heart anatomy are prerequisites for the development of modern and still experimental treatment strategies. Transthoracic and transesophageal echocardiography enable a standardized and clear visualization and assessment of the right heart anatomy and its pathological changes.

Predictors for short-term outcomes of patients undergoing transcatheter mitral valve interventions: analysis of 778 prospective patients from the German TRAMI registry focusing on baseline renal function

AIMS

Factors predicting outcomes after MitraClip implantation are not well defined. We aimed to report the influence of baseline renal function on short-term outcomes of patients enrolled in the investigator-initiated German transcatheter mitral valve interventions (TRAMI) registry.

METHODS AND RESULTS

Twenty participating German centres prospectively included 778 patients (mean age 76.0 years [71-81], 38.8% female gender) at high surgical risk (mean logistic EuroSCORE 20% [12-32%]) undergoing TMVR with the MitraClip for the treatment of symptomatic functional (70%) or degenerative (30%) mitral valve regurgitation (FMR, DMR). The patients were stratified according to renal function before clip implantation. The prevalence of moderate to severe renal impairment (glomerular filtration rate [GFR] <60 ml/min) was 62.7% (37.3%, normal renal function [GFR >60 ml/min]; 49.6%, moderate renal impairment [GFR 30-60 ml/min]; 13.1%, severe renal impairment [GFR <30 ml/min]). TMVR was successfully completed in 98.2% of cases; acute procedural failure, in-hospital and 30-day mortality rates were 1.8%, 2.3% and 4.4%, respectively. Acute procedural failure and mortality rates (in-hospital, 30-day) were significantly higher in patients with severe renal impairment (5.9%, 7.8%, 14.1%), as compared to patients with moderately (1%, 1.3%, 3.0%) or mildly impaired to normal (1.4%, 1.7%, 2.9%) renal function (p<0.0001). Following Cox regression analysis, the prevalence of severe renal impairment at the time of TMVR was the only predictor for increased 30-day mortality rates (hazard ratio 3.42, 95% confidence interval 1.88-6.2; p<0.0001).

CONCLUSIONS

Renal function at the time of interventional mitral valve repair with the MitraClip system is a strong predictor for procedural outcomes. Patients with severe renal impairment have a more than threefold increased risk for acute procedural failure, in-hospital death and 30-day mortality.

Kinetics of Circulating MicroRNAs in Response to Cardiac Stress in Patients With Coronary Artery Disease

Background

Circulating microRNAs (miRNAs/miRs) are regulated in patients with coronary artery disease. The impact of transient coronary ischemia on circulating miRNA levels is unknown. We aimed to investigate circulating miRNA kinetics in response to cardiac stress in patients with or without significant coronary stenosis.

Methods and Results

Eighty of 105 screened patients with stable coronary artery disease underwent dobutamine stress echocardiography before coronary angiography. Nine circulating vascular miRNAs (miRNA‐21, miRNA‐26, miRNA‐27a, miRNA‐92a, miRNA‐126‐3p, miRNA‐133a, miRNA‐222, miRNA‐223, and miRNA‐199‐5p) were quantified in plasma by reverse transcription polymerase chain reaction before, immediately after, and 4 and 24 hours after dobutamine stress echocardiography. Quantitative polymerase chain reaction revealed increased miRNA‐21, miRNA‐126‐3p, and miRNA‐222 levels at 24 hours after dobutamine stress echocardiography in all patients. On coronary angiography, significant coronary artery stenoses (>80% diameter stenosis) were found in 41 patients. Stratifying patients according to the prevalence of significant stenoses, patients with stenosis showed an increase of circulating miRNA‐21, miRNA‐126‐3p, and miRNA‐222 in response to cardiac stress. In patients without significant stenoses (<50% diameter stenosis), miRNA‐92a levels gradually increased in response to cardiac stress.

Conclusions

miRNAs are distinctly released into the circulation in response to cardiac stress depending on the prevalence of significant coronary stenoses.

Atherosclerotic Vessel Changes in Sarcoidosis

Sarcoidosis is a systemic granulomatous disease. Atherosclerosis is a chronic inflammatory vessel disease. The aim of our present study was to investigate whether sarcoidosis could be associated with increased risk of atherosclerotic vessel changes. Angiological analysis and blood tests were performed in 71 sarcoidosis patients and 12 matched controls in this prospective cross-sectional study. Specifically, angiological measurements comprised ankle brachial index (ABI), central pulse wave velocity (cPWV), pulse wave index (PWI), and duplex sonography of central and peripheral arteries. Sarcoidosis activity markers (angiotensin converting enzyme, soluble interleukin-2 receptor) and cardiovascular risk parameters such as cholesterol, lipoprotein(a), C-reactive protein, interleukin 6, fibrinogen, d-dimer, and blood count were analyzed in blood. We found no relevant differences in ABI, cPWV, and plaque burden between the sarcoidosis and control groups (1.10 ± 0.02 vs. 1.10 ± 0.02, 6.7 ± 0.5 vs. 6.1 ± 1.2, 53.7 % vs. 54.5 %, respectively). However, PWI was significantly higher in sarcoidosis patients (146.2 ± 6.8) compared with controls (104.9 ± 8.8), irrespectively of the activity of sarcoidosis and immunosuppressive medication. Except for increased lipoprotein(a) and d-dimer in sarcoidosis, the remaining cardiovascular markers were similar in both groups. We conclude that sarcoidosis is associated with increased pulse wave index, which may indicate an early stage of atherosclerosis.

Transcatheter Treatment of Severe Tricuspid Regurgitation With the Edge-to-Edge MitraClip Technique

BACKGROUND

Current surgical and medical treatment options for severe tricuspid regurgitation (TR) are limited, and additional interventional approaches are required. In the present observational study, the safety and feasibility of transcatheter repair of chronic severe TR with the MitraClip system were evaluated. In addition, the effects on clinical symptoms were assessed.

METHODS

Patients with heart failure symptoms and severe TR on optimal medical treatment were treated with the MitraClip system. Safety, defined as periprocedural adverse events such as death, myocardial infarction, stroke, or cardiac tamponade, and feasibility, defined as successful implantation of 1 or more MitraClip devices and reduction of TR by at least 1 grade, were evaluated before discharge and after 30 days. In addition, functional outcome, defined as changes in New York Heart Assocation class and 6-minute walking distance, were assessed.

RESULTS

We included 64 consecutive patients (mean age 76.6±10 years) deemed unsuitable for surgery who underwent MitraClip treatment for chronic, severe TR for compassionate use. Functional TR was present in 88%; in addition, 22 patients were also treated with the MitraClip system for mitral regurgitation as a combined procedure. The degree of TR was severe or massive in 88% of patients before the procedure. The MitraClip device was successfully implanted in the tricuspid valve in 97% of the cases. After the procedure, TR was reduced by at least 1 grade in 91% of the patients, thereof 4% that were reduced from massive to severe. In 13% of patients, TR remained severe after the procedure. Significant reductions in effective regurgitant orifice area (0.9±0.3cm² versus 0.4±0.2cm²; P<0.001), vena contracta width (1.1±0.5 cm versus 0.6±0.3 cm; P=0.001), and regurgitant volume (57.2±12.8 mL/beat versus 30.8±6.9 mL/beat; P<0.001) were observed. No intraprocedural deaths, cardiac tamponade, emergency surgery, stroke, myocardial infarction, or major vascular complications occurred. Three (5%) in-hospital deaths occurred. New York Heart Association class was significantly improved (P<0.001), and 6-minute walking distance increased significantly (165.9±102.5 m versus 193.5±115.9 m; P=0.007).

CONCLUSIONS

Transcatheter treatment of TR with the MitraClip system seems to be safe and feasible in this cohort of preselected patients. Initial efficacy analysis showed encouraging reduction of TR, which may potentially result in improved clinical outcomes.

Modulation of carotid strain by statin therapy in atherosclerosis patients

BACKGROUND

The beneficial effect of statin therapy on the progress of atherosclerotic disease has been demonstrated by numerous studies. Vascular strain imaging is an arising method to evaluate arterial stiffness. Our study examined whether an influence of statin therapy on the vessel wall could be detected by vascular strain imaging.

PATIENTS AND METHODS

88 patients with recently detected atherosclerosis underwent an angiological examination including ankle-brachial index (ABI), pulse wave index (PWI), central puls ewave velocity and duplex ultrasound. Captures for vascular strain analysis were taken in B-mode during ultrasound examination of the common carotid artery and evaluated using a workstation equipped with a speckle tracking based software. A statin therapy was recommended and after six months a follow-up examination took place. Meanwhile, the non-adherence of a group of patients (N = 18) lead to a possibility to observe statin effects on the vascular strain.

RESULTS

In the statin non-adherent group the ABI decreased significantly to a still non-pathological level (1.2 ± 0.2 vs. 1.0 ± 0.2; p = 0.016) whereas it stagnated in the adherent group (1.0 ± 0.2 vs. 1.0 ± 0.2; p = 0.383). The PWI did not differ in the non-adherent group (180.5 ± 71.9 vs. 164.4 ± 75.8; p = 0.436) but under statin therapy it decreased significantly (261.8 ± 238.6 vs. 196.4 ± 137.4; p = 0.016). In comparison to the adherent group (4.2 ± 2.0 vs. 4.0 ± 1.8; p = 0.548) under statin therapy the radial strain decreased significantly in the non-adherent group (4.7 ± 2.0 vs. 3.3 ± 1.1; p = 0.014).

CONCLUSIONS

Our findings reveal a beneficial influence of statin therapy on the arterial wall detected by vascular strain analysis.

Impact of baseline tricuspid regurgitation on long-term clinical outcomes and survival after interventional edge-to-edge repair for mitral regurgitation

AIMS

Tricuspid regurgitation (TR) in patients with mitral valve disease is associated with poor outcome and mortality. Only limited data on the impact of TR on functional outcome and survival in patients undergoing MitraClip procedures are available.

METHODS AND RESULTS

261 patients (mean age 76.6 ± 10, EuroScore 15.9 ± 15.1%) with symptomatic mitral regurgitation (MR) (75.2% functional MR) undergoing MitraClip procedure were included and followed for 721 ± 19.4 days. At baseline 54.7% presented with TR grade 0/I, 29.5% with grade II, 13.4% with grade III and 2.3% with grade IV. When dividing groups according to baseline TR grades, follow-up (FU)-NYHA class was significantly improved only in patients with TR ≤ II (p = 0.05). FU-6-min walking distance increased significantly in the overall cohort (p = 0.05), in patients with TR ≤ II (p = 0.007), but not in patients with TR > II (p = 0.4). Moreover, FU-NT-pro-BNP levels were higher in patients with TR > II (p = 0.05), compared to patients with TR ≤ II. There was a higher mortality according to baseline TR > II and multivariate Cox regression revealed TR > II as the strongest independent predictor for mortality (hazard ratio 2.04).

CONCLUSIONS

Concomitant TR at baseline negatively influences functional outcome and mortality in patients undergoing MitraClip procedures. Our results underline the need for dedicated interventional strategies for the treatment of TR in patients with symptomatic MR.

Transcatheter Tricuspid Repair With MitraClip for Severe Primary Tricuspid Regurgitation

Severe tricuspid regurgitation is an independent predictor of adverse outcomes, yet few patients undergo surgery and treatment with medical therapy is often inadequate. Recent studies have reported the use of the MitraClip system (Abbott Vascular) to treat secondary tricuspid regurgitation. We describe the first use of MitraClip to treat severe primary tricuspid regurgitation and right heart failure in a patient with previous cardiac transplantation and high surgical risk.

Coronary Sinus-Based Approach to Mitral Regurgitation

Functional, or secondary, mitral regurgitation (FMR) is clinically important because patient with congestive heart failure with FMR have worse clinical outcomes and associated higher risks than patients without FMR. There is interest in finding repair techniques which may modify the mitral valve dysfunction and reduce the clinical impact. Although several devices have taken advantage of the close anatomical relationship between the coronary sinus and the posterior annulus of the mitral valve, in order to provide a cinching force on the mitral annulus, only the Carillon device is currently in use in humans. A double blind randomized trial is currently being done to evaluate the value of this therapy, building upon the favorable result of three prior safety and efficacy trials, which have led to European approval of the device.

Invasive coronary angiography in patients with acute exacerbated COPD and elevated plasma troponin

BACKGROUND

In acute exacerbation of COPD, increased plasma levels of cardiac troponin are frequent and associated with increased mortality. Thus, we aimed at prospectively determining the diagnostic value of coronary angiography in patients with exacerbated COPD and concomitantly elevated cardiac troponin.

PATIENTS AND METHODS

A total of 88 patients (mean age 72.9±9.2 years, 56.8% male) hospitalized for acute exacerbation of COPD with elevated plasma troponin were included. All patients underwent coronary angiography within 72 hours after hospitalization. Complementary 12-lead electrocardiogram, transthoracic echocardiography, pulmonary function, and angiological testing were performed.

RESULTS

Coronary angiography objectified the presence of ischemic heart disease (IHD) in 59 patients (67.0%), of whom 34 patients (38.6% of total study population) underwent percutaneous coronary intervention. Among these 34 intervened patients, the vast majority (n=26, 76.5%) had no previously known IHD, whereas only eight out of 34 patients (23.5%) presented an IHD history. Patients requiring coronary intervention showed significantly reduced left ventricular ejection fraction (45.8%±13.1% vs 55.1%±13.3%, P=0.01) and a significantly more frequent electrocardiographic ST-segment depression (20.6% vs 7.4%, P=0.01). Neither additional laboratory parameters for inflammation and myocardial injury nor lung functional measurements differed significantly between the groups.

CONCLUSION

Angiographically confirmed IHD that required revascularization occurred in 38.6% of exacerbated COPD patients with elevated cardiac troponin. In this considerable portion of patients, coronary angiography emerged to be of diagnostic and therapeutic value.

Noninvasive model including right ventricular speckle tracking for the evaluation of pulmonary hypertension

AIM

To find parameters from transthorathic echocardiography (TTE) including speckle-tracking (ST) analysis of the right ventricle (RV) to identify precapillary pulmonary hypertension (PH).

METHODS

Forty-four patients with suspected PH undergoing right heart catheterization (RHC) were consecutively included (mean age 63.1 ± 14 years, 61% male gender). All patients underwent standardized TTE including ST analysis of the RV. Based on the subsequent TTE-derived measurements, the presence of PH was assessed: Left ventricular ejection fraction (LVEF) was calculated by Simpsons rule from 4Ch. Systolic pulmonary artery pressure (sPAP) was assessed with continuous wave Doppler of systolic tricuspid regurgitant velocity and regarded raised with values ≥ 30 mmHg as a surrogate parameter for RA pressure. A concomitantly elevated PCWP was considered a means to discriminate between the precapillary and postcapillary form of PH. PCWP was considered elevated when the E/e’ ratio was > 12 as a surrogate for LV diastolic pressure. E/e’ ratio was measured by gauging systolic and diastolic velocities of the lateral and septal mitral valve annulus using TDI mode. The results were then averaged with conventional measurement of mitral valve inflow. Furthermore, functional testing with six minutes walking distance (6MWD), ECG-RV stress signs, NT pro-BNP and other laboratory values were assessed.

RESULTS

PH was confirmed in 34 patients (precapillary PH, n = 15, postcapillary PH, n = 19). TTE showed significant differences in E/e’ ratio (precapillary PH: 12.3 ± 4.4, postcapillary PH: 17.3 ± 10.3, no PH: 12.1 ± 4.5, P = 0.02), LV volumes (ESV: 25.0 ± 15.0 mL, 49.9 ± 29.5 mL, 32.2 ± 13.6 mL, P = 0.027; EDV: 73.6 ± 24.0 mL, 110.6 ± 31.8 mL, 87.8 ± 33.0 mL, P = 0.021) and systolic pulmonary arterial pressure (sPAP: 61.2 ± 22.3 mmHg, 53.6 ± 20.1 mmHg, 31.2 ± 24.6 mmHg, P = 0.001). STRV analysis showed significant differences for apical RV longitudinal strain (RVAS: -7.5% ± 5.6%, -13.3% ± 4.3%, -14.3% ± 6.3%, P = 0.03). NT pro-BNP was higher in patients with postcapillary PH (4677.0 ± 7764.1 pg/mL, precapillary PH: 1980.3 ± 3432.1 pg/mL, no PH: 367.5 ± 420.4 pg/mL, P = 0.03). Patients with precapillary PH presented significantly more often with ECG RV-stress signs (P = 0.001). Receiver operating characteristics curve analyses displayed the most significant area under the curve (AUC) for RVAS (cut-off < -6.5%, AUC 0.91, P < 0.001), sPAP (cut-off > 33 mmHg, AUC 0.86, P < 0.001) and ECG RV stress signs (AUC 0.83, P < 0.001). The combination of these parameters had a sensitivity of 82.8% and a specificity of 17.2% to detect precapillary PH.

CONCLUSION

The combination of non-invasive measurements allows feasible assessment of PH and seems beneficial for the differentiation between the pre- and postcapillary form of this disease.

Speckle tracking echocardiography in chronic obstructive pulmonary disease and overlapping obstructive sleep apnea

Background

COPD and congestive heart failure represent two disease entities of growing global burden that share common etiological features. Therefore, we aimed to identify the degree of left ventricular (LV) dysfunction in COPD as a function of COPD severity stages and concurrently placed particular emphasis on the presence of overlapping obstructive sleep apnea (OSA).

Methods

A total of 85 COPD outpatients (64.1±10.4 years, 54.1% males) and 20 controls, matched for age, sex, and smoking habits, underwent speckle tracking echocardiography for LV longitudinal strain imaging. Complementary 12-lead electrocardiography, laboratory testing, and overnight screening for sleep-disordered breathing using the SOMNOcheck micro^® device were performed.

Results

Contrary to conventional echocardiographic parameters, speckle tracking echocardiography revealed significant impairment in global LV strain among COPD patients compared to control smokers (−13.3%±5.4% vs −17.1%±1.8%, P=0.04). On a regional level, the apical septal LV strain was reduced in COPD (P=0.003) and associated with the degree of COPD severity (P=0.02). With regard to electrocardiographic findings, COPD patients exhibited a significantly higher mean heart rate than controls (71.4±13.0 beats per minute vs 60.3±7.7 beats per minute, P=0.001) that additionally increased over Global Initiative for Chronic Obstructive Lung Disease stages (P=0.01). Albeit not statistically significant, COPD led to elevated N-terminal pro-brain natriuretic peptide levels (453.2±909.0 pg/mL vs 96.8±70.0 pg/mL, P=0.08). As to somnological testing, the portion of COPD patients exhibiting overlapping OSA accounted for 5.9% and did not significantly vary either in comparison to controls (P=0.07) or throughout the COPD Global Initiative for Chronic Obstructive Lung Disease stages (P=0.49). COPD-OSA overlap solely correlated with nocturnal hypoxemic events, whereas LV performance status was unrelated to coexisting OSA.

Conclusion

To conclude, COPD itself seems to be accompanied with decreased LV deformation properties that worsen over COPD severity stages, but do not vary in case of overlapping OSA.

Routine Endovascular Treatment With a Stent Graft for Access-Site and Access-Related Vascular Injury in Transfemoral Transcatheter Aortic Valve Implantation

Background—

Access-site and access-related vascular injury (ASARVI) is still a major limiting factor in transcatheter aortic valve implantation and affects the outcome of patients. Management strategies for ASARVI include manual compression, stent grafts, and vascular surgery. We hypothesized that the standard use of a self-expanding stent graft for the management of ASARVI is feasible and safe.

Methods and Results—

Of 407 patients treated by transfemoral transcatheter aortic valve implantation, 110 experienced ASARVI (27.0%). Of these, 96 (87.3%) were managed by the implantation of a self-expanding nitinol stent graft. In the majority of patients, minor vascular complications triggered the implantation of a stent graft (86.5%), mainly because of bleeding (90.6%) and dissection (5.2%) of the common femoral artery with high rates of primary treatment success (97.9%). Patients receiving stent grafts were more often female (62.2 versus 45.6%, P <0.01), had higher body mass indices (27.8±6.7 versus 25.7±4.7, P =0.01), and suffered more often from diabetes mellitus (34.4 versus 24.5%, P =0.04). Angiographic assessment after a median follow-up of 345 days (interquartile range, 23–745 days) revealed only one patient with moderate, asymptomatic instent-stenosis (1.0%). Compared with a propensity score–matched cohort of patients without ASARVI, stented patients had comparable long-term mortality, despite the occurrence of a vascular complication (1-year mortality: 17.7% versus 26.6%; stent versus matched cohort, respectively; P =0.1).

Conclusions—

Routine use of a self-expanding nitinol stent graft in selected patients experiencing ASARVI after transcatheter aortic valve implantation is feasible, safe, and associated with favorable short- and midterm clinical outcome.

Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF)

BACKGROUND

Data on left atrial/left atrial appendage (LA/LAA) thrombus resolution after non-vitamin K antagonist (VKA) oral anticoagulant treatment are scarce. The primary objective of X-TRA was to explore the use of rivaroxaban for the resolution of LA/LAA thrombi in patients with nonvalvular atrial fibrillation (AF) or atrial flutter, with the CLOT-AF registry providing retrospective data after standard-of-care therapy in this setting.

METHODS

X-TRA was a prospective, single-arm, open-label, multicenter study that investigated rivaroxaban treatment for 6 weeks for LA/LAA thrombus resolution in patients with nonvalvular AF or atrial flutter and LA/LAA thrombus confirmed at baseline on a transesophageal echocardiogram (TEE). CLOT-AF retrospectively collected thrombus-related patient outcome data after standard-of-care anticoagulant treatment for 3 to 12 weeks in patients with nonvalvular AF or atrial flutter who had LA/LAA thrombi on TEE recorded in their medical file.

RESULTS

In X-TRA, patients were predominantly (95.0%) from Eastern European countries. The adjudicated thrombus resolution rate was 41.5% (22/53 modified intention-to-treat [mITT] patients, 95% CI 28.1%-55.9%) based on central TEE assessments. Resolved or reduced thrombus was evident in 60.4% (32/53 mITT patients, 95% CI 46.0%-73.6%) of patients. In CLOT-AF, the reported thrombus resolution rate was 62.5% (60/96 mITT patients, 95% CI 52.0%-72.2%) and appeared better in Western European countries (34/50; 68.0%) than in Eastern European countries (26/46; 56.5%).

CONCLUSION

X-TRA is the first prospective, multicenter study examining LA/LAA thrombus resolution with a non-VKA oral anticoagulant in VKA-naïve patients or in patients with suboptimal VKA therapy. Rivaroxaban could be a potential option for the treatment of LA/LAA thrombi.

Thrombus Formation After Left Atrial Appendage Occlusion With the Amplatzer Amulet Device

OBJECTIVES

This study sought to define the ideal post-procedural anticoagulant regime and to systematically study the incidence of device-related thrombus.

BACKGROUND

Left atrial appendage occlusion (LAAo) is an alternative to life-long oral anticoagulation in selected patients with atrial fibrillation.

METHODS

This study included 24 atrial fibrillation patients (ages 79 ± 8 years; 75% male, CHA₂DS₂VASc [Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Previous Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years. Sex] score: 4.3 ± 1.5, HAS-BLED [Hypertension, Abnormal Renal and Liver Function, Stroke, Bleeding, Labile International Normalized Ratio, Elderly, Drugs or Alcohol] score: 3.6 ± 0.8) after LAAo with the use of the Amplatzer Amulet system. Dual antiplatelet therapy for 3 months was prescribed in 95.6% of the cases.

RESULTS

Transesophageal echocardiography identified a high rate of device adherent thrombi (16.7%, n = 4 of 23) after a mean of 11.0 ± 8.2 weeks. Thrombus formation occurred under dual antiplatelet therapy (3 of 4) or clopidogrel monotherapy (1 of 4). When compared with patients without thrombi, echocardiography showed higher degrees of spontaneous echo contrast grades within the LAA (3.0 ± 1.0 vs. 1.3 ± 1.1), lower LAA peak emptying velocities (17.5 ± 5.0 cm/s vs. 48.3 ± 21.1 cm/s), and decreased left ventricular function (39 ± 10% vs. 50 ± 13%) in patients with device-related thrombus. All thrombi were observed within the untrabeculated region of the LAA ostium between the left upper pulmonary vein ridge and the occluder disc, indicating suboptimal LAA occlusion.

CONCLUSIONS

Device-related thrombus is a frequent finding after LAAo with the Amplatzer Amulet device (St. Jude Medical, St. Paul, Minnesota). Our results emphasize the need for an optimized post-LAAo anticoagulation regimen, a revised implantation strategy, and possibly modified patient selection criteria.

Circulating Microparticles Decrease After Cardiac Stress in Patients With Significant Coronary Artery Stenosis

BACKGROUND

Cardiac stress leads to a dynamic increase of circulating microparticles (MPs) in healthy individuals that is diminished in individuals with vascular disease. The impact of coronary ischemia on circulating MP level is unknown. This study investigates the kinetics of circulating MPs during cardiac stress in patients with coronary artery stenosis.

HYPOTHESIS

Patients with significant coronary stenosis show altered circulating MP levels after cardiac stress.

METHODS

Eighty patients with stable coronary artery disease underwent dobutamine stress echocardiography (DSE) on the day before coronary angiography. Before, immediately after, at 4 hours, and at 24 hours after DSE, blood was drawn to determine CD144⁺ endothelial microparticles (EMPs), CD14⁺ CD16⁺ monocyte-derived microparticles (MMPs), and CD31⁺ CD42b⁺ platelet microparticles. A significant stenosis was defined as stenosis diameter ≥70% in a major native epicardial coronary artery with a diameter of ≥2.5 mm.

RESULTS

Significant coronary artery stenoses were found in 41 patients. In these patients, CD144⁺ -EMP and CD14⁺ CD16⁺ -MMP concentrations decreased immediately after DSE. Stimulation of target endothelial cells with sera from patients with significant coronary artery stenoses significantly augmented endothelial capacity to take up EMPs, but not MMPs, in vitro. Serum-induced enhancement of endothelial phosphatidylserine receptor expression was found as a potential mechanism of increased endothelial EMP uptake and subsequently reduced circulating EMP levels after cardiac stress.

CONCLUSIONS

Cardiac ischemia leads to reduced circulating MP levels under cardiac stress. Changes of endothelial MP uptake capacities could be one possible mechanism.