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Tanaka T, Sugiura A, Kavsur R, Vogelhuber J, Öztürk C, Zimmer S, Nickenig G, Weber M. Pulmonary Artery Pulsatility Index and Clinical Outcomes in Patients Undergoing Transcatheter Tricuspid Valve Interventions. JACC Cardiovasc Interv 2024; 17:952-954. [PMID: 38599704 DOI: 10.1016/j.jcin.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
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Tanaka T, Sugiura A, Kavsur R, Öztürk C, Wilde N, Zimmer S, Nickenig G, Weber M, Vogelhuber J. Changes in right ventricular function and clinical outcomes following tricuspid transcatheter edge-to-edge repair. Eur J Heart Fail 2024. [PMID: 38454641 DOI: 10.1002/ejhf.3183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 01/29/2024] [Accepted: 02/21/2024] [Indexed: 03/09/2024] Open
Abstract
AIMS Prognostic impact of post-procedural changes in right ventricular (RV) function after tricuspid transcatheter edge-to-edge repair (T-TEER) is still unclear. We investigated association of RV function and its post-procedural changes with clinical outcomes in patients undergoing T-TEER. METHODS AND RESULTS We retrospectively analysed 204 patients who underwent T-TEER and echocardiographic follow-up at 3 months after T-TEER. RV function was assessed by RV fractional area change (RVFAC), and RV dysfunction was defined as RVFAC <35%. Patients with an increase in RVFAC from baseline to the follow-up were considered as RV responders. Patients were divided into four groups according to baseline RVFAC and the RV responder. The primary outcome was a composite of mortality and hospitalization due to heart failure within 1 year. Forty-five of 204 patients (22.1%) had RVFAC <35% at baseline, and 71 (34.8%) were RV responders. The association between the RV responder and the composite outcome had a significant interaction with RVFAC at baseline. Among patients with baseline RVFAC <35%, RV responders had a lower risk of the composite outcome than RV non-responders, while this association was not significant in those with baseline RVFAC ≥35%. Among patients with baseline RVFAC <35%, a smaller RV diameter and a greater reduction of tricuspid regurgitation were predictors for the RV responder. CONCLUSION Post-procedural increase in RVFAC after T-TEER is associated with improved outcomes in patients with RV dysfunction. The factors related to the increase in RVFAC may support patient selection for T-TEER in patients with RV dysfunction.
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Affiliation(s)
- Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
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Silaschi M, Cattelaens F, Alirezaei H, Vogelhuber J, Sommer S, Sugiura A, Schulz M, Tanaka T, Sudo M, Zimmer S, Nickenig G, Weber M, Bakhtiary F, Wilde N. Transcatheter Edge-to-Edge Mitral Valve Repair versus Minimally Invasive Mitral Valve Surgery: An Observational Study. J Clin Med 2024; 13:1372. [PMID: 38592259 PMCID: PMC10932335 DOI: 10.3390/jcm13051372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Minimally invasive mitral valve surgery (MIC-MVS) has been established as preferred treatment of mitral regurgitation (MR), but mitral transcatheter edge-to-edge valve repair (M-TEER) is routinely performed in patients at high surgical risk and is increasingly performed in intermediate risk patients. Methods: From 2010 to 2021, we performed 723 M-TEER and 123 isolated MIC-MVS procedures. We applied a sensitivity analysis by matching age, left ventricular ejection fraction (LVEF), EuroSCORE II and etiology of MR. Results: Baseline characteristics showed significant differences in the overall cohort (p < 0.01): age 78.3 years vs. 61.5 years, EuroSCORE II 5.5% vs. 1.3% and LVEF 48.4% vs. 60.4% in M-TEER vs. MIC-MVS patients. Grade of MR at discharge was moderate/severe in 24.5% (171/697) in M-TEER vs. 6.5% (8/123) in MIC-MVS (p < 0.01). One-year survival was 91.5% (552/723) in M-TEER vs. 97.6% (95/123) in MIC-MVS (p = 0.04). A matching with 49 pairs (n = 98) showed comparable survival during follow-up, but a numerically higher mean mitral valve gradient of 4.1 mmHg (95% CI: 3.6-4.6) vs. 3.4 mmHg (95% CI: 3.0-3.8) in M-TEER (p = 0.04). Conclusions: Patients undergoing M-TEER had lower one-year survival than MIC-MVS, but differences disappeared after matching. Reduction in MR was less effective in M-TEER patients and postprocedural mitral valve gradients were higher.
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Affiliation(s)
- Miriam Silaschi
- Department of Cardiac Surgery, Heart Center Bonn, 53127 Bonn, Germany; (M.S.); (F.C.); (H.A.); (F.B.)
| | - Franca Cattelaens
- Department of Cardiac Surgery, Heart Center Bonn, 53127 Bonn, Germany; (M.S.); (F.C.); (H.A.); (F.B.)
| | - Hossien Alirezaei
- Department of Cardiac Surgery, Heart Center Bonn, 53127 Bonn, Germany; (M.S.); (F.C.); (H.A.); (F.B.)
| | - Johanna Vogelhuber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Susanne Sommer
- Department of Cardiac Surgery, Bundeswehrzentralkrankenhaus Koblenz, 56072 Koblenz, Germany;
| | - Atsushi Sugiura
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Max Schulz
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Tetsu Tanaka
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Mitsumasa Sudo
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Georg Nickenig
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Marcel Weber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Bonn, 53127 Bonn, Germany; (M.S.); (F.C.); (H.A.); (F.B.)
| | - Nihal Wilde
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (J.V.); (A.S.); (M.S.); (T.T.); (M.S.); (S.Z.); (G.N.); (M.W.)
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Tanaka T, Sugiura A, Vogelhuber J, Öztürk C, Böhm L, Wilde N, Zimmer S, Nickenig G, Weber M. Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation. EUROINTERVENTION 2024; 20:e250-e260. [PMID: 38389471 PMCID: PMC10870009 DOI: 10.4244/eij-d-23-00819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The prognostic benefits of transcatheter edge-to-edge repair (TEER) remain unclear in patients with atrial functional mitral regurgitation (AFMR). AIMS We aimed to investigate the clinical outcomes of TEER for patients with AFMR. METHODS We retrospectively classified functional mitral regurgitation (FMR) patients undergoing TEER into those with AFMR or ventricular FMR (VFMR). A residual MR ≤1+ at discharge was considered optimal mitral regurgitation (MR) reduction, and an elevated mean mitral valve pressure gradient (MPG) was defined as an MPG ≥5 mmHg at discharge. The primary outcome was a composite of all-cause mortality and hospitalisation due to heart failure within one year. RESULTS Of 441 FMR patients, 125 patients were considered as having AFMR. Residual MR ≤1+ was associated with a lower risk of the composite outcome in both AFMR and VFMR patients, while an MPG ≥5 mmHg was associated with a higher risk of the composite outcome in patients with AFMR but not with VFMR. AFMR patients with residual MR ≤1+ and an MPG ≥5 mmHg, as well as those with residual MR >1+, had a higher incidence of the composite outcome than those with residual MR ≤1+ and an MPG <5 mmHg (50.7%, 41.8%, and 14.3%, respectively; p<0.001). This association was consistent after adjustment for clinical and echocardiographic characteristics. CONCLUSIONS An MR reduction to ≤1+ following TEER was associated with a lower risk of clinical outcomes in patients with AFMR, while an MPG ≥5 mmHg was related to a higher risk of clinical outcomes. Optimal MR reduction by TEER may have potential benefits on the prognosis of patients with AFMR, although the prognostic benefit may be attenuated by an elevated MPG.
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Affiliation(s)
- Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Lukas Böhm
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
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Tanaka T, Balata M, Sugiura A, Kavsur R, Vogelhuber J, Öztürk C, Zimmer S, Nickenig G, Weber M. Chronic Obstructive Pulmonary Disease and Clinical Outcomes After Transcatheter Tricuspid Valve Repair. JACC Cardiovasc Interv 2024; 17:106-107. [PMID: 38069991 DOI: 10.1016/j.jcin.2023.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 01/12/2024]
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Vogelhuber J, Tenaka T, Sudo M, Sugiura A, Öztürk C, Kavsur R, Donner A, Nickenig G, Zimmer S, Weber M, Wilde N. Impact of body mass index in patients with tricuspid regurgitation after transcatheter edge-to-edge repair. Clin Res Cardiol 2024; 113:156-167. [PMID: 37792020 PMCID: PMC10808352 DOI: 10.1007/s00392-023-02312-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Obesity and underweight represent classical risk factors for outcome in patients treated for cardiovascular disease. This study describes the impact of different body mass index (BMI) categories on 1-year clinical outcome in patients with tricuspid regurgitation (TR) undergoing transcatheter-edge-to-edge repair (TEER). METHODS We analyzed 211 consecutive patients (age 78.3 ± 7.2 years, 55.5% female, median EuroSCORE II 9.6 ± 6.7) with tricuspid regurgitation undergoing TEER from June 2015 until May 2021. Patients were prospectively enrolled in our single center registry and were retrospectively analyzed. Patients were stratified according to body mass index (BMI) into 4 groups: BMI < 20 kg/m2 (underweight), BMI 20.0 to < 25.0 kg/m2 (normal weight), BMI 25.0 to > 30.0 kg/m2 (overweight) and BMI ≥ 30 kg/m2 (obese). RESULTS Kaplan-Meier survival curves demonstrated inferior survival for underweight and obese patients, but comparable outcomes for normal and overweight patients (global log rank test, p < 0.01). Cardiovascular death was significantly higher in underweight patients compared to the other groups (24.1% vs. 7.0% vs. 6.3% vs. 6.4%; p < 0.01). Over all, there were comparable rates of bleeding, stroke and myocardial infarction. Multivariable Cox regression analysis (adjusted for age, gender, coronary artery disease, chronic obstructive pulmonary disease, tricuspid annular plane systolic excursion, left-ventricular ejection fraction) confirmed underweight (HR 3.88; 95% CI 1.64-7.66; p < 0.01) and obesity (HR 3.24; 95% CI 1.37-9.16; p < 0.01) as independent risk factors for 1-year all-cause mortality. CONCLUSIONS Compared to normal weight and overweight patients, obesity and underweight patients undergoing TEER display significant higher 1-year all-cause mortality.
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Affiliation(s)
- Johanna Vogelhuber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tetsu Tenaka
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mitsumasa Sudo
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Anika Donner
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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Sugiura A, Tanaka T, Kavsur R, Öztürk C, Silaschi M, Goto T, Weber M, Zimmer S, Nickenig G, Vogelhuber J. Refining accuracy of RV-PA coupling in patients undergoing transcatheter tricuspid valve treatment. Clin Res Cardiol 2024; 113:177-186. [PMID: 38010521 PMCID: PMC10808486 DOI: 10.1007/s00392-023-02339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Assessing right ventricular (RV) function is paramount for risk stratification, which remains challenging in patients with tricuspid regurgitation (TR). We assessed RV-pulmonary artery (PA) coupling and its predictability of outcomes after transcatheter tricuspid valve repair (TTVR). METHODS Study participants comprised patients undergoing transcatheter tricuspid valve repair to treat symptomatic TR from June 2015 to July 2021. We calculated an RV-PA coupling ratio using a formula, which is dividing tricuspid annular plane systolic excursion (TAPSE) by echocardiographically estimated (ePASP) or invasively measured PASP (iPASP) at baseline. The primary outcome was all-cause mortality or heart failure rehospitalization within one year. RESULTS The study participants (n = 206) were at high surgical risk (EuroSCORE II: 7.4 ± 4.8%). The primary outcome occurred in 57 patients within one year. The c-statistics for the outcome were 0.565 (95% CI 0.488-0.643) for TAPSE/ePASP and 0.695 (95% CI 0.631-0.759) for TAPSE/iPASP. The correlation between the ePASP and iPASP was attenuated in patients with massive/torrential TR compared to those with severe TR (interaction p = 0.01). In the multivariable Cox proportional model, TAPSE/iPASP was inversely associated with the risk of the primary outcome (per 0.1-point increase: adjusted-HR 0.67, 95% CI 0.56-0.82, p < 0.001), independent of baseline demographics. According to the TAPSE/iPASP quartiles (i.e., ≤ 0.316; 0.317-0.407; 0.408-0.526; ≥ 0.527), the event-free survival was 43.4%, 48.3%, 77.9%, and 85.4% at one year after TTVR. CONCLUSION RV-PA coupling predicts one-year mortality and heart failure rehospitalization after TTVR in patients with TR. The predictability is improved if invasively-measured PA pressure is included.
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Affiliation(s)
- Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Miriam Silaschi
- Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Tanaka T, Sugiura A, Schulz M, Wilde N, Vogelhuber J, Sudo M, Zimmer S, Nickenig G, Weber M. Cardiac computed tomography-based assessment of mitral annular calcification in patients undergoing mitral transcatheter edge-to-edge repair. J Cardiovasc Comput Tomogr 2024; 18:26-32. [PMID: 38105119 DOI: 10.1016/j.jcct.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/27/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The role of assessment of mitral annular calcification (MAC) using cardiac computed tomography (CCT) in mitral transcatheter edge-to-edge repair (TEER) remains unclear. The aim of this study was to investigate the association of MAC assessed by CCT with procedural and clinical outcomes in patients undergoing TEER. METHODS We retrospectively analyzed 275 patients who underwent pre-procedural CCT prior TEER. Mitral calcium volume (MCV) and MAC score were measured by CCT. Functional procedural success was defined as residual mitral regurgitation of ≤2+ with mean transmitral gradient of <5 mmHg at discharge. All-cause mortality within two years after TEER was collected. RESULTS MAC was present in 115 of 275 patients (41.8 %). The median MCV was 198 mm3 (interquartile range [IQR]: 84 to 863 mm3), and the median MAC score was 3 (IQR: 2 to 4). Higher MCV and MAC score were inversely related to the rate of functional procedural success, independently of anatomical features of mitral valve. Patients with moderate/severe MAC, defined as MAC score of ≥4, had a lower rate of functional procedural success than those without MAC (56.1 % vs. 81.3 %; p = 0.002). Moreover, higher MCV and MAC score were associated with a higher risk of all-cause mortality within two years, irrespective of baseline characteristics and functional procedural success. CONCLUSIONS The presence and burden of MAC assessed by CCT were associated with procedural and clinical outcomes in patients undergoing TEER. The CCT-based assessment of MAC may improve patient selection for TEER.
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Affiliation(s)
- Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany.
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Max Schulz
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Mitsumasa Sudo
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
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Wilde N, Tanaka T, Vij V, Sugiura A, Sudo M, Eicheler E, Silaschi M, Vogelhuber J, Bakhtiary F, Nickenig G, Weber M, Zimmer S. Characteristics and outcomes of patients undergoing transcatheter mitral valve replacement with the Tendyne system. Clin Res Cardiol 2024; 113:1-10. [PMID: 36645506 PMCID: PMC10808407 DOI: 10.1007/s00392-023-02155-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/05/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Transcatheter mitral valve replacement (TMVR) has emerged as alternative to transcatheter edge-to-edge repair (TEER) for treatment of mitral regurgitation (MR); however, the role of TMVR with the Tendyne system among established treatments of MR is not well defined. We assessed characteristics and outcomes of patients treated with the Tendyne system in the current clinical practice. METHODS We reviewed patients who underwent cardiac computed tomography and were judged eligible for the Tendyne system. RESULTS A total of 63 patients were eligible for TMVR with the Tendyne system. Of these, 17 patients underwent TMVR, and 46 were treated by TEER. Patients treated with the Tendyne system were more likely to have a high transmitral pressure gradient and unsuitable mitral valve morphology for TEER than those treated with TEER. TMVR with the Tendyne system reduced the severity of MR to less than 1 + in 94.1% of the patients at discharge and achieved a greater reduction in left ventricular (LV) end-diastolic volume at the 30-day follow-up compared with TEER. In contrast, patients treated with the Tendyne system had a higher 30-day mortality than those treated with TEER, while the mortality between 30 days and one year was comparable between Tendyne and TEER. CONCLUSIONS Among patients eligible for the Tendyne system, approximately a quarter of the patients underwent TMVR with the Tendyne system, which led substantial reduction of MR and LV reverse remodeling than TEER. In contrast, the 30-day mortality rate was higher after TMVR with the Tendyne compared to TEER.
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Affiliation(s)
- Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Vivian Vij
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mitsumasa Sudo
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Eva Eicheler
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Miriam Silaschi
- Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Farhad Bakhtiary
- Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Tanaka T, Sugiura A, Kavsur R, Öztürk C, Vogelhuber J, Wilde N, Kütting D, Meyer C, Zimmer S, Grube E, Bakhtiary F, Nickenig G, Weber M. Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve repair. Eur Heart J Cardiovasc Imaging 2023; 24:1501-1508. [PMID: 37232362 DOI: 10.1093/ehjci/jead102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/03/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
AIMS The role of right ventricular function in patients undergoing transcatheter tricuspid valve repair (TTVR) is poorly understood. This study investigated the association of right ventricular ejection fraction (RVEF) assessed by cardiac computed tomography (CCT) with clinical outcomes in patients undergoing TTVR. METHODS AND RESULTS We retrospectively assessed three-dimensional (3D) RVEF by using pre-procedural CCT images in patients undergoing TTVR. RV dysfunction was defined as a CT-RVEF of <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within 1 year after TTVR. Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Procedural success and in-hospital mortality were comparable between patients with CT-RVEF <45% and ≥45%. However, CT-RVEF of <45% was associated with a higher risk of the composite outcome (hazard ratio: 2.99; 95% confidence interval: 1.65-5.41; P = 0.001), which had an additional value beyond two-dimensional echocardiographic assessments of RV function to stratify the risk of the composite outcome. In addition, patients with CT-RVEF ≥45% exhibited the association of procedural success (i.e. residual tricuspid regurgitation of ≤2+ at discharge) with a decreased risk of the composite outcome, while this association was attenuated in those with CT-RVEF <45% (P for interaction = 0.035). CONCLUSION CT-RVEF is associated with the risk of the composite outcome after TTVR, and a reduced CT-RVEF might attenuate the prognostic benefit of TR reduction. The assessment of 3D-RVEF by using CCT may refine the patient selection for TTVR.
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Affiliation(s)
- Tetsu Tanaka
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Atsushi Sugiura
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Refik Kavsur
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Can Öztürk
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Johanna Vogelhuber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Nihal Wilde
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Daniel Kütting
- Department of Radiology, University Hospital Bonn, Germany
| | - Carsten Meyer
- Department of Radiology, University Hospital Bonn, Germany
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Eberhard Grube
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Marcel Weber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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Wilde N, Silaschi M, Alirezaei H, Vogelhuber J, Sugiura A, Tanaka T, Sudo M, Kavsur R, Cattelaens F, El-Sayed Ahmad A, Doss M, Fehske W, Zimmer S, Nickenig G, Bakhtiary F, Weber M. Transcatheter edge-to-edge valve repair versus minimally invasive beating-heart surgery of the tricuspid valve: an observational study. EUROINTERVENTION 2023; 19:659-661. [PMID: 37403809 PMCID: PMC10591193 DOI: 10.4244/eij-d-23-00170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Affiliation(s)
- Nihal Wilde
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiac Surgery, Heart Center Bonn, Bonn, Germany
| | | | | | - Atsushi Sugiura
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
| | - Tetsu Tanaka
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
| | - Mitsumasa Sudo
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
| | - Refik Kavsur
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
| | | | | | - Mirko Doss
- Department of Cardiac Surgery, Helios Hospital Siegburg, Siegburg, Germany
| | - Wolfgang Fehske
- Department of Cardiology, Helios Hospital Siegburg, Siegburg, Germany
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
| | | | - Marcel Weber
- Department of Internal Medicine II, Heart Center Bonn, Bonn, Germany
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12
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Vogelhuber J, Tanaka T, Sugiura A, Galka N, Hupp-Herschel HE, Becher MU, Zimmer S, Nickenig G, Kavsur R, Weber M. Association of TRI-SCORE With Clinical Outcomes After Transcatheter Tricuspid Valve Repair. JACC Cardiovasc Interv 2023:S1936-8798(23)00694-5. [PMID: 37294224 DOI: 10.1016/j.jcin.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/04/2023] [Indexed: 06/10/2023]
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13
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Sudo M, Vij V, Wilde N, Tanaka T, Vogelhuber J, Silaschi M, Weber M, Bakhtiary F, Nickenig G, Zimmer S, Sugiura A. Contemporary Treatment and Outcomes of High Surgical Risk Mitral Regurgitation. J Clin Med 2023; 12:jcm12082978. [PMID: 37109312 PMCID: PMC10144978 DOI: 10.3390/jcm12082978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
Before the development of transcatheter interventions, patients with mitral regurgitation (MR) and high surgical risk were often conservatively treated and subject to poor prognoses. We aimed to assess the therapeutic approaches and outcomes in the contemporary era. The study participants were consecutive high-risk MR patients from April 2019 to October 2021. Among the 305 patients analyzed, 274 (89.8%) underwent mitral valve interventions, whereas 31 (10.2%) received medical therapy alone. Of the interventions, transcatheter edge-to-edge mitral repair (TEER) was the most frequent (82.0% of overall), followed by transcatheter mitral valve replacement (TMVR) (4.6%). In patients treated with medical therapy alone, non-optimal morphologies for TEER and TMVR were shown in 87.1% and 65.0%, respectively. Patients undergoing mitral valve interventions experienced less frequent heart failure (HF) rehospitalization compared to those with medical therapy alone (18.2% vs. 42.0%, p < 0.01). Mitral valve intervention was associated with a lower risk of HF rehospitalization (HR 0.36 [0.18-0.74]) and an improved New York Heart Association class (p < 0.01). Most high-risk MR patients can be treated with mitral valve interventions. However, approximately 10% remained on medical therapy alone and were considered as unsuitable for current transcatheter technologies. Mitral valve intervention was associated with a lower risk of HF rehospitalization and improved functional status.
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Affiliation(s)
- Mitsumasa Sudo
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
- Department of Cardiology, Division of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Vivian Vij
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
| | - Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
| | - Miriam Silaschi
- Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, 53179 Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
| | - Farhad Bakhtiary
- Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, 53179 Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, 53179 Bonn, Germany
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14
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Sugiura A, Zachoval C, Al-Kassou B, Shamekhi J, Vogelhuber J, Sudo M, Tanaka T, Weber M, Nickenig G, Zimmer S. Impact of New eGFR Equations on Risk Assessment In Patients Undergoing Transcatheter Aortic Valve Implantation. Cardiovasc Revasc Med 2023; 49:42-46. [PMID: 36609100 DOI: 10.1016/j.carrev.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Recently, the Chronic Kidney Disease-Epidemiology Collaboration working group has published new formulas for race-independent estimation of glomerular filtration rate (GFR). We investigated the old and new eGFR equations in patients transcatheter aortic valve implantation (TAVI). METHODS We conducted a retrospective analysis based on the data from a prospective registry of patients who underwent TAVI from January 2008 to May 2019. The primary endpoint was 30-day mortality after TAVI, and the secondary endpoints included one- and three-year mortality. RESULTS In total, 1792 patients undergoing TAVI were included in the present analysis. The thirty-day mortality was 4.6 % (95 % CI 3.8-5.7 %), and the one- and three-year mortality were 17.5 % (95 % CI 15.7-19.4 %) and 34.4 % (95 % CI 32.0-37.0 %). After the application of the new eGFR formula, 12.0 % of patients were reclassified within the GFR category in CKD, while 13.2 % of patients were reclassified within the GFR categories of the EuroSCORE II. Hazard ratios for 30-day, one-year, and three-year mortality increased after introduction of the new creatine-based eq. (1.51, 1.52, 1.49 vs. 1.87, 1.79, 1.74, respectively). Compared to the old equation, the new eGFR <60 ml/min/1.73 m2 had a better discrimination ability for the 30-day mortality (Harell's C: 0.563 (95 % CI 0.518-0.608) vs, 0.583 (95 % CI 0.546-0.636); delta Harell's C, 0.031 ± 0.022, p < 0.001). Similar findings were consistently observed in the cystatin creatinine-based equations. CONCLUSIONS The application of the new race-independent estimators of GFR results in the reassessment of renal function in a significant proportion of TAVI patients and may influence the risk stratification of this population.
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Affiliation(s)
- Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Christian Zachoval
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Baravan Al-Kassou
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Jasmin Shamekhi
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Mitsumasa Sudo
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Tetsu Tanaka
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Germany.
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15
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Tanaka T, Kavsur R, Sugiura A, Galka N, Oeztuerk C, Vogelhuber J, Becher MU, Weber M, Zimmer S, Nickenig G, Zachoval C. Prognostic impact of acute kidney injury following tricuspid transcatheter edge-to-edge repair. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
A considerable risk of acute kidney injury (AKI) following transcatheter interventions without iodinated contrast agents has also been recognized; however, little is known about the incidence and clinical relevance of post-procedural AKI in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR).
Purpose
This study aimed to investigate the prognostic impact and predictors of post-procedural AKI following TEER for TR.
Methods
We retrospectively analyzed 218 consecutive patients who underwent TEER for TR. Post-procedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dl within 48 hours or of ≥50% within seven days after the procedure, compared to baseline. Procedural success was defined as at least one grade reduction in TR severity upon discharge. We determined the association between post-procedural AKI and the composite outcome consisting of all-cause mortality and re-hospitalization due to heart failure within one year after the procedure.
Results
Overall, the mean age of the patients was 79±7 years, and 46.3% of the patients were male. Post-procedural AKI occurred in 32 patients (14.7%) (Figure 1). Among baseline characteristics, male sex and an estimated glomerular filtration rate of <60 ml/min/m2 were associated with the occurrence of AKI. In addition, patients without procedural success had a higher incidence of post-procedural AKI (30.4% vs. 1.8%; p=0.024).
Patients with AKI had a higher incidence of in-hospital mortality compared to those without AKI (12.5% vs. 1.1%; p=0.005). Moreover, AKI was associated with the incidence of the composite outcome within one year after TEER for TR (adjusted hazard ratio: 2.06; 95% confidence interval: 1.11–3.84; p=0.023). In addition, our restricted cubic spline curve showed that a post-procedural increase in the creatinine level within seven days after the procedure was associated with a linear trend of the risk of the composite outcome after TEER (Figure 2).
Conclusions
Post-procedural AKI occurred in 14.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. Male sex and CKD at baseline were related to the occurrence of AKI, and the procedural success of TEER was associated with a lower incidence of AKI. Our findings highlight the clinical impact of AKI following TEER for TR and should help with identifying patients at high risk of AKI.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- T Tanaka
- University hospital Bonn , Bonn , Germany
| | - R Kavsur
- University hospital Bonn , Bonn , Germany
| | - A Sugiura
- University hospital Bonn , Bonn , Germany
| | - N Galka
- University hospital Bonn , Bonn , Germany
| | - C Oeztuerk
- University hospital Bonn , Bonn , Germany
| | | | - M U Becher
- University hospital Bonn , Bonn , Germany
| | - M Weber
- University hospital Bonn , Bonn , Germany
| | - S Zimmer
- University hospital Bonn , Bonn , Germany
| | - G Nickenig
- University hospital Bonn , Bonn , Germany
| | - C Zachoval
- University hospital Bonn , Bonn , Germany
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16
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Tanaka T, Sugiura A, Oeztuerk C, Vogelhuber J, Tabata N, Wilde N, Zimmer S, Nickenig G, Weber M. Effectiveness of transcatheter edge-to-edge repair for atrial secondary mitral regurgitation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Atrial secondary mitral regurgitation (ASMR) is a subtype of SMR that is characterized by normal left ventricular (LV) function, an enlarged left atrium and mitral annulus, and flattened leaflets. This anatomical feature is different from ventricular SMR (VSMR) and might therefore impact the procedural results of transcatheter edge-to-edge repair (TEER). The effectiveness and durability of TEER in patients with ASMR has not yet been well-studied.
Purpose
This study aimed to investigate the effectiveness of TEER and anatomical characteristics related to optimal MR reduction in patients with ASMR.
Methods
We retrospectively analyzed consecutive patients who underwent MitraClip at our institution. ASMR was defined as cases that met all of the following criteria: 1) normal mitral leaflets without organic disorder, 2) LV ejection fraction >50%, and 3) absence of LV enlargement and segmental abnormality. The primary outcome measure was MR reduction to ≤1+, and its predictors were explored in a logistic regression analysis. Leaflet-to-annulus index (LAI) was measured using the mid-esophageal long-axis view in the A2-P2 segment as follows: (anterior leaflet length + posterior leaflet length) / anteroposterior length of the mitral annulus.
Results
Among 415 patients with SMR, 118 patients met the criteria for ASMR (mean age: 80±8 years; male: 39.8%) (Figure 1). Patients with ASMR had a larger mitral annulus diameter, shorter mobile posterior leaflet length, and smaller coaptation depth compared to those with VSMR.
The technical success rate was 90.7%, and the MR reduction to ≤1+ after TEER was achieved in 94 (79.7%) patients with ASMR, which was comparable with VSMR. The in-hospital mortality rate was 2.5%. In multivariable logistic analysis, a large left-atrial (LA) volume index and a low LAI were associated with a lower rate of MR reduction to ≤1+ after TEER for ASMR (odds ratio [OR]: 0.98; 95% confidence interval [CI]: 0.97–0.99, and OR per 0.1 increase: 1.98; 95% CI: 1.13–3.45, respectively). The combined assessment of the LA volume index and LAI stratified the risk of residual MR ≥2+ after TEER (Figure 2).
In addition, the use of a newer generation of the MitraClip systems (NTR/XTR or G4 systems) was associated with a higher rate of MR reduction to ≤1+ compared to older generations (OR: 4.65; 95% CI: 1.67–13.00).
Conclusions
TEER with the MitraClip system achieved a high rate of MR reduction to ≤1+ in patients with ASMR. Furthermore, the new generations of the MitraClip system may provide a more effective reduction in ASMR. Although our findings suggest that TEER with the MitraClip system is a safe and feasible approach in patients with ASMR, the combined assessment of the LA volume index and LAI might be useful to refine the device selection for transcatheter mitral valve treatment in this subgroup of SMR patients.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- T Tanaka
- University hospital Bonn , Bonn , Germany
| | - A Sugiura
- University hospital Bonn , Bonn , Germany
| | - C Oeztuerk
- University hospital Bonn , Bonn , Germany
| | | | - N Tabata
- University hospital Bonn , Bonn , Germany
| | - N Wilde
- University hospital Bonn , Bonn , Germany
| | - S Zimmer
- University hospital Bonn , Bonn , Germany
| | - G Nickenig
- University hospital Bonn , Bonn , Germany
| | - M Weber
- University hospital Bonn , Bonn , Germany
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17
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Tanaka T, Sugiura A, Kavsur R, Oeztuerk C, Vogelhuber J, Kuetting D, Meyer C, Zimmer S, Grube E, Bakhtiary F, Nickenig G, Weber M. Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve intervention. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The role of right-ventricular (RV) function in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI) is poorly understood. Although cardiac computed tomography (CCT) provides elaborate three-dimensional (3D) visualization of the entire anatomy of the RV and theoretically allows to assess the global RV systolic function. Nevertheless, the utility of the functional assessments of the RV using CCT remains unclear in patients undergoing TTVI.
Purpose
This study investigated the association of right-ventricular ejection fraction (RVEF) assessed by CCT with clinical outcome in patients undergoing TTVI.
Methods
We retrospectively assessed 3D-RVEF by using pre-procedural CCT images in patients undergoing TTVI with either edge-to-edge repair or annuloplasty device. RV dysfunction (RVD) was defined as a CT-RVEF <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within one year after TTVI.
Results
Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Patients with CT-RVEF <45% were more likely to be male, to have a previous history of coronary artery disease, and had higher EuroSCORE II and a lower LVEF compared to those with CT-RVEF ≥45%, while the severity of TR was comparable between the groups.
Among the patients with CT-RVEF <45%, acute procedural success was achieved in 93.1%, and in-hospital mortality was 1.7%, which were comparable to those with CT-RVEF ≥45%.
Patients with CT-RVEF <45% had an improvement in New York Heart Association functional class at follow-up compared to baseline; however, CT-RVEF <45% was associated with a higher risk of the composite outcome (adjusted hazard ratio: 3.23; 95% confidence interval: 1.52–6.88; p=0.002) (Figure 1). Furthermore, CT-RVEF had an additional value to stratify the risk of the composite outcome beyond two-dimensional transthoracic echocardiographic (TTE) assessments (Figure 2).
In addition, patients with CT-RVEF <45% exhibited an attenuated association between a reduction in TR to <3+ and a lower incidence of the composite outcome after TTVI compared to those with CT-RVEF ≥45%.
Conclusions
TTVI is safe and feasible regardless of baseline RV function, while RVD, defined as 3D-RVEF <45%, is associated with a higher risk of the composite outcomes within one year after TTVI. Furthermore, our findings suggest that the prognostic benefits of TR reduction might be attenuated in patients with RVD. Given the additional prognostic value of CT-RVEF to the conventional echocardiographic assessments, the assessments of 3D-RVEF with CCT may refine the patient selection for TTVI.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- T Tanaka
- University hospital Bonn , Bonn , Germany
| | - A Sugiura
- University hospital Bonn , Bonn , Germany
| | - R Kavsur
- University hospital Bonn , Bonn , Germany
| | - C Oeztuerk
- University hospital Bonn , Bonn , Germany
| | | | - D Kuetting
- University hospital Bonn , Bonn , Germany
| | - C Meyer
- University hospital Bonn , Bonn , Germany
| | - S Zimmer
- University hospital Bonn , Bonn , Germany
| | - E Grube
- University hospital Bonn , Bonn , Germany
| | | | - G Nickenig
- University hospital Bonn , Bonn , Germany
| | - M Weber
- University hospital Bonn , Bonn , Germany
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18
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Tanaka T, Kavsur R, Sugiura A, Haurand JM, Galka N, Öztürk C, Vogelhuber J, Becher MU, Weber M, Westenfeld R, Zimmer S, Kelm M, Nickenig G, Horn P, Zachoval C. Acute Kidney Injury Following Tricuspid Transcatheter Edge-to-Edge Repair. JACC Cardiovasc Interv 2022; 15:1936-1945. [PMID: 36008268 DOI: 10.1016/j.jcin.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Little is known about the incidence and clinical relevance of postprocedural acute kidney injury (AKI) in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR). OBJECTIVES The aim of this study was to investigate the prognostic impact of postprocedural AKI following TEER for TR. METHODS Two hundred sixty-eight patients who underwent TEER for TR at 2 centers were retrospectively analyzed. Postprocedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dL within 48 hours or ≥50% within 7 days after the procedure compared with baseline. The association between AKI and the composite outcome, consisting of all-cause mortality and rehospitalization for heart failure within 1 year after the procedure, was determined. RESULTS The mean age of the patients was 79.0 ± 6.8 years, and 43.3% were men. Postprocedural AKI occurred in 42 patients (15.7%). Age, male sex, an estimated glomerular filtration rate of <60 mL/min/1.73 m2, and absence of procedural success were associated with the occurrence of AKI. Patients with AKI had a higher incidence of in-hospital mortality than those without AKI (9.5% vs 0.9%; P = 0.006). Moreover, AKI was associated with the incidence of the composite outcome within 1 year after TEER for TR (adjusted HR: 2.39; 95% CI: 1.45-3.94; P = 0.001). CONCLUSIONS Postprocedural AKI occurred in 15.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. These findings highlight the clinical impact of AKI following TEER for TR and should help in identifying patients at high risk for AKI.
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Affiliation(s)
- Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Jean Marc Haurand
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Natalia Galka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marc Ulrich Becher
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Christian Zachoval
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany.
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Tanaka T, Sugiura A, Öztürk C, Vogelhuber J, Tabata N, Wilde N, Zimmer S, Nickenig G, Weber M. Transcatheter Edge-to-Edge Repair for Atrial Secondary Mitral Regurgitation. JACC Cardiovasc Interv 2022; 15:1731-1740. [DOI: 10.1016/j.jcin.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 12/12/2022]
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Tanaka T, Sugiura A, Kavsur R, Vogelhuber J, Öztürk C, Becher MU, Zimmer S, Nickenig G, Weber M. Leaflet-to-annulus index and residual tricuspid regurgitation following tricuspid transcatheter edge-to-edge repair. EUROINTERVENTION 2022; 18:e169-e178. [PMID: 35193837 PMCID: PMC9904375 DOI: 10.4244/eij-d-21-00862] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND A mismatch between tricuspid leaflet size and annular dilation is one of the morphological features tied to the development of tricuspid regurgitation (TR). AIMS We assessed the association of the leaflet-to-annulus index (LAI) with residual TR after transcatheter edge-to-edge repair (TEER). METHODS Consecutive patients who underwent TEER for TR were enrolled. Significant residual TR was defined as a post-procedural TR ≥3+, and patients were divided into two groups according to the amount of residual TR. The LAI was retrospectively calculated using procedural transoesophageal echocardiography and was defined as follows: (anterior leaflet length+septal leaflet length)/septolateral tricuspid annulus diameter. RESULTS Of 140 patients, 43 patients had residual TR ≥3+ after TEER. The patients with residual TR ≥3+ had a lower LAI compared to those with residual TR <3+ (1.04±0.10 vs 1.13±0.09; p=0.001). In multivariable analysis, the LAI was associated with residual TR ≥3+ (odds ratio [OR] [per 0.1 increase]: 0.57; 95% confidence interval [95% CI]: 0.35-0.94; p=0.02), independent of baseline TR severity or coaptation gap size. Patients with residual TR ≥3+ had a higher incidence of the composite outcome, consisting of all-cause mortality and heart failure hospitalisation within one year after TEER (47.1% vs 26.6%, p=0.02). Residual TR ≥3+ was an independent predictor of the composite outcome within one year (hazard ratio: 2.04; 95% CI: 1.01-4.11; p=0.04). CONCLUSIONS The leaflet-to-annulus mismatch (i.e., LAI) is associated with residual TR ≥3+ after TEER for TR. A detailed echocardiographic analysis of the tricuspid valve will be conducive to identifing suitable subjects for TEER.
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Affiliation(s)
- Tetsu Tanaka
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Herzzentrum Bonn, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Refik Kavsur
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
| | - Can Öztürk
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
| | - Marc Ulrich Becher
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
| | - Georg Nickenig
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
| | - Marcel Weber
- Medzinische Klinik und Poliklinik Ⅱ, Universitätsklinikum Bonn, Bonn, Germany
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Nelles D, Vij V, Al-Kassou B, Weber M, Vogelhuber J, Beiert T, Nickenig G, Schrickel JW, Sedaghat A. Incidence, persistence, and clinical relevance of iatrogenic atrial septal defects after percutaneous left atrial appendage occlusion. Echocardiography 2021; 39:65-73. [PMID: 34921426 DOI: 10.1111/echo.15271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/29/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To investigate the rate and clinical impact of a persisting iatrogenic atrial septal defect (iASD) after percutaneous left atrial appendage occlusion (LAAO). BACKGROUND Percutaneous LAAO is an alternative to oral anticoagulation (OAC) for the prevention of ischemic stroke and systemic embolism in patients with atrial fibrillation (AF). Data regarding incidence and persistence of iASD after LAAO procedures and its clinical relevance is scarce. METHODS We retrospectively analyzed 144 patients that underwent LAAO at our center between 2009 and 2020 who had at least one follow-up including transesophageal echocardiography (TEE). Baseline clinical, procedural data and echocardiographic characteristics in patients with and without evidence of an iASD were compared. We furthermore determined the rate of iASD persistence over time and evaluated outcomes of patients with and without spontaneous iASD closure. RESULTS After a median of 92 days (IQR 75-108 days) after LAAO, 50 patients (50/144, 34.7%) showed evidence of an iASD. Patients with iASD had higher CHADS-VASc-scores (4.9±1.5 vs 4.2±1.2, p = 0.03), larger left atrial volumes (80.5±30.5 ml vs 67.1±19.7 ml, p = 0.01) and were more likely to have relevant mitral regurgitation (≥° II) (46.0% vs 12.3%, p = 0.001). LAAO procedures took longer (50.1±24.3 vs 41.1±17.8 min, p = 0.06) in patients with a persisting iASD. Furthermore, larger device sizes were implanted (24.3±3.4 mm vs 22.1±2.8 mm, p = 0.03). The presence of an iASD had no impact on RV dysfunction, thromboembolism or mortality. Spontaneous closure of an iASD was documented in 52.0% (26/50). Hereby, similar risk factors were identified for the persistence of an iASD in follow-up.
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Affiliation(s)
- Dominik Nelles
- Med. Klinik und Poliklinik II - Herzzentrum Bonn, Bonn, Germany
| | - Vivian Vij
- Med. Klinik und Poliklinik II - Herzzentrum Bonn, Bonn, Germany
| | | | - Marcel Weber
- Med. Klinik und Poliklinik II - Herzzentrum Bonn, Bonn, Germany
| | | | - Thomas Beiert
- Med. Klinik und Poliklinik II - Herzzentrum Bonn, Bonn, Germany
| | - Georg Nickenig
- Med. Klinik und Poliklinik II - Herzzentrum Bonn, Bonn, Germany
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Vogelhuber J, Weber M, Nickenig G. Transcatheter Leaflet Strategies for Tricuspid Regurgitation TriClip and CLASP. Interv Cardiol Clin 2021; 11:51-66. [PMID: 34838297 DOI: 10.1016/j.iccl.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since the recognition of the impact of significant tricuspid regurgitation on the clinical course and mortality, intensive efforts have been made in identifying and developing individually suitable and catheter-based therapy strategies to offer those often older and multimorbid patients at high surgical risk safe, feasible, and efficacious treatment options with justifiable risk. Up to now, transcatheter edge-to-edge repair with leaflet approximation devices such as TriClip (Abbott, Santa Clara, CA, USA) and PASCAL Implant System (Edwards Lifesciences, Irvine, CA, USA) have been evaluated best and several clinical trials could prove safety, feasibility, and efficacy of said devices leading to their recent CE mark. However, further randomized controlled trial are pending and necessary to evaluate their impact on clinical course and outcome in comparison to established treatment recommendations.
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Affiliation(s)
- Johanna Vogelhuber
- Heart Centre, Department of Cardiology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Marcel Weber
- Heart Centre, Department of Cardiology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Georg Nickenig
- Heart Centre, Department of Cardiology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany.
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Sugiura A, Tanaka T, Kavsur R, Öztürk C, Vogelhuber J, Wilde N, Becher MU, Zimmer S, Nickenig G, Weber M. Leaflet Configuration and Residual Tricuspid Regurgitation After Transcatheter Edge-to-Edge Tricuspid Repair. JACC Cardiovasc Interv 2021; 14:2260-2270. [PMID: 34424200 DOI: 10.1016/j.jcin.2021.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES This study aimed to assess the anatomical leaflet variation and investigate its impact on the procedural outcome in patients undergoing transcatheter edge-to-edge tricuspid repair. BACKGROUND Tricuspid regurgitation (TR) is associated with a poor prognosis. METHODS The study participants were consecutive patients who underwent transcatheter edge-to-edge tricuspid repair with the MitraClip, TriClip, or PASCAL systems from June 2015 to July 2020 at the Bonn Heart Center. The tricuspid leaflet morphologies were imaged using 2-dimensional and 3-dimensional transesophageal echocardiography. The severity of TR was assessed according to the 5-grade scheme. The primary endpoint was residual TR ≥3+ within 30 days. RESULTS Of the 145 study participants, 103 (71.1%) participants were categorized as the 3-leaflet configuration, while 42 (28.9%) were categorized as the 4-leaflet configuration. Successful device implantation was achieved in 136 (93.8%) patients, with no statistical difference between the 3-leaflet and 4-leaflet configuration groups. However, compared with patients with a 3-leaflet configuration, patients with 4-leaflet configuration more frequently had residual TR ≥3+ (18.4% vs 38.1%; P = 0.018). In the multivariable model, the 4-leaflet configuration was associated with an increased risk of residual TR ≥3+ (odds ratio: 2.65; 95% CI 1.15-6.10; P = 0.022), independent of baseline TR grade, coaptation gap width, and TR jet location. After 1-year follow-up, compared with patients with residual TR <3+, patients with residual TR ≥3+ had a significantly higher incidence of the composite of all-cause mortality or heart failure hospitalization (27.7% vs 56.1%; P = 0.016). CONCLUSIONS A 4-leaflet configuration of the tricuspid valve is observed in approximately one-third of patients undergoing transcatheter edge-to-edge tricuspid repair, which is associated with an increased risk of residual TR after the procedure.
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Affiliation(s)
- Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Tetsu Tanaka
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marc Ulrich Becher
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
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Tanaka T, Sugiura A, Kavsur R, Vogelhuber J, Oeztuerk C, Becher MU, Zimmer S, Nickenig G, Weber M. Impact of leaflet-to-annulus index on residual tricuspid regurgitation following transcatheter edge-to-edge tricuspid valve repair. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Edge-to-edge transcatheter tricuspid valve repair (TTVR) is a promising treatment option for tricuspid regurgitation (TR), and it is required to identify anatomical parameters to predict the procedural success of TTVR.
Purpose
In this study, we assessed leaflet-to-annulus index (LAI), a simple tool to evaluate the remodeling of tricuspid annulus in relation to the leaflets, and investigated the association of the LAI with residual TR after edge-to-edge TTVR.
Methods
Consecutive 140 patients with symptomatic TR who underwent edge-to-edge TTVR from June 2015 to July 2020 were enrolled. The LAI was calculated using preprocedural transesophageal echocardiography and was defined as follows: (anterior leaflet length + septal leaflet length)/anteroseptal tricuspid annulus diameter (Figure 1). Primary outcome was residual TR ≥3+ at discharge, and patients were allocated into two groups as follows: residual TR ≥3+ and <3+. Secondary outcome was the composite outcome, consisting of all-cause mortality and heart failure hospitalization, within one year after TTVR.
Results
Of the 140 patients, 43 patients had residual TR ≥3+ after TTVR. The patients with residual TR ≥3+ had lower LAI compared to those with residual TR <3+ (1.06±0.10 vs. 1.13±0.09; p=0.001). Multivariable analysis revealed that LAI was associated with residual TR ≥3+ (odds ratio [by 0.1 increase]: 0.57; 95% confidence interval [95% CI]: 0.35–0.94; p=0.02), independently of baseline TR severity, location of TR jet, and coaptation gap size (Table 1). Patients with residual TR ≥3+ had a higher incidence of the composite outcome within one year after TTVR (34.9% vs. 18.6%; log-rank p=0.04) and residual TR ≥3+ was an independent predictor of the composite outcome within one year (hazard ratio: 2.04; 95% CI: 1.01–4.11; p=0.04).
Conclusion
Lower LAI is associated with residual TR ≥3+ after edge-to-edge TTVR, which itself was a significant predictor of the one-year composite outcome. Our findings suggest that LAI is a useful tool to identify patients to be successfully treated with edge-to-edge TTVR.
Funding Acknowledgement
Type of funding sources: None. Figure 1Table 1
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Affiliation(s)
- T Tanaka
- University hospital Bonn, Bonn, Germany
| | - A Sugiura
- University hospital Bonn, Bonn, Germany
| | - R Kavsur
- University hospital Bonn, Bonn, Germany
| | | | | | | | - S Zimmer
- University hospital Bonn, Bonn, Germany
| | | | - M Weber
- University hospital Bonn, Bonn, Germany
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Affiliation(s)
| | - Marcel Weber
- Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, University Hospital Bonn, Bonn, Germany
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Tanaka T, Kavsur R, Sugiura A, Vogelhuber J, Öztürk C, Weber M, Tiyerili V, Zimmer S, Nickenig G, Becher MU. Prognostic impact of hepatorenal function in patients undergoing transcatheter tricuspid valve repair. Sci Rep 2021; 11:14420. [PMID: 34257395 PMCID: PMC8277825 DOI: 10.1038/s41598-021-93952-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
Hepatorenal dysfunction is a strong risk factor in patients with heart failure (HF). We investigated the prognostic significance of hepatorenal dysfunction in 172 consecutive patients undergoing transcatheter tricuspid valve repair (TTVR). The model for end-stage liver disease excluding international normalized ratio (MELD-XI) score was calculated as 5.11 × ln(serum total bilirubin [mg/dl]) + 11.76 × ln(serum creatinine [mg/dl]) + 9.44. Patients were stratified into two groups: high (≥ 14) or low (< 14) MELD-XI score, according to the best cut-off value to predict a one-year composite outcome consisting of all-cause mortality and HF hospitalization. Compared to patients with low MELD-XI score (n = 121), patients with high MELD-XI score (n = 51) had a higher incidence of the composite outcome (47.1% vs. 17.4%; p < 0.0001). In the multivariable analysis, the MELD-XI score was an independent predictor of the composite outcome (adjusted hazard ratio: 1.12; 95% confidence interval [CI] 1.05–1.19; p = 0.0003). In addition, post-procedural TR < 3 + after TTVR was independently associated with a reduction in MELD-XI score six months after TTVR (adjusted odds ratio: 3.37; 95% CI 1.09–10.40; p = 0.03). Thus, the MELD-XI score was associated with the risk of one-year composite outcome, consisting of mortality and HF hospitalization, after TTVR and may help the risk stratification in patients undergoing TTVR.
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Affiliation(s)
- Tetsu Tanaka
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Refik Kavsur
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Atsushi Sugiura
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Johanna Vogelhuber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Can Öztürk
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Marcel Weber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Vedat Tiyerili
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Marc Ulrich Becher
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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Sugiura A, Wilde N, Weber M, Vogelhuber J, Zimmer S, Grube E, Nickenig G. Transcatheter Triple-Valve Intervention. JACC Cardiovasc Interv 2021; 14:e179-e181. [PMID: 34217628 DOI: 10.1016/j.jcin.2021.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/12/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
| | - Nihal Wilde
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany. https://twitter.com/Marcel_1983
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Eberhard Grube
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
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Ozturk C, Vogelhuber J, Sugiura A, Reckers D, Nickenig G, Weber M. One-year outcome of transcatheter repair of tricuspid regurgitation: comparison edge-to-edge repair versus anuloplasty. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Tricuspid regurgitation (TR) is found to be associated with increased mortality, morbidity, and impaired quality of life. The interventional tricuspid valve repair techniques are being increasingly performed. We aimed to compare the mid-term outcomes of both methods (Clipping and Banding) in our patient cohort. F
We retrospectively included 60 patients who underwent between January 2016 to March 2018 the transcatheter tricuspid valve edge-to-edge repair or annuloplasty in our center. Follow up (FU) examinations were done 12.6±7.6 months. Comprehensive transthoracic echocardiography inclusively 3D acquisitions were performed before and at FU in all patients. The 3D data were used for strain analysis of left and right ventricles and atriums through a dedicated automated offline program (TomTec).
We retrospectively included 60 patients (75±6.1 years, 40% female) with symptomatic (65% ascites, 95% edema, 100% NYHA>II, 75% liver congestion) severe TR (TR>II, 90% functional) at surgical high risk (EuroSCORE II: 5.2±3.2%). Forty patients underwent transcatheter TV edge-to-edge repair (TTVR, MitraClip, PASCAL), and twenty patients were treated by interventional annuloplasty (Cardioband).
At baseline, the patients underwent edge-to-edge (E2E) repair showed more comorbidities with higher EuroScore II and more decreased functional capacity. Echocardiographical, patients who underwent annuloplasty, presented a more significant coaptation gap with more impaired RV function and more dilated right atrium. In contrast, the E2E group showed to have higher right ventricular systolic pressure. Left ventricular dimensions and functions were comparable between the groups.
Left atrial volume and right atrial pressure were found to be statistically significantly reduced in both groups at FU. RV and RA fractional area change were found to be relevantly improved solely after interventional annuloplasty at FU. Left ventricular end-diastolic pressure significantly increased in the E2E group with relevant reduction of outflow/inflow ratio. Moreover, interventional annuloplasty, as expected, reduces SL diameter more significantly.
Patients showed lower symptoms and better functional capacity 12 months after interventional E2E therapy. Of note, improvement in walking distance was found to be significantly higher in patients who underwent annuloplasty. However, patients were hospitalized significantly more frequently after interventional annuloplasty.
In conclusion, both interventional techniques are safe, feasible, and effective for treatment of tricuspid regurgitation in patients at surgical high risk. Interventional annuloplasty significantly impacts on RV function and geometry, and reduces SL diameter significantly. Patients were found to have decreased symptoms, better functional capacity, as well as fewer rehospitalization 12 months after interventional E2E therapy, although they showed more comorbidities at baseline compared to interventional annuloplasty.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- C Ozturk
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - J Vogelhuber
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - A Sugiura
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - D Reckers
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - G Nickenig
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - M Weber
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
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Weber M, Vogelhuber J. Fusionsbildgebung – neue Entwicklungen in der interventionellen Kardiologie. Aktuel Kardiol 2020. [DOI: 10.1055/a-1018-3770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
ZusammenfassungMit der Etablierung der kathetergestützten Aortenklappenimplantation rückte die multimodale Bildgebung mittels Fluoroskopie und Computertomografie immer mehr ins Augenmerk der interventionellen Kardiologie. Im Zuge der minimalinvasiven Möglichkeiten zur Therapie der Mitral- und Trikuspidalklappeninsuffizienz hat zusätzlich die interventionelle Echokardiografie an Bedeutung gewonnen. Zur weiteren Optimierung der kathetergestützten Herzklappentherapien können 2 dieser 3 Bildmodalitäten übereinander gelegt bzw. fusioniert werden, um dem Untersucher einen bestmöglichen Blick auf die jeweilige Herzklappe oder -struktur zu ermöglichen. Die unterschiedlichen Fusionslösungen könnten in Zukunft zu einer verbesserten periprozeduralen Sichtbarkeit führen und damit die Prozedurzeit verkürzen bzw. Kontrastmittel einsparen. Die hybride Fusionsbildgebung hat somit das Potenzial, die prozedurale Sicherheit sowie die Effektivität hinsichtlich der Device-Platzierung zu steigern. Diese Techniken sind jedoch derzeit noch im Erprobungsstadium und noch nicht in der klinischen Routine etabliert.
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Affiliation(s)
- Marcel Weber
- Herzzentrum Bonn – Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn
| | - Johanna Vogelhuber
- Herzzentrum Bonn – Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn
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Ozturk C, Vogelhuber J, Reckers D, Becher MU, Nickenig G, Weber M. 43 Echocardiographical analysis of right ventricular function after transcatheter edge-to-edge repair of tricuspid regurgitation. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Tricuspid regurgitation (TR) is a frequent valvular heart disease associated with increased mortality and morbidity. RV function is mostly assessed using tricuspid annulus plane systolic excursion (TAPSE), which shows merely systolic RV function and can be influenced by many other pathologies and image quality. Furthermore, the impact of dedicated percutaneous clip treatment of TR on RV global function and clinical outcomes are scarce.
We aim to perform detailed echocardiographical global RV function analysis inclusively speckle tracking of RV before and after transcatheter edge-to-edge repair of TR (TTVR).
We evaluated 50 patients, who underwent between January 2017 to March 2018 TTVR in our center. Apical four chamber images were used to perform strain analysis of RV. The systolic velocity of free RV wall (S´ Vmax) was measured through PW doppler on lateral TV annulus in color tissue Doppler. RV myocardial performance index is a parameter for systolic as well as diastolic ventricle function and can be calculated using ratio between TV closure to opening time and RV ejection time (RVCOT-RVET/RVET), which can be assessed from PW Doppler of lateral TV annulus in color tissue Doppler.
We retrospectively included 40 patients (73 ± 5.6 years, 32% female) with symptomatic (65% ascites, 95% edema, 100% NYHA > II) high grade functional TR at surgical high risk (EuroSCORE II: 7.6%). 95% of all interventions were successfully performed (TR reduction at least I grade).
Our collective shows normal baseline left ventricle (LV) systolic function (Ejection fraction: 60.8 ± 4.6%) with diastolic LV dysfunction and increased LV end systolic pressure (E/E´ ratio: 17.7 ± 6.5). Baseline RV analysis presented impaired RV systolic function (TAPSE: 1.2 ± 3.2 cm, RV-FAC: 25.6 ± 9.8%, S´ Vmax: 5.6 ± 1.2cm/s) with decreased RV global longitudinal strain (RV-GLS: -8.9 ± 4.3). RV myocardial performance index (RV-MPI) was 0.51 ± 0.4 as a parameter for poor global RV function. Baseline echocardiography showed dilation of both atria (Left atrium: 80.5 ± 14.5ml, right atrium: 26.7 ± 7.8cm2) with pronounced right ventricle congestion (dilated vena cava inferior: 25.5 ± 3.4mm without breath modulation, paradoxical intraventricular septum motion, dilated RV: 57.7 ± 14.5cm2). All TR were high grade (PISA: 0.78 ± 0.3cm, VC width: 0.8 ± 0.2cm, EROA: 0.43 ± 0.1cm2, regurgitant volume: 67.1 ± 10.4ml) and functional with mostly anteroseptal (85%) coaptation defect (coaptation defect diameter: .5.7 ± 3.2mm).
The right heart failure symptoms significantly improved three months after the procedure. Patients with severe right heart failure (TAPSE < 1cm) showed more often rehospitalization and limited improvements in symptoms (p = 0.02).
RV function should be more comprehensively evaluated before interventional TR therapy. The patients with already preprocedural severe right heart failure should be more critically discussed. RV-GLS and RV-MPI are strongest independent parameter of clinical outcome after TTVR.
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Affiliation(s)
- C Ozturk
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - J Vogelhuber
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - D Reckers
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - M U Becher
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - G Nickenig
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
| | - M Weber
- University Hospital Bonn, Cardiology, Pneumology and Angiology, Bonn, Germany
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33
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De Nardo D, Labzin LI, Kono H, Seki R, Schmidt SV, Beyer M, Xu D, Zimmer S, Lahrmann C, Schildberg FA, Vogelhuber J, Kraut M, Ulas T, Kerksiek A, Krebs W, Bode N, Grebe A, Fitzgerald ML, Hernandez NJ, Williams BRG, Knolle P, Kneilling M, Röcken M, Lütjohann D, Wright SD, Schultze JL, Latz E. High-density lipoprotein mediates anti-inflammatory reprogramming of macrophages via the transcriptional regulator ATF3. Nat Immunol 2013; 15:152-60. [PMID: 24317040 PMCID: PMC4009731 DOI: 10.1038/ni.2784] [Citation(s) in RCA: 303] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/07/2013] [Indexed: 12/13/2022]
Abstract
High Density Lipoprotein (HDL) mediates reverse cholesterol transport and it is known to be protective against atherosclerosis. In addition, HDL has potent anti-inflammatory properties that may be critical for protection against other inflammatory diseases. The molecular mechanisms of how HDL can modulate inflammation, particularly in immune cells such as macrophages, remain poorly understood. Here we identify the transcriptional repressor ATF3, as an HDL-inducible target gene in macrophages that down-regulates the expression of Toll-like receptor (TLR)-induced pro-inflammatory cytokines. The protective effects of HDL against TLR-induced inflammation were fully dependent on ATF3 in vitro and in vivo. Our findings may explain the broad anti-inflammatory and metabolic actions of HDL and provide the basis for predicting the success of novel HDL-based therapies.
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Affiliation(s)
- Dominic De Nardo
- 1] Institute of Innate Immunity, University Hospitals, Biomedical Centre, University of Bonn, Bonn, Germany. [2]
| | - Larisa I Labzin
- 1] Institute of Innate Immunity, University Hospitals, Biomedical Centre, University of Bonn, Bonn, Germany. [2]
| | - Hajime Kono
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Reiko Seki
- Department of Clinical Laboratory Science, Teikyo University Faculty of Medical Technology, Tokyo, Japan
| | - Susanne V Schmidt
- Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Marc Beyer
- Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Dakang Xu
- 1] Monash Institute of Medical Research, Monash University, Melbourne, Victoria, Australia. [2] Institute of Ageing Research, Hangzhou Normal University School of Medicine, Hangzhou, China
| | - Sebastian Zimmer
- Department of Medicine/Cardiology, University of Bonn, Bonn, Germany
| | | | - Frank A Schildberg
- Institutes of Molecular Medicine and Experimental Immunology, University of Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Institute of Innate Immunity, University Hospitals, Biomedical Centre, University of Bonn, Bonn, Germany
| | - Michael Kraut
- Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Thomas Ulas
- Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Anja Kerksiek
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn, Bonn, Germany
| | - Wolfgang Krebs
- Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Niklas Bode
- Department of Medicine/Cardiology, University of Bonn, Bonn, Germany
| | - Alena Grebe
- Institute of Innate Immunity, University Hospitals, Biomedical Centre, University of Bonn, Bonn, Germany
| | - Michael L Fitzgerald
- Lipid Metabolism Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas J Hernandez
- Lipid Metabolism Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bryan R G Williams
- Monash Institute of Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Percy Knolle
- 1] Institutes of Molecular Medicine and Experimental Immunology, University of Bonn, Bonn, Germany. [2] Institute of Molecular Immunology, Technical University of Munich, Munich, Germany
| | - Manfred Kneilling
- 1] Department of Dermatology, Eberhard Karls University, Tuebingen, Germany. [2] Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, Eberhard Karls University, Tuebingen, Germany
| | - Martin Röcken
- Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - Dieter Lütjohann
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn, Bonn, Germany
| | - Samuel D Wright
- Cardiovascular Therapeutics, CSL Limited, Parkville, Australia
| | - Joachim L Schultze
- 1] Life and Medical Sciences Institute, University of Bonn, Bonn, Germany. [2]
| | - Eicke Latz
- 1] Institute of Innate Immunity, University Hospitals, Biomedical Centre, University of Bonn, Bonn, Germany. [2] Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA. [3] German Center for Neurodegenerative Diseases, Bonn, Germany. [4]
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