Correlation of Clinical Outcomes with the Prominent Indication of Transcatheter Paravalvular Leak Closure: A Multicenter Experience

BACKGROUND

A paravalvular leak (PVL) is a complication following valve replacement, which may lead to heart failure and hemolysis. The aim of this study is to investigate whether the clinical outcome after transcatheter PVL closure differs according to the prominent indication of the procedure (symptoms of heart failure or hemolysis).

METHODS

The data of consecutive patients who had transcatheter treatment for PVL between July 2011 and September 2022 in five Greek centers were analyzed. The primary endpoint was the technical, and clinical success rates with regards to the prominent indication of paravalvular leak closure. The secondary endpoints included the evaluation and comparison of the clinical and technical success in relation to the type of valve that was treated (aortic or mitral) as well as the survival analysis in relation to the closure indication and type of valve that was treated.

RESULTS

In total, 60 patients were retrospectively studied (39% men, mean age 69.5 ± 11 years). Regarding the primary outcomes, the technical success in patients mainly suffering from hemolysis was 86.1%, while in those presenting heart failure it was 95.8%, p = 0.387. Furthermore, the clinical success was 72.2% and 87.5% among hemolysis and heart failure patients, respectively, p = 0.210. During the follow-up period, the two-year survival rates were significantly better for patients treated for the aortic valve (78.94%) compared to those in the mitral position (48.78%), p = 0.014. In total, 25 patients died (41.7%) during 24 months of follow-up.

CONCLUSIONS

Transcatheter paravalvular leak closure can be performed with high technical and clinical success rates without any difference according to the prominent indication of closure.

Transcatheter closure of paravalvular leak: Multicenter experience and follow-up

BACKGROUND

Paravalvular leak (PVL) is a common complication following valve replacement, which leads to heart failure and hemolysis. Transcatheter PVL closure has emerged as a reliable alternative with promising results. We quote the combined three-center experience of PVL patients treated percutaneously.

METHODS

Consecutive patients treated percutaneously for PVL were retrospectively studied. Procedural characteristics, inhospital, and long-term clinical outcomes were assessed. Technical (successful deployment) and clinical (NYHA and/or hemolysis improvement) success were evaluated.

RESULTS

In total, 39 patients treated for PVL in either the aortic (12 patients) or the mitral (27 patients) position were studied. Amplatzer Vascular Plug III was the most commonly used device among the 45 devices totally implanted. Postprocedurally, the rates of at least moderate PVL (87.5% preprocedurally vs 10.5% at discharge) and functional status (mean NYHA class 2.8 ± 0.7 on admission vs 1.5 ± 0.8 at follow-up) were statistically significantly improved. Total population technical success rate was 89.7%, being comparable between patients treated for mitral or aortic valve PVLs (92.6% vs 83.3%, respectively). Clinical success was achieved in 82.1% of patient cohort without statistical difference among those with isolated aortic or mitral PVL or among those with PVL closure an indication of heart failure or hemolysis. During a mean follow-up of 33.5 months, five patients died, including one periprocedural death.

CONCLUSIONS

This multicenter recorded experience confirms that percutaneous PVL closure can be performed with high technical and clinical success rates and limited complications that lead to significant PVL reduction and functional status improvement.

Global Constructive Work predicts left ventricular reverse remodeling one year after MitraClip implantation in patients with functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVr) has recently been identified as an effective method for treating patients with functional mitral regurgitation. However, it is still unknown which patients will benefit by showing clinical improvement and left ventricular reverse remodeling.

Purpose

The purpose of this study is to analyze novel echocardiographic markers and identify markers of LV reverse remodeling after MitraClip implantation.

Methods

We retrospectively analyzed 58 high surgical risk (logistic EuroSCORE 23±15%) consecutive patients (aged 72±10yrs) with functional moderate-to-severe and severe mitral regurgitation (EROA 29±14mm2) and reduced LV contractility (EF 32±8%, GLS −8.6±3.7%). At baseline and 1-year after PMVr we assessed echocardiographic parameters such as MR severity, EF, Global Longitudinal Strain (GLS), Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE).

Results

In patients with MitraClip implantation there was a significant reduction of MR (3.7±0.4 vs 1.7±0.8, p<0.001) one year after the intervention. The EF and GLS did not improve after the implantation (32±8 vs 33±10%, p=0.178 & −8.6±3.7 vs −8.6±3.7%, p=0.922 respectively) but Global Work Index (GWI) and Global Constructive Work (GCW) demonstrated significant improvement (607±282 vs 650±260mmHg%, p=0.04 & 854±288 vs 949±325mmHg%, p<0.001 respectively). The baseline EF, GLS, GWI, GCW and EROA were the factors that were significantly associated with more than 20% reduction of LVEDV one year after intervention (p<0.02 for all). To be more specific, left ventricles with better performance and contractility combined with worse mitral regurgitation were the ones that responded better. Further, baseline GCW was the only factor that was significantly associated with reduction of the LVESV. A ROC curve analysis identified a cut-off value of 846mmHg% (AUC 0.759, 95% CI: 0.588–0.930; p=0.007) to be associated with 10% reduction of LVESV, with a sensitivity and specificity of 79% and 74% respectively.

Conclusions

Transcatheter edge-to-edge repair is an effective method for treating patients with FMR and improves LV performance one year after intervention. A preserved baseline GCW seems to be a good predictor of LV reverse remodeling after MitraClip implantation.

Funding Acknowledgement

Type of funding source: None

P1757 Novel echocardiographic markers as predictors for left ventricular reverse remodeling one year after edge-to-edge mitral valve repair in patients with functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) is a safe treatment option for high surgical risk patients with severe functional mitral regurgitation (FMR). Recent trials have proven this method’s efficiency but novel echocardiographic markers such as deformation imaging have never been analyzed in this subgroup of patients.

Purpose

The purpose of this study is to analyze novel echocardiographic parameters in patients treated for FMR and identify predictors of response in patients undergoing PMVR.

Methods

We retrospectively analyzed 79 consecutive high surgical risk patients (logistic EuroSCORE 21.8 ± 15.2%), with ischemic or dilated cardiomyopathy, reduced EF (31.0 ± 8.5%) and severe functional MR (FMR). Effective regurgitant orifice area (EROA) was measured at 28.8 ± 15.1mm2 and regurgitant volume (RV) at 41.7 ± 18.3ml. At baseline and 1-year after PMVR or optimal medical treatment (OMT) we assessed echocardiographic parameters such as LV global longitudinal strain (LVGLS) and peak left atrial longitudinal strain (PALS), LV end-systolic and end-diastolic volumes (LVESV, LVEDV), LA volume, MR severity along with BNP levels, NYHA class and 6 minute walking distance (6MWT).

Results

One year after PMVR there was a significant reduction of MR (3.7 ± 0.4 vs 1.7 ± 0.8) and BNP levels (980 ± 1027pg/ml vs 420 ± 338pg/ml, p = 0.005), improvement of NYHA class (3.20 ± 0.55 to 2.0 ± 0.6, P < 0.05) and increase of 6MWD (240 ± 137 to 298 ± 139m, P < 0.01). LA volume and LVEDV were reduced (141 ± 79ml to 114 ± 74ml and 221 ± 74 to 193 ± 62ml respectively) (P < 0.01 for all comparisons). On the other hand, patients treated with OMT didn’t have any change of their MR (3.4 ± 0.5 vs 3.4 ± 0.9), BNP levels (601 ± 652 vs 610 ± 748) or NYHA class status (2.6 ± 0.6 vs 2.4 ± 0.6). Additionally, LA and LV volumes were approximately the same (134 ± 69 vs 141 ± 61ml and 222 ± 64 vs 222 ± 56ml respectively) (p < 0.05 for all comparisons). Baseline LVGLS slightly increased post intervention (-8.5 ± 4.1% vs -9.1 ± 3.7%, r = 0.76, P < 0.01), and was associated with the absolute (r=-0.46, p = 0.01) and percentage difference in LVEDV (r= -0.61, P < 0.01). ROC curve analysis identified a cut-off value for GLS of -7.45% (AUC 0.815, 95% CI: 0.647-0.983; p = 0.007) associated with more than 15% LV reverse remodeling, with a sensitivity and specificity of 71% and 75% respectively.

Conclusions

Edge-to-edge repair is a safe and effective method for treating patients with functional MR and has a positive clinical impact in patients at one year follow up. A preserved LVGLS seems to be a good predictor of LV reverse modeling post intervention.

P1758 Global left ventricular myocardial work efficiency as a prognostic marker for clinical responders one year after edge-to-edge mitral valve repair in patients with functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has been proven to be effective for treating patients with functional MR (FMR). However it remains to be answered which patients will benefit more from this method. Novel echocardiographic markers like myocardial work efficiency can be quantified non-invasively and have never been analyzed in this subgroup of patients before.

Purpose

The purpose of this study is to analyze the myocardial work efficiency in patients treated with PMVR for FMR and identify predictors of clinical response.

Methods

We retrospectively analyzed 22 high surgical risk (logistic EuroSCORE 28.9 ± 18.2%) consecutive patients (aged 72 ± 8yrs) with functional moderate-to-severe and severe mitral regurgitation (EROA 28.6 ± 14.6mm2, RV 41.7 ± 15.8ml) and reduced LV contractility (EF 32.7 ± 7.5%, GLS -8.8 ± 3.4%). At baseline and 1-year after PMVR or optimal medical treatment (OMT) we assessed echocardiographic parameters such as MR severity, Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE), along with BNP levels and NYHA class status.

Results

One year after PMVR there was a significant reduction of MR (3.6 ± 0.5 vs 1.8 ± 0.8, p = 0.009) and BNP levels (901 ± 610pg/ml vs 479 ± 385pg/ml, p < 0.001) and significant improvement of NYHA class status (3.0 ± 0.6 to 2.2 ± 0.4, p < 0.001). On the other hand, patients treated with OMT didn’t have any significant change of their MR (3.6 ± 0.5 vs 3.3 ± 1.0), BNP levels (296 ± 114 vs 241 ± 183pg/ml) or NYHA class status (2.6 ± 0.5 vs 2.4 ± 0.5). In device group, there was a preservation of GWI (572 ± 290 vs 609 ± 299mmHg%) and GCW (757 ± 310 vs 789 ± 316mmHg%) and non significant change of GWW and GWE (140 ± 70 vs 150 ± 73mmHg% and 79 ± 9 vs 79 ± 10% respectively, p < 0.05 for all comparisons). On the other hand in medical treatment group there was a significant impairment of GWI (635 ± 263 vs 564 ± 267mmHg%, p = 0.08) and GWE (83 ± 9 vs 76 ± 11%, p = 0.03) and significant increase of GWW (123 ± 90 vs 162 ± 74mmHg%, p < 0.001). Further, baseline GCW was reversely associated with the difference in BNP (r=-0.559, p = 0.038), NYHA class (r=-0.501, p = 0.06) and 6MWT (r=-0.577, p = 0.08) after PMVR, meaning that patients with worse energetics will respond better.

Conclusions

PMVR is an effective method for treating patients with FMR and preserves myocardial work index after one year of FU in contrast to medically treated patients in whom deterioration is observed.

P1560 Acute changes of mitral annular dimensions after transcatheter egde-to-edge repair: an indirect annuloplasty method?

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) is a safe and alternative method for treating high-risk patients with severe mitral regurgitation (DMR or FMR). This transcatheter treatment aims at reducing the MR with a so-called "Alfieri stitch" method. However the impact on mitral annular dimensions after the device implantation is not well defined. The purpose of this study is to recognize the acute changes of mitral annular dimensions after transcatheter edge-to-edge repair.

Methods

We retrospectively analyzed 20 consecutive patients (aged 74 ± 10yrs) with degenerative or functional moderate-to-severe and severe mitral regurgitation (EROA 40.8 ± 20.5mm2, RV 52.6 ± 17.5ml) and reduced ejection fraction (EF 36.9 ± 15.4%). These patients were at high surgical risk or even inoperable in certain cases (logistic EuroSCORE 28.9 ± 18.2%) and evaluated by a heart team as candidates for transcatheter repair. All intraoperative transoesophageal echo studies were post processed with EchoPac v.203 or QLAB 9.0. 3D views of the mitral valve before and after the implantation of the device were analyzed with 4D AutoMVQ (GE) or MVQ (Phillips) software.

Results

PMVR was effective in treating the MR at the end of the operation (from 3.8 ± 0.4 to 1.3 ± 0.5 after the implantation, p < 0.05) in all patients. There was a significant reduction of the annulus area (from 12.25 ± 3.0cm2 to 10.18 ± 2.88cm2, p < 0.001) and circumference (from 13.23 ± 1.4cm to 12.18 ± 1.57cm, p < 0.001), in both DMR and FMR cases. The percentage reduction of annulus area and circumference after PMVR was 17.3 ± 0.8% and 8 ± 5% respectively and the number of the clips used for that purpose were 1.55 ± 0.6. Additionally, edge-to-edge repair significantly reduced the anterior-posterior diameter (from 3.49 ± 0.56cm to 3.02 ± 0.55cm, r = 0.86, p < 0.001) and the posteromedial-anterolateral diameter (from 4.15 ± 0.58cm to 3.88 ± 0.60cm, r = 0.9, p < 0.001). The number of the clips used did not play an important role in the percentage difference of the annulus dimensions (20% reduction with one clip vs 14.3 ± 7.6% with two or more, p < 0.05) and one possible explanation could be that patients receiving one clip had smaller annulus area comparing to the patients receiving two or more (11.2 ± 2.9mm2 vs 13.3 ± 2.7mm2 respectively, p < 0.05).

Conclusions

Transcatheter edge-to-edge repair is effective in treating MR in patients with DMR and FMR and has a direct impact on mitral annular dimensions acutely after the implantation.

P301Preserved global longitudinal strain predicts left ventricular reverse remodeling one year after edge-to-edge mitral valve repair in functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has emerged as an effective treatment modality for high surgical risk patients with severe functional mitral regurgitation (FMR). Novel echocardiographic parameters, such as deformation imaging and their predictive significance have not been analyzed in this group of patients.

Purpose

The purpose of this study is to identify echocardiographic predictors of response in patients with FMR undergoing PMVR.

Methods

We retrospectively analyzed 44 consecutive patients with ischemic or dilated cardiomyopathy, reduced ejection fraction and severe functional MR (FMR), aged 71±9 years, 71% males, LVEF 30.9±8.7%, mitral valve effective regurgitant orifice area (EROA)>20mm2, regurgitant volume (RV) >30ml and logistic EuroSCORE 22±14.7%. At baseline and 1-year after PMVR we assessed echocardiographic parameters such as LV longitudinal strain (LVGLS) and peak left atrial longitudinal strain (PALS) using speckle tracking echocardiography, LV end-systolic and end-diastolic volumes (LVESV, LVEDV), LA volume, MR severity by Doppler echocardiography along with BNP levels, NYHA class and 6 minute walking distance.

Results

One year after edge-to-edge repair there was a significant reduction of MR (74.2% had mild to moderate MR, 22.6% moderate-to-severe MR and 3.2% severe MR) and BNP levels (933±943pg/ml to 669±824pg/ml), improvement of NYHA class (3.11±0.55 to 2.0±0.6, P<0.05) and increase of the 6 minute walking distance (251±141 to 296±148m, P<0.05). LA volume was reduced (132.5±62.1ml to 115.2±57.7ml) and PALS was improved (6.89±3.47 to 7.94±5.27) (P<0.05 for all comparisons). Baseline LVGLS did not change significantly post intervention (−8.8±4.1 vs. −8.8±3.9, P=0.7) but the baseline value predicted the percentage difference in LVEDV (r=−0.61, P<0.01), LVESV (r=−0.47, P=0.03), BNP (r=0.45, P=0.04) and NYHA class (r=0.63, P<0.01). The best reverse LV remodeling was found in patients with GLS better than −10% and the trend was that the better the GLS the greater the LVEDV and LVESV reduction post-intervention. Additionally, patients with GLS between −10% and −5% had the largest improvement in BNP (P<0.05) and NYHA class (P=0.005).

Conclusions

Edge-to-edge repair is effective in reducing MR in patients with severe functional MR and has a positive impact in patients' clinical status at one year follow up. A preserved LVGLS seems to be a good predictor of reverse modeling and clinical improvement post intervention.

Challenging transfemoral valve-in-valve implantation in a degenerated stentless bioprosthetic aortic valve

Bioprosthetic heart valves are often preferred over mechanical valves as they may preclude the need for anticoagulation. Reoperation is the standard treatment for structural failure of bioprosthetic valves; however, it carries significant risk especially in inoperable elderly patients. Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) seems to be an effective and promising procedure in patients with degenerated bioprosthetic aortic valves avoiding the risks associated with the use of cardioplegia and redo cardiac surgery. We report an interesting case of a high-risk 74-year-old patient with a degenerated Sorin Freedom Solo stentless valve treated successfully with ViV TAVR.