Impact of coaptation gap location on procedural strategy and outcomes following tricuspid transcatheter edge-to-edge repair: insights from the TriClip bRIGHT study

Background

As tricuspid transcatheter edge-to-edge repair (TEER) gains momentum, a better understanding of coaptation gap size and location becomes increasingly important to properly select patients for this therapy. The tricuspid valve is complex and patient phenotypes may be highly variable. It is currently unknown how location of the coaptation gap may impact procedural strategy and clinical outcomes.

Purpose

To characterize the coaptation gap in patients receiving tricuspid TEER and investigate the effect of coaptation gap location on procedural strategy and short-term outcomes.

Methods

bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe tricuspid regurgitation. Detailed echocardiographic coaptation gap measurements were performed on 135 subjects (from 24 sites) with available echo. Procedural and short-term outcomes were stratified by coaptation gap location.

Results

The biplane RV inflow/outflow and short-axis transgastric (SAX TG) views were available in 90% (122/135) and 56% (76/135) of subjects, respectively. From the SAX TG view, coaptation gap measured 8.2±3.4 and 5.2±2.4 mm in the central and mid regions of the anterior-septal (AS) coaptation line, and 6.5±3.0 and 3.7±2.0 mm in the central and mid regions of the septal-posterior (SP) coaptation line (Figure 1). Coaptation gap measured 4.7±2.4, 5.2±2.4 and 4.6±3.0 mm in the anterior, mid and posterior aspects of the RV inflow/outflow view. The largest coaptation gap presented in the AS region in 79% (95/120) of subjects. A comparison of baseline characteristics, procedural strategy and outcomes stratified by location of the largest coaptation gap is provided in Table 1. Annulus and right ventricle size and presence of pacemakers were similar between groups. Torrential TR at baseline was more common in the SP group. Clipping strategy was similar with the majority of implants placed in the AS region. Implant success and acute procedural success (APS) were achieved in the majority of patients in both groups, with the SP group showing higher APS rates, 96% vs 85%, respectively. At 30-day follow-up, subjects with the largest gap in the SP region experienced more TR reduction at 30-day follow-up, 2.8±1.6 vs 2.1±1.3 grade reduction, respectively. Clinical improvements were observed in both groups: KCCQ increased by more than 15 points on average and the majority of subjects in both groups were NYHA I/II at 30-day follow-up.

Conclusion

Coaptation gap size varies across the tricuspid valve and measurements at the intended clipping location should be taken into account when determining appropriateness of a given anatomy for tricuspid TEER. TriClip TEER offered high rates of implant and procedural success and improved clinical outcomes regardless of coaptation gap location. Subjects with SP coaptation gap localization are infrequent but should not be excluded from TEER therapy.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott

Acute and chronic changes in LV performance in patients with primary severe mitral regurgitation undergoing percutaneous mitral valve repair

Funding Acknowledgements

Type of funding sources: None.

Background

The non-invasive assessment of myocardial work allow to evaluate LV performance by taking into account the effect of LV load. Aim of this study is to evaluate the acute and chronic impact of percutaneous mitral valve repair (PMVR) on left ventricular (LV) performance, in patients with severe primary mitral regurgitation (PMR).

Methods and Results

71 patients (age: 77 ± 9 years, females: 44%) with severe PMR (effective regurgitant orifice: 0.57 ± 0.31 cm2, regurgitant volume: 80 ± 34 ml) and preserved LV ejection fraction (LVEF: 60 ± 10%) underwent PMVR according to current recommendations. Myocardial work indices were evaluated before the procedure, 2 days after the procedure and at 1-year follow-up.  PMVR was associated with an acute reduction in LVEF, global longitudinal strain (GLS), myocardial work index (MWI), and work efficiency (MWE), and a significant increase in myocardial wasted work (MWW) and mechanical dispersion (MD). 1-year after the procedure, LV size significantly decreased, GLS, MWI, MWE and MD improved, whereas GWW remained significantly reduced. LVEF improved but remained significantly altered compared with baseline values (Table 1).

Conclusions

In patients severe PMR undergoing PMVR, the acute reduction in LV preload causes a significant impairment of all parameters of LV performance. After 1-year, progressive LV remodeling is associated a significant improvement in MCW, counterbalanced by a persistently high MWW, which can explain the partial recovery of LVEF. Abstract Figure.

Prevention of stroke and atrial arrhythmia consequences in hypertrophic cardiomyopathies: a clinical challenge that could be best managed by a better echocardiographic left atrial characterization

Funding Acknowledgements

Type of funding sources: None.

Background

There is a need to better predict the risk of atrial arrhythmia (AA) and stroke in patients with hypertrophic cardiomyopathy (HCM).

Purpose

We sought to look at atrial remodeling and atrial function by echocardiography in a HCM-cohort to assess the association with occurrence of AA and stroke.

Methods

We retrospectively studied 216 patients diagnosed for HCM (mean age 52 ± 16 years) from 2015 to 2020. All patients underwent transthoracic echocardiography with the assessment of left atrial volume (LAV) and peak left atrial strain (PLAS). Patients were followed-up for 2,9 years for the development of a composite endpoint comprising occurrence of atrial arrhythmias and/or stroke.

Results

78 patients had an event (24 stroke and 54 documented atrial arrhythmia). Univariate comparison analysis showed that LAV (37.2 ± 15.7 vs. 47 ± 20 ml/m², p = 0.0001) and anteroposterior LA diameter (41.7 ±7.58 vs. 45.8 ± 8.9 mm; p = 0.0006) were significantly higher in patients who met the composite endpoint, whereas PLAS was significantly impaired (27.1 ± 9.77 vs. 20.4 ± 10.5%; p < 0.0001). Other echographic parameters associated with the composite endpoint were mean E/e" ratio (0.65 [0.55-0.85] vs. 0.60 [0.45-0.75]; p = 0.0204) and tricuspid annular peak systolic velocity (S") (cm/s) (13.3 ± 2.92 vs. 12.2 ± 3.26; p = 0.0148). NTproBNP level (216 vs. 818 ; p < 0.0001), history of hypertension (42.3% vs. 62.3%; p = 0.005) and age at diagnosis (50.3 ± 16.7 vs. 57.1 ± 14.4; p = 0.0035) were the clinical parameters different between groups.

In a multivariable analysis, PLAS was the only independent maker associated with the occurrence of AA and stroke, particularly for stroke with an odd ratio of 0.53 ([0.32-0.86]; p = 0.00097). 

Interestingly, 19 of 28 stroke patients (67%) did not experience any documented AA. 

Conclusion

The decrease of PLAS is strongly associated with the risk of stroke, even in patients without documented atrial arrhythmia. Its use to guide the indication for an implantable holter monitoring and perhaps a prophylactic oral anticoagulation in HCM requires further investigation. Abstract Figure. Impaired PLAS in an HCM patient

Characterization of coaptation gap in patients receiving tricuspid transcatheter edge-to-edge repair: initial observations from the bRIGHT TriClip study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

As tricuspid transcatheter edge-to-edge repair (TEER) gains momentum, the proper measurement of coaptation gap to determine optimal patients for this therapy becomes increasingly important. Currently, a single septo-lateral measurement from the short-axis transgastric (SAX TG) or RV inflow/outflow biplane view is commonly used as the representative coaptation gap measurement for a patient. However, this measurement is not necessarily performed at the intended location for TEER and may overestimate the coaptation gaps to be treated.

Purpose

To characterize the coaptation gap in patients receiving tricuspid TEER which may provide insights on how to best determine eligibility for edge-to-edge repair.

Methods

bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe tricuspid regurgitation. Detailed echocardiographic coaptation gap measurements were performed on the first 46 subjects with available echo data by two experienced echocardiographers.  Coaptation gap was measured at four levels in the SAX TG view (Figure 1) and also at the resulting long axis view from a orthogonal view taken from a RV inflow/outflow view obtained at the anterior, mid and posterior aspect of the tricuspid valve (Figure 2).

Results

The biplane RV inflow/outflow and SAX TG views were available in 91% (42/46) and 93% (43/46) of subjects, respectively. From the SAX TG view, coaptation gap measured 9.0 ± 3.9 and 4.9 ± 2.7 mm in the central and mid regions of the anterior-septal coaptation line, and 7.6 ± 3.4 and 4.0 ± 2.1 mm in the central and mid regions of the septal-posterior coaptation line (Figure 1). The largest coaptation gap presented between the anterior and septal leaflets in 78% (33/43) of subjects, with the gap extending across the anterior-septal and septal-posterior coaptation lines in  98% (42/43) of subjects.  Coaptation gap measured 6.2 ± 2.8, 6.6 ± 2.8 and 6.0 ± 3.5 mm in the anterior, mid and posterior aspects of the RV inflow/outflow view (Figure 2). In subjects with both views available, the SAX TG view resulted in larger coaptation gap measurements (+3.4 ± 3.0 mm) in 95% (38/40) of subjects. A significant, positive correlation was observed between the maximum biplane and transgastric measurements (rho = 0.648, p < 0.0001).

Conclusion

A single septo-lateral measurement may overestimate the actual gap size and potentially exclude patients who are viable candidates for TEER. Measurements in both the SAX TG and RV inflow/outflow biplane should be taken into account when determining appropriateness of a given anatomy for tricuspid TEER Future work in larger cohorts is needed to determine which coaptation gap measurements are predictive of procedural outcomes and how these measurements may influence treatment strategy. Abstract Figure 1  Abstract Figure 2

Left atrial reservoir strain is an independent prognostic predictor in patients undergoing percutaneous mitral valve repair

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial reservoir strain (LARS) is a well-known prognostic predictor in several cardiac diseases. Aim of the presence study was to assess the value of LARS in predicting the occurrence of major adverse cardiovascular events (MACEs) in patients undergoing percutaneous mitral valve repair (PMVR)

Methods and results

112 patients (62% males, age: 74 ± 10 years) undergoing PMVR for severe primary (n = 71, 63%) or secondary MR were retrospectively included in the study underwent a comprehensive echocardiography before the procedure. Thirty-eight MACES occurred during a median follow-up of 18 months. At multivariable Cox-regression analysis, ischemic cardiomyopathy [HR 2.41 (1.11-5.24, p = 0.02)], indexed left atrial volume [HR 1.01 (1.00-1.01), p = 0.03], and LARS [HR 0.93 (0.88-0.99), p = 0.03] were all significant predictors of MACEs. A cut-off of 13% for LARS (AUC 0.66, p = 0.008) was able to predict MACEs with a 71% sensitivity and 41% specificity (Table 1).

Conclusions

LARS is an independent predictor of MACEs in patients undergoing percutaneous mitral valve repair, independently of the etiology of mitral regurgitation. Abstract Figure.

How myocardial work could be relevant in patients with an aortic valve stenosis?

Funding Acknowledgements

Type of funding sources: None.

Background

Speckle tracking based myocardial work calculation is an attractive method to assess left ventricular (LV) myocardial function. In case of aortic stenosis (AS), assessment of work indices is challenging because it requires an accurate evaluation of LV-pressure curves. Therefore, we sought to evaluate the performances of two distinct methods for the estimation of myocardial work indices and to provide a quantitative comparison with invasively measured data.

Methods

Model-based and template-based methods were defined and applied for the evaluation of LV pressures on 67 AS patients. Global Constructive (GCW), Wasted (GWW), Positive (GPW), Negative (GNW) myocardial work and Global Work Efficiency (GWE) and Index (GWI) parameters were calculated using the available software computing the indices using brachial blood pressure and trans-aortic mean pressure gradient for estimating the LV pressures versus using a model-based and homemade software. A complete comparison was performed with invasive measurements.

Results

Patients were characterized by mean pressure gradient of 49.8 ± 14.8 mmHg, LV ejection fraction of 59 ± 8%, the global longitudinal strain was -15.0 ± 4.04%, GCW was 2107 ± 800mmHg.% (model-based method) and 2483 ± 1068mmHg.% (template-based method). The root mean square error (RMSE) and correlation were calculated for each patient and for each pressure estimation methods. The mean RMSE are 33.9mmHg and 40.4mmHg and the mean correlation coefficients are 0.81 and 0.72 for the model-based and template-based methods respectively. Correlation coefficient and Bland-Altman analysis were performed for the six work indices. The two methods present correlation coefficient r2 > 0.75 for almost all the indices.

Conclusion

The two non-invasive methods of LV pressure estimation and the work indices computation correlate with invasive measurements and computations for AS patients. Although the model-based approach requires less information and is associated with slightly better performances, the implementation of template-based method is easier and seems more appropriate in a clinical practice. Abstract Figure. SUMMARY

Acute and chronic changes in LV performance in patients with secondary severe mitral regurgitation undergoing percutaneous mitral valve repair

Funding Acknowledgements

Type of funding sources: None.

Background

The non-invasive assessment of myocardial work allows to evaluate left ventricular (LV) performance by considering the effect of LV load on LV deformation. Aim of this study is to evaluate the acute and chronic impact of percutaneous mitral valve repair (PMVR) on LV function, in patients with severe secondary mitral regurgitation (SMR).

Methods and Results

41 patients (age: 69 ± 10 years, females: 29%) with severe SMR (effective regurgitant orifice: 0.42 ± 0.16 cm2, regurgitant volume: 65 ± 325 ml) underwent PMVR according to current recommendations. Myocardial work indices were evaluated before the procedure, 2 days after the procedure and at 1-year follow-up.  PMVR was associated with an acute reduction in LV ejection fraction (LVEF), global longitudinal strain (GLS), and myocardial constructive work (MCW) and with a significant increase in myocardial wasted work (MWW). 1-year after the procedure, we did not observe significant LV reverse remodeling. GWE remained significantly impaired despite the small improvement in GCW, which can explain the absence of improvement in MWE and GLS. Interestingly, LVEF modestly increased compared with the post-procedural values, but remained significantly reduced compared to baseline values (Table1).

Conclusions

In patients severe SMR undergoing PMVR, the acute reduction in LV preload causes a significant impairment of all parameters of LV performance. After 1-year, the absence of LV reverse remodelling is associated a significant impairment in GWW, without substantial improvement in the remaining parameters of LV function. Abstract Figure.

Contamination of a toothbrush with antibacterial properties by oral microorganisms

OBJECTIVES

The aim of this study was to examine the contamination and the survival rate of periodontopathic and cariogenic species on new toothbrushes with antibacterial properties (coated bristles with triclosan), after a single use in periodontitis patients. The decontamination effect of the use of toothpaste was also evaluated.

METHODS

Ten patients, who consulted the Department of Periodontology, for treatment of chronic periodontitis, were selected. In each patient four different toothbrushes were used. Two quadrants, randomly selected, were each brushed using a different antibacterial toothbrush. In one of these two quadrants toothpaste was used. The same happened with the remaining quadrants, only with regular toothbrushes. After brushing, the toothbrushes were rinsed and stored in room temperature and a dry environment. After 0, 4 and 24h, four tufts, from each toothbrush, were cut and processed for selective and non-selective culturing techniques, followed by identification and quantification of all species found.

RESULTS

Immediately after brushing the toothbrushes harbored a significant number of microorganisms, with no statistically significant difference between the two types of brushes (regular and antibacterial). The reduction of microorganisms from 0 to 4h after brushing was statistically significant (p<0.05). The difference was less obvious from 4 to 24h. When toothpaste was used, brushes harbored significantly (p<0.05) lower numbers of colony-forming units (CFU) compared to those without the use of toothpaste.

CONCLUSIONS

The antibacterial toothbrush with triclosan coated tufts failed to limit the bacterial contamination. The toothpaste, on the other hand, significantly reduced the contamination of toothbrushes.

Contamination of interdental brushes by periodontopathogens

Experimental studies have shown that intraoral transmission of bacteria can occur. Of course, the question arises as to how this transmission may happen. In this study, the contamination of interdental brushes by periodontopathogens is examined and compared to the microbial load of the periodontal pockets. In ten untreated chronic periodontitis patients, four interdental sites were professionally brushed with one interdental brush per patient. Subsequently, samples from the depths of the pockets (of the specific interdental sites) were obtained with paper-points. The interdental brush samples and the samples of the subgingival plaque, obtained by the pooled paper-points, were processed for dark-field microscopy examination as well as anaerobic culturing. The results showed that, although significant differences could be found between the brushes and paper-points with direct microscopy, the culturing did not uncover many differences. On the contrary, the detection frequencies of specific bacterial species were almost the same between the two. The total anaerobic colony-forming units (CFU), P. gingivalis, F. nucleatum, and E. corrodens found on the brushes showed a significant correlation with the subgingival plaque samples (P<0.005). These results suggest that, in untreated situations, interdental brushes are contaminated relatively easily by putative periodontopathogens in numbers comparable to their presence in periodontal pockets. This contamination could be a factor in the intraoral spread of bacteria.

Expectations and perceptions of Greek patients regarding the quality of dental health care

OBJECTIVE

The aim of this study was to investigate the perceptions and expectations of patients regarding the quality of dental health care they received and the criteria they used to select a dentist.

DESIGN

Descriptive study.

METHODS

Two questionnaires referring to the expectations and the perceptions of dental health care were handed to patients. Likert-type scales were used to evaluate the characteristics examined. These characteristics have been classified in four quality dimensions: 'assurance', 'empathy', 'reliability' and 'responsiveness'. STUDY PARTICIPANTS AND SETTING: Two hundred consecutive patients who visited the Dental Clinic of the School of Dentistry, University of Athens, Greece, in 1998-1999.

RESULTS

The patients' top priority was adherence to the rules of antisepsis and sterilization. Women of the middle and lower socio-economic groups were more demanding than men of the same groups, while men of the upper socio-economic group appeared to be more demanding than women (P = 0.02). Their perceptions of the dental service provided reflected their satisfaction regarding the adherence to the rules of antisepsis and sterilization, but also showed their moderate satisfaction regarding most of the other characteristics and their dissatisfaction regarding information on oral health and hygiene.

CONCLUSION

Expectations and demands regarding empathy (approach to the patient) and assurance were placed at the top of the patients' priorities. A highly significant quality gap was observed between the desires of the patients and their perceptions (P< 0.01) and the largest gap was noted concerning information they received about oral health diseases. The largest quality gap was also observed in characteristics regarding responsiveness.

[Protective measures against AIDS]

The Human Immunodeficiency Virus (HIV) has the same epidemiology and way of transmission as the Hepatitis B Virus (HBV). The HIV is destroyed by physical or chemical means easier than HBV and the HIV concentration in the blood is less than that of HBV. This fact leads us to the conclusion that there is the risk of transmission of HIV in the surgery but it is much less than that of HBV. Consequently the protective measures taken for HBV in the surgery are adequate for the protection from HIV. Each patient before undergoing treatment should be questioned by his dentist on his general state of health. The dentist must follow strictly the sterilization and disinfection procedures of the instruments and surfaces. The dentist should himself realise that the use of gloves, eyeglasses and mask will reduce the risk of transmission of HIV.