Staging Heart Failure Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Edge-to-Edge Repair

BACKGROUND

Secondary mitral regurgitation (SMR) is a progressive disease with characteristic pathophysiological changes that may influence prognosis. Although the staging of SMR patients suffering from heart failure with reduced ejection fraction (HFrEF) according to extramitral cardiac involvement has prognostic value in medically treated patients, such data are so far lacking for edge-to-edge mitral valve repair (M-TEER).

OBJECTIVES

This study sought to classify M-TEER patients into disease stages based on the phenotype of extramitral cardiac involvement and to assess its impact on symptomatic and survival outcomes.

METHODS

Based on echocardiographic and clinical assessment, patients were assigned to 1 of the following HFrEF-SMR groups: left ventricular involvement (Stage 1), left atrial involvement (Stage 2), right ventricular volume/pressure overload (Stage 3), or biventricular failure (Stage 4). A Cox regression model was implemented to investigate the impact of HFrEF-SMR stages on 2-year all-cause mortality. The symptomatic outcome was assessed with New York Heart Association functional class at follow-up.

RESULTS

Among a total of 849 eligible patients who underwent M-TEER for relevant SMR from 2008 until 2019, 9.5% (n = 81) presented with left ventricular involvement, 46% (n = 393) with left atrial involvement, 15% (n = 129) with right ventricular pressure/volume overload, and 29% (n = 246) with biventricular failure. An increase in HFrEF-SMR stage was associated with increased 2-year all-cause mortality after M-TEER (HR: 1.39; CI: 1.23-1.58; P < 0.01). Furthermore, higher HFrEF-SMR stages were associated with significantly less symptomatic improvement at follow-up.

CONCLUSIONS

The classification of M-TEER patients into HFrEF-SMR stages according to extramitral cardiac involvement provides prognostic value in terms of postinterventional survival and symptomatic improvement.

Staging heart failure patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge repair

Background

Heart failure with reduced ejection fraction (HFrEF) and secondary mitral regurgitation (SMR) are closely related. Progression of HFrEF-SMR is associated with characteristic pathophysiological changes. Recently, staging of HFrEF-SMR patients showed prognostic value in a SMR cohort on medical therapy. Whether these stages are prognostic for SMR patients undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) in addition to drug therapy is unknown.

Purpose

The present study aimed at classifying HFrEF-SMR patients undergoing M-TEER into progressive disease stages based on cardiac and extracardiac involvement. We sought to evaluate the impact of the disease stages on survival outcome and symptomatic improvement after M-TEER

Methods

Based on echocardiographic transthoracic evaluation, patients were assigned into one of the following subsequent HFrEF-SMR stages representing disease progression (Figure 1): left ventricular (LV) dysfunction alone (Stage 1, LV end diastolic volume ≥159 ml and/or LV ejection fraction &lt;50%); left atrial (LA) involvement (Stage 2, history of atrial fibrillation and/or indexed LA volume &gt;34 ml/m2); right ventricular (RV) pressure/volume overload (Stage 3, tricuspid regurgitation ≥3+ and/or systolic pulmonary artery pressure &gt;65 mmHg); biventricular failure (Stage 4, RV to pulmonary artery coupling &lt;0.274 mm/mmHg). A Cox regression model was implemented to investigate the impact of HFrEF-SMR stages on two-year all-cause mortality and symptomatic outcome was assessed with New York Heart Association (NYHA) functional class at follow-up.

Results

Among a total of 849 included patients who underwent M-TEER for symptomatic MR from 2008 until 2019, 9.5% (n=81) presented with LV dysfunction alone, 46% (n=393) with LA involvement, 15% (n=129) with pressure/volume overload and 29% (n=246) with biventricular failure. At baseline and follow-up, successive HFrEF-SMR stages were associated with more severe heart failure symptoms as expressed by NYHA functional class. An increase in HFrEF-SMR stage was associated with increased two-year all-cause mortality rates after M-TEER (Hazard ratio 1.39, confidence interval 1.23–1.58, p&lt;0.01, Figure 2).

Conclusions

Classifying HFrEF-SMR patients undergoing M-TEER into subsequent disease stages provides prognostic value regarding heart failure symptoms and survival.

Funding Acknowledgement

Type of funding sources: None.

EAPCI Core Curriculum for Percutaneous Cardiovascular Interventions (2020): Committee for Education and Training European Association of Percutaneous Cardiovascular Interventions (EAPCI). A branch of the European Society of Cardiology

The proposed 2020 Core Curriculum for Percutaneous Cardiovascular Interventions aims to provide an updated European consensus that defines the level of experience and knowledge in the field of percutaneous cardiovascular intervention (PCI). It promotes homogenous education and training programmes among countries, and is the cornerstone of the new EAPCI certification, designed to support the recognition of competencies at the European level and the free movement of certified specialists in the European Community. It is based on a thorough review of the ESC guidelines and of the EAPCI textbook on percutaneous interventional cardiovascular medicine. The structure of the current core curriculum evolved from previous EAPCI core curricula and from the "2013 core curriculum of the general cardiologist" to follow the current ESC recommendations for core curricula. In most subject areas, there was a wide - if not unanimous - consensus among the task force members on the training required for the interventional cardiologist of the future. The document recommends that acquisition of competence in interventional cardiology requires at least two years of postgraduate training, in addition to four years devoted to cardiology. The first part of the curriculum covers general aspects of training and is followed by a comprehensive description of the specific components in 54 chapters. Each of the chapters includes statements of the objectives, and is further subdivided into the required knowledge, skills, behaviours, and attitudes.

Does pre-existing aortic regurgitation protect from death in patients who develop paravalvular leak after TAVI?

OBJECTIVE

The aim of this study was to investigate interactions among pre-procedural aortic regurgitation (AR), post-procedural paravalvular leak (PVL) and long-term clinical outcomes.

METHODS AND RESULTS

We analyzed data prospectively collected in the Italian Transcatheter balloon-Expandable Registry (ITER) on aortic stenosis (AS) patients. The degree of pre-procedural AR and post-procedural PVL was stratified as: absent/trivial, mild, and moderate/severe. VARC definitions were applied to outcomes. Of 1708 patients, preoperatively, AR was absent/trivial in 40% of the patients, mild in 42%, and moderate in 18%. Postoperatively, PVL was moderate-severe in 5%, mild in 32% of patients, and absent/trivial in 63%. Clinical follow-up, median 821days (IQR 585.75), was performed in 99.7% of patients. PVL, but not preoperative AR, was a major predictor of adverse outcome (HR 1.33, CI 95% 0.9-2.05, p=0.012 for mild PVL, HR 1.36, CI 95% 0.9-2.05, p<0.001 for PVL≥moderate and OR 1.04, p=0.97 respectively). Patients with moderate-severe PVL and preoperative left ventricle (LV) dilatation (LVEDVi>75ml/m²) showed better survival than those without dilatation (HR 8.63, p=0.001).

CONCLUSIONS

In patients with severe AS treated with balloon-expandable TAVI, the presence of PVL, but not pre-procedural AR, was a major predictor of adverse outcome. Preoperative LV dilatation seemed to offer some clinical advantages.

Sub-Nyquist field trial using time frequency packed DP-QPSK super-channel within fixed ITU-T grid

Sub-Nyquist time frequency packing technique was demonstrated for the first time in a super-channel field trial transmission over long-haul distances. The technique allows a limited spectral occupancy even with low order modulation formats. The transmission was successfully performed on a deployed Australian link between Sydney and Melbourne which included 995 km of uncompensated SMF with coexistent traffic. 40 and 100 Gb/s co-propagating channels were transmitted together with the super-channel in a 50 GHz ITU-T grid without additional penalty. The super-channel consisted of eight sub-channels with low-level modulation format, i.e. DP-QPSK, guaranteeing better OSNR robustness and reduced complexity with respect to higher order formats. At the receiver side, coherent detection was used together with iterative maximum-a-posteriori (MAP) detection and decoding. A 975 Gb/s DP-QPSK super-channel was successfully transmitted between Sydney and Melbourne within four 50GHz WSS channels (200 GHz). A maximum potential SE of 5.58 bit/s/Hz was achieved with an OSNR = 15.8 dB, comparable to the OSNR of the installed 100 Gb/s channels. The system reliability was proven through long term measurements. In addition, by closing the link in a loop back configuration, a potential SE∙d product of 9254 bit/s/Hz·km was achieved.

Antegrade percutaneous valve implantation for mitral ring dysfunction, a challenging case

The operative risk for reoperation of degenerated bioprosthetic valves or failing mitral-valve annuloplasty is higher compared with the risks for first isolated native valve repair or replacement (Astor et al., Eur Heart J 2008;29:2382-2387). In the presence of comorbidities, these risks increase exponentially. The recent introduction of transcatheter valve implantation opened new perspectives for the treatment of patients at very high surgical risk. We report a percutaneous mitral valve (MV) implantation using a transatrial approach within a MV ring using the Edwars Sapien XT valve.

Usefulness of intravenous myocardial contrast echoardiography in the early left ventricular remodeling in acute myocardial infarction

The aim of this study was to assess the role of intravenous myocardial contrast echocardiography (IMCE) in the prediction of left ventricular (LV) remodeling in patients with acute myocardial infarction (AMI). Sixty-three patients with AMI, who were successfully treated with acute coronary angioplasty, underwent IMCE and low-dose dobutamine echocardiography during hospital admission. IMCE was graded semiquantitatively on a score of 0 (no visible contrast effect), 0.5 (patchy myocardial contrast enhancement), and 1 (homogenous contrast effect). Patients were considered to have microvascular impairment if <50% of segments within the infarct-related area had score of 1. A mean perfusion score index was calculated for each patient. Patients with a good perfusion at IMCE (IMCE+) showed a lower creatine kinase peak (p = 0.001) and lower creatine kinase-MB (p = 0.01), and a better baseline regional contractile function compared with patients who had negative results at IMCE (IMCE-) (p <0.0001) and a higher amount of myocardial viability at low-dose dobutamine echocardiography (p = 0.03). At follow-up, a higher improvement in regional systolic function (p = 0.0006) was observed in IMCE+ patients, whereas IMCE- patients showed an evident increase in LV end-diastolic volume from baseline to 6-month follow-up (p <0.0001), implying LV remodeling, which has been associated with a higher incidence of adverse cardiac events (p = 0.005). By stepwise multiple regression analysis, microvascular impairment at IMCE was a significant independent predictor of LV remodeling (p <0.0001). Thus, IMCE seems to be an important diagnostic tool, able to predict LV remodeling in patients with AMI.

The deployment of visual attention in the intact field of hemineglect patients

Patients with left hemispatial neglect after right hemisphere lesions and control patients with right hemisphere lesions were presented in the ipsilesional (i.e., intact) visual field with stimuli that could occupy left-right relative positions. The patients were required to discriminate between target stimuli and distractors by emitting go/no-go responses. Reaction times (RTs) and measures of sensitivity (d') and response bias (beta) were obtained. The within-subjects comparisons showed that neglect patients were faster in the right than the left relative position, whereas control patients were faster in the left than the right relative position. The between-subjects comparisons showed that neglect patients were faster than control patients in the right relative position but slower in the left relative position. These effects were due to changes in processing efficiency, as attested by the fact that the differences in response speed were accompanied by congruent differences in sensitivity, whereas no differences in response bias were found. The results were interpreted by assuming that neglect patients focus attention on the right relative position and, therefore, have a small attentional focus concentrated on that position. By contrast, control patients, like normal subjects, would distribute attention between the two possible stimulus positions and, therefore, allocate attention to a larger portion of the visual field.