Target-controlled infusion during MitraClip procedures in deep-sedation with spontaneous breathing

OBJECTIVE

Percutaneous mitral valve repair with the MitraClip system is an alternative procedure for high-risk patients not suitable for conventional surgery. The MitraClip can be safely performed under general anesthesia (GA) or deep sedation (DS) with spontaneous breathing using a combination of propofol and remifentanil. This study aimed to evaluate the benefits of target-controlled infusion (TCI) of remifentanil and administration of propofol during DS compared with manual administration of total intravenous anesthesia (TIVA) medication during GA in patients undergoing MitraClip. We assessed the impact of these procedures in terms of remifentanil dose, hemodynamic profile, adverse events, and days of hospital stay after the process.

PATIENTS AND METHODS

From March 2013 to June 2015 (mean age 73.5 ± 9,54), patients underwent transcatheter MitraClip repair, 27 received DS via TCI and 27 GA with TIVA.

RESULTS

Acute procedural success was 100%. DS-TCI group, in addition to a significant reduction of remifentanil dose administrated (249 µg vs. 2865, p < 0.01), resulted in a decrease in vasopressor drugs requirement for hemodynamic adjustments (29.6% vs. 63%, p = 0.03) during the procedure and a reduction of hypotension (p = 0.08). The duration of postoperative hospitalization did not differ between the two groups (5.4 days vs. 5.8 days, p = 0.4).

CONCLUSIONS

Administration of remifentanil by TCI for DS in spontaneously breathing patients offers stable anesthesia conditions, with a lower amount of drugs, higher hemodynamic stability, and decreased side effects.

Edge-to-edge repair for tricuspid valve regurgitation. Preliminary echo-data from the Tricuspid Regurgitation IMAging (TRIMA) study

Background

The natural history of tricuspid valve regurgitation (TR) is characterized by dismal prognosis and high in-hospital mortality when treated with isolated surgery. We report preliminary procedural and echocardiographic results of our experience with the TriClip System in a cohort of “real-life” patients with functional tricuspid regurgitation.

Methods

From June 2020 to March 2022, 27 consecutive patients with &gt; moderate TR have been screened, 12 underwent transcatheter TriClip repair. The anatomical feasibility was established through a complete transthoracic (TTE) and transesophageal echocardiogram (TEE), and a dedicated CT scan for the right cardiac chambers. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy.

Results

A total of 12 subjects (83% female) with significant comorbidities and at high surgical risk were included. The mean age was 82±4 years with an average EuroSCORE II of 8.5±4%. TR included functional (75%) and (25%) mixed etiology (lead-induced and functional) and all patients were classified as at least NYHA functional class III. Nine patients (75%) had severe, two patients (17%) massive and one patient (8%) torrential TR.

The implant and procedural success were achieved in all cases, implanting one device in 8 patients (67%) and two in 4 patients (33%). The device was positioned antero-septal in 83% (10of12) and postero-septal in 50% (6of12) of cases. A TR reduction of≥1 grade after procedure was achieved in all patients; 5 (42%) subjects had moderate, 6 (50%) mild, and one patient (8%) with previous torrential TR treated with two clips had severe post-procedural TR because of partial leaflet detachment 48-hours post-procedure. On TTE, significant reductions in effective regurgitant orifice area (0.61±0.28 to 0.31±0.22 cm2; p&lt;0.001) and regurgitant volume (56.3±16.7 to 27.5±16.6ml; p&lt;0.001) occurred between baseline and before hospital discharge. We also observed a significant reduction of tricuspid annulus diameter (43.8±5.6 to 39.8±4.2 mm; p&lt;0.001), right ventricular basal diameter (47.2±6.8 to 42.9±4.5 mm; p=0.001), right atrial area (28.8±8.8 to 26.7±9.4 cm2; p=0.033). While 3 patients demonstrated a reduced TAPSE/PASP ratio (&lt;0.31 mmHg) before the intervention, the overall ratio significantly improved after device placement (0.37±0.1 to 0.46±0.1 mmHg; p=0.011). At 30-days-follow-up, there was significant and sustained improvement in NYHA class with all patients reaching class II or less without additional reported hospitalizations.

Conclusion

In this single center experience, we have shown that treatment with the edge-to-edge TriClip device is safe and effective and is associated with marked clinical benefits and reduced rates of hospitalizations. The resulting echocardiographic improvements indicate leaflet grasping does not just significantly reduce the grade of TR, but also affects adjacent structures and improves right ventricular afterload adaptation.

Funding Acknowledgement

Type of funding sources: None.

Many hands make light work. Echocardiography and computed tomography results from the Tricuspid Regurgitation IMAging (TRIMA) study

Background

Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR), who are candidates for transcatheter tricuspid valve intervention (TTVI). Currently, echocardiography and computed tomography (CT) are available instruments to study the TV anatomy, guide the decision-making process and support the development of novel transcatheter therapies.

Purpose

The Tricuspid Regurgitation IMAging (TRIMA) study aimed to correlate CT parameters to commonly used echocardiographic variables.

Methods

This prospective, single-center study enrolled 22 consecutive patients with TR equal to or greater than severe (≥3+). All patients underwent transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) and cardiac CT study, in order to obtain anatomical dimensions of the tricuspid annulus and quantification of right-chambers remodeling and function. Novel CT scan measurements were analyzed. Correlation between measurements on echocardiography and CT imaging was assessed.

Results

Severe TR (3+) was present in 27.4% patients, massive (4+) in 4.8% and torrential (5+) in 3.2%. The mean right ventricle (RV) length, RV mid diameter, and right atrium area were 60.81±9.11 mm, 41.27±7.67 mm and 31.72±9.66 cm2, respectively. Tricuspid annular plane excursion, fractional area change, longitudinal myocardial velocity (S') were 16.09±3.25 mm, 33.36±9.47% and 9.18±1.94 cm/sec, respectively. The annular dimensions obtained by CT scan were generally observed to reduce from diastole to systole, except for eccentricity, angles and distance between the postero-septal and antero-posterior commissure and distance between centroid and antero-posterior commissure. A Kruskal-Wallis test showed a stepwise increase in the tricuspid anatomical regurgitant orifice area (AROA) values by CT across the expanded TR grades by TEE, χ2(2)=6,466, p=0.039. Using the Pearson correlation coefficient, we found a relationship between the AROA and TR grade (r=0.593; p&lt;0.004), as well as ARO-perimeter and TR grade (r=0.470; p&lt;0.027). Additionally, a significant correlation was found between septal lateral annulus diameter obtained by TEE and CT (r=0.637; p=0.001). Anyway, no correlations were found between novel CT variables and TR grade or RV function assessed by echocardiogram, as well as between CT systo-diastolic annulus variability and RV function.

Conclusions

Standard echocardiographic study provide invaluable information about the anatomy and function of the right-chambers, as well as an accurate grade of TR. Conventional and novel variables derived by CT scan may step up the anatomical assessment of the complex morphology of the TV apparatus, thanks to the high spatial resolution of the technique. Therefore, an integrated multimodality assessment is the key point of the screening process of TR candidates for TTVI.

Funding Acknowledgement

Type of funding sources: None.

Association between platelet reactivity and long-term bleeding complications following percutaneous coronary intervention in patients with and without diabetes

Background

The association between diabetes mellitus (DM) and bleeding complications following percutaneous coronary intervention (PCI) is controversial. We hypothesized that on-treatment platelet reactivity may have a role in the bleeding risk stratification of such patients.

Purpose

To investigate the role of low platelet reactivity (LPR) in the long-term bleeding risk stratification among patients with and without diabetes undergoing PCI.

Methods

In this observational, retrospective single-center study, 472 patients undergoing PCI for stable coronary artery disease were included. All patients were treated with dual antiplatelet therapy with aspirin and clopidogrel. Platelet reactivity was assessed using the VerifyNow P2Y(12) assay and LPR was defined by values of platelet reactivity unit (PRU) ≤178. Primary endpoint was the occurrence of all bleeding events at 5 years stratified by DM status and LPR.

Results

Out of the study population included, 30.5% had DM (N=144). LPR was numerically less frequent in patients with DM compared to those without (29.2% vs 37.6%; p=0.077). Overall, 11.9% of patients experienced a bleeding complication at 5-year follow-up; 44.6% of events were classified as major bleedings. The incidence of bleeding events per 1000 patients-year was 34.5 (95% CI 22.3–53.5) in DM and 24.2 (95% CI 17.3–33.8) in no DM (p=0.24). A stepwise increase in the crude rates of bleeding complications was observed across patients with and without DM and LPR (log-rank p=0.004), with those having both conditions being at the highest risk of events (Figure). LPR had a similar value for stratifying the risk of bleeding in patients with and without diabetes (p value for interaction between diabetes and LPR status=0.45).

Conclusions

Approximately 1 out of 3 patients undergoing PCI for stable coronary artery disease on clopidogrel has LPR. The assessment of LPR provides a significant incremental value for the prediction of bleeding events irrespective from DM status. While the presence of DM per se does not increase the risk of bleeding complications, the coexistence of DM and LPR identifies the subgroup at the highest risk of events who could benefit from a short-term and less intensive antiplatelet regimen.

Funding Acknowledgement

Type of funding sources: None.

Update on percutaneous mitral valve therapy: clinical results and real life experience

Mitral regurgitation (MR) is a common valvulopathy worldwide increasing in prevalence. Cardiac surgical intervention, preferable repair, is the standard of care, but a relevant number of patients with severe MR do not undergo surgery because of high peri-operative risk. Percutaneous mitral valve repair with the MitraClip System has evolved as a new tool for the treatment of severe MR. The procedure simulates the surgical edge-to-edge technique, developed by Alfieri in 1991, creating a double orifice valve by a permanent approximation of the two mitral valve leaflets. Several preclinical studies, registries and Food and Drug Administration approved clinical trials (EVEREST, ACCESS-EU) are currently available. The percutaneous approach has been recently studied in a randomized controlled trial, concluding that the device is less effective at reducing MR, when compared with surgery, by associated with a lower adverse event rate. The patients enrolled in this trial had a normal surgical risk and mainly degenerative MR with preserved left ventricular function. On the other hand, results derived from the clinical "real life" experience, show that patients actually treated in Europe present a higher surgical risk profile, more complex mitral valve anatomy and functional MR in the most of cases. Thus these data suggest that MitraClip procedure is feasible and safe in this subgroup of patients that should be excluded from the EVEREST trial due to rigid exclusion criteria. Despite the promising results clinical experience is still small, and no data related the durability are currently available. Therefore, MitraClip device should be reserved now to high risk or inoperable patients.

Reduction of mitral valve regurgitation with Mitraclip® percutaneous system

Mitral regurgitation (MR) is the second most common heart valve disease worldwide and the current gold-standard treatment is surgical repair or replacement. Nevertheless, many patients do not undergo surgical intervention due to several comorbidities. Percutaneous "edge-to-edge" mitral valve repair using the MitraClip System is an emerging and effective option to this subset of patients. This device has been used to treat both functional and degenerative mitral valve regurgitation and has been compared to surgery in the Endovascular Valve Edge-to-Edge Repair Study II (EVEREST II) randomized trial. Although the field of percutaneous management of MR is at an early stage, it has been demonstrated that percutaneous approaches can reduce MR, suggesting there is a great deal of potential for clinical benefit to patients with MR.

Nitric oxide test during cardiac catheterization decreases the serum concentrations of S100B protein in adult patients with idiopathic pulmonary hypertension

OBJECTIVE

Cardiac catheterization (CC) is a life-threatening procedure in adult patients. Complicated by idiopathic arterial pulmonary hypertension (IPAH), there is a potential risk of central nervous system (CNS) damage. We measured serum levels of a well-established brain damage marker, namely S100B, collected before, during and after CC in adult patients in whom the nitric oxide (NO) test had been performed.

MATERIAL AND METHODS

In 12 adult patients who had undergone CC for IPAH diagnosis, we recorded clinical and standard monitoring procedures (laboratory variables and echocardiographic patterns) and serum concentrations of S100B before (time 0), during (time 1) and after the NO test (time 2) and at 24 h after (time 3) the procedure in samples obtained from the systemic and pulmonary circulation. Patients were subdivided into NO test responders (n=6) and non-responders (n=6). Neurological evaluation was performed at admission and at discharge from hospital.

RESULTS

Adult patients subjected to CC showed no overt neurological injury at discharge from hospital. No significant differences (p > 0.05 for all) in S100B serum levels between groups at times 0, 1 and 3 have been shown independently from the sampling site. It was noteworthy that the concentration of protein in the responders group at time 2 was significantly decreased (p < 0.05, for all) compared to the responder group and to baseline values. A significant correlation was found between arterial oxygen partial pressure and individual S100B concentration in the pulmonary and systemic bloodstream in the entire study group (R = -0.66 and R = 0.71, respectively; p < 0.05, for both).

CONCLUSIONS

The data suggest that S100B protein assessment, as well as the NO test, may be useful when monitoring possible CNS damage during CC in patients with IPAH, and may also be valuable in relation to brain functions, especially when performed as an emergency procedure in severely hypoxic patients.

Transoesophageal atrial pacing combined with transthoracic two dimensional echocardiography: experience in patients operated on with arterial switch operation for transposition of the great arteries

OBJECTIVE

To assess the feasibility, safety, and diagnostic accuracy of transoesophageal atrial pacing stress echocardiography (TAPSE) combined with two dimensional transthoracic echocardiography (TTE) for evaluation of coronary perfusion in patients undergoing arterial switch operation for transposition of the great arteries.

DESIGN

TAPSE combined with TTE was performed at the end of cardiac catheterisation. An ischaemic response was defined as > 1.5 mm horizontal or downsloping ST segment depression or as a new or worsened wall motion abnormality. The results were compared with results of coronary angiography.

SETTING

Tertiary referral centre for paediatric cardiology and cardiac surgery.

PATIENTS

25 patients, mean (SD) age 29.5 (19) months, mean (SD) weight 12.5 (3.4) kg.

MAIN OUTCOME MEASURES

Target heart rate (200 beats/min) was attained in 22 of 25 (88%) patients. Electrocardiographic ischaemic changes occurred in 4 of 25 (16%) and wall motion abnormalities in 3 of 25 (12%). Coronary obstructions were found in 2 of 25 (8%) patients.

RESULTS

The test was feasible in all patients, without clinical complications requiring treatment. Compared with coronary angiography, the test had a sensitivity and a specificity of 100% and 95%, respectively, for the echocardiographic stress, and of 100% and 91%, respectively, for the electrocardiographic stress. The negative predictive value was 100% for both the echocardiographic and the electrocardiographic stress tests. The positive predictive value was 66% for the echocardiographic stress and 50% for the electrocardiographic stress tests.

CONCLUSIONS

In these patients TAPSE combined with TTE was feasible and safe and apparently an accurate diagnostic method for evaluation of coronary perfusion. Patients with a negative test may have a low likelihood of major coronary abnormalities and may not require coronary angiography.

Paraplegia following percutaneous balloon angioplasty of aortic coarctation: a case report

Balloon angioplasty of recurrent coarctation of the aorta is considered a low-risk procedure with high success rate. In the literature, the major complications are death, rupture of the aorta, recoarctation, aneurysm formation, cerebrovascular accident, and femoral artery thrombosis. Spinal cord ischemia as an unusual complication of balloon angioplasty is reported.

Analysis by mathematical model of haemodynamic data in the failing Fontan circulation

Several late complications jeopardize the clinical performance of recipients of the Fontan operation. The underlying causes have been referred to disturbed flow dynamics in the cavopulmonary connections. Presumably, the large pressure drops occurring in the inferior and superior connections play a pivotal role in the pressure level of the entire circulation, especially in the venous. To address this issue, we retrospectively reviewed catheterization data of six patients with failing Fontan circulation and compared them with those of six patients with functioning Fontan circulation. The impact on the systemic and pulmonary pressure of the increase in the cavopulmonary connection resistances was studied through a steady-state mathematical model of the univentricular closed-loop circulation. In the patients with failing Fontan, pressure in the venae cavae was found to be significantly higher, especially at the inferior cava (19.3 +/- 2.2 versus 12.5 +/- 2.3 mmHg) with the pressure drop at the inferior cavopulmonary connection significantly increased (4.7 +/- 3.1 versus 0.33 +/- 0.82 mmHg). The proposed mathematical model permits us to clearly relate the pressure increase in the venae cavae to an increased resistance in the cavopulmonary connections. Therefore, the present analysis confirms that, to avoid possible congestion of venous circulation, the definitive palliation of univentricular heart should not cause pressure drops at the cavopulmonary connections.

Evaluation of the morphology of the oval fossa for placement of devices

OBJECTIVES

First, to examine the morphology of heart specimens with defects of the oval fossa so as to define the factors that facilitate appropriate selection of the size of devices used for inteventional closure. Second, to examine the relationship between morphology and transthoracic and transesophageal echocardiography.

BACKGROUND

The success of transcatheter closure is influenced by the variable morphology of deficiencies with the oval fossa, and of the relationship of the fossa itself to adjacent structures. More appropriate selection could reduce the incidence of failures.

METHODS

From over 100 specimens in the cardiac registry at the University of California, San Francisco, we judged 16 hearts with atrial septal defects within the oval fossa, either in isolation or associated with other cardiac malformation, to be suitable for this study. We measured the dimensions of the defect and the surrounding rims of the fossa. All values were normalized to the diameter of the aortic root.

RESULTS

A fenestrated defect was present in 9 specimens (56%). The shape defect itself was oval in all specimens, with a ratio of major to minor axes of 1.70 + 0.63. The major axis took one of three main directions with respect to the vertical plane: in 11 specimens (69%o) it was at horizontal; in 3 (19%) it was at oblique at an angle of 45 degrees; and in 2 (12%) it was vertical. Discordance was noted in some hearts between the major axis of the defect and that of the oval fossa. Structures closest to the rim of the fossa were the aortic mound, the coronary sinus, and the hinge point of the aortic leaflet of the mitral valve.

CONCLUSIONS

Extrapolating from these specimens permitted identification of the major and minor axes of the atrial septal defect by transthoracic and transesophageal echocardiography. Our study has identified landmarks and dimensions that may be employed to improve effectiveness of selection of patients for transcatheter closure of defects within the oval fossa.

Aortic pulmonary autograft implant: medium-term follow-up with a note on a new right ventricular pulmonary artery conduit

BACKGROUND

The Ross operation has been applied to various aortic valve pathologies, particularly when somatic growth is an issue. However, associated cardiac disease and technical problems may limit its use with regard to associated procedures and issues of right ventricular outflow reconstruction.

MATERIALS AND METHODS

From December 1992 to March 1998, 24 patients underwent aortic pulmonary autograft implantation. There were 14 males and 10 females, 15+/-10 years of age (mean +/- SD) (range 1 to 50 years), weighing 42.8+/-20 kg (mean +/- SD) (range 8 to 78 kg). Aortic insufficiency was present in 15 (62.5%) patients, stenosis in 8 (33.3%) patients, and valvar stenosis associated with left ventricular outflow tract obstruction in 1 (4.1%) patient. Etiology was rheumatic in 17 patients and congenital in 7. The Ross procedure was accompanied by a partial-Konno left ventricular outflow enlargement in one patient, and mitral valve annuloplasty, mitral commissurotomy, and tricuspid valve replacement in three other patients, respectively. The right ventricular outflow was reconstructed with a valved pulmonary homograft in 14 patients and with a Shelhigh No-React porcine pulmonary conduit in 10 patients. Evaluation was done by New York Heart Association (NYHA) Class and by echocardiography at a follow-up of 22.8+/-24 months (mean +/- SD) (range 3 to 63 months).

RESULTS

There were no operative mortalities and no postoperative arrhythmias. One (4.1%) patient required intra-aortic balloon pump (IABP) support for 3 days, one (4.1%) patient died 2 years later of probable arrhythmia, and one (4.1%) patient required mechanical aortic valve replacement 2 years later for severe autograft insufficiency. Left ventricular ejection fraction was unchanged (preoperative 62.4%+/-30%, postoperative 64.2%+/-30% [mean +/- SD], [p = NS]) and no significant gradient was documented by echocardiographic Doppler in the right and left ventricular outflow tracts. The aortic insufficiency scale decreased from a mean of 3.9+/-0.2 to a mean of 1+/-0 (p < 0.01). NYHA Class decreased to I in all patients, from III (10) and II (14).

CONCLUSIONS

The pulmonary autograft in the aortic position is suitable for aortic valve replacement in pediatric and adult patients with good medium-term results and in patients with rheumatic etiology, and it provides a desirable solution in the presence of associated pathologies, such as left ventricular tract obstruction or associated multivalvular disease. The development of new means of right ventricular outflow reconstruction must parallel the progress achieved for the left side.

[Valvular lesions in the course of nonpenetrating thoracic trauma: their diagnosis by transesophageal echocardiography]

Two cases are reported with nonpenetrating chest trauma and involvement of mitral valve in one case and aortic valve cusps in the other, without aortic rupture. In both patients transesophageal echocardiography allowed us an accurate diagnosis, confirmed by surgical findings. In the patient with involvement of the aortic cusps, the regurgitation developed 3 months after the trauma. In conclusion, cardiac valve injuries are rare but not exceptional following nonpenetrating blunt chest trauma. Transesophageal echocardiography is the imaging technique of choice for these patients. The operator performing the study must be aware of the possible coexistence of different cardiac lesions secondary to blunt chest trauma. In the case of valvular regurgitation the accurate definition of the pathophysiological mechanism is mandatory in order to choose the appropriate surgical strategy. In the case of aortic incompetence of unknown origin, a nonpenetrating chest trauma must be searched out during the clinical interview.

Limitation of myocardial infarct size by nicorandil after sustained ischemia in pigs

Nicorandil is a compound with hybrid properties of nitrates and adenosine triphosphate (ATP)-sensitive potassium channel (KATP) opening. The effects of nicorandil and isosorbide dinitrate (ISDN) were investigated in a model of 60-min coronary occlusion/180-min reperfusion in open chest pigs. Three groups of 10 pigs were randomly assessed to receive saline or equihypotensive doses of nicorandil or ISDN. Drug infusion was started at 30 min of ischemia and continued throughout reperfusion. Area at risk (AAR) and infarcted area (IA) were assessed by monastral blue dye-triphenyltetrazolium dual staining technique and calculated by planimetry. Myeloperoxidase concentration (MPO) in the non-ischemic area and in the IA was assessed as an index of presence of neutrophils. Measurements of reduced glutathione (GSH), oxidized glutathione (GSSG), lipofuscine, and malondialdehyde were performed on coronary vein blood as indexes of oxidative stress. IA, as a percentage of AAR, was 78 +/- 10% after saline, 61 +/- 12% after N (p < 0.05 vs. saline), and 69 +/- 14% after ISDN (not significant vs. saline). Cardiac output and left ventricular dP/dt were depressed during coronary occlusion in all groups and their recovery during reperfusion was earlier in the nicorandil group. In the saline group, MPO was increased in the IA compared to the nonischemic area (78 +/- 63 vs. 21 +/- 21 micrograms/mg prot, p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)