"Mind the Gap": An 85-Year-Old Man with Severe Tricuspid Valve Regurgitation Who Underwent Percutaneous Edge-to-Edge Valve Leaflet Plication Using the New and Advanced MitraClip XTR System

Patient: Male, 85-year-old

Final Diagnosis: Severe tricuspid regurgitation

Symptoms: Cardiac decompenstion • dyspnea

Medication: —

Clinical Procedure: Edge-to-edge valve repair using MitraCLip System XTR

Specialty: Cardiology

Deep Sedation in a Patient Undergoing Transfemoral Tricuspid Valve Repair Using the PASCAL System

A 70-year-old man with severe tricuspid regurgitation and large coaptation gap (0.8 cm) was referred to transfemoral valve repair using the PASCAL system. The procedure was successful in reducing tricuspid regurgitation. The PASCAL device facilitated maximum leaflet insertion and to span large coaptation gap in severe tricuspid regurgitation without ventilation maneuvers under general anesthesia. (Level of Difficulty: Intermediate.)

STUDENTS POPULATION'S ATTITUDE CONCERNING ENVIRONMENTAL ISSUES IN GEORGIA

The aim of this study were to investigate the attitude of university students on the environmental issues, analyze the information received and develop measures for the participation of students in environmental health-improving and preventive activities.. The qualitative study was conducted by using face to face interviewing method with university students. Environmental pollution is one of the most important threats in Georgia and arount the world. The immediate objects of pollution are land, water, soil, air, which directly affects human health and worsens it. The participants have favorable attitudes toward the environment, but they are less involved in environmental activities. Basically these measures are limited to the so-called one-time campaigns. Based on the results, it is recommended the development of integrated measures and schemes to stimulate student participation in the implementation of socially active algorithms to improve the environment.

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy-Current Evidence and Practice

As the number of, and the indications for, structural heart interventions are increasing worldwide, the optimal secondary prevention to reduce device thrombosis is becoming more important. To date, most of the recommendations are empiric. The current review discusses mechanisms behind device-related thrombosis, the available evidence with regard to antithrombotic regimen after cardiac device implantation, as well as providing an algorithm for identification of risk factors for device thrombogenicity and for management of device thrombosis after implantation of patent foramen ovale and left atrial appendage occluders, MitraClips/transcatheter mitral valve replacement, pacemaker leads, and left ventricular assist devices. Of note, the topic of antithrombotic therapy and thrombogenicity of prostheses in aortic position (transcatheter aortic valve replacement, surgical, mechanical, and bioprostheses) is not part of the present article and is discussed in detail in other contemporary focused articles.

Improved mitral valve coaptation and reduced mitral valve annular size after percutaneous mitral valve repair (PMVR) using the MitraClip system

Aims

Improved mitral valve leaflet coaptation with consecutive reduction of mitral regurgitation (MR) is a central goal of percutaneous mitral valve repair (PMVR) with the MitraClip® system. As influences of PMVR on mitral valve geometry have been suggested before, we examined the effect of the procedure on mitral annular size in relation to procedural outcome.

Methods and results

Geometry of the mitral valve annulus was evaluated in 183 patients undergoing PMVR using echocardiography before and after the procedure and at follow-up. Mitral valve annular anterior-posterior (ap) diameter decreased from 34.0 ± 4.3 to 31.3 ± 4.9 mm (P < 0.001), and medio-lateral (ml) diameter from 33.2 ± 4.8 to 32.4 ± 4.9 mm (P < 0.001). Accordingly, we observed an increase in MV leaflet coaptation after PMVR. The reduction of mitral valve ap diameter showed a significant inverse correlation with residual MR. Importantly, the reduction of mitral valve ap diameter persisted at follow-up (31.3 ± 4.9 mm post PMVR, 28.4 ± 5.3 mm at follow-up).

Conclusion

This study demonstrates mechanical approximation of both mitral valve annulus edges with improved mitral valve annular coaptation by PMVR using the MitraClip® system, which correlates with residual MR in patients with MR.

GENDER SPECIFIC DIFFERENCES IN REPORTING DEPRESSIVE SYMPTOMS AMONG PATIENTS HOSPITALIZED WITH ACUTE CORONARY SYNDROME

In patients with acute coronary syndrome (ACS) low level of depressive symptoms is associated with coronary event recurrence and morbidity. Large epidemiological trials revealed that there is a disparity between males and females in their reports of different somatic depressive symptoms. The aim of our study was to identify gender differences in reporting depressive symptoms in patients with acute coronary events. Depreesion screening using BDI questionnaire was performed in patients with ACS in Emergency Cardiology center, Tbilisi, Georgia. The total number of participants was 84. Patients' data were collected from hospital records. Descriptive statistical tests were used for the calculation of frequencies, means and standard deviations. Chi-square test was applied for categorical variables in order to establish difference between groups. The Independent t-test was used to compare means for numerical variables. The mean age for both genders was 59.2 (10.2) years. Classic coronary risk factors were more prevalent in men than in women. However, women, compared to men have a greater number of cognitive as well as somatic depressive symptoms. Women hospitalized with an acute coronary syndrome reported greater number of depressive symptoms compared to men. Early detection of depressive symptoms will help healthcare providers reduce risks and improve outcome of ACS.

THE ROLE OF NON-PROFIT ORGANIZATIONS IN HEALTHCARE SYSTEM: WORLD PRACTICE AND GEORGIA (REVIEW)

The health care market is substantially different from other areas of the economy and therefore the behavior of health care providers operating in the health care market is different, which is mainly related to the form of ownership. If the market is mainly characterized by the pursuit of maximum profit, medical services market has for some public good features. Because of this, non-profit hospitals in western countries are considered as an alternative form of commercial hospitals. The purpose of the research was to study the role of not-for-profit hospitals, and in this regard examine the situation of the medical market in Georgia. The existing literature about non-profit hospitals, relevant legislation and statistical data, scientific articles, and other related works. The majority of the hospitals in Georgia represent profitable (commercial) organizations. 41,1% of the hospitals owned by private insurance companies, 29,1% by individuals, 18,4% by other types of companies, 3,2% by other forms and 8% is state-owned. In contrast to this, more than 50% of the healthcare system of West Europe as well as USA is composed of non-profit (commercial) hospitals. In Georgia there is no sufficient motivation for operating of hospitals as non-profit organizations. It is necessary to further adjust tax benefit in the Tax Code of Georgia and share European experiences. It is reasonable to increase the role of non-profit hospitals on the health care market that will increase accessibility to healthcare services for population and moreover. It will bring Georgian healthcare system close to the experience of civilized world.

Comparison of Deep Sedation With General Anesthesia in Patients Undergoing Percutaneous Mitral Valve Repair

BACKGROUND

Percutaneous edge-to-edge mitral valve repair (PMVR) has become an established treatment option for mitral regurgitation in patients not eligible for surgical repair. Currently, most procedures are performed under general anesthesia (GA). An increasing number of centers, however, are performing the procedure under deep sedation (DS). Here, we compared patients undergoing PMVR with GA or DS.

METHODS AND RESULTS

A total of 271 consecutive patients underwent PMVR at our institution between May 2014 and December 2016. Seventy-two procedures were performed under GA and 199 procedures under DS. We observed that in the DS group, doses of propofol (743±228 mg for GA versus 369±230 mg for DS, P<0.001) and norepinephrine (1.1±1.6 mg for GA versus 0.2±0.3 mg for DS, P<0.001) were significantly lower. Procedure time, fluoroscopy time, and dose area product were significantly higher in the GA group. There was no significant difference between GA and DS with respect to overall bleeding complications, postinterventional pneumonia (4% for GA versus 5% for DS), or C-reactive protein levels (361±351 nmol/L for GA versus 278±239 nmol/L for DS). Significantly fewer patients with DS needed a postinterventional stay in the intensive care unit (96% for GA versus 19% for DS, P<0.001). Importantly, there was no significant difference between DS and GA regarding intrahospital or 6-month mortality.

CONCLUSIONS

DS for PMVR is safe and feasible. No disadvantages with respect to procedural outcome or complications in comparison to GA were observed. Applying DS may simplify the PMVR procedure.

Platelet activation is less enhanced in the new balloon expandable Edwards Sapien 3 valve compared to its predecessor model (Edwards Sapien XT)

Stroke and thromboembolic events after transfemoral aortic valve replacement (TAVR) continue to be a problem. The aim of our study was to compare platelet aggregation (Agg) and platelet activation (PA) observed with two different catheter valves, the ESV-XT and the newer ESV-3 valve in patients (pts) undergoing TAVR on dual antiplatelet therapy (DAPT). A total of 174 patients with severe aortic stenosis and high surgical risk successfully underwent TAVR (60 ESV-XT; 114 ESV-3). Platelet Agg and PA (CD62P expression) were evaluated before and the following three days after TAVR under DAPT. Platelet Agg was inhibited to the same extent in both valve types and there was no significant difference in platelet drop between both valve types between day 0 and day 3 [ESV-XT vs ESV-3: median (25th-75th percentile): platelet count (x1000): 55 (42–74) vs 61(42–93), p=0.280]. However, there was an enhanced CD62P expression directly after TAVR with the ESV-XT compared to the ESV-3 [CD62P (MIF): 7.4 (6.8–8.6) vs 6.6 (6–7.9), p=0.014]. Surface expression of platelet CD62P was associated with the occurrence of residual aortic regurgitation (AR) and was significantly higher in patients with residual AR [CD62P (mild AR) vs CD 62P (no or trace AR): 7.9 (7.3–9.1) vs 7.1 (6.4–8.0), p < 0.001)]. PA was significantly enhanced in patients with the ESV-XT compared to the ESV-3 valve and was associated with the amount of residual AR which was significantly reduced by ESV-3. This may have implications for thromboembolic events following TAVR procedure

ROLE OF PRIMARY HEALTH CARE IN RE-HOSPITALIZATION OF PATIENTS WITH HEART FAILURE

Re-hospitalization of cardiac patients is a great financial burden not only for healthcare system, but also for patients. Main aim of the research is to identify features and reasons of re-hospitalization and to determine ways of reducing. Within the Quantitative research, we have analyzed data of re-hospitalized patients during 30 days. Within the qualitative study, in-depth survey of medical staff and patient conducted. Main reason of re-hospitalization is that patients do not fulfill doctor's prescriptions after discharging from hospital. This is because of financial difficulties and lack of developing family doctor institution in the country. Usually, after discharging patient from hospital, for medical supervision he/she addresses to family doctor very seldom. There is no coordination between family and hospital doctors. Primary health care plays a significant role in the reduction of re-hospitalization rate. In this regard, it is important to increase the role of the family doctor, to improve procedure of discharging patients, continuous medical supervision on patients, to expand outpatient services package in state healthcare programs, to improve day care centers.

Immediate increase of cardiac output after percutaneous mitral valve repair (PMVR) determined by echocardiographic and invasive parameters: Patzelt: Increase of cardiac output after PMVR

BACKGROUND

Successful percutaneous mitral valve repair (PMVR) in patients with severe mitral regurgitation (MR) causes changes in hemodynamics. Echocardiographic calculation of cardiac output (CO) has not been evaluated in the setting of PMVR, so far. Here we evaluated hemodynamics before and after PMVR with the MitraClip system using pulmonary artery catheterization, transthoracic (TTE) and transesophageal (TEE) echocardiography.

METHODS

101 patients with severe MR not eligible for conventional surgery underwent PMVR. Hemodynamic parameters were determined during and after the intervention. We evaluated changes in CO and pulmonary artery systolic pressure before and after PMVR. CO was determined with invasive parameters using the Fick method (COi) and by a combination of TTE and TEE (COe).

RESULTS

All patients had successful clip implantation, which was associated with increased COi (from 4.6±1.4l/min to 5.4±1.6l/min, p<0.001). Furthermore, pulmonary artery systolic pressure (PASP) showed a significant decrease after PMVR (47.6±16.1 before, 44.7±15.5mmHg after, p=0.01). In accordance with invasive measurements, COe increased significantly (COe from 4.3±1.7l/min to 4.8±1.7l/min, p=0.003). Comparing both methods to calculate CO, we observed good agreement between COi and COe using Bland Altman plots.

CONCLUSIONS

CO increased significantly after PMVR as determined by echocardiography based and invasive calculation of hemodynamics during PMVR. COe shows good agreement with COi before and after the intervention and, thus, represents a potential non-invasive method to determine CO in patients with MR not accessible by conventional surgery.

INTRODUCTION OF UNIVERSAL HEALTH PROGRAM IN GEORGIA: PROBLEMS AND PERSPECTIVES

Since 2013, Georgia enacted Universal Healthcare (UHC) program. Inclusion of uninsured population in the UHC program will have a positive impact on their financial accessibility to the health services. The study aims to analyze the referral rate of the beneficiaries to the health service providers before introduction and after application of the UHC program, particularly, how much it increased the recently uninsured population referral to primary health care units, and also to study the level of satisfaction with the UHC program. Research was conducted by qualitative and quantitative methods. The target groups' (program beneficiaries, physicians, personnel of the Social Service Agency) opinions were identified by means of face-to-face interviews. Enactment of the UHC programs significantly raised the population refferal to the family physicians, and the specialists. Insignificantly, but also increased the frequency of laboratory and diagnostic services. Despite the serious positive changes caused by UHC program implementation there still remain the problems in the primary healthcare system. Also, it is desirable to raise the financial availability of those medical services, which may cause catastrophic costs. In this respect, such medical services must be involved in the universal healthcare program and been expanded their scale. For the purpose of effective usage of the limited funds allocated for health care services provision, the private health insurance companies should be involved in UHC programs. This, together with the reduction of health care costs will increase a competition in the medical market, and enhance the quality of health service.

ASSOCIATION OF DEPRESSION WITH HOSPITAL LENGTH OF STAY IN PATIENTS WITH ACUTE CORONARY SYNDROME

Psychosocial risk factors are known to have a negative impact on coronary disease morbidity and mortality. The aim of our study was to establish contribution of depression on hospital length of stay in patients with acute coronary events. Depression screening was performed in the Chapidze Center, Tbilisi Georgia. Main inclusion criteria in the study were acute coronary events - non-ST elevation myocardial infarction or unstable angina. The total nomber of participants was 84. A binary logistic regression was used in order to assess contribution of depression on prolonged hospital stay. The mean age for both genders was 59.2 (10.2) years. Most patients had coronary risk factors. Higher BDI score was found in elderly patients, females, and in those with systolic dysfunction as well as in whom revascularization was not performed. In binary logistic regression model myocardial infarction and depression were found to be significant contributors of prolonged hospital stay. Depressive symptoms contribute independently to prolongation of hospital stay in patients with non-STEMI.

Gremlin-1 identifies fibrosis and predicts adverse outcome in patients with heart failure undergoing endomyocardial biopsy

BACKGROUND

Gremlin-1 (Grem1), an antagonist of bone morphogenetic proteins, is involved in fibrotic tissue formation in kidney and lung. The impact of myocardial Grem1 expression is unknown. We investigated the prognostic value of Grem1 expression in 214 consecutive patients with nonischemic heart failure (HF) undergoing endomyocardial biopsy.

METHODS

In all patients, the following risk factors were assessed: Grem1 expression (semiquantitative score scheme ranging from 1 to 4), presence of inflammatory markers, detection of viral genome, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), New York Heart Association functional class (NYHA), troponin I, and B-type natriuretic peptide. Degree of myocardial fibrosis was defined as an index. Study end point was a combination of all-cause death and HF-related rehospitalization within 3 years of follow-up.

RESULTS

Grem1 expression significantly correlated with the degree of myocardial fibrosis (correlation coefficient r = 0.619; P < .0001). Patients with the highest Grem1 expression (score 4) showed the most severely impaired LVEF and highest LVEDD (P < .0001 and P = .030, respectively, for comparison of semiquantitative scores). During follow-up, 33 patients (15.4%) reached the study end point. Grem1 expression and NYHA ≥II were independent predictors of the end point (Grem1: hazard ratio [HR] 7.5, 95% confidence interval [CI] 1.8-32.2; P = .006; NYHA ≥II: HR 2.0, 95% CI 1.0-4.1; P = .048).

CONCLUSIONS

Grem1 correlates with the degree of myocardial fibrosis and left ventricular dysfunction and is an independent predictor of adverse outcome in patients with nonischemic HF.

Macrophage migration inhibitory factor is enhanced in acute coronary syndromes and is associated with the inflammatory response

Background

Chronic inflammation promotes atherosclerosis in cardiovascular disease and is a major prognostic factor for patients undergoing percutaneous coronary intervention (PCI). Macrophage migration inhibitory factor (MIF) is involved in the progress of atherosclerosis and plaque destabilization and plays a pivotal role in the development of acute coronary syndromes (ACS). Little is known to date about the clinical impact of MIF in patients with symptomatic coronary artery disease (CAD).

Methods and Results

In a pilot study, 286 patients with symptomatic CAD (n = 119 ACS, n = 167 stable CAD) undergoing PCI were consecutively evaluated. 25 healthy volunteers served as control. Expression of MIF was consecutively measured in patients at the time of PCI. Baseline levels of interleukin 6 (IL-6), “regulated upon activation, normal T-cell expressed, and secreted” (RANTES) and monocyte chemoattractant protein-1 (MCP-1) were measured by Bio-Plex Cytokine assay. C-reactive protein (CRP) was determined by Immunoassay. Patients with ACS showed higher plasma levels of MIF compared to patients with stable CAD and control subjects (median 2.85 ng/mL, interquartile range (IQR) 3.52 versus median 1.22 ng/mL, IQR 2.99, versus median 0.1, IQR 0.09, p<0.001). Increased MIF levels were associated with CRP and IL-6 levels and correlated with troponin I (TnI) release (spearman rank coefficient: 0.31, p<0.001). Patients with ACS due to plaque rupture showed significantly higher plasma levels of MIF than patients with flow limiting stenotic lesions (p = 0.002).

Conclusion

To our knowledge this is the first study, demonstrating enhanced expression of MIF in ACS. It is associated with established inflammatory markers, correlates with the extent of cardiac necrosis marker release after PCI and is significantly increased in ACS patients with “culprit” lesions. Further attempts should be undertaken to characterize the role of MIF for risk assessment in the setting of ACS.

Expression of platelet-bound stromal cell-derived factor-1 in patients with non-valvular atrial fibrillation and ischemic heart disease

AIMS

Blood cell infiltration and inflammation are involved in atrial remodelling during atrial fibrillation (AF) although the exact mechanisms of inflammatory cell recruitment remain poorly understood. Platelet-bound stromal cell-derived factor-1 (SDF-1) is increased in cases of ischemic myocardium and regulates recruitment of CXCR4(+) cells on the vascular wall. Whether platelet-bound SDF-1 expression is differentially influenced by non-valvular paroxysmal or permanent atrial fibrillation (AF) in patients with stable angina pectoris (SAP) or acute coronary syndrome (ACS) has not been reported so far.

METHODS AND RESULTS

A total of 1291 consecutive patients with coronary artery disease (CAD) undergoing coronary angiography were recruited. Among the patients with SAP, platelet-bound-SDF-1 is increased in patients with paroxysmal AF compared with SR or to persistent/permanent AF (P < 0.05 for both). Platelet-bound SDF-1 correlated with plasma SDF-1 (r = 0.488, P = 0.013) in patients with AF and ACS, which was more pronounced among patients with persistent AF (r = 0.842, P = 0.009). Plasma SDF-1 was increased in persistent/permanent AF compared with SR. Patients with ACS presented with enhanced platelet-bound-SDF-1 compared with SAP. Interestingly, among patients with ACS, patients with paroxysmal or persistent/permanent AF presented with an impaired platelet-bound SDF-1 expression compared with patients with SR.

CONCLUSIONS

Differential expression of platelet-bound and plasma SDF-1 was observed in patients with AF compared with SR which may be involved in progenitor cell mobilization and inflammatory cell recruitment in patients with AF and ischemic heart disease. Further in vivo studies are required to elucidate the role of SDF-1 in atrial remodeling and the atrial fibrillation course.