Acute Reduction in Left Ventricular Function Following Transcatheter Mitral Edge-to-Edge Repair

Background Little is known about the impact of transcatheter mitral valve edge-to-edge repair on changes in left ventricular ejection fraction (LVEF) and the effect of an acute reduction in LVEF on prognosis. We aimed to assess changes in LVEF after transcatheter mitral valve edge-to-edge repair for both primary and secondary mitral regurgitation (PMR and SMR, respectively), identify rates and predictors of LVEF reduction, and estimate its impact on prognosis. Methods and Results In this international multicenter registry, patients with both PMR and SMR undergoing transcatheter mitral valve edge-to-edge repair were included. We assessed rates of acute LVEF reduction (LVEFR), defined as an acute relative decrease of >15% in LVEF, its impact on all-cause mortality, major adverse cardiac event (composite end point of all-cause death, mitral valve surgery, and residual mitral regurgitation grade ≥2), and LVEF at 12 months, as well as predictors for LVEFR. Of 2534 patients included (727 with PMR, and 1807 with SMR), 469 (18.5%) developed LVEFR. Patients with PMR were older (79.0±9.2 versus 71.8±8.9 years; P<0.001) and had higher mean LVEF (54.8±14.0% versus 32.7±10.4%; P<0.001) at baseline. After 6 to 12 months (median, 9.9 months; interquartile range, 7.8-11.9 months), LVEF was significantly lower in patients with PMR (53.0% versus 56.0%; P<0.001) but not in patients with SMR. The 1-year mortality was higher in patients with PMR with LVEFR (16.9% versus 9.7%; P<0.001) but not in those with SMR (P=0.236). LVEF at baseline (odds ratio, 1.03 [95% CI, 1.01-1.05]; P=0.002) was predictive of LVEFR for patients with PMR, but not those with SMR (P=0.092). Conclusions Reduction in LVEF is not uncommon after transcatheter mitral valve edge-to-edge repair and is correlated with worsened prognosis in patients with PMR but not patients with SMR. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05311163.

Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS.

Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy.

Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0–8.5] h vs. 1.0 [0.5–2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0–5.0] days vs. 2.0 [1.0–2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0–33.0] days vs. 9.0 [5.0–15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy.

Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.

Afterload Mismatch After MitraClip Implantation: Intraoperative Assessment and Prognostic Implications

AIM

To evaluate the acute hemodynamic effects after MitraClip implantation and to identify predictors of afterload mismatch and its prognostic implications.

METHODS

Acute hemodynamic effects were assessed intraoperatively by right heart catheterization and by transesophageal echocardiography before and after MitraClip implantation in 62 consecutive patients with severe mitral regurgitation (MR) (functional MR, 73.8%; EuroScore 2, 7.1 ± 4.9%; left ventricular ejection fraction [LVEF], 36 ± 15%; New York Heart Association class III/IV, 65%). Afterload mismatch was defined as a >15% decrease in LVEF (acute LV depression) or a >15% increase in LV end-diastolic volume (acute adverse LV remodeling). Patients were followed over a period of 24 months (mean, 18 ± 3 months) with all-cause mortality as the primary endpoint.

RESULTS

Successful MitraClip implantation with residual MR ≤2 was achieved in 85% of patients. Acute LV depression was observed in 23% of patients, and acute adverse LV remodeling was observed in 15% of patients. Acute adverse LV remodeling occurred in 40% of patients with EuroScores >12 vs in 10% of patients with EuroScores ≤12 (P=.02). Although acute adverse LV remodeling was well tolerated in the acute phase, it was associated with a higher mortality rate during follow-up (62% vs 26%; log-rank P=.04). In a multivariate model, EuroScore 2, but not afterload mismatch, was the most important prognostic risk factor, with an adjusted hazard ratio of 1.1 (95% confidence interval, 1.0-1.2).

CONCLUSION

Afterload mismatch, as assessed intraoperatively, is not uncommon after MitraClip implantation in patients with impaired LV function and is a risk marker of poor clinical outcome.