Percutaneous closure of mitral paravalvular leaks: a systematic review and meta-analysis.

BACKGROUND AND AIM OF THE STUDY: The percutaneous closure of mitral paravalvular leak (PVL) is emerging as an alternative treatment for high-risk surgical candidates. Several cases have been reported, and a few small studies have been conducted to investigate the outcome of the technique. A meta-analysis of the combined data would be considered helpful in deriving more powerful data; hence, the study aim was to conduct a meta-analysis of the percutaneous closure of mitral PVLs, as reported in the medical literature. METHODS: Searches were conducted of the PubMed, Embase, and CINAHL databases for reports of mitral PVL percutaneous closure. The data were extracted by two reviewers, who aggregated the information by using a random-effects model. RESULTS: Eight studies were included in the meta-analysis, with a total of 100 patients. The percutaneous closure of mitral PVLs was associated with a 15% cardiovascular mortality during the first year of follow up. Clinical success was noted in 48% of patients, while 52% failed to show any clinical improvement. Failures were mainly attributed either to deployment failure (18%), to the presence of a persistent leak, to hemolysis, or both (31%). Procedure-related complications (e.g., bleeding, stroke, endocarditis) were observed in 16% of patients. CONCLUSION: The percutaneous closure of mitral PVLs carries a 15% risk of cardiovascular mortality. The reported mortality rates for surgically treated patients ranged from 12% to 37%, but most patients who underwent percutaneous closure were considered high-risk surgical candidates with multiple comorbidities. While percutaneous closure appears promising, the development of lesion-specific occluders, standardized imaging techniques and parameters, and the design of randomized clinical trials to compare the outcome of surgical versus percutaneous intervention, are required before any final judgment may be made.

Effect of positional changes on inferior vena cava size.

AIM: To study the effect of positional change on inferior vena cava (IVC) diameter. The influence of positional change on IVC size is not well studied. Although the American Society of Echocardiography guidelines for chamber quantification recommend imaging the IVC in the left lateral position, many labs routinely image the IVC from the supine position. METHODS AND RESULTS: Forty-three patients (age 39.5 ± 9.4) with normal echocardiographic findings were studied. Subcostal imaging was used to assess the IVC in the supine and left lateral positions. IVC dimensions, hepatic vein (HV) Doppler and tricuspid regurgitation (TR) jet velocity were measured. IVC systolic and diastolic dimensions were larger in the supine compared with the left lateral position (17.2 ± 4.1 vs. 10.9 ± 4.4 mm, P < 0.001; 16.2 ± 4.5 vs. 9.9 ± 4.4 mm, P < 0.001, respectively). Position had no influence on HV systolic and diastolic peak velocity. (35.4 ± 23.7 vs. 31.8 ± 35.0 cm/s, P = 0.461; 24.2 ± 19.5 vs. 25.4 ± 31.9 cm/s, P = 0.775, respectively). CONCLUSIONS: The IVC dimension is larger in the supine position independent of the cardiac cycle. This may be due to increased intra-abdominal pressure and compression of the IVC by the liver in the left lateral position. HV systolic and diastolic peak Doppler velocities were not influenced by position.

Aneurysmal dilatation of the inferior vena cava.

AIM: Inferior vena cava aneurysms (IVCA) are rare, unlike aortic aneurysms. The diagnosis and treatment is challenging. This study defines clinical and echocardiographic findings in a prospective cohort of sixteen patients with fusiform IVCA. METHODS AND RESULTS: All patients referred to the Mayo Clinic between January 2006 and July 2009 for a clinically indicated echocardiogram (36,128 patients) were screened for a dilated IVC. Sixteen cases of fusiform IVCA were identified. Eleven cases (68.8%) were female. Mean age at presentation was 76 years (range 51-89). Eleven (68.8%) had structural heart disease: with right ventricular (RV) dysfunction in 45.5% (n = 5), moderate or greater tricuspid regurgitation (TR) was seen in 36.4% (n = 4) and RV enlargement was seen in 18.2% (n = 2). The most common clinical indication for echocardiography was dyspnea (25%; n = 4) and heart failure (18.8%; n = 3). The mean IVCA diameter was 4.1 cm (range 3.8-5 cm) and the mean length of the aneurysms was 6.2 cm (range 3.5-8.7 cm), with mean right ventricular systolic pressure of 55 mmHg (range 31-105 mmHg). Five (31.3%) had at least a moderate reduction in right ventricular ejection fraction and five (31.3%) had significant TR. Among these five patients with significant TR, severe TR was present in 80%; (n = 4) and moderate to severe TR was present in 20%; (n = 1). CONCLUSIONS: IVC aneurysms are more common in the elderly, and is associated with an increase in right sided heart pressures, significant TR, and RV dysfunction.

Echocardiographic measures of myocardial deformation by speckle-tracking technologies: the need for standardization?

BACKGROUND: Multiple vendor-specific two-dimensional speckle-tracking echocardiographic algorithms with which to characterize myocardial mechanics are commercially available. The purpose of this study was to compare global longitudinal strain (GLS) results between two independent software vendors using a neutral image platform. METHODS: A convenience sample of 100 prospectively collected patients was evaluated. Subjects with more than two left ventricular endocardial segments poorly delineated were excluded. GLS was obtained from the apical four-chamber, three-chamber, and two-chamber views using two independent speckle-tracking echocardiographic software packages (EchoInsight version 1.5.0 and Image-Arena version 4.5). Linear regression analysis and paired t tests were used to compare GLS results. Intraclass correlation coefficients and Bland-Altman plots were used for assessments of reliability. RESULTS: The "out-of-the-box" mean GLS was -12.99 ± 2.38% using EchoInsight and -16.87 ± 2.84% using Image-Arena (mean difference, 3.87 ± 2.42%; P = .0001). Agreement between the software packages was moderate (intraclass correlation coefficient, 0.43; 95% confidence interval, 0.32-0.55). Using uniform variables to derive GLS (Lagrangian strain measured in systole and diastole at the endocardium and averaging the peak segmental strain curves), EchoInsight GLS was -16.17 ± 2.90% and Image-Arena GLS was -16.87 ± 2.84% (mean difference, 0.70 ± 2.75%; P = .02), with an intraclass correlation coefficient of 0.70 (95% confidence interval, 0.52-0.79). CONCLUSIONS: Image-Arena GLS results were consistently different (more negative) than EchoInsight measures out of the box but became similar when information used to derive GLS was uniform. The evolution of measures of myocardial mechanics into routine clinical practice will require vigilance and standardization of the various techniques, necessitating independent validation of commercially available speckle-tracking echocardiographic products.

Constrictive pericarditis and restrictive cardiomyopathy in the modern era.

The differentiation between constrictive pericarditis and restrictive cardiomyopathy can be clinically challenging. Pericardial constriction results from scarring and consequent loss of pericardial elasticity leading to impaired ventricular filling. Restrictive cardiomyopathy is characterized by a nondilated rigid ventricle, severe diastolic dysfunction and restrictive filling producing hemodynamic changes, similar to those in constrictive pericarditis. While constrictive pericarditis is usually curable by surgical treatment, restrictive cardiomyopathy requires medical therapy and in appropriate patients, the definitive treatment is cardiac transplantation. Sufficient differences exist between the two conditions to allow noninvasive differentiation, but no single diagnostic tool can be relied upon to make this distinction. Newer echocardiographic techniques such as speckle-track imaging, velocity vector imaging, as well as cardiac computed tomography and cardiac MRI can help differentiate constriction from restriction with high sensitivity and specificity. Outcomes are better with early diagnosis of constriction in particular and early surgical resection.