Specific recommendations (or lack thereof) for older patients with cardiovascular disease in the current European Society of Cardiology guidelines : From the Dutch Working Group of Geriatric Cardiology of the Netherlands Society of Cardiology (NVVC) and Special Interest Group Geriatric Cardiology of the Netherlands Society for Clinical Geriatrics (NVKG).

Due to population ageing, the number of older and frail patients with cardiovascular disease is increasing. In the current guidelines of the European Society of Cardiology specific recommendations for this older population are missing or scarce, probably due to limited evidence concerning diagnosis and treatment of cardiovascular disease in older patients. Moreover, recommendations on shared decision making, palliative care and advanced care planning are also essential in these guidelines. In this article we evaluate the current European of Society of Cardiology guidelines (2013-2020) to determine whether specific recommendations for older patients have been included.

Paclitaxel-eluting balloon versus everolimus-eluting stent in patients with diabetes mellitus and in-stent restenosis: Insights from the randomized DARE trial.

OBJECTIVES: To investigate the relative performance of treatment with a paclitaxel-eluting balloon (PEB) compared with an everolimus-eluting stent (EES) for in-stent restenosis (ISR) in patients with diabetes mellitus (DM). BACKGROUND: ISR remains a challenge in contemporary clinical practice, particularly in patients with DM. METHODS: In the multicenter randomized DARE trial, patients with BMS or DES ISR were randomized in a 1:1 fashion to treatment with a PEB or an EES. Patients underwent angiographic follow-up after 6 months. For the purpose of this analysis, the relative performance of PEB versus EES in diabetic patients was investigated. RESULTS: Of 278 patients enrolled in DARE, 88 (32%) had DM, of whom 46 were randomized to EES and 42 to PEB treatment. Of patients with DM, 48 (55%) had DES-ISR. Angiographic follow-up was available in 30 patients (72%) in the PEB group and 36 patients (78%) in the DES group. There were no differences in terms of 6-months minimal lumen diameter in diabetic patients treated with EES (1.46 ± 0.66 mm) versus PEB (1.78 ± 0.58 mm, P = 0.15). Adverse events at one year follow-up were similar in both groups, with Major Adverse Events (MAE, death, target vessel MI, or TVR) occurring in 17.4% in the EES group versus 11.9% in the PEB group, P = 0.44. CONCLUSIONS: In patients with ISR and DM, use of a PEB resulted in similar 6-months in-segment minimal lumen diameter and comparable rates of MAE. In-segment late loss at 6 months was significantly lower in the PEB arm. Although larger trials in DM patients with ISR are necessary, PEB is a promising treatment option obviating the need for additional stent implantation.

Mitral regurgitation prior to transcatheter aortic valve implantation influences survival but not symptoms.

BACKGROUND: Current data about the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve implantation (TAVI) are conflicting. Our purpose was to analyze the clinical course of MR and to assess the influence of MR on survival and clinical status after TAVI. METHODS: We included 375 consecutive patients who underwent TAVI. MR grade and NYHA class were determined before TAVI and at follow-up. RESULTS: In total 171 patients (46%) had MR grade ≥ 2 at baseline and of these 29% improved to MR grade ≤ 1 after TAVI. MR grade ≤ 1 at baseline was present in 204 patients (54%) and of these 17% worsened to grade ≥ 2 after TAVI. Improvement of MR was associated with absence of atrial fibrillation (OR: 2.35, 95%CI: 1.17-4.71, p = 0.02). Worsening of MR was associated with moderate or more aortic valve regurgitation after TAVI (OR: 4.2, CI: 1.83-9.49, p = 0.001). NYHA class improved at follow-up. Baseline MR grade did not determine the degree of clinical improvement (MR grade ≤ 1: NYHA ≥ 3 from 67% to 17%; MR grade ≥ 2: NYHA ≥ 3 from 69% to 14%). Although patients with MR grade ≥ 2 at baseline improved symptomatically, this degree of MR was associated with reduced two year survival compared with patients with MR grade ≤ 1(mortality 37% vs 26%; HR 1.99; 95% CI 1.27-3.13; p = 0.003). CONCLUSION: In patients who undergo TAVI almost half have MR grade ≥ 2 prior to the procedure. TAVI had no influence on MR grade at follow-up. Although patients with MR grade ≥ 2 at baseline improved symptomatically after TAVI, concomitant MR at baseline significantly reduced two year survival.

Percutaneous mitral valve repair preserves right ventricular function.

BACKGROUND: Chronic mitral regurgitation (MR) often leads to diminished right ventricular (RV) function due to long-standing pressure and volume overload. Surgical intervention often adds to the preexisting RV dysfunction. Percutaneous mitral valve (MV) repair can reduce MR, but to what extent this affects the right ventricle is unknown. METHODS: Consecutive patients scheduled for percutaneous MV repair using the MitraClip system underwent transthoracic echocardiography at baseline and at 1- and 6-month follow-up. RV systolic function was evaluated using five echocardiographic parameters. RV afterload was evaluated using systolic pulmonary arterial pressure and the mean MV pressure gradient. Residual MR was defined as grade ≥ 3 and mitral stenosis (MS) as a mean MV pressure gradient ≥ 5 mm Hg. RESULTS: Sixty-eight patients (52% men; mean age, 75 ± 10 years) were included. Six months after MitraClip implantation, there were no significant changes in any of the RV parameters. MR decreased (P < .01) and the mean MV pressure gradient increased during follow-up (2.3 ± 1.4 mm Hg at baseline vs 4.5 ± 2.7 mm Hg at 6 months, P < .01). Patients with both residual MR and MS 6 months after MitraClip implantation showed significantly higher systolic pulmonary arterial pressure values (P < .01) and lower New York Heart Association functional classes (P < .01) compared with patients without residual MR or MS. CONCLUSIONS: Percutaneous MV repair, in contrast to surgical repair or replacement, does not negatively affect RV function. After repair, RV afterload and New York Heart Association functional class are improved in the case of successful repair but adversely affected in the presence of both residual MR and MS.

Predictors and permanency of cardiac conduction disorders and necessity of pacing after transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) with the Medtronic-CoreValve bioprosthesis (CoreValve Inc., Irvine, CA, USA) is associated with a high incidence of new-onset left bundle branch block (LBBB) and cardiac conduction disorders (CCDs) requiring permanent pacemaker (PPM) implantation. Our objective was to investigate the predictors and permanency of CCDs after TAVI and specifically to evaluate the necessity for pacing. METHODS: In this single-center study, we included patients who underwent TAVI with the Medtronic-CoreValve bioprosthesis. Electrocardiographic evaluation was performed pre- and post-TAVI and at follow-up. Pacemaker follow-up data were obtained and analyzed. RESULTS: We included 121 patients (age 81 ± 8 years). LBBB developed in 47 patients, for which prosthesis size (26 mm; odds ratio [OR]: 4.1, 95% confidence interval [CI]: 1.32-12.34, P = 0.01) and prosthesis depth (OR: 1.3, 95% CI: 1.09-1.57, P = 0.004) were independent predictors. In 19%, this new-onset LBBB was temporary. Requirement for a PPM occurred in 23 patients, for which mitral annular calcification (MAC; OR: 1.3, 95% CI: 1.05-1.56, P = 0.02) and preexisting right bundle branch block (RBBB; OR: 8.5, 95%CI: 1.61-44.91, P = 0.01) were independent predictors. At follow-up, 52% of the patients were continuously paced, but 22% of the patients had adequate atrioventricular conduction without the necessity for pacing. In the other 26% of the patients there was intermittent pacing. CONCLUSION: There is a high incidence of new-onset LBBB and PPM implantation following TAVI with a Medtronic-CoreValve bioprosthesis. Prosthesis depth and size were predictors for new LBBB, while MAC and preexistent RBBB were predictors for PPM implantation. In approximately one fifth of the patients, new-onset LBBB and the necessity for pacing are only temporary.

Mitral inflow patterns after MitraClip implantation at rest and during exercise.

BACKGROUND: MitraClip implantation reduces mitral regurgitation effectively but decreases mitral valve area, creating iatrogenic mitral stenosis. Evaluation with transesophageal echocardiography intraprocedurally is necessary to measure mitral regurgitation and mitral valve pressure gradient (MVPG) to determine whether it is necessary and safe to place more clips. The aim of this study was to investigate whether these intraprocedural hemodynamics represent postprocedural measurements and whether exercise is affected by the stenosis. METHODS: In this retrospective single-center study, 51 patients who underwent MitraClip implantation were included. Measurements were performed intraprocedurally using transesophageal echocardiography and postprocedurally using transthoracic echocardiography. In 23 of these patients, exercise echocardiography was performed at follow-up. RESULTS: Intraprocedural mean MVPG was 3.0 ± 1.6 mm Hg and increased to 4.3 ± 2.2 mm Hg postprocedurally (P < .001). During exercise, mean MVPG increased significantly compared with rest conditions (from 3.6 ± 1.7 to 6.3 ± 2.7 mm Hg, P < .001). Six patients had mean resting MVPGs ≥ 5 mm Hg at follow-up and had higher systolic pulmonary artery pressure (sPAPs) than patients with mean MVPGs < 5 mm Hg (47 ± 7 vs 35 ± 12 mm Hg, P = .035). Higher MVPG and sPAP did not lead to more symptoms of heart failure. Receiver operating characteristic curve analysis showed an estimated cutoff point for intraprocedural pressure half-time of 91 msec to identify patients with mitral stenosis and sPAP ≥ 50 mm Hg postprocedurally. CONCLUSIONS: Mean MVPG during MitraClip implantation measured by TEE underestimates the hemodynamics in daily life, of which operators should be aware when deciding on placing one or more clips. Pressure half-time seems to be the most robust parameter compared with mean and maximum MVPG and may contribute to this decision. Patients with higher mean MVPGs after MitraClip implantation have higher sPAPs at follow-up. However, more symptoms of heart failure were not detected at follow-up.

[Diagnostic and therapeutic strategies for the management of severe mitral valve regurgitation]. / Mitralisklepinsufficiëntie: het lek te lijf: diagnostiek en behandeling.

Mitral regurgitation is the second most frequent valvular heart disease. Echocardiography is the principal examination to determine severity, mechanism and hemodynamic consequences of mitral regurgitation and consequently contributes to the assessment and accurate timing of the best treatment strategy. To clarify clinical decision making in severe mitral regurgitation, this review will discuss the diagnostic work-up and treatment options according to the most recent guidelines. Mitral valve surgery, preferably repair, is indicated in symptomatic patients with severe, organic mitral regurgitation. Chronic, functional mitral regurgitation is often medically treated (including cardiac resynchronization therapy if indicated), however surgery (preferably annuloplasty) can be recommended. Percutaneous MitraClip-implantation may be considered as an alternative option in symptomatic patients with severe mitral regurgitation who are considered inoperable. At present, there is no consensus on the optimal care in asymptomatic patients with severe, organic mitral regurgitation and preserved left ventricular function. A prospective trial is highly needed to elucidate this best treatment strategy.

Treatment of in-stent restenosis involving a bifurcation lesion with a dedicated bifurcation device in combination with drug-eluting balloons.

It can be difficult to find a good treatment strategy in cases with in-stent restenosis with involvement of a bifurcation lesion. To avoid multiple stent layers and to treat the bifurcation lesion properly, the patient described in this case report was treated with a Tryton side branch stent and drug-eluting balloons. Angiographic follow-up at 8 months showed an excellent result.

Predictors and prognostic value of myocardial injury during transcatheter aortic valve implantation.

BACKGROUND: Myocardial injury is a common complication during cardiac surgery and percutaneous coronary intervention and is associated with postprocedural cardiovascular morbidity and mortality. Limited data have been reported about the occurrence of myocardial damage associated with transcatheter aortic valve implantation (TAVI). Therefore, our purpose was to investigate the incidence, predictors, and prognostic value of myocardial injury during TAVI. METHODS AND RESULTS: We studied 119 patients (aged 81±8 years; 47 male) who had undergone a TAVI with the Medtronic-CoreValve bioprosthesis. Serum creatine kinase-MB (CK-MB) and cardiac troponin T (cTnT) levels were measured before and after the procedure. Myocardial injury was defined as a postprocedural increase of CK-MB and/or cTnT level >5 times the upper reference limit. After TAVI, the incidence of myocardial injury was 17%, which was independently predicted by procedural duration (in minutes) (odds ratio [OR], 1.04; 95% CI, 1.01-1.06), preprocedural ß-blocker use (OR, 0.12; 95% CI, 0.03-0.45), peripheral arterial disease (OR, 6.36; 95% CI, 1.56-25.87), and prosthesis depth (in millimeters) (OR, 1.31; 95% CI, 1.08-1.59). The 30-day mortality after TAVI was 13% and was independently predicted by myocardial injury (OR, 8.54; 95% CI, 2.17-33.52), preprocedural hospitalization (OR, 9.36; 95% CI, 2.55-34.38), and left ventricular mass index (in g/m(2)) (OR, 1.02; 95% CI, 1.00-1.03). CONCLUSIONS: After transcatheter aortic valve implantation, serum levels of both CK-MB and cTnT increase, reflecting the occurrence of periprocedural myocardial injury. A longer procedural duration, the absence of ß-blocker use, peripheral arterial disease, and a deeper prosthesis insertion are associated with myocardial injury. Together with preprocedural hospitalization and left ventricular mass, myocardial injury is an independent predictor for 30-day mortality after TAVI.