Comprehensive echocardiographic prediction of postprocedural transmitral pressure gradient following transcatheter mitral valve repair.

Iatrogenic mitral stenosis following transcatheter mitral valve repair (TMVR) for relevant mitral regurgitation (MR) is a potential adverse side-effect, known to affect long-term outcome. However, only few determinants of an elevated mean transmitral pressure gradient (TMPG) have been described thus far. We sought to develop an integrative model for the prediction of TMPG following MitraClip (MC) therapy. From 01/2013 to 03/2017, a total of 175 consecutive patients were successfully (MR ≤ 2 + at discharge) treated with a MitraClip implantation at our centre. Of these, a total of 148 patients (54% male, 77.0 ± 6.0 years, 58% with secondary MR) had complete echocardiographic data sets comprising pre- and postinterventional two- and three-dimensional transthoracic (TTE) and transoesophageal (TOE) echocardiograms. Comprehensive studies of predefined parameters were performed. An expert-based prediction model including preprocedural variables (annular ellipticity, mitral valve commissure-to-commissure diameter, preprocedural transmitral pressure gradient and MR aetiology) was set up and validated with a total of 200 bootstrap samples. A nomogram was developed to predict the postprocedural TMPG based on selected echocardiographic variables. Introduction of nomogram-based guiding of MC therapy could help identify patients at risk for postprocedural mitral stenosis, have an influence on preprocedural patient selection and intraprocedural decision making.

MitraClip After Failed Surgical Mitral Valve Repair-An International Multicenter Study.

Background Recurrence of mitral regurgitation (MR) after surgical mitral valve repair (SMVR) varies and may require reoperation. Redo mitral valve surgery can be technically challenging and is associated with increased risk of mortality and morbidity. We aimed to assess the feasibility and safety of MitraClip as a treatment strategy after failed SMVR and identify procedure modifications to overcome technical challenges. Methods and Results This international multicenter observational retrospective study collected information for all patients from 16 high-volume hospitals who were treated with MitraClip after failed SMVR from October 29, 2009, until August 1, 2017. Data were anonymously collected. Technical and device success were recorded per modified Mitral Valve Academic Research Consortium criteria. Overall, 104 consecutive patients were included. Median Society of Thoracic Surgeons score was 4.5% and median age was 73 years. At baseline, the majority of patients (82%) were in New York Heart Association class ≥III and MR was moderate or higher in 86% of patients. The cause of MR pre-SMVR was degenerative in 50%, functional in 35%, mixed in 8%, and missing/unknown in 8% of patients. The median time between SMVR and MitraClip was 5.3 (1.9-9.7) years. Technical and device success were 90% and 89%, respectively. Additional/modified imaging was applied in 21% of cases. An MR reduction of ≥1 grade was achieved in 94% of patients and residual MR was moderate or less in 90% of patients. In-hospital all-cause mortality was 2%, and 86% of patients were in New York Heart Association class ≤II. Conclusions MitraClip is a safe and less invasive treatment option for patients with recurrent MR after failed SMVR. Additional/modified imaging may help overcome technical challenges during leaflet grasping.

Safety and feasibility of interventional left atrial appendage closure without contrast agent.

Aims: Interventional left atrial appendage closure (LAAC) is routinely performed under both echocardiographic and angiographic guiding. However, adverse outcomes, e.g., kidney injury and cerebral embolism, might be associated with injections of contrast agent into the LAA. Therefore, this prospective registry investigated the safety and feasibility of LAAC without the support of angiographic images as the default approach. Methods and results: This single-centre registry included a total of 46 non-selected, consecutive patients. In the first 25 patients (54%), LAAC with the Amulet device was performed routinely with LAA angiography prior to implantation and after release of the device. The following 21 patients (46%) were treated without the use of contrast agent. The combination of successful implantation and lack of procedural complications was regarded as the primary endpoint. Procedure time, number of recapture manoeuvres, change of device size, compression, leakage, dose area product and late thrombosis on the device were investigated as secondary endpoints. Besides the longer fluoroscopy time and duration of the procedure in the group using angiography, no significant differences could be found. Major complications occurred equally often in both cohorts. Conclusions: Interventional LAAC with the Amulet device can be performed safely without the use of contrast agent. This approach might help to enhance the use of LAAC in patients at high risk of contrast-induced nephropathy and procedural stroke.

Solitary neuroendocrine carcinoma of the heart: a case report.

BACKGROUND: Cardiac tumours are of rare incidence and usually occur in the form of secondary tumours. Most metastatic tumours are melanomas, sarcomas, lung, and haematological malignancies. Neuroendocrine carcinomas (NECs) of the heart are extremely unusual. This case report demonstrates a solitary high-grade NEC of the heart with an individual therapy strategy and follow-up. CASE SUMMARY: A 50-year-old gentleman presented with a 2 days history of recurrent episodes of chest pain. Echocardiography, computed tomography, and magnetic resonance imaging revealed tumorous lesions of the ventricles and aortic valve with large circular pericardial effusion. Histopathology results of the biopsy revealed a poorly differentiated small cell tumour of the neuroendocrine type. Despite further investigations with multiple imaging modalities and laboratory, no primary was found. Chemotherapy was initiated but size progression of the tumour was detected. As no other tumorous lesions were detected and resection was not possible because of the tumour complexity, decision on heart transplantation was made. However, due to the necessary immunosuppression after the heart transplantation, multiple metastasis where discovered in the course of treatment. DISCUSSION: The presence of a NEC in the heart without evidence of any other metastasis or evidence of primary tumour in other organs is clinically unique. For this individual case, heart transplantation was the therapy of choice due to tumour progression under chemotherapy and lacking possibility of resection, as no other suspect lesion was found other than the ones found in the heart. However, the risk of exacerbation of undiscovered micrometastases under necessary immunosuppression following the heart transplantation should be considered.