Transapical Transcatheter Valve-in-Valve Implantation for Failed Mitral Valve Bioprosthesis.

UNLABELLED: Background: The rate of mitral bioprosthesis implantation in clinical practice is increasing. Transcatheter valve-in- valve implantation has been described for high risk patients requiring redo valve surgery. OBJECTIVES: To report our experience with transapical valve-in-valve implantation for failed mitral bioprosthesis. METHODS: Since 2010, 10 patients have undergone transapical valve-in-valve implantation for failed bioprosthesis in our center. Aortic valve-in-valve implantation was performed in one of them and mitral valve-in-valve implantation in nine. Mean age was 82 ± 4 years and 6 were female (67%). Mean time from original mitral valve (MV) replacement to valve-in-valve procedure was 10.5 ± 3.7 years. Follow-up was completed by all patients with a mean duration of 13 ± 12 months. RESULTS: Preoperatively, all patients presented with significant mitral regurgitation, two with mitral stenosis due to structural valve failure. All nine patients underwent successful transapical valve-in-valve implantation with an Edwards Sapien balloon expandable valve. There was no in-hospital mortality. Mean and median hospital duration was 15 ± 18 and 7 days respectively. Valve implantation was successful in all patients and there were no major complications, except for major femoral access bleeding in one patient. At last follow-up, all patients were alive and in NYHA functional class I or II. Echocardiography follow-up demonstrated that mitral regurgitation was absent or trivial in seven patients and mild in two. At follow-up, peak and mean gradients changed from 26 ± 4 and 8 ± 2 at baseline to 16.7 ± 3 and 7.3 ± 1.5, respectively. CONCLUSIONS: Transcatheter transapical mitral valve-in-valve implantation for failed bioprosthesis is feasible in selected high risk patients. Our early experience with this strategy is encouraging. Larger randomized trials with long-term clinical and echocardiographic follow-up are recommended.

Echocardiography vs hemodynamic assessment of diastolic dysfunction.

OBJECTIVES: Ostial CTOs can be challenging to revascularize. We aim to describe the outcomes of ostial chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We examined the clinical and angiographic characteristics and procedural outcomes of 8788 CTO PCIs performed at 35 US and non-US centers between 2012 and 2022. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target-vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke. RESULTS: Ostial CTOs constituted 12% of all CTOs. Patients with ostial CTOs had higher J-CTO score (2.9 ± 1.2 vs 2.3 ± 1.3; P less than .01). Ostial CTO PCI had lower technical (82% vs. 86%; P less than .01) and procedural (81% vs. 85%; P less than .01) success rates compared with non-ostial CTO PCI. Ostial location was not independently associated with technical success (OR 1.03, CI 95% 0.83-1.29 P =.73). Ostial CTO PCI had a trend towards higher incidence of MACE (2.6% vs. 1.8%; P =.06), driven by higher incidence of in-hospital death (0.9% vs 0.3% P less than.01) and stroke (0.5% vs 0.1% P less than .01). Ostial lesions required more often use of the retrograde approach (30% vs 9%; P less than .01). Ostial CTO PCI required longer procedure time (149 [103,204] vs 110 [72,160] min; P less than .01) and higher air kerma radiation dose (2.3 [1.3, 3.6] vs 2.0 [1.1, 3.5] Gray; P less than .01). CONCLUSIONS: Ostial CTOs are associated with higher lesion complexity and lower technical and procedural success rates. CTO PCI of ostial lesions is associated with frequent need for retrograde crossing, higher incidence of death and stroke, longer procedure time and higher radiation dose.

Transcatheter edge-to-edge mitral valve repair in patients with acute decompensated heart failure due to severe mitral regurgitation.

BACKGROUND: Transcatheter edge-to-edge mitral valve repair (TEER) has been established as a therapy for severe symptomatic mitral regurgitation (MR) in stable patients, and it has recently emerged as a reasonable option for acutely ill patients. The aim of this study was to evaluate the safety and efficacy of TEER in hospitalized patients with acute decompensated heart failure (ADHF) and severe MR that was deemed to play a major role in their deterioration. METHODS: We included 31 patients who underwent emergent TEER for MR ≥ 3+ from 2012 to 2022 at Sheba Medical Center. Outcomes included procedural safety, procedural success, all-cause mortality, heart failure readmission, and functional improvement. Outcomes were evaluated at 3 months and at 1 year. Data were obtained retrospectively by chart review. RESULTS: Implantation of a TEER device was achieved in 97% of patients, and reduction in MR severity of at least two grades and final MR ≤ 2+ at discharge was achieved in 74%. No intra-procedural mortality or life-threatening complications were noted. Mortality at 30 days was 23%. No excess mortality occurred beyond 6 months, with a total mortality of 41%. At 1 year all survivors had MR ≤ 2+, all were free of heart failure hospitalizations, and 88% were at New York Heart Association class ≤ II. CONCLUSIONS: Mitral valve TEER for patients with ADHF and significant MR is safe, feasible, and achieves substantial reduction in MR severity. Despite high early mortality, procedural success is associated with good long-term clinical outcomes for patients surviving longer than 6 months.

Left atrial size predicts long-term outcome after balloon mitral valvuloplasty.

BACKGROUND: The treatment of choice for severe rheumatic mitral stenosis is balloon mitral valvuloplasty (BMV). Numerous predictors of immediate and long-term procedural success have been described. The aims of this study were to describe our experience with BMV over the last decade and to evaluate predictors of long-term event-free survival. METHODS: Medical records were retrospectively analyzed of patients who underwent BMV between 2009 and 2021. The primary outcome was a composite endpoint of all-cause mortality, mitral valve replacement (MVR), and repeat BMV. Long-term event-free survival was estimated using Kaplan-Meier curves. Logistic regression was used to create a multivariate model to assess pre-procedural predictors of the primary outcome. RESULTS: A total of 96 patients underwent BMV during the study period. The primary outcome occurred in 36 patients during 12-year follow-up: one (1%) patient underwent re-BMV, 28 (29%) underwent MVR, and eight (8%) died. Overall, event-free survival was 62% at 12 years. On multivariate analysis, pre-procedural left atrial volume index (LAVI) > 80 mL/m2 had a significant independent influence on event-free survival, as did previous mitral valve procedure and systolic pulmonary arterial pressure above 50 mmHg. CONCLUSIONS: Despite being a relatively low-volume center, excellent short and long-term results were demonstrated, with event-free survival rates consistent with previous studies from high-volume centers. LAVI independently predicted long-term event-free survival.

Outcomes of Patients Turned Down for Percutaneous Mitral Valve Repair.

BACKGROUND: Percutaneous mitral valve repair is an alternative treatment for high-risk patients with symptomatic mitral regurgitation (MR). Proper patient selection is crucial to ensure that patients will benefit from the procedure while avoiding futile and potentially harmful medical interventions. OBJECTIVES: To assess the reasons for and outcomes of patients who were declined MitraClip (Abbott Vascular) implantation and compare them with patients who underwent the procedure at our medical center. METHODS: We screened 182 patients for percutaneous mitral valve repair with the MitraClip device. Of these, 84 were referred for MitraClip implantation and 75 underwent the procedure. RESULTS: Procedural success was achieved in 64 patients (85%) and was associated with superior survival at 30 months (73%) compared with implanted patients who did not achieve procedural success (41%; P=.02). Ninety-eight patients were turned down for the procedure due to anatomical incompatibility (72%), lack of indication ("too well") (16%), and clinical incompatibility ("too sick") (12%). Among turned down patients, those who were deemed too well had the highest survival rate (85%) at 30 months, patients with anatomical incompatibility had intermediate survival rates (63%), and patients deemed "too sick" had a dismal survival rate of only 25% (P<.01). In fact, the patients who were too well had outcomes that were equivalent to patients who underwent successful MitraClip implantation. CONCLUSIONS: We identified a number of reasons for not performing MitraClip implantation that impact patient survival. The best outcomes were seen in patients who underwent successful MitraClip implantation and in patients who were deemed too well.

Survival after intervention in patients with low gradient severe aortic stenosis and preserved left ventricular function.

OBJECTIVE: The outcome of aortic valve replacement for patients with low gradient severe aortic stenosis and preserved ejection fraction has been debated. The aim of the present study was to evaluate the effect of aortic valve intervention on survival in that group. METHODS: A cohort of 416 consecutive patients with low gradient severe aortic stenosis (aortic valve area, ≤ 1 cm(2); mean pressure gradient, <40 mm Hg) and preserved ejection fraction (≥ 50%) were identified from the Sheba Medical Center echocardiography database. Clinical data, aortic valve intervention, and death were recorded. RESULTS: During an average follow-up of 28 months, of 416 study patients (mean age, 76 ± 14 years, 42% men), 97 (23%) underwent aortic valve intervention and 140 (32%) died. Mantel-Byar analysis showed that the cumulative probability of survival was significantly greater after aortic valve intervention. Multivariate analysis revealed a 49% reduction in the risk of death after surgery (P < .05). The survival benefit of aortic valve intervention was comparable with adjustment to older age, aortic valve area ≤ 0.8 cm(2), and a low (≤ 35 cm(2)/m(2)) or normal (>35 cm(2)/m(2)) stroke volume index. CONCLUSIONS: Our findings suggest that aortic valve intervention is associated with improved survival among patients with low gradient severe aortic stenosis and preserved left ventricular function. The presence of either a low or normal stroke volume index did not affect the mortality benefit.

Relation between stroke volume index to risk of death in patients with low-gradient severe aortic stenosis and preserved left ventricular function.

The aim of the present study was to evaluate whether assessment of stroke volume index (SVI) can be used to improve risk stratification among patients with low-gradient severe aortic stenosis and preserved ejection fraction (EF). Study population comprised 409 patients with aortic valve area ≤1.00 cm(2), mean gradient <40 mm Hg, and a normal EF (≥50%) who were followed up in a tertiary referral center from 2004 to 2012. Echocardiographic parameters and clinical data were collected. Multivariate Cox proportional hazards regression modeling was used to evaluate the association between SVI and the risk of all-cause mortality. Mean age of study patients was 78 ± 11 years, and 42% were men. The mean SVI was 39 ± 7 ml/m(2) (tertile 1 = 32 ± 4 ml/m(2); tertile 2 = 39 ± 1 ml/m(2); tertile 3 = 47 ± 4 ml/m(2)). Multivariate analysis showed that the SVI was the most powerful echocardiographic parameter associated with long-term outcome: each 5 ml/m(2) reduction in SVI was associated with a 20% increase in adjusted mortality risk (p = 0.01). Consistently, Kaplan-Meier analysis showed that the cumulative probability of survival during 3 years of follow-up was 60%, 72%, and 73% among patients in the low-, intermediate-, and high-SVI groups, respectively (p = 0.012). Our findings suggest that in patients with low-gradient severe aortic stenosis and preserved EF, there is a graded inverse relation between SVI and the risk of long-term mortality.