Temporal trend and potential impact of angiotensin receptor neprilysin inhibitors on transcatheter edge-to-edge mitral valve repair.

INTRODUCTION AND OBJECTIVES: Transcatheter edge-to-edge repair (TEER) should be considered in patients with heart failure and secondary mitral regurgitation (MR). Angiotensin receptor-neprilysin inhibitors (ARNIs) have been demonstrated to improve prognosis in heart failure. We aimed to evaluate the impact ARNIs on patient selection and outcomes. METHODS: The population of the Spanish TEER prospective registry (March 2012 to January 2021) was divided into 2 groups: a) TEER before the ARNI era (n=450) and b) TEER after the recommendation of ARNIs by European Guidelines (n=639), with further analysis according to intake (n=52) or not (n=587) of ARNIs. RESULTS: A total of 1089 consecutive patients underwent TEER for secondary MR. In the ARNI era, there was a reduction in left ventricle dilation (82mL vs 100mL, P=.025), and better function (35% vs 38%, P=.011). At 2 years of follow-up, mortality (10.6% vs 17.3%, P <.001) and heart failure readmissions (16.6% vs 27.8%, P <.001) were lower in the ARNI era, but not recurrent MR. In the ARNI era, 1- and 2-year mortality were similar irrespective of ARNI intake but patients on ARNIs had a lower risk of readmission+mortality at 2 years (OR, 0.369; 95%CI, 0.137-0.992; P=.048), better NYHA class, and lower recurrence of MR III-IV (1.9% vs 14.3%, P=.011). CONCLUSIONS: Better patient selection for TEER has been achieved in the last few years with a parallel improvement in outcomes. The use of ARNIs was associated with a significant reduction in overall events, better NYHA class, and lower MR recurrence.

Percutaneous Mitral Valve Repair: Outcome Improvement with Operator Experience and a Second-Generation Device.

BACKGROUND AND AIM: Recent randomized data comparing percutaneous mitral valve repair (PMVR) versus optimal medical treatment in patients with functional MR (FMR) seemed to highlight the importance of the learning curve not only for procedural outcomes but also for patient selection. The aim of the study was to compare a contemporary series of patients undergoing PMVR using a second-generation Mitraclip device (Mitraclip NT) with previous cohorts treated with a first-generation system. METHODS: This multicenter study collected individual data from 18 centers between 2012 and 2017. The cohort was divided into three groups according to the use of the first-generation Mitraclip during the first (control-1) or second half (control-2) or the Mitraclip NT system. RESULTS: A total of 545 consecutive patients were included in the study. Among all, 182 (33.3%), 183 (33.3%), and 180 (33.3%) patients underwent mitral repair in the control-1, control-2, and NT cohorts, respectively. Procedural success was achieved in 93.3% of patients without differences between groups. Major adverse events did not statistically differ among groups, but there was a higher rate of pericardial effusion in the control-1 group (4.3%, 0.6%, and 2.6%, respectively; p = 0.025). The composite endpoint of death, surgery, and admission for congestive heart failure (CHF) at 12 months was lower in the NT group (23.5% in control-1, 22.5% in control-2, and 8.3% in the NT group; p = 0.032). CONCLUSIONS: The present paper shows that contemporary clinical outcomes of patients undergoing PMVR with the Mitraclip system have improved over time.

Interhospital Variability in Drug Prescription After Acute Coronary Syndrome: Insights From the ACDC Study.

INTRODUCTION AND OBJECTIVES: To analyze the rate of patients admitted for acute coronary syndrome who concomitantly received acetylsalicylic acid, statins, and angiotensin-converting enzyme inhibitors at discharge, and to analyze interhospital variability in the prescription of these drugs and its potential prognostic impact. METHODS: Interhospital variability in drug prescription was estimated using the intraclass correlation coefficient and median odds ratio (hierarchical analysis). Cox regression analysis was used to estimate the risk of death or myocardial infarction associated with prescription of all 3 agents at 2-years of follow-up. RESULTS: In total, 489 (53.3%) of 917 patients were prescribed all 3 agents. The rate was similar in patients with hypertension and diabetes (56.8%). There was significant variability among centers in the prescription of the 3 drugs at discharge (from 23% to 77% of patients). Hypertension (odds ratio=1.93; 95% confidence interval, 1.42-2.61), ejection fraction < 45% (odds ratio=2.2; 95% confidence interval, 1.44-3.37), being in a clinical trial (odds ratio=1.89; 95% confidence interval, 1.24-2.88), and renal failure (odds ratio=0.53; 95% confidence interval, 0.29-0.94) were associated with prescription of the 3 drugs. After adjustment for these factors, residual variability persisted (intraclass correlation coefficient 0.046 [95% credibility interval, 0.007 to 0.192]; median odds ratio=1.46 [95% credibility interval, 1.16-2.32]). There was no clear association between the prescription of all 3 drugs and the risk of events during follow-up (hazard ratio=0.81, 95% confidence interval, 0.55-1.18; P=.27). CONCLUSIONS: The prescription rate for acetylsalicylic acid, angiotensin-converting enzyme inhibitors, and statins after acute coronary syndrome is suboptimal, varies among centers, and is possibly related to different health care approaches.

Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.

This study was conducted to compare the clinical outcomes of drug-eluting stents (DESs) with those of standard bypass surgery for the treatment of patients with left main lesions in a single-center experience. From January 2000 to October 2005, a total of 96 patients with significant unprotected left main disease were treated with DES implantation, and 245 with bypass surgery. Baseline features, such as Euroscore, were similar between groups, except for diabetes and hypertension, which were more frequent in the surgical group. The combination of death, Q-wave myocardial infarction, stroke, and repeated revascularization (major adverse cardiac and cerebrovascular events [MACCEs]) at 30 days occurred in 2.1% after DES implant and 9.0% after surgery (p=0.03). At 1 year, DES-treated patients more frequently needed repeat revascularization (5.2% vs 0.8%; p=0.02), although combined MACCE rates were similar (10.4% for DES, 11.4% for surgery; p=0.50). Moreover, after a mean follow-up of 1.3+/-0.8 and 3.2+/-1.6 years for the DES and surgical groups, there were no significant differences in MACCEs, respectively. In conclusion, in our experience, percutaneous treatment of patients with unprotected left main disease with DESs provided similar clinical results compared with surgical revascularization at a midterm follow-up.

One-year results of unprotected left main disease treatment with paclitaxel-eluting stents: results of a multicenter registry.

BACKGROUND: Preliminary data suggest that drug-eluting stents might have a role in selected cases of unprotected left main stenosis (ULMS). The purpose of this study was to determine the rates of death, myocardial infarction, and repeated revascularization in a multicenter, prospective series of patients with ULMS treated with paclitaxel-eluting stents. METHODS: A prospective registry was initiated in March 2003 through December 2004 in five tertiary centers including all patients with a significant (>50%) stenosis in ULMS treated with at least one paclitaxel-eluting stent. There were no clinical or angiographic exclusion criteria. Clinical follow-up was obtained at 6 and 12 months. RESULTS: A total of 100 patients were included. Mean age was 67.6 +/- 11.4 years and 36% were diabetics. Distal left main was affected in 53% of patients. Implantation of two stents was required in only 15%. Angiographic success was achieved in all cases. Significant periprocedural CK-MB elevation occurred in 5 patients and there was 1 intraprocedural death. At a median 9 months follow-up, cardiac death occurred in 7%, the majority of which (4%) in patients with ST-elevation myocardial infarction and cardiogenic shock before stent implantation. Only 3 patients (3%) required repeated target-vessel revascularization, all repeated angioplasty procedures. CONCLUSION: Percutaneous treatment of unprotected left main lesions with paclitaxel-eluting stents is associated with acceptable mid-term results in selected patients, with very low rates of repeated revascularization.

Transradial cardiac catheterization in patients with coronary bypass grafts: feasibility analysis and comparison with transfemoral approach.

The objective of this study was to analyze the feasibility and safety of transradial catheterization in patients with remote surgical cardiac revascularization. Selective catheterization of coronary bypass grafts might be more difficult and time-consuming from the radial artery as compared to the femoral route. This special patient subset has been either excluded or underrepresented in previous studies. Retrospective review was made of 304 cardiac diagnostic procedures performed from January 2001 through December 2004 in patients with coronary artery bypass grafts in a single center. Patients had to be considered eligible for both transradial and transfemoral approach to be included. Cases with double internal mammary or gastroepiploic grafts were excluded. Selection of the arterial access was individualized according to operator preferences. Among diagnostic cases, transradial access was attempted as first choice in 151 cases (left radial in 133) and transfemoral in 154. Total procedural time (41 +/- 22 vs. 40 +/- 23 min), fluoroscopy time (15 +/- 10 vs. 18 +/- 13 min), and dye volume (180 +/- 64 vs. 192 +/- 73 ml) were similar. Crossover rates were 4.0% in the transradial group and 1.3% in transfemoral (P = 0.28). Only two patients in transradial group needed transfemoral access because of failure to catheterize a bypass graft. Transradial angiography of coronary bypass grafts can be performed with similar success rates as compared with transfemoral procedures and without a significant time delay.