Single-center five-year outcomes after interventional edge-to-edge repair of the mitral valve.

BACKGROUND: The MitraClip procedure was established as a therapeutic alternative to mitral valve surgery for symptomatic patients with severe mitral regurgitation (MR) at prohibitive surgical risk. In this study, the aim was to evaluate 5-year outcomes after MitraClip. METHODS: Consecutive patients undergoing the MitraClip system were prospectively included. All patients underwent clinical follow-up and transthoracic echocardiography. RESULTS: Two hundred sixty-five patients (age: 81.4 ± 8.1 years, 46.7% female, logistic EuroSCORE: 19.7 ± 16.7%) with symptomatic MR (60.5% secondary MR [sMR]). Although high procedural success of 91.3% was found, patients with primary MR (pMR) had a higher rate of procedural failure (sMR: 3.1%, pMR: 8.6%; p = 0.04). Five years after the MitraClip procedure, the majority of patients presented with reduced symptoms and improved functional capacity (functional NYHA class: p = 0.0001; 6 minutes walking test: p = 0.04). Sustained MR reduction (≤ grade 2) was found in 74% of patients, and right ventricular (RV) function was significantly increased (p = 0.03). Systolic pulmonary artery pressure (sPAP) was significantly reduced during follow-up only in sMR patients (p = 0.05, p = 0.3). Despite a pronounced clinical and echocardiographical amelioration and low interventional failure, 5-year mortality was significantly higher in patients with sMR (p = 0.05). The baseline level of creatinine (HR: 0.695), sPAP (HR: 0.96) and mean mitral valve gradient (MVG) (HR: 0.82) were found to be independent predictors for poor functional outcome and mortality. CONCLUSIONS: Transcatheter mitral valve repair with the MitraClip system showed low complication rates and sustained MR reduction with improved RV function and sPAP 5 years after the procedure was found in all patients, predominantly in patients with sMR. Despite pronounced functional amelioration with low procedure failure, sMR patients had higher 5-year mortality and worse outcomes. Baseline creatinine, MVG, and sPAP were found to be independent predictors of poor functional outcomes and 5-year mortality.

Prognostic Impact of Redo Transcatheter Mitral Valve Repair for Recurrent Mitral Regurgitation.

There is little known about the prognostic impact of a redo transcatheter mitral valve repair (TMVR) for residual or recurrent mitral regurgitation (MR). From January 2011 to March 2019, we identified 43 consecutive patients who underwent a redo TMVR procedure with the MitraClip system. A control cohort was treated medically for MR ≥2+ after the first TMVR and was propensity score 1:1 matched using age, gender, MR severity, trans-mitral pressure gradient, and etiology of MR. To investigate the association of redo TMVR with 1-year mortality, we fitted a Cox proportional hazard model. The technical success rate of redo TMVR was 95%. A reduction in MR to ≤2+ was achieved in 79% of patients, with a significant decline of tricuspid regurgitation pressure gradient and improvement of the New York Heart Association class. After matching was performed, 43 well-matched pairs of patients were analyzed. Redo TMVR patients showed lower 1-year mortality (10.5% vs 37.6%, p = 0.01) compared with the control patients. Redo TMVR was associated with better survival (hazard ratio [HR] 0.26, 95% confidence interval [CI] 0.08 to 0.79, p = 0.02) and lower risk of the composite end point (mortality and rehospitalization due to HF: HR 0.34, 95% CI 0.15 to 0.78; p = 0.01) at 1-year follow-up. The association with the primary end point remained significant after accounting for the New York Heart Association class III/IV, TR ≥severe, the type of MR (i.e., recurrent or residual MR), or the type of previous implanted TMVR device. In conclusion, redo TMVR in selected patients with residual or recurrent MR may be associated with lower 1-year mortality than medical therapy alone.

Contrast-free, echocardiography-guided left atrial appendage occlusion (LAAo): a propensity-matched comparison with conventional LAAo using the AMPLATZER™ Amulet™ device.

AIMS: Percutaneous left atrial appendage occlusion (LAAo) is commonly performed under fluoroscopy including the use of contrast dye. In this study, we aimed to assess feasibility and safety of contrast-free, 3D-echo-based LAAo with the use of the AMPLATZER™ Amulet™ device. METHODS AND RESULTS: We analyzed 20 patients (74 ± 10 years, 65% males) at an increased thromboembolic and bleeding risk (CHA2DS2VASC 4.0 ± 1.3; HAS-BLED 3.5 ± 0.9) with chronic renal failure (GFR 41 ± 21 ml/min) undergoing LAAo without the use of contrast dye at our center and compared the results with a propensity-matched cohort (1:1 matching) of conventionally treated patients receiving contrast agent. Contrast-free LAAo was associated with less radiation exposure (13.1 ± 19.2 vs. 32.9 ± 21.2 Gy*cm2, p < 0.01) and fluoroscopy time (5.0 ± 3.4 vs. 11.6 ± 4.9 min, p < 0.01). Procedural success rates were excellent in both groups (100%) without severe periprocedural complications (i.e. procedural death, stroke/systemic embolism, myocardial infarction, cardiac tamponade or major bleeding). CONCLUSIONS: Echocardiographically guided LAAo without the use of contrast dye appears safe and feasible. This approach appears to be associated with reduced radiation exposure and may represent an alternative to traditional LAAo, especially in patients in whom the avoidance of contrast dye is warranted.

Left atrial thrombus resolution in non-valvular atrial fibrillation or flutter: biomarker substudy results from a prospective study with rivaroxaban (X-TRA).

BACKGROUND: Non-vitamin K antagonist oral anticoagulants including rivaroxaban are widely used for stroke prevention in patients with atrial fibrillation (AF). We investigated the relationship between plasma biomarkers (indicative of thrombogenesis, fibrinolysis and inflammation) and left atrial thrombus resolution after rivaroxaban treatment. METHODS: This was an ancillary analysis of the X-TRA study, which was a prospective interventional study evaluating the use of rivaroxaban for left atrial/left atrial appendage (LA/LAA) thrombus resolution in AF patients. We assessed various biomarkers of thrombogenesis/fibrinolysis [D-dimer, plasminogen activator inhibitor-1 (PAI-1), prothrombin fragment 1 + 2 (F1,2), thrombin-antithrombin (TAT) complexes, von Willebrand factor (vWF)] and inflammation [high-sensitivity interleukin-6 (hsIL-6), and high-sensitivity C-reactive protein (hsCRP)], measured at baseline and after 6 weeks' of rivaroxaban treatment. RESULTS: There was a significant decrease in the mean levels of hsCRP, D-dimer, vWF, and TAT from baseline to end of treatment with rivaroxaban. Although none of the thrombogenesis/fibrinolysis biomarkers showed a significant relationship with thrombus resolution, high inflammatory biomarkers at baseline were significantly associated with an increased chance of the thrombus being completely resolved (hsIL-6) or reduced/resolved (hsCRP). CONCLUSIONS: Biomarkers of inflammation are significantly associated with LA/LAA thrombus outcomes in AF patients prospectively treated with rivaroxaban.

High rate of persistent iatrogenic atrial septal defect after single transseptal puncture for cryoballoon pulmonary vein isolation.

PURPOSE: Congenital atrial septal defect (ASD) is associated with increased morbidity, whereas little is known about the rate of spontaneous closure, associated clinical and echocardiographic parameters, or complications of iatrogenic atrial septal defect (iASD) beyond 1 year of follow-up. Persistent iASD after transseptal puncture for PVI has been described in up to 38% of small cohorts of patients in short-term follow-up after transseptal puncture. We sought to investigate the course of iASD after single transseptal puncture for first pulmonary vein isolation (PVI) with cryoballoon, along with possible risk factors for persistent iASD. METHODS: After a first PVI with cryoballoon, 102 patients (64 ± 10 years, 64% male) underwent long-term clinical follow-up and comprehensive transthoracic and transesophageal echocardiographic study. RESULTS: Prevalence of iASD after PVI was 37% after 2.9 (1.6-4.9) years. No clinical complications or deterioration of echocardiographic parameters were associated with iASD. Lower left atrial appendage flow velocity was associated with higher risk of persistence of iASD (3.5% for every 1 cm/s decrease, p = 0.002). CONCLUSIONS: Despite a high rate of iASD after cryoballoon PVI in long-term follow-up, this was not associated with increased clinical complications. Lower LAA velocity was associated with higher risk of persistent iASD. Repeated routine echocardiographic follow-up may not be necessary in these patients.

Transcatheter Treatment of Severe Tricuspid Regurgitation With the Edge-to-Edge MitraClip Technique.

BACKGROUND: Current surgical and medical treatment options for severe tricuspid regurgitation (TR) are limited, and additional interventional approaches are required. In the present observational study, the safety and feasibility of transcatheter repair of chronic severe TR with the MitraClip system were evaluated. In addition, the effects on clinical symptoms were assessed. METHODS: Patients with heart failure symptoms and severe TR on optimal medical treatment were treated with the MitraClip system. Safety, defined as periprocedural adverse events such as death, myocardial infarction, stroke, or cardiac tamponade, and feasibility, defined as successful implantation of 1 or more MitraClip devices and reduction of TR by at least 1 grade, were evaluated before discharge and after 30 days. In addition, functional outcome, defined as changes in New York Heart Assocation class and 6-minute walking distance, were assessed. RESULTS: We included 64 consecutive patients (mean age 76.6±10 years) deemed unsuitable for surgery who underwent MitraClip treatment for chronic, severe TR for compassionate use. Functional TR was present in 88%; in addition, 22 patients were also treated with the MitraClip system for mitral regurgitation as a combined procedure. The degree of TR was severe or massive in 88% of patients before the procedure. The MitraClip device was successfully implanted in the tricuspid valve in 97% of the cases. After the procedure, TR was reduced by at least 1 grade in 91% of the patients, thereof 4% that were reduced from massive to severe. In 13% of patients, TR remained severe after the procedure. Significant reductions in effective regurgitant orifice area (0.9±0.3cm2 versus 0.4±0.2cm2; P<0.001), vena contracta width (1.1±0.5 cm versus 0.6±0.3 cm; P=0.001), and regurgitant volume (57.2±12.8 mL/beat versus 30.8±6.9 mL/beat; P<0.001) were observed. No intraprocedural deaths, cardiac tamponade, emergency surgery, stroke, myocardial infarction, or major vascular complications occurred. Three (5%) in-hospital deaths occurred. New York Heart Association class was significantly improved (P<0.001), and 6-minute walking distance increased significantly (165.9±102.5 m versus 193.5±115.9 m; P=0.007). CONCLUSIONS: Transcatheter treatment of TR with the MitraClip system seems to be safe and feasible in this cohort of preselected patients. Initial efficacy analysis showed encouraging reduction of TR, which may potentially result in improved clinical outcomes.

Transcatheter aortic valve implantation leads to a restoration of von Willebrand factor (VWF) abnormalities in patients with severe aortic stenosis - Incidence and relevance of clinical and subclinical VWF dysfunction in patients undergoing transfemoral TAVI.

BACKGROUND: In this study, we sought to analyze the incidence and relevance of von Willebrand factor (VWF) abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI), especially on perioperative bleeding. Furthermore, we hypothesized that, similar to aortic valve surgery, TAVI results in a restoration of VWF abnormalities. METHODS AND RESULTS: We performed a prospective analysis of periinterventional VWF parameters in 74 patients (80±7years, female in 37.5%) undergoing transfemoral TAVI for severe symptomatic aortic valve stenosis. At baseline, VWF:Ag was 210±90IU/dl with a mean VWF activity of 166±106IU/dl; activity-to-antigen ratio was 0.85±0.45. Heyde's syndrome (severe aortic stenosis plus GI bleeding from angiodyplasia) was observed in 2/74 (2.7%). Whereas preprocedural loss of high-molecular-weight (HMW) VWF multimers was found in thirty-six patients (48.6%), none of the patients fulfilled criteria for possible acquired VW syndrome. After TAVI, an increase of both VWF:Ag and activity compared to baseline was observed (p<0.01). In patients with HMW multimer loss, post-interventional recovery of multimers occurred in all cases. In the two patients with Heyde's syndrome, a trend towards reduced VWF:Ag was seen, with loss of HMW multimers in one patient. Of interest, all patients suffering from periprocedural major bleeding (5/74; 6.8%) exhibited activity-to-antigen ratios <0.7, indicating subclinical VWF dysfunction. CONCLUSION: Whereas clinically relevant VWF dysfunction is rare, loss of HMW VWF multimers is common in TAVI patients. Similar to surgery, TAVI leads to a restoration of this loss. Furthermore, VWF parameters may be useful parameter to evaluate risk of periprocedural bleeding.

Transcatheter Tricuspid Repair With MitraClip for Severe Primary Tricuspid Regurgitation.

Severe tricuspid regurgitation is an independent predictor of adverse outcomes, yet few patients undergo surgery and treatment with medical therapy is often inadequate. Recent studies have reported the use of the MitraClip system (Abbott Vascular) to treat secondary tricuspid regurgitation. We describe the first use of MitraClip to treat severe primary tricuspid regurgitation and right heart failure in a patient with previous cardiac transplantation and high surgical risk.

Speckle tracking echocardiography in chronic obstructive pulmonary disease and overlapping obstructive sleep apnea.

BACKGROUND: COPD and congestive heart failure represent two disease entities of growing global burden that share common etiological features. Therefore, we aimed to identify the degree of left ventricular (LV) dysfunction in COPD as a function of COPD severity stages and concurrently placed particular emphasis on the presence of overlapping obstructive sleep apnea (OSA). METHODS: A total of 85 COPD outpatients (64.1±10.4 years, 54.1% males) and 20 controls, matched for age, sex, and smoking habits, underwent speckle tracking echocardiography for LV longitudinal strain imaging. Complementary 12-lead electrocardiography, laboratory testing, and overnight screening for sleep-disordered breathing using the SOMNOcheck micro(®) device were performed. RESULTS: Contrary to conventional echocardiographic parameters, speckle tracking echocardiography revealed significant impairment in global LV strain among COPD patients compared to control smokers (-13.3%±5.4% vs -17.1%±1.8%, P=0.04). On a regional level, the apical septal LV strain was reduced in COPD (P=0.003) and associated with the degree of COPD severity (P=0.02). With regard to electrocardiographic findings, COPD patients exhibited a significantly higher mean heart rate than controls (71.4±13.0 beats per minute vs 60.3±7.7 beats per minute, P=0.001) that additionally increased over Global Initiative for Chronic Obstructive Lung Disease stages (P=0.01). Albeit not statistically significant, COPD led to elevated N-terminal pro-brain natriuretic peptide levels (453.2±909.0 pg/mL vs 96.8±70.0 pg/mL, P=0.08). As to somnological testing, the portion of COPD patients exhibiting overlapping OSA accounted for 5.9% and did not significantly vary either in comparison to controls (P=0.07) or throughout the COPD Global Initiative for Chronic Obstructive Lung Disease stages (P=0.49). COPD-OSA overlap solely correlated with nocturnal hypoxemic events, whereas LV performance status was unrelated to coexisting OSA. CONCLUSION: To conclude, COPD itself seems to be accompanied with decreased LV deformation properties that worsen over COPD severity stages, but do not vary in case of overlapping OSA.

Routine Endovascular Treatment With a Stent Graft for Access-Site and Access-Related Vascular Injury in Transfemoral Transcatheter Aortic Valve Implantation.

BACKGROUND: Access-site and access-related vascular injury (ASARVI) is still a major limiting factor in transcatheter aortic valve implantation and affects the outcome of patients. Management strategies for ASARVI include manual compression, stent grafts, and vascular surgery. We hypothesized that the standard use of a self-expanding stent graft for the management of ASARVI is feasible and safe. METHODS AND RESULTS: Of 407 patients treated by transfemoral transcatheter aortic valve implantation, 110 experienced ASARVI (27.0%). Of these, 96 (87.3%) were managed by the implantation of a self-expanding nitinol stent graft. In the majority of patients, minor vascular complications triggered the implantation of a stent graft (86.5%), mainly because of bleeding (90.6%) and dissection (5.2%) of the common femoral artery with high rates of primary treatment success (97.9%). Patients receiving stent grafts were more often female (62.2 versus 45.6%, P<0.01), had higher body mass indices (27.8±6.7 versus 25.7±4.7, P=0.01), and suffered more often from diabetes mellitus (34.4 versus 24.5%, P=0.04). Angiographic assessment after a median follow-up of 345 days (interquartile range, 23-745 days) revealed only one patient with moderate, asymptomatic instent-stenosis (1.0%). Compared with a propensity score-matched cohort of patients without ASARVI, stented patients had comparable long-term mortality, despite the occurrence of a vascular complication (1-year mortality: 17.7% versus 26.6%; stent versus matched cohort, respectively; P=0.1). CONCLUSIONS: Routine use of a self-expanding nitinol stent graft in selected patients experiencing ASARVI after transcatheter aortic valve implantation is feasible, safe, and associated with favorable short- and midterm clinical outcome.

Treatment of Chronic Functional Mitral Valve Regurgitation With a Percutaneous Annuloplasty System.

BACKGROUND: Current surgical and medical treatment options for functional mitral regurgitation (FMR) are limited and additional interventional approaches are required. OBJECTIVES: This study sought to report the safety and performance data from the feasibility study with a novel direct annuloplasty system. METHODS: Seventy-one patients with moderate to severe FMR (mean 67.7 ± 11.3 years of age, left ventricular [LV] ejection fraction 34.0 ± 8.3%), on stable medical heart failure medication were prospectively enrolled. RESULTS: Device success rate was 70.4% (n = 50 of 71). No intraprocedural death occurred. In patients receiving implants, 4 patients (8.9%) experienced cardiac tamponade. Thirty-day (n = 45) and 6-month (n = 41) rates for all-cause mortality, stroke, and myocardial infarction were 4.4%, 4.4%, and 0.0% and 12.2%, 4.9%, and 0%, respectively. At 6 months, nonurgent mitral surgery was performed in 1 patient (2.4%) and nonurgent percutaneous repair in 7 patients (17.1%). Echocardiographic core analysis after 6 months showed mitral regurgitation reduction in 50% of treated patients by a mean of 1.3 grades. Concerning mitral valve (MV) annular geometry, we found significant reduction of anterior-posterior (-0.31 ± 0.4 cm) and septal-lateral dimensions (-0.21 ± 0.3 cm), a decreased MV-tenting area (-0.57 ± 1.1 cm(2)) and increase in MV coaptation length (0.13 ± 0.2 cm). Transthoracic echocardiography indicated reverse LV remodeling with reduction of LV end-diastolic diameter (-0.20 ± 0.4 mm) and volume (-22 ± 39 ml). Treatment was associated with significant improvement in 6-min walking distances (56.5 ± 92.0 m) and improvements in New York Heart Association functional class III/IV at 6 months from 53.3% to 23.3%. CONCLUSIONS: Percutaneous direct annuloplasty is feasible and safe in high-risk FMR patients. This treatment initiates LV reverse remodeling, and provides clinical improvement during 6 months after treatment. (Mitralign Percutaneous Annuloplasty First in Man Study; NCT01852149).

Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system.

AIM: The aim of this study was to show technical principles and feasibility of transcatheter tricuspid valve repair by use of the MitraClip system. METHODS AND RESULTS: Three consecutive patients were treated successfully for severe symptomatic Tricuspid regurgitation. Three-dimensional transoesophageal echocardiography confirmed reduction of measured effective regurgitant orifice in all patients [effective regurgitant orifice area-baseline/post-procedure (cm(2)): 0.7/0.3; 1.5/0.8; 0.4/0.1], which was accompanied by an increase in left ventricular stroke volumes [baseline/post-procedure (mL): 42.8/45.4; 38/45; 35.2/45], decrease of measured levels of N terminal pro brain natriuretic peptide (pg/mL: baseline/post-procedure: 548/440; 2526/1702; 1754/623), and significant relief of clinical symptoms for chronic right heart failure in all patients. CONCLUSIONS: Transcatheter tricuspid valve repair by use of interventional edge-to-edge repair with the MitraClip system was feasible, and safe in three consecutive patients. Reduction of tricuspid insufficiency associates with relief of clinical symptoms for right heart failure. This strategy seems a promising treatment option for patients at prohibitive surgical risk.

Catch of the day: interventional device retrieval after late embolization of an Amplatzer cardiac plug left atrial appendage occluder.

Transcatheter left atrial appendage (LAA) closure has proven to be an effective method to reduce the risk of thromboembolic events in patients who have nonvalvular atrial fibrillation (AF) that is unsuitable for chronic oral anticoagulation. In this case report, we describe the rare case of a late LAA occluder (28-mm Amplatzer cardiac plug) embolization, which was treated uneventfully with interventional device capture. Special interventional and device specific characteristics must be taken into account when planning such a complex procedure as described in our case.

Impact of endoscopic lung volume reduction on right ventricular myocardial function.

INTRODUCTION: Endoscopic lung volume reduction (ELVR) provides a minimally invasive therapy for patients with severe lung emphysema. As its impact on right ventricular (RtV) function is undefined, we examined the extent of RtV functional changes following ELVR, as assessed by use of speckle tracking-based RtV deformation analysis. METHODS: We enrolled 32 patients with severe emphysematous COPD scheduled for bronchoscopic LVR using endobronchial valves (Zephyr, PulmonX, Inc.), comprising 16 matched clinical responders and 16 non-responders. Echocardiography was conducted one day prior to ELVR and at an eight-week postprocedural interval. RESULTS: Patients were predominantly of late middle-age (65.8 ± 8.7 yrs), male (62.5%) and presented advanced COPD emphysema (means FEV1 and RV: 32.6% and 239.1% of predicted, respectively). After ELVR, RtV apical longitudinal strain improved significantly in the total study cohort (-7.96 ± 7.02% vs. -13.35 ± 11.48%, p = 0.04), whereas there were no significant changes in other parameters of RtV function such as RtV global longitudinal strain, TAPSE or pulmonary arterial systolic pressure. In responding patients, 6MWT-improvement correlated with a decrease in NT-proBNP (Pearson´s r: -0.53, p = 0.03). However, clinical non-responders did not exhibit any RtV functional improvement. DISCUSSION: ELVR beneficially impacts RtV functional parameters. Speckle tracking-based RtV apical longitudinal strain analysis allows early determination of RtV contractile gain and identification of clinical responsiveness.

Persistence of iatrogenic atrial septal defect after interventional mitral valve repair with the MitraClip system: a note of caution.

OBJECTIVES: The purpose of this study was to investigate the persistence rates of iatrogenic atrial septal defect (iASD) after interventional edge-to-edge repair with serial transesophageal echocardiography examinations and close clinical follow-up (FU). BACKGROUND: Transcatheter mitral valve repair (TMVR) with the MitraClip system (Abbott Vascular, Abbott Park, Illinois) is a therapeutic alternative to surgery in selected high-risk patients. Clip placement requires interatrial transseptal puncture and meticulous manipulation of the steerable sheath. The persistence of iASD after MitraClip procedures and its clinical relevance is unknown. METHODS: A total of 66 patients (76.7% male, mean age 77.1 ± 7.9 years) with symptomatic mitral regurgitation (MR) at prohibitive surgical risk (EuroSCORE II 10.1 ± 6.1%) underwent MitraClip procedures and completed 6 months of FU. RESULTS: Transesophageal echocardiography after FU showed persistent iASD in 50% of cases. Patients with iASD did not significantly differ from patients without ASD concerning baseline characteristics, New York Heart Association functional class, severity of MR, and acute procedural success rates (p > 0.05). When comparing procedural details and hemodynamic measures between groups, MitraClip procedures took longer in patients without iASD (82.4 ± 39.7 min vs. 68.9 ± 45.5 min; p = 0.05), and echocardiography after FU showed less decrease of systolic pulmonary artery pressures in the iASD group (-1.6 ± 14.1 mm Hg vs. 9.3 ± 17.4 mm Hg; p = 0.02). Clinically, patients with iASD presented more often with New York Heart Association functional classes >II after FU (57% vs. 30%; p = 0.04), showed higher levels of N-terminal pro-brain natriuretic peptide (6,667.3 ± 7,363.9 ng/dl vs. 4,835.9 ± 6,681.7 ng/dl; p = 0.05), and had less improvement in 6-min walking distances (20.8 ± 107.4 m vs. 114.6 ± 116.4 m; p = 0.001). Patients with iASD showed higher death rates during 6 months (16.6% vs. 3.3%; p = 0.05). Cox regression analysis found that only persistence of iASD (p = 0.04) was associated with 6-month survival. CONCLUSIONS: The persistence rate of 50% iASD after MitraClip procedures is considerably high. Persistent interatrial shunting was associated with worse clinical outcomes and increased mortality. Further studies are warranted to investigate if persistent interatrial shunting is the mediator or marker of advanced disease in these patients.

Solitary right ventricular metastasis of endometrial adenocarcinoma.

A woman presented with a solitary cardiac metastasis 5 months after curative surgery for endometrial adenocarcinoma (FIGO IB). The tumor was deemed inoperable and palliative ambulatory chemotherapy was initiated. We aimed at a palliative reduction of tumor mass after chemotherapy and atypical vascularization of the metastasis was demonstrated by coronary angiography. We identified two tumor vessels originating from the ramus circumflexus suitable to palliative percutaneous coronary intervention. Within 5 weeks, the initially mild dyspnea increased to New York Heart Association class III and readmission was planned. Regrettably, our patient died from congestive right heart failure only 2 months after diagnosis of tumor recurrence. This report illustrates the need for resolute action without delay even in cases of only mild right heart failure. .

Doppler-based renal resistance index for the detection of acute kidney injury and the non-invasive evaluation of paravalvular aortic regurgitation after transcatheter aortic valve implantation.

AIMS: Acute kidney injury (AKI) is a strong but rather late predictor of mortality after transcatheter aortic valve implantation (TAVI). Early clinically useful markers for the detection of AKI and prediction of outcome are needed in order to control and improve management of periprocedural complications after TAVI. The aim of our study was to assess the predictive value of the Doppler-based renal resistance index (RRI), which correlates inversely with effective renal blood flow and creatinine clearance, for AKI in patients undergoing TAVI and to evaluate its association with paravalvular aortic regurgitation (PAR). METHODS AND RESULTS: TAVI was performed with the Medtronic CoreValve prosthesis in 132 consecutive high-risk patients (mean logistic EuroSCORE: 30.3±18.2%). RRI, serum creatinine and cystatin C level were determined before, and 4 hrs, 24 hrs, 48 hrs, 72 hrs, and 7 days after TAVI. AKI occurred in 32/132 patients (24.2%). While serum creatinine and cystatin C levels decreased at first after TAVI (also in most patients developing AKI), the RRI increased significantly immediately after the procedure from 0.79±0.09 to 0.87±0.12 in patients developing AKI (p=0.003). A RRI >0.85 predicted post-interventional AKI with a sensitivity of 58% and specificity of 86%, and was superior to the serum creatinine level (p<0.001). In addition, an elevated RRI was significantly related to haemodynamic changes after TAVI and was associated with the occurrence of moderate/severe PAR (p<0.001). CONCLUSIONS: Measurement of the Doppler-based RRI predicts risk for AKI and increased mortality rates at an early post-procedural time point and is related to the occurrence of more-than-mild paravalvular aortic regurgitation after TAVI.

Decrease of pulmonary hypertension impacts on prognosis after transcatheter aortic valve replacement.

AIMS: Transcatheter aortic valve replacement (TAVR) is established as a treatment strategy for patients with end-stage aortic stenosis, many of whom are suffering from severe pulmonary hypertension (PH). In cardiac surgery patients, PH is associated with less symptomatic improvement and increased late mortality. This study elucidates the impact of PH on outcome after TAVR. METHODS AND RESULTS: Pre and 90 days post-TAVR, pulmonary artery systolic pressure (PASP) was determined non-invasively by echocardiography in 353 patients undergoing TAVR. PH was classified as absent (<30 mmHg), mild-to-moderate (30-60 mmHg), and severe (>60 mmHg). Three hundred and fifty-three patients at high surgical risk, indicated by a logistic EuroSCORE of 26.6±16.5%, underwent TAVR. The severity of PH before TAVR was related to outcome with two-year mortality rates of 13.9%, 27.3%, and 48.4% for PASP <30 mmHg, 30-60 mmHg, and >60 mmHg, respectively (p=0.001). In patients with baseline PASP >60 mmHg, PASP decreased from 65.6±7.6 mmHg to 49.5±14.0 mmHg (p<0.001) at 90 days after TAVR. Patients with persistent severe PH had a worse prognosis than patients with a decrease of PASP below 60 mmHg (two-year mortality rate: 50.0% vs. 18.6%; p=0.001). CONCLUSIONS: Severe pulmonary hypertension predicts adverse outcome after TAVR. Reduction of PASP after the procedure is associated with favourable prognosis.