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BACKGROUND: Calcific mitral stenosis (calcific MS) presents a challenge for surgical treatment and is a contraindication for most contemporary transcatheter mitral valve replacement devices (TMVR), rendering patients with very limited therapeutic options. AIMS: This study aims to assess the clinical and hemodynamic follow-up after mitral valve lithotripsy (MVL). METHODS: All consecutive patients who underwent MVL to treat symptomatic calcific MS at St Michael's Hospital, Toronto, Canada, were included. Patients were deemed unsuitable for mitral surgery or TMVR after heart team assessment. Patients with rheumatic MS or ≥moderate mitral regurgitation (MR) were excluded. The primary endpoint was a reduction in the invasive mitral gradient by ≥50% without significant (≥moderate) MR. RESULTS: Fifteen patients underwent MVL between 2021 and 2023 with a mean age of 74 ± 9 years; 53% were female, with a mean STS score of 10% ± 0.1%. Following MVL, there was a reduction in the invasively measured mean trans-mitral gradient compared to baseline (14 mmHg vs. 6 mmHg; p < 0.05). The primary endpoint was achieved in 8 patients (53%) with no major procedural complications. At follow-up (median 90 days, IQR 58-115 days), 14 (93%) patients reported improved symptoms from New York Heart Association (NYHA) Class III-IV to NYHA Class I-II (p < 0.01) with stable echo-derived mean gradient (7.7 mmHg ± 2 mmHg vs. 8.4 mmHg ± 2.9 mmHg (p = 0.7). CONCLUSIONS: In selected patients with symptomatic inoperable calcific MS, MVL was safe and associated with significant short-term clinical and hemodynamic improvement. MVL may represent a new compassionate therapy for this challenging cohort. Further studies are needed to determine the long-term outcomes and help define the role of IVL technology in treating calcific valvular conditions.
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Valvuloplastia con Balón , Calcinosis , Hemodinámica , Litotricia , Estenosis de la Válvula Mitral , Válvula Mitral , Recuperación de la Función , Humanos , Femenino , Masculino , Resultado del Tratamiento , Estenosis de la Válvula Mitral/fisiopatología , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/terapia , Anciano , Calcinosis/terapia , Calcinosis/fisiopatología , Calcinosis/diagnóstico por imagen , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Factores de Tiempo , Anciano de 80 o más Años , Estudios Retrospectivos , Persona de Mediana Edad , OntarioRESUMEN
BACKGROUND AND AIMS: For patients with symptomatic, severe tricuspid regurgitation (TR), early results of transcatheter tricuspid valve (TV) intervention studies have shown significant improvements in functional status and quality of life associated with right-heart reverse remodelling. Longer-term follow-up is needed to confirm sustained improvements in these outcomes. METHODS: The prospective, single-arm, multicentre TRISCEND study enrolled 176 patients to evaluate the safety and performance of transcatheter TV replacement in patients with ≥moderate, symptomatic TR despite medical therapy. Major adverse events, reduction in TR grade and haemodynamic outcomes by echocardiography, and clinical, functional, and quality-of-life parameters are reported to one year. RESULTS: Enrolled patients were 71.0% female, mean age 78.7 years, 88.0% ≥ severe TR, and 75.4% New York Heart Association classes III-IV. Tricuspid regurgitation was reduced to ≤mild in 97.6% (P < .001), with increases in stroke volume (10.5 ± 16.8â mL, P < .001) and cardiac output (0.6 ± 1.2â L/min, P < .001). New York Heart Association class I or II was achieved in 93.3% (P < .001), Kansas City Cardiomyopathy Questionnaire score increased by 25.7 points (P < .001), and six-minute walk distance increased by 56.2â m (P < .001). All-cause mortality was 9.1%, and 10.2% of patients were hospitalized for heart failure. CONCLUSIONS: In an elderly, highly comorbid population with ≥moderate TR, patients receiving transfemoral EVOQUE transcatheter TV replacement had sustained TR reduction, significant increases in stroke volume and cardiac output, and high survival and low hospitalization rates with improved clinical, functional, and quality-of-life outcomes to one year. Funded by Edwards Lifesciences, TRISCEND ClinicalTrials.gov number, NCT04221490.
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Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Humanos , Femenino , Anciano , Masculino , Insuficiencia de la Válvula Tricúspide/epidemiología , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Estudios Prospectivos , Calidad de Vida , Resultado del Tratamiento , Cateterismo Cardíaco/métodos , Índice de Severidad de la EnfermedadRESUMEN
PURPOSE OF REVIEW: Chronic primary mitral regurgitation (MR) is a common heart valve disease with a rising prevalence with the aging populations worldwide. The timing of surgical intervention in patients who have severe MR but remain asymptomatic is often debated. Herein we synthesize the latest American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/ European Association for Cardio-Thoracic Surgery (ESC/EACTS) heart valve guidelines in such patients and illustrate how circulating and/or imaging biomarkers can be used to help refine decision making algorithms. RECENT FINDINGS: The approach to decision making and strength of guideline recommendations in patients with asymptomatic stage C1 (left ventricular ejection fraction [LVEF] > 60% and left ventricular end systolic dimension [LVESD] < 40âmm) and stage C2 disease (LVEF ≤ 60% and/or LVESD ≥ 40âmm) are reviewed. While surgical intervention is clearly indicated in patients with stage C2 disease, a multifaceted approach that integrates repairability, expertise, sub-clinical evidence of left ventricular (LV) dysfunction, and patient preferences is required to identify the optimal approach to surveillance vs. surgery. The role of imaging (3D echocardiography, contrast echocardiography, left ventricular global longitudinal strain, and cardiovascular magnetic resonance imaging [CMR]) and circulating (natriuretic peptides) biomarkers in decision making is also reviewed. SUMMARY: The decision making around timing of intervention in chronic primary MR requires a personalized approach that is based on accurate assessments of severity of MR, LV dimensions, LV function, valve morphology/repairability, surgeon and center expertise, and patient wishes. Biomarkers hold promise in refining decision making.
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Insuficiencia de la Válvula Mitral , Disfunción Ventricular Izquierda , Humanos , Insuficiencia de la Válvula Mitral/diagnóstico , Función Ventricular Izquierda , Volumen Sistólico , Corazón , BiomarcadoresRESUMEN
PURPOSE OF REVIEW: Mitral valve transcatheter edge-to-edge repair (TEER) is becoming increasingly common to treat severe mitral regurgitation. However, the lack of concomitant annuloplasty raises concerns regarding its durability. As a result, there is an emerging body of literature evaluating the impacts of TEER on mitral annular geometry. In this review, we summarize the most recent literature evaluating the impacts of TEER on annular geometry in the acute, intermediate and long-term. We also review the relationship between changes in annular geometry and clinical endpoints. RECENT FINDINGS: Current evidence suggests that TEER acutely induces favourable changes in mitral annular size and shape, which may persist for at least up to 1 year. Few studies suggest that TEER-induced annular remodelling is associated with positive clinical outcomes. SUMMARY: The current body of literature is sparse and limited to primarily small case series. Data from the surgical literature suggest that ringless edge-to-edge repair is associated with eventual failure. Unfortunately, few studies evaluate TEER-induced annular changes beyond the acute postprocedural phase. Future research needs to focus on and evaluate the significance of TEER-induced changes in annular dimensions in the long-term.
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Procedimientos Quirúrgicos Cardíacos , Implantación de Prótesis de Válvulas Cardíacas , Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Válvula Mitral/cirugía , Anuloplastia de la Válvula Mitral/métodos , Insuficiencia de la Válvula Mitral/cirugía , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: The burden of tricuspid regurgitation (TR) is high in the aging population, almost 4% in the age group over 75 have moderate or more TR. This carries a poor prognosis and an increased incidence of mortality, prolonged hospitalization, and rehospitalization in symptomatic patients with severe TR is observed. Percutaneous tricuspid valve intervention has emerged as a viable therapeutic option, with an increasingly large toolbox of both tricuspid repair and replacement devices. The optimal strategy, timing and patient selection for transcatheter intervention are yet to be determined. This review focuses on the current strengths and limitations of transcatheter tricuspid repair vs. replacement, drawing on lessons learned from surgery. RECENT FINDINGS: Early outcome studies have been published in the last 2 years for many of the new percutaneous tricuspid valve devices. We have summarized these results and compared them to surgical tricuspid valve repair and replacement. We found that surgical data shows a tendency to better outcome with tricuspid valve repair compared to replacement. For transcatheter interventions studies comparing repair and replacement are lacking but both interventions show good procedural success rates and are efficient in reducing the grade of tricuspid regurgitation. SUMMARY: Transcatheter tricuspid valve interventions offer a safe and effective alternative to tricuspid surgery or medical therapy. The decision between valve replacement and repair should be based on patient anatomy, operator experience and device availability until head-to-head comparison of different devices are available.
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Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Anciano , Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Resultado del Tratamiento , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
BACKGROUND: This study aimed to compare echocardiographic findings in low-risk patients with severe aortic stenosis after surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). METHODS: The PARTNER 3 trial (Placement of Aortic Transcatheter Valves) randomized 1000 patients with severe aortic stenosis and low surgical risk to undergo either transfemoral TAVR with the balloon-expandable SAPIEN 3 valve or SAVR. Transthoracic echocardiograms obtained at baseline and at 30 days and 1 year after the procedure were analyzed by a consortium of 2 echocardiography core laboratories. RESULTS: The percentage of moderate or severe aortic regurgitation (AR) was low and not statistically different between the TAVR and SAVR groups at 30 days (0.8% versus 0.2%; P=0.38). Mild AR was more frequent after TAVR than SAVR at 30 days (28.8% versus 4.2%; P<0.001). At 1 year, mean transvalvular gradient (13.7±5.6 versus 11.6±5.0 mm Hg; P=0.12) and aortic valve area (1.72±0.37 versus 1.76±0.42 cm2; P=0.12) were similar in TAVR and SAVR. The percentage of severe prosthesis-patient mismatch at 30 days was low and similar between TAVR and SAVR (4.6 versus 6.3%; P=0.30). Valvulo-arterial impedance (Zva), which reflects total left ventricular hemodynamic burden, was lower with TAVR than SAVR at 1 year (3.7±0.8 versus 3.9±0.9 mm Hg/mL/m2; P<0.001). Tricuspid annulus plane systolic excursion decreased and the percentage of moderate or severe tricuspid regurgitation increased from baseline to 1 year in SAVR but remained unchanged in TAVR. Irrespective of treatment arm, high Zva and low tricuspid annulus plane systolic excursion, but not moderate to severe AR or severe prosthesis-patient mismatch, were associated with increased risk of the composite end point of mortality, stroke, and rehospitalization at 1 year. CONCLUSIONS: In patients with severe aortic stenosis and low surgical risk, TAVR with the SAPIEN 3 valve was associated with similar percentage of moderate or severe AR compared with SAVR but higher percentage of mild AR. Transprosthetic gradients, valve areas, percentage of severe prosthesis-patient mismatch, and left ventricular mass regression were similar in TAVR and SAVR. SAVR was associated with significant deterioration of right ventricular systolic function and greater tricuspid regurgitation, which persisted at 1 year. High Zva and low tricuspid annulus plane systolic excursion were associated with worse outcome at 1 year whereas AR and severe prosthesis-patient mismatch were not. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02675114.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Ecocardiografía , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Femenino , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Hemodinámica , Humanos , Masculino , América del Norte , Valor Predictivo de las Pruebas , Diseño de Prótesis , Falla de Prótesis , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: The combination of mitral regurgitation and tricuspid regurgitation is common in patients with multiple valvular disease and patient management can be challenging. Surgical combined mitral and tricuspid valve surgery is a treatment option for patients meeting criteria but has demonstrated inconsistent long-term benefits. RECENT FINDINGS: Transcatheter mitral and tricuspid edge-to-edge repair has demonstrated early promising results in patients with a prohibitive surgical risk, making it an interesting treatment option. The present review will discuss the physiopathology of this complex disease and contemporary data regarding treatment options for the treatment of combined mitral and tricuspid regurgitation. SUMMARY: Combined transcatheter mitral and tricuspid edge-to-edge repair is a novel treatment option for patients with multiple valvular disease. Further studies are needed to determine optimal patient selection and timing of intervention and demonstrate survival benefit and improvement in clinical outcomes. Advances in technology, with dedicated devices and enhanced imaging techniques may also improve patient outcomes.
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Insuficiencia Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Cateterismo Cardíaco , Insuficiencia Cardíaca/terapia , Humanos , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugíaAsunto(s)
Remoción de Dispositivos , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Humanos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Remoción de Dispositivos/métodos , Insuficiencia de la Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/etiología , Válvula Tricúspide/cirugía , Masculino , Femenino , Marcapaso Artificial/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , AncianoRESUMEN
PROPOSE OF REVIEW: To highlight the evidence to support the measurement of left ventricular (LV) global longitudinal strain (GLS) in the risk assessment and management of patients with valvular heart disease. RECENT FINDINGS: Subclinical myocardial dysfunction that is characterized by impaired LV GLS is often present in patients with valvular disease. The addition of GLS to the LV systolic function assessment refines disease classification and improves both prognosis and management of valvular disease. SUMMARY: The measurement of global systolic function is essential in risk assessment and management of all patients with valvular heart disease. Although LV ejection fraction remains the main parameter of systolic function, strain measurement has emerged as a promising systolic function marker. Strain describes deformation of the myocardium that occurs during the cardiac cycle in the longitudinal, circumferential, and radial planes. Of all the regional strain deformation measurements, evidence gathered over the last decade has shown that GLS improves detection of systolic dysfunction beyond LV ejection fraction and provides additional prognostic information.
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Ecocardiografía , Disfunción Ventricular Izquierda , Cardiólogos , Competencia Clínica , Humanos , Miocardio , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico por imagen , Función Ventricular IzquierdaRESUMEN
PURPOSE OF REVIEW: Worldwide experience in transcatheter tricuspid valve intervention is increasing as more options become available for the treatment of severe tricuspid regurgitation. These devices can be categorized by their primary mechanism of action, including edge-to-edge leaflet devices, space occupying devices, annuloplasty devices, complete valve replacement and caval valve implantation. This review summarizes the current technologies in use, early clinical results and factors that may affect procedural success. RECENT FINDINGS: Almost all transcatheter devices for tricuspid regurgitation are investigational with very limited evidence. The most commonly used device is the MitraClip (Abbott, Santa Clara, CA, USA) edge-to-edge leaflet device, which is often more effective when the leaflet coaptation gap is not too large (ideally under 7âmm). The Tricuspid Cardioband (Edwards Lifesciences, Irvine, CA, USA) annuloplasty device has CE mark approval with promising short-term procedural results. Guideline-based assessment of disease severity and medication optimization is crucial during heart team evaluation of eligibility for intervention. SUMMARY: Although important lessons have been learned thus far regarding patient and device selection for transcatheter tricuspid regurgitation interventions, the field remains young and further research is needed to optimize treatment in terms of who, when and with what device. Our proposed algorithm for patient selection based on current knowledge incorporates both clinical and anatomic factors.
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Algoritmos , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Selección de Paciente , Insuficiencia de la Válvula Tricúspide , Cateterismo Cardíaco , Humanos , Resultado del Tratamiento , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
BACKGROUND: In patients with severe aortic regurgitation (AR), the left ventricular ejection fraction (LVEF) and left ventricle (LV) size are crucial for determining clinical prognosis and timing of valve intervention. In clinical practice, LV internal diameters obtained at end-diastole are used to assess the degree of LV dilatation. Whether quantification of LV volumes would provide more robust information as compared to LV linear dimensions is unknown. METHODS: We retrospectively analyzed preoperative and postoperative transthoracic echocardiograms of patients who underwent aortic valve replacement (AVR) for severe AR. Indexed linear LV end-diastolic and end-systolic diameters along with indexed LV end-diastolic and end-systolic volumes were obtained as per current guidelines. Post-AVR LV reverse remodeling, defined as ≥10% reduction in measures of LV volumes (Teichholz and Simpson's methods), was determined. Positive and negative agreement was calculated between the volume- and diameter-based LV reverse remodeling. RESULTS: Sixty-two consecutive patients were included. Nine patients (17%) without LV reverse remodeling based on Teichholz were reclassified as having LV reverse remodeling based on Simpson (positive agreement 0.846 [95% CI 0.772, 0.921], negative agreement 0.200 [95% CI -0.350, 0.435]). Left ventricle (LV) reverse remodeling assessed by the Teichholz method was underestimated by a mean of 31 mL/m2 (ß = -0.65 [95% CI -1.06 to -0.24], P = .003) compared to Simpson method. CONCLUSION: Compared to the volume-based method, diameter-based LV measurement incorrectly identified LV reverse remodeling post-AVR in 17% of patients with severe AR. Left ventricle (LV) volume may be a better measure to assess LV remodeling post-AVR than LV diameter-based measurements.
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Insuficiencia de la Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/cirugía , Ecocardiografía/métodos , Implantación de Prótesis de Válvulas Cardíacas , Ventrículos Cardíacos/diagnóstico por imagen , Remodelación Ventricular/fisiología , Válvula Aórtica/fisiopatología , Femenino , Prótesis Valvulares Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Transcatheter tricuspid valve replacement (TTVR) abolishes tricuspid regurgitation (TR) and has emerged as a definitive treatment for TR. OBJECTIVES: The purpose of this multicenter, observational study was to determine the clinical characteristics and short-term outcomes of patients with TR screened for TTVR. METHODS: Patients underwent TTVR screening at 7 centers on a compassionate-use basis. The primary endpoints were NYHA functional class and TR grade at 30-day follow-up. Secondary endpoints included all-cause mortality, heart failure hospitalization, technical success, and reasons for TTVR screening failure. RESULTS: A total of 149 patients (median age 79 years [Q1-Q3: 72-84 years], 54% women) underwent TTVR screening. The TTVR screening failure rate was 74%, mainly related to large tricuspid annular diameter. Patients undergoing TTVR (n = 38) had significant functional improvements (NYHA functional class I or II from 21% to 68%; P < 0.001), with TR ≤1+ in 97% at 30-day follow-up (P < 0.001 from baseline). Technical success was achieved in 91%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 8%, heart failure hospitalization 5%, major bleeding 18%, and reintervention 9%. Patients who failed screening for TTVR and subsequently underwent "bailout" transcatheter edge-to-edge repair (n = 26) had favorable outcomes (NYHA functional class I or II from 27% to 58%; P < 0.001), with TR ≤1+ in 43% at 30-day follow-up (P < 0.001 from baseline). CONCLUSIONS: This first real-world report of TTVR screening demonstrated a high screening failure rate, mainly related to large tricuspid annular diameter. Patients undergoing TTVR had superior TR reduction and symptom alleviation compared with bailout tricuspid transcatheter edge-to-edge repair, at the cost of greater procedural complications.
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Insuficiencia Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Humanos , Femenino , Anciano , Masculino , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hemodinámica , Cateterismo Cardíaco/efectos adversos , Resultado del Tratamiento , Recuperación de la Función , Factores de Tiempo , Índice de Severidad de la Enfermedad , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugía , Sistema de RegistrosRESUMEN
BACKGROUND: The CLASP IID randomized trial (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial) demonstrated the safety and effectiveness of the PASCAL system for mitral transcatheter edge-to-edge repair (M-TEER) in patients at prohibitive surgical risk with significant symptomatic degenerative mitral regurgitation (DMR). OBJECTIVES: This study describes the echocardiographic methods and outcomes from the CLASP IID trial and analyzes baseline variables associated with residual mitral regurgitation (MR) ≤1+. METHODS: An independent echocardiographic core laboratory assessed echocardiographic parameters based on American Society of Echocardiography guidelines focusing on MR mechanism, severity, and feasibility of M-TEER. Factors associated with residual MR ≤1+ were identified using logistic regression. RESULTS: In 180 randomized patients, baseline echocardiographic parameters were well matched between the PASCAL (n = 117) and MitraClip (n = 63) groups, with flail leaflets present in 79.2% of patients. Baseline MR was 4+ in 76.4% and 3+ in 23.6% of patients. All patients achieved MR ≤2+ at discharge. The proportion of patients with MR ≤1+ was similar in both groups at discharge but diverged at 6 months, favoring PASCAL (83.7% vs 71.2%). Overall, patients with a smaller flail gap were significantly more likely to achieve MR ≤1+ at discharge (adjusted OR: 0.70; 95% CI: 0.50-0.99). Patients treated with PASCAL and those with a smaller flail gap were significantly more likely to sustain MR ≤1+ to 6 months (adjusted OR: 2.72 and 0.76; 95% CI: 1.08-6.89 and 0.60-0.98, respectively). CONCLUSIONS: The study used DMR-specific echocardiographic methodology for M-TEER reflecting current guidelines and advances in 3-dimensional echocardiography. Treatment with PASCAL and a smaller flail gap were significant factors in sustaining MR ≤1+ to 6 months. Results demonstrate that MR ≤1+ is an achievable benchmark for successful M-TEER. (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID]; NCT03706833).
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Cateterismo Cardíaco , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Válvula Mitral , Valor Predictivo de las Pruebas , Recuperación de la Función , Índice de Severidad de la Enfermedad , Humanos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/fisiopatología , Masculino , Femenino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Resultado del Tratamiento , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/efectos adversos , Anciano , Factores de Riesgo , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Factores de Tiempo , Anciano de 80 o más Años , Prótesis Valvulares Cardíacas , Estudios de Factibilidad , Medición de Riesgo , Diseño de Prótesis , Ecocardiografía TridimensionalRESUMEN
OBJECTIVES: In the Canadian Mitral Research Alliance (CAMRA) Trial CardioLink-2 leaflet resection versus preservation techniques for posterior leaflet prolapse was investigated and no difference was shown in their effect on mean mitral gradient at peak exercise at 12 months postoperatively. The purpose of this subanalysis was to evaluate the effect of the 2 strategies on left ventricular (LV) reverse remodeling after repair. METHODS: A total of 104 patients were randomized to either a leaflet resection or leaflet preservation strategy. Echocardiograms, performed at baseline (preoperative), predischarge, and 12 months postoperatively, were analyzed in a blinded fashion at a core laboratory. RESULTS: All patients underwent successful mitral repair. At discharge, 3 patients showed moderate mitral regurgitation, whereas the remainder showed mild or less regurgitation. Compared with the baseline echocardiogram, the indexed end diastolic volume was reduced at the discharge echocardiogram (P < .0001) and was further reduced at the 12-month echocardiogram (P = .01). In contrast, the indexed end systolic volume did not significantly change from baseline assessed at the predischarge echocardiogram (P = .32) but improved at 12 months postoperatively (P < .0001), resulting in a corresponding improvement in ejection fraction at 12 months (P < .0001). The type of mitral repair strategy had no significant effect on LV reverse remodeling trends. CONCLUSIONS: The mitral repair strategies used did not influence postoperative LV reverse remodeling, which occurred in stages. Although LV end diastolic dimensions recovered before discharge, improvements in LV end systolic dimension were evident 12 months after repair.
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Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Humanos , Canadá , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Ecocardiografía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Remodelación VentricularRESUMEN
Acute afterload mismatch and left ventricular dysfunction after mitral valve repair are well established. The impact of transcatheter tricuspid valve repair (TTVr) on right ventricular (RV) function is less clearly defined. To our knowledge, there are no reports of acute RV dysfunction after TTVr. Here we report a case of acute afterload mismatch after successful TTVr. (Level of Difficulty: Advanced.).
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The prevalence of severe tricuspid regurgitation in older patients is high, and the clinical relevance is perceived more and more in recent years. Many of these patients are not suitable for surgery because of their age and comorbidities. Therefore, a variety of percutaneous interventions have been developed to address this unmet need. Procedural success strongly depends on adequate imaging during the intervention. Although transesophageal echocardiography is the standard of care, imaging may be limited due to anatomic factors and adverse acoustic shadowing. In this review, we discuss the current and future role of intracardiac echocardiography in tricuspid valve interventions.
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Insuficiencia de la Válvula Tricúspide , Anciano , Ecocardiografía Transesofágica , Humanos , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
Aortic regurgitation (AR) is not the most common valvular disease; however, its prevalence increases with age, with more than 2% of those aged >70 years having at least moderate AR. Once symptoms related to AR develop, the prognosis becomes poor. Transcatheter aortic valve implantation for patients with pure severe AR and at prohibitive surgical risk is occasionally performed, but remains a clinical challenge due to absence of valvular calcium, large aortic root and increased stroke volume. These issues make the positioning and deployment of transcatheter aortic valve implantation devices unpredictable, with a tendency to prosthesis embolisation or malposition. To date, the only two dedicated transcatheter valves for AR are the J-Valve (JC Medical) and the JenaValve (JenaValve Technology). Both devices have been used successfully via the transapical approach. The transfemoral experience is limited to first-in-human publications and to a clinical trial dedicated to AR, for which the completion date is still pending.
RESUMEN
OBJECTIVES: The aim of this study was to report the midterm outcomes at 1 year in the expanded first-in-human experience with the transfemoral EVOQUE system (Edwards Lifesciences) for tricuspid regurgitation (TR). BACKGROUND: Untreated TR is associated with excess mortality and morbidity. The first-in-human experience with the EVOQUE tricuspid valve replacement system reported favorable 30-day outcomes with no mortality in a compassionate use population. METHODS: Twenty-seven patients with severe TR were treated with the EVOQUE system in a compassionate use experience at 7 centers between May 2019 and July 2020. All patients had clinical right-sided heart failure (HF) and were deemed inoperable and unsuitable for transcatheter edge-to-edge repair by the institutional heart teams. The clinical outcomes collected included all-cause mortality, symptom status, TR severity, HF hospitalization, and major adverse cardiovascular events. RESULTS: At baseline, all patients (age: 77 ± 8 years, 89% female) were at high surgical risk (mean Society of Thoracic Surgeons score: 8.6% ± 5.5%), with 89% New York Heart Association functional class III/IV. TR was predominantly functional in etiology (19/27, 70%). At 1 year, mortality was 7% (2/27), 70% of patients were New York Heart Association functional class I/II, and 96% and 87% of patients had a TR grade ≤2+ and ≤1+, respectively. Between 30 days and 1 year, 2 patients experienced HF hospitalizations, and 1 patient required a new pacemaker implantation. CONCLUSIONS: In this early, compassionate use experience, the transfemoral transcatheter EVOQUE tricuspid valve replacement system demonstrated durable efficacy, persistent improvement in symptom status, and low rates of mortality and HF hospitalizations at a 1-year follow-up. Further studies are underway to validate its efficacy.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Recuperación de la Función , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
Concomitant tricuspid regurgitation (TR) is common in patients with mitral regurgitation (MR). While current guidelines recommend repair of both valves at the time of surgery when feasible, high risk patients are often undertreated, leading to significant morbidity and mortality. With advances in transcatheter edge-to-edge repair (TEER) devices and technique, combined TEER for treating significant MR and TR has emerged as a new tool for heart failure management. Recent evidence has shed light on which patients with severe TR should be targeted for transcatheter intervention either in isolation or in combination with a MV TEER procedure and allows for expanded treatment options in patients who otherwise would be limited to medical management. Technological advancements remain ahead of robust clinical data, and thus randomized clinical studies in patients with severe MR and TR will be instrumental in determining the best approach in treating these patients with transcatheter therapies.
RESUMEN
BACKGROUND: Transcatheter tricuspid leaflet repair (TTVr) using the MitraClip is a promising option for patients with severe tricuspid regurgitation (TR) and heart failure. However, no comparative studies of the NTR and XTR systems have been reported. OBJECTIVES: The aim of this study was to assess the relative efficacy, safety, and clinical outcomes of patients with severe TR treated with the MitraClip NTR and XTR systems. METHODS: Forty consecutive patients with severe TR underwent TTVr. The primary outcome was procedural success, with NYHA functional class, TR grade and major adverse cardiac and cerebrovascular events (MACCE) assessed at 30-day follow-up. RESULTS: The majority of patients had functional TR and a greater proportion of XTR patients had torrential TR with larger coaptation gaps. Procedural success was achieved in 70% vs 80% in the NTR and XTR cohorts. Single leaflet device attachment was equal in both groups (5%). At 30-day follow-up, 70% vs 85% of NTR and XTR patients were in NYHA Class I/II. The mean reduction in TR grade was greater in the XTR group (1.5 ± 0.3 vs 2.3 ± 0.4, p-0.012). In patients with torrential TR at baseline, 55% in the XTR group achieved TR ≤ 2+ compared to none in the NTR group (p < 0.001). CONCLUSIONS: In this first study comparing the MitraClip NTR and XTR systems for TTVr, we found both to be safe and effective, while the XTR system allowed treatment of larger coaptation gaps, greater mean reduction in TR grade, with more effective reduction of torrential TR.