Concept of the central clip: when to use one or two MitraClips®.

AIMS: Percutaneous edge-to-edge mitral valve repair with the MitraClip(®) was shown to be a safe and feasible alternative compared to conventional surgical mitral valve repair. We analyse the concept of the central clip and the predictors for the need of more than one MitraClip(®) in our high-risk surgical population with severe mitral regurgitation (MR). METHODS AND RESULTS: Patients with severe MR (3 or 4+) and high operative risk (as defined by logistic EuroSCORE) refused for conventional mitral valve repair were considered for MitraClip(®). The procedure was performed under general anaesthesia with transoesophageal echocardiographic (TOE) guidance. Device success was defined as placement of one or more MitraClips(®) with a reduction of MR to ≤2+. Patients were followed up clinically and with TOE at one month and one year. From September 2009 to March 2012, 43 patients with severe MR with a mean age of 74.8±10.7 years (30 males, 13 females; mean logistic EuroSCORE 24.1±11, mean LVEF 47.5±18.5%; mean±SD) were treated. Median follow-up was 385 days (104-630; Q1-Q3). Device implantation success was 93%. All patients were treated following the central clip concept: 52.5% of MR was degenerative in aetiology and 47.5% was functional. The degree of MR was reduced from 3.6±0.4 to 1.4±0.6 (p<0.001); NYHA Class improved from 3.1±0.4 to 1.8±0.7 (p<0.001). Nineteen patients (47.5%) received two or more clips. Vena contracta (p<0.001) and the presence of two broad jets (p<0.001) were correlated with the need for a second clip. The presence of a restricted posterior mitral valve leaflet (PML) was inversely correlated with the need for more than one clip (p=0.02). A cut-off value of ≥7.5 mm for vena contracta predicted the need for a second clip (sensitivity 83%, specificity 90%, p=0.01). CONCLUSIONS: The central MitraClip(®) concept achieved a significant reduction in the degree of mitral regurgitation in the majority of patients treated. The presence of a broad jet (quantified by a vena contracta greater than 7.5 mm) significantly predicted the need for more than one clip.

Increase in J-CTO lesion complexity score explains the disparity between recanalisation success and evolution of chronic total occlusion strategies: insights from a single-centre 10-year experience.

OBJECTIVE: To investigate whether treatment of lesions of greater complexity is now undertaken and to assess the rates of procedural success per class of lesion complexity. DESIGN: Observational study. SETTING: Despite impressive progress in treatment strategies and equipment, the success rate of percutaneous coronary intervention for chronic total occlusion (CTO) has remained relatively stable. PARTICIPANTS: 483 patients consecutively treated with CTO from 2003 to 2012. MAIN OUTCOME MEASURES: The Multicenter CTO Registry of Japan (J-CTO) score was used to classify lesion complexity. The study population was subdivided into an early (period 1, n=288) and a late (period 2, n=195) period according to the routine implementation of novel techniques and advanced equipment. RESULTS: Period 2 was marked by more 'difficult' and 'very difficult' lesions (J-CTO grades 2 and 3) being attempted, with procedural success increasing from 68.4% to 88.1% (p<0.001) and from 42.0% to 78.9% (p<0.001), respectively. 'Easy' and 'intermediate' lesions (J-CTO grades 0 and 1) were less common, but with similarly high success rates (89.1% vs 96.6% (p=0.45) for easy, and 86.3% vs 86.1% (p=0.99) for intermediate). Period 2 was characterised by a trend for more successful procedures overall (by 6.1%, p=0.09). Procedural complications were similarly low in both periods. J-CTO score and technical era were identified as independent correlates of success in the total population by logistic regression analysis. CONCLUSIONS: Advanced CTO techniques and equipment have resulted in an increase in the successful treatment of highly complex lesions. Total success rate did not substantially improve, as it was counterbalanced by the increased rate at which complex lesions were attempted.

Optical coherence tomography for guidance of distal cell recrossing in bifurcation stenting: choosing the right cell matters.

AIMS: The aim of this study was to assess the ability of optical coherence tomography (OCT) to guide recrossing during percutaneous coronary interventions in bifurcations and to reduce strut malapposition. METHODS AND RESULTS: Fifty-two patients undergoing elective treatment of bifurcation lesions using provisional stenting as default strategy were included in the study. Patients were divided into two groups: OCT-guided stent recrossing (group 1, n=12), and angiography-guided recrossing (group 2, n=40). Malapposition in the various bifurcation segments was compared in the two groups, using propensity score analysis to correct for confounders. In 4/12 patients (33%) of the OCT-guided group after the first attempt to recross the stent towards the SB the wire was found to have crossed in a proximal cell, requiring a second and in one case a third attempt to successfully cross through a distal cell. Patients who were treated using OCT-guided recrossing had a significantly lower number of malapposed stent struts, especially in the quadrants towards the SB ostium (9.5%[7.5-17.4%] vs 42.3%[31.2-54.7%] in the angiography-guided group, p<0.0001). CONCLUSIONS: The rate of strut malapposition was significantly reduced when OCT was used to confirm that wire recrossing was performed in a distal cell of the SB ostium.

Ambulatory blood pressure monitoring in resistant hypertension.

ABPM constitutes a valuable tool in the diagnosis of RH. The identification of white coat RH and masked hypertension (which may fulfill or not the definition of RH) is of great importance in the clinical management of such patients. Moreover, the various ABPM components such as average BP values, circadian BP variability patterns, and ambulatory BP-derived indices, such as ambulatory arterial stiffness index (AASI), add significantly to the risk stratification of RH. Lastly, ABPM may indicate the need for implementation of specific therapeutic strategies, such as chronotherapy, that is, administration-time dependent therapy, and the evaluation of their efficacy.

Association of nighttime hypertension with central arterial stiffness and urinary albumin excretion in dipper hypertensive subjects.

Both blood pressure (BP) non-dipping and nighttime hypertension have been associated with accelerated target-organ damage (TOD). However, increased nighttime BP in subjects with a dipping circadian BP profile has never been reported or associated with TOD. Here, we investigated the relationships of nighttime BP with indices of vascular and kidney damage in dipper hypertensive subjects. We studied 402 subjects with untreated stage I-II essential hypertension. According to ambulatory BP recordings, 127 dipper subjects were selected and subdivided into nighttime hypertensives (NH, n = 69) (nighttime BP ≥ 120/70) and nighttime normotensives (NN, n = 50) (nighttime BP <120/70 mm Hg). All participants underwent echocardiographic examination and assessments of carotid-to-femoral pulse wave velocity (c-f PWV), albumin-to-creatinine ratio (ACR), metabolic profile and high sensitivity C-reactive protein (hs-CRP) level. Compared with NN dippers, NH dippers had higher c-f PWV (P < 0.001), ACR values (P = 0.01) and hs-CRP levels (P < 0.001). Multiple regression analysis showed that nighttime BP was more correlated with c-f PWV and ACR than was daytime BP. Among dippers, nighttime BP is associated more closely with c-f PWV and ACR than is daytime BP. These findings imply that even in dippers, absolute nighttime BP values should be taken into account when predicting surrogate end points such as arterial stiffness and urinary albumin excretion.