Bioprosthetic mitral valve paravalvular leak closure using intracardiac echocardiography-guided three dimensional electroanatomic mapping.

The development of paravalvular leak (PVL) following surgical replacement of an aortic or mitral valve is an uncommon complication with significant morbidity and mortality. Surgical or percutaneous repair of PVL can be technically challenging. We describe the application of intracardiac echocardiography guided 3-dimensional electroanatomic mapping to facilitate PVL closure in a symptomatic patient with a previously placed bioprosthetic mitral valve. © 2017 Wiley Periodicals, Inc.

Transcatheter mitral valve repair with the MitraClip(®) can be performed without general anesthesia and without conscious sedation.

BACKGROUND: General anesthesia is known to be associated with an increased risk for complications, especially in elderly and multi-morbid patients, the primary target population of the MitraClip(®) technique. The aim is to assess whether general anesthesia and even conscious sedation can be avoided during the MitraClip(®) procedure. METHODS: A total of 91 consecutive patients who underwent MitraClip(®) implantation [median 77 years, (IQR 72-83), 40 % female] were retrospectively analyzed. The first 26 patients were treated in general anesthesia. Afterwards, local anesthesia was chosen as primary anesthetic approach. Altogether, 28 (31 %) patients received general anesthesia, local anesthesia was performed in 35 (38 %) patients with sedation and in 28 (31 %) patients without sedation. RESULTS: The respective patient groups were similar regarding their baseline characteristics. Procedural success (successful implantation of at least one clip and post-procedure MR grade ≤2) was achieved in 89 % with no difference between the groups (93 % in general anesthesia, 89 % in local anesthesia with sedation, 86 % in local anesthesia without sedation, p = ns). No difference regarding hospital complications was noted. Local anesthesia with and without sedation was associated with less necessity for ICU/IMC stay (100 % in general anesthesia, 14 % in local anesthesia with sedation, 14 % in local anesthesia without sedation; p < 0.0001). One-year estimated survival was not significantly different among the groups (63, 82 and 75 %; p = ns). CONCLUSIONS: Transcatheter mitral valve repair with the MitraClip(®) can be performed without general anesthesia and even without conscious sedation with similar procedural success and complication rates.

Treatment of secondary mitral valve regurgitation: why we need combined and evolving percutaneous strategies to tackle this moving target.

Secondary mitral regurgitation (MR) has a complex pathophysiology that includes global or segmental left ventricular (LV) motion abnormalities (of non-ischaemic or ischaemic origin) leading to impaired leaflet coaptation of a normally structured mitral valve (MV). In this context, the LV functional and geometrical changes result in MV leaflet tethering, MV annulus flattening and the decrement of systolic MV closing forces. In light of its complexity, management of secondary MR remains a challenge. In fact, a long-lasting successful treatment using a single medical device and/or intervention that addresses solely the MV target cannot, at least at the present time, be proposed.

A systematic review and meta-analysis of surgical outcomes following mitral valve surgery in octogenarians: implications for transcatheter mitral valve interventions.

AIMS: To evaluate the outcomes of mitral valve surgery in octogenarians with severe symptomatic mitral regurgitation (MR). METHODS AND RESULTS: We performed a systematic review and meta-analysis of data on octogenarians who underwent mitral valve replacement (MVR) or mitral valve repair (MVRpr). Our search yielded 16 retrospective studies. Using Bayesian hierarchical models, we estimated the pooled proportion of 30-day mortality, postoperative stroke, and long-term survival. The pooled proportion of 30-day postoperative mortality was 13% following MVR (10 studies, 3,105 patients, 95% credible interval [CI] 9-18%), and 7% following MVRpr (six studies, 2,642 patients, 95% CI: 3-12%). Furthermore, pooled proportions of postoperative stroke were 4% (six studies, 2,945 patients, 95% CI: 3-7%) and 3% (three studies, 348 patients, 95% CI: 1-8%) for patients undergoing MVR and MVRpr, respectively. Pooled survival rates at one and five years following MVR (four studies, 250 patients) were 67% (95% CI: 50-80%) and 29% (95% CI: 16-47%), and following MVRpr (three studies, 333 patients) were 69% (95% CI: 50-83%) and 23% (95% CI: 12-39%), respectively. CONCLUSIONS: Surgical treatment of MR in octogenarians is associated with high perioperative mortality and poor long-term survival with an uncertain benefit on quality of life. These data highlight the importance of patient selection for operative intervention and suggest that future transcatheter mitral valve therapies such as transcatheter mitral valve repair (TMVr) and/or transcatheter mitral valve implantation (TMVI), may provide an alternative therapeutic approach in selected high-risk elderly patients.

Feasibility of percutaneous transcatheter mitral valve repair with the MitraClip system using conscious sedation.

We report the first human case of percutaneous transcatheter mitral valve repair with the MitraClip system under conscious sedation in a patient with severe mitral regurgitation. The procedure was performed using the standard MitraClip technique, in the catheterization laboratory, with transesophageal echocardiographic and fluoroscopic guidance. Transesophageal echocardiography is the primary imaging modality of the MitraClip procedure, which usually necessitates general anesthesia to guarantee complete immobilization of the patient allowing precise delivery of the MitraClip device. We successfully performed the procedure under deep sedation, using remifentanil and local anesthesia in a patient who had serious contraindications to general anesthesia. The success of this procedure suggests that percutaneous transcatheter mitral repair with the MitraClip system can be safely realized using conscious sedation. Conscious sedation may represent a convenient alternative approach for selected patients who undergo this innovative procedure.

Comparison of the correlation of rebreathing method and echocardiography in heart failure patients with moderate to severe mitral regurgitation.

OBJECTIVE: To follow-up and estimate cardiac function in 11 heart failure patients with moderate to severe mitral regurgitation who underwent cardiac resynchronization therapy (CRT) and to compare echocardiography to the rebreathing method (indirect Fick method) which were used for estimation. DESIGN: Prospective, observational, clinical study. SETTING: University teaching hospital. METHODS: Eleven cases (8 males and 3 females) were selected and followed-up during presurgery, postsurgery, and 1, 3, and 6 months after pacemaker implantation. Stroke volume was measured by echocardiography (Simpson's method and velocity-time integral method) and rebreathing each time. RESULTS: Correlations were found between stroke volume with the rebreathing method (RSV) and stroke volume with the velocity-time integral (VSV), R = 0.89, although ANOVA, the q test, and paired t test showed no statistical differences between them. Stroke volume with Simpson's rule (SSV) was poorly correlated with stroke volume using the Indirect Fick method (RSV) and with stroke volume using the velocity-time integral method (VSV) (R = 0.58 and 0.54, respectively). CONCLUSION: The rebreathing method (indirect FICK method) and velocity-time integral method are noninvasive methods with which to measure cardiac function and exhibited good correlation during the follow-up study.

Selective atrionodal input ablation for induction of proximal complete heart block with stable junctional escape rhythm in patients with uncontrolled atrial fibrillation.

BACKGROUND: The study tests the hypothesis that ablating all inputs to the atrioventricular (AV) node can result in complete heart block with stable junctional escape rhythm. METHODS AND RESULTS: We attempted atrionodal input ablation in 76 consecutive patients with uncontrolled atrial fibrillation. Fast and slow pathways were first ablated. If there was no AV block, additional energy applications were done between fast and slow pathway locations. The patients were followed for 42 +/- 11 months. Group I (n = 57) comprised patients with complete heart block and junctional escape rhythm (53 +/- 4 beats/min) at the end of the procedure. The escape rhythm remained stable throughout follow-up. Group II (n = 15) were patients who failed the stepwise atrionodal input ablation and required AV junctional ablation guided by His bundle potential to achieve complete heart block. Four patients showed a slow escape rhythm after ablation (33 +/- 4 beats/min). Others had no escape rhythm. All 15 pts remained pacemaker dependent. The total death rate of groups I and II was 18/57 (31.6%) vs 10/15 (66.7%), respectively (p < 0.02). These differences could not be explained by a difference of left ventricular ejection fraction (0.42 +/- 0.07 vs 0.41 +/- 0.04, respectively, p = NS). CONCLUSIONS: (1) In most patients, ablation of both fast and slow pathways did not result in complete heart block, indicating the presence of multiple atrionodal inputs. (2) Ablation of all atrionodal inputs may result in complete heart block with stable junctional escape rhythm. (3) As compared with AV junctional ablation, atrionodal input ablation was associated with a lower mortality rate on long-term follow up.

Traditional Chinese medical treatment of heart disease.

Western conventional approaches have limited value in the treatment of cardiac diseases because they do not address the true causes of the problems and focus only on treating the heart and lungs. Little attention is paid to the organ systems involved (KI, SP, LIV) and the significance of symptoms seemingly unrelated to cardiopulmonary pathology. Acupuncture used in conjunction with conventional medications (diuretics, beta-blockers, peripheral dilators, etc.) can greatly enhance results. The use of Chinese herbal formulas can reduce the dosage of drugs, which exhaust Qi, and can produce greater longevity because they nourish the Yin organs.

[Atrial synchronous ventricular stimulation with reduced a.v. delay time as a therapeutic principle in hypertrophic obstructive cardiomyopathy]. / Vorhofsynchrone Ventrikelstimulation mit verkürzter a.v. Verzögerungszeit als Therapieprinzip der hypertrophischen obstruktiven Kardiomyopathie.

For the hypertrophic obstructive cardiomyopathy with left-ventricular pressure gradient in rest a causal therapy is nowadays not yet known. Therefore, it should be tested, in what respect from former observations over reductions of the pressure gradient by an untimely foreign excitation of the ventricles from the apex of the right ventricle a therapy principle can be derived. For this purpose out of a group of 84 patients by left-right heart catheterization, coronarography, computer cardio-tomography and scintigraphy of the myocardium 23 test persons with typical hypertrophic obstructive cardiomyopathy and a left-ventricular gradient in rest greater than or equal to 30 mm Hg were selected for the transitory electrostimulation. After placing of one electrode in the right atrium and another one in the right ventricle one after another a VOO-, VAT- and DOO-pacing were used. For the two last mentioned forms of stimulation as electronic atrio-ventricular retardation times 100, 40, 20, 10 and 5 ms were selected. With all three kinds of stimulation in 5 of the patients (group A) reductions of gradients greater than or equal to 51% and in 12 cases of hypertrophic obstructive cardiomyopathy (group B) diminishments between 30 and 50% could be obtained. Only in 6 patients (group C) reductions of less than or equal to 29% were registered. The optimum of prematurity necessary for obtaining maximum pressure reductions is individually different, but is almost in every case between 5 and 20 ms. Further seven parameters measured during the stimulation phases showed that these reductions are not caused by a decrease of the stroke volume, but by an enlargement of the effective opening of the outlet. Apparently, in a part of the patients with hypertrophic obstructive cardiomyopathy by the foreign excitation from the apex of the ventricle a temporary and spatial course of excitation can be induced, by means of which the degree of functional stenosing is decreased. Since for several patients the removal of the disturbance of the systolic function is to be regarded as therapeutically reasonable partial success, the transitory diagnostic pacing is recommended for all patients with typical hypertrophic obstructive cardiomyopathy and a gradient in rest greater than or equal to 30 mm Hg. The indications and technical prerequisites for a permanent electrostimulation with suitable systems are represented.

[Effect of hyperbaric oxygenation on the circulatory function in rheumatic mitral valve disease]. / Vliianie giperbaricheskoi oksigenatsii na funktsiiu krovoobrashcheniia u bol'nykh revmaticheskim mitral'nym porokom.

The effect of a hyperbaric oxygenation course (10-14 exposures, one exposure daily at 0.7-1.0 ATA) upon the circulation function was studied in 61 patients with rheumatic mitral valve disease combined with systemic circulation insufficiency. The obtained results (reduction of the heart volume, acceleration of the blood stream within the heart and the body, increase of the stroke index, of the blood flow in the muscles of the extremities, reduction of the arterial and central venous pressure) demonstrate that the contractility of the myocardium and redistribution of the cardiac output between separate vascular regions is improved under the effect of hyperbaric oxygenation. The authors suggest that the increase of contractility in the right or left heart predominantly depends on the prevalence of mitral stenosis or circulatory insufficiency.