Cardiac Structural and Functional Remodeling After Transcatheter Mitral Valve in Valve Implantation: Early Changes and Prognostic Significance.

Background: Transcatheter mitral valve-in-valve (MViV) replacement has emerged as an alternative to redo mitral valve (MV) surgery for the management of failed bioprosthetic MVs. The degree of cardiac remodeling assessed by echocardiography has been shown to have prognostic implications in degenerative mitral regurgitation patients undergoing MV surgery. The impact of transcatheter MViV in patients with degenerative bioprosthetic MV failure on cardiac remodeling and its associated prognosis remains undescribed. Objectives: The aim of this study is to describe the early anatomic and functional changes of the left-sided chambers and right ventricle by echocardiography posttranscatheter MViV intervention and their impact on mortality outcomes. Additionally, we sought to analyze the outcome of heart failure in bioprosthetic MV failure patients undergoing transcatheter MViV replacement. Methods: We analyzed consecutive patients undergoing MViV intervention for symptomatic bioprosthetic MV failure. Echocardiograms before intervention and within 100 days postintervention were analyzed. A chart review was performed to obtain baseline characteristics, follow-up visits, 30-day heart failure and 1-year all-cause mortality outcomes. Results: A total of 62 patients (mean age 69 ± 13 years, 61% male) were included in the study. Most patients were undergoing MViV intervention for prosthetic mitral stenosis n = 48 (77.4%) and the rest for mitral regurgitation or mixed disease. Compared with baseline, significant reductions were observed in median left atrial volume (LAV; 103 [81-129] ml vs. 95.2 [74.5-117.5] ml, p < 0.01) and mean (SD) left atrial conduit strain (9.1% ± 5.2% vs. 10.8% ± 4.8%, p = 0.039) within 100 days postintervention. Early reduction in right ventricular free wall global longitudinal strain and fractional area change also occurred postintervention. No significant change in left ventricular chamber dimensions or ejection fraction was observed. During the 1-year follow up period, 5 (8%) patients died. While baseline LAV was not associated with 1-year all-cause mortality (OR 0.98 CI 0.95-1.01; p = 0.27), a change in LAV in the follow up period was associated with all-cause mortality at 1 year (OR 1.06 CI 1.01-1.12; p = 0.023). At 30 days postintervention, 65% of patients had an improvement in their New York Heart Association functional class. Conclusion: In this retrospective study of patients undergoing transcatheter MViV intervention for failed bioprosthetic MVs, early reverse remodeling of the left atrium occurs within 100 days postintervention and reduction in LAV is associated with reduced all-cause mortality at 1 year. In addition, there is significant improvement in heart failure symptoms at 30 days following intervention but further investigation into the longitudinal remodeling changes and long-term outcomes is needed.

Primary Mitral Regurgitation and Heart Failure: Current Advances in Diagnosis and Management.

Primary mitral regurgitation is a frequent etiology of congestive heart failure and is best treated with intervention when patients are symptomatic or when additional risk factors exist. Surgical intervention improves outcomes in appropriately selected patients. However, for those at high surgical risk, transcatheter intervention provides less invasive repair and replacement options while providing comparable outcomes to surgery. The excess mortality and high prevalence of heart failure in untreated mitral regurgitation illuminate the need for further developments in mitral valve intervention ideally fulfilled by expanding these types of procedures and eligibility to these procedures beyond only those at high surgical risk.

Recovery of Left Ventricular Systolic Function and Clinical Outcomes in Young Adults With Myocardial Infarction.

BACKGROUND: Left ventricular ejection fraction (EF) recovery is associated with better long-term outcomes after myocardial infarction (MI). However, the association between long-term outcomes and EF recovery among young MI patients has not been investigated. OBJECTIVES: This study sought to evaluate the prevalence of left ventricular systolic dysfunction among patients who experience their first MI at a young age and to compare outcomes between those who recovered their EF versus those who did not. METHODS: The YOUNG-MI registry is a retrospective cohort study of patients who experienced an MI at ≤50 years of age. EF at the time of MI and within 180 days post-MI were determined from all available medical records. The primary outcomes were all-cause and cardiovascular mortality. RESULTS: There were 1,724 patients with baseline EF data: 503 (29%) had EF <50%, whereas 1,221 (71%) had a normal baseline EF. Patients with lower EF were more likely to have experienced ST-segment elevation MI, have higher troponin values, and have more severe angiographic coronary artery disease. Among patients with abnormal baseline EF, information on follow-up EF was available for 216, of whom 90 (42%) recovered their EF to ≥50%. Patients who experienced EF recovery had less severe angiographic disease, lower alcohol use, and a lower burden of comorbidities. Over a median follow-up of 11.1 years, EF recovery was associated with an ∼8-fold reduction in all-cause mortality (adjusted hazard ratio: 0.12; p = 0.001) and a ∼10-fold reduction in cardiovascular mortality (adjusted hazard ratio: 0.10; p = 0.025). CONCLUSIONS: Nearly one-third of young patients presented with left ventricular dysfunction post-MI. Among them, EF recovery occurred in more than 40% and was independently associated with a substantial decrease in all-cause and cardiovascular mortality.

Understanding and Managing Atrial Fibrillation in Patients with Kidney Disease.

Chronic kidney disease (CKD) is on the rise due to the increased rate of related comorbidities such as diabetes and hypertension. Patients with CKD are at higher risk of cardiovascular events and atrial fibrillation is more common in this patient population. It is estimated that the prevalence of chronic atrial fibrillation in patients with CKD is two to three times higher than general population. Furthermore, patients with CKD are less likely to stay in sinus rhythm. Atrial fibrillation presents a major burden in this population due to difficult treatment decisions in the setting of a lack of evidence from randomized clinical trials. Patients with CKD have higher risk of stroke with more than half having a CHADS2 score ≥ 2. Anticoagulation have been shown to significantly decrease embolic stroke risk, however bleeding complications such as hemorrhagic stroke is twofold higher with warfarin. Although newer novel anticoagulation drugs have shown promise with lower intracranial hemorrhage risk in comparison to warfarin, lack clinical trial data in CKD and the unavailability of an antidote remains an issue. In this review, we discuss the treatment options available including anticoagulation and the evidence behind them in patients with chronic kidney disease suffering from atrial fibrillation.