Acute Reduction in Left Ventricular Function Following Transcatheter Mitral Edge-to-Edge Repair.

Background Little is known about the impact of transcatheter mitral valve edge-to-edge repair on changes in left ventricular ejection fraction (LVEF) and the effect of an acute reduction in LVEF on prognosis. We aimed to assess changes in LVEF after transcatheter mitral valve edge-to-edge repair for both primary and secondary mitral regurgitation (PMR and SMR, respectively), identify rates and predictors of LVEF reduction, and estimate its impact on prognosis. Methods and Results In this international multicenter registry, patients with both PMR and SMR undergoing transcatheter mitral valve edge-to-edge repair were included. We assessed rates of acute LVEF reduction (LVEFR), defined as an acute relative decrease of >15% in LVEF, its impact on all-cause mortality, major adverse cardiac event (composite end point of all-cause death, mitral valve surgery, and residual mitral regurgitation grade ≥2), and LVEF at 12 months, as well as predictors for LVEFR. Of 2534 patients included (727 with PMR, and 1807 with SMR), 469 (18.5%) developed LVEFR. Patients with PMR were older (79.0±9.2 versus 71.8±8.9 years; P<0.001) and had higher mean LVEF (54.8±14.0% versus 32.7±10.4%; P<0.001) at baseline. After 6 to 12 months (median, 9.9 months; interquartile range, 7.8-11.9 months), LVEF was significantly lower in patients with PMR (53.0% versus 56.0%; P<0.001) but not in patients with SMR. The 1-year mortality was higher in patients with PMR with LVEFR (16.9% versus 9.7%; P<0.001) but not in those with SMR (P=0.236). LVEF at baseline (odds ratio, 1.03 [95% CI, 1.01-1.05]; P=0.002) was predictive of LVEFR for patients with PMR, but not those with SMR (P=0.092). Conclusions Reduction in LVEF is not uncommon after transcatheter mitral valve edge-to-edge repair and is correlated with worsened prognosis in patients with PMR but not patients with SMR. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05311163.

Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach.

Refractory congestion is common in acute and chronic heart failure, and it significantly impacts functional class, renal function, hospital admissions, and survival. In this paper, the pathophysiological mechanisms involved in cardiorenal syndrome and the interplay between heart failure and chronic kidney disease are reviewed. Although the physical exam remains key in identifying congestion, new tools such as biomarkers or lung, vascular, and renal ultrasound are currently being used to detect subclinical forms and can potentially impact its management. Thus, an integrated multimodal diagnostic algorithm is proposed. There are several strategies for treating congestion, although data on their efficacy are scarce and have not been validated. Herein, we review the optimal use and monitorization of different diuretic types, administration route, dose titration using urinary volume and natriuresis, and a sequential diuretic scheme to achieve a multitargeted nephron blockade, common adverse events, and how to manage them. In addition, we discuss alternative strategies such as subcutaneous furosemide, hypertonic saline, and albumin infusions and the available evidence of their role in congestion management. We also discuss the use of extracorporeal therapies, such as ultrafiltration, peritoneal dialysis, or conventional hemodialysis, in patients with normal or impaired renal function. This review results from a multidisciplinary view involving both nephrologists and cardiologists.

Management of long-term cardiovascular risk factors post organ transplant.

PURPOSE OF REVIEW: Cardiovascular disease is one of the leading causes of death in solid organ transplant (SOT) recipients. Early identification of cardiovascular risk factors and their adequate management in this population is key for prevention and improved outcomes. RECENT FINDINGS: Approximately 80% of SOT present one or more cardiovascular risk factors, with increasing prevalence with time posttransplantation. They are due to the interplay of pretransplant conditions and metabolic consequences of immunosuppressive agents, mainly corticosteroids and calcineurin inhibitors. Among the pharmacological management strategies, statins have shown an important protective effect in SOT. SUMMARY: Strict surveillance of cardiovascular risk factors is recommended in SOT due to their high prevalence and prognostic implications. Further studies on the best managements strategies in this population are needed.

Initial Results after the Implementation of an Edge-To-Edge Transcatheter Tricuspid Valve Repair Program.

Transcatheter tricuspid valve repair (TTVr) has emerged as an alternative for the treatment of severe tricuspid regurgitation (TR). We report our initial experience with an edge-to-edge TTVr system in a high-volume institution. METHODS: We included consecutive patients who underwent edge-to-edge TTVr systems. The primary efficacy endpoint was a reduction in the TR of at least one grade. The primary safety endpoint was procedure-related clinical serious adverse events. RESULTS: A total of 28 patients underwent TTVr with edge-to-edge systems. All patients presented with at least severe TR with a high impact on quality of life (82% of patients in NYHA class ≥ III). The Triclip system was the most used device (89%). The primary efficacy endpoint was met in all patients. Only one patient experienced a procedural complication (femoral pseudoaneurysm). At three-month follow-up, 83% of patients were in NYHA I or II (18% baseline vs. 83% 3 months follow-up; p < 0.001). Echocardiography follow-up showed residual TR ≤ 2 in 79% of patients (paired p < 0.001). At the maximum follow-up (median follow up = 372 days), no patients had died. CONCLUSIONS: Edge-to-edge TTVr systems seem to represent a very valid alternative to prevent morbidity and mortality associated with TR as depicted by the favorable efficacy and safety.

Current and future trends in multimodality imaging of coronary artery disease.

Nowadays, there is a wide array of imaging studies available for the evaluation of coronary artery disease, each with its particular indications and strengths. Cardiac single photon emission tomography is mostly used to evaluate myocardial perfusion, having experienced recent marked improvements in image acquisition. Cardiac PET has its main utility in perfusion imaging, atherosclerosis and endothelial function evaluation, and viability assessment. Cardiovascular computed tomography has long been used as a reference test for non-invasive evaluation of coronary lesions and anatomic characterization. Cardiovascular magnetic resonance is currently the reference standard for non-invasive ventricular function evaluation and myocardial scarring delineation. These specific strengths have been enhanced with the advent of hybrid equipment, offering a true integration of different imaging modalities into a single, simultaneous and comprehensive study.