Risk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis.

BACKGROUND: Iatrogenic mitral stenosis is a known limitation of transcatheter edge-to-edge mitral valve repair (TMVr), but determinants of increased postprocedural mean diastolic gradient (MG) are not well defined. The aim of this study was to determine correlates of increased post-TMVr MG or aborted clip implantation due to increased MG. METHODS: Procedural three-dimensional transesophageal echocardiographic (TEE) data sets of 112 patients who underwent TMVr were retrospectively analyzed. Three-dimensional TEE mitral valve area (MVA) planimetry and mitral annular calcification (MAC) were quantified using multiplanar reconstruction. When MAC extension into the mitral leaflets was present, MAC with leaflet calcification (MAC-LC) length was recorded as the maximum distance from the mitral annulus to the most distal leaflet calcification. Increased MG after TMVr, measured on intraprocedural TEE imaging, was defined as ≥5 mm Hg or aborted clip implantation due to increased MG. RESULTS: Baseline MVA was 5.9 ± 1.7 cm2, baseline MG was 2.1 ± 1.2 mm Hg, and MAC-LC length was 4.0 ± 4.5 mm. Thirty-two patients (29%) had increased post-TMVr MG. Risk for increased post-TMVr MG was 86%, 28%, and 14% in patients with baseline MVA < 4.0, 4.0 to 6.0, and >6.0 cm2, respectively (P < .001). In patients with baseline MVA 4.0 to 6.0 cm2, concurrent baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm was associated with higher risk for increased post-TMVr MG (53% vs 12%, P = .002). In patients with baseline MVA < 4.0 and >6.0 cm2, the risk for increased post-TMVr MG was similar in the presence or absence of baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm (P > .05 for both). CONCLUSIONS: Patients with baseline three-dimensional TEE MVA < 4.0 cm2 are at high risk for increased post-TMVr MG. Additionally, patients with borderline MVA (4.0-6.0 cm2) and concurrent MAC-LC length ≥ 6 mm or baseline MG ≥ 4 mm Hg are at moderate risk for increased MG after TMVr.

Adult Intraoperative Echocardiography: A Comprehensive Review of Current Practice.

Intraoperative transesophageal echocardiography is a mature imaging modality and critical component of contemporary heart surgery, in which it plays a key role in surgical planning, determination of cardiac chamber filling and function early after cardiopulmonary bypass, and timely assessment of surgical interventions. Intraoperative transesophageal echocardiography affords the unique opportunity to correct suboptimal surgical results before leaving the operating room. Herein, the authors provide a comprehensive review of their institution's experience with intraoperative transesophageal echocardiography, emphasizing a practical assessment of commonly encountered noncongenital surgical heart lesions in adults, anticipation of potential surgical complications, and imaging approaches to facilitate timely surgical correction of unsatisfactory results.

Quantitative Three-Dimensional Echocardiographic Correlates of Optimal Mitral Regurgitation Reduction during Transcatheter Mitral Valve Repair.

BACKGROUND: Patient selection for transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging because of heterogenous mitral valve pathology and highly variable anatomy. The aim of this study was to investigate whether quantitative three-dimensional (3D) transesophageal echocardiographic modeling parameters are associated with optimal mitral regurgitation (MR) reduction in patients undergoing TMVR. METHODS: Fifty-nine patients underwent 3D transesophageal echocardiography during TMVR. Volumetric data sets were retrospectively analyzed using mitral valve quantitative 3D modeling software (Mitral Valve Navigator). Optimal MR reduction was defined as less than moderate residual MR. Logistic regression was used to correlate 3D transesophageal echocardiographic quantitative data to procedural success. RESULTS: Thirty-five patients had primary MR, 24 had mixed or secondary MR, and all patients had grade ≥ 3/4 MR before the procedure. Optimal MR reduction was achieved in 40 of 59 patients (68%). Univariate correlates of optimal MR reduction in patients with primary MR were lower mitral leaflet tenting volume (P = .049) and lower tenting height (P = .025); tenting height < 3 mm and tenting volume < 0.7 mL were associated with increased likelihood of optimal MR reduction (92% vs 48% [P = .01] and 81% vs 47% [P = .03], respectively). In mixed or secondary MR, annular height ≥ 5.5 mm was associated with increased likelihood of optimal MR reduction (94% vs 38%; P = .03). During follow-up, redo TMVR or surgical mitral valve replacement occurred exclusively in patients with suboptimal anatomy defined by 3D transesophageal echocardiography (10% vs 0%, P = .045). CONCLUSIONS: Quantitative 3D echocardiographic data are associated with favorable response to TMVR and could help optimize patient selection.

A hybrid technique for treatment of commissural primary mitral regurgitation.

BACKGROUND: MitraClip is an effective transcatheter therapy for mitral regurgitation (MR). However, MitraClip is challenging in commissural MR and the optimal therapeutic approach is unclear. METHODS: We describe a case series of six consecutive patients with severe commissural primary mitral regurgitation who underwent MitraClip insertion followed by an Amplatzer Vascular Plug (AVP) II occluder between the commissure and the MitraClip. RESULTS: The procedure was successful in all patients. MR was reduced from severe to mild/trivial in 50% and moderate in 50% of cases. On 30-day follow-up, NYHA class had improved from III (6 patients) to I (2 patients), II (2 patients), and III (2 patients). The mean transmitral gradient was 2.5 ± 1.8 mmHg at baseline and 4.8 ± 2.6 mmHg following the procedure. One patient developed hemolysis immediately post procedure. The other five patients remained well during a median follow-up of 20 months (range 5-50 months) with no reported device dislodgement. CONCLUSIONS: Elective treatment of severe commissural MR with a laterally or medially placed MitraClip coupled with an AVP II occluder between the clip and the commissure is feasible and safe. This approach may provide a useful management alternative in selected patients.

Mitral Valve Anatomic Predictors of Hemodynamic Success With Transcatheter Mitral Valve Repair.

BACKGROUND: Mitral regurgitation is a heterogeneous disease. Determining which patients derive optimal outcomes from transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging. We sought to determine whether baseline mitral valve anatomic characteristics are predictive of left atrial pressure (LAP) changes during TMVR with MitraClip. METHODS AND RESULTS: Consecutive patients with severe mitral regurgitation undergoing TMVR (n=112) underwent continuous intraprocedural LAP monitoring and retrospective echocardiographic analysis for specific mitral anatomic characteristics. Procedural success (optimal LAP reduction) was defined as ≥40% reduction in left atrial V-wave pressure compared with baseline. Echocardiographic predictors of optimal LAP reduction and increased postprocedure mean diastolic gradient were evaluated. Mean age was 79±14 years, and 36 patients (32%) were women. Primary, mixed, and secondary mitral regurgitation were present in 78 patients (70%), 22 patients (20%), and 12 patients (10%), respectively. Baseline mean LAP and V-wave were 22±6 and 38±13 mm Hg; after TMVR, these decreased to 19±5 and 27±10 mm Hg, respectively (P<0.0001 for both). Independent predictors of optimal LAP reduction were the presence of a flail scallop, mitral regurgitation localized to a single scallop, and high-quality 3-dimensional echocardiographic imaging. Independent predictors of elevated postprocedure mean diastolic gradient were elevated preprocedure mean diastolic gradient, mitral annular calcification, and implantation of multiple clips. CONCLUSIONS: Mitral valve pathoanatomic features, including a flail leaflet and single jet, are predictive of optimal LAP reduction with TMVR. High-quality 3-dimensional imaging may help select patients with the highest likelihood of optimal hemodynamic results with TMVR. These data expand current knowledge about patient selection for TMVR and deserve further study in larger cohorts.

Comparative study of bicuspid vs. tricuspid aortic valve stenosis.

Aims: To examine differences and similarities in bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) stenosis occurring during the same age and whether any differences impact outcomes following aortic valve replacement (AVR). Methods and results: An age-matched cohort of 198 BAV stenosis and 198 TAV stenosis patients was identified from 888 consecutive patients undergoing AVR for severe AS. Mean age 68 ± 6 years; 68% male. Patients with BAV were less likely to have multiple comorbidities, as measured by the Charlson Comorbidity Index (CCI) >2 (3 vs. 10%, P = 0.007). Indexed aortic valve area (0.44 ± 0.09 vs. 0.42 ± 0.08 cm2/m2, P = 0.17) and left ventricular ejection fraction (LVEF) were similar (62 ± 11 vs. 61 ± 12%, P = 0.12), but E/e' ≥15 (46 vs. 66%, P = 0.0002) was less common in BAV stenosis. A tissue aortic valve prosthesis was more commonly utilized in both groups (81 vs. 78%, P = 0.54). Overall indexed effective orifice area was larger in BAV compared with TAV (1.08 ± 0.33 vs. 0.96 ± 0.25 cm2/m2, P = 0.0008). Five-year survival following AVR was lower in TAV compared with BAV stenosis (61 vs. 79%, P = 0.02). Independent predictors of survival following AVR were LVEF < 50% [hazard ratio (HR): 4.8, P = 0.0005], CCI > 2 (HR: 3.1, P = 0.015), effective orifice area index ≤0.85 cm2/m2 (HR: 2.5, P = 0.004), and bioprosthesis (HR: 3.7, P = 0.02). Conclusion: In an age-matched cohort, TAV compared with BAV stenosis is associated with greater prevalence of cardiovascular risk factors and cardiac impairment and worse survival after AVR.

3D transesophageal echocardiography: A new imaging tool for assessment of mitral regurgitation and for guiding percutaneous edge-to-edge mitral valve repair.

Real time three dimensional transesophageal echocardiography (3D TEE) is probably the most powerful and convincing imaging method for understanding the complicated multiform morphology and for evaluating geometry, dynamics and function of degenerative and functional mitral valve (MV) regurgitation. Moreover, color Doppler 3D TEE has been valuable to identify the location of the regurgitant orifice and the severity of the mitral regurgitation. 3D TEE has been shown to be of enormous value in helping surgeons to perform MV repair. In addition, due to its ability to show a "panoramic" view of the "theater" where the procedure takes place, it has become an indispensable companion of 2D TEE during percutaneous edge-to-edge repair. A novel hybrid imaging modality where echocardiography is merged with fluoroscopy, may in the future further improve guidance of this and other complex percutaneous transcatheter interventions.

Building Blocks of Structural Intervention: A Novel Modular Paradigm for Procedural Training.

Structural heart disease is a rapidly evolving field, and approaches to procedural training are not standardized. We describe a novel modular approach to procedural training that considers each procedure as a series of building blocks that may be taught and assessed separately. Ten key structural heart disease building blocks can be identified, which, when combined with the cognitive skills of structural intervention and device-specific training, allow appropriate planning and implementation of structural procedures. Structural procedures require careful navigation of the aorta, left atrium, and right heart, including detailed understanding of relational anatomy. Component blocks include large bore vascular access, navigation within the left atrium, occlusion, snaring, and 3-dimensional relational anatomy. These building blocks also provide the foundation for new procedures through innovative use of the skill sets and devices to approach new clinical problems. The addition of device-specific training may be provided via proctoring and industry support. Using this approach, competency in less common procedures may be achieved and maintained. We discuss each building block in detail, approaches specific to the structural heart disease patient, the need for cross-discipline training, and empirical recommendations for training using this approach. We postulate that this new paradigm may be the preferred approach for training and assessment of structural heart disease interventional skills.

Characteristics and outcomes of re-do percutaneous paravalvular leak closure.

BACKGROUND: Percutaneous paravalvular leak (PVL) closure is an alternative treatment option for severely symptomatic, high-surgical risk patients with PVL. Some patients require multiple percutaneous PVL closure procedures. However, the procedural characteristics and success rate of re-do PVL closure have not been well studied. AIMS: The aim of this study is to investigate the indications, procedural characteristics, technical success rate, and 30-day major adverse cardiovascular events (MACE) in patients who underwent re-do PVL closure. METHODS: Consecutive patients who underwent percutaneous paramitral or paraaortic leak closure at Mayo Clinic, Rochester, Minnesota from 2004 through 2015 were studied. Clinical and procedural characteristics of patients who underwent re-do PVL closure were compared to age- and sex-matched patients who underwent their first percutaneous PVL closure. Procedure success and 30-day MACE were compared in both the groups. RESULTS: Among 223 identified percutaneous PVL closures, 16 (7%) were re-do procedures. Patients who underwent re-do PVL closure were predominantly men (87.5%) with a mean age of 68 ± 15 years and an estimated mean Society of Thoracic Surgery (STS) 30-day mortality of 4.6 ± 2.8. Half of the re-do PVL closures were performed on mechanical valves and 62.5% were performed on paramitral defects. Indications for re-do PVL closure were: (1) emergence of new significant paravalvular defects in 50%, (2) incomplete index defect closure in 43.75%, and (3) index procedural complication in 6.25% of the cases. Procedural success was 75% in re-do procedures vs. 85.4% in age- and sex-matched control group (P = 0.45). Thirty-day MACE was 12.5% in the re-do group compared to 4.2% in the age- and-sex matched patients who underwent PVL closure for the first time (P = 0.35). CONCLUSION: Re-do percutaneous PVL closure is feasible with favorable procedural success rate and low 30-day MACE. Development of new paravalvular defects is the most common indication for re-do PVL closure, highlighting the importance of careful longitudinal monitoring and follow-up. © 2017 Wiley Periodicals, Inc.

The Learning Curve for Transcatheter Mitral Valve Repair With MitraClip.

OBJECTIVES: This study sought to assess the learning curve for TMVR for treatment of primary mitral regurgitation (MR). BACKGROUND: Data are lacking regarding the technical experience required to achieve optimal clinical outcomes with transcatheter mitral valve repair (TMVR) using the edge-to-edge MitraClip technique. METHODS: We examined the sequential experience of the first 75 patients (age 80 ± 9 years; 77% male) who underwent TMVR at our institution. A sequence number of each patient was assigned as a continuous variable and in tertiles for analysis. RESULTS: TMVR with MitraClip was successful in 97% with an average procedural time of 106 ± 39 minutes. The 30-day rate of major adverse cardiovascular events was 7%. With increased case experience, there were decreases in procedural time, fluoroscopy time, length of hospital stay, and major adverse cardiovascular events. Procedural success, residual mitral regurgitation and NYHA functional classification at 30-day follow-up remained unchanged throughout the experience. CONCLUSIONS: The learning curve for TMVR with MitraClip for treatment of primary MR is characterized by a sequential reduction in procedure time, fluoroscopy time, procedural complications, and hospital length of stay at a tertiary academic medical center. Thirty-day procedural results are favorable and similar during the initial learning period.

Percutaneous Transvenous Transseptal Transcatheter Valve Implantation in Failed Bioprosthetic Mitral Valves, Ring Annuloplasty, and Severe Mitral Annular Calcification.

OBJECTIVES: This study sought to examine the feasibility, safety, and intermediate-term outcomes in patients undergoing percutaneous transvenous transcatheter mitral valve implantation in failed bioprosthesis, ring annuloplasty, and calcific mitral stenosis. BACKGROUND: Surgical mitral valve replacement in patients with previous surgery or severe mitral annular calcification (MAC) is often associated with high or prohibitive risk. METHODS: Percutaneous transfemoral antegrade transseptal implantation of Edwards SAPIEN prosthesis (Edwards Lifesciences, Irvine, California) was performed in 48 patients with degenerated mitral bioprosthesis (n = 33), previous ring annuloplasty (n = 9), and severe MAC (n = 6). RESULTS: The mean Society of Thoracic Surgeons risk score was 13.2 ± 7.4% with a mean age 76 ± 11 years. Acute procedural success was achieved in 42 of 48 patients (88%) in the overall group and 31 of 33 (94%) in the failed bioprosthetic mitral valve group and success rate of 11 of 15 (73%) in patients with failed annuloplasty rings and MAC. After successful procedure, no patients had > mild residual mitral prosthetic or periprosthetic regurgitation; mean transvalvular gradients were 6 ± 2.5 mm Hg. Thirty-day survival free of death and cardiovascular surgery was 85% in the overall group and 91% in the failed bioprosthetic mitral valve subgroup. CONCLUSIONS: Transfemoral percutaneous transvenous mitral valve implantation in high-risk patients with degenerated bioprosthesis is safe, effective, and associated with rapid improvement in hemodynamics, short length of stays, and improved functional status. Percutaneous mitral valve implantation in patients with failed annuloplasty rings and severe MAC is a promising therapy with significant short-term morbidity and mortality that requires further study.

Acute LVOT Obstruction with a Carbomedics Mechanical Valve Prosthesis.

A 62-year-old female with severe symptomatic rheumatic mitral stenosis was referred for mitral valve replacement. A 27-mm Carbomedics mechanical mitral valve was placed using everting sutures. As the patient was weaned off cardiopulmonary bypass, she became hemodynamically unstable. Intraoperative transesophageal echocardiogram revealed a significant drop in left ventricular function along with severe LVOT obstruction. The Carbomedics prosthesis was replaced by a 27-mm St. Jude mechanical valve using noneverting sutures which relieved the LVOT obstruction. doi: 10.1111/jocs.12749 (J Card Surg 2016;31:376-379).

Echocardiographic and Fluoroscopic Fusion Imaging for Procedural Guidance: An Overview and Early Clinical Experience.

There has been significant growth in the volume and complexity of percutaneous structural heart procedures in the past decade. Increasing procedural complexity and accompanying reliance on multimodality imaging have fueled the development of fusion imaging to facilitate procedural guidance. The first clinically available system capable of echocardiographic and fluoroscopic fusion for real-time guidance of structural heart procedures was approved by the US Food and Drug Administration in 2012. Echocardiographic-fluoroscopic fusion imaging combines the precise catheter and device visualization of fluoroscopy with the soft tissue anatomy and color flow Doppler information afforded by echocardiography in a single image. This allows the interventionalist to perform precise catheter manipulations under fluoroscopy guidance while visualizing critical tissue anatomy provided by echocardiography. However, there are few data available addressing this technology's strengths and limitations in routine clinical practice. The authors provide a critical review of currently available echocardiographic-fluoroscopic fusion imaging for guidance of structural heart interventions to highlight its strengths, limitations, and potential clinical applications and to guide further research into value of this emerging technology.

Sex-related differences in calcific aortic stenosis: correlating clinical and echocardiographic characteristics and computed tomography aortic valve calcium score to excised aortic valve weight.

AIMS: Calcific aortic valve stenosis (AS) is purportedly associated with less calcium burden in women than in men. We sought to examine sex-related differences and correlates of surgically excised aortic valve weight (AVW) in pure AS. METHODS AND RESULTS: Clinical and echocardiographic characteristics of 888 consecutive patients who underwent aortic valve replacement for severe AS were correlated to AVW, and in 126 patients, AVW was also correlated to computed tomography aortic valve calcium (AVC) score. Women and men had similar indexed valve area (0.42 ± 0.09 vs. 0.42 ± 0.07 cm (2)/m(2), P = 0.95) and mean systolic gradient (53 ± 15 vs. 52 ± 13 mmHg, P = 0.11), but women had higher New York Heart Association class (2.63 ± 0.70 vs. 2.50 ± 0.70, P = 0.01) and less prevalent coronary artery disease (38 vs. 52%, P < 0.0001). Aortic valve weight was lower in women (1.94 ± 0.88 vs. 3.08 ± 1.32 g, P < 0.0001) even when indexed to body surface area (1.09 ± 0.48 vs. 1.48 ± 0.62 g/m(2), P < 0.0001) or left ventricular outflow tract (LVOT) area (0.54 ± 0.23 vs. 0.71 ± 0.29 g/cm(2), P < 0.0001). Using multivariate analysis, male sex (P < 0.0001), bicuspid valve (P < 0.0001), and larger LVOT area (P < 0.0001) were the major determinants of increased AVW, along with current cigarette smoking (P = 0.007). Diabetes (P = 0.004) and hypertension (P = 0.03) were independently associated with lower AVW. Aortic valve calcium correlated well with AVW (r = 0.81, P < 0.0001) and was lower in women than in men (2520 ± 1199 vs. 3606 ± 1632 arbitrary units, P < 0.0001). CONCLUSIONS: Despite the same degree of AS severity, women have less AVC and lower AVW compared with men, irrespective of valve morphology. Aortic valve calcium is correlated to excised AVW. Hypertension, diabetes, and current cigarette smoking were independently associated with AVW.