Transcatheter edge-to-edge repair following surgical valve repair with ring implantation: Results from the multicentre "Clip-in-Ring" registry.

BACKGROUND: Management of mitral regurgitation recurrence after failed surgical valve repair with ring implantation is controversial. AIM: To describe the French experience regarding midterm safety and efficacy of transcatheter edge-to-edge mitral valve repair (TEER) in patients with failed surgical valve repair with ring implantation. METHODS: The "Clip-in-Ring" registry is a multicentre registry conducted in 11 centres in France, approved by local institutional review boards, of consecutive TEER following surgical valve repair with ring implantation. Outcomes were Mitral Valve Academic Research Consortium (MVARC) technical success, modified 30-day device and procedural success (where 10mmHg is considered as a cut-off for significant mitral stenosis) and MVARC complications. RESULTS: Twenty-three patients were studied: mean age, 69±10years; male sex, 74%; EuroSCORE II, 16±17; left ventricular ejection fraction, 53±12%; mitral regurgitation grade 3+/4+, 17%/78%; New York Heart Association class III/IV, 47%/22%; median surgery to TEER delay, 23 (6-94) months. Technical success was 100%. At discharge, residual mitral regurgitation grade was≤2+ in 87% and median transmitral gradient was 4 (3-5) mmHg. Thirty-day modified MVARC device and procedural success was 82%: four patients (17%) had residual mitral regurgitation grade>2+, including two patients who needed complementary surgery. No patient had a 30-day transmitral gradient>7mmHg. No patient died or had a stroke or any life-threatening complications. One patient presented a vascular access complication requiring transfusion. No other MVARC-2 adverse event was reported. CONCLUSIONS: TEER in patients with failed mitral ring is feasible and safe. Further studies should delineate its exact role in the therapeutic armamentarium for this medical issue.

Effectiveness and Safety of P2Y12 Inhibitors Pretreatment in Primary Percutaneous Coronary Intervention with Long Transfer Times.

BACKGROUND: Early initiation of a new P2Y12 inhibitor in ST-elevation myocardial infarction (STEMI) patients prior to primary percutaneous coronary intervention (PCI) is recommended over clopidogrel. However, comparative data remain limited, especially in semi-rural regions with subsequent longer transfer times. OBJECTIVES: We aimed to assess the determinants, effectiveness, and safety of pretreatment with new P2Y12 inhibitors compared with clopidogrel in a primary PCI regional network. METHODS: Outcomes of 1235 primary PCI patients pretreated with new P2Y12 inhibitors (n = 1050) or clopidogrel (n = 185) were evaluated using a prospective registry. Primary effectiveness endpoint was the composite of death, recurrent myocardial infarction, stroke, or new revascularization. Serious bleedings were defined as Bleeding Academic Research Consortium ≥ 2. RESULTS: Clopidogrel was more likely to be used in older and female patients with more comorbidities. Mean transfer time was longer in the clopidogrel group (123.3 ± 67.3 vs. 102.3 ± 57.2 min; p < 0.01). The primary endpoint was less frequent with new P2Y12 inhibitors compared with clopidogrel (14.9 vs. 30.3%; odds ratio 0.58, 95% confidence interval [CI] 0.39-0.87; p < 0.01), mostly driven by a reduced rate of death (4.5 vs. 26% respectively; hazard ratio 0.25, 95% CI 0.16-0.38; p < 0.01). Bleeding rates did not differ between groups (1 vs. 0.5%, respectively; p = 0.96). CONCLUSION: Compared with clopidogrel, pretreatment with new P2Y12 inhibitors seems to be associated with lower risks of mortality and ischemic outcomes, and similar risks of bleeding in a real-world registry. Our results are in line with the guidelines recommending the preferential pre-PCI administration of new P2Y12 inhibitors in STEMI patients referred for primary PCI.

EFFICACY OF AN ADDITIONAL MOBILE LEADED SHIELD ON OPERATOR RADIATION DURING PERCUTANEOUS CORONARY ANGIOGRAPHY.

Operator radiation protection during percutaneous coronary angiography (CA) is a growing concern in the catheterisation laboratory (cath lab). The purpose of this study was to evaluate the efficacy of an additional mobile leaded shield on operator radiation exposure during diagnostic CA. The study involved two operators from the same cath lab and patients scheduled for diagnostic coronary catheterisation over a period of 2 months. Procedures were performed with standard radiation equipment during the first month. An additional mobile lead shield was added during the second month. Radiation exposure was measured by three dosimeters positioned on the operator's left hand, on their chest under the lead apron and on lead glasses. The intra-operator results were compared. Ninety-nine per cent of the procedures were carried out by radial access. For Operators 1 and 2, the mobile shield, respectively, decreased the radiation dose to the eyes by 43 and 33 % and to the hands by 61 and 83 %. Thorax dose was less than the minimum measurable dose (<0.01 mSv) for each operator. There was no significant difference in total procedure duration, fluoroscopy time or contrast dose required between the two groups of patients. Improved operator radiation protection is an important issue in the face of increased occupational doses. Mobile leaded shield, combined with standard preventive measures, seems to be an effective additional option to reduce the radiation exposure during diagnostic CA.

Clinical and electrocardiographic predictors of a positive response to cardiac resynchronization therapy in advanced heart failure.

AIMS: Cardiac resynchronization therapy (CRT) is an effective treatment for refractory congestive heart failure (CHF). However, up to 30% of patients do not respond to CRT. The aim of this study was to identify clinical and electrocardiographic (ECG) predictors of a positive response to CRT. METHODS AND RESULTS: This retrospective study included 139 consecutive patients successfully implanted with a CRT device (mean age, 68+/-9 years, 113 men). At baseline, 69% of patients were in New York Heart Association (NYHA) functional class III, and 31% in class IV, mean left ventricular ejection fraction was 21+/-6%, and mean QRS duration was 188+/-28 ms. In each patient, left and right ventricular leads were placed to attain the shortest QRS duration during biventricular stimulation. Patients were classified at 6 months as responders to CRT (n=100) if they were alive, they had not been re-hospitalized for management of CHF, and the NYHA class had decreased by 1 point, and/or peak VO(2) or 6 min hall-walk increased by >10%. All others were classified as non-responders (n=38; one patient was lost to follow-up). Uni- and multivariate logistic regression analyses were performed to detect a pre- or intra-operative predictor of a positive response to CRT. Among multiple demographic, clinical, and ECG variables, the amount of QRS shortening (DeltaQRS) associated with biventricular stimulation was the only independent predictor of a positive (37+/-23 ms) vs. negative (11+/-23 ms) response to CRT (P<0.001). CONCLUSION: A positive response to CRT was observed in 73% of patients at 6 months and predicted only by DeltaQRS.

Inflow effect in first-pass cardiac and renal MRI.

PURPOSE: To estimate the effect of the inflow effect on the arterial input function in vivo in cardiac and renal MR perfusion imaging using fast gradient echo (GRE) sequences and contrast media. MATERIALS AND METHODS: The MR exam protocol was designed to acquire images at different phases of the cardiac cycle. The arterial input was thus influenced by various blood flow velocities. RESULTS: It was found that the inflow effect was negligible in the left ventricle of the heart, while it was significantly higher in the aorta for the kidney perfusion measurement. This was principally due to the higher through-the-plane component of the blood flow velocity in the aorta than in the left ventricle. CONCLUSION: The inflow effect can be neglected in the heart cavity, but should be taken into account in renal perfusion.