Transgastric imaging-The key to successful periprocedural TEE guiding for edge-to-edge repair of the tricuspid valve.

Intraprocedural transesophageal echocardiography (TEE) guidance plays an essential role in transcatheter repair therapy of the tricuspid valve (TV). So far, several different imaging concepts are in use. We propose an imaging protocol that fully addresses the morphological complexity of the TV and further offers efficacious workarounds for the frequently occurring restrictions of TV imaging in edge-to-edge repair of the TV. As a tertiary referral center with a large experience of more than 250 cases of transcatheter edge-to-edge repair (TEER) of the TV performed at the Heart Valve Center in Mainz/Germany, we have constantly adapted our peri-interventional echocardiographic approach to accomplish both. As a key measure for success, we intensely rely on the transgastric acoustic windows that not only deliver high-resolution information on the morphology of the TV and all relevant procedural steps but also help to avoid the frequent shadowing artifacts experienced in transesophageal imaging.

Minimizing Paravalvular Regurgitation With the Novel SAPIEN 3 Ultra TAVR Prosthesis: A Real-World Comparison Study.

Objectives: We investigated performance and outcome of the latest-generation balloon-expandable SAPIEN 3 Ultra prosthesis (S3U) compared to the established SAPIEN 3 prosthesis (S3) in a real-world cohort, with focus on paravalvular regurgitation (PVR). Background: PVR is an adverse prognostic indicator of short- and long-term survival after transcatheter aortic valve replacement (TAVR). The S3U has been designed to improve sealing. Methods: We enrolled 343 consecutive patients presenting with severe native aortic valve stenosis eligible for a balloon-expandable prosthesis. The established S3 was implanted in the first 200 patients, the following 143 patients received the novel S3U after introduction in our institution. Primary endpoint was PVR after TAVR. Furthermore, we investigated procedural parameters and in-hospital and 30-day outcome. Results: PVR was significantly lower in the S3U cohort compared to the S3 cohort. They differed in their rate of mild PVR (11.2 vs. 48.0%, p < 0.001), whereas at least moderate PVR was similarly low in both cohorts (0.7 vs. 0.5%, p = 0.811). A significant reduction of post-dilatation rate, fluoroscopy time, and amount of contrast was observed in patients treated with the novel S3U (p < 0.001). The rate of adverse events in the in-hospital course and at 30 days were similarly low. At 30 days more patients receiving S3U improved in NYHA class (improvement ≥2 grades 34.6 vs. 19.9%, p = 0.003). Conclusion: The current study provides evidence that the novel S3U strongly minimizes PVR, thereby demonstrating the efficacy of improved sealing. Further studies will have to address if the observed reduction of PVR with S3U has prognostic significance.

Reversibility of severe mitral valve regurgitation after left ventricular assist device implantation: single-centre observations from a real-life population of patients.

OBJECTIVES: This study evaluates the impact of untreated preoperative severe mitral valve regurgitation (MR) on outcomes after left ventricular assist device (LVAD) implantation. METHODS: Of the 234 patients who received LVAD therapy in our centre during a 6-year period, we selected those who had echocardiographic images of good quality and excluded those who underwent mitral valve replacement prior to or mitral valve repair during LVAD placement. The 128 patients selected were divided into 2 groups: Group A with severe MR (n = 65) and Group B with none to moderate MR (n = 63, 28 with moderate MR). We evaluated transthoracic echocardiography preoperatively [15 (7-28) days before LVAD implantation; median (interquartile range)] and postoperatively up to the last available follow-up [501 (283-848) days after LVAD]. We collected mortality, complications and clinical status indicators of the patient cohort. RESULTS: We observed a significant decrease in the severity of MR after LVAD implantation (severe MR 51% pre- vs 6% post-LVAD implantation, P < 0.001). There was no difference between groups in terms of right heart failure, rate of urgent heart transplantation, pump thrombosis or ventricular arrhythmias. There was no difference in 1-year survival and 3-year survival (87.7% vs 88.4% and 71.8% vs 66.6% for Groups A and B, respectively, P = 0.97). CONCLUSIONS: Preoperative severe MR resolves in the majority of patients early on after LVAD implantation and is not associated with worse clinical outcomes or intermediate-term survival.

Influence of aortic valve opening in patients with aortic insufficiency after left ventricular assist device implantation.

OBJECTIVES: Aortic valve insufficiency (AI) following left ventricular assist device (LVAD) implantation can potentially limit the success of mechanical circulatory support. We examined the prevalence of significant AI in the new generation of LVADs and analysed the role of aortic valve opening in the development of AI in these patients. METHODS: Currently, 102 patients that received a continuous flow LVAD (cf-LVAD) between July 2009 and December 2013 are being treated in our outpatient clinic with an HeartWare ventricular assist device (HVDA) (n = 77) or HeartMate II (HMII, n = 25) and were included and analysed in a retrospective study. The mean age of the 12 female and 90 male patients was 54 ± 12 years. Ischaemic cardiomyopathy was diagnosed in 40% of patients. Echocardiographic measurements were reviewed before and after implantation. AI was considered significant if it was more than mild. RESULTS: Mean LVAD support duration was 572 ± 437 days. Significant AI was found in 32 patients (31.4%). De novo AI occurred in mean after 183 ± 246 days of support. One patient presented severe AI and received an aortic valve replacement. A permanently closed aortic valve correlates with a greater prevalence of AI when compared with intermittent or complete opening of aortic valve (P = 0.004). Aetiology of the cardiomyopathy and the type of device had no influence on the development of AI. Smaller left ventricle end-diastolic diameter and lower body surface area were significantly associated with the development of aortic insufficiency in our cohort. CONCLUSION: Aortic insufficiency has a high prevalence following assist device continuous flow support. Echocardiographic parameters are an integral part of ambulatory care of these patients and can guide the optimal setting for LVAD. An aortic valve that does not open should be avoided in order to prevent AI. Patients with HMII or HVAD did not show any differences terms of the prevalence of aortic insufficiency prevalence.

Barlow's Mitral Valve Disease: A Comparison of Neochordal (Loop) and Edge-To-Edge (Alfieri) Minimally Invasive Repair Techniques.

BACKGROUND: Barlow's mitral valve (MV) disease remains a surgical challenge. We compared short- and medium-term outcomes of neochordal ("loop") versus edge-to-edge ("Alfieri") minimally invasive MV repair in patients with Barlow's disease. METHODS: From January 2009 to April 2014, 123 consecutive patients with Barlow's disease (defined as bileaflet billowing or prolapse [or both], excessive leaflet tissue, and annular dilatation with or without calcification) underwent minimally invasive MV operations for severe mitral regurgitation (MR) at our institution. Three patients (2.4%) underwent MV replacement during the study period and were excluded from subsequent analysis. The loop MV repair technique was used in 68 patients (55.3%) and an edge-to-edge repair was performed in 44 patients (35.8%). Patients who underwent a combination of these 2 techniques (n = 8 [6.5%]) were excluded. The median age was 48 years, and 62.5% of patients were men. Concomitant procedures included closure of a patent foramen ovale or atrial septal defect (n = 19), tricuspid valve repair (n = 5), and atrial fibrillation ablation (n = 15). Follow-up was performed 24.7 ± 17 months postoperatively and was 98% complete. RESULTS: No deaths occurred perioperatively or during follow-up. Aortic cross-clamp time (64.1 ± 17.6 minutes versus 95.9 ± 29.5 minutes) and cardiopulmonary bypass (CPB) time (110.0 ± 24.2 minutes versus 146.4 ± 39.1 minutes) were significantly shorter (p < 0.001) in patients who received edge-to-edge repair. Although patients who underwent edge-to-edge repair received a larger annuloplasty ring (38.6 ± 1.5 mm versus 35.8 ± 2.7 mm; p < 0.001), the early postoperative resting mean gradients were higher (3.3 ± 1.2 mm Hg versus 2.6 ± 1.2 mm Hg; p = 0.007) and the mitral orifice area tended to be smaller in this group (2.8 ± 0.7 cm(2) versus 3.0 ± 0.7 cm(2); p = 0.06). The amount of residual MR was similar between groups (0.3 ± 0.6 versus 0.6 ± 1.0 for edge-to-edge versus loop procedures, respectively; p = 0.08). More than mild MR requiring early MV reoperation was present in 3 patients who underwent loop procedures (4.4%) and in no patients who had edge-to-edge procedures (p = 0.51). During follow-up, 2 patients (1 in each group) required MV replacement for severe MR. The 4-year freedom from MV reoperation was 92.8% ± 5.0% in the Alfieri group compared with 90.9% ± 4.6% in the loop group (p = 0.94). CONCLUSIONS: Minimally invasive MV repair can be accomplished with excellent early and medium-term outcomes in patients with Barlow's disease. The edge-to-edge (Alfieri) repair can be performed with reduced operative times when compared with the loop technique, but it results in mildly increased transvalvular gradients and mildly decreased valve opening areas without any difference in residual MR.