Transcatheter mitral valve repair with MitraClip: comparison of NT, NTr, and XTr Devices.

OBJECTIVES: Transcatheter edge-to-edge repair (TEER) has become an established minimally invasive treatment for significant mitral regurgitation. Ongoing refinements and the availability of different clipping devices have expanded the indications for and effectiveness of TEER, but comprehensive comparative data on this issue are lacking. In this study, we compared NT, NTr, and XTr MitraClip devices (Abbot) for TEER. METHODS: Details on patient, imaging, and procedural details, as well as short- and long-term outcomes, were sought from a national prospective clinical registry on TEER with MitraClip. The primary outcome of interest was discharge after procedural success without major clinical complications. RESULTS: A total of 2236 patients were included, 1228 (54.9%) in whom NT implantation only was attempted, 233 (10.4%) in whom NTr but not XTr implantation was attempted, and 775 (34.7%) in whom XTr implantation was attempted. Clinical and imaging features differed substantially across the groups, reflecting expanding indications with NTr and XTr devices. In-hospital outcomes were largely similar among the 3 groups, including death. Long-term unadjusted estimates of effect showed significant differences in several outcomes, including death, rehospitalization, and their composite, which demonstrated that NT was associated with more unfavorable outcomes compared with the other devices (all P less than .05). However, most differences depended on baseline features, as adjusted analysis showed no significant differences for early as well as long-term outcomes, including long-term death, rehospitalization, and their composite (all P greater than .05). CONCLUSIONS: New-generation MitraClip devices are associated with favorable procedural and clinical outcomes, despite being used in patients with more adverse features, when compared with patients treated with previous devices.

Myocardial strain of the left ventricle by speckle tracking echocardiography: From physics to clinical practice.

Speckle tracking echocardiography (STE) is a reliable imaging technique of recognized clinical value in several settings. This method uses the motion of ultrasound backscatter speckles within echocardiographic images to derive myocardial velocities and deformation parameters, providing crucial insights on several cardiac pathological and physiological processes. Its feasibility, reproducibility, and accuracy have been widely demonstrated, being myocardial strain of the various chambers inserted in diagnostic algorithms and guidelines for various pathologies. The most important parameters are Global longitudinal strain (GLS), Left atrium (LA) reservoir strain, and Global Work Index (GWI): based on large studies the average of the lower limit of normality are -16%, 23%, and 1442 mmHg%, respectively. For GWI, it should be pointed out that myocardial work relies primarily on non-invasive measurements of blood pressure and segmental strain, both of which exhibit high variability, and thus, this variability constitutes a significant limitation of this parameter. In this review, we describe the principal aspects of the theory behind the use of myocardial strain, from cardiac mechanics to image acquisition techniques, outlining its limitation, and its principal clinical applications: in particular, GLS have a role in determine subclinical myocardial dysfunction (in cardiomyopathies, cardiotoxicity, target organ damage in ambulatory patients with arterial hypertension) and LA strain in determine the risk of AF, specifically in ambulatory patients with arterial hypertension.

Cardiac Magnetic Resonance for Prophylactic Implantable-Cardioverter Defibrillator Therapy in Ischemic Cardiomyopathy: The DERIVATE-ICM International Registry.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) therapy is the most effective prophylactic strategy against sudden cardiac death (SCD) in patients with ischemic cardiomyopathy (ICM) and left ventricle ejection fraction (LVEF) ≤35% as detected by transthoracic echocardiograpgy (TTE). This approach has been recently questioned because of the low rate of ICD interventions in patients who received implantation and the not-negligible percentage of patients who experienced SCD despite not fulfilling criteria for implantation. OBJECTIVES: The DERIVATE-ICM registry (CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy; NCT03352648) is an international, multicenter, and multivendor study to assess the net reclassification improvement (NRI) for the indication of ICD implantation by the use of cardiac magnetic resonance (CMR) as compared to TTE in patients with ICM. METHODS: A total of 861 patients with ICM (mean age 65 ± 11 years, 86% male) with chronic heart failure and TTE-LVEF <50% participated. Major adverse arrhythmic cardiac events (MAACE) were the primary endpoints. RESULTS: During a median follow-up of 1,054 days, MAACE occurred in 88 (10.2%). Left ventricular end-diastolic volume index (HR: 1.007 [95% CI: 1.000-1.011]; P = 0.05), CMR-LVEF (HR: 0.972 [95% CI: 0.945-0.999]; P = 0.045) and late gadolinium enhancement (LGE) mass (HR: 1.010 [95% CI: 1.002-1.018]; P = 0.015) were independent predictors of MAACE. A multiparametric CMR weighted predictive derived score identifies subjects at high risk for MAACE compared with TTE-LVEF cutoff of 35% with a NRI of 31.7% (P = 0.007). CONCLUSIONS: The DERIVATE-ICM registry is a large multicenter registry showing the additional value of CMR to stratify the risk for MAACE in a large cohort of patients with ICM compared with standard of care.

Myocardial Fibrosis at Cardiac MRI Helps Predict Adverse Clinical Outcome in Patients with Mitral Valve Prolapse.

Background Patients with mitral valve prolapse (MVP) may develop adverse outcomes even in the absence of mitral regurgitation or left ventricular (LV) dysfunction. Purpose To investigate the prognostic value of mitral annulus disjunction (MAD) and myocardial fibrosis at late gadolinium enhancement (LGE) cardiac MRI in patients with MVP without moderate-to-severe mitral regurgitation or LV dysfunction. Materials and Methods In this longitudinal retrospective study, 118 144 cardiac MRI studies were evaluated between October 2007 and June 2020 at 15 European tertiary medical centers. Follow-up was from the date of cardiac MRI examination to June 2020; the minimum and maximum follow-up intervals were 6 months and 156 months, respectively. Patients were excluded if at least one of the following conditions was present: cardiomyopathy, LV ejection fraction less than 40%, ischemic heart disease, congenital heart disease, inflammatory heart disease, moderate or worse mitral regurgitation, participation in competitive sport, or electrocardiogram suggestive of channelopathies. In the remainder, cardiac MRI studies were reanalyzed, and patients were included if they were aged 18 years or older, MVP was diagnosed at cardiac MRI, and clinical information and electrocardiogram monitoring were available within 3 months from cardiac MRI examination. The end point was a composite of adverse outcomes: sustained ventricular tachycardia (VT), sudden cardiac death (SCD), or unexplained syncope. Multivariable Cox regression analysis was performed. Results A total of 474 patients (mean age, 47 years ± 16 [SD]; 244 women) were included. Over a median follow-up of 3.3 years, 18 patients (4%) reached the study end point. LGE presence (hazard ratio, 4.2 [95% CI: 1.5, 11.9]; P = .006) and extent (hazard ratio, 1.2 per 1% increase [95% CI: 1.1, 1.4]; P = .006), but not MAD presence (P = .89), were associated with clinical outcome. LGE presence had incremental prognostic value over MVP severity and sustained VT and aborted SCD at baseline (area under the receiver operating characteristic curve, 0.70 vs 0.62; P = .03). Conclusion In contrast to mitral annulus disjunction, myocardial fibrosis determined according to late gadolinium enhancement at cardiac MRI was associated with adverse outcome in patients with mitral valve prolapse without moderate-to-severe mitral regurgitation or left ventricular dysfunction. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Gerber in this issue.

Effective 3 Leaflet Grasping During TriClip Procedure: The "3-Point" Buzzer Beater.

To the best of our knowledge, this is the first report of simultaneous grasping of the 3 leaflets during TriClip (Abbott Cardiovascular) implantation. The final valve configuration with a triple orifice resembled the result of the clover surgical technique. This technique should be considered in selected cases of challenging grasping.

Right ventricle remodeling after transcatheter tricuspid leaflet repair in patients with functional tricuspid regurgitation: Lessons from the surgical experience.

Clinically significant tricuspid regurgitation (TR) is common and associated with excess mortality. At the same time right ventricular (RV) failure is a complex clinical syndrome that results from many causes, but is often associated with long-term prognosis. Whilst results of isolated tricuspid valve (TV) surgery are often unsatisfactory and limited by the prohibitive risk of most patients, the recent development of percutaneous recovery techniques has opened new scenarios. In consideration of the complexity of the mechanisms that lead to right heart failure and RV dysfunction it is important to understand the real advantages that percutaneous TV treatment can offer, more specifically the effect of TR reduction on RV remodeling in the setting of functional tricuspid regurgitation (fTR).

Infective Endocarditis in People Who Inject Drugs: Report from the Italian Registry of Infective Endocarditis.

Intravenous drug use is a predisposing condition for infective endocarditis (IE). We report the clinical features of IE, taken from the Italian Registry of IE, in people who inject drugs (PWIDs). The registry prospectively collected epidemiological, clinical, in-hospital, and follow-up data on patients with IE from 17 Italian centers. A total of 677 patients were enrolled, and 61 (9%) were intravenous drug users (IDUs). Most PWIDs were male (78.6%), and aged between 41 and 50 years old (50%). The most frequent comorbidities were HIV (34.4%) and chronic liver disease (32%). Predisposing factors for IE were present in 6.5% of the patients, and 10% had minor valvular abnormalities. IE had occurred previously in 16.4% of the patients, and 50% of them had undergone heart surgery. Overall mortality was 9.8% in IDUs and 20% in patients with recurrent IE. IE in PWIDs mostly affected the native valves (90%). The echocardiographic diagnosis of IE was based on the detection of vegetation in 91.82% of cases. Staphylococcus aureus was the main microorganism isolated (70%) from blood cultures. Thirty patients (49%) underwent heart surgery: thirteen had aortic valves, eleven had mitral valves, and six had tricuspid valve interventions. IE in PWIDs was relatively common, and patients with native valve right-sided IE had a better prognosis, with a low rate of surgical interventions.

A Case of Catheter-Based Tricuspid Valve Repair Reversing the Previous Success of Transcatheter Mitral Valve Repair: A New Scenario Requires New Answers.

Concomitant severe mitral-tricuspid regurgitation is observed in up to 30% of patients with reduced left ventricular ejection fraction. In symptomatic subjects at high surgical risk, transcatheter treatment is a viable option in the presence of suitable anatomy. We present a case of mitral regurgitation worsening after TriClip (Abbott, Abbott Park, IL) implantation in a patient with a previous successful MitraClip (Abbott) intervention. The correction of tricuspid regurgitation by catheter repair improves overall hemodynamics, but it can sometimes paradoxically worsen mitral regurgitation, as herein displayed. Clinical care is needed to detect tricuspid regurgitation repair-induced worsening of mitral regurgitation and ensure optimal management.

Sutureless versus transcatheter aortic valve replacement: A multicenter analysis of "real-world" data.

BACKGROUND: Recent data suggested that transcatheter aortic valve replacement (TAVR) may be indicated also for low-risk patients. However, robust evidence is still lacking, particularly regarding valve performance at follow-up that confers a limitation to its use in young patients. Moreover, a literature gap exists in terms of 'real-world' data analysis. The aim of this study is to compare the cost-effectiveness of sutureless aortic valve replacement (SuAVR) versus transfemoral TAVR. METHODS: Prospectively collected data were retrieved from a centralized database of nine cardiac surgery centers between 2010 and 2018. Follow-up was completed in June 2019. A propensity score matching (PSM) analysis was performed. RESULTS: Patients in the TAVR group (n=1002) were older and with more comorbidities than SuAVR patients (n=443). The PSM analysis generated 172 pairs. No differences were recorded between groups in 30-day mortality [SuAVR vs TAVR: n=7 (4%) vs n=5 (2.9%); p=0.7] and need for pacemaker implant [n=10 (5.8%) vs n=20 (11.6%); p=0.1], but costs were lower in the SuAVR group (20486.6±4188€ vs 24181.5±3632€; p<0.01). Mean follow-up was 1304±660 days. SuAVR patients had a significantly higher probability of survival than TAVR patients (no. of fatal events: 22 vs 74; p<0.014). Median follow-up was 2231 days and 2394 days in the SuAVR and TAVR group, respectively. CONCLUSION: The treatment of aortic valve stenosis with surgical sutureless or transcatheter prostheses is safe and effective. By comparing the two approaches, patients who can undergo surgery after heart team evaluation show longer lasting results and a more favorable cost ratio.

Acute Right Ventricular Reshaping After TriClip in Ebstein's-Like Anomaly Assessed by Multimodality Imaging.

The efficacy of transcatheter edge-to-edge tricuspid valve repair (TTVR) has been recently demonstrated not only for the reduction of tricuspid regurgitation (TR) but also in terms of right ventricular remodeling. We report the case of a 78-year-old female patient with a history of atrial fibrillation and severe isolated TR in New York Heart Association functional classification III despite optimal medical therapy. These case images help to illustrate immediate and considerable right ventricular reshaping due to successful TTVR with a sustained result at 6 months in isolated primary TR.

CarDiac magnEtic Resonance for prophylactic Implantable-cardioVerter defibrillAtor ThErapy in Non-Ischaemic dilated CardioMyopathy: an international Registry.

AIMS: The aim of this registry was to evaluate the additional prognostic value of a composite cardiac magnetic resonance (CMR)-based risk score over standard-of-care (SOC) evaluation in a large cohort of consecutive unselected non-ischaemic cardiomyopathy (NICM) patients. METHODS AND RESULTS: In the DERIVATE registry (www.clinicaltrials.gov/registration: RCT#NCT03352648), 1000 (derivation cohort) and 508 (validation cohort) NICM patients with chronic heart failure (HF) and left ventricular ejection fraction <50% were included. All-cause mortality and major adverse arrhythmic cardiac events (MAACE) were the primary and secondary endpoints, respectively. During a median follow-up of 959 days, all-cause mortality and MAACE occurred in 72 (7%) and 93 (9%) patients, respectively. Age and >3 segments with midwall fibrosis on late gadolinium enhancement (LGE) were the only independent predictors of all-cause mortality (HR: 1.036, 95% CI: 1.0117-1.056, P < 0.001 and HR: 2.077, 95% CI: 1.211-3.562, P = 0.008, respectively). For MAACE, the independent predictors were male gender, left ventricular end-diastolic volume index by CMR (CMR-LVEDVi), and >3 segments with midwall fibrosis on LGE (HR: 2.131, 95% CI: 1.231-3.690, P = 0.007; HR: 3.161, 95% CI: 1.750-5.709, P < 0.001; and HR: 1.693, 95% CI: 1.084-2.644, P = 0.021, respectively). A composite clinical and CMR-based risk score provided a net reclassification improvement of 63.7% (P < 0.001) for MAACE occurrence when added to the model based on SOC evaluation. These findings were confirmed in the validation cohort. CONCLUSION: In a large multicentre, multivendor cohort registry reflecting daily clinical practice in NICM work-up, a composite clinical and CMR-based risk score provides incremental prognostic value beyond SOC evaluation, which may have impact on the indication of implantable cardioverter-defibrillator implantation.

Performance of Synthetic Extracellular Volume Fraction in Different Cardiac Phenotypes From a Prospective Cohort of Patients Referred for Cardiac Magnetic Resonance.

BACKGROUND: A synthetic myocardial extracellular volume fraction (sECV) can be obtained without blood hematocrit (Hct) by using the linear relationship between Hct and the longitudinal relaxation time of blood. Concerns have been raised about the widespread clinical application of this approach. PURPOSE: To assess the relationship between measured ECV (m-ECV) and sECV, using both a published model and a locally derived one. STUDY TYPE: Single-center, prospective. FIELD STRENGTH/SEQUENCE: A 1.5 T/modified Look Locker (MOLLI) sequence. SUBJECTS: Fifty-two healthy subjects and 113 patients (76 with and 37 without a hypertrophic cardiac phenotype). ASSESSMENT: Three ECV values were obtained for each patient: 1) measured ECV (m-ECV), using Hct from a venous blood sample; 2) Fent-synthetic ECV (F-sECV), using the equation proposed by Fent et al; and 3) Local-synthetic ECV (L-sECV), using the equation obtained from a local derivation cohort comprising 83 subjects. STATISTICAL TESTS: Shapiro-Wilk test, analysis of variance, Kruskal Wallis test, Pearson correlation, Bland-Altman analysis, univariate and multivariable regression analysis. RESULTS: In the validation cohort (N = 82), Bland-Altmann analysis revealed an excellent agreement between m-ECV and L-sECV with a statistically insignificant bias (-0.1%, limits of agreement: -2.8% and 2.6%; P = 0.528), while in the overall population (N = 165), the mean bias between m-ECV and F-sECV was small but significant (1.2%, limits of agreement: -1.5% and 3.9%, P < 0.05). F-sECV bias was significantly higher for measured Hct (m-Hct) values <0.372 (2.3% vs. 1.0%, P < 0.05). Among the phenotype subgroups, amyloidotic patients showed a higher bias compared to others, both with F-sECV and L-sECV (2.3% vs. 1.1%, P < 0.05 and 1.1% vs. 0.2%, P < 0.05, respectively). DATA CONCLUSION: Although synthetic ECV performs well in an external cohort, the use of a local formula further improves the accuracy of ECV estimate over a broad spectrum of cardiac phenotypes. Local sECV performs better for a wider range of Hct values, compared to the published model. Amyloidosis is the only group associated with a lower accuracy. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 2.

The New ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes: the Good and the Not So Good.

During the annual meeting in Paris, the European Society of Cardiology released the new guidelines for the diagnosis and management of chronic coronary syndromes that will replace the 2013 guidelines on stable coronary artery disease. We intend to provide a brief commentary on what, in our opinion, is good and what is not as good. Our careful analysis shows that the 2019 guidelines contain a number of positive innovations, including a new definition, a central role of non-invasive testing for myocardial ischaemia, the most contemporary prevalence of the disease, the fact that medical therapy remains paramount despite the important advances in revascularisation and many other good issues as well as some limitations. The section on medical therapy of chronic coronary syndromes patients shows some inconsistency between text and the suggested scheme as well as contradictions with recommendations of regulatory agencies. It is not immediate to appreciate what is good and what is not so good in guidelines, which are often read in a hurry. We have provided a short commentary for the readers who usually concentrate more on the figures and flowcharts rather than on the text.

Current evidence on the diagnostic and prognostic role of native T1 mapping in heart diseases.

Tissue characterization represents a prerogative of cardiac magnetic resonance. Beside late gadolinium enhancement, native T1 mapping (nT1m) reveals tissue composition. It could represent a useful tool for example when contrast medium can't be administrated. The present review summarises current evidence about nT1m in main heart diseases.

Acute Tricuspid Valve Remodelling After MitraClip Deployment: Rationale for a Dual-Staged Procedure.

A 70-year-old woman was admitted to our hospital for severe tricuspid regurgitation caused by cardioverter-defibrillator lead impingement; treatment with MitraClip system (Abbott Vascular, Santa Clara, CA) was attempted. After realizing the impossibility of grasping in the regurgitant area because of extensive leaflets gap, we implanted a clip in another commissure, even in the absence of regurgitation originating from that area. In this way, we achieved a significant acute valve remodelling, which allowed the subsequent successful deployment of a second clip in the regurgitant area. This proposed dual-staged approach can be considered systematically for the treatment of anatomies generally regarded as unfavourable or unsuitable.

Percutaneous Treatment of a Four-Leaf Clover Valve Using the MitraClip Technology.

Percutaneous treatment of tricuspid valve regurgitation using MitraClip can be performed safely achieving improvement in reduction of regurgitation. Tricuspid valve shows different anatomic variations, in particular regarding the number of leaflets, which could represent a challenge for transcatheter valve intervention. We present a case of massive tricuspid regurgitation in a 4-leaf clover valve. We implanted a first MitraClip into the anteroseptal commissure and then a second one between the 2 posterior leaflets, with a successful reduction of residual regurgitation. In conclusion, this approach can be safely performed in a 4-leaflet right ventricular valve.

Valve-in-Valve Transcatheter Aortic Valve Implantation With Acurate neo for a Degenerated bio-Bentall.

A 79-year-old man with heart failure was referred to our attention for a degenerated bio-Bentall Mitroflow 27. The Heart Team decided for a valve-in-valve (ViV) transcatheter aortic valve implantation with an Acurate neo M associated to coronary protection due to high risk of coronary obstruction (CO). Besides the supra-anular design, this case shows additional potential advantages of the Acurate neo in ViV procedures: the upper crown, which is meant to favor supra-anular anchoring, also let to cap the bioprosthesis leaflets and minimize the risk of CO; there is not any interference between the valve cage and the stents protruding into the aorta, avoiding potential stent crushing and assuming an easier future coronary engagement.

A Challenging Case of MitraClip on a Tricuspid Valve With a Redundant Eustachian Valve: Surfing Into the Right Atrium.

Transcatheter tricuspid valve intervention is gaining importance due to the development of percutaneous techniques addressing tricuspid regurgitation. The presence of a redundant eustachian valve can increase procedural complexity by restricting the manipulation of transcatheter devices. We present a case of torrential tricuspid regurgitation and a redundant eustachian valve hampering the manipulation of the delivery system. We were able to reach the tricuspid valve by looping 2 standard guidewires into the atrium. We performed a tricuspid-plasty by implanting 2 MitraClips with a satisfactory final result. This technique can be applied when the eustachian valve impairs navigation in the right atrium.