RESUMO
BACKGROUND: Intravascular lithotripsy (IVL) combined with rotational atherectomy (RA), known as Rotatripsy, is used to treat severe coronary artery calcification (CAC), though data on efficacy, midterm safety and use sequence is limited. We aimed to identify indicators for Rotatripsy use and to assess its safety and success rates, both acutely and at 1-year follow-up. METHODS: Patients undergoing Rotatripsy for severe CAC across six centers from May 2019 to December 2023 were included. Demographic, clinical, procedural and follow-up data were collected. Efficacy endpoints included device success (delivery of the RA-burr and IVL-balloon across the target lesion and administration of therapy without related complications), technical success (TIMI 3 flow and residual stenosis <30% by quantitative coronary analysis) and procedural success [composite of technical success with absence of in-hospital major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). Safety endpoints comprised Rotatripsy-related complications and MACE at 1-year follow-up. RESULTS: A total of 114 patients (75 ± 9 years, 78% male) underwent Rotatripsy for 120 lesions. In the majority of procedures RA was followed by IVL, mostly electively (n = 68, 57%) but also for balloon underexpansion (n = 37, 31%) and stent crossing failure (n = 1, 1%). Diverse and complex target lesions were addressed with an average SYNTAX score of 24.6 ± 13.0. Device, technical and procedural success were 97%, 94% and 93%, respectively. Therapy-related complications included two (2%) coronary perforations, one (1%) coronary dissection and one (1%) burr entrapment. At 1-year follow-up(present in 77(67%) patients), MACE occurred in 7(9%) cases. CONCLUSIONS: Over a 1-year follow-up period, Rotatripsy was safe and effective, predominantly using RA electively before IVL.
Assuntos
Aterectomia Coronária , Doença da Artéria Coronariana , Litotripsia , Índice de Gravidade de Doença , Calcificação Vascular , Humanos , Masculino , Feminino , Idoso , Fatores de Tempo , Aterectomia Coronária/efeitos adversos , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/terapia , Calcificação Vascular/mortalidade , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Idoso de 80 Anos ou mais , Litotripsia/efeitos adversos , Fatores de Risco , Estudos Retrospectivos , Estados UnidosRESUMO
Coronary access difficulty and stent compression by the juxtaposed aortic valve leaflet hamper percutaneous management of delayed coronary artery obstruction (CAO) after valve-in-valve (Edwards Sapien 3 in St. Jude Trifecta) transcatheter aortic valve replacement (TAVR). Here, we present a case of delayed post-TAVR CAO treated with intravascular lithotripsy and multistenting to overcome stent compression by the adjacent calcified leaflet.
Assuntos
Estenose da Valva Aórtica , Oclusão Coronária , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/etiologia , Oclusão Coronária/terapia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Desenho de PróteseRESUMO
AIMS: To evaluate the effects of MitraClip on left ventricular (LV) and left atrial (LA) myocardial wall stress as assessed with the use of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and strain imaging. METHODS AND RESULTS: Sixty-five patients with symptomatic moderate and severe mitral regurgitation (MR; age 75 ± 9 y, 57% male, 89% functional MR) treated with the use of MitraClip were evaluated. Patients were divided according to 6-month NT-proBNP tertiles. Changes in echocardiographic parameters over 6 months were assessed. Reductions in LV end-diastolic volumes (178 ± 77 mL to 170 ± 79 mL; P = .045) and LV end-systolic volumes (120 ± 70 mL to 111 ± 69 mL; P = .040) were observed in the overall population. Interestingly, low-NT-proBNP-tertile patients showed slight improvements in LV and LA longitudinal strain, whereas high-NT-proBNP-tertile patients showed impairment. CONCLUSIONS: Although MitraClip induces hemodynamic unloading in patients with predominantly functional MR, myocardial wall stress is not consistently improved. In patients with reduced NT-proBNP, improvements in LA volume index and LV and LA strains were observed. Patients who showed an increase in NT-proBNP exhibited impairment in LV and LA strain, suggesting an increase of myocardial wall stress.
Assuntos
Função do Átrio Esquerdo/fisiologia , Átrios do Coração/fisiopatologia , Implante de Prótese de Valva Cardíaca/métodos , Ventrículos do Coração/fisiopatologia , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Função Ventricular Esquerda/fisiologia , Idoso , Ecocardiografia , Feminino , Seguimentos , Átrios do Coração/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/fisiopatologia , Desenho de Prótese , Fatores de Tempo , Remodelação VentricularRESUMO
BACKGROUND: Ischemic mitral regurgitation (MR) is a known complication of ST-segment elevation myocardial infarction (STEMI) with important prognostic implications. We evaluated changes over time in ischemic MR after STEMI and the prevalence and predictors of significant (grade ≥2) MR at 12 months. Furthermore, the prognostic additional value of significant MR at 12-month follow-up over acute MR was assessed. METHODS: STEMI patients (n = 1,599; 77% male; 60 ± 12 years) treated with primary percutaneous coronary intervention underwent echocardiography <48 hours of admission (baseline) and at 12 months. Mortality data were collected during long-term follow-up. RESULTS: At baseline, significant MR was present in 103 (6%) patients. After 12 months, MR worsened ≥1 grade in 321 (20%) patients, remained stable in 963 (60%), and improved ≥1 grade in 315 (20%). Significant MR was present in 135 patients at 12 months (8%, P = .01 vs baseline). Age, left ventricular end-systolic volume, and significant MR at baseline were independently associated with significant MR at follow-up. During follow-up (median, 50 months), 121 (8%) patients died (40% of cardiovascular cause). Significant MR at follow-up was independently associated with all-cause (hazard ratio, 1.65, 95% CI, 1.02-2.99) and cardiovascular mortality (hazard ratio, 2.47; 95% CI, 1.24-4.92), also after adjusting for significant MR at baseline. CONCLUSIONS: The prevalence of significant MR after STEMI increases over time. Age, baseline left ventricular end-systolic volume, and baseline significant MR are independently associated with significant MR at follow-up. Significant MR at 12 months is associated with subsequent all-cause and cardiovascular mortality and shows additional prognostic value over acute MR.
Assuntos
Insuficiência da Valva Mitral/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Idoso , Doenças Cardiovasculares/mortalidade , Causas de Morte , Progressão da Doença , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/fisiopatologia , Mortalidade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Índice de Gravidade de Doença , Volume Sistólico , Fatores de TempoRESUMO
AIMS: Low gradient severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) may be attributed to aortic valve area index (AVAi) underestimation due to the assumption of a circular shape of the left ventricular outflow tract (LVOT) with 2-dimensional echocardiography. The current study evaluated whether fusing Doppler and multidetector computed tomography (MDCT) data to calculate AVAi results in significant reclassification of inconsistently graded severe AS. METHODS AND RESULTS: In total, 191 patients with AVAi < 0.6 cm2/m2 and LVEF ≥ 50% (mean age 80 ± 7 years, 48% male) were included in the current analysis. Patients were classified according to flow (stroke volume index <35 or ≥35 mL/m2) and gradient (mean transaortic pressure gradient ≤40 or >40 mmHg) into four groups: normal flow-high gradient (n = 72), low flow-high gradient (n = 31), normal flow-low gradient (n = 46), and low flow-low gradient (n = 42). Left ventricular outflow tract area was measured by planimetry on MDCT and combined with Doppler haemodynamics on continuity equation to obtain the fusion AVAi. The group of patients with normal flow-low gradient had significantly larger AVAi and LVOT area index compared with the other groups. Although MDCT-derived LVOT area index was comparable among the four groups, the fusion AVAi was significantly larger in the normal flow-low gradient group. By using the fusion AVAi, 52% (n = 24) of patients with normal flow-low gradient and 12% (n = 5) of patients with low flow-low gradient would have been reclassified into moderate AS due to AVAi ≥ 0.6 cm2/m2. CONCLUSION: The fusion AVAi reclassifies 52% of normal flow-low gradient and 12% of low flow-low gradient severe AS into true moderate AS, by providing true cross-sectional LVOT area.
RESUMO
A 54-year-old woman was referred for veno-venous extracorporeal oxygenation membrane (VV-ECMO) due to refractory hypoxic respiratory failure caused by COVID-19, despite mechanical ventilation and prolonged prone positioning.
Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Feminino , Humanos , Pessoa de Meia-Idade , Decúbito VentralRESUMO
BACKGROUND: Use of intravascular lithotripsy (IVL) for treating peri-stent calcification is increasing. However, this indication remains 'off-label'. We aimed to investigate the efficacy and clinical outcomes of in-stent IVL. METHODS: Patients from five European centers who underwent in-stent IVL were included between 2019 and 2023. Demographic, clinical, procedural and follow-up data were collected from electronic hospital records. Angiographic and intracoronary imaging (ICI) data were analyzed in a centralized core-laboratory. RESULTS: Of 101 patients (71.2 ± 9.2 years), 56(55 %) received in-stent IVL for late stent failure (median 109 days post-PCI) due to calcific neoatherosclerosis or extra-stent calcification(late-IVL), while 45(45 %) underwent bail-out IVL due to stent infraexpasion (immediate-IVL). Both late-IVL and immediate-IVL significantly improved angiographic %diameter stenosis (73.7[59.6-89.8]% to 16.4 [10.4-26.9]%;p < 0.0001 and 28.6[22.5-43.3]% to 14.1[10.3-29.4]%;p < 0.0001, and minimum lumen area (MLA) (3.4 ± 1.2 to 8.6 ± 2.5 mm2;p < 0.002 and 5.4 ± 1.9 to 7.3 ± 1.9;p < 0.0001).Device(98 %) and procedural success(80 %) were high. MACE rates in-hospital (2 %), 30-days (3 %),6-months(5 %) and 1-year(7 %) were low and comparable in both groups. Acute diameter gain was lower in immediate-IVL (2.1 ± 0.7 mm vs. 0.5 ± 0.4 mm;p < 0.0001). This, however, was explained by significant differences in pre-IVL angiographic and ICI parameters (%diameter stenosis 73.7[59.6-89.8] vs. 28.6[22.5-43.3]%; p < 0.0001 and MLA (3.4 ± 1.2 vs 5.4 ± 1.9 mm2; p < 0.0001), whereas post-IVL percentage diameter stenosis (16.4(10.4-26.9) vs. 14.1(10.3-29.4);p = 0.914) and MLA (8.6 ± 2.5vs. 7.4 ± 1.9 mm2;p = 0.064) in late- and immediate-IVL were comparable. CONCLUSIONS: IVL in-stent due to peri-stent calcification is an effective strategy, both late and immediately after stent implantation. Overall, MACE rates at short- and mid-term were low and comparable in both groups, although clinical findings should be taken with caution.
Assuntos
Calcinose , Litotripsia , Intervenção Coronária Percutânea , Calcificação Vascular , Humanos , Constrição Patológica , Litotripsia/efeitos adversos , Stents , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/terapiaRESUMO
BACKGROUND: Coronary artery bypass grafting (CABG) is a cornerstone treatment for coronary artery disease, with the use of saphenous vein grafts (SVGs) being prevalent. However, SVGs are susceptible to high failure rates due to graft inflammation, intimal hyperplasia, and atherosclerosis, leading to a substantial number of patients requiring revascularization. Percutaneous coronary intervention (PCI) of SVGs poses unique challenges, including increased risk of distal embolization and perforation due to the grafts' structure and atherosclerotic nature. The role of intravascular lithotripsy (IVL) in calcific SVG lesions has not been elucidated. METHODS: We retrospectively analyzed four cases of patients treated with IVL for SVG stenosis at Leiden University Medical Centre between May 2019 and December 2023. Quantitative coronary analysis and intravascular ultrasound were utilized to assess procedural success and mid- to long-term clinical outcomes were reported as well. RESULTS: In all 4 cases, IVL was performed in stent (2 due to calcific in-stent neoatherosclerosis; 2 bail-out due to extrinsic stent calcification). No major adverse cardiovascular events (MACE) were reported during mid- to long-term follow-up. The procedure demonstrated effective calcium cracking, leading to optimal stent expansion and minimal residual stenosis with a low risk of procedural complications. CONCLUSIONS: IVL represents a promising approach for managing calcified peri-stent SVG lesions, showing potential for safe and effective revascularization with minimal complications. These findings suggest that IVL could be incorporated into the treatment paradigm for calcified peri-stent SVG stenosis, warranting further investigation in larger, prospective studies to validate its efficacy and safety.
RESUMO
BACKGROUND: Transcatheter edge-to-edge repair (TEER) using the MitraClip (Abbott Vascular) system has emerged as a standard treatment for patients with symptomatic severe secondary or inoperable primary mitral regurgitation (MR). The relatively recent approval of the PASCAL Transcatheter Valve Repair System (Edwards Lifesciences) has expanded the options of TEER devices. However, evidence comparing PASCAL with MitraClip systems is still limited. METHODS: We conducted a systematic literature research and meta-analysis in PubMed, Medline, and EMBASE databases for studies comparing PASCAL and MitraClip systems. RESULTS: Four observational studies and 1 randomized controlled trial, involving 1315 patients total, were eligible for inclusion. All patients exhibited symptomatic (NYHA II-IV) MR grades 3+ or 4+. Baseline characteristics were comparable across all included studies. The clinical outcomes were assessed according to the Mitral Valve Academic Research Consortium consensus. The procedural success rates for the 2 devices were comparable in terms of achieving post-procedural MR grades of less than or equal to 2+ and less than or equal to 1+. Furthermore, most patients improved their clinical status, with no significant differences between patients treated with PASCAL and those treated with MitraClip. In terms of safety, both procedures exhibited low overall mortality rates and occurrence of major adverse events (MAE), without significant difference between the 2 devices. These findings remained consistent in both short- and long-term follow-up assessments. CONCLUSIONS: Our study revealed similar effectiveness and safety profiles between the PASCAL and MitraClip devices in patients experiencing significant symptomatic MR.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Mitral , Humanos , Cateterismo Cardíaco/métodos , Catéteres , Implante de Prótese de Valva Cardíaca/métodos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/cirurgia , Insuficiência da Valva Mitral/etiologia , Resultado do TratamentoAssuntos
Anomalias dos Vasos Coronários , Fístula Vascular , Humanos , Resultado do Tratamento , Ecocardiografia , Fístula Vascular/diagnóstico por imagem , Fístula Vascular/etiologia , Fístula Vascular/cirurgia , Angiografia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Angiografia CoronáriaAssuntos
Angioplastia Coronária com Balão , Aterectomia Coronária , Doença da Artéria Coronariana , Litotripsia , Calcificação Vascular , Humanos , Aterectomia Coronária/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Angioplastia Coronária com Balão/efeitos adversos , Coração , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/terapia , Angiografia CoronáriaRESUMO
AIMS: Our aim was to evaluate the acute effects of transcatheter edge-to-edge mitral valve repair using the MitraClip device on mitral valve geometry in patients with functional mitral regurgitation (FMR). METHODS AND RESULTS: Forty-two patients (age 73 years [IQ range 66.1-78.0], 55% men, 62% ischaemic FMR) with moderate-to-severe and severe FMR treated with the MitraClip were included. Three-dimensional transoesophageal echocardiography was performed prior to and immediately after MitraClip implantation. Acute changes of mitral annular and leaflet geometry were assessed with dedicated mitral modelling software. FMR less than moderate grade was achieved in 36 (86%) patients. After MitraClip implantation, the mitral annulus became more elliptical (ellipticity from 122±17% to 129±18%; p=0.04) with a non-significant reduction in anteroposterior diameter (33±6 to 32±5 mm, p=0.08). The coaptation area increased from 350 mm2 (IQ range 289-493 mm2) to 434 mm2 (IQ range 328-523 mm2, p=0.008). In particular, a larger part of the anterior mitral leaflet was included in the coaptation, leaving a smaller exposed anterior leaflet length of the A2 segment (from 27±6 mm to 25±5 mm, p<0.05) while the exposed length of the posterior leaflet (P2 level) remained unchanged (12±4 mm pre- vs. 13±4 mm post-repair, p=0.15). There was no change in total leaflet area (1,811±582 mm2 pre- vs. 1,870±506 mm2 post-repair, p=0.18). Annular height to intercommissural width ratio and tenting volume remained unchanged, suggesting no increase in leaflet stress. CONCLUSIONS: The MitraClip device affects MV geometry in FMR patients by increasing mitral annular ellipticity and coaptation area.
Assuntos
Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Idoso , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/fisiopatologia , Modelos Anatômicos , Resultado do TratamentoRESUMO
AIMS: Our aim was to evaluate the acute effects of transcatheter edge-to-edge mitral valve repair using the MitraClip device on mitral valve geometry in patients with functional mitral regurgitation (FMR). METHODS AND RESULTS: Forty-two patients (age 73 years [IQ range 66.1-78.0], 55% men, 62% ischaemic FMR) with moderate-to-severe and severe FMR treated with the MitraClip were included. Three-dimensional transoesophageal echocardiography was performed prior to and immediately after MitraClip implantation. Acute changes of mitral annular and leaflet geometry were assessed with dedicated mitral modelling software. FMR less than moderate grade was achieved in 36 (86%) patients. After MitraClip implantation, the mitral annulus became more elliptical (ellipticity from 122±17% to 129±18%; p=0.04) with a non-significant reduction in anteroposterior diameter (33±6 to 32±5 mm, p=0.08). The coaptation area increased from 350 mm2 (IQ range 289-493 mm2) to 434 mm2 (IQ range 328-523 mm2, p=0.008). In particular, a larger part of the anterior mitral leaflet was included in the coaptation, leaving a smaller exposed anterior leaflet length of the A2 segment (from 27±6 mm to 25±5 mm, p<0.05) while the exposed length of the posterior leaflet (P2 level) remained unchanged (12±4 mm pre- vs. 13±4 mm post-repair, p=0.15). There was no change in total leaflet area (1,811±582 mm2 pre- vs. 1,870±506 mm2 post-repair, p=0.18). Annular height to intercommissural width ratio and tenting volume remained unchanged, suggesting no increase in leaflet stress. CONCLUSIONS: The MitraClip device affects MV geometry in FMR patients by increasing mitral annular ellipticity and coaptation area.
Assuntos
Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Instrumentos Cirúrgicos/efeitos adversos , Idoso , Ecocardiografia Tridimensional/instrumentação , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/instrumentação , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/fisiopatologiaRESUMO
Elevated systolic pulmonary artery pressure (SPAP) after ST-segment elevation myocardial infarction (STEMI) has been associated with adverse outcome. However, little is known about the development of increased SPAP after STEMI treated with primary percutaneous coronary intervention. The aims of this study were to investigate the incidence and determinants of elevated SPAP (SPAP ≥36 mm Hg at 12 months) after first STEMI and to analyze its prognostic implications. A total of 705 patients (60 ± 12 years; 75% men; left ventricular ejection fraction [LVEF] 47 ± 9%) with first STEMI treated with primary percutaneous coronary intervention were evaluated. Two-dimensional echocardiography was available at baseline and 12-month follow-up. Data on all-cause mortality were collected at long-term follow-up. Incident elevated SPAP was present in 5% (n = 38) of patients. Patients with incident elevated SPAP were older (66 ± 12 vs 60 ± 11 years, p = 0.001), had more systemic hypertension (58% vs 30%, p <0.001) and lower LVEF (43 ± 9% vs 48 ± 8%, p <0.001) than their counterparts. Left atrial volume was larger (23 ± 11 vs 18 ± 6 ml/m(2), p = 0.006), and moderate to severe mitral regurgitation was more prevalent in patients with incident elevated SPAP (16% vs 7%, p = 0.05). Independent correlates of incident elevated SPAP at 12-month follow-up were age (odds ratio [OR] 1.04, 95% CI 1.01 to 1.08, p = 0.01), hypertension (OR 2.52, 95% CI 1.23 to 5.14, p = 0.01), baseline LVEF (OR 0.94, 95% CI 0.90 to 0.98, p = 0.003), and baseline left atrial volume (OR 1.08, 95% CI 1.03 to 1.12, p = 0.001). Incident elevated SPAP was independently associated with all-cause mortality (hazard ratio 3.84, 95% CI 1.76 to 8.39, p = 0.001). In conclusion, although the incidence of elevated SPAP after STEMI is low, its presence is independently associated with increased risk of all-cause mortality at follow-up.
Assuntos
Intervenção Coronária Percutânea , Artéria Pulmonar/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Idoso , Feminino , Humanos , Hipertensão Pulmonar/epidemiologia , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/epidemiologia , Razão de Chances , Prognóstico , Modelos de Riscos Proporcionais , Pressão Propulsora Pulmonar , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Volume Sistólico , Sístole , Resultado do TratamentoRESUMO
Mitral regurgitation is one of the most prevalent valvular heart diseases and its prevalence is related to population aging. Elderly patients with age-associated co-morbidities have an increased risk for conventional mitral valve surgery. Transcatheter mitral valve repair has emerged as a feasible and safe alternative in patients with contraindications for surgery or high operative risk. Several transcatheter mitral repair technologies have been developed during the last decade. While the development of some devices was abandoned due to suboptimal results, others demonstrated to be safe and effective and have been included in current practice guidelines. Not all technologies are suitable for all mitral anatomies and regurgitation mechanisms. Therefore, accurate evaluation of mitral valve anatomy and function are pivotal to the success of these therapies. Cardiac imaging plays a central role in selecting patients, guiding the procedure and evaluating the durability of the repair at follow-up.
Assuntos
Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca/métodos , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/cirurgia , Cirurgia Assistida por Computador , Humanos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/etiologiaRESUMO
BACKGROUND: Changes in mitral valve geometry in patients with significant aortic regurgitation (AR) have not been evaluated. The aim of the present study was to assess the prevalence of significant secondary mitral regurgitation (MR; grade ≥ 2) and the geometric characteristics of the mitral valve in patients with moderate and severe AR (grade ≥ 2) undergoing aortic valve and root surgery. METHODS: One-hundred twenty patients (mean age, 54 ± 15 years; 65% men) with AR grade ≥ 2 undergoing aortic valve and root surgery were retrospectively evaluated. The presence of MR grade ≥ 2 and geometry of the mitral valve were assessed on preoperative transthoracic echocardiography. Left ventricular (LV) dimensions and mitral valve geometry were compared between patients with MR grade ≥ 2 and patients without. RESULTS: MR grade ≥ 2 was present in 28 patients (23%). Patients with MR grade ≥ 2 had higher European System for Cardiac Operative Risk Evaluation II scores and more often used ß-blockers and diuretics than their counterparts. Patients with MR grade ≥ 2 had larger tenting areas (mean, 1.59 ± 0.79 vs 1.25 ± 0.41 cm(2); P = .003), larger inter-papillary muscle distances (mean, 28.4 ± 9.5 vs 24.8 ± 5.2 mm; P = .014), larger left atria (mean, 40.9 ± 13.7 vs 32.0 ± 12.2 mL/m(2); P = .002), and lower LV ejection fractions (mean, 47.3 ± 12.2% vs 54.3 ± 9.3%; P = .002) as compared to patients with MR grade < 2. However, there were no differences in indexed LV volumes. On multivariate logistic regression analysis, LV ejection fraction (odds ratio, 0.94; 95% confidence interval, 0.89-0.99; P = .018) and indexed left atrial volume (odds ratio, 1.05; 95% confidence interval, 1.01-1.10; P = .019) remained independently associated with MR grade ≥ 2 after correcting for tenting area and inter-papillary muscle distance. CONCLUSIONS: Among patients with AR grade ≥ 2 undergoing aortic valve and root surgery, the prevalence of MR grade ≥ 2 was 23%. Lower LV ejection fraction and larger left atrial volume were independently associated with MR grade ≥ 2.
Assuntos
Insuficiência da Valva Aórtica/complicações , Insuficiência da Valva Aórtica/diagnóstico por imagem , Ecocardiografia/métodos , Interpretação de Imagem Assistida por Computador/métodos , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Recently, it has been hypothesized that mitral leaflet remodelling may play a role in the pathophysiology of functional mitral regurgitation (FMR). We investigated the characteristics, determinants, and relation of mitral leaflet remodelling to FMR severity. METHODS AND RESULTS: Three-dimensional transoesophageal echocardiographic data of the mitral valve (MV) were studied in 30 patients with FMR ≥ grade 3 (≥3), 24 patients with FMR < grade 3 (<3), and 22 controls with normal MV. FMR <3 and ≥3 patients showed leaflet remodelling compared with control subjects with larger overall MV leaflet areas (11.47 ± 3.16 and 9.58 ± 1.99 vs. 7.30 ± 1.57 cm(2)/m(2), respectively; all P < 0.01). Tenting volume (r(2) = 0.55), left ventricular (LV) ejection fraction (r(2) = 0.20), annulus area (r(2) = 0.87), and LV sphericity index (r(2) = 0.25) were correlated with overall MV leaflet area (all P < 0.001). Although these correlates were similar between FMR <3 and ≥3 patients (all P > 0.05), the overall MV leaflet area was smaller in FMR ≥3 compared with FMR <3 patients (P = 0.01), indicating less remodelling despite similar tethering degree. Particularly, coaptation/overall MV leaflet area ratio ≤0.24, reflecting insufficient leaflet remodelling, was associated with FMR ≥3 [area under receiver operating characteristic (ROC) curve = 0.93, sensitivity 90%, and specificity 91%]. This ratio was independently associated with FMR ≥3 (odds ratio 70.0, 95% confidence interval 11.7-419.9, P < 0.001) and showed significant correlation with effective regurgitant orifice area (r(2) = 0.38, P < 0.001). CONCLUSION: MV leaflet remodelling in FMR is common and relates to LV function, LV sphericity, MV tenting volume, and annulus dilatation. Insufficient leaflet remodelling relative to the mitral annular and LV changes is independently associated with FMR severity.
Assuntos
Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/fisiopatologia , Valva Mitral/fisiologia , Regeneração/fisiologia , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Análise Multivariada , Curva ROC , Valores de Referência , Índice de Gravidade de Doença , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Remodelação Ventricular/fisiologiaRESUMO
BACKGROUND: Atheroembolic renal disease, due to dislodgement of cholesterol crystals during maneuvering of a large catheter across the aorta and deployment of the transcatheter prosthesis within a calcified aortic valve, may be one of the pathophysiological mechanisms of acute kidney injury (AKI) complicating transcatheter aortic valve implantation (TAVI). OBJECTIVE: To investigate the association between the atherosclerotic burden and plaque characteristics of the aortic valve and thoracic aorta, evaluated with multidetector CT (MDCT), and the occurrence of AKI after TAVI. METHODS: Aortic valve calcification, atherosclerosis burden, and plaque characteristics of the thoracic aorta (including aortic root, ascending aorta, aortic arch, and descending aorta) were analyzed in preprocedural MDCT data of 210 TAVI patients (age, 81 ± 7.1 years; 51.4% men). The thoracic aorta was divided into ascending aorta, aortic arch, and descending thoracic aorta which was further divided into 5 to 8 segments according to the posterior intercostal arteries. Each segment where the maximum wall thickness exceeded ≥ 2 mm was defined as diseased segment with atherosclerotic plaque. Aortic atherosclerosis burden was defined as the proportion of thoracic aortic segments with atherosclerosis. AKI was defined by a creatinine level ≥ 1.5 × baseline or ≥ 26.4 µmol/L above baseline. MDCT data were correlated with the occurrence of postprocedural AKI in a multivariate logistic regression model. RESULTS: Postprocedural AKI occurred in 51 patients (24.3%). In patients with AKI, the burden of overall (87.5% [75%-90%] vs 71.4% [50%-87.5%]; P < .001) and noncalcified atherosclerosis (42.9% [22.2%-62.5%] vs 12.5% [0%-28.6%]; P < .001) and the maximum plaque thickness (5.7 ± 1.8 mm vs 4.5 ± 1.4 mm; P < .001) were larger compared with patients without AKI. The burden of noncalcified atherosclerosis remained independently associated with AKI (odds ratio, 1.03 [per each 1% of increase in aortic segments with noncalcified atherosclerosis]; 95% confidence interval 1.01-1.05; P = .006) after adjusting for baseline renal function, logistic EuroSCORE, and procedural access. In contrast, aortic valve calcification was not independently associated with AKI. CONCLUSION: In patients undergoing TAVI, occurrence of postprocedural AKI was associated with the extent of noncalcified atherosclerotic plaque burden of the thoracic aorta.