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1.
Echocardiography ; 41(10): e70001, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-39412444

RESUMO

INTRODUCTION: The hemodynamic effects of mitral valve repair (MVr) with respect to transmitral pressure gradients (TMPGs) have not been described well in patients undergoing leaflet preservation techniques. In a population of patients undergoing robotic MVr with leaflet preservation, we investigate the expected change of the postrepair intraoperative TMPG in the postoperative follow-up period. METHODS: We retrospectively studied 144 adult patients who underwent robotic MVr. Demographic, clinical, procedural, and echocardiographic data were collected and analyzed. RESULTS: We found a slight increase in the mean TMPG from the intraoperative postrepair to the immediate postoperative period (intraoperative 3.3 ± 1.4 mmHg vs. first postoperative transthoracic echocardiography [TTE] follow-up 3.6 ± 1.9 mmHg, p = 0.016) with a gradual decline in the long-term follow-up (mean TMPG at last follow-up TTE 2.4+2.1 mmHg). When dichotomizing the patient population using a cutoff of 3 mmHg for the intraoperative mean TMPG, patients with an intraoperative mean TMPG > 3 mmHg had higher mean TMPG gradients at first TTE (4.5 ± 2.4 vs. 3.1 ± 1.3 mmHg, p < 0.001) as well as at last TTE (3.0± 2.2 vs. 2.1 ± 2.0 mmHg, p = 0.01) when compared with patients with an intraoperative mean TMPG ≤ 3 mmHg. There was no difference in clinical outcomes. CONCLUSIONS: Although the hemodynamic effect of MVr seems to be small, patients with an intraoperative TMPG > 3 mmHg have a higher mean TMPG at follow-up. The hemodynamic effect does not seem to have an impact on clinical outcome.


Assuntos
Insuficiência da Valva Mitral , Valva Mitral , Procedimentos Cirúrgicos Robóticos , Humanos , Feminino , Masculino , Insuficiência da Valva Mitral/cirurgia , Insuficiência da Valva Mitral/fisiopatologia , Estudos Retrospectivos , Valva Mitral/cirurgia , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento , Ecocardiografia/métodos , Seguimentos , Idoso
2.
Eur Heart J ; 44(21): 1910-1923, 2023 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-36924209

RESUMO

AIMS: Severe tricuspid regurgitation (TR) exhibits high 1-year morbidity and mortality, yet long-term cardiovascular risk overall and by subgroups remains unknown. This study characterizes 5-year outcomes and identifies distinct clinical risk profiles of severe TR. METHODS AND RESULTS: Patients were included from a large US tertiary referral center with new severe TR by echocardiography based on four-category American Society of Echocardiography grading scale between 2007 and 2018. Patients were categorized by TR etiology (with lead present, primary, and secondary) and by supervised recursive partitioning (survival trees) for outcomes of death and the composite of death or heart failure hospitalization. The Kaplan-Meier estimates and Cox regression models were used to evaluate any association by (i) TR etiology and (ii) groups identified by survival trees and outcomes over 5 years. Among 2379 consecutive patients with new severe TR, median age was 70 years, 61% were female, and 40% were black. Event rates (95% confidence interval) were 30.9 (29.0-32.8) events/100 patient-years for death and 49.0 (45.9-52.2) events/100 patient-years for the composite endpoint, with no significant difference by TR etiology. After applying supervised survival tree modeling, two separate groups of four phenoclusters with distinct clinical prognoses were separately identified for death and the composite endpoint. Variables discriminating both outcomes were age, albumin, blood urea nitrogen, right ventricular function, and systolic blood pressure (all P < 0.05). CONCLUSION: Patients with newly identified severe TR have high 5-year risk for death and death or heart failure hospitalization. Partitioning patients using supervised survival tree models, but not TR etiology, discriminated clinical risk. These data aid in identifying relevant subgroups in clinical trials of TR and clinical risk/benefit analysis for TR therapies.


Assuntos
Insuficiência Cardíaca , Insuficiência da Valva Tricúspide , Humanos , Idoso , Insuficiência da Valva Tricúspide/etiologia , Estudos Retrospectivos , Prognóstico , Ecocardiografia , Insuficiência Cardíaca/complicações , Resultado do Tratamento , Índice de Gravidade de Doença
3.
J Card Surg ; 37(2): 290-296, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34665478

RESUMO

BACKGROUND: The durability of surgical repair for degenerative versus ischemic mitral regurgitation (MR) is thought to be markedly different. We, therefore, examined late outcomes and durability for mitral repair in a large cohort of patients receiving a single annuloplasty device. METHODS: A total of 749 consecutive patients receiving mitral repair for degenerative mitral regurgitation (DMR) or ischemic mitral regurgitation (IMR) were evaluated from a prospective database. Patients with tricuspid or maze surgery were included. Papillary muscle rupture and mixed valve etiologies were excluded. Outcomes were compared for IMR versus DMR. RESULTS: Patients with DMR were younger and less urgent. Patients with IMR had mean end-systolic diameter 4.5 ± 1.1 cm. All patients received the same complete semirigid annuloplasty device with median ring size 32 mm for DMR and 24 mm for IMR. New York Heart Association failure class improved from 2.8 to 1.5 (p < .001). Patients with DMR had lower operative mortality (1/384 [0.3%] vs. 26/365 [7%], p < .0001) and shorter length of stay. A 15-year survival was better with DMR (63% ± 3% vs. 13% ± 2%, p < .001). At 10 years, the incidence of recurrent ≥2+ MR (10% ± 2% vs. 16% ± 2%, p = .16) was not significantly different. Predictors of recurrent ≥2+ MR were female gender (odds ratio [OR]: 3.0 (1.9-4.8, p < .0001), and prior operation (OR: 2.4 [1.3-4.5], p = .02) but not IMR (OR: 1.4 [0.9-2.3], p = .15). CONCLUSIONS: In this series, where patients with IMR had relatively preserved ventricular dimensions, the primary determinants of late recurrent MR were female gender and prior operation but not IMR versus DMR. Selected patients with IMR can obtain relatively durable mitral repair despite higher operative risk and lower survival compared to DMR.


Assuntos
Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Feminino , Seguimentos , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Resultado do Tratamento , Valva Tricúspide
4.
J Card Surg ; 36(9): 3205-3206, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34218461

RESUMO

Zubarevich et al. present the 30 day and 1-year outcomes of redo mitral valve replacement in 58 high-risk patients. The authors conclude that careful patient selection and risk stratification provides acceptable surgical results in this cohort. This series reminds us that increased use of bioprostheses, increased use of mitral replacement instead of repair, and an aging population drive the volume of high-risk redo mitral replacement. It remains to be seen whether redo mitral mortality is getting better or worse, but the risk and the patients will be with us for some time.


Assuntos
Bioprótese , Implante de Prótese de Valva Cardíaca , Idoso , Humanos , Valva Mitral/cirurgia , Reoperação , Resultado do Tratamento
5.
J Card Surg ; 36(12): 4652-4653, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34558108

RESUMO

BACKGROUND: Techniques and results of aortic valve repair remain challenging. AIMS: Safari et al. seek to improve aortic valve repair by either aortic patching or valve sparing root replacement. MATERIALS AND METHODS: The results of bicuspid aortic valve (BAV) repair in 142 patients were examined withor without valve sparing root replacement. RESULTS: Isolated BAV repair with or without valve sparing root replacement provided goodclinical outcomes with relatively low reoperation rate and durable valve function. DISCUSSION: While clinical outcome from BAV repair was generally good, the authors have stopped pericardial patch augmentation of BAV leaflets due to suboptimal durability. CONCLUSION: Thelack of a durable valve patch material and the modest durability of BAV repairin general point out that aortic valve repair remains an ongoing struggle inmaterial science.


Assuntos
Insuficiência da Valva Aórtica , Doença da Válvula Aórtica Bicúspide , Procedimentos Cirúrgicos Cardíacos , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Humanos , Ciência dos Materiais , Reoperação , Estudos Retrospectivos , Resultado do Tratamento
6.
J Card Surg ; 36(1): 390-391, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33135218

RESUMO

Maeda et al. present what may be the second reported case of transcatheter aortic valve replacement (TAVR) followed by staged open surgical aortic valve replacement (SAVR) in a high-risk patient. The authors propose that TAVR may serve as a bridge procedure before SAVR for aortic stenosis in selected younger patients with high surgical risk. Further experience may clarify how long to wait after TAVR to perform SAVR. Timing will be a balance between improving surgical risk versus increasing difficulty removing the prosthesis. Knowledge of TAVR durability will ultimately be needed to decide between "destination" TAVR versus bridging to SAVR with a more durable device.


Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Humanos , Fatores de Risco , Resultado do Tratamento
7.
J Card Surg ; 36(7): 2452-2453, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33896041

RESUMO

Habertheuer et al. present a risk scoring system for predicting morbidity and mortality in 1181 patients undergoing surgery for drug associated endocarditis. The authors conclude that drug-related endocarditis is associated with significant morbidity and mortality and that an easily-applied risk stratification score may aid in clinical decision making. The authors demonstrate excellent predictive accuracy in a multi-institutional dataset, and the system is applicable to multivalve patients. Time will tell if application of this or other risk scoring systems can truly provide a roadmap to improved outcomes.


Assuntos
Endocardite , Tomada de Decisão Clínica , Endocardite/cirurgia , Humanos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
8.
J Card Surg ; 36(4): 1219-1225, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33462900

RESUMO

BACKGROUND: Port-access (PORT) and robotic (ROBO) mitral repair are well established, but differences in patient selection and outcomes are not well documented. METHODS: A retrospective analysis was performed on 129 ROBO and 628 PORT mitral repairs at one institution. ROBO patients had 4 cm nonrib spreading incisions with robotic assistance, while PORT patients had 6-8 cm rib spreading incisions with thoracoscopic assistance. Propensity score analysis matched patients for differences in baseline characteristics. RESULTS: Unmatched ROBO patients were younger (58 ± 11 vs. 61 ± 13, p = .05), had a higher percentage of males (77% vs. 63%, p = .003) and had less NYHA Class 3-4 symptoms (11% vs. 21%, p < .01), less atrial fibrillation (19% vs. 29%, p = .02) and less tricuspid regurgitation (14% vs. 24%, p = .01). Propensity score analysis of matched patients showed that pump time (275 ± 57 vs. 207 ± 55, p < .0001) and clamp time (152 ± 38 vs. 130 ± 34, p < .0001) were longer for ROBO patients. However, length of stay, postoperative morbidity, and 5-year survival (97 ± 1% vs. 96 ± 3%, p = .7) were not different. For matched patients with degenerative valve disease, 5-year incidence of mitral reoperation (3 ± 2% vs. 1 ± 1%), severe mitral regurgitation (MR) (6 ± 4% vs. 1 ± 1%), or ≥2 + MR (12 ± 5% vs. 12 ± 4%), were not significantly different between ROBO versus PORT approaches. Predictors of recurrent moderate MR were connective tissue disease, functional etiology, and non-White race, but not surgical approach. CONCLUSIONS: In this first comparison out to 5 years, robotic versus port-access approach to mitral repair had longer pump and clamp times. Perioperative morbidity, 5-year survival, and 5-year repair durability were otherwise similar.


Assuntos
Insuficiência da Valva Mitral , Valva Mitral , Procedimentos Cirúrgicos Robóticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Pontuação de Propensão , Estudos Retrospectivos , Resultado do Tratamento
9.
J Card Surg ; 36(6): 1969-1978, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33651483

RESUMO

BACKGROUND: Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented. METHODS: From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk. RESULTS: Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46). CONCLUSIONS: In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.


Assuntos
Bioprótese , Endocardite , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Valva Aórtica/cirurgia , Endocardite/cirurgia , Humanos , Reoperação , Estudos Retrospectivos
10.
Circulation ; 139(1): 37-47, 2019 01 02.
Artigo em Inglês | MEDLINE | ID: mdl-30586701

RESUMO

BACKGROUND: Secondary mitral regurgitation (SMR) occurs in the absence of organic mitral valve disease and may develop as the left ventricle dilates or remodels or as a result of leaflet tethering with impaired coaptation, most commonly from apical and lateral distraction of the subvalvular apparatus, with late annular dilatation. The optimal therapy for SMR is unclear. This study sought to evaluate the 1-year adjudicated outcomes of all patients with SMR undergoing the MitraClip procedure in the EVEREST II (Endovascular Valve Edge-to-Edge Repair Study) Investigational Device Exemption program, which is comprised of the randomized clinical trial, the prospective High-Risk Registry, and the REALISM Continued Access Registry (Multicenter Study of the MitraClip System). METHODS: Patients with 3+/4+ SMR enrolled in EVEREST II were stratified by non-high surgical risk (non-HR) and high surgical risk (HR) status (defined as Society of Thoracic Surgeons risk of mortality ≥12% or predefined risk factors). Clinical, echocardiographic, and functional outcomes at 1 year were evaluated. RESULTS: A total of 616 patients (482 HR, 134 non-HR; mean age, 73.3±10.5 years; Society of Thoracic Surgeons risk, 10.2±6.9%) with SMR underwent the MitraClip procedure. At baseline, 80.5% of patients were in New York Heart Association class III/IV. Major adverse events at 30 days included death (3.6%), stroke (2.3%), and renal failure (1.5%). At discharge, 88.8% had MR ≤2+. At 1 year, there were 139 deaths, and the Kaplan-Meier estimate of freedom from mortality was 76.8%. The majority of surviving patients (84.7%) remained with MR ≤2+ and New York Heart Association class I/II (83.0%). Kaplan-Meier survival at 1 year was 74.1% in HR patients and 86.4% in non-HR patients ( P=0.0175). At 1 year, both groups achieved comparable MR reduction (MR ≤2+, 84.0% versus 87.0%) and improvement in left ventricular end-diastolic volume (-8.0 mL versus -12.7 mL), whereas New York Heart Association class I/II was found in 80.1% versus 91.8% ( P=0.008) of HR and non-HR patients, respectively. In HR patients, the annualized rate of heart failure hospitalizations decreased from 0.68 to 0.46 in the 12 months before to 12 months after the procedure ( P<0.0001). CONCLUSIONS: Transcatheter mitral valve repair with the MitraClip in patients with secondary MR is associated with acceptable safety, reduction of MR severity, symptom improvement, and positive ventricular remodeling. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov . Unique identifiers: NCT00209274, NCT01940120, and NCT01931956.


Assuntos
Cateterismo Cardíaco/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Ecocardiografia Transesofagiana , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/fisiopatologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Desenho de Prótese , Recuperação de Função Fisiológica , Sistema de Registros , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
11.
Curr Cardiol Rep ; 21(4): 23, 2019 03 04.
Artigo em Inglês | MEDLINE | ID: mdl-30828749

RESUMO

PURPOSE OF REVIEW: Detail the current strategies for the management of valve dysfunction in Marfan syndrome (MFS), understand the limitations of surgical interventions, and delineate the likely direction of future innovations. RECENT FINDINGS: Significant advances in both medical and surgical management of MFS have been made over the last 50 years. This has resulted in improved overall outcomes. As MFS patients age, new clinical challenges that were once rare have emerged and can require complex care strategies. Medical management has seen advances and focuses on anti-impulse and molecular-based pharmacotherapy, along with close monitoring with serial imaging to minimize acute aortic dissection risk by selecting appropriate timing of prophylactic surgical intervention with increasing aortic dimensions. Ongoing trials are evaluating other potential drug therapies with the ultimate goal of targeted treatment. Over the last 50 years, significant advances have been made in the understanding and management of MFS. A move to prophylactic surgery for aortopathy and valve disease has progressed from a valve replacement to a valve-sparing strategy in many cases. However, the durability of these repairs is variable and the possibility of reintervention looms.


Assuntos
Dissecção Aórtica , Doenças das Valvas Cardíacas , Síndrome de Marfan , Dissecção Aórtica/complicações , Aorta , Doenças das Valvas Cardíacas/complicações , Humanos , Síndrome de Marfan/complicações
12.
Hum Brain Mapp ; 39(2): 985-1003, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29164774

RESUMO

OBJECTIVES: Older adults often display postoperative cognitive decline (POCD) after surgery, yet it is unclear to what extent functional connectivity (FC) alterations may underlie these deficits. We examined for postoperative voxel-wise FC changes in response to increased working memory load demands in cardiac surgery patients and nonsurgical controls. EXPERIMENTAL DESIGN: Older cardiac surgery patients (n = 25) completed a verbal N-back working memory task during MRI scanning and cognitive testing before and 6 weeks after surgery; nonsurgical controls with cardiac disease (n = 26) underwent these assessments at identical time intervals. We measured postoperative changes in degree centrality, the number of edges attached to a brain node, and local coherence, the temporal homogeneity of regional functional correlations, using voxel-wise graph theory-based FC metrics. Group × time differences were evaluated in these FC metrics associated with increased N-back working memory load (2-back > 1-back), using a two-stage partitioned variance, mixed ANCOVA. PRINCIPAL OBSERVATIONS: Cardiac surgery patients demonstrated postoperative working memory load-related degree centrality increases in the left dorsal posterior cingulate cortex (dPCC; p < .001, cluster p-FWE < .05). The dPCC also showed a postoperative increase in working memory load-associated local coherence (p < .001, cluster p-FWE < .05). dPCC degree centrality and local coherence increases were inversely associated with global cognitive change in surgery patients (p < .01), but not in controls. CONCLUSIONS: Cardiac surgery patients showed postoperative increases in working memory load-associated degree centrality and local coherence of the dPCC that were inversely associated with postoperative global cognitive outcomes and independent of perioperative cerebrovascular damage.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Disfunção Cognitiva/etiologia , Disfunção Cognitiva/fisiopatologia , Giro do Cíngulo/fisiopatologia , Memória de Curto Prazo/fisiologia , Complicações Pós-Operatórias/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/diagnóstico por imagem , Feminino , Giro do Cíngulo/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem
13.
Am Heart J ; 203: 39-48, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30015067

RESUMO

BACKGROUND: We aimed to determine the association of MR severity and type with all-cause death in a large, real-world, clinical setting. METHODS: We reviewed full echocardiography studies at Duke Echocardiography Laboratory (01/01/1995-12/31/2010), classifying MR based on valve morphology, presence of coronary artery disease, and left ventricular size and function. Survival was compared among patients stratified by MR type and baseline severity. RESULTS: Of 93,007 qualifying patients, 32,137 (34.6%) had ≥mild MR. A total of 8094 (8.7%) had moderate/severe MR, which was primary myxomatous (14.1%), primary non-myxomatous (6.2%), secondary non-ischemic (17.0%), and secondary ischemic (49.4%). At 10 years, patients with primary myxomatous MR or MR due to indeterminate cause had survival rates of >60%; primary non-myxomatous, secondary ischemic, and non-ischemic MR had survival rates <50%. While mild (HR 1.06, 95% CI 1.03-1.09), moderate (HR 1.31, 95% CI 1.27-1.37), and severe (HR 1.55, 95% CI 1.46-1.65) MR were independently associated with all-cause death, the relationship of increasing MR severity with mortality varied across MR types (P ≤ .001 for interaction); the highest risk associated with worsening severity was seen in primary myxomatous MR followed by secondary ischemic MR and primary non-myxomatous MR. CONCLUSIONS: Although MR severity is independently associated with increased all-cause death risk for most forms of MR, the absolute mortality rates associated with worse MR severity are much higher for primary myxomatous, non-myxomatous, and secondary ischemic MR. The findings from this study support carefully defining MR by type and severity.


Assuntos
Ecocardiografia Doppler em Cores/métodos , Insuficiência da Valva Mitral/diagnóstico , Valva Mitral/diagnóstico por imagem , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Adulto , Idoso , Causas de Morte/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/fisiopatologia , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
14.
Am Heart J ; 205: 1-11, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30134187

RESUMO

BACKGROUND: Patients with heart failure (HF) and symptomatic secondary mitral regurgitation (SMR) have a poor prognosis, with morbidity and mortality directly correlated with MR severity. Correction of isolated SMR with surgery is not well established in this population, and medical management remains the preferred approach in most patients. The Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial was designed to determine whether transcatheter mitral valve (MV) repair with the MitraClip device is safe and effective in patients with symptomatic HF and clinically significant SMR. STUDY DESIGN: The COAPT trial is a prospective, randomized, parallel-controlled, open-label multicenter study of the MitraClip device for the treatment of moderate-to-severe (3+) or severe (4+) SMR (as verified by an independent echocardiographic core laboratory) in patients with New York Heart Association class II-IVa HF despite treatment with maximally tolerated guideline-directed medical therapy (GDMT) who have been determined by the site's local heart team as not appropriate for MV surgery. A total of 614 eligible subjects were randomized in a 1:1 ratio to MV repair with the MitraClip plus GDMT versus GDMT alone. The primary effectiveness end point is recurrent HF hospitalizations through 24 months, analyzed when the last subject completes 12-month follow-up, powered to demonstrate superiority of MitraClip therapy. The primary safety end point is a composite of device-related complications at 12 months compared to a performance goal. Follow-up is ongoing, and the principal results are expected in late 2018. CONCLUSIONS: HF patients with clinically significant SMR who continue to be symptomatic despite optimal GDMT have limited treatment options and a poor prognosis. The randomized COAPT trial was designed to determine the safety and effectiveness of transcatheter MV repair with the MitraClip in symptomatic HF patients with moderate-to-severe or severe SMR.


Assuntos
Insuficiência Cardíaca/complicações , Implante de Prótese de Valva Cardíaca/métodos , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Avaliação de Resultados em Cuidados de Saúde , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/mortalidade , Morbidade/tendências , Estudos Prospectivos , Desenho de Prótese , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
15.
Am Heart J ; 189: 146-157, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28625371

RESUMO

MitraClip is an approved therapy for mitral regurgitation (MR); however, health care resource utilization pre- and post-MitraClip remains understudied. METHODS: Patients with functional and degenerative MR at high surgical risk in the EVEREST II High-Risk Registry and REALISM Continued-Access Study were linked to Medicare data. Pre- and post-MitraClip all-cause death, stroke, myocardial infarction, heart failure (HF), and bleeding hospitalizations were identified. Inpatient costs, adjusted to 2010 US dollars, were calculated, and event rate ratios and cost ratios were estimated with multivariable modeling. RESULTS: Among 403 linked patients, the mean age was 80 years, 60% were male, mean baseline left ventricular ejection fraction was 49.6%, 83.3% were New York Heart Association class III/IV, 78.2% were MR grade 3+/4+, and 63.3% had functional MR. All-cause hospitalization decreased from 1,854 to 1,435/1,000 person-years (P<.001). HF hospitalization decreased following MitraClip (749 vs 332/1000 person-years, P<.001), but bleeding increased (199 vs 298/1000 person-years, P<.001). Changes in stroke and myocardial infarction were not statistically significant. Overall mean Medicare costs per patient were similar pre- and post-MitraClip, although there was a significant decrease in mean costs among those that survived a full year after MitraClip ($18,131 [SD $25,130] vs $11,679 [SD $22,486], P=.02). CONCLUSIONS: MitraClip was associated with a reduced rate of all-cause and HF hospitalizations and an increased rate of bleeding hospitalizations. One-year Medicare costs were reduced in those who survived a full year after the MitraClip procedure. Payors and providers seeking to reduce HF hospitalizations and associated Medicare costs may consider MitraClip among appropriate patients likely to survive 1 year.


Assuntos
Cateterismo Cardíaco/métodos , Recursos em Saúde/estatística & dados numéricos , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/economia , Custos e Análise de Custo , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/economia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/economia , Complicações Pós-Operatórias/economia , Período Pós-Operatório , Período Pré-Operatório , Desenho de Prótese , Sistema de Registros , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
16.
J Heart Valve Dis ; 26(2): 155-160, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28820544

RESUMO

BACKGROUND: Minimally invasive aortic valve replacement (MIAVR) through a mini-thoracotomy is comparable to AVR through a sternotomy, but may have increased surgical times. The development of adjuncts such as the automatic knot fastener and percutaneous coronary sinus (CS) catheter may reduce this disadvantage. METHODS: A retrospective review conducted between 2002 and 2015 at a single institution revealed 78 patients who underwent MIAVR with adjuncts. The automatic knot fastener was used on all patients, and a successful CS catheter was placed and confirmed by echocardiography in 67 patients (86%). Patients were propensity matched against those who had MIAVR without adjuncts (n = 78) and through a median sternotomy (n = 78) for assessment of major morbidity. Variables were compared using an unpaired t-test, Wilcoxon rank sum test, chi-squared and Fisher's exact test where appropriate. RESULTS: Patients who underwent MIAVR with adjuncts had shorter cross-clamp times (70.5 versus 108.1 and 84.4 min; p <0.0001) and cardiopulmonary bypass (CPB) times (101.1 versus 166.12 and 127.7 min; p <0.0001) than those who underwent MIAVR without adjuncts or through a median sternotomy. Patients who underwent MIAVR received fewer blood transfusions compared to those undergoing AVR via a median sternotomy (0.6 and 1.2 versus 2.5; p <0.012). Patients who underwent MIAVR with adjuncts had similar rates of new-onset atrial fibrillation (AF) than those undergoing MIAVR without adjuncts (33% versus 22%; p = 0.11), but had higher rates of AF compared to the sternotomy group (33% versus 17%; p = 0.02). Rates of in-hospital morbidity and mortality were similar between all groups. CONCLUSIONS: The use of adjuncts during MIAVR led to a significant shortening of cross-clamp and CPB times, and to a requirement for fewer blood transfusions. Morbidity and mortality rates after MIAVR were similar to those in patients undergoing a median sternotomy.


Assuntos
Valva Aórtica/cirurgia , Ponte Cardiopulmonar , Implante de Prótese de Valva Cardíaca/métodos , Duração da Cirurgia , Esternotomia , Toracotomia/métodos , Idoso , Valva Aórtica/fisiopatologia , Fibrilação Atrial/etiologia , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue , Cateterismo Cardíaco , Distribuição de Qui-Quadrado , Constrição , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Esternotomia/efeitos adversos , Esternotomia/mortalidade , Toracotomia/efeitos adversos , Toracotomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
17.
Eur Heart J ; 37(28): 2276-86, 2016 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-26787441

RESUMO

AIMS: We aimed to determine the frequency of aortic valve surgery (AVR) with or without coronary artery bypass grafting (CABG), among patients with moderate/severe aortic stenosis (AS) and left ventricular systolic dysfunction (LVSD), and its relationship with survival. METHODS AND RESULTS: The Duke Echocardiographic Database (N = 132 804) was queried for patients with mean gradient ≥25 mmHg and/or peak velocity ≥3 m/s and LVSD (left ventricular ejection fraction ≤50%) from 1 January 1995-28 February 2014. For analyses purposes, AS was defined both by mean gradient and calculated aortic valve area (AVA) criteria. Time-dependent indicators of AVR in multivariable Cox models were used to assess the relationship of AVR and all-cause mortality. A total of 1634 patients had moderate (N = 1090, 67%) or severe (N = 544, 33%) AS by mean gradient criteria. Overall, 287 (26%) patients with moderate AS and 263 (48%) patients with severe AS underwent AVR within 5 years of the qualifying echo. There were 863 (53%) deaths observed up to 5 years following index echo. After multivariable adjustment in an inverse probability weighted regression model, AVR was associated with higher 5-year survival amongst patients with moderate AS and severe AS whether classified by AVA or mean gradient criteria. Over all, AVR ± CABG compared with medical therapy was associated with significantly lower mortality [hazard ratio, HR = 0.49 (0.38, 0.62), P < 0.0001]. Compared with CABG alone, CABG + AVR was associated with better survival [HR = 0.18 (0.12, 0.27), P < 0.0001]. CONCLUSIONS: In patients with moderate/severe AS and LVSD, mortality is substantial and amongst those selected for surgery, AVR with or without CABG is associated with higher survival. Research is required to understand factors contributing to current practice patterns and the possible utility of transcatheter approaches in this high-risk cohort.


Assuntos
Estenose da Valva Aórtica , Valva Aórtica , Ponte de Artéria Coronária , Implante de Prótese de Valva Cardíaca , Humanos , Resultado do Tratamento , Disfunção Ventricular Esquerda
19.
J Card Surg ; 31(8): 503-6, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27401021

RESUMO

BACKGROUND: Systolic anterior motion (SAM) of the mitral valve, left ventricular outflow tract (LVOT) obstruction, and mitral regurgitation (MR) are known adverse outcomes that can occur after septal myectomy for hypertrophic obstructive cardiomyopathy. The objective of this study was to describe outcomes of a surgical technique to prevent these complications. METHODS: We have adopted a technique where we place an Alfieri stitch in the mitral valve through the aortotomy while performing septal myectomy. A retrospective review was performed and outcomes associated with this technique were noted. RESULTS: Twenty-four patients underwent septal myectomy and mitral valve repair using this technique. Mean age was 57 ± 10 years. Twenty patients were in class III/IV heart failure, and all had documented SAM. Mean LVOT gradient improved from 78 ± 48 mmHg preoperatively to 19 ± 20 mmHg after myectomy (p < 0.001). No patients had postoperative SAM, and no patients required a second aortic crossclamping for mitral repair. Seventeen of 19 patients with ≥mild MR had improvement in MR. During follow-up, 16 patients had no/trivial MR, seven had mild MR, and one had moderate MR. The mean postoperative mitral gradient was 4.5 ± 3.0 mmHg. Thirteen patients had postoperative complications including one death in a patient who developed a ventricular septal defect. CONCLUSIONS: Trans-aortic Alfieri stitch placement during septal myectomy is feasible in most cases as an additional tool to improve MR and minimize SAM. This technique may have a role in addressing mitral disease, such as a long anterior leaflet or fibrotic mitral valve, at the time of myectomy without the need for left atriotomy for mitral exposure.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cardiomiopatia Hipertrófica/cirurgia , Septos Cardíacos/cirurgia , Técnicas de Sutura/instrumentação , Suturas , Cardiomiopatia Hipertrófica/diagnóstico , Cardiomiopatia Hipertrófica/fisiopatologia , Ecocardiografia Transesofagiana , Feminino , Seguimentos , Septos Cardíacos/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Função Ventricular Esquerda/fisiologia
20.
Eur Heart J ; 36(40): 2733-41, 2015 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-26233850

RESUMO

AIMS: The management and outcomes of patients with functional moderate/severe mitral regurgitation and severe left ventricular (LV) systolic dysfunction are not well defined. We sought to determine the characteristics, management strategies, and outcomes of patients with moderate or severe mitral regurgitation (MR) and LV systolic dysfunction. METHODS AND RESULTS: For the period 1995-2010, the Duke Echocardiography Laboratory and Duke Databank for Cardiovascular Diseases databases were merged to identify patients with moderate or severe functional MR and severe LV dysfunction (defined as LV ejection fraction ≤ 30% or LV end-systolic diameter > 55 mm). We examined treatment effects in two ways. (i) A multivariable Cox proportional hazards model was used to assess the independent relationship of different treatment strategies and long-term event (death, LV assist device, or transplant)-free survival among those with and without coronary artery disease (CAD). (ii) To examine the association of mitral valve (MV) surgery with outcomes, we divided the entire cohort into two groups, those who underwent MV surgery and those who did not; we used inverse probability weighted (IPW) propensity adjustment to account for non-random treatment assignment. Among 1441 patients with moderate (70%) or severe (30%) MR, a significant history of hypertension (59%), diabetes (28%), symptomatic heart failure (83%), and CAD (52%) was observed. Past revascularization in 26% was noted. At 1 year, 1094 (75%) patients were treated medically. Percutaneous coronary intervention was performed in 114 patients, coronary artery bypass graft (CABG) surgery in 82, CABG and MV surgery in 96, and MV surgery alone in 55 patients. Among patients with CAD, compared with medical therapy alone, the treatment strategies of CABG surgery [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.42-0.76] and CABG with MV surgery (HR 0.58, 95% CI 0.44-0.78) were associated with long-term, event-free survival benefit. Percutaneous intervention treatment produced a borderline result (HR 0.78, 95% CI 0.61-1.00). However, the relationship with isolated MV surgery did not achieve statistical significance (HR 0.64, 95% CI 0.33-1.27, P = 0.202). Among those with CAD, following IPW adjustment, MV surgery was associated with a significant event-free survival benefit compared with patients without MV surgery (HR 0.71, 95% CI 0.52-0.95). In the entire cohort, following IPW adjustment, the use of MV surgery was associated with higher event-free survival (HR 0.69, 95% CI 0.53-0.88). CONCLUSION: In patients with moderate or severe MR and severe LV dysfunction, mortality was substantial, and among those selected for surgery, MV surgery, though performed in a small number of patients, was independently associated with higher event-free survival.


Assuntos
Insuficiência da Valva Mitral/terapia , Disfunção Ventricular Esquerda/terapia , Cardiotônicos/uso terapêutico , Ponte de Artéria Coronária/mortalidade , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/mortalidade , Intervenção Coronária Percutânea/mortalidade , Resultado do Tratamento , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/mortalidade
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