Efficacy of Polymer Injection for Ischemic Mitral Regurgitation: Persistent Reduction of Mitral Regurgitation and Attenuation of Left Ventricular Remodeling

ObjectivesThe aim of this study was to examine the chronic effects of polyvinyl-alcohol (PVA) injection on mitral regurgitation (MR) reduction, mitral valve geometry, and left ventricular (LV) remodeling in a chronic ischemic MR sheep model.BackgroundPrevious studies have demonstrated acute efficacy of PVA hydrogel polymer injection into infarcted myocardium underlying the papillary muscle to relieve MR by papillary muscle repositioning. However, the chronic efficacy of PVA injection in the chronic infarction setting remains unclear.MethodsSixteen sheep developed chronic MR 8 weeks after induced inferoposterior myocardial infarction. Ten consecutive sheep underwent PVA injection (PVA group) and 6 sheep served as control subjects with saline injection. Epicardial 2-/3-dimensional echocardiography was performed at the baseline, chronic MR (pre-injection), and sacrifice (8 weeks after injection) stages.ResultsBoth groups were comparable at the baseline and chronic MR stages. At sacrifice, MR decreased from moderate to trace or mild (vena contracta: 0.17 ± 0.08 cm vs. 0.56 ± 0.10 cm, p < 0.001) in the PVA group but progressed to moderate to severe in the control group. End-systolic and -diastolic volumes remained stable in the PVA group but increased significantly in the control group (both p < 0.05). At sacrifice, compared with the control group, the PVA group had significantly less left ventricular remodeling (end-systolic volume: 41.1 ± 10.4 ml vs. 55.9 ± 12.4 ml, p < 0.05), lower MR severity (vena contracta: 0.17 ± 0.08 cm vs. 0.60 ± 0.14 cm, p < 0.01), and favorable changes in mitral valve geometry.ConclusionsPolymer injection in a chronic ischemic MR model results in persistent reduction of MR and attenuation of continued left ventricular remodeling over 8 weeks of follow-up.     

Transapical off-pump mitral valve repair with NeoChord™ implantation: An early single-center Portuguese experience

IntroductionTransapical off-pump NeoChord DS1000™ implantation is a minimally invasive surgical mitral valve repair (MVr) procedure to treat degenerative mitral regurgitation (MR), which is performed using the NeoChord DS1000™ system with two and three-dimensional transesophageal echocardiographic guidance on a beating heart. It has been demonstrated to be safe and effective in carefully selected patients.ObjectiveThe authors aim to analyze short-term clinical and echocardiographic results after mitral valve repair using the NeoChord™ system.MethodsAll patients that underwent transapical off-pump mitral valve repair with NeoChord™ implantation at our center, between December 2017 and December 2019, were included. The procedure was performed by left minithoracotomy, under general anesthesia. All patients presented severe primary MR due to flail/prolapse of one leaflet (anterior or posterior).ResultsEighteen patients were included in the analysis, the mean age was 65±15 years, 72% were male. The mean EuroSCORE II was 1.9±1.6. All patients had New York Heart Association (NYHA) class ≥ II. Mean effective regurgitant orifice area was 1.0±0.4 cm², with a mean regurgitant volume 146±42 mL, and a mean leaflet-to-annulus index of 1.29±0.14. MR was due to leaflet prolapse in 50% (N=9), and flail leaflet in 50% (N=9). Anatomic type A (isolated P2 defect) was the predominant form in 66.5% (N=12). Successful repair, defined by none, trace or mild mitral regurgitation, by implantation of two to four neochordae, was achieved in all 18 patients. No major complications arose intra-procedurally. The median follow-up was 194 days. NYHA class was ≤II in 94.5% patients at six-month follow-up, which represented a significant improvement in symptomatic status (p=0.002). At follow-up, 72% of patients (N=13) had grade ≤2 MR. There was a significant reduction in mean indexed left atrium volume (63±7 mL/m² vs. 45±6 mL/m², p=0.038), mean indexed left ventricular end-diastolic volume (87±7 mL/m² vs. 79±9 ml/m², p=0.001), and pulmonary arterial systolic pressure (44±4 vs. 31±8 mmHg, p=0.002). The re-intervention rate was 11.1% (N=2, both patients underwent reintervention, either a re-do NeoChord™ or conventional MV repair on-pump surgery). No major adverse cardiac or cerebrovascular events were registered.ConclusionsIn selected patients, minimally invasive MVr using the NeoChord™ system is safe, effective and reproducible. Early clinical and echocardiographic results suggest a significant symptomatic improvement, sustained MR grade decrease, and favorable left cardiac chamber remodeling, with low re-intervention rates. These results warrant further confirmation in larger cohorts, on longer period of follow-up.     

老年慢性心衰患者高敏C反应蛋白和血尿酸变化的意义

目的:探讨老年慢性心力衰竭(CHF)患者高敏C反应蛋白(hs-CRP)、血尿酸(UA)的浓度变化及意义。方法:选择67例NYHAⅡ一Ⅳ级老年CHF患者(心衰组)及29例正常老年人(正常对照组),测定血清UA、hs-CRP的水平,超声心动图测量左心室射血分数(LVEF)。结果:心衰组患者血清hs-CPR[(8.78±4.35)mg/L∶(1.27±0.48)mg/L]、UA[(451±83)μmol/L∶(289±25)μmol/]均较正常对照组明显增高(P均0.01)。且随着NYHY心功能级别增高,血UA水平逐渐升高,其组间差异性显著(P0.01),二者呈正相关(r=0.39;P0.01)。血清hs-CPR随NYHA分级的增加而升高,但组间无显著性差异(r=0.187,P=0.079)。血UA水平与血清hs-CRP无显著相关(r=0.389,P=0.065)。结论:老年慢性心力衰竭患者血尿酸水平与心衰分级有很好的相关性,它结合NYHA分级方法及左室射血分数能更好地反映心衰患者的严重程度。     

MitraClip for radiotherapy-related mitral valve regurgitation

ObjectiveOwing to mediastinal and cardiac damage burden, the surgical treatment of radiotherapy-related mitral regurgitation (MR) may be associated with high operative risk or might even contraindicated. We evaluated the feasibility and outcome of MitraClip therapy in patients with radiotherapy-related MR as an alternative to surgery.MethodsBased on Doppler Echocardiography, 15 of 33 screened patients underwent MitraClip implantation.ResultsFollowing MitraClip MR improved (residual MR ≤2+) without significant mitral valve stenosis (planimetric area 2.83 ± 0.8 cm², mean gradient 4.6 ± 1.8 mm Hg). All patients completed a 6-month follow-up, while 14 of 15 patients achieved a longer follow-up, ranging from 12 to 72 months (median 24 months, IQR 42 months). At 6-month follow-up we observed NYHA improvement in 13 patients with an increase of 6-min walking covered distance (from 260 ± 34 to 367 ± 70, p < 0.001), sustained moderate or less MR, mild mitral stenosis in 3 patients, and significant systolic Pulmonary Artery Pressure (PAPs) reduction (from 52.5 ± 14 to 42 ± 9, p < 0.01). Sustained clinical improvement and ≤2+ MR was observed in 13 of 14 patients who completed the 12-month follow-up. Two patients died of acute pneumonia (11 months and 60 months, respectively). One patient developed moderate MV stenosis (MVA 1.4 cm²) at last follow-up (48 months) without related clinical instability. Tricuspid regurgitation improved in 12 patients with further improvement at late follow-up in 2 of 3 patient with 3+.ConclusionMitraClip may be an effective treatment for RT-induced MR, although unexpected late stenosis may occur in the context of sustained reactive mitral apparatus damage following mediastinal radiation.     

Valve Resistance in Mitral Stenosis

To evaluate the value and the determinants of valve resistance in mitral stenosis, 95 patients with pure mitral stenosis were examined by Doppler echocardiography during their clinical follow-up, measuring cavity dimensions, left ventricular function, mitral area (by planimetry and pressure half time), mean transmitral pressure gradient, aortic flow, and pulmonary artery systolic pressure. The mitral resistance was calculated as mean transmitral pressure gradient/aortic flow ratio. To graduate the severity of the morphological abnormalities in valvular structure, we used a point score system with evaluation of leaflet and subvalvular thickness, calcification, and valvular mobility. The functional class was determined according to NYHA classifcation. In this study, both mitral area (r = -0.79, P < 0.001 and r_p= -0.60, P < 0.001) and mitral score (r = 0.68, P < 0.001 and r_p= 0.25, P = -0.013) were independent determinants of mitral resistance. In multivariate analysis, mitral resistance and female gender were selected by multiple linear regression analysis as determinants of pulmonary artery systolic pressure, and mitral area and pulmonary artery systolic pressure were selected by logistic linear regression analysis as determinants of NYHA functional class. In patients with moderate or severe mitral stenosis, the estimated probability for III and IV NYHA functional class considering mitral area 1 cm² or below went from 51.1–86.4% when mitral resistance below or above 130 dynes.sec.cm,⁻⁵ respectively, was considered together. Thus, mitral valve resistance should be used as a complement to the mitral area method in assessment of mitral stenosis, adding the effects of the reduction in mitral area and the damage in mitral valve apparatus.     

Association between serum levels of high sensitive C-reactive protein and inflammation activity in chronic gastritis patients

Background Gastritis is an important premalignant lesion and recent studies suggested a production of inflammatory cytokine-like C-reactive protein during gastritis. This study aimed to determine any relationship between high sensitive C-reactive protein (hs-CRP) and inflammation activity among patients with gastritis. Methods Demographic and clinical variables of participants were collected by a validated questionnaire. Using histology of the gastric mucosa, Helicobacter pylori status was investigated and serum concentrations of hs-CRP were measured among dyspeptic patients. Correlation between hs-CRP serum levels and inflammation activities was evaluated by logistic regression analysis. The relation between active inflammation and other variables was evaluated by logic link function model. Results Totally 239 patients (56.6% female) were analysed. The prevalence of mild, moderate and severe inflammation activities was 66.5%, 23.8% and 9.6% respectively. Mean?±?SD of hs-CRP among men and women were 2.85?±?2.84?mg/dl and 2.80?±?4.80?mg/dl (p?=?0.047) respectively. Mean?±?SD of hs-CRP among patients with H. pylori infection, gland atrophy, metaplasia and dysplasia were 2.83?±?3.80?mg/dl, 3.52?±?5.1?mg/dl, 2.22?±?2.3?mg/dl and 5.3?±?5.04?mg/dl respectively. Relationship between hs-CRP and inflammation activities (p?p?p?Conclusion Although serum hs-CRP is not a specific biomarker for gastritis, elevated hs-CRP levels may be considered as a predictive marker of changes in gastric mucosa and a promising therapeutic target for patients with gastritis.     

Persistence of Iatrogenic Atrial Septal Defect After Interventional Mitral Valve Repair With the MitraClip System: A Note of Caution

ObjectivesThe purpose of this study was to investigate the persistence rates of iatrogenic atrial septal defect (iASD) after interventional edge-to-edge repair with serial transesophageal echocardiography examinations and close clinical follow-up (FU).BackgroundTranscatheter mitral valve repair (TMVR) with the MitraClip system (Abbott Vascular, Abbott Park, Illinois) is a therapeutic alternative to surgery in selected high-risk patients. Clip placement requires interatrial transseptal puncture and meticulous manipulation of the steerable sheath. The persistence of iASD after MitraClip procedures and its clinical relevance is unknown.MethodsA total of 66 patients (76.7% male, mean age 77.1 ± 7.9 years) with symptomatic mitral regurgitation (MR) at prohibitive surgical risk (EuroSCORE II 10.1 ± 6.1%) underwent MitraClip procedures and completed 6 months of FU.ResultsTransesophageal echocardiography after FU showed persistent iASD in 50% of cases. Patients with iASD did not significantly differ from patients without ASD concerning baseline characteristics, New York Heart Association functional class, severity of MR, and acute procedural success rates (p > 0.05). When comparing procedural details and hemodynamic measures between groups, MitraClip procedures took longer in patients without iASD (82.4 ± 39.7 min vs. 68.9 ± 45.5 min; p = 0.05), and echocardiography after FU showed less decrease of systolic pulmonary artery pressures in the iASD group (−1.6 ± 14.1 mm Hg vs. 9.3 ± 17.4 mm Hg; p = 0.02). Clinically, patients with iASD presented more often with New York Heart Association functional classes >II after FU (57% vs. 30%; p = 0.04), showed higher levels of N-terminal pro-brain natriuretic peptide (6,667.3 ± 7,363.9 ng/dl vs. 4,835.9 ± 6,681.7 ng/dl; p = 0.05), and had less improvement in 6-min walking distances (20.8 ± 107.4 m vs. 114.6 ± 116.4 m; p = 0.001). Patients with iASD showed higher death rates during 6 months (16.6% vs. 3.3%; p = 0.05). Cox regression analysis found that only persistence of iASD (p = 0.04) was associated with 6-month survival.ConclusionsThe persistence rate of 50% iASD after MitraClip procedures is considerably high. Persistent interatrial shunting was associated with worse clinical outcomes and increased mortality. Further studies are warranted to investigate if persistent interatrial shunting is the mediator or marker of advanced disease in these patients.     

Impact of catheter ablation for atrial fibrillation in patients with heart failure and left ventricular systolic dysfunction

Introduction and AimsCatheter ablation has been shown to improve left ventricular (LV) ejection fraction (LVEF) in patients with atrial fibrillation (AF) and heart failure (HF). Our aim was to assess the impact of AF ablation on the outcome of patients with HF and LV systolic dysfunction.MethodsWe performed a retrospective observational cohort study of all patients with HF and LVEF <50% and with no apparent cause for systolic dysfunction other than AF who underwent catheter ablation in a tertiary referral center between July 2016 and November 2018. The primary endpoint was a ≥5% improvement in LVEF. Secondary endpoints included improvement in New York Heart Association (NYHA) class and reduction in LV end-diastolic diameter (LVEDD) and left atrial diameter (LAD).ResultsOf 153 patients who underwent AF ablation in this period, 22 (77% male, median age 61 [IQR 54-64] years) fulfilled the inclusion criteria. Median follow-up was 11.1 months (IQR 6.1-19.0). After ablation, median LVEF increased from 40% (IQR 33-41) to 58% (IQR 55-62) (p<0.01), mean NYHA class improved from 2.35±0.49 to 1.3±0.47 (p<0.001), and median LAD and LVEDD decreased from 48.0 (IQR 43.5-51.5) mm to 44 (IQR 40-49) mm (p<0.01) and from 61.0 (IQR 54.0-64.8) mm to 55.0 (52.2-58.0) mm (p<0.01), respectively.ConclusionIn patients with HF and LV systolic dysfunction, AF ablation is associated not only with improved functional status but also with favorable structural remodeling, including improvement in LVEF and decreases in LAD and LVEDD.     

Early results with the batista procedure for end-stage heart failure

The Batista procedure (partial left ventriculectomy) has emerged as an adjunct or possible replacement to cardiac transplantation as a surgical management for end-stage congestive heart failure. Clinical experience in various centres has shown widely divergent degrees of success. From May to November 1996, we performed partial left ventriculectomy in 32 patients, of whom 31 (97%) were heart transplant candidates. The range of ages was 34 to 72 years (mean, 54.6); 60% were NYHA Class IV and 40% Class III. Preoperatively 30 patients were thought to have idiopathic dilated cardiomyopathy; 1 case was familial, and 1 valvular. The lateral ventricular wall (circumflex territory) between the papillary muscles was the location for ventriculectomy in 31 patients. In 13 patients (40%) one or both papillary muscles were divided with additional left ventricular wall resection, and the papillary muscles were reimplanted. For 31 patients, the anterior and posterior mitral valve leaflets were approximated (Alfieri repair); 1 patient had mitral valve replacement. Echocardiography showed a significant decrease in left ventricular dimensions after resection: 83±1.1 cm to 6.0±0.7 cm (p<0.001), and a reduction in mitral regurgitation with an increase in forward ejection fraction 15±5.0% to 33±10.7% in the operating room (p<0.001). Six patients (16%) required a perioperative left ventricular assist device. At 3 months, actuarial survival was 93%. We conclude that the Batista procedure with mitral valve repair offers functional and clinical improvement to an unpredictable subgroup of patients. Predicting successful outcome on a case-by-case basis is now the main thrust of our ongoing investigation.     

Insufficient Mitral Leaflet Remodeling in Relation to Annular Dilation and Risk of Residual Mitral Regurgitation After MitraClip Implantation

ObjectivesThe purpose of this study was to determine whether the mitral valve (MV) total leaflet area (TLA)-to-mitral annular area (MAA) (TLA/MAA) ratio measured using 3-dimensional (3D) transesophageal echocardiography (TEE) was associated with residual mitral regurgitation (MR) after MitraClip implantation in patients with secondary MR.BackgroundThe factors influencing the results of MitraClip implantation for secondary MR are controversial. This study hypothesized that insufficient remodeling of the mitral leaflets relative to the annular dilation may be associated with significant MR after MitraClip implantation.MethodsThis study included patients with secondary MR treated with MitraClips. Using 3D TEE dataset, the TLA in diastole and MAA in systole were measured with dedicated software.ResultsIn a total cohort of 119 patients (mean age 74 ± 9 years; 61% male), significant residual MR (≥2+) was present in 43 patients (36%). In patients with significant residual MR, MAA was greater than in patients without residual MR (10.7 ± 2.4 cm² vs. 9.0 ± 2.1 cm²; p < 0.001) whereas no significant difference was observed in TLA (12.2 ± 2.6 cm² vs. 12.0 ± 2.9 cm²; p = 0.836). TLA/MAA ratio was lower in patients with significant residual MR as compared to their counterparts (1.14 ± 0.15 vs. 1.34 ± 0.16; p < 0.001), suggesting insufficient leaflet remodeling relative to annular dilation. On receiver-operating characteristic curve analysis, the TLA/MAA ratio had better discriminative power to identify patients who will have significant residual MR compared to MAA alone (area under the curve [AUC]: 0.830 vs. 0.723; p = 0.049).ConclusionsIn patients with secondary MR, insufficient mitral leaflet remodeling relative to the annulus dilation, as reflected by a lower TLA/MAA ratio, is associated with significant residual MR after MitraClip implantation.     

Valve Strain Quantitation in Normal Mitral Valves and Mitral Prolapse With Variable Degrees of Regurgitation

ObjectivesThe aim of this study was to quantitate patient-specific mitral valve (MV) strain in normal valves and in patients with mitral valve prolapse with and without significant mitral regurgitation (MR) and assess the determinants of MV strain.BackgroundFew data exist on MV deformation during systole in humans. Three-dimensional echocardiography allows for dynamic MV imaging, enabling digital modeling of MV function in health and disease.MethodsThree-dimensional transesophageal echocardiography was performed in 82 patients, 32 with normal MV and 50 with mitral valve prolapse (MVP): 12 with mild mitral regurgitation or less (MVP ? MR) and 38 with moderate MR or greater (MVP + MR). Three-dimensional MV models were generated, and the peak systolic strain of MV leaflets was computed on proprietary software.ResultsLeft ventricular ejection fraction was normal in all groups. MV annular dimensions were largest in MVP + MR (annular area: 13.8 ± 0.7 cm²) and comparable in MVP ? MR (10.6 ± 1 cm²) and normal valves (10.5 ± 0.3 cm²; analysis of variance: p < 0.001). Similarly, MV leaflet areas were largest in MVP + MR, particularly the posterior leaflet (8.7 ± 0.5 cm²); intermediate in MVP ? MR (6.5 ± 0.7 cm²); and smallest in normal valves (5.5 ± 0.2 cm²; p < 0.0001). Strain was overall highest in MVP + MR and lowest in normal valves. Patients with MVP ? MR had intermediate strain values that were higher than normal valves in the posterior leaflet (p = 0.001). On multivariable analysis, after adjustment for clinical and MV geometric parameters, leaflet thickness was the only parameter that was retained as being significantly correlated with mean MV strain (r = 0.34; p = 0.008).ConclusionsMVs that exhibit prolapse have higher strain compared to normal valves, particularly in the posterior leaflet. Although higher strain is observed with worsening MR and larger valves and annuli, mitral valve leaflet thickness—and, thus, underlying MV pathology—is the most significant independent determinant of valve deformation. Future studies are needed to assess the impact of MV strain determination on clinical outcome.     

Clinical efficacy of surgical heart failure therapy by ventricular restoration and restrictive mitral annuloplasty

BackgroundTreatment of heart failure by advanced surgical procedures such as ventricular restoration (SVR) and restrictive mitral annuloplasty (RMA) is increasingly applied. We studied clinical efficacy of heart failure surgery in patients with severe heart failure.Methods and ResultsThirty-three patients (New York Heart Association (NYHA) class III/IV, left ventricular ejection fraction ≤35%) were included. Patients with moderate to severe mitral regurgitation underwent RMA (85%) and patients with anteroseptal aneurysm underwent SVR (52%). A combined procedure was performed in 12 patients, and additional coronary artery bypass grafting in 27 patients. Clinical and echocardiographic parameters were assessed at baseline and 6 months after surgery. Operative mortality was 3% (n = 1), in-hospital mortality was 9% (n = 3), and there was no late mortality. All clinical parameters were significantly improved at 6 months' follow-up (P < .001); NYHA class improved from 3.4 ± 0.5 to 1.5 ± 0.5, Quality-of-life score improved from 44 ± 22 to 16 ± 12, and 6-minute walking distance increased from 248 ± 134 m to 422 ± 113 m. Left ventricular end-diastolic volume decreased from 107 ± 32 to 80 ± 20 mL/m² (P < .001) and end-systolic volume decreased from 78 ± 32 to 53 ± 15 mL/m² (P < .001), whereas ejection fraction improved from 29 ± 9 to 35 ± 7% (P < .01).ConclusionsSurgical treatment of severe heart failure by SVR or RMA was associated with 12% mortality at 6 months. Surviving patients showed highly significant functional and clinical improvements.     

Uric acid significantly correlates with the presence of low-voltage areas at the endocardial mapping in patients with non-valvular atrial fibrillation

Background and aimsInterest in the role of atrial substrate in maintaining Atrial Fibrillation (AF) is growing. Fibrosis is the culprit in the electrical derangement of the myocytes. Many cardiovascular risk factors are known to be linked to atrial scarring; among them Uric Acid (UA) is emerging. The purpose of our study is to find whether UA is associated with Left Atrium (LA) with pathological substrate.Methods and results81 patients who underwent radiofrequency transcatheter ablation for nonvalvular AF at the cardiological department of the Niguarda Hospital were enrolled in an observational, cross-sectional, single-center study. UA levels were analysed before the procedure. High density electroanatomic mapping of the LA was performed and patients were divided according to the presence or not of areas of pathological substrate (bipolar voltage <0.5 mV in sinus rhythm). 19 patients showed a LA with pathological substrate. These subjects showed a significant higher prevalence of persistent phenotype of AF (84.2 vs. 25.8%, p < 0.001). UA levels were significantly higher in the group of patients with LA with pathological substrate (6.8 ± 1.9 vs 5.3 ± 1.4 mg/dL, p < 0.001) as well as the prevalence of hyperuricemia (26.5 vs. 6.5%, p = 0.021). The association between uric acid LA with pathological substrate remains significant even after correction for confounding factors (age, left ventricular dysfunction, valvular disease, arrythmia phenotype and furosemide use) and also when the ratio UA/creatinine was evaluated.ConclusionsIn a population of patients who underwent AF ablation, higher UA levels were significantly associated with pathological LA substrate at electro-anatomical mapping.     

Transcatheter Treatment of Residual Significant Mitral Regurgitation Following TAVR: A Multicenter Registry

ObjectivesThe aim of this study was to describe baseline characteristics, and periprocedural and mid-term outcomes of patients undergoing transcatheter mitral valve interventions post-transcatheter aortic valve replacement (TAVR) and examine their clinical benefit.BackgroundThe optimal management of residual mitral regurgitation (MR) post-TAVR is challenging.MethodsThis was an international registry of 23 TAVR centers.ResultsIn total, 106 of 24,178 patients (0.43%) underwent mitral interventions post-TAVR (100 staged, 6 concomitant), most commonly percutaneous edge-to-edge mitral valve repair (PMVR). The median interval post-TAVR was 164 days. Mean age was 79.5 ± 7.2 years, MR was >moderate in 97.2%, technical success was 99.1%, and 30-day device success rate was 88.7%. There were 18 periprocedural complications (16.9%) including 4 deaths. During a median follow-up of 464 days, the cumulative risk for 3-year mortality was 29.0%. MR grade and New York Heart Association (NYHA) functional class improved dramatically; at 1 year, MR was moderate or less in 90.9% of patients (mild or less in 69.1%), and 85.9% of patients were in NYHA functional class I/II. Staged PMVR was associated with lower mortality versus medical treatment (57.5% vs. 30.8%) in a propensity-matched cohort (n = 156), but this was not statistically significant (hazard ratio: 1.75; p = 0.05).ConclusionsFor patients who continue to have significant MR, remain symptomatic post-TAVR, and are anatomically suitable for transcatheter interventions, these interventions are feasible, safe, and associated with significant improvement in MR grade and NYHA functional class. These results apply mainly to PMVR. A staged PMVR strategy was associated with markedly lower mortality, but this was not statistically significant. (Transcatheter Treatment for Combined Aortic and Mitral Valve Disease. The Aortic+Mitral TRAnsCatheter Valve Registry [AMTRAC]; NCT04031274)     

Ischemia-Mediated Dysfunction in Subpapillary Myocardium as a Marker of Functional Mitral Regurgitation

ObjectivesThe goal of this study was to test whether ischemia-mediated contractile dysfunction underlying the mitral valve affects functional mitral regurgitation (FMR) and the prognostic impact of FMR.BackgroundFMR results from left ventricular (LV) remodeling, which can stem from myocardial tissue alterations. Stress cardiac magnetic resonance can assess ischemia and infarction in the left ventricle and papillary muscles; relative impact on FMR is uncertain.MethodsVasodilator stress cardiac magnetic resonance was performed in patients with known or suspected coronary artery disease at 7 sites. Images were centrally analyzed for MR etiology/severity, mitral apparatus remodeling, and papillary ischemia.ResultsA total of 8,631 patients (mean age 60.0 ± 14.1 years; 55% male) were studied. FMR was present in 27%, among whom 16% (n = 372) had advanced (moderate or severe) FMR. Patients with ischemia localized to subpapillary regions were more likely to have advanced FMR (p = 0.003); those with ischemia localized to other areas were not (p = 0.17). Ischemic/dysfunctional subpapillary myocardium (odds ratio: 1.24/10% subpapillary myocardium; confidence interval: 1.17 to 1.31; p < 0.001) was associated with advanced FMR controlling for infarction. Among a subgroup with (n = 372) and without (n = 744) advanced FMR matched (1:2) on infarct size/distribution, patients with advanced FMR had increased adverse mitral apparatus remodeling, paralleled by greater ischemic/dysfunctional subpapillary myocardium (p < 0.001). Although posteromedial papillary ischemia was more common with advanced FMR (p = 0.006), subpapillary ischemia with dysfunction remained associated (p < 0.001), adjusting for posteromedial papillary ischemia (p = 0.074). During follow-up (median 5.1 years), 1,473 deaths occurred in the overall cohort; advanced FMR conferred increased mortality risk (hazard ratio: 1.52; 95% confidence interval: 1.25 to 1.86; p < 0.001) controlling for left ventricular ejection fraction, infarction, and ischemia.ConclusionsIschemic and dysfunctional subpapillary myocardium provides a substrate for FMR, which predicts mortality independent of key mechanistic substrates.     

Cardiac rehabilitation in older patients: Indication or limitation?

ObjectiveTo assess the clinical impact of a cardiac rehabilitation program in an older population.MethodsThis is a retrospective analysis of 731 coronary patients who attended phase 2 of a cardiac rehabilitation program between January 2009 and December 2016. We compared the response to the program of older (≥65 years) and younger (<65 years) patients, analyzing changes in metabolic profile (including body mass index, waist circumference and lipid profile), exercise capacity, cardiac autonomic regulation parameters (such as chronotropic index and resting heart rate), and health-related quality of life scores.ResultsOlder patients represented 15.9% of our cohort. They showed significant reductions in waist circumference (male patients: 98.0±7.9 cm vs. 95.9±7.9 cm, p<0.001; female patients: 90.5±11.4 cm vs. 87.2±11.7 cm, p<0.001), LDL cholesterol (102.5 [86.3-128.0] mg/dl vs. 65.0 [55.0-86.0] mg/dl, p<0.001) and triglycerides (115.0 [87.8-148.5] mg/dl vs. 97.0 [81.8-130.0] mg/dl, p<0.001). Post-training data also showed a noticeable improvement in older patients’ exercise capacity (7.6±1.8 METs vs. 9.3±1.8 METs, p<0.001), along with a higher chronotropic index and lower resting heart rate. Additionally, health-related quality of life indices improved in older subjects. However, our overall analysis found no significant differences between the groups in changes of the studied parameters.ConclusionOlder coronary patients benefit from cardiac rehabilitation interventions, similarly to their younger counterparts. Greater involvement of elderly patients in cardiac rehabilitation is needed to fully realize the therapeutic and secondary preventive potential of such programs.     

Usefulness of the brain natriuretic peptide to atrial natriuretic peptide ratio in determining the severity of mitral regurgitation

BACKGROUND: Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels were characterized in subjects with mitral regurgitation (MR). METHODS: Sixty-two cases of moderate or severe chronic MR were studied. The blood levels of neurohormonal factors were stratified by the known MR prognostic factors of New York Heart Association (NYHA) functional class, left ventricular end-diastolic diameters, left ventricular end-systolic diameter (LVDs), ejection fraction (EF), left atrial diameter and presence of atrial fibrillation (AF). RESULTS: ANP levels were higher in NYHA class II and lower in classes I and III/IV (P=0.0206). BNP levels were higher in NYHA class II than class I (P=0.0355). The BNP/ANP ratio was significantly higher in NYHA classes II and III/IV than in class I (P=0.0007). To differentiate between NYHA classes I/II and III/IV, a cut-off BNP/ANP ratio of 2.97 produced a sensitivity of 78% and specificity of 87%. Compared with subjects in sinus rhythm, patients with AF had an enlarged left atrium and lower ANP levels. The BNP/ANP ratio correlated significantly with left atrial diameter, LVDs and EF (r=0.429, P=0.0017; r=0.351, P=0.0117; and r=-0.349, P=0.0122; respectively), and was significantly higher among all the known operative indications for MR tested (LVDs 45 mm or more, EF 60% or less, NYHA class II or greater and AF; P=0.0073, P=0.003, P=0.0102 and P=0.0149, respectively). CONCLUSIONS: In chronic MR, levels of ANP and BNP, and the BNP/ANP ratio are potential indicators of disease severity.     

不稳定型心绞痛患者妊娠相关血浆蛋白A与高敏C反应蛋白的相关性

目的探讨不稳定型心绞痛患者妊娠相关血浆蛋白A水平与高敏C反应蛋白的关系及其与动脉粥样硬化斑块稳定性的关系.方法不稳定型心绞痛组与稳定型心绞痛组患者,行冠状动脉造影前采用酶联免疫法检测妊娠相关血浆蛋白A水平,并检测高敏C反应蛋白及其他血清学指标,对造影结果进行Jenkins评分.结果不稳定型心绞痛组与稳定型心绞痛组之间相比,高敏C反应蛋白和妊娠相关血浆蛋白A水平的差异均有显著性(P＜0.001);两组Jenkins评分差异有显著性(P＜0.001).妊娠相关血浆蛋白A水平与高敏C反应蛋白呈正相关(r=0.44);多因素回归分析显示妊娠相关血浆蛋白A水平与高敏C反应蛋白正相关和肌钙蛋白Ⅰ存在直线关系,Jenkins评分与妊娠相关血浆蛋白A水平、肌钙蛋白Ⅰ及高密度脂蛋白存在直线关系.结论妊娠相关血浆蛋白A水平可作为临床评估冠心病患者病情稳定程度,并进而可能成为评价冠状动脉斑块稳定性的指标之一.     

Preoperative Right Ventricular Function in Patients with Organic Mitral Regurgitation

Aims: To assess the right ventricular (RV) function in patients with severe mitral regurgitation (MR); to find a relation between preoperative and postoperative parameters. Methods: RV function was echocardiographically assessed by determining the tricuspid annular plane systolic excursion (TAPSE) and the peak systolic velocity of the lateral tricuspid annulus (Sa) in 45 patients with severe organic MR (53.3% men, age 58 ± 10 years). Mean NYHA class was 2.6 ± 0.4, LVEF was 55.3 ± 12%, RV end‐diastolic diameter was 28.7 ± 4.7, left ventricular end‐systolic diameter (LVESD) was 44.6 ± 12.6 mm, and LV end‐diastolic volume (Simpson) was 160.6 ± 50.3 ml. All patients underwent mitral valve replacement with posterior chordal sparing. Results: Mean preoperative TAPSE and Sa were 19.4 ± 4.3 mm and 10.3 ± 3 cm/sec, respectively. RV dysfunction, defined as TAPSE < 22 mm, had 66.6% of the patients, and Sa < 11 cm/sec was found in 62.2% of the patients preoperatively. Preoperative TAPSE and Sa were significantly correlated (P < 0.00001, r = 0.61). Both TAPSE and Sa were correlated with the RV end‐diastolic diameter (P < 0.01), LVESD (P < 0.05) left ventricular dp/dt (P < 0.05), and LVEF (P < 0.0001). Postoperative LVEF was 50% (P < 0.001), Sa 5.3 ± 2 cm/sec (P < 0.001), and TAPSE 8.7 ± 3.2mm (P < 0.001). Twenty‐one patients (46.6%) reached the study end point of decrease of LVEF by more than 10%. Univariate predictors were age (P = 0.04), male gender (P = 0.01), TAPSE (P = 0.007), and Sa (P = 0.009), while a trend was found for regurgitation fraction (P = 0.058) and LV end‐diastolic volume index (P = 0.09). By multivariate analysis, TAPSE (P = 0.01) and Sa (P = 0.01) were predictive for the study end point. Conclusion: The assessment of the RV function by echocardiography is a simple tool that provides prognostic information in patients with MR. (Echocardiography 2010;27:282‐285)     

Serum resistin,insulin resistance and carotid intima-media thickness as an indication of subclinical atherosclerosis in systemic lupus erythematosus patients

Aim of the workTo evaluate resistin level in systemic lupus erythematosus (SLE) patients and to assess the relationship with insulin resistance, disease characteristics, inflammatory markers and carotid intima-media thickness (CIMT) as a marker of subclinical atherosclerosis.Patients and methodsThirty adult SLE patients and twenty age and sex-matched control were enrolled. All patients were subjected to history taking, clinical examination and assessment of anthropometric measurements. Laboratory investigations included serum resistin, measures of insulin resistance, highly sensitive C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR) and lipid profile. Carotid duplex was performed for measurement of CIMT. SLE disease activity index (SLEDAI-2k) and damage index were evaluated.ResultsThe 30 patients were 23 (76.7%) females and 7 (23.3%) males (F:M 3.3:1) with a mean age of 30.9 ± 7.9 years. The disease duration was 4.8 ± 1.8 years. The mean serum resistin in patients was 7.7 ± 2.9 ng/dl and in control was 8.5 ± 5.1 ng/dl (p = 0.8). The ESR and hs-CRP were significantly increased (p < 0.001) and the high-density lipoprotein (HDL) decreased (p < 0.001). The mean CIMT was significantly increased in cases (0.62 ± 0.16 mm) compared to control (0.51 ± 0.11 mm)(p = 0.006). Serum resistin significantly correlated with hs-CRP, HDL and anti-nuclear antibody (p = 0.027, p < 0.001,p = 0.013 respectively). There was no significant correlation between resistin and markers of insulin resistance, SLEDAI-2 k and CIMT.ConclusionResistin expression in the serum of patients with SLE was not significantly higher than controls. Although resistin was correlated with two cardiovascular risk factors (HDL-C, hs-CRP), it did not correlate significantly with insulin resistance, disease activity, damage index and CIMT in SLE patients.