Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy

Background

Patients with mitral restenosis who have undergone prior PTMC or surgical commissurotomy have increased. Predictors of outcome of repeat PTMC in either subgroup of patients may be different.

Aims and objectives

Aim was to assess and compare the immediate results of PTMC in patients who had undergone a prior PTMC or surgical commissurotomy.

Methods and results

This is a single center, prospective, open label study. Of 70 patients in study, 44 (62.85%) patients had prior history of PTMC and 26 (37.15%) had prior surgical commissurotomy (closed/open). Average time from the initial procedure was 8.88 ± 5.36 years overall, 6.75 ± 3.38 for patients with prior PTMC and 16.73 ± 3.67 for patients with prior surgical commissurotomy. Prior PTMC group had 75% female, patients with prior surgical commissurotomy were older (44 ± 7 vs 33.57 ± 9.1 years, p = 0.001), had higher NYHA class (III/IV in100% vs 86.36%, p = 0.006.), higher atrial fibrillation (73.1% vs 25% p < 0.0001) and higher Wilkins'' score (>8 in 88.46% vs 68.18%, p = 0.05). Successful PTMC was lower (65.4% vs 84.1%) in patients with prior surgical commissurotomy, though statistically not significant (p = 0.07). After PTMC, mitral valve area, PA systolic pressure, LA mean pressure and trans-mitral gradient were similar. Post procedure complications were not different in both the groups.

Conclusion

PTMC for mitral restenosis in patients with prior surgical valvotomy is as effective as in patients with prior PTMC despite older age, higher NYHA class, higher Wilkins score and atrial fibrillation and can be considered in all patients with restenosis irrespective of the type of past procedures done.     

重度二尖瓣狭窄球囊分离术42例分析

目的 探索重度二尖瓣狭窄球囊分离术治疗的新方法.方法 房间隔穿刺点定位,采用吞钡食管左心房压迹定位法,以压迹上下缘的中下1/4水平线为房间隔穿刺高度,与脊柱中右1/4垂线的交点为房间隔穿刺点,穿刺成功率100%.穿刺成功后于右前斜位25°下行直接左心房造影,根据二尖瓣口位置调整二尖瓣探条(stylet),引导Inoue球囊过二尖瓣口,必要时在超声心动图指导下进左心室,选用直径23～28mm球囊扩张.结果 全部患者均成功,跨二尖瓣压差自18～51(34±11)mmHg降至4～9(7±3)mmHg(t=2.623,P<0.01).左心房平均压自20～60(38±13)mmHg,降至6～13(8±3)mmHg,二尖瓣听诊区雷鸣样舒张期杂音明显减轻或消失,效果显著(t=2.714,P<0.01).结论 对于风湿性心脏病重度二尖瓣狭窄,食管左心房压迹定房间隔穿刺点,安全而方便.右前斜位25°下,直接左心房造影显示二尖瓣口,指导Inoue球囊导管进左心室成功率高.     

二尖瓣球囊扩张术和机械分离术的临床评价

目的探讨二尖瓣球囊扩张术和机械扩张术治疗二尖瓣狭窄的特点和治疗效果。方法2001年2月～2002年8月,采用二尖瓣球囊扩张术(percutaneous balloon mitral valvuloplasty,PBMV)治疗二尖瓣狭窄52例,评分(7±1);采用机械扩张术(percutaneous mechanical mitral commissurotomy,PMMC)治疗二尖瓣狭窄36例,评分(10±2)。对术后24h、1年的心脏超声检查随访结果进行对比分析。结果PBMV成功率94%(49/52);PMMC成功率92%(33/36)。PBMV后二尖瓣面积(mitral valve area,MVA)(1.7±0.2)cm2,PMMC后MVA(2.1±0.5)cm2,差异有统计学意义(P<0.01)。心包填塞并发症:PBMV发生率5.7%;PMMC5.5%。PBMV和PMMC增加二尖瓣反流面积大于3cm2例数分别占14%(7/52)和10%(3/33),差异有统计学意义(P<0.01)。术后1年,PBMV组需外科换瓣手术3例,PMMC组无手术换瓣病例。结论PBMV和PMMC都是治疗二尖瓣狭窄有效的方法,P...     

Plasma noradrenaline as an indicator of functional state in hearts with mitral stenosis: The influence of acutely reduced left atrial pressure by balloon mitral commissurotomy

Summary To investigate the mechanism in which plasma noradrenaline concentration (pNA) is elevated in heart failure, the effect of balloon mitral valvulo-plasty was used as a model of acute manipulation of the left atrial pressure reduction in ten patients with mitral stenosis. Gorlin mitral valve area and pNA were correlated with New York Heart Association functional class and found to have a significant exponential inverse relationship with each other ([pNA, pg/ml] = 198.9 × [mitral valve area, cm²]^–0.696;P = 0.003). Elevated pNA could be partially explained by a reduced cardiac index (CI) ([pNA, pg/ml] = 403.4 × [CI, l/min/m²]^–0.889;P = 0.027;r = 0.495), especially in severely failed hearts, but not by pulmonary capillary wedge pressure (PCWP). However, the percent changes (%) of variables early after balloon valvulo-plasty exhibited aparadoxical contrast; % pNA showing a clear negative exponential correlation with % PCWP ([% pNA] = 436.0 × [% PCWP + 80]^–0.679 – 80;P = 0.021), but not with % CI. These results suggest that pNA should be considered an indicator of cardiac functional class in mitral stenosis. PNA is modulated by both cardiac index and pulmonary capillary pressure, but in different ways.     

经皮二尖瓣球囊扩张术后血浆B型钠尿肽水平的变化

目的:观察心房压力快速变化对血浆B型钠尿肽(BNP)水平的影响。方法:采用床边快速BNP试验法检测30例成功施行二尖瓣球囊扩张术(PBMV)的风湿性二尖瓣狭窄患者术前、术后20min及术后24h血浆BNP浓度,与正常对照组(8例)比较,并将患者血浆BNP浓度与平均左房压(mLAP)等血流动力学参数作相关分析。结果:术前,二尖瓣狭窄患者血浆BNP水平显著高于正常对照组[(123.55±69.49)ng/L∶(16·39±7·64)ng/L,P<0·01)];且与mLAP呈显著正相关(r=0·441,P<0·05);BNP浓度在心房颤动(房颤)患者与窦性心律患者间差异无统计学意义(P>0·05)。术后,房颤患者血浆BNP浓度无明显改变[术前(111.62±53.41)ng/L,术后20min(122.04±68.70)ng/L,术后24h(106.11±56.19)ng/L,两两比较P>0·05];而窦律患者有显著下降[术前(128.66±75.96)ng/L,术后20min(88.59±61.99)ng/L,术后24h(43.39±26.70)ng/L,两两比较P<0·05)]。窦律患者中,术后20min的BNP变化(ΔBNP)与mLAP变化(ΔmLAP)呈显著正相关(r=0·696,P<0·01);术后24h的BNP变化(ΔBNP')与二尖瓣口面积(MVA)的扩大值(ΔMVA)及左房内径(LAD)的变化(ΔLAD)无相关性(分别r=0·048,P>0·05;r=-0·070,P>0·05)。结论:二尖瓣狭窄患者血浆BNP水平的升高和左房压升高显著相关。BNP是反映窦律患者球囊扩张术后左房压变化的敏感指标。     

重度二尖瓣狭窄合并左心耳血栓患者的球囊扩张术

目的　评价经皮二尖瓣球囊扩张术 (PBMV)治疗重度二尖瓣狭窄合并左心耳血栓的可行性、安全性和有效性。方法　选择经华法令抗凝治疗 12周以上的重度二尖瓣狭窄合并左心耳部位血栓患者 11例 ,男性 2例 ,女性 9例 ,年龄 2 5～ 6 2岁 ,平均 (40 6± 5 7)岁。采用Inoue单球囊技术行PBMV。术后随访 1年以上 ,观察术中及随访期间有无体循环血栓栓塞并发症。结果　手术成功率10 0 % ,术中及随访期间无 1例发生血栓栓塞并发症。术后即刻及随访期间血流动力学及心功能明显改善。结论　对于经适当的华法令抗凝治疗后的重度二尖瓣狭窄合并左心耳血栓的患者 ,PBMV不仅安全可行而且可取得满意的疗效。     

Specifics of technique in percutaneous mitral commissurotomy in a case of dextrocardia and situs inversus with mitral stenosis

Percutaneous mitral commissurotomy (PMC) was successfully performed in a 48-year-old woman with dextrocardia and situs inversus and a severe mitral stenosis. After PMC, the valve area increased from 0.97 to 1.89 cm², and no complication occurred. This case shows that PMC is practicable in a case of dextrocardia with situs inversus. The procedure appears to be safer and easier when carried out with the Inoue balloon, image inversion on the screen, and under transesophageal echocardiographic monitoring. © 1996 Wiley-Liss, Inc.     

经皮球囊二尖瓣成形术后房颤患者ANP和BNP水平变化研究

目的探讨房颤患者行经皮球囊二尖瓣成形术（PBMV）后心房利钠肽（ANP）和脑钠肽（BNP）变化及与血流动力学参数的关系。方法选择因风湿性二尖瓣狭窄伴持续性房颤成功行PBMV患者38例,术前、术后1d及半年分别用放射免疫法和酶链免疫法测定血浆中ANP、BNP值,由超声心动图测左房内径（LAD）、二尖瓣口面积（MVA）、二尖瓣跨瓣压差（MPG）及肺动脉压（PAP）。结果PBMV术后患者血流动力学参数明显改善;术后1d及半年ANP水平较术前明显下降,BNP变化不明显。术后半年与术前比较,LAD与ANP下降相关（r=0．774,P〈0．05）,△BNP与△MPG相关（r=0．574,P〈0．05）。结论房颤患者PBMV术后半年血中ANP逐步下降,BNP降低不明显。房颤律时△ANP和△BNP仍是反映LAD和MPG变化的有效指标。     

“Balloon impasse”: A marker for severe mitral subvalvular disease and a predictor of mitral regurgitation in inoue-balloon percutaneous transvenous mitral commissurotomy

In certain instances of percutaneous transvenous mitral commissurotomy, the Inoue catheter balloon, although deflated and properly aligned, becomes held up or checked at the mitral valve. This “balloon impasse,” observed in 13 of 760 patients undergoing the commissurotomy, reflects severe obstructive subvalvular disease even though echocardiographic evidence suggests otherwise. Our experience shows that the sign portends severe mitral regurgitation if the usual balloon sizing method is used. Such a situation occurred with four of the first six patients. In the next seven patients, the use of smaller balloon catheters (PTMC-18 or PTMC-20) for the initial set of stepwise dilatations averted creation of severe mitral regurgitation. When the “balloon impasse” sign is encountered during the commissurotomy procedure, the catheter selection and balloon sizing method should be judiciously altered. © 1995 Wiley-Liss. Inc.     

Changes in the levels of plasma atrial natriuretic peptide, hemodynamic measurements, and the levels of vasoactive hormones during the clinical course of congestive heart failure

To investigate the mechanism for the release of human atrial natriuretic peptide (hANP) and the pathophysiological role of hANP in patients with congestive heart failure (CHF), plasma hANP levels in patients with dilated cardiomyopathy (DCM) or acute myocardial infarction (AMI) were determined serially, and the relationship between plasma ANP levels and hemodynamic measurements or various vasoactive hormones was analyzed during the clinical course of congestive heart failure. In 63 patients with either AMI or DCM, plasma hANP, plasma renin activity, aldosterone concentration, and catecholamines were measured over 4 weeks, during the course of CHF. Cardiac catheterization with a Swan-Ganz catheter was also performed. Plasma hANP in patients with DCM was elevated continuously during the clinical course. Plasma hANP levels in patients with AMI of Groups II and IV of Forrester's class decreased on days 7 and 14 and those in patients with AMI of Group I changed within normal limits. Plasma hANP levels were correlated positively with pulmonary artery pressure and pulmonary capillary wedge pressure in patients with AMI or DCM. Plasma renin activity, noradrenaline, and adrenaline levels were elevated in the acute phase of myocardial infarction and had a tendency to decrease upon improvement in clinical status. Plasma renin activity and noradrenaline level correlated positively with plasma hANP levels. These data indicate that plasma hANP levels are regulated by atrial distension and severity of cardiac impairment, and that plasma hANP and plasma renin activity or catecholamines correlated closely during the clinical course of CHF, indicating that these hormones may be involved in the volume and electrolytes status in CHF.     

风湿性二尖瓣狭窄伴左室偏小患者球囊扩张术后的近期临床观察

目的　观察风湿性二尖瓣狭窄伴左室偏小患者经皮二尖瓣球囊扩张术 (PBMV)的球囊直径及扩张后心功能 ,血流动力学及心腔大小的变化。方法　选择风湿性二尖瓣狭窄伴左室偏小患者共 2 7例 ,采用Inoue法行PBMV ,球囊扩张直径为身高 / 10 +10mm ,分别测定其扩张前后左房及左室压力 ;随访其术前及术后近期心功能 ;超声评价术前 1周、术后 1周、1、3、6月二尖瓣瓣口面积、二尖瓣跨瓣压差、最大肺动脉收缩压及心腔大小的变化。结果　扩张即刻左房压力及二尖瓣跨瓣压差明显下降 ,舒张期杂音减轻 ,左室舒张末期压力增加 ;术后一周左房内径变小 ,左室内径增大 ,心功能改善不明显 ;术后一月左房内径变小 ,左室内径增大及心功能改善均达最佳效果 ,并维持至观察结束时。结论　风湿性二尖瓣狭窄伴左室偏小患者仍可以球囊直径 =身高 / 10 +10mm进行扩张 ;术后 1周心腔大小明显变化 ,1月达最佳效果 ;心功能的改善 1月才达最佳效果。     

2型糖尿病患者左心室舒张功能与B型脑钠肽的关系

目的分析2型糖尿病患者左心室舒张功能与B型脑钠肽的关系。方法收集100例2型糖尿病患者(B型脑钠肽≥100 pg/mL)。超声心动图测量指标包括左心房收缩末期容积指数(LAVI)、舒张早期二尖瓣血流峰值与舒张晚期血流峰值的比值(E/A)、左心室射血分数。用SPSS 18.0软件对测量数据进行Pearson相关分析。结果100例2型糖尿病患者心率为(81.8±5.6)次/min,B型脑钠肽浓度为(269.1±201.9)pg/mL,左心室射血分数为61.1%±5.8%,E/A值为0.83±0.07,左心房收缩末期容积指数为(20.07±4.38)mL/m2。E/A、左心房收缩末期容积指数与B型脑钠肽呈正相关(r=0.062,P=0.539;r=0.762,P<0.01)。结论 BNP和LAVI可有望作为早期识别左心室舒张功能不全或评价治疗效果的指标。     

Usefulness of bedside tissue Doppler echocardiography and B-type natriuretic peptide (BNP) in differentiating congestive heart failure from noncardiac cause of acute dyspnea in elderly patients with a normal left ventricular ejection fraction and permanent, nonvalvular atrial fibrillation: insights from a prospective, monocenter study

BACKGROUND: The incremental role of bedside tissue Doppler echocardiography and B-type natriuretic peptide (BNP) over the clinical judgment has been recently reported in the emergency diagnosis of congestive heart failure with a normal left ventricular ejection fraction (HFNEF). However, how well does this diagnostic strategy be applicable in the setting of atrial fibrillation is unknown. OBJECTIVE: To investigate the usefulness of bedside tissue Doppler echocardiography and BNP in the emergency diagnosis of HFNEF in elderly patients with permanent, nonvalvular atrial fibrillation. METHODS: Forty-one consecutive elderly patients with an ejection fraction > or =50% (mean age 84 years; 22 with HFNEF and 19 with noncardiac cause), hospitalized for acute dyspnea at rest, were prospectively enrolled; bedside septal E/Ea and BNP were obtained at admission. Results: By multivariable logistic regression analysis including the clinical judgment of heart failure, E/Ea and BNP, E/Ea (P = 0.014) and BNP (P = 0.018) provided independent diagnostic information. Optimal cutoffs were 13 for E/Ea (area under the ROC curve of 0.846, P < 0.0001; sensitivity 81.8%, specificity 89.5%) and 253 pg/ml for BNP (area under the ROC curve of 0.928, P < 0.0001; sensitivity 86.4%, specificity 89.5%). The concordance between the clinical judgment and BNP concentration at the cutoff of 253 pg/ml correctly classified 24 of 25 patients; E/Ea at the cutoff of 13 correctly classified 14 of the 16 patients with discrepancy. CONCLUSION: Bedside tissue Doppler echocardiography and BNP provide useful additional diagnostic information over the clinical judgment for the emergency diagnosis of HFNEF in elderly patients with permanent, nonvalvular atrial fibrillation.     

Pro B-type natriuretic peptide plasma value: A new criterion for the prediction of short- and long-term outcomes after transcatheter aortic valve implantation

Background

To determine the prognostic value of pro B-type natriuretic peptide (pro-BNP) to predict mortality after transcatheter aortic valve implantation (TAVI). Logistic EuroSCORE (LES) overestimates observed mortality after TAVI. A new risk score specific to TAVI is needed to accurately assess mortality and outcome.

Methods

Eighty-five patients were included. Indications for TAVI were nonoperable or surgically high-risk patients (LES > 20%). Pro-BNP was measured 24 h before the procedure. Cox proportional hazards model was used to evaluate clinical factors. The predictive accuracy of these Cox models was determined by using time-dependent receiver operating characteristic (ROC) curves.

Results

Pro-BNP levels (log-transformed) were significantly higher in non-survivors than in survivors at 30 days (3.36 ± 0.43 vs. 3.81 ± 0.43, p < 0.004) and at the end of follow-up (3.34 ± 0.42 vs. 3.63 ± 0.48, p < 0.011). Multivariate analysis revealed that only increased log pro-BNP levels were associated with higher mortality rate at short [hazard ratio (HR) (95% confidence intervals (CI)] = 5.35 (1.74–16.5), p = 0.003] and long-term follow-ups [HR = 11 (CI: 1.51–81.3), p = 0.018]. LES was not associated with increased mortality at either time point [HR = 1.03 (CI: 0.95–1.10), p = 0.483 and HR = 1.03 (CI: 0.98–1.07), p = 0.230, respectively]. At 30, 90, 180, and 365 days, the c-index was 0.72 for log pro-BNP and 0.63 for LES (p = 0.044).

Conclusion

Pre-procedure log transform of plasma pro-BNP levels are an independent and strong predictor of short- and long-term outcomes after TAVI and are more discriminatory than LES.     

Melatonin supplementation improves N‐terminal pro‐B‐type natriuretic peptide levels and quality of life in patients with heart failure with reduced ejection fraction: Results from MeHR trial,a randomized clinical trial

BackgroundMelatonin, the major secretion of the pineal gland, has beneficial effects on the cardiovascular system and might advantage heart failure with reduced ejection fraction (HFrEF) by attenuating the effects of the renin–angiotensin–aldosterone and sympathetic system on the heart besides its antioxidant and anti‐inflammatory effects.HypothesisWe hypothesized that oral melatonin might improve echocardiographic parameters, serum biomarkers, and a composite clinical outcome (including quality of life, hospitalization, and mortality) in patients with HFrEF.MethodsA placebo‐controlled double‐blinded randomized clinical trial was conducted on patients with stable HFrEF. The intervention was 10 mg melatonin or placebo tablets administered every night for 24 weeks. Echocardiography and measurements of N‐terminal pro‐B‐type natriuretic peptide (NT‐Pro BNP), high‐sensitivity C‐reactive protein, lipid profile, and psychological parameters were done at baseline and after 24 weeks.ResultsOverall, 92 patients were recruited, and 85 completed the study (melatonin: 42, placebo: 43). Serum NT‐Pro BNP decreased significantly in the melatonin compared with the placebo group (estimated marginal means for difference [95% confidence interval]: 111.0 [6.2–215.7], p = .044). Moreover, the melatonin group had a significantly better clinical outcome (0.93 [0.18–1.69], p = .017), quality of life (5.8 [0.9–12.5], p = .037), and New York Heart Association class (odds ratio: 12.9 [1.6–102.4]; p = .015) at the end of the trial. Other studied outcomes were not significantly different between groups.ConclusionsOral melatonin decreased NT‐Pro BNP and improved the quality of life in patients with HFrEF. Thus it might be a beneficial supplement in HFrEF.     

联合N端脑钠肽前体、估算的肾小球滤过率及超敏C-反应蛋白对急性心肌梗死患者院内发生1型心肾综合征的危险分层评估

目的观察N端脑钠肽前体(NT-proBNP)、估算的肾小球滤过率(eGFR)及超敏C-反应蛋白(hs-CRP)对急性心肌梗死患者在院内发生1型心肾综合征(CRS1)及危险分层中的作用。方法回顾性分析2012年12月至2017年2月北京友谊医院心血管中心数据库中急性心肌梗死患者2 094例。收集包括NT-proBNP、eGFR及hs-CRP在内的临床资料。按照每组人数大致相等的原则,分段考察NT-proBNP、eGFR及hs-CRP的值与CRS1发生率和院内死亡率之间的关系。采用SPSS 22.0统计软件进行统计学分析。Kaplan-Meier生存分析及COX比例风险回归评估异常指标的数目对院内死亡的影响。结果随着NT-proBNP的升高、eGFR的下降以及hs-CRP的升高,急性心肌梗死患者的院内CRS1发生率及院内死亡率均有升高趋势(P0.05)。随着CRS1加重,eGFR有下降趋势,NT-proBNP及hs-CRP在CRS1达到重度之前具有升高趋势。Kaplan-Meier生存分析显示,患者的院内累积生存率随着异常指标数目的增加而降低(P0.001)。≥2个指标异常是患者院内死亡的独立危险因素(RR=2.452,95%CI 1.105～5.440;P=0.027)。结论联合NT-proBNP、eGFR和hs-CRP将有助于对急性心肌梗死患者院内发生CRS1进行危险分层。     

A reduction in total isovolumic time with cardiac resynchronisation therapy is a predictor of clinical outcomes

Background

Total isovolumic time (t-IVT) reflects left ventricular (LV) asynchrony (when the ventricle is neither ejecting nor filling). It is prolonged in left bundle branch block (LBBB). Cardiac resynchronisation therapy (CRT) is a treatment for patients with heart failure, reduced LV ejection fraction and LBBB. CRT shortens t-IVT, but the long-term clinical benefit of such reduction after CRT has not been studied in this patient group.

Methods

Seventy-three patients who underwent CRT had t-IVT measured before and after CRT implantation. The study end-point was a composite of unplanned heart failure hospitalisation and all-cause mortality.

Results

Baseline t-IVT showed considerable scatter: 30 patients had t-IVT values longer than 15 s/min (upper 95% limit of normal). The change in t-IVT with CRT was also variable: t-IVT shortened in 50 patients (from 16.2 ± 4.8 s/min to 11.7 ± 3.7 s/min: group A), and lengthened in 23 patients (from 11.7 ± 4.2 s/min to 14.5 ± 4.33 s/min: group B). The magnitude of change in t-IVT with CRT negatively correlated with baseline t-IVT (r = − 0.619, p < 0.001); thus t-IVT (significantly longer in group A than group B before CRT: 16.2 ± 4.8 s/min vs. 11.7 ± 4.2 s/min, p < 0.001) became significantly shorter in group A compared to group B after CRT (11.7 ± 3.7 s/min vs. 14.5 ± 4.3 s/min, p = 0.005). After follow-up of 30 months, 70% group A patients had event-free survival compared to 39% group B patients. The presence of any fall in t-IVT after CRT was an independent predictor of event-free survival.

Conclusion

T-IVT is a marker of global cardiac asynchrony that has predictive capacity on functional, symptomatic, and mortality endpoints in patients with advanced heart failure.