Contemporary application of cardiovascular hemodynamics: transcatheter aortic valve interventions

Over the past two decades, echocardiography has replaced cardiac catheterization for aortic valvular hemodynamic assessment. In recent years, however, there has been a rapid evolution of transcatheter aortic valve technology and, with its refinement, there has been the increasing recognition of the value of transcatheter hemodynamic assessment in complementing the information provided by contemporary echocardiography. With an emphasis on transcatheter hemodynamics, this article reviews the symbiotic application of these assessment modalities pertaining to contemporary transcatheter aortic valve implantation.     

经导管二尖瓣夹合术的临床结果介绍

目的 评估经导管二尖瓣夹合术（MitraClip）治疗中重度或重度二尖瓣反流患者的安全性和有效性.方法 2013年10月至2014年3月,使用MitraClip系统对10例有症状的中重度（1例）或重度（9例）二尖瓣反流患者行经导管二尖瓣修复术,分析10例患者手术即刻效果和30d随访结果.结果 10例患者的平均年龄（74±10.6）岁,功能性反流8例,器质性反流2例.所有手术均成功开展,顺利置入1个（5例）或2个（5例）MitraClip.手术即刻效果提示,5例患者二尖瓣反流下降3级,5例患者下降2级,未发生相关并发症.30d超声心动图随访提示,所有患者二尖瓣反流较术前降低≥2级,左心室射血分数（LVEF）由（40.2±11.9）％提高到（44.8±11.6）％,左心房内径和舒张期左心室内径分别由（6.4±0.5） cm和（6.1±0.8） cm缩小至（6.0±0.5） cm和（6.0±0.8） cm.所有患者的主观症状较术前有不同程度的改善,纽约心功能分级均较术前提高1级,生活质量评分和6 min步行试验分别由（0.7±0.2）和（279.0±123.0）m提高到（0.9±0.1）和（347.0±91.0）m.结论 本中心初步经验提示,经导管二尖瓣夹合术（MitraClip）可以带来超声心动图指标的改善和早期的临床获益,是安全有效的,但中远期效果有待于进一步随访.     

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.     

Percutaneous mitral valve repair: A new treatment for mitral regurgitation

Mitral valve disease affects more than 4 million people in the United States. The gold standard of treatment in these patients is surgical repair or replacement of the valve with a prosthesis. The MitraClip (Abbott Vascular, Menlo Park, CA) is a new technology, which offers an alternative to open surgical repair or replacement via a minimally invasive route. We present an evidence-based clinical update that provides an overview of this technology as it relates to managing patients with significant mitral regurgitation. This review article is particularly useful to noninterventional cardiologists and interventional cardiologists who will be managing patients with this novel technology in increased volumes over the next decade but who do not perform this procedure.     

经皮二尖瓣球囊成形术治疗二尖瓣狭窄伴主动脉瓣关闭不全的疗效评价

目的　探讨风湿性心脏病 (RHD)二尖瓣狭窄 (MS)合并轻、中度主动脉瓣关闭不全 (AR)患者行经皮二尖瓣球囊成形术 (PBMV)的效果。方法　将 2 6例MS合并轻、中度AR患者 (A组 )和 34例单纯MS患者 (B组 )的PBMV术后即刻及随访结果作对比研究。结果　A组左心房平均压力(MLAP)从术前 2 3 5± 4 6mmHg降至 11 2± 2 9mmHg(P <0 0 1) ,二尖瓣跨瓣压差 (MVG)从 17 2±7 7mmHg降至 2 3± 2 6mmHg(P <0 0 1) ,二尖瓣口面积 (MVA)从 1 1± 0 2cm2 增至 2 1± 0 2cm2(P <0 0 1) ,左心房内径 (LAD)从 43 3± 5 0mm降至 36 4± 3 7mm(P <0 0 1)。二尖瓣区舒张期杂音消失率为 73%。心功能分级 (NYHA)从术前 2 7± 0 5级改善至 1 1± 0 7级 (P <0 0 1)。随访与术后比较 ,除MVA外各项指标均无显著性差异 (P >0 0 5 )。以上各项参数与B组比较 ,差异均无显著性(P >0 0 5 )。且A组随访左心室内径 (LVD)仍在正常范围 ,亦无主动脉瓣返流增加。结论　对于MS合并轻、中度AR ,PBMV是一种有效和安全的治疗措施 ,应列入PBMV的手术适应症。     

MitraClip: Catheter-based treatment of mitral regurgitation

Mitral regurgitation (MR) is the second most prevalent heart valve disease requiring surgery. Despite the evidence of unfavourable prognosis, around half of patients with severe MR are not referred for surgery due to high per-operative risk. MitraClip (Abbott Vascular-Structural Heart, Menlo Park, California, United States) implantation is an emerging percutaneous technique with edge-to-edge MV repair inspired by the Alfieri surgery. Favourable safety profile together with improvement of functional status and decrease of MR severity in high-surgical-risk patients have been demonstrated in randomized clinical trials and “real-world” registries for both primary and secondary MR. Our own data confirmed its safety and efficacy comparing to minimally invasive MV surgery in treatment of functional MR in population with severe systolic heart failure.     

二尖瓣狭窄并中度反流的经皮二尖瓣球囊扩张术42例及随访观察

目的　探讨二尖瓣狭窄 (MS)并中度反流 (MR)患者经皮二尖瓣球囊扩张术 (PBMV)近远期疗效。方法　采用Inoue单球囊对 42例风心病二尖瓣狭窄并中度反流患者行PAMV治疗。结果　二尖瓣口面积由 (0 92± 0 2 2 )cm2 增至 (1 94± 0 2 5 )cm2 (P <0 0 1) ;二尖瓣跨瓣压差由 (2 7± 1 0 1)kPa降至 (1 0 2± 0 5 6 )kPa(P <0 0 1) ;心功能由 (2 6 1± 0 2 2 )级改善至 (1 42± 0 46 )级 (P <0 0 1) ;左室最大前后径无明显变化 (P >0 0 5 )。 2例患者二尖瓣反流较术前加重。随访 37例患者 (18± 4)个月 ,二尖瓣口面积、左室最大前后径及心功能与术后比较 ,均无明显变化 (P >0 0 5 )。结论　掌握好病例选择 ,严格把握球囊扩张尺度 ,风心病二尖瓣狭窄并中度反流患者PBMV近、远期疗效满意     

经导管主动脉瓣置入手术在主动脉瓣狭窄合并二尖瓣反流治疗中的疗效分析

目的:分析经导管主动脉瓣置入术在主动脉瓣狭窄合并二尖瓣反流(MR)的疗效。方法:选取我院就诊的主动脉瓣狭窄合并MR流患者31例,所有患者均行经导管主动脉瓣置入术,按照患者的MR流严重程度分为A组(轻度)和B组(中度、重度)。比较两组的并发症发生率、术后1个月的LVEF、LVEDD、MR和NYHA分级,比较两组在术后1个月、3个月时的死亡率和生活质量。结果:两组的各并发症发生率差异无统计学意义(P>0.05);A组在术后1个月时的LVEF和日常生活能力量表(ADL)评分均明显高于B组(P<0.05);A组在术后1个月时的死亡率、LVEDD、MR和NYHA分级明显低于B组(P<0.05);两组患者在术后3个月时的死亡率和ADL评分均差异无统计学意义(P>0.05)。结论:经导管主动脉瓣置入手术可用于主动脉瓣狭窄合并不同程度MR流患者的治疗中,反流的严重程度对患者远期死亡率和生活质量恢复的影响较小。     

MitraClip in CRT non-responders with severe mitral regurgitation

Background

Severe mitral regurgitation (MR) ≥ 3 + and left ventricular dyssynchrony in heart failure patients are markers of CRT non response. The MitraClip (MC) implantation is a therapy for MR ≥ 3 + in patients with high surgical risk of mitral valve reconstruction.

Methods and results

We investigated 42 patients with CRT and MR ≥ 3 + who received an MC device at our center. One and two year mortality rates were compared with the predicted mortality by Seattle Heart Failure Model (SHFM) and meta-analysis global group in chronic heart failure (MAGGIC), using the baseline characteristics of patients at the time of MC implantation.The median time interval between CRT and MC implantation was 20.1 (4.5–43.3) months. In 19 patients we observed a functional regurgitation with normal leaflets and in 23 patients a degenerative mechanism for mitral regurgitation. There was no change in mean QRS duration by biventricular pacing or MC implantation. The use of MC led to significant reductions in: median N-terminal pro-brain natriuretic peptide (NT-proBNP) level (pg/ml) from 3923 to 2636 (p = 0.02), tricuspid regurgitation pressure gradient (TRPG) from 43 to 35 mm Hg (p = 0.019) and in left ventricular end-diastolic volume (LVEDV) by MC (p = 0.008). At the 2 year follow-up interval the all-cause mortality was 25%.

Conclusion

MC implantation leads to an improvement of NT-proBNP level, TRPG and LVEDV in both functional and degenerative MR but does not influence QRS duration. Two year all-cause mortality was 25% and did not differ significantly from that predicted by SHFM and MAGGIC.     

Three-dimensional echocardiography in mitral valve disease.

Three-dimensional echocardiography offers great promise for improving the understanding of the mitral valve anatomy, function, and pathology. It may have important implications for medical or surgical management of different mitral valve disease. In this article we provide an overview of the three-dimensional anatomy of the mitral valve. Based on the studies using three-dimensional echocardiography we describe the topography of the mitral valve, its nonplanarity as well as dynamics of the mitral annulus. Furthermore, we review the use of three-dimensional echocardiography in the evaluation of different mitral valve disease. Three-dimensional echocardiography has become a new clinical standard in the assessment of the severity of mitral stenosis by means of accurate mitral valve area measurement. Also, unconventional indices, like the geometry and mitral valve volume may be assessed by three-dimensional echocardiography. It is a very suitable technique for monitoring the efficacy and complications of percutaneous mitral valvuloplasty. Three-dimensional echocardiography allows accurate identification and quantification of prolapse of individual segments of the mitral valve leaflets. Three-dimensional color flow imaging makes echocardiography an accurate method also in the assessment of mitral regurgitation severity. Finally, we outline three-dimensional echocardiography as a potentially useful guide for a surgeon, particularly in mitral valve repair.     

MDCT to guide transcatheter aortic valve replacement and mitral valve repair

Percutaneous management of valvular heart disease is becoming a reality, with multicenter trials supporting minimally invasive procedures for both aortic and mitral valve disease. Historically, the treatment of choice has been aortic valve replacement with conventional surgery for patients with severe aortic stenosis, as the prognosis of untreated patients is poor, particularly if the patient is symptomatic. Transcatheter aortic valve replacement is now available as a minimally invasive option to treat select high-risk patients with severe aortic stenosis. At present more than 30,000 procedures have been performed worldwide, mostly confined to patients at high surgical risk. The short- and medium-term outcomes have been promising.     

Cardio-hepatic syndrome in patients undergoing mitral valve transcatheter edge-to-edge repair

Aims

The impact of the cardio-hepatic syndrome (CHS) on outcomes in patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) for relevant mitral regurgitation (MR) is unknown. The objectives of this study were three-fold: (i) to characterize the pattern of hepatic impairment, (ii) to investigate the prognostic value of CHS, and (iii) to evaluate the changes in hepatic function after M-TEER.

Methods and results

Hepatic impairment was quantified by laboratory parameters of liver function. In accordance with existing literature, two types of CHS were distinguished: ischaemic type I CHS (elevation of both transaminases) and cholestatic type II CHS (elevation of two out of three parameters of hepatic cholestasis). The impact of CHS on 2-year mortality was evaluated using a Cox model. The change in hepatic function after M-TEER was assessed by laboratory testing at follow-up. We analysed 1083 patients who underwent M-TEER for relevant primary or secondary MR at four European centres between 2008 and 2019. Ischaemic type I and cholestatic type II CHS were observed in 11.1% and 23.0% of patients, respectively. Predictors for 2-year all-cause mortality differed by MR aetiology. While in primary MR cholestatic type II CHS was independently associated with 2-year mortality, ischaemic CHS type I was an independent mortality predictor in secondary MR patients. At follow-up, patients with MR reduction ≤2+ (obtained in 90.7% of patients) presented with improved parameters of hepatic function (median reduction of 0.2 mg/dl, 0.2 U/L and 21 U/L for bilirubin, alanine aminotransferase and gamma-glutamyl transferase, respectively, p < 0.01).

Conclusions

The CHS is frequently observed in patients undergoing M-TEER and significantly impairs 2-year survival. Successful M-TEER may have beneficial effects on CHS.     

经皮球囊导管二尖瓣扩张术治疗风心病二尖瓣狭窄102例

对102例风湿性心脏辩膜病二尖瓣狭窄患者进行了经皮球囊导管二尖辩成形术。结果成功101例，二尖辩口面积由0．79±0．34cm2增至1．88±0．32cm2，跨瓣压差由259±077kPa降至0．83±0．42kPa，左房平均压由3．84±1．15kPa降至1．86±0．59kPa。1例发生脑梗塞，其他患者未出现严重合并症。本文对该术疗效、技术操作及严重合并症的预防进行了探讨。     

A systematic approach for transcatheter mitral valve edge-to-edge repair of isolated commissure prolapse

Although transcatheter mitral valve edge-to-edge repair (TEER) has been widely used for non-central degenerative mitral regurgitation (MR), few reports have described therapeutic strategies for commissure prolapse. Furthermore, no standard approach for TEER for commissure has established. Thus, we categorized various grasping strategies into three patterns, and proposed a promising systematic strategy to observe three possible grasping patterns for identifying appropriate grasping target. Here, we report a successful TEER case of isolated posterior commissure prolapse in which we used a systematic approach.     

Isolated cleft posterior mitral valve leaflet: an uncommon cause of mitral regurgitation

A 53-year-old woman with a history of hypertension was referredfor an echocardiogram by her primary care physician after anunspecified abnormal ECG. The echocardiogram showed normal leftventricular size and function; however, an isolated cleft posteriormitral valve leaflet was identified with concomitant bileafletprolapse and mild mitral regurgitation. She was subsequentlyreferred to a cardiologist for clinical evaluation. Cleft mitralvalve leaflet (CMVL) is an uncommon congenital cause of mitralregurgitation. Clefts, defined as slit-like holes or defects,are hypothesized to be a result of incomplete expression ofan endocardial cushion defect which most commonly involves theanterior mitral valve leaflet with a paediatric incidence of1:1340. Clefts affecting only the posterior mitral valve leafletare extremely rare with only four cases being reported in themedical literature. Important co-existing anomalies with eitherposterior and/or anterior CMVL include counterclockwise rotationof the papillary muscles, the presence of an accessory papillarymuscle or mitral valve leaflet, atrial septal defects, and mitralvalve prolapse. Regurgitation from CMVL can lead to importantphysiological and anatomical changes within the cardiac system.Regurgitation results from blood flow directly through the cleftitself or from malcoaptation from accessory chordae with orwithout papillary muscle distortion. Significant chronic mitralregurgitation elevates left atrial filling pressures and leadsto chamber enlargement and eccentric left ventricular hypertrophy.Early detection through two-dimensional echocardiography canprovide accurate anatomical images of the various mitral valvestructures and identify associated congenital anomalies. Earlysurgical correction is preferred before mitral regurgitationcauses unfavourable remodelling. Most mitral valve cleft defectscan easily be repaired by suturing the edges of the cleft. Ifa cleft resection leads to limited residual valve tissue, theleaflet of the mitral valve can be reconstructed using an autologouspericardial patch pre-treated with buffered glutaraldehyde.Posterior CMVL is an uncommon but clinically important causeof mitral insufficiency. Early recognition of this rare clinicalentity and possible co-existent anomalies can identify the patientswho would benefit from surgical intervention before compensatoryleft ventricular remodelling and contractile dysfunction develop.     

不同类型先天性心脏病并发二尖瓣反流手术效果随访分析

目的:随访观察不同类型先天性心脏病(先心病)合并二尖瓣反流(MR)患儿术后MR的转归。方法:回顾性分析MR术后病例229例(166例行二尖瓣成形术、63例二尖瓣未处理),比较不同类型先心病合并MR患儿行心脏畸形矫正后,二尖瓣处理组与未处理组术后早期、远期MR的转归情况。结果:144例室间隔缺损(VSD)修补同时二尖瓣成形组与29例仅行VSD修补二尖瓣未处理组患儿相比,术后早期和远期MR改善率前者均高于后者;40例动脉导管未闭(PDA)合并MR组与16例主动脉缩窄(CoA)合并MR组,术后早期二尖瓣成形组MR改善率均高于未处理组(P均0.05),而术后远期二尖瓣成形组与未处理组MR改善率均无统计学差异(P0.05)。结论:不同类型先心病合并MR可能需要采取不同的处理方案。VSD合并MR者,建议在修补缺损同时对较重度MR行二尖瓣成形术;而PDA或CoA合并MR患儿可先矫正心脏畸形,再根据患儿远期预后,决定是否行二尖瓣成形术。