A Novel Assessment Using Projected Transmitral Gradient Improves Diagnostic Yield of Doppler Hemodynamics in Rheumatic and Calcific Mitral Stenosis

ObjectivesThe aims of this study were to: 1) develop a formula for projected transmitral gradient (TMG), expected gradient under normal heart rate (HR), and stroke volume (SV); and 2) assess the prognostic value of projected TMG.BackgroundIn mitral stenosis (MS), TMG is highly dependent on hemodynamics, often leading to discordance between TMG and mitral valve area.MethodsAll patients with suspected MS based on echocardiography from 2001 to 2017 were analyzed. Data were randomly split (2:1); projected TMG was modeled in the derivation cohort, then tested in the validation cohort. The composite endpoint was death or mitral valve intervention.ResultsOf 4,973 patients with suspected MS, severe and moderate MS, defined as mitral valve area ≤1.5 and >1.5 to 2.0 cm², were present in 437 (9%) and 936 (19%), respectively. In the derivation cohort (n = 3,315; age 73 ± 12 years; 34% male), corresponding gradients were TMG ≥6 and 4 to <6 mm Hg, respectively, under normal hemodynamics. Based on the impact of hemodynamics on TMG, the formula was projected TMG = TMG ? 0.07 (HR ? 70) ? 0.03 (SV ? 97) in men and projected TMG = TMG ? 0.08 (HR ? 72) ? 0.04 (SV ? 84) in women. In the validation cohort (n = 1,658), projected TMG had better agreement with MS severity than TMG (kappa 0.61 vs. 0.28). Among 281 patients with TMG ≥6 mm Hg, projected TMG ≥6 mm Hg, present in 171 patients (61%), was associated with higher probability of the endpoint versus projected TMG <6 mm Hg (adjusted hazard ratio: 1.8; 95% confidence interval: 1.2 to 2.6; p < 0.01).ConclusionsThe novel concept of projected TMG, constructed using the observed impact of HR and SV on TMG, significantly improved the concordance of gradient and valve area in MS and provided better risk stratification than TMG.     

The Learning Curve for Transcatheter Mitral Valve Repair With MitraClip

Objectives

This study sought to assess the learning curve for TMVR for treatment of primary mitral regurgitation (MR).

Background

Data are lacking regarding the technical experience required to achieve optimal clinical outcomes with transcatheter mitral valve repair (TMVR) using the edge‐to‐edge MitraClip technique.

Methods

We examined the sequential experience of the first 75 patients (age 80 ± 9 years; 77% male) who underwent TMVR at our institution. A sequence number of each patient was assigned as a continuous variable and in tertiles for analysis.

Results

TMVR with MitraClip was successful in 97% with an average procedural time of 106 ± 39 minutes. The 30‐day rate of major adverse cardiovascular events was 7%. With increased case experience, there were decreases in procedural time, fluoroscopy time, length of hospital stay, and major adverse cardiovascular events. Procedural success, residual mitral regurgitation and NYHA functional classification at 30‐day follow‐up remained unchanged throughout the experience.

Conclusions

The learning curve for TMVR with MitraClip for treatment of primary MR is characterized by a sequential reduction in procedure time, fluoroscopy time, procedural complications, and hospital length of stay at a tertiary academic medical center. Thirty‐day procedural results are favorable and similar during the initial learning period.

     

Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers

Increasing numbers of orphaned and vulnerable children resulting from AIDS deaths requires practical placement strategies. While the extended family is regarded as both the most likely and the preferred option by most key planners and organizations, warnings of the limitations of this alternative have been increasing. This study assessed the views of 1400 adults (both current and prospective caregivers) regarding the placement of children. Most current caregivers believed that either their partner (30%), a grandparent (25%) or another family member (33%) would look after the child/children if they were no longer able to. However, 12% of parents could not identify a carer or predicted only a bleak future for their children. There was strong willingness amongst adults of various relational proximity to take in children if required to -71% of both fathers and grandparents, 63% of siblings and 23% of best friends said they would take in children. Nonetheless this research suggests that the willingness may not necessarily be translated into reality. Most prospective caregivers identified significant additional stressors (most importantly financial) and expressed a strong need for assistance if they were to take in additional children. The HIV status of the child is also likely to sway placement decisions for some people. Nonetheless opportunities to keep children in families are clearly high, but people will need considerable help to realize this potential. For some children alternatives other than the extended family will be required.     

Systolic and diastolic heart failure in the community

Context  The heart failure (HF) syndrome is heterogeneous. While it can be defined by ejection fraction (EF) and diastolic function, data on the characteristics of HF in the community are scarce, as most studies are retrospective, hospital-based, and rely on clinically indicated tests. Further, diastolic function is seldom systematically assessed based on standardized techniques. Objective  To prospectively measure EF, diastolic function, and brain natriuretic peptide (BNP) in community residents with HF. Main Outcome Measures  Echocardiographic measures of EF and diastolic function, measurement of blood levels of BNP, and 6-month mortality. Design, Setting, and Participants  Olmsted County residents with incident or prevalent HF (inpatients or outpatients) between September 10, 2003, and October 27, 2005, were prospectively recruited to undergo assessment of EF and diastolic function by echocardiography and measurement of BNP. Results  A total of 556 study participants underwent echocardiography at HF diagnosis. Preserved EF (50%) was present in 308 (55%) and was associated with older age, female sex, and no history of myocardial infarction (all P<.001). Isolated diastolic dysfunction (diastolic dysfunction with preserved EF) was present in 242 (44%) patients. For patients with reduced EF, moderate or severe diastolic dysfunction was more common than when EF was preserved (odds ratio, 1.67; 95% confidence interval [CI], 1.11-2.51; P = .01). Both low EF and diastolic dysfunction were independently related to higher levels of BNP. At 6 months, mortality was 16% for both preserved and reduced EF (age- and sex-adjusted hazard ratio, 0.85; 95% CI, 0.61-1.19; P = .33 for preserved vs reduced EF). Conclusions  In the community, more than half of patients with HF have preserved EF, and isolated diastolic dysfunction is present in more than 40% of cases. Ejection fraction and diastolic dysfunction are independently related to higher levels of BNP. Heart failure with preserved EF is associated with a high mortality rate, comparable to that of patients with reduced EF.