Asma Hussaini

Impact of pulmonary hypertension on outcomes in patients with functional mitral regurgitation undergoing percutaneous edge-to-edge repair.

Preexisting pulmonary hypertension (PH) is associated with poor outcomes after surgical mitral valve repair for functional mitral regurgitation (FMR). However its clinical impact on MitraClip therapy remains unknown. The aim of this study was therefore to evaluate the impact of preexisting PH on MitraClip therapy for patients with FMR. Ninety-one consecutive patients who had FMR and who underwent the MitraClip procedure were studied. They were divided into 2 groups on the basis of pulmonary artery systolic pressure: the PH group (n = 48) and the non-PH group (n = 43). PH was defined as pulmonary artery systolic pressure >50 mm Hg using Doppler echocardiography. Procedural success (defined as magnetic resonance reduction to grade 2+ or less) and 30-day mortality were similar in the 2 groups. At 12 months, New York Heart Association functional class had improved to class I or II in most patients in the PH (from 2.9% to 94.3%) and non-PH (from 9.4% to 96.9%) groups. The mean pulmonary artery systolic pressure of the PH group significantly decreased from baseline but remained higher than that of the non-PH group (50.8 ± 15.3 vs 36.7 ± 11.6 mm Hg, p <0.001). After a mean of 25.0 ± 16.9 months of follow-up, Kaplan-Meier analysis demonstrated significantly higher all-cause mortality in the PH group. In Cox regression analysis, preexisting PH was the most powerful predictor of all-cause mortality (hazard ratio 3.731, 95% confidence interval 1.653 to 8.475, p = 0.002). In conclusion, MitraClip therapy reduced FMR and alleviated symptoms with an excellent early safety profile in the PH and non-PH groups. However, preexisting PH was associated with worse all-cause mortality.

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.

MitraClip: a novel percutaneous approach to mitral valve repair

As life expectancy increases, valvular heart disease is becoming more common. Management of heart disease and primarily valvular heart disease is expected to represent a significant proportion of healthcare provided to the elderly population. Recent years have brought a progression of surgical treatments toward less invasive strategies. This has given rise to percutaneous approaches for the correction of valvular heart disease. Percutaneous mitral valve repair using the MitraClip system (Abbott Vascular, Santa Clara, CA, USA) creates a double orifice and has been successfully used in selected patients with mitral regurgitation. We review the rationale, procedural aspects, and clinical data thus far available for the MitraClip approach to mitral regurgitation.

Optimizing procedural outcomes in percutaneous mitral valve therapy using transesophageal imaging: a stepwise analysis

Moderate or severe mitral regurgitation is the most common valve disease in the USA. Without treatment, severe mitral regurgitation has a 5-year survival rate of approximately 40%. Surgery plays a pivotal role in the treatment of these patients. However, close to 50% of patients can be denied surgery due to being deemed to be high risk. The pioneering work of St Goar led to the development of a catheter-based system, the MitraClip™, that percutaneously accomplishes the Alfieri’s method. With this percutaneous technique, rather than sutures, one or two clips are placed under transesophageal guidance attaching the midportions of the anterior and posterior leaflets, creating a double mitral orifice. The procedure requires seven basic steps with strong collaboration between the interventional cardiologist and echocardiologist. This paper focuses on the role of echocardiography for patient selection and procedural guidance for the MitraClip insertion.

Comparison between transradial and transfemoral percutaneous coronary intervention in acute ST-elevation myocardial infarction.

Transradial (TR) access is increasingly being used in percutaneous coronary intervention (PCI). However, its role in PCI for ST-segment elevation myocardial infarction remains controversial because of concerns of procedural complexity adversely affecting the promptness of reperfusion. In this study, 150 consecutive patients who underwent PCI for acute ST-segment elevation myocardial infarction over a period of 24 months were prospectively evaluated; 46 had TR access (31%) and 104 (69%) had transfemoral (TF) access. All patients received thienopyridines, aspirin, and heparin per routine management. There were no significant differences between the TR access and TF access groups with respect to age (62.2 ± 11.6 vs 64.7 ± 14.1, p = 0.28), gender (76.1% vs 72.1% men, p = 0.69), or incidence of diabetes (23.9% vs 26.9%, p = 0.84). The TR and TF access groups were comparable with respect to door-to-balloon time (79.2 ± 32.3 vs 86.8 ± 51.8 minutes, p = 0.67) and amount of contrast used (190.5 ± 101.5 vs 172.2 ± 81.7 ml, p = 0.24). Total fluoroscopy time was longer in the TR access group compared to the TF access group (21.7 ± 12.7 vs 14.4 ± 10.4 minutes, p <0.0001). Postprocedural Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow was comparable for the 2 groups (87% for the TF group and 96% for the TR group, p = 0.15). There were no vascular complications in the TR access group compared to the TF access group (0% vs 5.8%, p = 0.18). In conclusion, this single-center observational study shows that TR access for PCI in STEMI is feasible and that it has fewer vascular complications and shorter length of hospital stay than the TF approach.

Percutaneous Mitral Valve Repair: Potential in Heart Failure Management

As a large portion of the US demographic advances into the later decades of life, the incidence of valvular heart disease is expected to increase. Mitral regurgitation (MR) caused by primary valve abnormality (degenerative) or secondary to cardiomyopathy (functional) is an important cause of heart failure. Management of valvular heart disease is expected to account for a large segment of services provided to heart failure patients. Recent years have seen a transition from surgical therapy to minimally invasive techniques, specifically percutaneous approaches for the correction of heart valve disease. The double orifice technique of mitral valve repair using the MitraClip™ System (Abbott Vascular, Menlo Park, CA) is one of many percutaneous approaches to treat significant MR. This technique is effective in patients with both degenerative and functional MR, reducing MR severity and improving heart failure symptoms. Broad acceptance of this percutaneous technology requires collaboration among cardiologists and cardiac surgeons in centers with superior catheter experience and knowledge of echocardiography.

ANEMIA PREDICTS MORTALITY IN ATRIAL FIBRILLATION PATIENTS UNDERGOING LEFT ATRIAL APPENDAGE OCCLUSION USING WATCHMAN DEVICE

Background: Anemia is associated with mortality and poor outcomes in patients with cardiovascular disease undergoing interventional procedures, including percutaneous coronary intervention, transcatheter aortic valve implantation, and percutaneous mitral valve repair. In patients with atrial

Mitral annular calcification is not associated with decreased procedural success, durability of repair, or left ventricular remodelling in percutaneous edge-to-edge repair of mitral regurgitation.

AIMS Mitral annular calcification (MAC) negatively influences outcomes in surgical mitral valve (MV) repair for mitral regurgitation (MR). However, there are no data on whether MAC impacts on outcomes of MitraClip percutaneous MV edge-to-edge repair. This study sought to investigate whether the presence of MAC impacts on the procedural success and durability of percutaneous transcatheter repair of MR using the MitraClip. METHODS AND RESULTS One hundred and seventy-three patients undergoing MitraClip repair for significant MR were studied. Patients with moderate-or-severe MAC (n=28) were compared to those with no-or-mild MAC. Post-procedural MR severity was not different (p=0.642) and MR reduction to moderate-or-less was equally high in patients with moderate-or-severe MAC (100%) and those without (96.7%), p=1.000. At one year, MR severity was not different (p=0.831), and there was no difference in the repair durability when comparing patients with moderate-or-severe MAC (93.8%) to those without (90.6%), p=1.000. All patients with moderate-or-severe MAC assessed at one year were in NYHA functional Class I-II and had haemodynamic improvements with a decrease in pulmonary artery systolic pressure (-6.5±13.1 mmHg), p=0.021, and end-diastolic left ventricular internal diameter (-3.9±6.5 mm), p=0.034, not different to those achieved by patients without MAC (both p>0.100). CONCLUSIONS Moderate-or-severe MAC scored by echocardiography and confirmed on fluoroscopy was not associated with decreased procedural success or durability of repair. Patients with moderate-or-severe MAC had improvements in clinical symptoms and haemodynamics, as well as decreased left ventricular dimensions.

Comparison of mitral valve geometrical effect of percutaneous edge-to-edge repair between central and eccentric functional mitral regurgitation: clinical implications

AIMS Percutaneous edge-to-edge repair alters mitral valve (MV) geometry in functional mitral regurgitation (FMR). We sought to characterize MV morphology in patients with central and eccentric FMR, compare the geometrical effect of MitraClip therapy, and elucidate different mechanisms of MR improvement according to FMR subtypes. METHODS AND RESULTS Seventy-six symptomatic patients with Grade 3 to 4+ FMR (central, n = 39; eccentric, n = 37) underwent three-dimensional transoesophageal echocardiography during MitraClip implantation. We defined procedural success as a reduction of MR by ≥1 grade with having a residual mitral regurgitation (MR) of ≤ grade 2+. Procedural success rate was similar between central and eccentric FMR (77% vs. 78%, P = 0.55). After MitraClip, the reduction in anterior-posterior diameter did not differ between FMR subtypes, but patients with eccentric FMR had a greater reduction in the averaged tethering angle difference (P < 0.001) with less reduction in tenting volume and height (both P < 0.001) than did patients with central FMR. On multivariable analysis, in central FMR, MR reduction post-clip was associated with shortening in anterior-posterior diameter [coefficient 0.388, 95% confidence interval (CI) 0.216-0.561; P < 0.001] and an increase in coaptation area (coefficient 0.117, 95% CI 0.039-0.194; P = 0.004), whereas in eccentric FMR MR reduction was mainly associated with a decrease in the averaged tethering angle difference (coefficient 0.050, 95% CI 0.021-0.078; P = 0.001). CONCLUSION MV geometrical effect and its association with MR improvement after MitraClip therapy differ according to FMR subtypes. Our results indicate the MR jet direction and the leaflet tethering pattern may be considered in the strategy for percutaneous treatment for FMR.

IMPACT OF RESIDUAL LEFT ATRIAL APPENDAGE TRABECULATIONS AFTER WATCHMAN DEVICE IMPLANTATION IN ATRIAL FIBRILLATION PATIENTS

Backgrounds: Percutaneous left atrial appendage (LAA) closure using WATCHMAN device has been reported to be effective in atrial fibrillation patients. Although residual LAA trabeculations is observed after WATCHMAN implantation in some cases, the clinical impact of the residual trabeculations is