Chi-Hion Li

Initial experience of percutaneous treatment of mitral regurgitation with MitraClip® therapy in Spain.

INTRODUCTION AND OBJECTIVES Symptomatic mitral regurgitation has an unfavorable prognosis unless treated by surgery. However, the European registry of valvular heart disease reports that 49% of patients with this condition do not undergo surgery. Percutaneous treatment of mitral regurgitation with MitraClip® has been proved a safe, efficient adjunct to medical treatment in patients with this profile. The objective of the present study is to describe initial experience of MitraClip® therapy in Spain. METHODS Retrospective observational study including all patients treated between November 2011 and July 2013 at the 4 Spanish hospitals recording the highest numbers of implantations. RESULTS A total of 62 patients (77.4% men) were treated, mainly for restrictive functional mitral regurgitation (85.4%) of grade III (37%) or grade IV (63%), mean (standard deviation) ejection fraction 36% (14%), and New York Heart Association functional class III (37%) or IV (63%). Device implantation was successful in 98% of the patients. At 1 year, 81.2% had mitral regurgitation ≤ 2 and 90.9% were in New York Heart Association functional class ≤ II. One periprocedural death occurred (sepsis at 20 days post-implantation) and another 3 patients died during follow-up (mean, 9.1 months). Two patients needed a second implantation due to partial dehiscence of the first device and 2 others underwent heart transplantation. CONCLUSIONS In Spain, MitraClip® therapy has principally been aimed at patients with functional mitral regurgitation, significant systolic ventricular dysfunction, and high surgical risk. It is considered a safe alternative treatment, which can reduce mitral regurgitation and improve functional capacity.

Role of Imaging Techniques in Percutaneous Treatment of Mitral Regurgitation.

Mitral regurgitation is the most prevalent valvular heart disease in the United States and the second most prevalent in Europe. Patients with severe mitral regurgitation have a poor prognosis with medical therapy once they become symptomatic or develop signs of significant cardiac dysfunction. However, as many as half of these patients are inoperable because of advanced age, ventricular dysfunction, or other comorbidities. Studies have shown that surgery increases survival in patients with organic mitral regurgitation due to valve prolapse but has no clinical benefit in those with functional mitral regurgitation. In this scenario, percutaneous repair for mitral regurgitation in native valves provides alternative management of valvular heart disease in patients at high surgical risk. Percutaneous repair for mitral regurgitation is a growing field that relies heavily on imaging techniques to diagnose functional anatomy and guide repair procedures.

Myocardial remodelling and tissue characterisation by cardiovascular magnetic resonance (CMR) in endurance athletes

There is still some controversy about the benignity of structural changes observed in athlete’s heart, especially regarding the observation of increased biomarkers and the presence of myocardial fibrosis (MF). Aim Our purpose was to evaluate by cardiovascular magnetic resonance (CMR) the presence of diffuse as well as focal MF in a series of high-performance veteran endurance athletes. Methods Thirty-four veteran healthy male endurance athletes, still being in regular training, with more than 10 years of training underwent a CMR. A cardiopulmonary exercise test was also performed to assess their maximal physical performance. The control group consisted in 12 non-trained normal individuals. Results We found an increase in both, right and left ventricular (LV) volumes in the athlete’s group when compared with controls. There was no increase in indexed LV myocardial mass despite of a significantly increased maximal myocardial wall thickness in comparison to controls. Native T1 values and extracellular volume (ECV) were normal in all cases. We did not find differences in native T1 values and ECV between both groups. In three athletes (9%), non-ischaemic late gadolinium enhancement (LGE) was observed. We did not find a correlation between total training volume and presence of LGE or with the ECV value. Conclusions Our results show that the majority of veteran endurance athletes present with myocardial remodelling without MF as a physiological adaptive phenomenon. In the only three athletes with focal MF, the LGE pattern observed suggests an intercurrent event not related with the remodelling phenomenon.

Prevalence of optimal valve morphology for MitraClip in patients with mitral regurgitation

To evaluate how often patients with moderate‐to‐severe or severe mitral regurgitation (MR) meet the anatomical criteria for MitraClip implant and to examine the role of transthoracic echocardiography (TTE) for this task.

WITHDRAWN: Use of Repositionable Transcatheter Aortic Valve Systems in Past Mechanical Prosthetic Mitral Valve Recipients

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Acute coronary syndrome due to occlusion of the conus artery.

Paciente varon de 46 anos con antecedentes de hipercolesterolemia y obesidad, que fue admitido en el servicio de urgencias del hospital con diagnostico de sindrome coronario agudo con elevacion del segmento ST en V1 y V2. Se realizo coronariografia invasiva emergente, que mostro lesion del 30% tanto en el origen de la arteria descendente anterior y como en el origen de la arteria descendente posterior. Ante dicho resultado, se decidio completar el estudio con cardiorresonancia magnetica, que mostro alteracion de la contractilidad segmentaria a nivel de camara de salida del ventriculo derecho (figura 1, flecha en panel superior), que coincidia con una zona de captacion de contraste tardia compatible con necrosis (figura 1, flechas en el panel inferior). Un posterior estudio por angiografia coronaria no invasiva por tomografia computarizada con multidetectores confirmo las lesiones objetivadas en el cateterismo y mostro, ademas, una rama conal de distribucion en el area infartada con oclusion trombotica en su origen (figuras 2A y B, flechas). Tal lesion habia pasado inadvertida en el cateterismo, pero en una de las proyecciones reanalizadas se visualizaba el munon correspondiente al origen de dicha rama conal ocluida (figura 2C, flecha). El caso ilustra la alta sensibilidad de la cardiorresonancia magnetica en la deteccion de areas de necrosis de cualquier localizacion, asi como la utilidad de combinar la tomografia computarizada con multidetectores para un analisis integral de la enfermedad arterial coronaria. Contraste tardio Sistole Diastole

Four MitraClips ® Deployed in a Mitral Valve

Presentamos un caso excepcional de tratamiento con cuatro dispositivos MitraClip en un paciente varon de 72 anos afecto de una miocardiopatia isquemica. Se presento en 1985 con un infarto anterior no revascularizado. En 2004 sufrio 2 episodios coronarios agudos, y una coronariografia mostro oclusion de la arteria descendente anterior. El estudio isotopico mostro ligera isquemia anterolateral, con necrosis apical e inferior, para lo que se decidio un manejo conservador. Durante el seguimiento presento remodelado ventricular negativo, reduccion importante de la fraccion de eyeccion y una insuficiencia mitral secundaria importante. Tras la terapia de resincronizacion mejoro su capacidad funcional, aunque transitoriamente, por lo que se le remitio para la valoracion de MitraClip. Partiendo de una valvula mitral con area de 5 cm, gradiente medio basal de 2 mmHg y regurgitacion de grado III-IV (figuras A-C), tras el implante de cuatro clips (figura D) quedo sin regurgitacion (figura E) y con un gradiente medio final de 4 mmHg sin incremento de las presiones de llenado en la auricula izquierda (el patron Doppler de las venas pulmonares paso de una inversion de la onda sistolica de llenado auricular antes del procedimiento a su normalizacion). Las figuras B y C muestran la apertura valvular mitral antes del procedimiento en ecocardiografia transesofagica tridimensional (figura B) y en un modelo esquematico (figura C). Tras el implante de los cuatro MitraClips, observamos la union de la zona central con la apertura de los 2 orificios laterales caracteristicos de este procedimiento, con representacion en la ecocardiografia transesofagica tridimensional (figura F) y en el modelo esquematico (figura G).

Myocardial Hypoperfusion in Acute Aortic Dissection

Presentamos un caso de hipoperfusion miocardica detectada excepcionalmente por tomografia computarizada secundaria a una diseccion aortica aguda con afectacion coronaria. Se trataba de un paciente varon de 55 anos con el unico antecedente de hipertension arterial. Consulto a urgencias de nuestro centro por dolor centrotoracico y abdominal intenso, con signos de mala perfusion periferica y asimetria de pulsos. El ECG presentaba un ritmo sinusal con supradesnivel del ST en I, aVL, V1 y V2 y cambios especulares en II, III y aVF. Ante la sospecha de un sindrome aortico agudo con afectacion coronaria, se realizo una tomografia computarizada toracoabdominal con adquisicion prospectiva, sincronizada con el ECG, que mostro la presencia de una diseccion aortica tipo I de DeBakey (figura A). La puerta de entrada se situaba a nivel del tronco braquiocefalico, con afectacion retrograda hasta la raiz aortica y diseccion del ostium del tronco coronario izquierdo (TCI), sin afectar a la arteria coronaria derecha (figura B, asterisco). Las arterias coronarias no presentaban lesiones ateroscleroticas estenoticas. La luz verdadera del TCI mostraba trombosis secundaria a compresion extrinseca desde la luz falsa (figura B, flecha), hallazgos confirmados quirurgicamente. El miocardio ventricular izquierdo mostraba amplia hipodensidad en los segmentos dependientes del TCI (figuras C y D, flechas); el infarto se confirmo analiticamente, con extensa acinesia anterolateral en el ecocardiograma. El paciente fue intervenido de sustitucion de aorta ascendente y arco aortico (elephant trunk) con resuspension de comisuras de la valvula aortica. El curso posquirurgico tuvo un desenlace fatal por insuficiencia cardiaca y sepsis refractarias al tratamiento. Figura.