E. Lubos

Noninvasive Vascular Function Measurement in the Community Cross-Sectional Relations and Comparison of Methods

Background— Several methods of noninvasive vascular function testing have been suggested for cardiovascular risk screening in the community. A direct comparison of the different methods and their relation to classical cardiovascular risk factors in a large cohort is missing. Methods and Results— In 5000 individuals (mean age, 55.5±10.9 years; age range, 35 to 74 years; women, 49.2%) of the population-based Gutenberg Heart Study, we performed simultaneous measurement of flow-mediated dilation (FMD) and peripheral arterial volume pulse determined by infrared photo (reflection index) and pneumatic plethysmography (PAT) and explored their associations. All function measures were recorded at baseline and after reactive hyperemia induced by 5-minute brachial artery occlusion. Correlations between different measures of vascular function were statistically significant but moderate. The strongest association for hyperemic response variables was observed for PAT ratio and FMD (Spearman r =0.17; age- and sex-adjusted partial correlation, 0.068). Classical risk factors explained between 15.8% (baseline reflection index) and 58.4% (brachial artery diameter) of the baseline values but only accounted for 3.2% (reflection index), 15.4% (FMD), and 13.9% (PAT ratio) of the variability of reflective hyperemic response. Regression models varied in their relations to classical risk factors for the individual vascular function measures. Consistently associated with different vascular function methods were age, sex, body mass index, and indicators of hypertension. Peripheral tonometry also showed a relation to fasting glucose concentrations. Conclusions— Noninvasive measures of conduit artery and peripheral arterial function are modestly correlated, differ in their relation to classical cardiovascular risk factors, and may thus reflect different pathologies.Background—Several methods of noninvasive vascular function testing have been suggested for cardiovascular risk screening in the community. A direct comparison of the different methods and their relation to classical cardiovascular risk factors in a large cohort is missing. Methods and Results—In 5000 individuals (mean age, 55.5±10.9 years; age range, 35 to 74 years; women, 49.2%) of the population-based Gutenberg Heart Study, we performed simultaneous measurement of flow-mediated dilation (FMD) and peripheral arterial volume pulse determined by infrared photo (reflection index) and pneumatic plethysmography (PAT) and explored their associations. All function measures were recorded at baseline and after reactive hyperemia induced by 5-minute brachial artery occlusion. Correlations between different measures of vascular function were statistically significant but moderate. The strongest association for hyperemic response variables was observed for PAT ratio and FMD (Spearman r=0.17; age- and sex-adjusted partial correlation, 0.068). Classical risk factors explained between 15.8% (baseline reflection index) and 58.4% (brachial artery diameter) of the baseline values but only accounted for 3.2% (reflection index), 15.4% (FMD), and 13.9% (PAT ratio) of the variability of reflective hyperemic response. Regression models varied in their relations to classical risk factors for the individual vascular function measures. Consistently associated with different vascular function methods were age, sex, body mass index, and indicators of hypertension. Peripheral tonometry also showed a relation to fasting glucose concentrations. Conclusions—Noninvasive measures of conduit artery and peripheral arterial function are modestly correlated, differ in their relation to classical cardiovascular risk factors, and may thus reflect different pathologies.

Surgical or percutaneous mitral valve repair for secondary mitral regurgitation: comparison of patient characteristics and clinical outcomes.

OBJECTIVES Corrective surgery for secondary mitral regurgitation (MR) by restrictive annuloplasty has proven beneficial in that it improves New York Heart Association (NYHA) functional class and induces reverse left ventricular remodelling. However, proof of a survival benefit for these patients is still pending. Percutaneous techniques of mitral valve repair (MVR) have become a viable treatment alternative for selected high-risk patients with severe secondary MR. METHODS We retrospectively analysed our prospective hospital database of patients with severe secondary MR undergoing either surgical MVR or percutaneous treatment using the MitraClip device. Patient characteristics and 6-month clinical and effectiveness outcomes are reported. RESULTS From March 2002 through June 2010, 76 patients with secondary MR underwent isolated surgical MVR, while 95 were treated using the MitraClip device at our centre. Patients undergoing MitraClip treatment were significantly older (mean 72.8 ± 8.2 vs 64.5 ± 11.4 years, P < 0.001), had a lower left ventricular ejection fraction (mean 36.2 ± 12.5 vs 42.1 ± 16.2%, P = 0.014) and were generally more high risk, with a significantly higher mean logistic EuroSCORE I compared with surgical candidates (33.7 ± 18.7 vs 10.1 ± 8.7%, P < 0.001). Procedural success was 98.7 (75 of 76) for MVR and 95.8% (91 of 95) for MitraClip treatment (P = 0.383). Thirty-day mortality was 4.2 (4 of 95) and 2.6% (2 of 76; P = 0.557), and the mean grade of residual MR was 1.4 ± 0.8 and 0.2 ± 0.4 (P < 0.001) after MitraClip treatment and surgical MVR, respectively. Six-month survival rates after adjustment for baseline differences were not significantly different in the respective groups (P = 0.642). CONCLUSIONS In our experience, characteristics and risk factors of patients with severe secondary MR undergoing surgery differ significantly from those considered for percutaneous therapy. Surgery was more effective compared with MitraClip in reducing MR. However, a large proportion of patients benefits from percutaneous intervention with sustained MR Grade <2+ and improvement in NYHA functional class at 6 months. MitraClip therapy seems to be an adequate alternative to surgery, especially for elderly patients with reduced left ventricular function and relevant comorbidities. Assessment, treatment and postprocedural care of patients by an interdisciplinary team are of paramount importance for clinical success.

Transcatheter valve-in-valve therapy using 6 different devices in 4 anatomic positions: Clinical outcomes and technical considerations

OBJECTIVES Transcatheter valve-in-valve implantation (ViV) is emerging as a novel treatment option for patients with deteriorated bioprostheses. We report our cumulative experience using 6 types of transcatheter heart valves (THVs) in all anatomic positions. METHODS Seventy-five consecutive patients (74.1 ± 12.9 years, 50.7% male (38/75), logEuroSCORE I 26.2% ± 17.8%, STS-PROM 8.8% ± 7.4%) receiving ViV procedures from 2008 to 2014 were included for analysis. Data were prospectively gathered and retrospectively analyzed. RESULTS ViV was performed in aortic (72.0%, 54/75), mitral (22.7%, 17/75), tricuspid (2.7%, 2/75), and pulmonary (2.7%, 2/75) positions. THVs used were Edwards SAPIEN (XT)/SAPIEN3 (52.0%, 39/75), Medtronic Core Valve/Core Valve Evolut(R) (34.7%, 26/75), St Jude Portico (4.0%, 3/75), Boston Scientific Lotus (4.0%, 3/75), Jena Valve (2.7%, 2/75), and Medtronic Engager (2.7%, 2/75). Interval from index procedure to ViV was 9.3 ± 4.9 years. Access was transapical in 53.3% (40/75), transfemoral (transarterial or transvenous) in 42.7% (32/75), transaortic in 2.7% (2/75), and transjugular in 1.3% (1/75). ViV was successful in 97.3% (73/75) with 2 patients requiring sequential THV implantation for initial malpositioning. Overall immediate procedural (≤72 hours) and all-cause 30-day mortality were 2.7% (2/75) and 8.0% (6/75). Corresponding values after aortic ViV were 1.9% (1/54) and 5.6% (3/54). No periprocedural strokes or cases of coronary obstruction occurred. Paravalvular leakage was less than or equal to mild in all cases. After aortic ViV, gradients were max/mean 34.1 ± 14.2/20.1 ± 7.1 mm Hg and effective orifice area (EOA) was 1.5 ± 1.4 cm(2). Corresponding values after mitral ViV were gradients max/mean 14.2 ± 8.2/4.7 ± 3.1 mm Hg and EOA 2.4 ± 0.9 cm(2). CONCLUSIONS ViV can be performed in all anatomic positions with acceptable hemodynamic and clinical outcome in high-risk patients. Increasing importance of ViV can be anticipated considering growing use of surgical bioprostheses.

Safety and efficacy of MitraClip™ therapy in patients with severely impaired left ventricular ejection fraction: results from the German transcatheter mitral valve interventions (TRAMI) registry

The aim of the present study was to assess the safety and efficacy of percutaneous mitral valve repair using the MitraClip™ device in patients with severely reduced systolic left ventricular (LV) function.

Acute and Long-Term Hemodynamic Effects of MitraClip Implantation on a Preexisting Secondary Right Heart Failure

Positive results of MitraClip in terms of improvement in clinical and left ventricular parameters have been described in detail. However, long-term effects on secondary pulmonary hypertension were not investigated in a larger patient cohort to date. 70 patients with severe mitral regurgitation, additional pulmonary hypertension, and right heart failure as a result of left heart disease were treated in the heart centers Hamburg and Göttingen. Immediately after successful MitraClip implantation, a reduction of the RVOT diameter from 3.52 cm to 3.44 cm was observed reaching a statistically significant value of 3.39 cm after 12 months. In contrast, there was a significant reduction in the velocity of the tricuspid regurgitation (TR) from 4.17 m/s to 3.11 m/s, the gradient of the TR from 48.5 mmHg to 39.3 mmHg, and the systolic pulmonary artery pressure (PAPsyst) from 58.6 mmHg to 50.0 mmHg. This decline continued in the following months (Vmax TR 3.09 m/s, peak TR 38.6 mmHg, and PAPsyst 47.4 mmHg). The tricuspid annular plane systolic excursion (TAPSE) increased from 16.5 mm to 18.9 mm after 12 months. MitraClip implantation improves pulmonary artery pressure, tricuspid regurgitation, and TAPSE after 12 months. At the same time, there is a decrease in the RVOT diameter without significant changes in other right ventricular and right atrial dimensions.

TCT-740 Comparison of Procedural, Clinical and Functional Outcome after either Balloon- or Mechanical-expanding Transcatheter Heart Valve Implantation

The analysis aims on comparing outcome after transcatheter aortic valve implantation using either the balloon-expanding Sapien 3 (S3; Edwards Lifesciences, Irvine, USA) or the mechanical-expanding Lotus (Boston Scientific, Marlborough, USA) Transcatheter Heart Valve (THV). Data is derived from the