Eleonora Avenatti

Tricuspid regurgitation repair with a MitraClip device: the pivotal role of 3D transoesophageal echocardiography

A 77-year-old male presented with congestive heart failure (NYHA class IV) despite maximal medical therapy. Right sided features were predominant; transoesophageal echocardiography (TEE) revealed severe tricuspid regurgitation (TR) ( Panel A : 1: 3D TEE; 2. 2D TEE, 3. Colour Doppler; see Supplementary data online, video 1 ) without leaflet coaptation (white asterisk). Due to prohibitive surgical risk, …

Percutaneous Repair of Severe Eccentric Mitral Regurgitation Due to Medial Commissural Flail: Challenges for Imaging and Intervention

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Percutaneous Repair for Recurrent Mitral Regurgitation After Surgical Repair: A Mitraclip Experience

ABSTRACT Background: The aim of our study was to evaluate the acute feasibility and short-term efficacy of mitral valve repair using the MitraClip device in patients with prior surgical repair. Mitral regurgitation (MR) may recur after surgical repair. Because reoperation is associated with significant mortality and morbidity, a transcatheter approach appears appealing. Methods: Between April 2015 and December 2016, 12 patients with MR after a previous surgical repair underwent the MitraClip procedure. Procedural details, intraoperative echocardiographic features, and baseline and 30-day clinical follow-up data were analyzed and compared to those of patients undergoing MitraClip therapy with no prior surgical repair (n = 54) within the same timeframe. Results: Past medical history, MR severity, and NYHA class did not differ between the two groups. A MitraClip was deployed in all 12 patients in the surgical repair (SR) group and in 51 patients in the no surgical repair (NR) group. Induction of mitral stenosis precluding final device deployment occurred in one and two cases, respectively. The procedure was associated with successful reduction of MR to ≤ moderate in all SR patients and in 47 (96%) NR patients. Total procedural time, fluoroscopy time, time from transseptal access to first MitraClip release, and final diastolic gradients were not different between the groups. Clinical outcomes—NYHA class and KCCQ scores—were not different at 30 days. Conclusions: In selected patients with recurrent MR after surgical repair, the MitraClip procedure is feasible and effective without significant increase in procedural time, fluoroscopy time, diastolic mitral gradient compared to MitraClip therapy in patients without prior surgical repair.

Intraventricular Vortex Interaction between Transmitral Flow and Paravalvular Leak

Paravalvular leak (PVL) is a complication of transcatheter aortic valve replacement. Despite its marked clinical impact, no previous study has reported how PVL affects the intraventricular fluid dynamics. This study aims to delineate vortex interaction between PVL and transmitral flow and the influence of PVL orifice location on intraventricular fluid dynamics using Echocardiographic Particle Image Velocimetry. Three different conditions of no PVL, anterior PVL and posterior PVL were experimentally studied and clinically compared. Circulation, impulse, kinetic energy (KE) and change in KE (ΔKE) were calculated. As well, vortex formation analyses and streamline description were performed to study vortex interactions. The anterior PVL jet streamed into the LV and interfered with the transmitral flow. Posterior PVL jet formed a large clockwise vortex and collided with transmitral flow, which resulted in flow disturbance. Compared to no PVL condition, average circulation, impulse, KE and ΔKE increased in presence of PVL. In conclusion, we found that PVL jets lead to abnormal vortex formation that interfere with natural advancement of transmitral flow, and negatively affect the LV fluid dynamics parameters. PVL orifice location strongly affects the intraventricular vortex formation, and posterior PVL may have more negative effects compared to anterior PVL.

Changes in Left Atrial Function After Transcutaneous Mitral Valve Repair

Left atrial (LA) reverse remodeling occurs after transcatheter mitral valve repair, but additional data are needed about changes in LA function. Changes in LA stiffness in patients undergoing MitraClip implantation were evaluated. Baseline, procedural, and 30-day follow-up clinical and imaging data of patients undergoing MitraClip were reviewed. LA operating chamber stiffness was calculated as the ratio of systolic change in LA pressure to LA systolic strain and to stroke volume. Matched preprocedure and postprocedure LA strain analyses were performed in 35 patients, 21 with primary and 14 with functional mitral regurgitation (MR). Procedural success occurred in 34 of 35 cases with significant improvement of all invasive hemodynamic parameters. LA operating chamber stiffness decreased significantly in the overall population (p <0.001). At follow-up, sustained improvement in MR severity occurred, together with left ventricular (LV) and LA reverse remodeling. After MitraClip deployment, LA operating chamber stiffness showed a significant correlation with follow-up pulmonary artery systolic pressure, LV end systolic volume, and LV EF, irrespective of MR etiology (p <0.05). A significant inverse correlation was seen between change in LA operating chamber stiffness and improvement in 6-min walking distance. In conclusion, LA operating chamber stiffness decreases after MitraClip deployment, irrespective of MR etiology. It is related to pulmonary artery systolic pressure and functional status.

Transcatheter Aortic Valve Replacement

Three dimensional (3D) stereolithographic printing can be used to convert clinical imaging data into life size, patient-specific physical models replicating the anatomic characteristics of calcific aortic valve disease. Creation of these full-scale models requires a combination of several technologies including high spatial resolution electrocardiogram-gated computed tomography, computer-aided design software, and fused multimaterial 3D printing. By selecting specific print material properties, it is possible to replicate the geometry of the entire aortic root complex combining regions of compliant tissue with regions of hard and immobile “calcified” tissue. 3D printing of calcific aortic valve disease has been taken another step forward in replicating not only the anatomy but also the basic functional characteristics of these valves: stenosis and regurgitation. These functional models allow for accurate evaluation of diseased patient-specific physiology and represent a potentially very powerful new tool. Development of functional patient-specific models has several potential applications in medicine: training of medical teams for transcatheter aortic valve replacement (TAVR) procedures; investigating the flow dependency of aortic stenosis or regurgitation using flow phantoms; determining the accuracy and limitations of noninvasive imaging methods to quantify valve dysfunction; and evaluating patient-specific procedural adjustments a priori that may influence acute procedural success during catheter-based valve intervention. Functional 3D-printed models and accurate replication of patient-specific hemodynamics can create an environment for testing percutaneous valve devices and optimization of their design. Current effort is focused on applying these models to both predict and prevent paravalvular regurgitation.

3D PRINTED PATIENT-SPECIFIC MULTI-MATERIAL MODELING OF MITRAL VALVE APPARATUS

Background: We have reported that the approximate mechanical properties of mitral leaflet tissue can be replicated using multi-material 3D printing. We sought to create multi-material patient-specific replicas of the entire mitral valve (MV) apparatus. Methods: CT images (systolic and diastolic) of

Detection of an Atrioesophageal Fistula on a Transthoracic Echocardiogram

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