Fritz Mellert

Transcatheter mitral valve replacement using a balloon-expandable prosthesis in a patient with calcified native mitral valve stenosis

A 75-year-old female presented with progressive dyspnoea NYHA functional class IV. Echocardiography revealed moderate regurgitation and severe stenosis ( P mean 13 mmHg) of degenerated mitral valve (MV) with severe mitral annular calcification (MAC) ( Panel A ). Multislice computed tomography (MSCT) showed a ring-like pattern of the MAC with involvement of both MV leaflets …

Risk scores and biomarkers for the prediction of 1-year outcome after transcatheter aortic valve replacement

BACKGROUNDnUp to 50% of the patients still die or have to be rehospitalized during the first year after transcatheter aortic valve replacement (TAVR). This emphasizes the need for more strategic patient selection. The aim of this prospective observational cohort study was to compare the prognostic value of risk scores and circulating biomarkers to predict all-cause mortality and rehospitalization in patients undergoing TAVR.nnnMETHODSnWe calculated the hazard ratios and C-statistics (area under the curve [AUC]) of 4 risk scores (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE], EuroSCORE II, Society of Thoracic Surgeons predicted risk of mortality, and German aortic valve score) and 5 biomarkers of inflammation and/or myocardial dysfunction (high-sensitivity C-reactive protein, growth differentiation factor (GDF)-15, interleukin-6, interleukin-8, and N-terminal pro-B-type natriuretic peptide) for the risk of death (n = 80) and the combination of death or rehospitalization (n = 132) during the first year after TAVR in 310 consecutive TAVR patients.nnnRESULTSnThe EuroSCORE II and GDF-15 had the strongest predictive value for 1-year mortality (EuroSCORE II, AUC 0.711; GDF-15, AUC 0.686) and for the composite end point (EuroSCORE II, AUC 0.690; GDF-15, AUC 0.682). When added to the logistic EuroSCORE and EuroSCORE II, GDF-15 enhanced the prognostic performance of the score and enabled substantial reclassification of patients. Combinations of increasing tertiles of the logistic EuroSCORE or EuroSCORE II and GDF-15 allowed the stratification of the patients into subgroups with mortality rates ranging from 4.0% to 49.1% and death/rehospitalization rates ranging from 15.3% to 68.4%.nnnCONCLUSIONSnOur study identified GDF-15 in addition to the logistic EuroSCORE and the EuroSCORE II as the most promising predictors of a poor outcome after TAVR.

Impact of left ventricular conduction defect with or without need for permanent right ventricular pacing on functional and clinical recovery after TAVR

BackgroundLeft ventricular conduction disturbances (VCD) with or without need for pacemaker (PM) implantation are common after transcatheter aortic valve replacement (TAVR). Its effect on patients’ functional recovery after TAVR is unclear.Methods and results212 patients (Age 80.8xa0±xa06.4xa0years, logEuroscore 28.95xa0±xa017.37xa0%) underwent TAVR with the self-expanding CoreValve prosthesis and completed 9-month follow-up (FU). After TAVR 125xa0(59xa0%) patients were diagnosed with VCD. This group consists of 41xa0(19xa0%) patients with a new PM after TAVR, 33xa0(16xa0%) patients with PM prior TAVR and markedly increased ventricular stimulation rate, 48xa0(23xa0%) patients with new LBBB post-TAVR and three (1xa0%) patients with LBBB prior TAVR. After FU, the presence of VCD alone was associated with worse recovery of left ventricular ejection fraction (LVEF) (VCD: LVEFbaseline 51.7xa0±xa018.2xa0%, LVEFFU 53.9xa0±xa013.0xa0%; pxa0=xa00.8; noVCD: LVEFbaseline 53.8xa0±xa012.9xa0%, LVEFFU 63.4xa0±xa010.1xa0%; pxa0<xa00.01) but had no impact on functional outcomes after TAVR (pxa0>xa00.05). Especially patients with VCD caused by permanent RV pacing showed worse functional outcomes presenting with higher functional NYHA classes (pxa0<xa00.05), and higher NT-proBNP levels (pxa0<xa00.05). 20.4xa0% of patients with need for PM after TAVR remained in NYHA class ≥3, as compared to 5xa0% of patients without PM (VCD but no PM: 4.7xa0%, pxa0<xa00.001; noVCD: 5.3xa0%, pxa0<xa00.001). VCD with or without need for PM had no impact on survival after FU.ConclusionThe occurrence of VCD after TAVR is common and associated with unfavorable left ventricular functional recovery. However, only the combination of VCD with permanent right ventricular pacing has adverse impact on heart failure-related symptoms after TAVR.

Kidney Dysfunction and Deterioration of Ejection Fraction Pose Independent Risk Factors for Mortality in Implantable Cardioverter‐Defibrillator Recipients for Primary Prevention

A growing number of patients with advanced heart failure fulfill a primary‐prevention indication for an implantable cardioverter‐defibrillator (ICD). This study seeks to identify new predictors of overall mortality in a Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT)‐like collective to enhance risk stratification.

Pre-Procedural Hemodynamic Status Improves the Discriminatory Value of the Aortic Regurgitation Index in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVESnThe aims of this study were to increase the discriminatory value of the aortic regurgitation index (ARI) for the assessment of paravalvular regurgitation (PVR) and to further elucidate the association between aortic regurgitation severity and mortality after transcatheter aortic valve replacement (TAVR).nnnBACKGROUNDnHemodynamic parameters such as the ARI complement predominantly angiographically guided TAVR. However, the ARI depends on several baseline and periprocedural characteristics.nnnMETHODSnThe ARI was prospectively calculated before and after TAVR in 600 patients. The severity of PVR was assessed in all patients by angiography and echocardiography according to a 3-class scheme. To account for pre-procedural hemodynamic status, the ARI ratio was calculated as post- over pre-procedural ARI.nnnRESULTSnApart from the degree of PVR (β = -0.396, p < 0.001), pre-procedural hemodynamic status in the form of the ARI before TAVR (β = 0.227, p < 0.001) was associated with post-procedural ARI in multivariate regression analysis. The ARI ratio increased the specificity of post-procedural ARI alone for the prediction of both more than mild PVR and 1-year mortality from 75.1% to 93.2% and from 75.0% to 93.3%, respectively. Patients with post-procedural ARI values <25 after TAVR had significantly increased 1-year mortality only when the ARI ratio was <0.60 (50.0% vs. 26.3%, p = 0.001).nnnCONCLUSIONSnThe ARI ratio integrating pre- and post-procedural hemodynamic status increases the discriminatory value of post-procedural ARI. The ARI ratio, which reflects acute hemodynamic changes after TAVR, is useful to identify patients with negative outcomes.

CoreValve degeneration with severe transvalvular aortic regurgitation treated with valve-in-valve implantation.

A 77-year old woman presented with sudden onset of dyspnea New York Heart Association functional class IV, bilateral pleural effusion, and acute renal failure (serum creatinine 2.1 mg/dl) occurring 3 years after transcatheter aortic valve replacement (TAVR) with use of a self-expanding CoreValve 29-

Impact of coronary artery disease in patients undergoing transfemoral transcatheter aortic valve implantation

BACKGROUNDnThe impact of coronary artery disease (CAD) and revascularization on outcome in patients undergoing transcatheter aortic valve implantation (TAVI) has not been fully elucidated so far.nnnOBJECTIVESnTo assess whether the degree of CAD influences the prognosis of patients undergoing TAVI.nnnMETHODSnBefore TAVI, all patients underwent revascularization of the proximal vessels or the left main stem if indicated (stenosis ≥70% or 50%, respectively). In 666 patients, we calculated the baseline (bSS) and residual SYNTAX Score (rSS) prior to TAVI. In patients with revascularization, we determined the SYNTAX Revascularization Index (SRI=(1-(rSS/bSS))∗100). We also assessed the SYNTAX Score II (SS-II), combining anatomical and clinical variables. The primary endpoint was 3-year all-cause mortality.nnnRESULTSnHigher baseline and residual SYNTAX Score were associated with increased 3-year mortality (no CAD 26.2%, low bSS 34.8%, high bSS 46.8%; p=0.001, respectively, no CAD 25.9%, low rSS 31.4%, high rSS 41.5%; p=0.01). The extent of revascularization represented by the SRI was not associated with outcome. The SYNTAX Score II was also associated with increased 3-year mortality. However, baseline and residual SYNTAX Score as well as SYNTAX Score II did not independently predict mortality.nnnCONCLUSIONnThe anatomic severity of CAD as assessed by the baseline and residual SYNTAX Score is associated with survival after TAVI. Coronary artery disease seems to reflect general comorbidity burden and is associated with a higher risk profile of the patient.

Long-Term Outcome and Quality of Life in Aortic Type A Dissection Survivors

BACKGROUNDnAortic dissection is a severe and sophisticated disease that is often linked with a number of possible complications. Our study concerns with long-term outcome and quality of life (QoL) in acute aortic dissection type A (AADA) survivors.nnnMETHODSnFrom January 1999 until December 2006, 120 consecutive patients with AADA received an emergency operation. Of the total number of patients, 84 were males (70.0%) and 36 females (30.0%), mean aged 59.8u2009±u200912 years with a mean follow-up (FU) of 99.2u2009±u20096 months.nnnRESULTSnOverall mortality was 39.1% during the observational period with a maximum of 156 months. SF-36 observation showed a significant decay in both Physical Component Summary (PCS) and Mental Component Summary (MCS) in FUII (PCSu2009=u200938.4) versus FUI (PCSu2009=u200943.4, pu2009=u20090.013).nnnCONCLUSIONnWith ongoing postoperative time, patients did not recover but instead have got worse in terms of QoL. The decrease in MCP and linked subscores is an underestimated factor in QoL and long-term outcome after AADA. This is especially true in younger patients, which are judged to compensate better than older patients.

Antegrade transcatheter mitral valve-in-valve implantation with combined atrial septal defect closure

An 88-year-old male patient with history of ischemic dilated cardiomyopathy, previously treated with mitral valve replacement and percutaneous coronary revascularization, presented with worsening symptoms of heart failure, currently New York Heart Association class IV. Echocardiography revealed moderate-to-severe left-ventricular dysfunction (ejection fraction 35 %) and a degenerated 29 mm Carpentier-Edwards mitral bioprosthesis (Edwards Lifesciences, Irvine, CA, USA), with severe regurgitation (vena contracta 0.77 cm; PISA: 1.6 cm; effective regurgitant orifice area: 0.85 cm), Fig. 1, panel a, and a stenotic component (mean peak gradient 6.5 mmHg). Owing to a probably overestimated, but nevertheless high, surgical risk (logistic EuroSCORE 41.7 %) [1], the Heart Team opted for percutaneous antegrade transcatheter mitral valve-in-valve implantation (TMVIV), with an Edwards Sapien 3 device (Edwards Lifesciences, Irvine, CA, USA). After transseptal puncture, atrial septal dilatation with a 14 mm Osypka Balloon (Osypka AG, Rheinfelden-Herten, Germany) was performed at low pressures (panel b). We opted for a 14 mm balloon for because of previous TMViV cases that we used 10 and 12 mm balloons for septum predilatation and nevertheless were insufficient to allow valve passage after sheath introduction. Afterwards, valve positioning and implantation were carried out (panel c) over a pre-shaped stiff Confida wire (Medtronic, Minneapolis, MN, USA). No mitral stenosis or regurgitation was observed after the procedure (panel d). As expected, a significant iatrogenic atrial septal defect (ASD) was apparent after sheath removal. Even though the clinical significance of this defect is not clear [2], we performed the ASD closure as a safety measure, considering the risk of left-side thrombus embolization since we visualized thrombus formation in the right atrium on echocardiography during the procedure despite an activated clotting time above 200 s. Therefore, we utilized a 14 mm Amplatzer ASD-Occluder (St. Jude Medical, St. Paul, MN, USA), panel e, f. The patient was extubated immediately and on repeat echocardiogram predischarge, there was no evidence of thrombus in the cardiac chambers. We discharged the patient 5 days after the procedure with marked improvement in symptoms and on empirical dual antiplatelet therapy for 6 months. Valve-invalve procedures are an increasingly more utilized option for the treatment of failing bioprosthesis [3], including the latest Edward valve, the Sapien 3 [4]. Despite previous descriptions of antegrade TMVIV [5], most catheter-based mitral valve procedures are done through the transapical route [6]. Moreover, to our knowledge this is the first description of an antegrade TMVIV with an Edwards Sapien 3 valve with combined ASD closure. This case illustrates the feasibility and readiness of antegrade TMVI through transseptal access followed by ASD closure in the same procedure. & Felipe C. Fuchs fcfuchs@terra.com.br

Operative Behandlung der Mitralklappeninsuffizienz

Die Mitralklappeninsuffizienz ist ein häufiges Vitium. Liegt eine bakterielle Endokarditis als Ursache vor, kann ein vorgezogener operativer Eingriff indiziert sein. Neben dem Rückgang des mechanischen Klappenersatzes wird eine weitere Zunahme der Mitralklappenrekonstruktionen verzeichnet, der Zugang zum Herzen gelingt zunehmend minimalinvasiv. Dieser Trend setzt sich fort mit der Entwicklung von Operationsverfahren am schlagenden Herzen.