Mario Gössl

Severe Mitral Annular Calcification : First Experience With Transcatheter Therapy Using a Dedicated Mitral Prosthesis

A 75-year-old woman presented with debilitating mitral regurgitation (MR) due to severe mitral annular calcification (MAC) ([Figure 1][1]). Severe MAC is a high-risk condition in which surgery may be prohibitive due to the potential for fatal atrioventricular groove disruption. Transcatheter options

Maneuvers for technical success with transcatheter mitral valve repair

Mitral valve regurgitation (MR) is common, with a prevalence that exceeds 9% for those patients >75 years of age. For symptomatic patients with prohibitive surgical risk, transcatheter mitral valve repair with the MitraClip® system (Abbott Vascular, Menlo Park, CA) is available for clinical use and is effective in reducing MR in select patients. For optimal clinical success, the procedure requires mastery of complex catheterization skills with application of an in‐depth understanding of the mitral valve anatomy. We herein describe elementary and advanced maneuvers for successful transcatheter mitral valve repair with MitraClip®.

Current Status of Catheter-Based Treatment of Mitral Valve Regurgitation

Purpose of ReviewThis review examines the current status of catheter-based repair and replacement for mitral valve disease, with a focus on native primary and secondary mitral valve regurgitation.Recent FindingsTranscatheter mitral valve repair with the MitraClip®, with >40,000 performed procedures worldwide, has significantly advanced the field of transcatheter therapy for mitral valve regurgitation. Transcatheter mitral valve replacement remains in the early stages of development, mainly due to the complex anatomy and physiology of the mitral valve. Early feasibility studies in high-risk patients show promising procedural success, yet the adverse events require further study.SummaryTranscatheter therapies for mitral valve disease are the next endeavor for the pioneers of percutaneous structural heart disease interventions. Early results are encouraging but also show that further rigorous study is needed to determine efficacy and safety.

Impact of Transcatheter Mitral Valve Repair on Left Ventricular Remodeling in Secondary Mitral Regurgitation: A Meta-Analysis

ABSTRACT Background: Secondary mitral regurgitation (MR) arises from left ventricular (LV) dilatation and remodeling, and commonly is treated with transcatheter mitral valve repair. We examined the impact of MitraClip on reverse cardiac remodeling in patients with severe, symptomatic secondary MR. Methods:: An electronic search was performed through January 2018 for studies that reported cardiac chamber dimensions prior to and after treatment with MitraClip in patients with secondary MR. The mean difference (MD) with 95% CI was calculated using fixed or random inverse variance models. Outcomes of interest were changes in LV end-systolic and end-diastolic volumes (LVESV, LVEDV) and dimensions (LVESD, LVEDD). Secondary outcomes included left atrial (LA) volume, systolic pulmonary artery pressure (sPAP) and LV ejection fraction (LVEF). Results: A total of 16 studies with 1,266 patients were included in the present analysis. The weighted mean follow-up period (±SD) was 11.5 ± 7.2 months. MitraClip was associated with significant reduction in LVEDV (−14.24 ml, 95% CI [−22.53, −5.94], p = 0.0008), LVESV (−7.67 ml, CI [−12.30, −3.03], p = 0.001), LVEDD (−2.92 mm [−3.65, −2.19 mm], p < 0.00001), and LVESD (−1.92 mm [−2.92, −0.92], p = 0.0002). MitraClip was also associated with reduction in LA volume (−16.36 ml [23.23, −9.49 ml], p < 0.00001) and sPAP (−6.93 mmHg [−8.76, −5.10], p < 0.00001), and a significant increase in LVEF (+ 2.78% [0.91, 4.66], p = 0.004). Conclusions: In patients with severe symptomatic secondary MR, MitraClip is associated with modest, but favorable LV and LA reverse remodeling. The impact of these changes on clinical outcomes deserves further study.

Meta-analysis of the impact of successful chronic total occlusion percutaneous coronary intervention on left ventricular systolic function and reverse remodeling

BACKGROUND We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on left ventricular (LV) function. METHODS We performed a systematic review and meta-analysis of studies published between January 1980 and November 2017 on the impact of successful CTO PCI on LV function. RESULTS A total of 34 observational studies including 2735 patients were included in the meta-analysis. Over a weighted mean follow-up of 7.9 months, successful CTO PCI was associated with an increase in LV ejection fraction by 3.8% (95%CI 3.0-4.7, P < 0.0001, I2  = 45%). In secondary analysis of 15 studies (1248 patients) that defined CTOs as occlusions of at least 3-month duration and reported follow-up of at least 3-months after the procedure, successful CTO PCI was associated with improvement in LV ejection fraction by 4.3% (95%CI [3.1, 5.6], P < 0.0001). In the 10 studies (502 patients) that reported LV end-systolic volume, successful CTO PCI was associated with a decrease in LV end-systolic volume by 4 mL, (95%CI -6.0 to -2.1, P < 0.0001, I2  = 0%). LV end-diastolic volume was reported in 9 studies with 403 patients and did not significantly change after successful CTO PCI (-2.3 mL, 95%CI -5.7 to 1.2 mL, P = 0.19, I2  = 0%). CONCLUSIONS Successful CTO PCI is associated with a statistically significant improvement in LV ejection fraction and decrease in LV end-systolic volume, that may reflect a beneficial effect of CTO recanalization on LV remodeling. The clinical implications of these findings warrant further investigation.

Expecting the unexpected: preventing and managing the consequences of coronary perforations

ABSTRACT Introduction: Coronary artery perforations are more likely to occur during percutaneous coronary intervention of complex coronary lesions, such as heavily calcified lesions and chronic total occlusions. Areas covered: Authors provide an update on the management of coronary perforations by performing a critical review of the related, recently published literature. Expert commentary: Meticulous attention to guidewire position and to device selection is critical for minimizing the risk for coronary perforation. If a perforation occurs, following a structured, algorithmic approach can maximize the likelihood of a successful outcome.

Waiting to Exhale: Transcatheter Repair of Mitral Regurgitation and Survival

Mitral regurgitation (MR) is the most common valvular disease in Western countries, affecting 2 to 4 million people in the United States alone.1 When severe and left untreated, MR leads to adverse ventricular remodeling and, in many patients, impaired survival with a high rate of morbidity because of heart failure. For primary MR, surgery, particularly valve repair, is the standard of care and is recommended for patients with either symptoms or significant left ventricular dysfunction.2 Conversely, guideline-directed medical therapy is emphasized for patients with secondary MR and typically consists of β-receptor blockers, vasodilators, diuretics, and aldosterone antagonists, with or without cardiac resynchronization.3 For secondary MR, such therapy targets ventricular dysfunction as the cause of MR and has established efficacy for improving symptoms and the prognosis of patients with heart failure.3 See Article by Kortlandt et al Transcatheter mitral repair with MitraClip (Abbott Vascular, Menlo Park, CA) first became available for high-risk or inoperable patients in 2008, when it received Conformite Europeene mark for clinical use in those with primary or secondary MR in Europe. Agency approval in the United States (primary only) and parts of Asia (primary or secondary or both) soon followed, with the most recent commercial launch occurring in Japan earlier this year. The broad, multinational adoption of transcatheter repair of MR with MitraClip is notable, particularly given (1) the relatively small size of the reported randomized clinical trials of this therapy, (2) the absence of demonstrated superior efficacy of the therapy in comparison with current standards for MR treatment, and (3) for patients with secondary MR, the considerable controversy regarding the benefits of MR correction by any means, be it surgical or transcatheter. Indeed, practice guidelines have given a class IIb recommendation for transcatheter repair of MR (primary or secondary MR in Europe; …

Incidence, predictors, management and outcomes of coronary perforations

We examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation.

Impact of sleep deprivation on the outcomes of percutaneous coronary intervention

This study sought to compare the clinical outcomes of percutaneous coronary interventions (PCIs) performed by sleep deprived and non‐sleep deprived operators.

Prevalence, trends, and outcomes of higher risk percutaneous coronary interventions among patients without acute coronary syndromes

BACKGROUND/PURPOSE Patients and lesions at a higher procedural risk for percutaneous coronary intervention (PCI) are an understudied population. We examined the frequency, clinical characteristics, and outcomes of higher risk and non-higher risk PCIs at a large tertiary center. METHODS/MATERIALS The following procedures were considered higher risk: unprotected left main PCI, chronic total occlusion PCI, PCI requiring atherectomy, multivessel PCI, bifurcation PCI, PCI in prior coronary artery bypass graft surgery (CABG) patients, pre-PCI left ventricular ejection fraction ≤30%, or use of hemodynamic support. RESULTS Of the 1975 PCIs performed from 6/29/09 to 12/30/2016 in patients without acute coronary syndromes, 1230 (62%) were higher risk. Patients undergoing higher risk PCI were more likely to have a history of CABG, myocardial infarction, PCI, cerebrovascular disease, peripheral arterial disease, or congestive heart failure. Higher risk PCIs required more stents (2.0 vs. 1.0, p < 0.001), and had longer median fluoroscopy times (17.3 vs. 8.5 min, p < 0.001) and higher median contrast doses (160 vs. 120 mL, p < 0.001). In higher risk PCIs, the risks for technical failure and periprocedural complications were 2.9 (95% CI 1.2-7.4) times and 2.2 (95% CI 0.9-5.4) times higher as compared with non-higher risk PCI procedures. CONCLUSIONS In summary, over half of the PCIs performed in non-acute coronary syndrome patients were higher risk and were associated with lower odds of technical success and higher periprocedural complication rates as compared with non-higher risk PCIs. SUMMARY We examined the frequency, clinical characteristics, and outcomes of higher risk and non-higher risk PCIs at a large tertiary center. Higher risk PCI was associated with lower odds of technical and procedural success and higher odds of procedural complications as compared with non-higher risk PCI. However, the risk/benefit ratio may still be favorable for many of these higher-risk patients and should be estimated on a case by case basis.