O. Alfieri

The edge-to-edge technique: a simplified method to correct mitral insufficiency

OBJECTIVEnRepair of mitral regurgitation (MR) is more demanding in case of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets. We evaluated a repair which consists of anchoring the free edge of the prolapsing leaflet to the corresponding free edge of the facing leaflet: the edge-to-edge (E-to-E) technique. The correction results in a double orifice valve when the prolapse is in the middle portion of the leaflet and in a smaller valve orifice when the prolapse is close to a commissure.nnnMETHODSnOut of 432 patients with MR submitted to valve repair between January 1991 and September 1997, 121 (mean age 56 +/- 15.8 years) underwent E-to-E correction. The most prevalent etiology was degenerative disease (82 patients, 68%). The mechanism of MR was anterior leaflet prolapse (61 patients), posterior leaflet prolapse (24 patients), prolapse of both leaflets (28 patients) and other complex mechanisms (8 patients). In 72 patients, a double orifice was created, the paracommissural repair was done in 49 patients.nnnRESULTSnHospital mortality was 1.6%. Overall survival was 92 +/- 3.1% at 6 years with 95 +/- 4.8% freedom from reoperation. Mortality was unrelated to the type of repair. Mitral stenosis was never observed after the correction. At the follow-up (mean 2.2 +/- 1.5 years), all patients but 15 are class I or II. Symptoms at the follow-up are not related to residual MR.nnnCONCLUSIONSnMidterm results of this alternative repair technique are promising, considering the high prevalence of complex anatomical lesions. The technique is simple, easily reproducible and rapidly feasible also when mitral exposure is suboptimal.

Interventional vs. surgical mitral valve therapy

Mitral regurgitation (MR) is the most frequent valvular heart disease in developed countries. Surgical repair represents the optimal treatment for severe degenerative MR; however, surgical correction of functional MR is controversial. The Euro Heart Survey showed that up to 50u2009% of patients with severe MR are today denied surgical treatment. Therefore, new transcatheter techniques have been developed to treat MR with less invasive approaches. Currently, the device with the widest clinical use is the MitraClip System. In this scenario, a multidisciplinary team approach is key in providing optimal individually tailored treatment for patients with MR.ZusammenfassungDie Mitralklappeninsuffizienz (MI) ist der häufigste Herzklappenfehler in den Industrieländern. Die chirurgische Korrektur stellt die optimale Behandlung für die schwere degenerative MI dar; im Gegensatz dazu ist die chirurgische Korrektur der funktionellen MI umstritten. Der Euro Heart Survey zeigte, dass heute bis zu 50u2009% der Patienten mit schwerer MI eine chirurgische Behandlung verwehrt bleibt. Deshalb wurden neue Transkathetertechniken entwickelt, um MI minimalinvasiv zu behandeln. Die größte klinische Erfahrung liegt für den Einsatz des MitraClip-Systems vor. In diesem Szenario ist die Falldiskussion in einem interdisziplinären Team der Schlüssel, um die optimale maßgeschneiderte Behandlung für den einzelnen Patienten mit MI zu gewährleisten.

Interventional vs. surgical mitral valve therapy@@@Interventionelle vs. chirurgische Mitralklappentherapie Therapie: Which technique for which patient?@@@Welche Technik für welchen Patienten?

Mitral regurgitation (MR) is the most frequent valvular heart disease in developed countries. Surgical repair represents the optimal treatment for severe degenerative MR; however, surgical correction of functional MR is controversial. The Euro Heart Survey showed that up to 50u2009% of patients with severe MR are today denied surgical treatment. Therefore, new transcatheter techniques have been developed to treat MR with less invasive approaches. Currently, the device with the widest clinical use is the MitraClip System. In this scenario, a multidisciplinary team approach is key in providing optimal individually tailored treatment for patients with MR.ZusammenfassungDie Mitralklappeninsuffizienz (MI) ist der häufigste Herzklappenfehler in den Industrieländern. Die chirurgische Korrektur stellt die optimale Behandlung für die schwere degenerative MI dar; im Gegensatz dazu ist die chirurgische Korrektur der funktionellen MI umstritten. Der Euro Heart Survey zeigte, dass heute bis zu 50u2009% der Patienten mit schwerer MI eine chirurgische Behandlung verwehrt bleibt. Deshalb wurden neue Transkathetertechniken entwickelt, um MI minimalinvasiv zu behandeln. Die größte klinische Erfahrung liegt für den Einsatz des MitraClip-Systems vor. In diesem Szenario ist die Falldiskussion in einem interdisziplinären Team der Schlüssel, um die optimale maßgeschneiderte Behandlung für den einzelnen Patienten mit MI zu gewährleisten.

040 Outcomes following transcatheter aortic valve implantation comparing Edwards SAPIEN with Medtronic CoreValve ReValving system devices: results from the Milan registry

Background To assess clinical outcomes of transcatheter aortic valve implantation comparing Medtronic CoreValve ReValving System® with Edwards SAPIEN XT. Methods All consecutive patients in our center with aortic stenosis treated with transfemoral Medtronic CoreValve ReValving System® (MCV) from November 2009 to September 2011 (learning curve patients excluded) or Edwards SAPIEN XT (ESV) from April 2010 to September 2011 when the device became available were included. Results In total, there were 192 patients in this analysis. The overall mean age was 79.4±8.1u2005years, logistic EuroSCORE 21.1±15.9% and STS-PROM score 8.8±8.6%. The MCV group consisted of a greater proportion of males (60.3% vs 43.7%; p=0.026) with a corresponding larger aortic annulus size (24.7±2.0 vs 23.4±1.7; p<0.001). The median clinical follow-up length was 171 (IQR 54–357)u2005days. 30-day all cause mortality was 4.0%, myocardial infarction rate 1.0% and stroke 0.5%, with no differences between valve types. Life-threatening bleeding occurred in 14.7% and 11.5% had a major vascular complication. There were no differences in the combined safety endpoint at 30u2005days (ESV 72.2% vs MCV 71.9%; p=0.936). However, there was a significantly higher rate of device success among the ESV group (98.3% vs 90.4%; p=0.012) with additionally a significantly higher rate of conduction disturbances/arrhythmia (31.5% vs 16.0%; p=0.011) as well as pacemaker implantation (28.8% vs 5.0%; p<0.001) with MCV compared with ESV. Conclusions In our single center experience, transcatheter aortic valve implantation was a relatively safe and effective procedure utilising both commercially available devices. However, there was an increased incidence of arrhythmia and pacemaker implantation in the MCV group.

Ischemic mitral regurgitation: the role of the »edge-to-edge« repair

Mitral insufficiency is considered to be ischemic in origin when the valve leaflet and chordae are structurally normal and the valve dysfunction is caused by the consequences of myocardial infarction. The main mechanism responsible for ischemic mitral regurgitation (IMR) is tethering of the leaflets which may result either from localized or diffuse left ventricular dysfunction with changes in geometry of the left ventricle (LV) and displacement of one or both papillary muscles. Annular dilatation is often concomitantly present, particularly when the valve insufficiency is severe and long-standing and the LV is remarkably dilated. The diagnosis of IMR is provided by echocardiography, which is able to show the location of the regurgitant jet, the presence of global and regional ventricular wall motion abnormalities, and the severity of MR. Since the mitral valve is structurally normal in the majority of patients with IMR, inspection during the operation is not helpful, and the surgical procedure is guided by the information provided by echocardiography.

913 Preservation of systolic aortic — pushing effect — with flexible mitral ring annuloplasty. A three-dimensional echocardiography study

Conclusion: Data suggest that the flexible rings allow maintenance of the physiological shape of the mitral annulus and the dynamics of mitral-aortc valve interaction leading to systolic expansion of ascending aorta (pushing effect) which was not observed with rigid rings. Further studies will be necessary in order to assess the clinical implication of these findings on the long-term valve function and aortic mechanics after repair.