Sidakpal S. Panaich

Acute Changes in Left Atrial Pressure After MitraClip Are Associated With Improvement in 6-Minute Walk Distance

Background— Data on the clinical use of left atrial (LA) hemodynamic monitoring during MitraClip procedure are limited. This study evaluated the association between intraprocedural changes in LA pressure after MitraClip and improvement in exercise capacity as documented by 6-minute walk test (6MWT). Methods and Results— Study population included 50 patients who underwent MitraClip at the Mayo Clinic (Rochester, MN), between June 2014 and July 2016 and completed both baseline and 30-day follow-up 6MWT. Primary outcome for the current analysis was defined as 6MWT improvement above the median. Mean age of the study population was 79±10 years, and 34 (68%) were men. Baseline preprocedural 6MWT distance was 308 m (interquartile range [IQR], 234–394 m). Acute, intraprocedural change in LA pressure after MitraClip was 3 mm Hg (IQR, 1–6 mm Hg), and change in V wave was 11 mm Hg (IQR, 6–19 mm Hg). Median 6MWT improvement was 25 m (IQR, 19–47 m). Univariate analysis showed that patients with ⩽ mild postprocedural mitral regurgitation were 4-fold more likely to experience an improvement in 6MWT (P=0.02). Multivariate model demonstrated that each 5 mm Hg decrease in V wave was associated with 49% increased likelihood for improvement in 6-minute walk (P=0.04). Similar model with V-wave change as a dichotomous variable showed that patients with a V-wave decrease of ≥11 mm Hg were 3.8× more likely to improve their 6MWT (P=0.05). Conclusions— Acute changes in LA pressure after MitraClip procedure are associated with clinical improvement as measured by 6MWT. Continuous LA pressure monitoring may be a useful tool for procedural guidance during transcatheter mitral repair.

Left atrial pressure and predictors of survival after percutaneous mitral paravalvular leak closure

Data on the clinical utility of left atrial (LA) hemodynamic monitoring during percutaneous mitral interventions are limited.

Building Blocks of Structural Intervention: A Novel Modular Paradigm for Procedural Training

Structural heart disease is a rapidly evolving field, and approaches to procedural training are not standardized. We describe a novel modular approach to procedural training that considers each procedure as a series of building blocks that may be taught and assessed separately. Ten key structural heart disease building blocks can be identified, which, when combined with the cognitive skills of structural intervention and device-specific training, allow appropriate planning and implementation of structural procedures. Structural procedures require careful navigation of the aorta, left atrium, and right heart, including detailed understanding of relational anatomy. Component blocks include large bore vascular access, navigation within the left atrium, occlusion, snaring, and 3-dimensional relational anatomy. These building blocks also provide the foundation for new procedures through innovative use of the skill sets and devices to approach new clinical problems. The addition of device-specific training may be provided via proctoring and industry support. Using this approach, competency in less common procedures may be achieved and maintained. We discuss each building block in detail, approaches specific to the structural heart disease patient, the need for cross-discipline training, and empirical recommendations for training using this approach. We postulate that this new paradigm may be the preferred approach for training and assessment of structural heart disease interventional skills.

Comparison of In-Hospital Outcomes and Readmission Rates in Acute Pulmonary Embolism Between Systemic and Catheter-Directed Thrombolysis (from the National Readmission Database)

There are sparse comparative data on in-hospital outcomes and readmission rates in patients with acute pulmonary embolism (PE) who receive systemic thrombolytics versus catheter-directed thrombolysis (CDT). The study cohort was derived from the National Readmission Database 2013 to 2014, subset of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Systemic and CDT were identified using appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes. The co-primary outcomes were in-hospital mortality and 30-day readmissions and secondary outcome was combined in-hospital mortality + gastrointestinal bleed + intracranial hemorrhage. We used propensity score match analysis without replacement using Greedys algorithm to adjust for possible confounders. We identified a total of 4,426 patients (3,107: systemic thrombolysis and 1,319: CDT) with acute PE who were treated with thrombolysis. In our 2:1 propensity score algorithm, in-hospital mortality was lower in the CDT group (6.12%) versus systemic thrombolytics (14.94%) (odds ratio 0.37, 95% confidence interval 0.28 to 0.49, p <0.001). There was also a lower composite secondary outcome (in-hospital mortality + gastrointestinal bleed + intracranial hemorrhage) in patients who received CDT (8.42%) versus those who received systemic thrombolytics (18.13%) (odds ratio 0.41, 95% confidence interval 0.33 to 0.53, p <0.001). Thirty-day readmission was lower in patients with CDT group (7.65%) compared with systemic thrombolytics (10.58%, p = 0.009). In conclusion, in-hospital mortality, as well as bleeding during primary admission was significantly lower with CDT compared with systemic thrombolytics for patients with acute PE. There was also significant decrease in rate of readmissions among patients receiving CDT compared with systemic thrombolytics.

Procedural trends, outcomes, and readmission rates pre-and post-FDA approval for MitraClip from the National Readmission Database (2013-14)

There are sparse clinical data on the procedural trends, outcomes and readmission rates following FDA approval and expansion of Transcatheter mitral valve repair/MitraClip®. Whether a complex new technology can be disseminated safely and quickly is controversial.

Current Status of MitraClip for Patients with Mitral and Tricuspid Regurgitation

Mitral valve regurgitation (MR) affects approximately 4 million people in the United States alone, increasing in prevalence with age. Approved by the Food and Drug Administration (FDA) in October 2013, percutaneous edge-to-edge transcatheter mitral valve repair (also known as the MitraClip system) has been used in over 40,000 patients globally. Additionally, there is keen interest and early exploration into the use of MitraClip for treatment of severe symptomatic tricuspid regurgitation, another undertreated disease with significant morbidity and mortality. In this manuscript, we aim to review the current indications, procedural details as well as emerging indications for this novel technology.

Case-Based Discussion Regarding Challenges in Patient Selection and Procedural Planning in Left Atrial Appendage Occlusion

Abstract Atrial fibrillation (AF) accounts for most embolic strokes, especially in elderly individuals. Although anticoagulation is known to reduce the risk of embolic stroke, a significant proportion of patients have relative or absolute contraindications to anticoagulation. The left atrial appendage has been implicated as the major source of emboli in more than 90% of ischemic strokes in nonvalvular AF. Left atrial appendage occlusion offers an alternative for stroke prevention in patients with an elevated stroke risk (CHADS2 score ≥2 or CHA2DS2‐VASc score ≥3) who have a rationale for avoiding long‐term oral anticoagulation after a shared decision‐making process. However, there remain significant challenges in left atrial appendage occlusion therapy related to patient selection, the procedure itself, and postprocedural patient management decisions. In this review article, we discuss some of these challenges in a case discussion–based approach.

Effect of percutaneous paravalvular leak closure on hemolysis

To study the effect of percutaneous paravalvular leak closure on hemolysis.

TRANSCATHETER MITRAL VALVE REPAIR (MITRACLIP) IN UNITED STATES: ETIOLOGIES AND PREDICTORS OF READMISSION AND IN-HOSPITAL MORTALITY FROM THE NATIONWIDE READMISSION DATABASE

Background: The primary objective of our study was to evaluate real-world outcomes of Transcatheter mitral valve repair (TMVR) (MitraClip) including in-hospital mortality and short-term readmission rates. Methods: The study cohort was derived from the National Readmission Data (NRD) 2013. TMVR was

TRANSCATHETER MITRAL VALVE REPAIR(MITRA CLIP) IN UNITED STATES: LENGTH OF STAY AND COST OF HOSPITALIZATIONS FROM THE NATIONWIDE READMISSION DATABASE.

Background: The primary objective of our study was to evaluate real-world outcomes of Transcatheter mitral valve repair (MitraClip) in terms of length of stay (LOS) and cost of care. Methods: The study cohort was derived from the National Readmission Data (NRD) 2013, a subset of the Healthcare Cost