Impact of disproportionate secondary mitral regurgitation in patients undergoing edge-to-edge percutaneous mitral valve repair.
- 作者列表："Adamo M","Cani DS","Gavazzoni M","Taramasso M","Lupi L","Fiorelli F","Giannini C","Branca L","Zuber M","Curello S","Petronio AS","Maisano F","Metra M
AIMS:The aim of this study was to evaluate the prognostic role of echocardiographic parameters assessing secondary mitral regurgitation (SMR) severity and left ventricular dimension, including proportionate versus disproportionate SMR, in MitraClip recipients. METHODS AND RESULTS:We analysed 137 patients undergoing MitraClip implantation for SMR at three centres. SMR was classified as proportionate or disproportionate based on the median value of the ratio between effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV). The primary endpoint was a composite of cardiovascular mortality and heart failure hospitalisation at two-year follow-up. Mean age was 70±10 years, 80% were male, and median EuroSCORE II was 5.7%. No differences were observed in the disproportionate compared to the proportionate group except for a more severe NYHA class and their expected higher EROA and lower LVEDV. Number of clips deployed, device success and procedural success were similar between the two groups. Residual mitral regurgitation (MR) >1+ at 30 days was more common among patients with an EROA >0.42 cm2 compared to those with an EROA ≤0.42 cm2 (81.3% vs 58%; p=0.004). The relative risk of the primary endpoint was independent from any echocardiographic parameter, including the presence of disproportionate SMR. The only independent predictors of clinical events were EuroSCORE II >8%, NYHA class and residual MR >1+ at 30 days. CONCLUSIONS:Echocardiographic parameters, including the EROA/LVEDV ratio, do not have independent prognostic value in patients undergoing MitraClip implantation. High surgical risk, advanced symptoms and non-optimal MR reduction increase the relative risk of two-year clinical events. Visual summary. Distribution of effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV) in our population and in those of the COAPT and MITRA-FR trials according to the proportionate/disproportionate classification of secondary mitral regurgitant (SMR) proposed by Grayburn et al (A). Kaplan-Meier curves for the primary endpoint (cardiovascular death or HF hospitalisation at 2 years post MitraClip) of the population stratified by the presence of proportionate SMR (EROA/LVEDV ratio below the median value) or disproportionate SMR (EROA/LVEDV ratio above the median value) (B). Residual SMR (30 days post MitraClip) in patients with baseline EROA above or below the median value (C). Multivariable analysis for the primary endpoint (D).
目的: 本研究的目的是评估超声心动图参数评估继发性二尖瓣反流 (SMR) 严重程度和左心室尺寸的预后作用，包括成比例与不成比例的SMR。 方法和结果: 我们分析了137例在三个中心接受MitraClip植入治疗SMR的患者。根据有效返流口面积 (EROA) 和左心室舒张末期容积 (LVEDV) 之间的比值的中值，SMR被分类为成比例或不成比例。主要终点是两年随访时心血管死亡率和心力衰竭住院的复合终点。平均年龄为70 ± 10岁，80% 为男性，EuroSCORE II评分中位数为5.7%。与成比例组相比，没有观察到不成比例的差异，除了更严重的NYHA分级和预期更高的EROA和更低的LVEDV。两组之间部署的剪辑数量、设备成功和手术成功相似。与eeroa ≤ 0.42平方厘米的患者相比，eeroa> 0.42平方厘米的患者在30天残余二尖瓣反流 (MR) >1 + 更常见 (81.3% vs 58%; p = 0.004)。主要终点的相对风险独立于任何超声心动图参数，包括存在不成比例的SMR。临床事件的唯一独立预测因素是EuroSCORE II >8%，NYHA分级和30天时残余MR >1 +。 结论: 超声心动图参数，包括EROA/LVEDV比值，在接受MitraClip植入的患者中没有独立的预后价值。高手术风险、晚期症状和非最佳MR降低增加了两年临床事件的相对风险。可视化摘要。根据Grayburn等 (A) 提出的继发性二尖瓣反流 (SMR) 比例/不成比例分类，有效反流口面积 (EROA) 和左心室舒张末期容积 (LVEDV) 在我们人群以及COAPT和MITRA-FR试验中的分布。根据存在比例SMR (EROA/LVEDV比值低于中位值) 或不成比例SMR (EROA/LVEDV比值高于中位值) (B) 分层的人群主要终点 (MitraClip后2年的心血管死亡或HF住院) 的Kaplan-Meier曲线。基线EROA高于或低于中值 (C) 的患者的残余SMR (MitraClip后30天)。主要终点的多变量分析 (D)。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.