Structural Heart最新文献

Background

Actual expansion of a transcatheter heart valve (THV) might differ from nominal, particularly during nonaortic valve-in-valve for a degenerated bioprosthetic surgical heart valve (SHV). This pilot study compared THV expansion measured using large-field-of-view intravascular ultrasound (IVUS) vs. multi-slice computed tomography (MSCT) and assessed the correlation between THV dimensions and transvalvular gradients.

Methods

Fourteen patients were successfully treated with mitral/tricuspid valve-in-valve SAPIEN 3 implantation sized using the true SHV inner diameter; all 14 had baseline MSCT and transvalvular gradients measured at baseline, postprocedure, and at discharge. Periprocedural IVUS (in 6 patients using a Philips 10MHz Vision PV035) was compared with postprocedural MSCT (in 9 patients) with offline measurements performed at 1-mm steps along the THV height. Overall, 190 MSCT and paired 124 IVUS cross-sections were analyzed.

Results

There was very good agreement between IVUS THV dimensions and corresponding MSCT measurements (intraclass correlation coefficient ≥0.986 and p < 0.001). IVUS measured THV expansion (percent of the nominal cross-sectional area) was smaller within the inflow and middle of the THV overlapping the ring (85.9% ± 11.3%, 83.8% ± 11.8%) than within the outflow (98.8% ± 12.7%). The residual mean transvalvular gradient increased from periprocedural to predischarge (3.5 ± 2.0 vs. 6.3 ± 1.7 mmHg, p < 0.001). The only independent predictor of predischarge maximal transvalvular gradient was the smallest minimal inner THV frame diameter (r² = 0.67), predicted by true SHV internal diameter (Beta = 0.066, 95% CI = 0.015-0.117, r² = 0.49, p = 0.037).

Conclusions

This pilot study is the first to report the feasibility of a large field-of-view IVUS for periprocedural measurement of actual THV expansion when deployed valve-in-valve. Minimal inner THV stent frame dimensions correlate with increased postprocedural transvalvular gradients.

Background

Percutaneous mitral balloon commissurotomy (PMBC) is the gold standard for the treatment of patients with symptomatic rheumatic mitral valve (MV) stenosis and favorable valve morphology. Intracardiac ultrasound (ICE)-guided PMBC is an attractive alternative to standard transesophageal echocardiography guidance for simplification of procedure and avoiding general anesthesia.

Methods

We conducted a retrospective analysis of all ICE-guided PMBC cases at our institution between July 2020 and November 2023. Procedural success was defined as post-PMBC MV area ≥1.5 cm²; or an increase of ≥0.5 cm² in MV area associated with echocardiographic mitral regurgitation (MR) that is ≤moderate post-PMBC. Six-month follow-up data were collected.

Results

We identified 11 subjects for whom ICE-guided PMBC was attempted. The mean age of the subjects was 61.7 (±12.1) years. All, but one, were females. Out of the 11 subjects, 2 did not undergo PMBC; one had baseline severe MV regurgitation identified on ICE, and the other developed a pericardial effusion following transeptal puncture that needed an urgent pericardial window. The protocol-defined procedural success was achieved in all nine patients who underwent PMBC. Post-PMBC mean MV gradient was 4.4 (±2.0) as compared to 11.1 (±2.9) mmHg at baseline. At 6-month follow-up, 8 of the 9 patients had ≤New York Heart Association class II symptoms.

Conclusions

ICE-guided PMBC appears to be feasible and safe. ICE-guided PMBC offers several advantages over transesophageal echocardiography guidance including improving patient comfort and eliminating the need for patient intubation and general anesthesia.

Background

Vascular complications remain high in transfemoral transcatheter aortic valve implantation (TAVI). Careful evaluation of the femoral arteries is important to select the optimal access site.

Objectives

This study sought to describe a novel risk score (the passage-puncture score) for transfemoral access using a single suture-based closure system.

Methods

The passage-puncture score consists of the evaluation of 1) passage feasibility of the ilio-femoral arteries (passage score) and 2) puncture site feasibility (puncture score) based on pre-TAVI computed tomography. All patients underwent fluoroscopy-guided arterial puncture and closure with a suture-based closure system. The primary endpoint was the rate of vascular complications in discharge, including minor and major vascular complications according to the definitions of the Third Valve Academic Research Consortium.

Results

From September 2020 to June 2021, transfemoral TAVI was performed in 98 of 99 patients. Passage score (right) was significantly higher in patients treated by left compared to those treated by right femoral access (3 vs. 1; p <0.001). Puncture score was significantly different between patients undergoing mid-femoral as compared to nonmid-femoral puncture (0 vs. 3, p <0.001). Minor vascular complications occurred in six (6%) patients.

Conclusions

The passage-puncture score is effective in defining the optimal access site for transfemoral TAVI. The systematic evaluation has the potential to further reduce access-site complications.

Background

The implications of pulmonary vein (PV) flow patterns in patients with heart failure (HF) and mitral regurgitation (MR) are uncertain. We examined PV flow patterns in the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation (COAPT) trial (NCT01626079), in which patients with HF and moderate-to-severe or severe functional MR were randomized to transcatheter edge-to-edge repair (TEER) with the MitraClip device plus guideline-directed medical therapy (GDMT) vs. GDMT alone. We sought to evaluate the prognostic utility of baseline PV systolic flow reversal (PVSFR) in HF patients with severe MR and to determine whether the presence of PVSFR can discriminate patients most likely to benefit from TEER in COAPT trial patients.

Methods

Patients were categorized by the echocardiographic core laboratory-assessed baseline presence of PVSFR. Two-year outcomes were examined according to PVSFR and treatment.

Results

Baseline PV flow patterns were evaluable in 526/614(85.7%) patients, 48.9% of whom had PVSFR. Patients with PVSFR had more severe MR, reduced stroke volume and cardiac output, greater right ventricular dysfunction, and worse hemodynamics. By multivariable analysis, PVSFR was not an independent predictor of 2-year all-cause death, or heart failure hospitalization (HFH). The reductions in the 2-year rates of all-cause death and HFH with TEER compared with GDMT alone were similar in patients with and without PVSFR (P_interaction = 0.40 and 0.12, respectively). The effect of TEER on improving Kansas City Cardiomyopathy Questionnaire scores and 6-minute walk distance were also independent of PVSFR.

Conclusions

In the COAPT trial, PVSFR identified HF patients with severe MR and more advanced heart disease. Patients with and without PVSFR had consistent reductions in mortality, HFH, and improved quality-of-life and functional capacity after TEER.

Clinical Trial Registration

ClinicalTrial.gov IdentifierNCT01626079.

Background

JenaValve’s Trilogy transcatheter heart valve (THV) (JenaValve Inc, Irvine, CA) is the only conformité européenne-marked THV system for the treatment of aortic regurgitation (AR) or aortic stenosis (AS). However, its efficacy has not been quantitatively investigated pre- and post-implantation using video-densitometric analysis.

Methods

Using the CAAS-A-Valve 2.1.2 software (Pie Medical Imaging, Maastricht, the Netherlands), an independent core lab retrospectively analyzed the aortograms of 88 consecutive patients (68 severe AR; 20 severe AS) receiving the JenaValve THV in three European centers. Video-densitometric AR was categorized by the regurgitant fraction (RF) as none/trace AR (RF ≤ 6%), mild (6% < RF ≤ 17%), and moderate/severe AR (RF > 17%).

Results

Pre- and post-THV aortograms were analyzable in 17 (22.4%) and 47 (54.0%) patients, respectively. The main reasons preventing analysis were the descending aorta overlap of the outflow tract (30%) and insufficient frame count (6%). The median RF pre- and post-THV implant was 31.0% (interquartile range 21.5-38.6%) and 5.0% (interquartile range 1.0-7.0%, p < 0.001), respectively. The post-THV incidence of none/trace AR was 72.3%, and of mild AR, 27.7%, with no cases of moderate/severe AR. Video-densitometry analysis of the 12 AR cases with paired pre- and post-THV showed a reduction in the RF of 21.8% ± 8.1%.

Conclusions

Quantitative aortography confirms the low rates of AR and the large reduction in RF following the implantation of Jenavalve’s Trilogy THV, irrespective of implant indication. However, these limited data need corroborating in prospective studies using standardized acquisition protocols.

Background

Tricuspid regurgitation (TR) is a common valvular disorder with limited treatment options. It occurs when tricuspid leaflet closure is prevented by dilation of the right heart or in patients with cardiac implantable rhythm devices when the transvalvular lead impedes proper closure of the valve. The management of these patients can be complicated. The removal of the lead often does not improve the TR, and surgical repair is usually not possible because of comorbidities. A number of percutaneous TR repair and replacement devices have been developed; however, the presence of the right ventricular lead can prevent the delivery of these devices, or the device may displace the pacemaker lead. We report the first implant of the CroíValve DUO Transcatheter Tricuspid Coaptation Valve System (Dublin, Ireland) in a patient with massive TR and a right ventricular lead.

Methods

The patient was not a fit for surgical treatment and underwent transcatheter treatment following compassionate use approval. The procedure was performed under general anesthetic with echo and X-ray guidance. The device was delivered through the right internal jugular vein.

Results

The device was implanted successfully, and the TR was reduced from massive to mild at 90-day follow-up. The patient’s quality of life improved significantly with an improvement in 6-minute walk test (382 m at baseline to 467 m at follow-up), the New York Heart Association classification (III at baseline to I at follow-up), and the Kansas City Cardiomyopathy Questionnaire (baseline score 43 increased to 60). The efficacy and clinical improvement have been stable over the past 90 days of follow-up, and the patient has not suffered any adverse events.

Conclusions

This is the first implantation of the CroíValve DUO Coaptation Valve System in a patient with a pacemaker lead. In these patients, this device may offer advantages over other current transcatheter approaches.

Moderate aortic stenosis is increasingly recognized as a disease entity with poor prognosis. Diagnosis of moderate aortic stenosis may be complemented by laboratory tests and advanced imaging techniques focused at detecting signs of cardiac damage such as increase of cardiac enzymes (N-terminal pro-B-type Natriuretic Peptide, troponin), left ventricular remodeling (hypertrophy, reduced left ventricular ejection fraction), or myocardial fibrosis. Therapy should include guideline-directed optimal medical therapy for heart failure. Patients with signs of cardiac damage may benefit from early intervention, which is the focus of several ongoing randomized controlled trials. As yet, no evidence-based therapy exists to halt the progression of aortic valve calcification.