2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

ACC/AHA
: American College of Cardiology/American Heart Association
ACCF/AHA
: American College of Cardiology Foundation/American Heart Association
ACE
: angiotensin-converting enzyme
ACEI
: angiotensin-converting enzyme inhibitor
ACS
: acute coronary syndrome
AF
: atrial fibrillation

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2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

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ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 : The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC

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ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC.

2018 ESC/ESH Guidelines for the management of arterial hypertension.

In a paper published in this issue of the Journal by Lee et al, from Korea, the authors describe a modified Bentall procedure using a subannular inverted graft and rapid deployment valve for aortic root reconstruction in a patient with cardiac Behçet’s disease and aortic regurgitation. During the procedure, they also repaired a small subannular/ annular false aneurysm. Behçet’s disease is a rare disorder that causes blood vessel inflammation (vasculitis) throughout the body. It may be an autoimmune disorder and is more prevalent in countries of the Middle East and East Asia. In the aortic root, it is associated with extreme weakness of the vessel wall, annulus and valve, causing aortic regurgitation. Because of this, classical aortic valve replacement results in a very high rate of dehiscence of valve prostheses. Thus, use of a Bentall procedure, or one of its modifications, is recommended in this disease to decrease the risk of dehiscence. To suture the conduit below the annulus, in the normal tissues of the left ventricular outflow tract (LVOT), the authors inverted the valveless Dacron tube into the ventricular cavity. Then, after everting the conduit, a rapid-deployment prosthesis was implanted. Conduit inversion and suture in the LVOTendocardium is a maneuver frequently used for homograft implantation in patients with infective endocarditis and aortic root abscesses. It facilitates the precision of the proximal anastomosis, whether in a continuous or in an interrupted suture fashion. Other modified Bentall operations for patients

Commentary: Treatment of aortic regurgitation in Behçet's disease: More than one way to skin a cat

In this issue of the Journal, De Bonis et al. [1], from the Milan group, review their experience with the use of MitraClip for repair of secondary mitral regurgitation (MR) in patients with severe left ventricular (LV) dysfunction. With this aim, they compared the first consecutive patients treated with surgical (n = 65) or percutaneous (n = 55) edge-to-edge repair (Alfieri procedure). Age and logistic EuroSCORE were significantly higher in the MitraClip group, but the remaining characteristics of the patients were similar, hence we can accept the comparison, even if the two series are consecutive rather than contemporaneous, a limitation of this study which, together with other limitations, was duly acknowledged by the authors. They report freedom from cardiac death at 4 years (80.8 ± 4.9 vs 79.1 ± 5.9%, respectively in the surgical and MitraClip groups), which was not significantly different, but residual MR (≥2+) hospital discharge (7.6 vs 29%) and freedom from MR ≥2+ at 4 years (74.9 ± 5.6 vs 51.4 ± 7.4%) were. In this experience, the use of MitraClip was an independent predictor of recurrence of MR. Hence, they conclude ‘MitraClip therapy is a safe therapeutic option in selected high-risk patients with secondary MR and relevant comorbidities. The surgical edge-to-edge provides higher efficacy, both postoperatively and at mid-term follow-up’. This confirms and expands the conclusions of a previous report, also published in the Journal by the same group [2]. Previous studies had demonstrated the feasibility, safety and favourable results with the percutaneous procedure, particularly in this pathology. Early in the clinical experience with this device, Franzen et al. [4] showed that the ‘MitraClip therapy reduces functional MR in patients with end-stage heart failure and marked LV dysfunction and entails clinical benefit at 6 months’ [3]. However, the EVEREST II study demonstrated that the MitraClip was inferior to surgery for the end-points death, need for mitral valve surgery and MR recurrence grade ≥3 [5]. But the population in the EVEREST II study was relatively younger and less sick than that of the ACCESS-EU observational study that showed that ‘in the realworld, postapproval experience in Europe, patients undergoing the MitraClip therapy are high-risk, elderly patients, mainly affected by functional MR. In this patient population, the MitraClip procedure is effective with low rates of hospital mortality and adverse events’ [6–8]. The current report by our colleagues from Milan is timely as there is now an ever-increasing enthusiasm surrounding the novel techniques of percutaneous treatment of heart valve pathology. While it is quite clear, and now widely accepted, that these techniques are of benefit to patients who are either not candidates or very high risk for surgery, there is, as yet, no evidence that they may benefit patients who remain surgical candidates. From these authors’ experience, it is obvious that the percutaneous procedure is much less efficient than surgery. Although there was no difference in cardiac mortality, presumably with a longer follow-up the greater incidence of residual or recurrent MR there would be an impact on survival. In fact, in the current study, the persistence of significant MR (either residual or recurrent) was associated with higher mid-term cardiac mortality in the MitraClip group but not in surgically treated patients, and this was especially relevant in patients with greater degrees of regurgitation, more prevalent in the percutaneous group. The obvious difference between the two modalities of treatment lies in the complement of the annuloplasty used in surgery and as yet not possible with the MitraClip. The Milan group has previously demonstrated that the Alfieri ‘stitch’ performs better when associated to an annuloplasty [9]. A major shortcoming of most MitraClip studies performed so far is that they define success as ability to reduce MR to grade ≤2 and the long surgical experience has shown that even mild degrees of residual MR tend to increase in the medium and long term, and are associated to increased need for reoperation and even to late mortality. As the technique is still in its infancy and most of the studies have follow-ups limited to 6 months or 1 year, clearly we are still far from knowing the complete truth. In this series of De Bonis et al., the mean length of the follow-up was 6.2 ± 3.9 years (median: 6.6 years) for the surgical group and 2.9 ± 1.4 years (median: 3.1) for the MitraClip patients. Although this is still short, it is nevertheless longer than in other reports and that may be the main reason for the late differences encountered, especially revealed by a much greater incidence of MR recurrence ≥grade 3.

MitraClip therapy and surgical edge-to-edge repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: is the solution here?

From Walton Lillehei, who performed the first successful open mitral valve surgery in 1956, until the advent of robotic surgery in the 21st Century, only 50 years have passed. The introduction of the first heart valve prosthesis, in 1960, was the next major step forward. However, correction of mitral disease by valvuloplasty results in better survival and ventricular performance than mitral valve replacement. However, the European Heart Survey demonstrated that only 40% of the valves are repaired. The standard procedures (Carpentier’s techniques and Alfieri’s edge-to-edge suture) are the surgical basis for the new technical approaches. Minimally invasive surgery led to the development of video-assisted and robotic surgery and interventional cardiology is already making the first steps on endovascular procedures, using the classical concepts in highly differentiated approaches. Correction of mitral regurgitation is a complex field that is still growing, whereas classic surgery is still under debate as the ...

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Current surgical management of mitral regurgitation

Brucella endocarditis was diagnosed in two patients with acute renal failure. Both patients had major aortic insufficiency, congestive cardiac failure and clinical and laboratory signs of an active infection, although adequate antibacterial therapy had already been introduced. Replacement of the aortic valve, together with the aortic root in one of the cases, were carried out as emergency procedures, followed by antibacterial treatment with rifampicin, doxycycline and co-trimoxazole. Both patients left the hospital cured and are well 2.5 and 2 years after the surgery, respectively. © 1998 Elsevier Science B.V.

Case report Brucella endocarditis of the aortic valve

Aortic arch aneurysms are a therapeutic challenge, as they are usually associated with a high surgical risk and their natural history is poorly understood. The authors present a case report of a 74-year-old man, with widespread atherosclerotic disease and an inoperable aortic arch aneurysm. Despite the severity of his condition, the patient survived for four years. Through regular follow-up, it was possible to document the growth mechanism of the aneurysm and the associated complications. We highlight the lack of information in the literature regarding the evolution and natural history of aneurysms of the aortic arch and the urgent need for new therapeutic strategies, especially a percutaneous approach, which could provide better treatment and outcome for high-risk surgical patients.

Manuel J. Antunes

Papers

Commentary: Treatment of aortic regurgitation in Behçet's disease: More than one way to skin a cat

MitraClip therapy and surgical edge-to-edge repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: is the solution here?

Current surgical management of mitral regurgitation

Case report Brucella endocarditis of the aortic valve

Natural history of aortic arch aneurysm: the need for new therapeutic approaches.