Showing papers by "Patric Biaggi published in 2013"

Predictors for efficacy of percutaneous mitral valve repair using the MitraClip system: the results of the MitraSwiss registry

Abstract: Background Percutaneous mitral valve repair (MVR) using the MitraClip system has become a valid alternative for patients with severe mitral regurgitation (MR) and high operative risk. Objective To identify clinical and periprocedural factors that may have an impact on clinical outcome. Design Multi-centre longitudinal cohort study. Setting Tertiary referral centres. Patients Here we report on the first 100 consecutive patients treated with percutaneous MVR in Switzerland between March 2009 and April 2011. All of them had moderate–severe (3+) or severe (4+) MR, and 62% had functional MR. 82% of the patients were in New York Heart Association (NYHA) class III/IV, mean left ventricular ejection fraction was 48% and the median European System for Cardiac Operative Risk Evaluation was 16.9%. Interventions MitraClip implantation performed under echocardiographic and fluoroscopic guidance in general anaesthesia. Main outcome measures Clinical, echocardiographic and procedural data were prospectively collected. Results Acute procedural success (APS, defined as successful clip implantation with residual MR grade ≤2+) was achieved in 85% of patients. Overall survival at 6 and 12 months was 89.9% (95% CI 81.8 to 94.6) and 84.6% (95% CI 74.7 to 91.0), respectively. Univariate Cox regression analysis identified APS (p=0.0069) and discharge MR grade (p=0.03) as significant predictors of survival. Conclusions In our consecutive cohort of patients, APS was achieved in 85%. APS and residual discharge MR grade are important predictors of mid-term survival after percutaneous MVR.

Real-Time Left Ventricular Pressure-Volume Loops During Percutaneous Mitral Valve Repair With the MitraClip System

Abstract: Background—Percutaneous mitral valve repair with the MitraClip device has emerged as an alternative to surgery for treating severe mitral regurgitation. However, its effects on left ventricular loading conditions and contractility have not been investigated yet. Methods and Results—Pressure-volume loops were recorded throughout the MitraClip procedure using conductance catheter in 33 patients (mean age, 78±10 years) with functional (45%), degenerative (48%), or mixed (6%) mitral regurgitation. Percutaneous mitral valve repair increased end-systolic wall stress (WSES; from [median] 184 mm Hg [interquartile range (IQR), 140–200 mm Hg] to 209 mm Hg [IQR, 176–232 mm Hg]; P=0.001) and decreased end-diastolic WS (WSED; from 48 mm Hg [IQR, 28–58 mm Hg] to 34 mm Hg [IQR, 21–46 mm Hg]; P=0.005), whereas the end-systolic pressure-volume relationship was not significantly affected. Conversely, cardiac index increased (from 2.6 L·min−1·m−2 [IQR, 2.2–3.0 L·min−1·m−2] to 3.2 L·min−1·m−2 [IQR, 2.6–3.8 L·min−1·m−2]; P<0....

Assessment of mitral valve area during percutaneous mitral valve repair using the MitraClip system: comparison of different echocardiographic methods.

Abstract: Background— Quantification of the mitral valve area (MVA) is important to guide percutaneous mitral valve repair using the MitraClip system. However, little is known about how to best assess MVA in this specific situation. Methods and Results— Immediately before and after MitraClip implantation, comprehensive 3-dimensional (3D) transesophageal echocardiography data were acquired for MVA assessment by the pressure half-time method and by two 3D quantification methods (mitral valve quantification software and 3D quantification software). In addition, transmitral gradients by continuous-wave Doppler (dPmeanCW) were measured to indirectly assess MVA. Data are given as median (interquartile range). Thirty-three patients (39% women) with a median age of 77.1 years (12.4 years) were studied. Before intervention, the median MVAs by the pressure half-time method, mitral valve quantification software, and 3D quantification software were 4.4 cm2 (2.0 cm2), 4.7 cm2 (2.4 cm2), and 6.2 cm2 (2.4 cm2), respectively ( P <0.001). After intervention, MVA was reduced to 1.9 cm2 (0.7 cm2), 2.1 cm2 (1.1 cm2), and 2.8 cm2 (1.1 cm2), respectively ( P =0.001). The median values for dPmeanCW before and after intervention were 1.0 mm Hg (1.0 mm Hg) and 3.0 mm Hg (3.0 mm Hg; P <0.001), respectively. At discharge, the median dPmeanCW was 4.0 mm Hg (3.0 mm Hg). In multivariate regression analyses including body surface area, the 3 different MVA methods, and dPmeanCW, a post-dPmeanCW ≥5 mm Hg was the best independent predictor of an elevated transmitral gradient at discharge. Conclusions— Transmitral gradients by continuous-wave Doppler are quick, feasible in all patients, and superior to direct peri-interventional assessment of MVA. A postinterventional transmitral gradient by continuous-wave Doppler of ≥5 mm Hg best predicted elevated transmitral gradients at discharge.

Integrated x-ray and echocardiography imaging for structural heart interventions.

Abstract: Treatment of structural heart disease (SHD) represents a growing need and, with increasing device availability, an increasing number of SHD can be and will be treated percutaneously. However, interventional treatment of SHD is challenging. Long procedure times and steep learning curves are recognised obstacles. The main difficulties arise, however, from the inability to visualise simultaneously the anatomy and the devices using a single imaging technology. In fact, the majority of percutaneous interventions in SHD are guided by fluoroscopy. On the other hand, a multitude of imaging technologies are presently available to guide the interventionalist. Of these technologies, transoesophageal echocardiography (TEE), and particularly 3-D TEE, is rapidly becoming the imaging modality of choice for many of these procedures because it provides critical insights into soft tissue anatomy. However, adequate visualisation and appreciation of the relationships between the cardiac structures and the devices using various imaging modalities remain a challenge. Hence, the interaction between the operator and imager is a crucial factor in attaining procedural success. Innovative technology that fuses live 3-D TEE with live x-ray in an intuitive way could have an important added value. This new imaging technology seeks to improve the communication between the echocardiographer and the interventionalist, to increase the confidence and anatomical awareness, to assist in guidance, and to increase procedural efficiency.

A novel electrocardiographic index for the diagnosis of diastolic dysfunction

Abstract: Background: Although the assessment of diastolic dysfunction (DD) is an integral part of routine cardiologic examinations, little is known about associated electrocardiographic (ECG) changes. Our aim was to investigate a potential role of ECG indices for the recognition of patients with DD. Methods and Results: ECG parameters correlating with echocardiographic findings of DD were retrospectively assessed in a derivation group of 172 individuals (83 controls with normal diastolic function, 89 patients with DD) and their diagnostic performance was tested in a validation group of 50 controls and 50 patients. The patient group with a DD Grade 1 and 2 showed longer QTc (422±24ms and 434±32ms vs. 409±25ms, p<0.0005) and shorter Tend–P and Tend–Q intervals, reflecting the electrical and mechanical diastole (240±78ms and 276±108ms vs. 373±110ms, p<0.0001; 409±85ms and 447±115ms vs. 526±119ms, p<0.0001). The PQ–interval was significantly longer in the patient group (169±28ms and 171±38ms vs. 153±22ms, p<0.005). After adjusting for possible confounders, a novel index (Tend–P/[PQxAge]) showed a high performance for the recognition of DD, stayed robust in the validation group (sensitivity 82%, specificity 93%, positive predictive value 93%, negative predictive value 82%, accuracy 88%) and proved a substantial added value when combined with the indexed left atrial volume (LAESVI, sensitivity 90%, specificity 92%, positive predictive value 95%, negative predictive value 86%, accuracy 91%). Conclusions: A novel electrocardiographic index Tend–P/(PQxAge) demonstrates a high diagnostic accuracy for the diagnosis of DD and yields a substantial added value when combined with the LAESVI.

Implantation of personalized, biocompatible mitral annuloplasty rings: feasibility study in an animal model

Abstract: OBJECTIVES: Implantation of an annuloplasty ring is an essential component of a durable mitral valve repair. Currently available offthe-shelf rings still do not cover all the variations in mitral annulus anatomy and pathology from subject to subject. Computed tomography (CT) and echo imaging allow for 3-D segmentation of the mitral valve and mitral annulus. The concept of tailored annuloplasty rings has been proposed although, to date, no surgically applicable implementation of patient-specific annuloplasty rings has been seen. The objective of this trial was to prove the concept of surgical implantation of a model-guided, personalized mitral annuloplasty ring, manufactured based on individual CT-scan models. METHODS: ECG-gated CT angiography was performed in six healthy pigs under general anaesthesia. Based on the individual shape of the mitral annulus in systole, a customized solid ring with integrated suturing holes was designed and manufactured from a biocompatible titanium alloy by a rapid process using laser melting. The ring was implanted three days later and valve function was assessed by intraoperative echocardiography. The macroscopic annulus–annuloplasty match was assessed after heart explantation. RESULTS: CT angiography provided good enough image quality in all animals to allow for segmentation of the mitral annulus. The individually tailored mitral rings were manufactured and successfully implanted in all pigs. In 50%, a perfect matching of the implanted ring and the mitral annulus was achieved. In one animal, a slight deviation of the ring shape from the circumference was seen postoperatively. The rings implanted in the first two animals were significantly oversized but the deviation did not affect valve competence. CONCLUSIONS: CT image quality and accuracy of the dimensions of the mitral annulus were sufficient for digital modelling and rapid manufacturing of mitral rings. Implantation of individually tailored annuloplasty rings is feasible.

What happens to functional mitral regurgitation after aortic valve replacement for aortic stenosis

Abstract: Background : Patients with aortic stenosis (AS) treated with aortic valve replacement (AVR) may also present with associated functional mitral valve regurgitation (FMR). Whether to also address the mitral valve at the time of AVR remains unclear. This study was designed to determine the influence of MR on survival and its evolution over time. Methods : We retrospectively reviewed 74 patients with FMR who underwent isolated AVR between 1999 and 2006 at our institution. Inclusion criteria were surgery for AVR with severe AS (mean age, 69 years; N = 47; 64% women) and FMR (grade I, 80%; grade II, 19%; grade III, 1%). Echocardiography follow-up data were obtained by mail questionnaires sent to the referring cardiologists of all survivors. All parameters were analyzed with the Kaplan-Meier method and the sign test. Results : The operative mortality rate was 2%, and 9 patients (12%) died during follow-up. The mean (SD) follow-up time was 48 ± 33 months, and follow-up 96% complete. The follow-up demonstrated a decrease of FMR by 2 degrees in 3 patients (4%), and 1 degree in 14 patients (19%); regurgitation remained unchanged in the majority of patients (n = 47; 63%). FMR worsened in 10 patients overall (14%), and new-onset atrial fibrillation was found in 24 patients (33%); however, the statistical analysis failed to demonstrate an impact of worsening FMR on survival. Conclusion : MR in patients with severe AS and FMR at the time of AVR does not appear to worsen significantly over time. Not dealing with the mitral valve at the time of AVR might be warranted for selected patients.

Complete graft dehiscence 8 months after repair of acute type A aortic dissection

Abstract: Acute type A aortic dissection is a dreaded differential diagnosis of acute chest pain. Long-term outcome mainly depends on pre-existing comorbidities and post-operative complications. We present a patient with aortic graft dehiscence and subsequent severe aortic regurgitation due to fungal graft infection 8 months after repair of acute type A aortic dissection. Redo aortic surgery had to be delayed for 28 days due to intracerebral haemorrhage caused by septic embolism and clipping of a mycotic left middle cerebral artery aneurysm. Surgery revealed a circumferentially detached graft at the site of the proximal anastomosis thereby forming a massive pseudoaneurysm. The patient underwent successful aortic root replacement using a Freestyle porcine root bioprosthesis (25 mm), followed by re-anastomosis of the coronary arteries and partial replacement of the ascending aorta with a 28 mm Dacron graft. The patient was discharged on day 67 in stable cardiac condition with persistent neurological deficits. This case highlights the challenging management of patients with aortic graft infection and neurological dysfunction after redissection of the ascending aorta who require redo cardiac surgery.

Triple trouble in the heart.

Abstract: A 47-year-old man with a history of systemic hypertension and type 2 diabetes mellitus was admitted to our centre in cardiogenic shock. He experienced rapidly progressive shortness of breath for the past 3 weeks. The ECG on admission showed atrial flutter with 2:1 conduction and a ventricular rate of 142 b.p.m. ( Panel A ). Transoesophageal echocardiography prior to cardioversion ( Panels B and C , …