Showing papers by "Robert J. Siegel published in 2019"

Guidelines for the Evaluation of Valvular Regurgitation After Percutaneous Valve Repair or Replacement: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions, Japanese Society of Echocardiography, and Society for Cardiovascular Magnetic Resonance

Abstract: The followi document: MD, FASE; sukochi, M following a M. Asch, M core lab pro tis, Abbott/ DirectFlow D. Gillam,M tronic; Pau dyne and r Medtronic, Guidelines for the Evaluation of Valvular Regurgitation After Percutaneous Valve Repair or Replacement A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions, Japanese Society of Echocardiography, and Society for Cardiovascular Magnetic Resonance

Prevalence and Resolution of Left Atrial Thrombus in Patients With Nonvalvular Atrial Fibrillation and Flutter With Oral Anticoagulation

Abstract: Left atrial appendage (LAA) thrombus in nonvalvular atrial fibrillation or flutter (AF) is a major cause of stroke and presents a therapeutic dilemma in a rhythm-control strategy. The prevalence and resolution of LAA thrombus has not been studied well in the era of non-vitamin K antagonist oral anticoagulant use. This study sought to establish (1) the prevalence of LAA thrombus (2) the prevalence of LAA thrombus despite antithrombotic therapy, (3) the rate of persistence of LAA thrombus despite appropriate anticoagulant prescriptions, and (4) determinants of LAA thrombus persistence. Consecutive transesophageal echocardiograms (TEE) performed in patients with AF were reviewed to estimate the overall prevalence of LAA thrombus and the resolution rate in those with repeat studies. Multivariable logistic regression was used to identify clinical and echocardiographic predictors of thrombus resolution. Of 1,485 patients with AF, 117 (8%) had LAA thrombus. Of those, 62 had repeat TEE within 1 year and 58 (94%) were prescribed adequate anticoagulation in TEE studies (mean interval 96 ± 72 days). Thirty-seven patients (60%) had LAA thrombus resolution. Thrombus resolution rate was only 79% in patients considered on appropriate anticoagulation. Patients with persistent LAA thrombus were more likely to have diabetes; no other clinical or echocardiographic variable was independently associated with thrombus resolution. There was no significant difference in LAA thrombus resolution between non-vitamin K antagonist oral anticoagulants and warfarin. LAA thrombus persistence despite adequate anticoagulation is relatively common and difficult to predict clinically; TEE before electrical cardioversion should be considered regardless of anticoagulation status.

Rheumatic Mitral Valve Stenosis: Diagnosis and Treatment Options.

Abstract: This review provides an update on rheumatic mitral stenosis. Acute rheumatic fever (RF), the sequela of group A β-hemolytic streptococcal infection, is the major etiology for mitral stenosis (MS). While the incidence of acute RF in the Western world had substantially declined over the past five decades, this trend is reversing due to immigration from non-industrialized countries where rheumatic heart disease (RHD) is higher. Pre-procedural evaluation for treatment of MS using a multimodality approach with 2D and 3D transthoracic and transesophageal echo, stress echo, cardiac CT scanning, and cardiac MRI as well as hemodynamic assessment by cardiac catheterization is discussed. The current methods of percutaneous mitral balloon commissurotomy (PMBC) and surgery are also discussed. New data on long-term follow-up after PMBC is also presented. For severe rheumatic MS, medical therapy is ineffective and definitive therapy entails PMBC in patients with suitable morphological mitral valve (MV) characteristics, or surgery. As procedural outcomes depend heavily on appropriate case selection, definitive imaging and interpretation are crucial. It is also important to understand the indications as well as morphological MV characteristics to identify the appropriate treatment with PMBC or surgery.

Percutaneous Edge-to-Edge Repair for Atrial Functional Mitral Regurgitation: A Real-Time 3-Dimensional Transesophageal Echocardiography Study.

Abstract: Isolated annular dilation, such as occurs in patients with lone atrial fibrillation (AF), is an increasingly important cause of secondary mitral regurgitation (MR) [(1,2)][1]. Although percutaneous edge-to-edge repair using the MitraClip (Abbott Vascular, Santa Clara, California) has been performed

Usefulness of Intraprocedural Pulmonary Venous Flow for Predicting Recurrent Mitral Regurgitation and Clinical Outcomes After Percutaneous Mitral Valve Repair With the MitraClip.

Abstract: Objectives The aim of this study was to determine the prognostic value of pulmonary venous (PV) flow during MitraClip implantation. Background The clinical significance of PV flow information during MitraClip implantation is unknown. Methods A total of 300 patients who underwent MitraClip implantation and in whom the measurement of PV flow was completed using intraprocedural transesophageal echocardiography were retrospectively reviewed. The optimal threshold of the ratio of systolic velocity-time integral (Svti) to diastolic velocity-time integral (Dvti) ratio after MitraClip placement for major adverse cardiovascular events (all-cause death, redo MitraClip implantation, mitral valve surgery, and heart transplantation) during 12 months was assessed. The best cutoff ratio was 0.72. Patients were divided into 2 groups using this cutoff ratio (low Svti/Dvti, n = 91; high Svti/Dvti, n = 209). Results Following mitral regurgitation reduction by MitraClip placement, Svti increased in the both groups. The frequency of mitral regurgitation 3/4+ immediately after MitraClip implantation, at 1-month follow-up, and at 12-month follow-up was significantly higher in patients with low Svti/Dvti ratios than in those with high Svti/Dvti ratios (after MitraClip placement, 5.5% vs. 0%; p Conclusions PV flow information in the catheterization laboratory immediately after MitraClip implantation predicted recurrent mitral regurgitation and worse long-term outcomes.

Predictors and Outcomes of Persistent Tricuspid Regurgitation After Transcatheter Aortic Valve Implantation.

Abstract: Persistent tricuspid regurgitation (TR) after transcatheter aortic valve implantation (TAVI) has been reported to increase mortality. The aim of this study was to investigate clinical and echocardiographic determinants and outcome of persistent TR after TAVI. We reviewed 1,085 patients who underwent TAVI. Among them, 100 patients who had ≥moderate TR without organic dysfunction of the tricuspid valve apparatus were studied. Preprocedural and follow-up transthoracic echocardiography after TAVI were analyzed. After TAVI, patients were divided into persistent TR group and improved TR group. Clinical event was defined as all-cause mortality and readmission for heart failure within 1,000 days. Fifty-three (53%) patients had persistent TR, whereas 47 (47%) patients had improved TR. Risk of clinical event was significantly higher in the persistent TR group compared with the improved TR group. Atrial fibrillation (AF) and tricuspid annular dimension (TAD; p <0.05 for all) were independent predictors of persistent TR. Receiver operating characteristic curve showed the optimal cut-off value of TAD for predicting persistent TR was 37 mm. The combination of AF and TAD ≥37 mm was associated with persistent TR (p <0.001). In conclusion, AF and dilated TAD before TAVI predicted persistent TR which was associated with higher all-cause mortality and readmission for heart failure.

Left atrial pressure is associated with iatrogenic atrial septal defect after mitral valve clip.

Abstract: Objectives Mitral valve (MV) clip procedure requires interatrial trans-septal puncture to access the left atrium (LA). Iatrogenic atrial septal defect (iASD) is not uncommon and may remain for a while. However, haemodynamic and echocardiographic determinants of persistent iASD are not well investigated. We sought to find haemodynamic and echocardiographic determinants of iASD after MV clip. Methods A total of 131 patients with grades 3 to 4+ mitral regurgitation who underwent MitraClip and completed invasive haemodynamic measurement, baseline, 1 month and approximately 12 months of transthoracic echocardiography (TTE) follow-up were retrospectively reviewed. Results TTE at 1 month showed persistent iASD in 57% (1M-iASD). Mean LA pressure after clip was significantly higher in patients with 1M-iASD than patients without 1M-iASD (17±6 mm Hg vs 15±5 mm Hg, p=0.01). Among patients with 1M-iASD, 24 patients (35%) had persistent iASD at 12 months (12M-iASD). Mean LA pressure after clip was significantly higher in patients with 12M-iASD than patients without 12M-iASD (19±6 mm Hg vs 16±6 mm Hg, p=0.04). Patients with 12M-iASD did not significantly differ from patients without 12M-iASD in terms of right heart enlargement, estimated systolic pulmonary artery pressure, New York Heart Association functional class and brain natriuretic peptide at 12 months. Logistic regression analysis, however, showed that mean LA pressure after clip was significantly associated with persistent iASD at 12 months in patients with 1M-iASD even after adjustment for cardiac index after clip and the prevalence of mitral regurgitation ≥3+ at 12 months (OR 1.10 per 1 mm Hg, 95% CI 1.01 to 1.21, p=0.04). Conclusions Elevated LA pressure after MV clip was associated with persistent iASD.

Comparison of Accuracy of Left Atrial Area and Volume by Two-dimensional Trans-thoracic Echocardiography Versus Computed Tomography.

Abstract: Left atrial (LA) size is prognostic of cardiovascular events and can be quantified as diameter, area, or volume. While LA area measurement by 2-dimensional (2D) echocardiography is performed by tracing LA borders in the apical 4-chamber view, LA volume is derived from a formula that is based on geometrical assumptions. We compared LA area and volume measurements obtained by trans-thoracic echocardiography (TTE) to those obtained using multi-detector computed tomography (MDCT). Sixty-four patients with MDCT and TTE performed within a 1-week period were included in the study. End-systolic LA area was planimetered from the 4-chamber view by TTE and MDCT. LA end-systolic volume was calculated using the biplane area-length (AL) method in both TTE and MDCT. Mean LA volume measurement using MDCT was significantly larger than TTE measurement (92 ± 31 mL vs 68 ± 27 mL, p <0.001). There was moderate correlation between MDCT and TTE in both LA area (0.74, p <0.0001), and volumetric measurements (0.77, p <0.0001). Bland-Altman agreement plots demonstrated a significantly lower bias and narrower 95% confidence intervals (CI) for the 2D area (bias: -5.5; 95% CI: -14.3 to 3.3) as compared with volumetric measurements (bias: -23.7; 95% CI: -64.9 to 17.5, p <0.0001). Contrary to current guidelines for chamber quantification, 2D TTE LA area has better agreement with MDCT than volumetric measurements by TTE. LA volumetric measurements are desirable; however, they are currently less reliable than the direct LA area tracing by 2D TTE and therefore represent a suboptimal and less reproducible method to determine LA size.

Comparison of mitral valve geometrical effect of percutaneous edge-to-edge repair between central and eccentric functional mitral regurgitation: clinical implications

Abstract: AIMS Percutaneous edge-to-edge repair alters mitral valve (MV) geometry in functional mitral regurgitation (FMR). We sought to characterize MV morphology in patients with central and eccentric FMR, compare the geometrical effect of MitraClip therapy, and elucidate different mechanisms of MR improvement according to FMR subtypes. METHODS AND RESULTS Seventy-six symptomatic patients with Grade 3 to 4+ FMR (central, n = 39; eccentric, n = 37) underwent three-dimensional transoesophageal echocardiography during MitraClip implantation. We defined procedural success as a reduction of MR by ≥1 grade with having a residual mitral regurgitation (MR) of ≤ grade 2+. Procedural success rate was similar between central and eccentric FMR (77% vs. 78%, P = 0.55). After MitraClip, the reduction in anterior-posterior diameter did not differ between FMR subtypes, but patients with eccentric FMR had a greater reduction in the averaged tethering angle difference (P < 0.001) with less reduction in tenting volume and height (both P < 0.001) than did patients with central FMR. On multivariable analysis, in central FMR, MR reduction post-clip was associated with shortening in anterior-posterior diameter [coefficient 0.388, 95% confidence interval (CI) 0.216-0.561; P < 0.001] and an increase in coaptation area (coefficient 0.117, 95% CI 0.039-0.194; P = 0.004), whereas in eccentric FMR MR reduction was mainly associated with a decrease in the averaged tethering angle difference (coefficient 0.050, 95% CI 0.021-0.078; P = 0.001). CONCLUSION MV geometrical effect and its association with MR improvement after MitraClip therapy differ according to FMR subtypes. Our results indicate the MR jet direction and the leaflet tethering pattern may be considered in the strategy for percutaneous treatment for FMR.

Cleft mitral leaflets and severe mitral regurgitation: Testing the limits of percutaneous mitral valve repair

Abstract: Repair of mitral regurgitation (MR) with the MitraClip device (Abbot Vascular, Menlo Park, CA) to treat degenerative MR is associated with improved acute and long-term outcomes. There is an increasing adoption of the device and operators are now testing the limits of the therapy even for unfavorable anatomies. Isolated cleft mitral leaflets are rare but represent a challenge to percutaneous repair. We present two cases of successful repair of severe MR and cleft mitral leaflets. In the first case, a 52-year-old male with a dilated cardiomyopathy and an ejection fraction (EF) of 15% presented in decompensated heart failure. Workup revealed a pseudo-cleft anterior mitral leaflet and a cleft posterior leaflet. A strategy to treat the restricted posterior leaflet lateral of the posterior cleft with a provisional second clip resulted in trace residual MR with only one clip, and an EF improvement to 50% at 2-month follow-up. In the second case, an 80-year-old male with a history of obstructive CAD with a normal EF but severe MR and a restricted anterior leaflet presented with severe shortness of breath. An initial strategy to grasp the middle of the valve was unsuccessful due to the cleft. Instead, two clips were placed side-by-side on either side of the cleft resulting in trivial residual MR. Despite challenging anatomy percutaneous repair can allow for dramatic reduction in MR, resulting in significant left ventricular remodeling and improvement of EF and cardiac output.

Degenerative Mitral Regurgitation: Assessment, Physical Examination, and Imaging.

Abstract: In this review, we provide a comprehensive approach to assess degenerative mitral regurgitation. In the evaluation of MR, it is important to differentiate between primary (degenerative/organic) MR in which an intrinsic mitral valve lesion(s) is responsible for the occurrence of MR and secondary (functional) MR where the mitral valve is structurally normal, but alterations of the left ventricular geometry cause deterioration of the MV apparatus. Advanced imaging modalities, foremost two-dimensional and three-dimensional echocardiography, are essential for this determination. In the evaluation of degenerative MR, the exact mechanism, the extent of the disease, associated valve lesions, the grade of mitral regurgitation severity, and hemodynamic consequences require careful assessment in order to provide patients with appropriate monitoring and treatment.

Yes We (S)can

Abstract: Marbach and colleagues reported a systematic review and meta-analysis of the comparative accuracy of focused cardiac ultrasonography examination using a hand-held device versus a clinical examinati...

Malignant intestinal obstruction during twin pregnancy: surgical resection of a myxoid liposarcoma without induction of labour.

Abstract: Myxoid liposarcoma (MLS) represents one of the three main morphological subgroups of liposarcomas Extrapulmonary recurrence to the retroperitoneum and abdomen is common in MLS A pregnant patient was referred to our hospital due to abdominal pain and obstipation In the past, she had received a multimodal treatment of an MLS of the left dorsal thigh Now, MRI revealed a 146×101×124 cm-sized tumour adjacent to the uterus with a known twin pregnancy (26th week) We performed surgery under tocolytic therapy The tumour has been completely removed The histopathological examination revealed a nodular manifestation of a moderately differentiated MLS arising from the mesentery Eleven weeks later, our patient delivered healthy twins This is the first report of surgical resection of MLS during a twin pregnancy With a multidisciplinary approach and a concerted treatment by surgeons and obstetricians, surgical resection resolved malignant intestinal obstruction and enabled an uncomplicated continuation of pregnancy