RESUMEN
Despite being a rare phenomenon, pericardial hydatid cysts present unique diagnostic challenges and require a multimodality imaging as well as a multidisciplinary approach for a curative management. The authors here present a case of a middle aged man who was referred to them for management of new onset atrial flutter with mitral regurgitation.
Asunto(s)
Aleteo Atrial , Equinococosis , Insuficiencia de la Válvula Mitral , Humanos , Masculino , Aleteo Atrial/complicaciones , Aleteo Atrial/diagnóstico , Equinococosis/complicaciones , Equinococosis/diagnóstico , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/complicaciones , Persona de Mediana Edad , Diagnóstico Diferencial , Pericardio/diagnóstico por imagen , Ecocardiografía/métodos , Quiste Mediastínico/complicaciones , Quiste Mediastínico/diagnóstico , Quiste Mediastínico/diagnóstico por imagenRESUMEN
Atrial fibrillation is the most common cardiac arrhythmia, leading to progressive dilation of cardiac chambers, abnormal contraction patterns of the atria and ventricles and, potentially, atrioventricular valvular insufficiency. Moreover, heart failure with preserved ejection fraction is often present and closely intertwined with disease initiation and progression. Surgical valve repair with a true-sized ring annuloplasty is a well-established treatment option in atrial functional mitral regurgitation. While early results are good, recent studies have brought the durability of this repair approach into question, highlighting the need for further refinement of the surgical strategy. In particular, repair strategies that simultaneously target the mitral valve as well as the left ventricle could provide improved repair durability.
Asunto(s)
Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral , Humanos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico , Anuloplastia de la Válvula Mitral/métodos , Atrios Cardíacos/fisiopatología , Atrios Cardíacos/cirugía , Fibrilación Atrial/cirugía , Fibrilación Atrial/fisiopatología , Válvula Mitral/cirugía , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/métodosRESUMEN
Pectus excavatum presents challenges in cardiac operations due to anatomical abnormalities and limited exposure. We report a case of a 58-year-old male with severe pectus excavatum and significant mitral regurgitation successfully treated with minimally invasive mitral valve repair. Preoperative imaging revealed leftward heart displacement and a Haller index of 3.8. Surgical intervention involved adaptations in atrial retraction and valve repair technique. Postoperative outcomes were favourable, with normal mitral function and a short hospital stay. Despite technical challenges, minimally invasive approaches offer benefits in pectus excavatum patients. This case underscores the feasibility and safety of minimally invasive surgery in patients with extensive pectus excavatum, emphasizing its potential as a preferred approach.
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Tórax en Embudo , Procedimientos Quirúrgicos Mínimamente Invasivos , Insuficiencia de la Válvula Mitral , Humanos , Masculino , Tórax en Embudo/cirugía , Tórax en Embudo/complicaciones , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Válvula Mitral/cirugía , Resultado del TratamientoAsunto(s)
Cateterismo Cardíaco , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Humanos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Insuficiencia de la Válvula Tricúspide/fisiopatología , Insuficiencia de la Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/diagnóstico , Resultado del Tratamiento , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Prótesis Valvulares CardíacasRESUMEN
The evolution of percutaneous procedures that use transseptal puncture to treat left-sided structural heart disease has led to the emergence of iatrogenic atrial septal defects as a potential complication. These defects can result in hemodynamic decompensation and worsening clinical outcomes. Some iatrogenic atrial septal defects require immediate closure, others do not. This case report presents 2 patients who underwent transcatheter edge-to-edge mitral valve repair with transseptal puncture and required iatrogenic atrial septal defect closure (1 immediate and 1 delayed). The goal of this report is to highlight iatrogenic atrial septal defect assessment and the possible need for closure after transseptal puncture.
Asunto(s)
Cateterismo Cardíaco , Ecocardiografía Transesofágica , Defectos del Tabique Interatrial , Enfermedad Iatrogénica , Insuficiencia de la Válvula Mitral , Válvula Mitral , Humanos , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Defectos del Tabique Interatrial/cirugía , Defectos del Tabique Interatrial/diagnóstico , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Masculino , Anciano , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Lesiones Cardíacas/etiología , Lesiones Cardíacas/diagnóstico , Lesiones Cardíacas/cirugía , Resultado del Tratamiento , Anciano de 80 o más Años , PuncionesRESUMEN
OBJECTIVE: Minimally invasive mitral valve surgery (mini-MVS) is typically reserved for patients who have not undergone open cardiac surgery. In the reoperative setting, using intrapericardial dissection for crossclamping the aorta through a minimally invasive approach can be difficult and, at times, risky. Cold fibrillatory cardiac arrest (CFCA) with systemic cardiopulmonary bypass without cross-clamping is a well-described technique; however, data about its safety for patients who undergo reoperative mini-MVS are limited. METHODS: Data for 34 patients who underwent reoperative mini-MVS with CFCA from March 2017 to March 2022 were reviewed retrospectively. A mini right thoracotomy (n = 30) or robotic (n = 4) approach was used. Systemic hypothermia was induced to a target temperature of 25 °C. RESULTS: Patient mean (SD) age was 64.5 (9.6) years, and 15 of 34 (44.1%) patients were women. Of those 34 patients, 23 (67.6%) had severe regurgitation, and 11 (32.4%) had severe stenosis. Before mini-MVS, 28 patients had undergone valve surgery, and 8 had undergone coronary artery bypass graft surgery. The mitral valve was repaired in 5 of 34 (14.7%) and replaced in 29 of 34 (85.3%) patients. No difference was observed in preoperative and postoperative left ventricular function (P = .82). In 1 patient, kidney failure developed that necessitated dialysis. No postoperative stroke or mortality at 30 days occurred. CONCLUSION: Mini-MVS with CFCA is well tolerated in patients with prior cardiac surgery. Myocardial function was not impaired, nor was the risk of stroke increased in this cohort, indicating that CFCA is a safe alternative in this high-risk population.
Asunto(s)
Procedimientos Quirúrgicos Mínimamente Invasivos , Válvula Mitral , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Resultado del Tratamiento , Procedimientos Quirúrgicos Cardíacos/métodos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Anciano , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Paro Cardíaco Inducido/métodos , Reoperación , Hipotermia Inducida/métodos , Estudios de SeguimientoRESUMEN
An 83-year-old woman with symptomatic severe aortic stenosis was referred for transcatheter aortic valve replacement. Diagnostic left heart catheterization documented diffuse 3-vessel coronary artery disease.
Asunto(s)
Estenosis de la Válvula Aórtica , Cateterismo Cardíaco , Insuficiencia de la Válvula Mitral , Choque Cardiogénico , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Anciano de 80 o más Años , Femenino , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/complicaciones , Choque Cardiogénico/etiología , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/terapia , Cateterismo Cardíaco/métodos , Índice de Severidad de la Enfermedad , Angiografía Coronaria , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/complicaciones , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiologíaRESUMEN
In a 39-year-old male with mitral valve endocarditis, after 6 weeks of intravenous antibiotics, echocardiography confirmed multiple vegetations on both leaflets, a flail posterior leaflet flail and contained perforation of the anterior leaflet in a windsock-like morphology. All vegetations, diseased and ruptured chords and the windsock-like contained rupture of the anterior leaflet were carefully resected via a right minithoracotomy and with femoral cannulation. Three repair techniques were blended to reconstruct the valve: (1) A large, infected portion of the prolapsing posterior leaflet was resected in a triangular fashion, and the edges were re-approximated using continuous 5-0 polypropylene sutures. (2) The anterior leaflet defect was repaired with a circular autologous pericardial patch that had been soaked in glutaraldehyde. (3) A set of artificial chords for P2 was created using CV-4 polytetrafluoroethylene sutures and adjusted under repeated saline inflation. A 38-mm Edwards Physio-I annuloplasty ring was implanted. The artificial chords were adjusted again after annuloplasty and then tied. Transoesophageal echocardiography (TEE) confirmed the absence of residual mitral regurgitation and systolic anterior motion and a mean pressure gradient of 3 mmHg. The patient was discharged after 5 days with a peripherally inserted central catheter to complete an additional 4 weeks of intravenous antibiotics and had an uneventful recovery.
Asunto(s)
Ecocardiografía Transesofágica , Válvula Mitral , Humanos , Masculino , Adulto , Válvula Mitral/cirugía , Anuloplastia de la Válvula Mitral/métodos , Endocarditis Bacteriana/cirugía , Endocarditis Bacteriana/diagnóstico , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Técnicas de Sutura , Implantación de Prótesis de Válvulas Cardíacas/métodos , Endocarditis/cirugía , Endocarditis/diagnóstico , Pericardio/trasplanteRESUMEN
Rheumatic heart disease remains a major cause of cardiovascular death worldwide. Limited real-world nationwide data are available to compare the long-term outcomes between mitral valve repair and replacement in rheumatic heart disease. For patients with RHD, MVP is the superior choice of surgical intervention owing to better long-term survival, reduced incidence of early mortality and thromboembolic events. However, it entails higher chances of re-operation at follow-up at four, eight and twelve years. Although feasible, surgeons may opt for MVR in patients with a worse prognosis. Whereas degenerative mitral repair for severe MR has been proven superior to replacement, the optimal operative strategy for mitral RHD remains unclear. In developing countries, mitral RHD commonly develops in young patients, predominantly consists of MR rather than MS, and occurs more frequently than in the United States. In addition, the predominant MR etiology (rather than MS), relatively early intervention in the RHD timeline, and variation in Carpentier MR types among developing world populations further make these rheumatic MVs more amenable to repair than replacement. Patients should be carefully selected for mitral valve repair because of its higher reoperation rate, particularly those with previous percutaneous transvenous mitral commissurotomy. Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Válvula Mitral , Cardiopatía Reumática , Humanos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Válvula Mitral/cirugía , Anuloplastia de la Válvula Mitral/métodos , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Cardiopatía Reumática/cirugía , Cardiopatía Reumática/complicaciones , Resultado del TratamientoRESUMEN
OBJECTIVES: Transcatheter edge-to-edge repair (TEER) has become an established minimally invasive treatment for significant mitral regurgitation. Ongoing refinements and the availability of different clipping devices have expanded the indications for and effectiveness of TEER, but comprehensive comparative data on this issue are lacking. In this study, we compared NT, NTr, and XTr MitraClip devices (Abbot) for TEER. METHODS: Details on patient, imaging, and procedural details, as well as short- and long-term outcomes, were sought from a national prospective clinical registry on TEER with MitraClip. The primary outcome of interest was discharge after procedural success without major clinical complications. RESULTS: A total of 2236 patients were included, 1228 (54.9%) in whom NT implantation only was attempted, 233 (10.4%) in whom NTr but not XTr implantation was attempted, and 775 (34.7%) in whom XTr implantation was attempted. Clinical and imaging features differed substantially across the groups, reflecting expanding indications with NTr and XTr devices. In-hospital outcomes were largely similar among the 3 groups, including death. Long-term unadjusted estimates of effect showed significant differences in several outcomes, including death, rehospitalization, and their composite, which demonstrated that NT was associated with more unfavorable outcomes compared with the other devices (all P less than .05). However, most differences depended on baseline features, as adjusted analysis showed no significant differences for early as well as long-term outcomes, including long-term death, rehospitalization, and their composite (all P greater than .05). CONCLUSIONS: New-generation MitraClip devices are associated with favorable procedural and clinical outcomes, despite being used in patients with more adverse features, when compared with patients treated with previous devices.
Asunto(s)
Cateterismo Cardíaco , Insuficiencia de la Válvula Mitral , Válvula Mitral , Humanos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Femenino , Masculino , Cateterismo Cardíaco/métodos , Anciano , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Anciano de 80 o más Años , Estudios Prospectivos , Sistema de Registros , Ecocardiografía Transesofágica/métodos , Estudios de Seguimiento , Prótesis Valvulares CardíacasAsunto(s)
Fibrilación Atrial , Electrocardiografía , Insuficiencia de la Válvula Mitral , Humanos , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/cirugía , Masculino , Femenino , Atrios Cardíacos/fisiopatología , Atrios Cardíacos/diagnóstico por imagen , Frecuencia Cardíaca , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Anciano , Potenciales de AcciónRESUMEN
Klippel-Feil syndrome, characterized by congenital fusion of any 2 or more cervical vertebrae, is a rare disorder in which skeletal and other organ system-related abnormalities have been reported. This article reports a case of mitral valve regurgitation in a patient with Klippel-Feil syndrome and related thoracic deformity who underwent mitral valvuloplasty. Postoperatively, the mitral valve regurgitation disappeared, and there has been no recurrence for 3 years. This case highlights mitral valvuloplasty via median sternotomy as an excellent treatment for mitral valve regurgitation in a patient with thoracic deformity related to Klippel-Feil syndrome.
Asunto(s)
Síndrome de Klippel-Feil , Insuficiencia de la Válvula Mitral , Adulto , Humanos , Masculino , Valvuloplastia con Balón , Síndrome de Klippel-Feil/complicaciones , Síndrome de Klippel-Feil/diagnóstico , Síndrome de Klippel-Feil/cirugía , Válvula Mitral/cirugía , Válvula Mitral/anomalías , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/diagnóstico , Esternotomía , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Mitral valve disorder (MVD) stands as the most prevalent valvular heart disease. Presently, a comprehensive clinical index to predict mortality in MVD remains elusive. The aim of our study is to construct and assess a nomogram for predicting the 28-day mortality risk of MVD patients. METHODS: Patients diagnosed with MVD were identified via ICD-9 code from the MIMIC-III database. Independent risk factors were identified utilizing the LASSO method and multivariate logistic regression to construct a nomogram model aimed at predicting the 28-day mortality risk. The nomogram's performance was assessed through various metrics including the area under the curve (AUC), calibration curves, Hosmer-Lemeshow test, integrated discriminant improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA). RESULTS: The study encompassed a total of 2771 patients diagnosed with MVD. Logistic regression analysis identified several independent risk factors: age, anion gap, creatinine, glucose, blood urea nitrogen level (BUN), urine output, systolic blood pressure (SBP), respiratory rate, saturation of peripheral oxygen (SpO2), Glasgow Coma Scale score (GCS), and metastatic cancer. These factors were found to independently influence the 28-day mortality risk among patients with MVD. The calibration curve demonstrated adequate calibration of the nomogram. Furthermore, the nomogram exhibited favorable discrimination in both the training and validation cohorts. The calculations of IDI, NRI, and DCA analyses demonstrate that the nomogram model provides a greater net benefit compared to the Simplified Acute Physiology Score II (SAPSII), Acute Physiology Score III (APSIII), and Sequential Organ Failure Assessment (SOFA) scoring systems. CONCLUSION: This study successfully identified independent risk factors for 28-day mortality in patients with MVD. Additionally, a nomogram model was developed to predict mortality, offering potential assistance in enhancing the prognosis for MVD patients. It's helpful in persuading patients to receive early interventional catheterization treatment, for example, transcatheter mitral valve replacement (TMVR), transcatheter mitral valve implantation (TMVI).
Asunto(s)
Bases de Datos Factuales , Unidades de Cuidados Intensivos , Nomogramas , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Bases de Datos Factuales/tendencias , Factores de Riesgo , Medición de Riesgo/métodos , Valor Predictivo de las Pruebas , Mortalidad/tendencias , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/diagnóstico , Estudios Retrospectivos , Válvula Mitral , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/diagnósticoRESUMEN
Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.
Asunto(s)
Atrios Cardíacos , Insuficiencia Cardíaca , Ventrículos Cardíacos , Insuficiencia de la Válvula Mitral , Volumen Sistólico , Humanos , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/complicaciones , Volumen Sistólico/fisiología , Atrios Cardíacos/fisiopatología , Ventrículos Cardíacos/fisiopatología , Ventrículos Cardíacos/diagnóstico por imagen , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Hemodinámica/fisiologíaRESUMEN
Transcatheter aortic valve replacement is quickly becoming the standard of care for patients with severe aortic stenosis thanks to its minimally invasive nature and favorable outcomes. Recently, left ventricular pacing has been proposed as a safer alternative to traditional right heart pacing, which could simplify the transcatheter aortic valve replacement procedure overall, although procedural complications may still occur. This report describes a rare case of left ventricular pacing wire-induced acute severe mitral valve regurgitation during transcatheter aortic valve replacement.
Asunto(s)
Estenosis de la Válvula Aórtica , Insuficiencia de la Válvula Mitral , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Enfermedad Aguda , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico , Estimulación Cardíaca Artificial/métodos , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/fisiopatología , Marcapaso Artificial/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Resultado del Tratamiento , Función Ventricular Izquierda/fisiologíaAsunto(s)
Cateterismo Cardíaco , Insuficiencia de la Válvula Mitral , Válvula Mitral , Dispositivo Oclusor Septal , Humanos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Cateterismo Cardíaco/métodos , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Implantación de Prótesis de Válvulas Cardíacas/métodos , Falla de Prótesis , Prótesis Valvulares Cardíacas/efectos adversos , Ecocardiografía Transesofágica/métodos , Resultado del TratamientoRESUMEN
AIMS: This study aims to assess the applicability of the mitral regurgitation (MR) proportionality concept in patients with atrial functional mitral regurgitation (aFMR) treated with transcatheter edge-to-edge repair (M-TEER). We hypothesized that patients with disproportionate MR (higher MR relative to left ventricular size) would exhibit different outcomes compared to those with proportionate MR, despite undergoing M-TEER. METHODS AND RESULTS: We retrospectively analysed 98 patients with aFMR from the EuroSMR registry who underwent M-TEER between 2008 and 2019. Patients met criteria for aFMR (normal indexed left ventricular end-diastolic volume [LVEDV], preserved left ventricular ejection fraction [LVEF] ≥ 50% without regional wall motion abnormalities, and structurally normal mitral valves). We excluded patients with missing effective regurgitant orifice area (EROA) or LVEDV data. The primary endpoint was 2-year mortality, with an EROA/LVEDV ratio employed to differentiate disproportionate from proportionate MR. Procedural success and baseline characteristics were analysed, and multivariate Cox proportional hazards models were used to identify mortality predictors. The mean patient age was 79 ± 7.3 years, with 68.8% female, and 79% had a history of atrial fibrillation. The mean EROA was 0.27 ± 0.14 cm2, and LVEDV was 95.6 ± 33.7 mL. Disproportionate MR was identified with an EROA/LVEDV ratio >0.339 cm2/100 mL. While procedural success was similar in both groups, disproportionate MR was associated with a numerically higher estimate of systolic pulmonary artery pressures (sPAP) and rates of NYHA ≥III and TR ≥ 3+. Disproportionate MR had a significant association with increased 2-year mortality (P < 0.001). The EROA/LVEDV ratio and tricuspid annular plane systolic excursion (TAPSE) were independent predictors of 2-year mortality (EROA/LVEDV: HR: 1.35, P = 0.010; TAPSE: HR: 0.85, P = 0.020). CONCLUSIONS: This analysis introduces the MR proportionality concept in aFMR patients and its potential prognostic value. Paradoxically, disproportionate MR in aFMR was linked to a 1.35-fold increase in 2-year mortality post-M-TEER, emphasizing the importance of accurate preprocedural FMR characterization. Our findings in patients with disproportionate MR indicate that a high degree of aFMR with high regurgitant volumes may lead to aggravated symptoms, which is a known contributor to increased mortality following M-TEER. These results underline the need for further research into the pathophysiology of aFMR to inform potential preventative and therapeutic strategies, ensuring optimal patient outcomes.
Asunto(s)
Cateterismo Cardíaco , Atrios Cardíacos , Insuficiencia de la Válvula Mitral , Válvula Mitral , Humanos , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Femenino , Masculino , Estudios Retrospectivos , Anciano , Cateterismo Cardíaco/métodos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Atrios Cardíacos/fisiopatología , Atrios Cardíacos/diagnóstico por imagen , Tasa de Supervivencia/tendencias , Estudios de Seguimiento , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Sistema de Registros , Ecocardiografía Transesofágica/métodosRESUMEN
Effects of angiotensin receptor/neprilysin inhibitors (ARNI) on ventricular remodeling in patients with heart failure, especially heart failure with reduced ejection fraction (HFrEF), are better than those of angiotensin-converting enzyme inhibitors (ACEI). Acute myocardial infarction (AMI) complicated by mitral regurgitation exacerbates ventricular remodeling and increases the risk of heart failure. There is limited evidence on the effects of early administration of ARNI in patients with AMI complicated by mitral regurgitation. The aim of this trial was to examine the effectiveness and the safety of early administration of sacubitril/valsartan after coronary artery revascularization in patients with AMI complicated by moderate-to-severe mitral regurgitation. This was a randomized, single-blind, parallel-group, controlled trial. From June 2021 to June 2022, we enrolled 142 consecutive patients with AMI complicated by moderate-to-severe mitral regurgitation and followed them for 12 months. The patients received standard treatment for AMI and were randomly assigned to receive ARNI or benazepril. The primary efficacy end points were the differences in mitral regurgitant jet area (MRJA), mitral regurgitant volume (MRV), concentration of n-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), and left ventricular end-diastolic volume and end-systolic volume (LVEDV and LVESV) between groups and within groups at baseline, 1, 3, 6, and 12 months. Secondary end points included the rates of heart failure hospitalization, all-cause mortality, refractory angina, malignant arrhythmias, recurrent myocardial infarction, and stroke. Safety end points included the rates of hyperkalemia, renal dysfunction, hypotension, angioedema, and cough. The ARNI group had significantly lower NT-proBNP levels than the benazepril group at 1 month and later (P < 0.001). MRJA and MRV significantly improved in the ARNI group compared with the benazepril group at 12 months (MRJA: - 3.21 ± 2.18 cm2 vs. - 1.83 ± 2.81 cm2, P < 0.05; MRV: - 27.22 ± 15.22 mL vs. - 13.67 ± 21.02 mL, P < 0.001). The ARNI group also showed significant reductions in LVEDV and LVESV (P < 0.05) and improvement in LVEF (P < 0.05). Secondary end point analysis showed a significantly higher rate of heart failure hospitalization in the benazepril group compared with the ARNI group (HR = 2.03, 95% CI 1.12-3.68, P = 0.021). Safety end point analysis showed a higher rate of hypotension in the ARNI group (P < 0.05). Early use of sacubitril/valsartan after coronary artery revascularization in patients with AMI complicated by moderate-to-severe mitral regurgitation can significantly reduce mitral regurgitation, improve ventricular remodeling, and decrease heart failure hospitalization. Nevertheless, caution is needed to avoid hypotension. Chinese Clinical Trial Registry (ChiCTR2100054255) registered on December 11, 2021.