Percutaneous Treatment of Tricuspid Regurgitation

Tricuspid valve regurgitation is one of the most common valvular disorders and moderate to severe tricuspid regurgitation is consistently associated to an increased morbidity and mortality. From an etiopathological perspective, tricuspid regurgitation can be classified in primary, due to the organic disease of any of the valve components, or secondary, as a result of tricuspid valve annulus dilatation, adverse right ventricular remodeling and tricuspid valve leaflet tethering. Despite its poor prognosis, most patients with tricuspid insufficiency are managed conservatively and only those with concomitant left heart valvular disease do finally go surgery in the real-world setting. In fact, outcomes of conventional surgery in patients with isolated tricuspid regurgitation are poor and this approach has not proven yet any survival benefit over stand-alone medical therapy. Given this unmet need, new transcatheter techniques have been developed in the last years, including leaflet plication, percutaneous annuloplasty and valve implantation in either the tricuspid position (orthotopic implantation) or in a different position such as the vena cava (heterotopic implantation). These techniques, with promising outcomes, are seen as an interesting alternative to open-heart surgery given the much lower periprocedural risk

Mortalidad intrahospitalaria y angina preinfarto temprana: metaanálisis de los estudios publicados

Introducción y objetivos. La presencia de angina preinfarto (AP) reduce el tamaño de la necrosis miocárdica e induce más cantidad de miocardio viable y una mejor función ventricular izquierda. Sin embargo, la asociación entre mortalidad y AP es controvertida. El objetivo de este estudio fue determinar si la AP se asocia con la mortalidad intrahospitalaria. Método. Se realizó un metaanálisis (modelo de efectos fijos) de los estudios publicados hasta el momento en los que se analiza la mortalidad intrahospitalaria de pacientes con infarto agudo de miocardio según presenten o no AP, definida como la que acontece en las 24 h previas al comienzo del infarto. A partir de las bases de datos MEDLINE y EMBASE se realizó una búsqueda en junio de 2004 con los términos «preinfarction angina or prodromal angina and mortality» y se incluyeron finalmente 6 trabajos, con un total de 3.497 pacientes. Resultados. En sólo uno de los estudios se encuentra una asociación beneficiosa estadísticamente significativa entre AP y mortalidad intrahospitalaria. Tras agrupar los datos se encontró una reducción significativa en la probabilidad de muerte intrahospitalaria en pacientes con AP (odds ratio = 0,61; intervalo de confianza del 95%, 0,48-0,78; p < 0,0001). No se encontró heterogeneidad significativa entre los estudios (?² = 5,92; p = 0,31). Conclusiones. La presencia de angina en las 24 h previas al inicio del infarto de miocardio se asocia con una reducción significativa de la mortalidad intrahospitalaria del 39

The prognostic impact of frailty in patients undergoing percutaneous mitral valve repair

Aim: Percutaneous mitral valve repair (PMVR) with MitraClip® has proven to be an effective therapy to reduce mitral regurgitation in patients at high risk for conventional surgery. This population is currently characterized by advance age and high prevalence of comorbidities. Our aim was to evaluate the prevalence of frailty in a cohort of patients undergoing PMVR and its impact on clinical outcomes during follow-up.Methods: A prospective registry was performed including all consecutive patients who underwent elective PMVR between June 2014 and March 2018 in our institution. Frailty was evaluated at admission with the functional FRAIL scale. In-hospital and 30-day procedural outcomes were collected. Clinical follow up was carried out including New York Heart Association (NYHA) functional class, heart failure hospitalization and death.Results: Overall, 70 patients were included (mean age 75.3 ± 9.9 years, 65.7% male). Among them, 27 patients (38.6%) had a pre-procedural FRAIL score greater than 2, meeting frailty criteria. No differences between frail and non-frail patients were found in technical success (P = 1.0) or 30-day device success (P = 0.739). At six months follow up, both groups showed a significant improvement in NYHA functional class compared to baseline (frail: P = 0.002; non-frail: P &lt; 0.001). During a median follow up of 675 (range 416-976) days, frailty patients had a higher incidence of HF admission and all-cause mortality (P = 0.013). In multivariate COX regression analysis, FRAIL score greater than 2 was significantly related to the primary composite endpoint (HR = 2.45; 95%CI: 1.02-5.88; P = 0.044).Conclusion: Frailty was common in patients undergoing PMVR in our institution. Despite post-procedural clinical improvement, frailty was related to adverse outcomes in our series

Percutaneous treatment of mitral regurgitation recurrence after mitral valve surgery

Mitral regurgitation is one of the most common cardiac valve disorders worldwide and the second most frequent indication of cardiac surgery for heart valve disease. During the last decades, open-heart mitral valve repair and replacement have been considered the sole and gold standard invasive therapy for this complex disorder. However, a significant proportion of patients experiences recurrence of mitral regurgitation during long-term follow-up, which entails an important increase in morbidity and mortality. In this scenario, percutaneous therapies to treat mitral regurgitation have become an appealing alternative to conventional surgery given high risk for repeat surgery. The present review describes current evidence of transcatheter mitral valve repair and replacement therapies to treat mitral regurgitation recurrence after surgery

Incidence and prognostic implications of late bleeding events after percutaneous mitral valve repair

Objectives: MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip. Methods: Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE. Results: During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20–17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03–11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66–8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ± 1.3 vs 2.1 ± 0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507–0.848]) in this subgroup. Conclusions: BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients. Keywords: MitraClip, Atrial fibrillation, Bleeding event