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

Safety and Feasibility of MitraClip Implantation in Patients with Acute Mitral Regurgitation after Recent Myocardial Infarction and Severe Left Ventricle Dysfunction

Patients with severe mitral regurgitation (MR) after myocardial infarction (MI) have an increased risk of mortality. Transcatheter mitral valve repair may therefore be a suitable therapy. However, data on clinical outcomes of patients in an acute setting are scarce, especially those with reduced left ventricle (LV) dysfunction. We conducted a multinational, collaborative data analysis from 21 centers for patients who were, within 90 days of acute MI, treated with MitraClip due to severe MR. The cohort was divided according to median left ventricle ejection fraction (LVEF)-35%. Included in the study were 105 patients. The mean age was 71 ± 10 years. Patients in the LVEF \u3c 35% group were younger but with comparable Euroscore II, multivessel coronary artery disease, prior MI and coronary artery bypass graft surgery. Procedure time was comparable and acute success rate was high in both groups (94% vs. 90%, p = 0.728). MR grade was significantly reduced in both groups along with an immediate reduction in left atrial V-wave, pulmonary artery pressure and improvement in New York Heart Association (NYHA) class. In-hospital and 1-year mortality rates were not significantly different between the two groups (11% vs. 7%, p = 0.51 and 19% vs. 12%, p = 0.49) and neither was the 3-month re-hospitalization rate. In conclusion, MitraClip intervention in patients with acute severe functional mitral regurgitation (FMR) due to a recent MI in an acute setting is safe and feasible. Even patients with severe LV dysfunction may benefit from transcatheter mitral valve intervention and should not be excluded

La septostomía auricular en pacientes con hipertensión arterial pulmonar y predictores de alto riesgo trans procedimiento. Reporte de cinco procedimientos.

La hipertensión arterial pulmonar  es incurable. La farmacoterapia específica mejora calidad y expectativa de vida, pero en Cuba sólo disponemos del Sildenafilo. La septostomía auricular constituye último peldaño para enfrentarla. Objetivos: demostrar que la septostomía auricular puede ser una alternativa en el tratamiento de la HAP. Método: previo consentimiento informado de pacientes y familiares se realizó septostomía auricular siguiendo la técnica de Sandoval y cols. Presentamos los resultados de las primeras 5 septostomías balón realizadas en el Instituto de cardiología y cirugía cardiovascular de La Habana. Las pacientes  se encontraban en clase funcional IV de la OMS, 4 presentaban síncope. Post septostomía auricular, todas pasaron a clase II y desaparición de los síncopes.  Pre-proceder la presión media de aurícula derecha era > 20 mmHg en cuatro de las pacientes, con elementos de falla ventricular derecha (derrame pericárdico y ascitis). Post proceder se comprobó caída de la misma y mejoría de los signos de hipertensión venosa,  aumento del gasto cardiaco sistémico relacionado con el cortocircuito derecha-izquierda, creado por la septostomía y un descenso de la resistencia vascular sistémica y pulmonar total. Se produjeron 2 complicaciones menores trans-procedimiento. Conclusión: La SA, es un procedimiento factible en enfermos con HAP, mejora su calidad de vida

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 < 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

Sex-gender disparities in nonagenarians with acute coronary syndrome

Background: Acute coronary syndrome (ACS) remains one of the leading causes of mortality for women, increasing with age. There is an unmet need regarding this condition in a fast-growing and predominantly female population, such as nonagenarians. Hypothesis: Our aim is to compare sex-based differences in ACS management and long-term clinical outcomes between women and men in a cohort of nonagenarians. Methods: We included consecutive nonagenarian patients with ACS admitted at four academic centers between 2005 and 2018. The study was approved by the Ethics Committee of each center. Results: A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non-ST-segment elevation ACS and 307 (45%) with ST-segment elevation myocardial infarction (STEMI). Men presented a higher disease burden compared to women. Conversely, women were frailer with higher disability and severe cognitive impairment. In the STEMI group, women were less likely than men to undergo percutaneous coronary intervention (PCI) (60% vs. 45%; p = .01). Overall mortality rates were similar in both groups but PCI survival benefit at 1-year was greater in women compared to their male counterparts (82% vs. 68%; p = .008), persisting after sensitivity analyses using propensity-score matching (80% vs. 64%; p = .03). Conclusion: Sex-gender disparities have been observed in nonagenarians. Despite receiving less often invasive approaches, women showed better clinical outcomes. Our finding may help increase awareness and reduce the current gender gap in ACS management at any age

Incidence, morbidity and mortality, and management of acute coronary syndrome during the time of COVID-19 lockdown

ABSTRACT Introduction and objectives: During the lockdown due to the pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a decrease in the number of admissions due to acute coronary syndrome (ACS) was observed. The objective of our study was to evaluate the impact lockdown had on the incidence, morbidity and mortality, and management of ACS. Methods: A retrospective and multicenter study was conducted including patients admitted due to ACS from February 14 through June 24, 2020. Patients with acute myocardial infarction and coronary arteries without significant lesions were excluded. The following groups were established based on the period of admission: a) 1 month before lockdown; b) during lockdown; and c) 1 month after lockdown. The differences in mortality seen among the 3 groups were evaluated, as well as the temporal differences reported between symptom onset and the first medical contact (FMC). Results: a total of 634 patients were included (group a, 205; group b, 303, and group c, 126). A 41% decrease in the number of admissions due to ACS was observed during the first month of lockdown compared to the previous month, as well as diagnostic delay during this same period (group a, 66 minutes (45-180), group b, 120 minutes (60-240), and group c, 120 minutes (60-240), P = .007). However, a higher mortality rate during confinement was not reported (RR, 1.26; 95%CI, 0.53-2.97; P = .60). Conclusions: During lockdown, a remarkable decrease in the number of admissions due to ACS was observed, and although there was an increase in the time elapsed from symptom onset to the FCM in this period in patients with STEMI, the mortality rate was similar in the 3 groups studied

Incidencia, morbimortalidad y tratamiento del síndrome coronario agudo durante el confinamiento por COVID-19

RESUMEN Introducción y objetivos: Durante el confinamiento por la pandemia provocada por el coronavirus del síndrome respiratorio agudo grave de tipo 2 (SARS-CoV-2) se observó un descenso en los ingresos por síndrome coronario agudo (SCA). El objetivo de este estudio fue evaluar el impacto del confinamiento en la incidencia, la morbimortalidad y el manejo del SCA. Métodos: Estudio retrospectivo y multicéntrico, en el que se incluyeron los pacientes ingresados por SCA entre el 14 de febrero y el 24 de junio de 2020. Se excluyeron los pacientes con infarto agudo de miocardio y coronarias sin lesiones significativas. Se establecieron 3 grupos en función del periodo de ingreso: a) 1 mes antes del confinamiento; b) durante el confinamiento; y c) 1 mes después del confinamiento. Se evaluaron las diferencias en la mortalidad entre los 3 grupos, así como las diferencias temporales entre el inicio de los síntomas y el primer contacto médico. Resultados: Se incluyeron 634 pacientes (grupo A: 205; grupo B: 303; grupo C: 126). Se observó un descenso del 41% en los ingresos por SCA durante el primer mes del confinamiento respecto al mes previo, así como un retraso en el diagnóstico durante este mismo periodo: grupo A, 66 minutos (45-180); grupo B, 120 minutos (60-240); grupo C, 120 minutos (60-240) (p = 0,007). Sin embargo, no hubo mayor mortalidad durante el confinamiento (riesgo relativo, 1.26; intervalo de confianza del 95%, 0.53-2.97; p = 0,60). Conclusiones: Durante el confinamiento se produjo un marcado descenso en los ingresos por SCA y, a pesar de que se dilató el tiempo desde el inicio de los síntomas hasta el primer contacto médico en este periodo en los pacientes con SCA con elevación del segmento ST, la mortalidad fue similar en los 3 grupos estudiados