Implementing Formal Mitral Heart Team Improves Multidisciplinary Evaluation Rate and Survival of Patients With Severe Primary Mitral Regurgitation.

BACKGROUND: Multidisciplinary heart team (HT) evaluation is recommended for patients with severe primary mitral regurgitation to optimize treatment decisions. However, its impact on patient outcomes remains unknown. We evaluated the impact of implementing mitral HT on patient survival. METHODS AND RESULTS: We conducted a retrospective cohort study of patients with new diagnoses of severe primary mitral regurgitation in a large healthcare network echocardiogram database between 2016 and 2020. We compared the incidence of multidisciplinary evaluation by structural cardiology and cardiac surgery services and 2-year survival before and after mitral HT implementation. The 1:1 propensity-score matching between pre- and post-mitral HT used Society of Thoracic Surgeons Predicted Risk of Mortality for mitral repair, age, sex, race, heart failure symptoms, inpatient setting, history of MI, and dementia as covariates. Logistic regression identified variables associated with the likelihood of undergoing multidisciplinary evaluation. Among 70 510 echocardiograms performed, 391 patients had severe primary mitral regurgitation (median age, 77 years; 46% women). Multidisciplinary evaluation increased from 29% to 89% (P<0.001), and intervention increased from 24% to 75% following mitral HT implementation (P<0.001). Among 180 propensity-score matched patients, mortality was lower post-mitral HT at 2 years (19% versus 32%, P=0.04). The multivariable model showed that mitral HT implementation and heart failure symptoms were associated with higher odds of undergoing multidisciplinary evaluation (OR [odds ratio], 18.7 and 2.72, respectively), whereas female sex and older age were associated with lower odds (OR, 0.39 and 0.93, respectively). CONCLUSIONS: Implementation of mitral HT was associated with drastic improvement in multidisciplinary evaluation for patients with severe primary mitral regurgitation. This coincided with higher proportions of patients undergoing mechanical correction of MR and improved overall patient survival

The axial distribution of lesion-site atherosclerotic plaque components: An in vivo volumetric intravascular ultrasound radiofrequency analysis of lumen stenosis, necrotic core, and vessel remodeling

Coronary atherosclerosis is an inflammatory process characterized by lipid accumulation in the vessel intima, an overlying fibrous cap, and a variable amount of lipid and necrotic cellular debris at its core. Percutaneous intravascular ultrasound (IVUS) uses a 3F imaging catheter to provide realtime, in vivo, cross-sectional images of the arterial wall, lumen, and plaque. Radiofrequency analysis of IVUS data characterizes atherosclerotic plaques into necrotic core (NC), dense calcium (DC), fibrofatty (FF), and fibrotic (FI) tissue. We hypothesized that the minimum lumen area (MLA) site will have a different Virtual Histology (VH) IVUS signature than sites proximal or distal. Pre-intervention VH-IVUS was performed in 81 patients (90 de novo lesions: 43 LAD and 47 RCA). Plaque burden, remodeling index, and VH-IVUS plaque composition were assessed throughout the lesion and reference segments as well as at the MLA and maximum (MaxNC) sites. A catheter pullback length of 31.1±12.0mm was used to span a lesion length of 13.8±9.5mm. The MaxNC site was located at the MLA in 3.3% of lesions, proximal to the MLA in 61% of lesions (by 4.11mm) and distal to the MLA in 35.6% of lesions (by 3.56mm). The %DC was greater at the MaxNC and %FI and %FF plaque were less at the MaxNC than at the MLA site. Lesion fibroatheromas (FAs) were more often detected at the MaxNC than the MLA (96% vs 51%) and were more often classified as thin-capped or multilayered than the MLA sites. The remodeling index was greater at the MaxNC than at the MLA sites and correlated with the NC area both at the MLA (r2 0.068, p=0.013) and at the MaxNC (r2 0.074, p=0.009). A greater %DC was found in negatively remodeled vessels at the MLA. In summary, greyscale and VH-IVUS show that the site of greatest potential instability (largest NC and remodeling) is rarely at the MLA, but is most often proximal to the MLA. Also, necrotic core on VH is correlated with remodeling index. These in vivo findings are consistent with previously reported histopathologic data and have important implications for the detection and treatment of coronary artery disease

Fusion Imaging Guidance for Coronary Reaccess After Valve-in-Valve Transcatheter Aortic Valve Replacement

Coronary reaccess can be difficult after valve-in-valve transcatheter aortic valve replacement. We present a case whereby prior valve-in-valve transcatheter aortic valve replacement created difficulty with coronary reaccess. Computed tomography-fluoroscopy fusion imaging was used for guidance to successfully engage the coronary arteries and perform percutaneous coronary intervention

Transcatheter Mitral Valve Replacement: Procedural Planning, Utility, and Applicability

Since the first native transcatheter mitral valve implantation in 2012, transcatheter mitral valve replacement (TMVR) has expanded its use to degenerated bioprostheses, failed annuloplasty ring repair, and mitral annular calcification. However, high-screen failure rates in trials have persisted due to predicted left ventricular outflow tract obstruction and unfavorable anatomy. Preprocedural planning in this patient population with multidetector computed tomography and transesophageal echocardiography is paramount to intraprocedural success. In patients with favorable left ventricular outflow tract anatomy who are not surgical candidates, the transseptal approach is preferred. In those who are surgical candidates, TMVR can be performed via a transapical or transatrial approach. Currently, a plethora of TMVR devices targeting the native mitral pathologies are undergoing clinical trials. Data have consistently shown the greatest benefit of this procedure in native mitral regurgitation and failed bioprostheses rather than failed annuloplasty rings or mitral annular calcification. With technological advancement and careful patient selection, this therapy will serve as a complement to surgical and TMV repair and will continue to expand to address MV diseases in a broader patient population