The Learning Curve in Percutaneous Repair of Paravalvular Prosthetic Regurgitation An Analysis of 200 Cases

ObjectivesThis study sought to assess the learning curve for percutaneous repair of paravalvular prosthetic regurgitation.BackgroundPercutaneous repair of prosthetic paravalvular regurgitation is a complex procedure. There is a paucity of data on the professional experience and tools needed to achieve optimal clinical outcomes.MethodsWe examined the chronological experience of 200 patients (age 66 ± 13 years; 57% men) who underwent percutaneous closure of paravalvular prosthetic regurgitation at our institution. A sequence number of the patient was assigned as a continuous variable for analysis.ResultsA total of 243 paravalvular defects (74% mitral; 26% aortic) were treated. Device delivery was successful in 92% with an average procedural time of 139 ± 47 min. The 30-day rate of major adverse cardiovascular events was 7%. With increased case experience and adoption of dedicated imaging and catheter techniques, there were decreases in procedural time, fluoroscopy time, contrast volume administered, length of hospital stay, and major adverse cardiovascular events. Procedural success remained unchanged throughout the experience. The predominant reason for procedural failure was prosthetic leaflet impingement, which accounted for 9 of 21 failed cases.ConclusionsIn this single-center experience, there was evidence of a learning curve that occurred with the adoption of dedicated techniques for catheter delivery and echocardiographic imaging. In experienced operators, the potential for prosthetic leaflet impingement is the predominant limitation of the procedure. These data have implications for physician training and performance in complex structural heart disease interventions

Outcome of Mildly Symptomatic or Asymptomatic Obstructive Hypertrophic Cardiomyopathy A Long-Term Follow-Up Study

ObjectivesThe purpose of this study was to characterize the prognosis of minimally symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM).BackgroundRecent data have suggested that obstruction may be present in the majority of HCM patients, irrespective of cardiac symptoms. The prognosis of minimally symptomatic obstructive HCM remains poorly defined.MethodsWe examined 544 consecutive adult patients (age 59 ± 16 years; 55% men) with obstructive HCM documented by Doppler echocardiography who were free of severe cardiac symptoms, and we performed clinical follow-up (median 9.3 years).ResultsThere was only a slight excess mortality of the cohort in comparison to the expected survival of a similar U.S. general population (10-year observed vs. expected survival, 69.3% vs. 71.9%; p = 0.04) and 46% of the deaths were attributable to noncardiac causes. However, there was a clear relation between increasing severity of the left ventricular outflow tract (LVOT) gradient and outcome. For patients with high resting gradients (Doppler peak velocity >4 m/s), survival was significantly impaired (53% at 10 years; p = 0.001 vs. expected), and death or severe symptoms occurred in 68% of these patients within 10 years after the initial evaluation. Conversely, there was no impairment of long-term survival for patients with less-severe resting obstruction. Independent predictors of mortality in the entire cohort were age, prior stroke, and LVOT gradient severity.ConclusionsPatients with obstructive HCM and mild or no symptoms have only slight excess mortality. However, patients with markedly elevated resting LVOT gradients are at a high risk of heart failure and death. These findings may have important implications for therapy, including the timing of septal reduction therapy

Meta-analysis of the impact of successful chronic total occlusion percutaneous coronary intervention on left ventricular systolic function and reverse remodeling

We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on left ventricular (LV) function.We performed a systematic review and meta-analysis of studies published between January 1980 and November 2017 on the impact of successful CTO PCI on LV function.A total of 34 observational studies including 2735 patients were included in the meta-analysis. Over a weighted mean follow-up of 7.9 months, successful CTO PCI was associated with an increase in LV ejection fraction by 3.8% (95%CI 3.0-4.7, P < 0.0001, I2 = 45%). In secondary analysis of 15 studies (1248 patients) that defined CTOs as occlusions of at least 3-month duration and reported follow-up of at least 3-months after the procedure, successful CTO PCI was associated with improvement in LV ejection fraction by 4.3% (95%CI [3.1, 5.6], P < 0.0001). In the 10 studies (502 patients) that reported LV end-systolic volume, successful CTO PCI was associated with a decrease in LV end-systolic volume by 4 mL, (95%CI -6.0 to -2.1, P < 0.0001, I2 = 0%). LV end-diastolic volume was reported in 9 studies with 403 patients and did not significantly change after successful CTO PCI (-2.3 mL, 95%CI -5.7 to 1.2 mL, P = 0.19, I2 = 0%).Successful CTO PCI is associated with a statistically significant improvement in LV ejection fraction and decrease in LV end-systolic volume, that may reflect a beneficial effect of CTO recanalization on LV remodeling. The clinical implications of these findings warrant further investigation

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease

The recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted as the document was compiled through December 2008. Repeated literature searches were performed by the guideline development staff and writing committee members as new issues were considered. New clinical trials published in peer-reviewed journals and articles through December 2011 were also reviewed and incorporated when relevant. Furthermore, because of the extended development time period for this guideline, peer review comments indicated that the sections focused on imaging technologies required additional updating, which occurred during 2011. Therefore, the evidence review for the imaging sections includes published literature through December 2011

Percutaneous treatment for native mitral regurgitation

Severe mitral regurgitation (MR) confers an adverse prognosis, frequently with debilitating symptoms of heart failure. While open surgical correction has been the standard of care for decades, novel catheter-based technologies have emerged that are highly effective in the treatment of MR. These percutaneous technologies, which include methods for both repair as well as valve replacement, have the potential to address unmet clinical needs in patients with MR, and serve as a viable alternative to surgery