Prosthesis–Patient Mismatch in Patients Undergoing Transcatheter Aortic Valve Replacement
http://www.onlinejacc.org/content/72/22/2701
On the basis of the discharge echocardiographic effective valve area indexed to body surface area, PPM was classified as severe (<0 .65="" 0.85="" cm2="" m2="" moderate="" none="" or="" to="">0.85 cm2/m2).
Severe and moderate PPM were present following TAVR in 12% and 25% of patients, respectively.
Severe PPM after TAVR was present in 12% of patients and was associated with higher mortality and HF rehospitalization at 1 year.
Generally, PPM after SAVR doesn't matter. Moreover, PPM might be thought as old fashion in new prosthetic aortic valve (Crown and Trifecta) era.
It seems that severe PPM after SAVR and TAVI is quite different.
It might be reason why the incidence of severe PPM after TAVI is generally less than SAVR.
2018年12月31日月曜日
2018年12月28日金曜日
Functional Mitral Regurgitation: Therapeutic Strategies for a Ventricular Disease
Functional Mitral Regurgitation: Therapeutic Strategies for a Ventricular Disease
J Cardiac Fail 2014;20:252 -267
ABSTRACT
Functional mitral regurgitation is a highly prevalent condition among patients with ischemic and dilated cardiomyopathies. Arising from remodeling of both the mitral valve annulus and the left ventricle, it is associated with high mortality and morbidity. In selected patients, cardiac resynchronization therapy helps to reduce functional mitral regurgitation, but surgical intervention remains the mainstay of therapy when medical therapy for left ventricular dysfunction has been inadequate. It is, however, associated with significant perioperative risks and does not alter long-term mortality. Percutaneous devices, and more recently the Mitraclip in particular, represent a promising alternative that can improve symptoms and ventricular remodeling with significantly lower periprocedural risk.
It remains unclear whether fMR repair is beneficial to this ventricular-valvular disease paradigm.
Current ACC/AHA and ESC guidelines do not make a distinction in recommended diagnostic modalities or in classification schema for severity, between fMR and
other etiologies of MR.
Medical therapy is limited in its ability to fully correct fMR.
CRT specifically targets myocardial dyssynchrony, which can be especially pronounced in those patients with segmental wall motion abnormalities and contributes to fMR.
MV surgery significantly reduces or eliminates fMR, reduces LV dimensions, and improves symptoms, but it is also associated with periprocedural complications,
such as mortality, bleeding, stroke, and renal dysfunction, and provides no clear long-term mortality benefit. There have been no randomized trials to compare the effectiveness of different surgical repair techniques.
Although there have been no prospective studies comparing the effects of MV surgery alone with the combination procedure of valve surgery and SVR, the combination procedure allowed for more consistent reduction in fMR but not
mortality, and they are accompanied by high perioperative risk.
Edge-to-Edge Repair (Mitraclip) corrects fMR with significantly lower periprocedural risk.
J Cardiac Fail 2014;20:252 -267
ABSTRACT
Functional mitral regurgitation is a highly prevalent condition among patients with ischemic and dilated cardiomyopathies. Arising from remodeling of both the mitral valve annulus and the left ventricle, it is associated with high mortality and morbidity. In selected patients, cardiac resynchronization therapy helps to reduce functional mitral regurgitation, but surgical intervention remains the mainstay of therapy when medical therapy for left ventricular dysfunction has been inadequate. It is, however, associated with significant perioperative risks and does not alter long-term mortality. Percutaneous devices, and more recently the Mitraclip in particular, represent a promising alternative that can improve symptoms and ventricular remodeling with significantly lower periprocedural risk.
It remains unclear whether fMR repair is beneficial to this ventricular-valvular disease paradigm.
Current ACC/AHA and ESC guidelines do not make a distinction in recommended diagnostic modalities or in classification schema for severity, between fMR and
other etiologies of MR.
Medical therapy is limited in its ability to fully correct fMR.
CRT specifically targets myocardial dyssynchrony, which can be especially pronounced in those patients with segmental wall motion abnormalities and contributes to fMR.
MV surgery significantly reduces or eliminates fMR, reduces LV dimensions, and improves symptoms, but it is also associated with periprocedural complications,
such as mortality, bleeding, stroke, and renal dysfunction, and provides no clear long-term mortality benefit. There have been no randomized trials to compare the effectiveness of different surgical repair techniques.
Although there have been no prospective studies comparing the effects of MV surgery alone with the combination procedure of valve surgery and SVR, the combination procedure allowed for more consistent reduction in fMR but not
mortality, and they are accompanied by high perioperative risk.
Edge-to-Edge Repair (Mitraclip) corrects fMR with significantly lower periprocedural risk.
2018年12月27日木曜日
Pulmonary Hypertension
Pulmonary Hypertension
Two blood flow patterns of PH with different prognoses have been reported in patients with heart failure. In the most common, called post-capillary PH (IpcPH), PH is solely caused by increased left-sided filling pressures. However, 10-15% of patients have both pre- and post-capillary PH (CpcPH), characterized by high filling pressures and a pulmonary vascular component.
This form of PH has similarities with pulmonary arterial hypertension, and is defined by a combined elevation of mean pulmonary artery wedge pressure (mPAWP), a measure of pressure in the upper left heart chamber, or atrium; pulmonary vascular resistance (PVR), reflecting changes in arteries that supply blood to the lungs; and/or diastolic pressure gradient (DPG), which is the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressure.
Old
Transpulmonary pressure gradient（TPG：mean PAP － mean PAWP)
12< CpcPH, 12> IpcPH
New
Diastolic pressure gradient (DPG : diastolic PAP - mean PAWP)
7< CpcPH, 7> IpcPH
PVR ＞ 3.0 Wood CpcPH, PVR ≦ 3.0 Wood IpcPH
Prognosis
CpcPH BAD
IpcPH better
Two blood flow patterns of PH with different prognoses have been reported in patients with heart failure. In the most common, called post-capillary PH (IpcPH), PH is solely caused by increased left-sided filling pressures. However, 10-15% of patients have both pre- and post-capillary PH (CpcPH), characterized by high filling pressures and a pulmonary vascular component.
This form of PH has similarities with pulmonary arterial hypertension, and is defined by a combined elevation of mean pulmonary artery wedge pressure (mPAWP), a measure of pressure in the upper left heart chamber, or atrium; pulmonary vascular resistance (PVR), reflecting changes in arteries that supply blood to the lungs; and/or diastolic pressure gradient (DPG), which is the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressure.
Old
Transpulmonary pressure gradient（TPG：mean PAP － mean PAWP)
12< CpcPH, 12> IpcPH
New
Diastolic pressure gradient (DPG : diastolic PAP - mean PAWP)
7< CpcPH, 7> IpcPH
PVR ＞ 3.0 Wood CpcPH, PVR ≦ 3.0 Wood IpcPH
Prognosis
CpcPH BAD
IpcPH better
2018年12月24日月曜日
Cost-Effectiveness of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis at Intermediate Risk: Results From the PARTNER 2 Trial
https://www.ctsnet.org/jans/cost-effectiveness-transcatheter-versus-surgical-aortic-valve-replacement-patients-severe?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F21%2F2018
Cost-effective analysis of TAVR versus SAVR in 3110 intermediate-risk aortic stenosis patients from the PARTNER-2 trial
Costs were ~$20,000 higher with TAVR than SAVR.
Total cost differences for the index hospitalization were
only $2888 higher with XT-TAVR (p=0.014) and
$4155 lower with S3-TAVR (p<0 .001="" nbsp="" p="">owing to reductions in length of stay with TAVR.
Follow-up costs were significantly lower with XT-TAVR (△-$9304; p<0 .001="" and="" compared="" nbsp="" p="" s3-tavr="" savr.="" with="">
Over a lifetime horizon, TAVR was projected to lower total costs by $8000-$10,000 and to increase quality-adjusted survival by 0.15-0.27 years.
XT-TAVR and S3-TAVR were found to be economically dominant compared with SAVR in 84% and 97% of bootstrap replicates, respectively.
Q
TAVR Durability is same as SAVR? We'll see.
If the durability of TAVR is inferior, the results might be changed.
https://www.ctsnet.org/jans/cost-effectiveness-transcatheter-versus-surgical-aortic-valve-replacement-patients-severe?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F21%2F2018
Cost-effective analysis of TAVR versus SAVR in 3110 intermediate-risk aortic stenosis patients from the PARTNER-2 trial
Costs were ~$20,000 higher with TAVR than SAVR.
Total cost differences for the index hospitalization were
only $2888 higher with XT-TAVR (p=0.014) and
$4155 lower with S3-TAVR (p<0 .001="" nbsp="" p="">owing to reductions in length of stay with TAVR.
Follow-up costs were significantly lower with XT-TAVR (△-$9304; p<0 .001="" and="" compared="" nbsp="" p="" s3-tavr="" savr.="" with="">
Over a lifetime horizon, TAVR was projected to lower total costs by $8000-$10,000 and to increase quality-adjusted survival by 0.15-0.27 years.
XT-TAVR and S3-TAVR were found to be economically dominant compared with SAVR in 84% and 97% of bootstrap replicates, respectively.
Q
TAVR Durability is same as SAVR? We'll see.
If the durability of TAVR is inferior, the results might be changed.
2018年12月21日金曜日
“Respect When You Can, Resect When You Should”: A Realistic Approach to Posterior Leaflet Mitral Valve Repair
“Respect When You Can, Resect When You Should”: A Realistic Approach to Posterior Leaflet Mitral Valve Repair
https://www.ctsnet.org/jans/%E2%80%9Crespect-when-you-can-resect-when-you-should%E2%80%9D-realistic-approach-posterior-leaflet-mitral-valve?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
J Thorac Cardiovasc Surg 2018;156:1856-66
“respect when you can, resect when you should” concept
Resection was performed only if an excess tissue in height or width was present. The excess tissue in height was treated if P2, after a complete unfolding, was twice as high than P1 or P3. In such cases, a transverse resection of P2 was performed to bring it to approximately the same height as P1 and P3 (P2 being slightly higher than P1 and P3 in a normal valve).
This usually removes the rough area that was thickened. During this
operative step, great care was taken to individualize the secondary, and
even marginal, chordae that were at the adequate length (when compared
with the reference point) to resuspend the new free edge of P2. As far as
the excess in width is concerned, it was treated and carried out each time
there was an obvious and natural transverse folding of the leaflet. The
most objective way to evaluate such an excess of tissue in width was to
lay P2 on the posterior ventricular wall and to see if there was any natural
folding. When this happened, a small triangular resection was performed,
the base of the triangle being at the level of the free edge and the apex at the
annulus. A small resection was often effective in eliminating the excess
transverse tissue without putting the posterior leaflet (PL) under tension
2005 - 2015
701 consecutive severe mitral regurgitation
441 degenerative: 376 posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments)
aged 65.8 ± 13 years, and 70.5% were male.
Median follow-up was 61.1 months.
There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%).
After 1, 5, and 10 years,
overall survival was 97.8%, 93.6%, and 86.7%
recurrent/residual >2+ mitral regurgitation was 0.7%, 1.9%, and 5.9%
New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%.
https://www.ctsnet.org/jans/%E2%80%9Crespect-when-you-can-resect-when-you-should%E2%80%9D-realistic-approach-posterior-leaflet-mitral-valve?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
J Thorac Cardiovasc Surg 2018;156:1856-66
“respect when you can, resect when you should” concept
Resection was performed only if an excess tissue in height or width was present. The excess tissue in height was treated if P2, after a complete unfolding, was twice as high than P1 or P3. In such cases, a transverse resection of P2 was performed to bring it to approximately the same height as P1 and P3 (P2 being slightly higher than P1 and P3 in a normal valve).
This usually removes the rough area that was thickened. During this
operative step, great care was taken to individualize the secondary, and
even marginal, chordae that were at the adequate length (when compared
with the reference point) to resuspend the new free edge of P2. As far as
the excess in width is concerned, it was treated and carried out each time
there was an obvious and natural transverse folding of the leaflet. The
most objective way to evaluate such an excess of tissue in width was to
lay P2 on the posterior ventricular wall and to see if there was any natural
folding. When this happened, a small triangular resection was performed,
the base of the triangle being at the level of the free edge and the apex at the
annulus. A small resection was often effective in eliminating the excess
transverse tissue without putting the posterior leaflet (PL) under tension
2005 - 2015
701 consecutive severe mitral regurgitation
441 degenerative: 376 posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments)
aged 65.8 ± 13 years, and 70.5% were male.
Median follow-up was 61.1 months.
There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%).
After 1, 5, and 10 years,
overall survival was 97.8%, 93.6%, and 86.7%
recurrent/residual >2+ mitral regurgitation was 0.7%, 1.9%, and 5.9%
New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%.
2018年12月20日木曜日
Outcomes Following Surgical Revascularization With Single Versus Bilateral Internal Thoracic Arterial Grafts in Patients With Left Main Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting: Insights From the EXCEL Trial
Outcomes Following Surgical Revascularization With Single Versus Bilateral Internal Thoracic Arterial Grafts in Patients With Left Main Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting: Insights From the EXCEL Trial
Eur J Cardiothorac Surg. 2018 Aug 27. doi: 10.1093/ejcts/ezy291.
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The unadjusted 3-year composite primary endpoint of
death, stroke or myocardial infarction (MI) 15.6% of SITA = 11.6% of BITA
all-cause death 6.7% = 3.3%
Sternal wound dehiscence within 30 days 1.8% = 2.2% !!!
CONCLUSIONS:
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
Eur J Cardiothorac Surg. 2018 Aug 27. doi: 10.1093/ejcts/ezy291.
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The unadjusted 3-year composite primary endpoint of
death, stroke or myocardial infarction (MI) 15.6% of SITA = 11.6% of BITA
all-cause death 6.7% = 3.3%
Sternal wound dehiscence within 30 days 1.8% = 2.2% !!!
CONCLUSIONS:
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
2018年12月9日日曜日
Outcomes Following Surgical Revascularization With Single Versus Bilateral Internal Thoracic Arterial Grafts in Patients With Left Main Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting: Insights From the EXCEL Trial
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
SITA vs. BITA
The EXCEL trial randomized 1905 patients with LMT coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The BITA group
younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020)
less likely female (24.3% vs 14.3%, P = 0.002)
diabetic (28.8% vs 15.2%, P < 0.001)
a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040).
The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17).
The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070).
Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups.
After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71–1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60–3.12; P = 0.46) was significantly higher with SITA.
The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93–1.74; P = 0.13).
Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99).
CONCLUSIONS
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
The selection of SITA or BITA was not randamized.
So probably SITA group had more likely complicated pts and worse results.
It seems to me that no differences and more comfortable with BITA due to less anastomosis.
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
SITA vs. BITA
The EXCEL trial randomized 1905 patients with LMT coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The BITA group
younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020)
less likely female (24.3% vs 14.3%, P = 0.002)
diabetic (28.8% vs 15.2%, P < 0.001)
a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040).
The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17).
The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070).
Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups.
After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71–1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60–3.12; P = 0.46) was significantly higher with SITA.
The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93–1.74; P = 0.13).
Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99).
CONCLUSIONS
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
The selection of SITA or BITA was not randamized.
So probably SITA group had more likely complicated pts and worse results.
It seems to me that no differences and more comfortable with BITA due to less anastomosis.
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