Tricuspid edge-to-edge repair for tricuspid valve prolapse and flail leaflet: feasibility in comparison to patients with secondary tricuspid regurgitation.

AIMS: Transcatheter tricuspid edge-to-edge repair (T-TEER) has gained widespread use for the treatment of tricuspid regurgitation (TR) in symptomatic patients with high operative risk. Although secondary TR is the most common pathology, some patients exhibit primary or predominantly primary TR. Characterization of patients with these pathologies in the T-TEER context has not been systematically performed. METHODS AND RESULTS: Patients assigned to T-TEER by the interdisciplinary heart team were consecutively recruited in two European centres over 4 years. Echocardiographic images were evaluated to distinguish between primary and secondary causes of TR. Both groups were compared concerning procedural results. A total of 339 patients were recruited, 13% with primary TR and 87% with secondary TR. Patients with primary TR had a smaller right ventricle (basal diameter 45 vs. 49 mm, P = 0.004), a better right ventricular function (fractional area change 45 vs. 41%, P = 0.001), a smaller right (28 vs. 34 cm2, P = 0.021) and left (52 vs. 67 mL/m2, P = 0.038) atrium, and a better left ventricular ejection fraction (60 vs. 52%, P = 0.005). The severity of TR was similar in primary and secondary TR at baseline (TR vena contracta width pre-interventional 13 ± 4 vs. 14 ± 5 mm, P = 0.19), and T-TEER significantly reduced TR in both groups (TR vena contracta width post-interventional 4 ± 3 vs. 5 ± 5 mm, P = 0.10). These findings remained stable after propensity score matching. Complications were similar between both groups. CONCLUSION: T-TEER confers equally safe and effective reduction of TR in patients with primary and secondary TR.

Transcatheter tricuspid valve edge-to-edge repair after a heart transplant: a single-centre experience with a novel therapy†.

OBJECTIVES: Tricuspid regurgitation (TR) in patients who had heart transplants is associated with poor outcome. The increased risk for surgical and postoperative complications might be reduced in these vulnerable patients by transcatheter therapies. METHODS: All patients with a prior heart transplant (HTX) undergoing transcatheter edge-to-edge repair in the tricuspid position (T-TEER) were prospectively enrolled in an institutional registry. RESULTS: Seven patients who had heart transplants (5/7 female) at a mean age of 53 [48; 64] and median TRI-SCORE of 14 [7; 22] underwent T-TEER to treat symptomatic TR ≥ IV in an elective (n = 6) and urgent (n = 1) setting, respectively. The median time from HTX to T-TEER was 13 years. A total of 2 (n = 4) and 3 (n = 3) clips were implanted with a technical success in 6/7 (one single- device detachment). TR reduction was effective and durable within a median echocardiographic follow-up time of 10 months (TR baseline vs last follow-up: P = 0.03). Further, significant right ventricular remodelling (right ventricular end-diastolic diameter: 50 mm-36 mm, P = 0.02), decrease in the inferior vena cava diameter (24 mm-18 mm, P = 0.04) and in the gamma-glutamyl-transferase (255 U/l-159 U/l, P = 0.04) was found. Four of 7 patients were free of cardiovascular death (n = 1, 267 days after T-TEER), cardiac redo surgery (n = 1) and heart failure hospitalization (n = 2) and had no further clinical signs of right heart failure. CONCLUSIONS: T-TEER after HTX is feasible and effective regarding TR reduction in a short-term follow-up. The initial results may pave the way for a novel approach in TR management in patients having HTX.

Treating Recurrent Tricuspid Regurgitation and Iatrogenic Atrial Septal Defect.

Heterotopic caval valve implantation may be a reasonable option for alleviating symptoms in select high-risk patients with recurrent tricuspid regurgitation after failed interventional tricuspid valve repair. However, altered right atrial hemodynamic status should be considered in procedural planning to avoid potential right-left shunting in cases of septal defects. (Level of Difficulty: Advanced.).

Off-label transapical beating-heart transcatheter mitral valve replacement in severe mitral annular calcification.

The recent CE mark approval of a novel transapical transcatheter beating-heart replacement system, anchored by an apical pad, expanded the therapeutic options for patients with a significantly diseased mitral valve who are not eligible for conventional surgery. However, this self-expandable bioprosthesis is-despite promising data from the first European real-world experience-not approved for patients with severe mitral annular calcification. In this video tutorial, we provide a step-by-step description of an off-label transapical mitral valve replacement in a patient with severe degenerative mitral valve disease and limited alternative treatment options.

Invasive Hemodynamic Assessment and Procedural Success of Transcatheter Tricuspid Valve Repair-Important Factors for Right Ventricular Remodeling and Outcome.

Introduction: Severe tricuspid regurgitation (TR) is a common condition promoting right heart failure and is associated with a poor long-term prognosis. Transcatheter tricuspid valve repair (TTVR) emerged as a low-risk alternative to surgical repair techniques. However, patient selection remains controversial, particularly regarding the benefits of TTVR in patients with pulmonary hypertension (PH). Aim: We aimed to investigate the impact of preprocedural invasive hemodynamic assessment and procedural success on right ventricular (RV) remodeling and outcome. Methods: All patients undergoing TTVR with a TR reduction of ≥1 grade without precapillary or combined PH [mean pulmonary artery pressure (mPAP) ≥25 mmHg, mean pulmonary artery Wedge pressure ≤ 15 mmHg, pulmonary vascular resistance ≥3 Wood units] were assigned to the responder group. All patients with a TR reduction of ≥1 grade and precapillary or combined PH were classified as non-responders. Patients with a TR reduction ≥2 grade were directly classified as responders, and patients without TR reduction were directly assigned as non-responders. Results: A total of 107 patients were enrolled, 75 were classified as responders and 32 as non-responders. We observed evidence of significant RV reverse remodeling in responders with a decrease in RV diameters (-2.9 mm, p = 0.001) at a mean follow-up of 229 days (±219 SD) after TTVR. RV function improved in responders [fractional area change (FAC) + 5.7%, p < 0.001, RV free wall strain +3.9%, p = 0.006], but interestingly further deteriorated in non-responders (FAC -4.5%, p = 0.003, RV free wall strain -3.9%, p = 0.007). Non-responders had more persistent symptoms than responders (NYHA ≥3, 72% vs. 11% at follow-up). Subsequently, non-response was associated with a poor long-term prognosis in terms of death, heart failure (HF) hospitalization, and re-intervention after 2 years (freedom of death, HF hospitalization, and reintervention at 2 years: 16% vs. 78%, log-rank: p < 0.001). Conclusion: Hemodynamic assessment before TTVR and procedural success are significant factors for patient prognosis. The hemodynamic profiling prior to intervention is an essential component in patient selection for TTVR. The window for edge-to-edge TTVR might be limited, but timely intervention is an important factor for a better outcome and successful right ventricular reverse remodeling.

[Transcatheter mitral valve replacement : Indications, options, and techniques as well as important aspects for perioperative care]. / Interventioneller Mitralklappenersatz : Indikationen, Möglichkeiten und Technik sowie wichtige Aspekte für die perioperative Betreuung.

Transcatheter therapy of the mitral valve is more challenging compared to the aortic valve. Interventional therapy with the Mitra-Clip system, mimicking the surgical edge-to-edge repair, was first introduced in 2003 and received the CE mark in 2008. The first implantation of the Tendyne system, which is currently the only commercially available system for mitral valve replacement, was performed in 2014, and routine clinical use was approved in 2020. Several new valve platforms are in clinical development and will expand the treatment portfolio. This article will discuss the clinical indications, technical challenges and specific requirements for perioperative management.

Cefuroxime plasma and tissue concentrations in patients undergoing elective cardiac surgery: Continuous vs bolus application. A pilot study.

AIMS: Surgical site infections contribute to morbidity and mortality after surgery. The authors hypothesized that higher antibiotic tissue concentrations can be reached for a prolonged time span by continuous administration of prophylactic cefuroxime compared to bolus administration. METHODS: Twelve patients undergoing elective cardiac surgery were investigated. Group A received 1.5 g cefuroxime as bolus infusions before surgery, and 12 and 24 hours thereafter. In group B, a continuous infusion of 3.0 g cefuroxime was started after a bolus of 1.5 g. Cefuroxim levels were determined in blood and tissue (microdialysis). T-test, Wilcoxon signed rank test and χ2 test were used for statistical analysis. RESULTS: The area under the curve (AUC) of plasma cefuroxime concentrations was greater in group B (399 [333-518]) as compared to group A (257 [177-297] h mg L-1 , [median and interquartile range], P = .026). Furthermore, a significantly longer percentage of time > minimal inhibitory concentrations of 2 mg L-1 (100% vs 50%), 4 mg L-1 (100% vs 42%), 8 mg L-1 (100% vs 17%) and 16 mg L-1 (83% vs 8%) was found for free plasma cefuroxime in group B. In group B, area under the curve in subcutaneous tissue (78 [61-113] h mg L-1 ) and median peak concentration (33 [26-38] mg L-1 ) were markedly higher compared to group A (P = 0.041 and P = .026, respectively). CONCLUSIONS: Higher cefuroxime concentrations were measured in plasma and subcutaneously over a prolonged period of time when cefuroxime was administered continuously. The clinical implication of this finding still has to be elucidated.

A conclusion from the first 125 patients treated with the vacuum assisted closure system for postoperative sternal wound infection.

Consensus exists that early recognition of sternal wound infection is crucial to prevent involvement and destruction of the sternal bone, which prohibits secondary sternal closure and necessitates the use of muscle flaps for wound closure. Since November 2001 to September 2005, 125 patients received a VAC system after surgical debridement. Thirty-eight patients had a superficial infection (2A) and 87 patients had a deep infection (2B). From those, 59 patients underwent secondary sternal closure after VAC therapy, whereas 28 patients needed muscle flap closure. The time of diagnosis of sternal infection had great impact on the outcome. It was made on POD 10.6+/-8.3 in the 2A group, and on POD 13.2+/-11.1 in the 2B group. In the patients from Group 2A who had a recurrence of infection, the initial diagnosis of infection was made on POD 13.1+/-11.1. In patients where an SC was possible the time of diagnosis was on POD 11.1+/-6.6 whereas POD 17.7+/-16.2 in the MF group. The key to successful management of sternal wound infection is early recognition and aggressive treatment with reopening of the entire wound and sternum, which seems mandatory to achieve a low recurrence rate.

Effects of volatile anesthetics on elastic stiffness in isometrically contracting ferret ventricular myocardium.

The effects of halothane, isoflurane, and sevoflurane on elastic stiffness, which reflects the degree of cross-bridge attachment, were studied in intact cardiac muscle. Electrically stimulated (0.25 Hz, 25 degrees C), isometrically twitching right ventricular ferret papillary muscles (n = 15) at optimal length (L(max)) were subjected to sinusoidal length oscillations (40 Hz, 0.25- 0.50% of L(max) peak to peak). The amplitude and phase relationship with the resulting force oscillations was decomposed into elastic and viscous components of total stiffness in real time. Increasing extracellular Ca(2+) concentration in the presence of anesthetics to produce peak force equal to control increased elastic stiffness during relaxation, which suggests a direct effect of halothane and sevoflurane on cross bridges.