Effect of Mitral Valve Gradient After MitraClip on Outcomes in Secondary Mitral Regurgitation: Results From the COAPT Trial.

OBJECTIVES: The authors sought to evaluate the association between mean mitral valve gradient (MVG) and clinical outcomes among patients who underwent MitraClip treatment for secondary mitral regurgitation (SMR) in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial. BACKGROUND: In the COAPT trial, patients with heart failure (HF) and severe SMR who remained symptomatic despite guideline-directed medical therapy had marked 2-year reductions in mortality and HF hospitalizations after treatment with MitraClip. METHODS: MitraClip-treated patients were divided into quartiles (Q) based on discharge echocardiographic MVG (n = 250). Endpoints including all-cause mortality, HF hospitalization, and health status measures at 2 years were compared between quartiles. RESULTS: Mean MVG after MitraClip was 2.1 ± 0.4 mm Hg, 3.0 ± 0.2 mm Hg, 4.2 ± 0.5 mm Hg, and 7.2 ± 2.0 mm Hg in Q1 (n = 63), Q2 (n = 61), Q3 (n = 62), and Q4 (n = 64), respectively. There was no difference across quartiles in the 2-year composite endpoint of all-cause mortality or HF hospitalization (43.2%, 49.2%, 40.6%, and 40.9%, respectively; p = 0.80), nor in improvements in New York Heart Association functional class, Kansas City Cardiomyopathy Questionnaire score, or 6-min walk time. Results were similar after adjustment for baseline clinical and echocardiographic characteristics, post-procedure MR grade, and number of clips (all-cause mortality or HF hospitalization Q4 [44.6%] vs. Q1 to Q3 [40.3%]; adjusted hazard ratio: 1.23, 95% confidence interval: 0.60 to 2.51; p = 0.57). CONCLUSIONS: Among HF patients with severe SMR, higher MVGs on discharge did not adversely affect clinical outcomes following MitraClip. These findings suggest that in select patients with HF and SMR otherwise meeting the COAPT inclusion criteria, the benefits of MR reduction may outweigh the effects of mild-to-moderate mitral stenosis after MitraClip.

Instabilities in Aortic Length After TEVAR and Reoperation: 12 Years of Follow-Up Imaging.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) remains an important minimally invasive tool for the treatment of descending thoracic aneurysm. The long-term effects of these repairs in reduction of the aneurysmal sac size as well as stability of the stented portion require study. We report the results of 12 years of radiographic follow-up. METHODS: All patients who underwent TEVAR for descending thoracic aneurysms from January 2005 to December 2017(n = 371) were evaluated for immediate postoperative and follow-up computed tomographic scans suitable for 3-dimensional reconstruction of the aorta (excluding those with an interim reoperation). We found 62 patients who met these criteria (median duration of radiographic follow-up, 1.8 years). Measurements were taken of centerline, greater and lesser curvatures from the most distal patent brachiocephalic vessel to the first uncovered mesenteric vessel, and between proximal and distal edges of the stented portion of the aorta. RESULTS: All measured segments, except covered length, were significantly increasing in length for centerline, greater and lesser curvatures, with a median increase of 7.6 mm (interquartile range, 1.7-16 mm). Cox regression for mortality and reoperation found no significant correlation between these changes and mortality and a significant correlation between stented segment greater curvature increase and reoperation (adjusted hazard ratio, 1.06; P < .05). CONCLUSIONS: Increases in the centerline and greater curve length of the aorta were found to be occurring. This appears to be primarily driven by growth in the nonstented segments. However, changes in the outer curve length of the stented segment were associated with a greater risk of reoperation.

Central Repair With Antegrade TEVAR for Malperfusion Syndromes in Acute Debakey I Aortic Dissection.

BACKGROUND: In acute DeBakey I aortic dissection presenting with malperfusion syndromes, we assessed whether standard open repair with concomitant antegrade stent grafting (thoracic endovascular aneurysm repair; TEVAR) of the descending thoracic aorta (DTA) improves outcomes compared with standard repair alone. METHODS: From 2005 to 2012, 277 patients with acute DeBakey I dissection underwent emergent operation. Of these, 104 patients (37%) presenting with end-organ malperfusion were divided into those undergoing standard distal repair entailing transverse hemiarch replacement (Standard group, n = 65) versus standard repair with concomitant DTA TEVAR during circulatory arrest (TEVAR group, n = 39). Prospectively maintained aortic dissection database was retrospectively reviewed. RESULTS: Demographic characteristics and preoperative comorbidities were similar. Circulatory arrest (56 ± 12 versus 34 ± 14 minutes, p < 0.001) and cross-clamp (176 ± 43 versus 119 ± 80, p = 0.001) times were longer in the TEVAR group. Overall, postoperative stroke rate (5% [n = 2] versus 6% [n = 4], p = 1), paraplegia rate (5% [n = 2] versus 5% [n = 3], p = 1.0), and renal failure rate (10% [n = 4] versus 22% [n = 14], p = 0.2) were similar. In-hospital/30-day mortality rate was lower in the TEVAR group but was not significant (18% (n = 7) versus 34% [n = 22], p = 0.1). In patients presenting with malperfusion involving greater than one end-organ system, the mortality rate was significantly improved in the TEVAR group (28% [n = 6] versus 58% [n = 14], p = 0.05). CONCLUSIONS: Standard repair with antegrade TEVAR of the DTA for acute DeBakey I aortic dissection presenting with malperfusion syndromes can be safely performed. Further, true lumen stabilization achieved through DTA TEVAR may provide a survival benefit in patients with distal multiorgan malperfusion.

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair.

BACKGROUND: There remains concern that moderate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) may provide suboptimal distal organ protection compared with deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (RCP). We compared postoperative acute kidney injury (AKI) in in patients who underwent elective hemiarch repair with either DHCA/RCP or MHCA/ACP. METHODS: This was a retrospective review of all patients undergoing elective aortic hemiarch reconstruction for aneurysmal disease between 2009 and 2014. Patients were stratified according to the use of DHCA/RCP versus MHCA/ACP. The primary outcome was the occurrence of AKI at 48 hours, as defined by the Risk, Injury, Failure, Loss, End-Stage (RIFLE ) criteria. A multivariable logistic regression identified risk factors for AKI. RESULTS: One hundred eighteen patients who underwent ACP and 471 patients who underwent RCP were included. The mean lowest temperature was 26.4°C in patients who underwent MHCA/ACP and 17.5°C in patients who underwent DHCA/RCP. Baseline demographics were similar except that patients who underwent DHCA/RCP were more likely to have peripheral arterial disease or bicuspid aortic valves. Cardiopulmonary bypass and aortic cross-clamp times were shorter in the MHCA/ACP group. AKI occurred in 19 (16.2%) patients who underwent MHCA/ACP and 67 (14.3%) patients who underwent DHCA/RCP. Four (0.8%) patients who underwent DHCA/RCP required postoperative dialysis. In-hospital mortality tended to increase with increasing RIFLE classification (RIFLE class-0 (No AKI) = 0.41%; Risk = 1.35%, and Injury = 10.0%; p = 0.09). On multivariable analysis, the lowest temperature and cerebral perfusion strategy were not significant predictors of AKI. Lower baseline glomerular filtration rate (GFR), lower preoperative ejection fraction, and longer cardiopulmonary bypass (CPB) time were independently associated with higher AKI. CONCLUSIONS: We applied the sensitive RIFLE criteria to examine AKI in patients undergoing elective aortic hemiarch replacement for aneurysmal disease. Baseline renal dysfunction, lower ejection fraction, and longer CPB time are independent predictors of AKI. Compared with DHCA/RCP, our data suggest that an MHCA/ACP cerebral protection strategy does not appear to be associated with worse postoperative renal outcomes.