Mid-term repair durability after MitraClip implantation in patients with functional mitral regurgitation.

BACKGROUND: The aim of this study was to identify variables that are associated with the durability of percutaneous repair of secondary mitral regurgitation at 6-month follow-up. METHODS AND RESULTS: Thirty-five consecutive patients with functional mitral regurgitation scheduled for MitraClip implant were enrolled. Left ventricular (LV) volumes and function and mitral valve characteristics were assessed before and immediately after MitraClip implantation using three-dimensional transesophageal echocardiography. Five patients with an unsuccessful procedure were excluded. The other patients were subdivided according to repair durability: group 1 with a durable repair (19 patients, 65%) and group 2 with significant mitral regurgitation recurrence (11 patients, 35%). At baseline, group 1 patients had smaller and more elliptical mitral valve annulus (1055 ±â€Š241 vs. 1273 ±â€Š359 mm, P = 0.02 and 125 ±â€Š11 vs. 117 ±â€Š16%, P = 0.02), a smaller left atrial volume (54.1 ±â€Š26 vs. 71.5 ±â€Š20 ml, P = 0.005) and lower systolic pulmonary artery pressure (38 ±â€Š11 vs. 49 ±â€Š12 mmHg, P = 0.03). Baseline LV end systolic volume had a linear correlation with the 3D annulus area (P = 0.048) and an inverse correlation with annulus ellipticity (P = 0.021). Group 1 patients showed an increase in annulus ellipticity after MitraClip (125 ±â€Š17 vs. 141 ±â€Š23%, P = 0.014). CONCLUSION: Percutaneous mitral valve repair leads to a significant and stable mitral regurgitation reduction in a large number of patients. Annulus dimensions and remodeling as well as left atrial area and pulmonary hypertension seem to be associated with durability of the procedure.

2D/3D Echocardiographic features of patients with reverse remodeling after cardiac resynchronization therapy.

PURPOSE: To describe clinical and echocardiographic characteristics associated with reverse left ventricular (LV) remodeling after 6 months of cardiac resynchronization therapy (CRT) in patients with nonischemic dilated cardiomyopathy. METHODS: Twenty-four consecutive patients underwent 2D and 3D echocardiography before and after 6 months of CRT implant. Several echocardiographic parameters including global longitudinal strain (GLS) and 3D mechanical dyssynchrony (MD) index were calculated. CRT response was defined as a decrease in LV end-systolic volume (LVESV) of at least 10% at follow-up. Patients were divided in two groups according to CRT response. RESULTS: Cardiac resynchronization therapy responder (CRTR+) rate was 50%. Nonresponder (CRTR-) patients showed a less significant improvement in NYHA class at follow-up. At baseline, CRTR- presented with higher LV end-diastolic volume (LVEDV) (P = 0.031), LVESV (P = 0.024), lower left ventricular ejection fraction (LVEF) (P = 0.002) and less negative GLS (P = 0.03), and with higher diastolic dysfunction, more impaired right ventricle (RV), and higher pulmonary artery systolic pressure (PASP) (P = 0.002). No significant differences in echocardiographic parameters of MD were found. Univariate determinants of CRTR+ were LVEF (OR = 1.59, CI 95% = 1.13-2.22, P = 0.007) and TAPSE (OR 1.21, CI 95% = 1.024-1.429, P = 0.025). A ROC curve analysis showed a cutoff value of LVEF of 22.15% significantly related to CRTR+ (SE 80%, SP 50%). CONCLUSIONS: Our findings suggest that end-stage HF patients, presenting before CRT with LVEF <22.15%, may not benefit from the procedure after 6 months. Mechanical dyssyncronicity did not provide additional information to improve candidate selection.

2D/3D echocardiographic determinants of left ventricular reverse remodelling after MitraClip implantation.

AIMS: The aim of this study was to describe incidence and determinants of left ventricular reverse remodelling (r-LVR) at 6 months follow-up after MitraClip implantation in patients with secondary severe mitral regurgitation (MR) and reduced left ventricular ejection fraction (LVEF). METHODS AND RESULTS: Forty-five patients, undergoing MitralClip implantation with low ejection fraction and high surgical risk were enrolled in this study. Three of them died before the scheduled 6 months follow-up period and one patient had cardiac surgery due to MitraClip detachment. All patients underwent transthoracic 2D and 3D echocardiography before and 6 months after the procedure. A significant MR severity reduction and an improvement in New York Heart Association (NYHA) class were detected in all patients. The study population was divided in two groups according to the presence of r-LVR (51%, n = 23 patients) or not (non-rLVR group, 18 patients). Non-significant differences in MR aetiology and number of clips implanted were found. Left ventricular reverse remodelling patients showed significant lower values of logistic EuroSCORE and STS score, left ventricular end-diastolic volume index (LVEDV/i), right ventricular end systolic area, and pulmonary artery systolic pressure (PASp) at baseline evaluation. At multivariable analysis, baseline PASp value resulted to be the only independent predictor of r-LVR [odds ratio 95% confidence interval 0.94 (0.89-0.99), P = 0.021]. In r-LVR patients, a significant improvement in LVEF and global longitudinal strain and a reduction in left atrial volume index were detected after 6 months, whereas in non-rLVR subgroup a significant increase in both LVEDV/i and left ventricular end-systolic volume index was observed at follow-up. CONCLUSION: Even if a reduction of MR was detected in all patients after MitralClip implant, our findings suggest that end-stage patients presenting with higher left ventricular volumes, logistic scores, and PASp may not benefit from the procedure at longer follow-up in terms of left ventricular function.

Hidden in the heart: A peculiar type of left ventricular remodeling after acute myocardial infarction.

We reported an unusual case of left ventricular pouch, in a 72-year-old man who had an acute coronary syndrome treated with percutaneous revascularization. The echocardiogram showed a sort of pouch, delimited by epicardium and endocardium, confirmed by 3D echo. This finding appeared as an echo free area, with a really slight color flow inside. We consequently supposed it would be a dissecting hematoma, a rare complication of the ischemic disease, due to the rupture of the intramyocardial vessels among the spiral myocardial fibers. This would produce a hemorrhagic pouch contained by epicardial and endocardial layers, which could evolve into mural thrombi.

Significant increase of flow kinetic energy in "nonresponders" patients to cardiac resynchronization therapy.

BACKGROUNDS: It's still unclear if different patterns of intraventricular flow dynamics may be detected in patients nonresponders to cardiac resynchronization therapy (CRT) as compared to responders ones. Aim of this study was to evaluate the characteristics of left ventricular (LV) flow dynamics 6-months after CRT to identify Echo-particle imaging velocity (PIV) patterns were more frequently detected in nonresponders patients. METHODS: Thirty-two patients with dilated cardiomyopathy, undergoing CRT, were enrolled in this study. All patients underwent 2D and 3D echo and fluid dynamics assessment 6 months after CRT, during active CRT (CRT-ON) and during a temporarily discontinued state (CRT-OFF). LV volumes systolic and diastolic volumes (LVESV and LVEDV), ejection fraction (LVEF), global longitudinal strain (GLS), systolic dyssynchrony index (SDI), and several geometrical and functional Echo-PIV-derived parameters were calculated. Patients were divided in two groups: "responders" to CRT (decrease in LVESV>15% 6 months after CRT) and "nonresponders." RESULTS: During CRT-OFF, LVEF, GLS were lower, while SDI and LVESV were higher in nonresponders group (P=.030, P=.051, P=.035, and P=.025, respectively). Energy dissipation, vortex area, and vorticity fluctuation were higher in "nonresponders" patients during CRT-OFF (P=.038, P=.054, and P=.035, respectively). During CRT-ON, energy dissipation, vortex area, and vorticity fluctuation further increase in nonresponders patients (P=.020, P=.038, and P=.030, respectively) with a concomitant worsening of SDI (P=.045). CONCLUSION: Our data show a significant worsening in flow-derived parameters in CRT "nonresponders" patients as compared with responders. Further larger longitudinal studies are necessary to assess whether these more chaotic intraventricular flow-patterns may contribute to a persistent adverse remodeling observed in this subset of patients.

Value of two-dimensional longitudinal strains analysis to assess the impact of thrombus aspiration during primary percutaneous coronary intervention on left ventricular function: a speckle tracking imaging substudy of the EXPIRA trial.

BACKGROUND: Thrombectomy during primary percutaneous coronary intervention (Th-PCI) improves myocardial reperfusion in the absence of significant changes, in the acute phase, in traditional two-dimensional (2D) echo indexes of left ventricular (LV) function. The aim of this study was to evaluate the potential of 2D speckle tracking echocardiography (2DSTE) analysis in assessing the efficacy of thrombectomy as compared to standard 2D echo and cardiac magnetic resonance (CMR) data. METHODS: Two-dimensional speckle tracking echocardiography analysis was performed in 60 anterior ST-segment elevation myocardial infarction (STEMI) patients to assess global (GLS), segmental (SLS) and regional longitudinal strain (RLS). 2D echo and CMR were performed within 5 days after PCI. Patients were divided into 2 groups according to the different methods of reperfusion used: 28 pts Th-PCI and 32 pts standard PCI (S-PCI). RESULTS: Baseline clinical and angiographic characteristics, 2D echo, and DE-CMR data before and after PCI were similar in the 2 groups, except for microvascular obstruction (MVO), significantly lower (P = 0.001) in Th-PCI group. Conversely, GLS was significantly higher in Th-PCI group (P < 0.001), and in particular in the subset of patients without MVO (P = 0.012). RLS was also significantly higher in Th-PCI group (P = 0.001). GLS significantly correlates with infarct size, (R = 0.47; P = 0.03) and MVO (R = 0.69, P = 0.001). Finally, SLS was significantly lower in the DE segments (P < 0.001). CONCLUSIONS: Patients treated with Th-PCI had a more preserved microvascular integrity resulting in a better myocardial longitudinal deformation. 2DSTE analysis adds significant information on the efficacy of thrombus aspiration as compared to standard echocardiography and it is closely related to the extent of microvascular damage.