Cardiology

Kosmidou, I., Lindenfeld, J., Abraham, W.T., Kar, S., Lim, D.S., Mishell, J.M., Whisenant, B.K., Kipperman, R.M., Boudoulas, K.D., Redfors, B., Shahim, B., Zhang, Z., Mack, M.J. and Stone, G.W. (2020). “Transcatheter Mitral Valve Repair in Patients With and Without Cardiac Resynchronization Therapy: The COAPT Trial.” Circ Heart Fail 13(11): e007293

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BACKGROUND: In the COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation), treatment of heart failure (HF) patients with moderate-severe or severe secondary mitral regurgitation with transcatheter mitral valve repair (TMVr) using the MitraClip plus guideline-directed medical therapy (GDMT) reduced 2-year rates of HF hospitalization and all-cause mortality compared with GDMT alone. Whether the benefits of the MitraClip extend to patients with previously implanted cardiac resynchronization therapy (CRT) is unknown. We sought to examine the effect of prior CRT in patients enrolled in COAPT. METHODS: Patients (N=614) with moderate-severe or severe secondary mitral regurgitation who remained symptomatic despite maximally tolerated doses of GDMT were randomized 1:1 to the MitraClip (TMVr arm) versus GDMT only (control arm). Outcomes were assessed according to prior CRT use. RESULTS: Among 614 patients, 224 (36.5%) had prior CRT (115 and 109 randomized to TMVr and control, respectively) and 390 (63.5%) had no CRT (187 and 203 randomized to TMVr and control, respectively). Patients with CRT had similar 2-year rates of the composite of death or HF hospitalization compared with those without CRT (57.6% versus 55%, P=0.32). Death or HF hospitalization at 2 years was lower with TMVr versus control treatment in patients with prior CRT (48.6% versus 67.2%, hazard ratio, 0.60 [95% CI, 0.42-0.86]) and without CRT (42.5% versus 66.9%, hazard ratio, 0.52 [95% CI, 0.39-0.69]; adjusted P(interaction)=0.23). The effects of TMVr with the MitraClip on reducing the 2-year rates of all-cause death (adjusted P(interaction)=0.14) and HF hospitalization (adjusted P(interaction)=0.82) were also consistent in patients with and without CRT as were improvements in quality-of-life and exercise capacity. CONCLUSIONS: In the COAPT trial, TMVr with the MitraClip improved the 2-year prognosis of patients with HF and moderate-severe or severe secondary mitral regurgitation who remained symptomatic despite maximally tolerated GDMT, regardless of prior CRT implantation.

Podgaetz, E. and Konda, V. (2020). “Experience and Technique for Zenker’s Diverticulum Per Oral Endoscopic Myotomy: Z-POEM.” Thorac Cardiovasc Surg Oct 21. [Epub ahead of print].

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OBJECTIVE: With the advent of minimally invasive surgery, incisionless surgery, and third-space endoscopy, the treatment for Zenker’s diverticulum has also moved toward less invasive techniques METHODS:  New incisionless per oral techniques can be applied for cricopharyngeal myotomy in Zenker’s diverticulum. RESULTS:  Five patients underwent Zenker’s diverticulum per oral endoscopic myotomy (Z-POEM) without complications, minimal discomfort, and narcotic consumption, with complete resolution of their symptoms by history and Eckardt scores. CONCLUSIONS:  Z-POEM is performed entirely endoscopically with very little associated pain or complication rates, with short-term follow-up having excellent functional and symptomatic results.

Hamandi, M., Lanfear, A.T., Squiers, J.J., George, T., Harrington, K., Szerlip, M.A., DiMaio, J.M. and Smith, R.L. (2020). “Double Valve Replacement in Patients with Mitral Annular Calcification and Aortic Stenosis.” Ann Thorac Surg Oct 31;S0003-4975(20)31839-7. [Epub ahead of print].

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Mitral annular calcification (MAC) is a degenerative process of the fibrous structure of the mitral valve (MV). Surgical MV replacement in the presence of MAC is technically challenging due to high calcium burden and is associated with prohibitive operative mortality. There is no standard management strategy for patients with severe aortic stenosis and severe MV disease with MAC. We report a case series of three patients who underwent concomitant surgical, transatrial implantation of a transcatheter heart valve in the mitral position and transcatheter aortic valve replacement.

Hamandi, M., Amiens, P., Grayburn, P.A., Al-Azizi, K., van Zyl, J.S., Lanfear, A.T., Rabilloud, M., Riche, B., Gopal, A., Szerlip, M.A., Potluri, S., DiMaio, J.M., Mack, M.J., Harbaoui, B. and Lantelme, P. (2020). “Usefulness of Thoracic Aortic Calcium to Predict 1-Year Mortality After Transcatheter Aortic Valve Implantation.” Am J Cardiol Nov 2;S0002-9149(20)31177-2. [Epub ahead of print].

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In patients who underwent transcatheter aortic valve implantation (TAVI), vascular disease is associated with increased risk of mortality. Thoracic aortic calcification (TAC), an objective surrogate of vascular disease, could be a predictor of mortality after TAVI. We aimed to analyze the association between TAC burden and 1-year all-cause mortality in patients who underwent TAVI in a US population. From July 2015 through July 2017, a retrospective review of TAVI procedures was performed at Baylor Scott & White-The Heart Hospital, Plano, Texas. Patients were analyzed for comorbidities, cardiac risk factors, and 30-day and 1-year all-cause mortality. Restricted cubic splines analysis was used to define low, moderate, and high TAC categories. The association between TAC and survival was evaluated using unadjusted and adjusted Cox models. A total of 431 TAVI procedures were performed, of which TAC was measured in 374 (81%) patients. Median (interquartile range) age was 82 (77, 87) years, and 51% were male. Median (interquartile range) STS PROM was 5.6 (4.1, 8.2) %. Overall 30-day and 1-year all-cause mortality was 1% and 10%, respectively. TAC was categorized as low (<1.6 cm(3)), moderate (1.6 to 2.9 cm(3)), and high (>2.9 cm(3)). At 1 year, all-cause mortality was 16% in patients with high TAC compared with 6% in the low and moderate TAC categories (p = 0.008). Unadjusted and adjusted Cox regression analysis showed a significant increase in mortality for patients with high TAC compared with low TAC (hazard ratio 2.98, 95% confidence interval [1.34-6.63]), but not significant compared with moderate TAC group. TAC is a predictor of late mortality after TAVI. In conclusion, adding TAC to preoperative evaluation may provide an objective, reproducible, and potentially widely available tool that can help in shared decision-making.

Webb, J., Hensey, M., Fam, N., Rodés-Cabau, J., Daniels, D., Smith, R., Szeto, W., Boone, R., Ye, J., Moss, R., Peterson, M., Ong, G., Paradis, J.M., Dagenais, F., Wintzer-Wehekind, J., Shafi, B., Nair, D., Szerlip, M., Grayburn, P., Silvestry, F., Koulogiannis, K., Hermiller, J., Guyton, R. and Herrmann, H. (2020). “Transcatheter Mitral Valve Replacement With the Transseptal EVOQUE System.” JACC Cardiovasc Interv 13(20): 2418-2426.

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OBJECTIVES: The aim of this study was to examine the initial experience with a novel transseptal transcatheter mitral valve replacement (TMVR) system. BACKGROUND: Transseptal TMVR may offer a less invasive option than surgery for mitral regurgitation (MR) with greater efficacy and fewer anatomic limitations than transcatheter repair. METHODS: Patients were treated with the EVOQUE TMVR system from September 2018 to October 2019. Key inclusion criteria were moderate or greater MR, New York Heart Association functional class ≥II, and high or prohibitive surgical risk. The primary outcome was technical success, defined by Mitral Valve Academic Research Consortium criteria. RESULTS: Fourteen patients were treated, all with at least moderate to severe MR. The median age was 84 years, and the median Society of Thoracic Surgeons score was 4.6%. MR was degenerative in 4 (28.6%), functional in 3 (21.4%), and mixed in 7 (50%). Technical success was achieved in 13 patients (92.9%), and 1 patient was converted to surgery. At 30 days there was 1 noncardiovascular mortality (7.1%), 2 strokes (14.3%), no myocardial infarctions, and no rehospitalizations. Two patients (14.3%) underwent paravalvular leak closure. One patient (7.1%) underwent alcohol septal ablation for left ventricular outflow tract obstruction. Including the 2 patients with paravalvular leak closure, MR was mild or less in all implanted patients at 30 days, with no MR in 10 (83.3%). Mean mitral gradient was 5.8 mm Hg (median). New York Heart Association functional class improved to ≤II in 9 patients (81.8%). CONCLUSIONS: This first-in-human experience has demonstrated the feasibility of the transseptal EVOQUE TMVR system. Further clinical studies are required to establish safety and clinical outcomes.