Nuove acquisizioni in termini di insufficienza mitralica: complicanze tromboemboliche dopo chirurgia della valvola mitrale: incidenza, predittori e implicazioni cliniche

Objectives: to define in patients undergoing surgery for mitral regurgitation (MR) the risk of thrombo-embolic complications, particularly ischemic stroke (IS) compared to that in the general population. Background: MR is frequent, occurs mostly in the elderly and guidelines recommend surgery in asymptomatic patients but IS risks are unknown. Methods: in 1344 patients (65±12 years) consecutively operated for MR (procedures: 897 valve repair, MRep; 447 valve replacement, 231 mechanical, MVRm; 216 biological, MVRb), thrombo-embolic complications particularly IS (diagnosed by a neurologist) during follow-up were assessed early (<30 days), mid-term (30-180 days) and long-term (180 days). Results: IS occurred in 130 patients and IS or transient ischemic attack in 201. IS rates were 1.9±0.4% and 2.7±0.5%, at 30 and 180 days and 8.1±0.8% at 5 years. IS rates were lowest after MRep vs. MVRb and MVRm (6.1±0.9, 8±2.1 and 16.1±2.7% at 5 years, p<0.001). Comparison to IS expected rates in the population showed high risk within 30 days of surgery (Risk-ratio 41[26-60], p<0.001 but p>0.10 between procedures) and moderate risk after 30 days (risk-ratio 1.7 overall, p<0.001; 1.3 for MRep, p=0.07; 0.98 for MVRb, p=0.95; 4.8 for MVRm, p<0.001). Beyond 180 days, IS risk declined further and was not different from the general population for MRep (1.2, p=0.30) and for MVRb (0.9, p=0.72). Risk of IS or transient ischemic attack was higher than the general population in all groups up to 180 days. The risk of bleeding beyond 30 days was lowest in MRep vs. MVRb and MVRm (7±1, 14±4 and 16±3% at 10 years, p<0.001). Conclusion: thrombo-embolic complications after MR surgery are both reason for concern and encouragement. IS risk is notable early, irrespective of the procedure performed, but long-term is not higher than in the general population after MRep and MVRb. Preference for MRep should be emphasized and trials aimed at preventing IS should be conducted to reduce the thrombo-embolic and hemorrhagic risk in patients undergoing surgery for MR.

Utilzzo dei parametri ecocardiografici tradizionali ed a Doppler tissutale nella valutazione della disfunzione atrio-ventricolare in cani affetti da malattia mitralica cronica

In questo lavoro ci siamo posti come obiettivo lo studio della disfunzione atrio-ventricolare mediante tecniche ecocardiografiche avanzate (come il Tissue Doppler Imaging - TDI) in cani affetti da malattia mitralica cronica (MVD). Una prima parte è volta alla valutazione della funzionalità diastolica del ventricolo destro. Ci siamo proposti di analizzare la funzione del ventricolo destro in cani affetti da malattia del cuore sinistro per comprendere se quest’ultima possa condizionare direttamente la performance del settore cardiaco controlaterale. I risultati più importanti che abbiamo riscontrato sono: l’assenza di differenze significative nella disfunzione sisto-diastolica del ventricolo destro in cani con MVD a diverso stadio; la diretta correlazione tra le variabili TDI di funzionalità del ventricolo destro con il grado di disfunzione del ventricolo sinistro, come indicatori di interdipendenza ventricolare; ed infine il riscontro di una maggior tendenza ad alterazioni diastoliche del ventricolo sinistro in cani con ipertensione polmonare. A quest’ultimo proposito, per quanto riguarda le variabili TDI, il rapporto E/e’ dell’anulus mitralico laterale e settale è risultato avere una differenza significativa tra i cani con ipertensione polmonare e quelli privi di ipertensione polmonare (P<0,01). Nel secondo studio abbiamo applicato il TDI per l’analisi della funzione sisto-diastolica dell’atrio sinistro. Il lavoro è stato articolato in una parte di validazione della metodica su cani normali ed una su animali affetti da MDV. I risultati ottenuti mostrano che la valutazione ecocardiografica delle proprietà di deformazione dell’atrio sinistro basata sul TDI è attuabile e riproducibile nel cane. Abbiamo fornito dei valori di normalità per questa specie e confrontato questi dati con quelli ricavati in cani portatori di MVD. Le differenza tra le varie classi di malattia, nei diversi gradi di dilatazione atriale, sono risultate limitate, ma abbiamo individuato delle correlazioni tra i parametri TDI ed alcune variabili di funzionalità atriale.

Balloon Aortic Valvuloplasty as Bridge-to-Decision in High Risk Patients with Severe Aortic Valve Stenosis

Background. A sizable group of patients with symptomatic aortic stenosis (AS) can undergo neither surgical aortic valve replacement (AVR) nor transcatheter aortic valve implantation (TAVI) because of clinical contraindications. The aim of this study was to assess the potential role of balloon aortic valvuloplasty (BAV) as a “bridge-to-decision” in selected patients with severe AS and potentially reversible contraindications to definitive treatment. Methods. We retrospectively enrolled 645 patients who underwent first BAV at our Institution between July 2007 and December 2012. Of these, the 202 patients (31.2%) who underwent BAV as bridge-to-decision (BTD) requiring clinical re-evaluation represented our study population. BTD patients were further subdivided in 5 groups: low left ventricular ejection fraction; mitral regurgitation grade ≥3; frailty; hemodynamic instability; comorbidity. The main objective of the study was to evaluate how BAV influenced the final treatment strategy in the whole BTD group and in its single specific subgroups. Results. Mean logistic EuroSCORE was 23.5±15.3%, mean age was 81±7 years. Mean transaortic gradient decreased from 47±17 mmHg to 33±14 mmHg. Of the 193 patients with BTD-BAV who received a second heart team evaluation, 72.5% were finally deemed eligible for definitive treatment (25.4%for AVR; 47.2% for TAVI): respectively, 96.7% of patients with left ventricular ejection fraction recovery; 70.5% of patients with mitral regurgitation reduction; 75.7% of patients who underwent BAV in clinical hemodynamic instability; 69.2% of frail patients and 68% of patients who presented relevant comorbidities. 27.5% of the study population was deemed ineligible for definitive treatment and treated with standard therapy/repeated BAV. In-hospital mortality was 4.5%, cerebrovascular accident occurred in 1% and overall vascular complications were 4% (0.5% major; 3.5% minor). Conclusions. Balloon aortic valvuloplasty should be considered as bridge-to-decision in high-risk patients with severe aortic stenosis who cannot be immediate candidates for definitive percutaneous or surgical treatment.