et al.. Percutaneous repair or medical treatment for secondary mitral regurgitation: outcomes at 2 years Methods and results. AimsThe MITRA-FR trial showed that among symptomatic patients with severe secondary mitral regurgitation, percutaneous repair did not reduce the risk of death or hospitalization for heart failure at 12 months compared with guideline-directed medical treatment alone.At 37 centres, we randomly assigned 304 symptomatic heart failure patients with severe secondary mitral regurgitation (effective regurgitant orifice area >20 mm 2 or regurgitant volume >30 mL), and left ventricular ejection fraction between 15% and 40% to undergo percutaneous valve repair plus medical treatment (intervention group, n = 152) or medical treatment alone (control group, n = 152). The primary efficacy outcome was the composite of all-cause death and unplanned hospitalization for heart failure at 12 months. At 24 months, all-cause death and unplanned hospitalization for heart failure occurred in 63.8% of patients (97/152) in the intervention group and 67.1% (102/152) in the control group [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.77-1.34]. All-cause *Corresponding author. Hôpital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque, mortality occurred in 34.9% of patients (53/152) in the intervention group and 34.2% (52/152) in the control group (HR 1.02, 95% CI 0.70-1.50). Unplanned hospitalization for heart failure occurred in 55.9% of patients (85/152) in the intervention group and 61.8% (94/152) in the control group (HR 0.97, 95% CI 0.72-1.
This article describes a new technique of LV lead insertion, using transseptal catheterization performed through the right internal jugular vein, to obtain a totally endocardial biventricular chronic pacing in end-stage heart failure. Three patients with QRS widening (> 180 ms) linked to complete left bundle branch block (n = 2) or right ventricular pacing (n = 1) were included in this preliminary study. Catheterization was performed under fluoroscopy and transesophageal echocardiography guidance. Transseptal catheterization was achieved by puncture of the right internal jugular vein at the base of the neck and by using a Brockenbrough needle, the tip curve of which was more curved than the standard model. A flexible long sheath was advanced in the left atrium through the interatrial septum and then a unipolar electrode was placed easily in the LV. The proximal tip of the LV lead was tunneled from the neck to the subclavian area and connected to the ventricular channel of a dual (n = 1) or simple (n = 2) chamber pacemaker. Efficient acute sensing (V wave amplitude = 13 +/- 3 m V) and pacing (acute pacing threshold = 0. 7 +/- 0.4 V) were obtained in the three patients. Early loss of capture occurred in two patients requiring lead replacement. Functional status dramatically improved in all three patients. At 6-month follow-up, biventricular pacing was maintained in all patients (mean threshold 1.4 V) who were free of clinical embolic event with oral anticoagulation therapy. This modified technique of jugular transseptal catheterization appears promising for the development of left heart pacing.
The role of transcranial Doppler ultrasonography (TCD) in individual risk assessment of embolic complications and the development of prevention strategies during coronary angiography remains to be determined. The purpose of this study was to assess the prevalence, time of occurrence and potential significance of microembolic signals (MES) detected with TCD during femoral left heart catheterization. TCD monitoring of the right and left middle cerebral artery was performed in 51 consecutive patients (36 men, 15 women) who were referred for coronary angiography. Percutaneous coronary angioplasty was performed during the same procedure in 16 patients. MES were counted manually during and after (off-line analysis) the procedure. Two patients were excluded from analysis because of the absence of an adequate acoustic temporal window. No neurological event occurred within 24 h in the 49 included patients. MES were detected in all except 2 patients (mean number 17.1 ± 12.8 per patient), mainly during left ventriculography (38%) and contrast media injection into the coronary arteries (55%), suggesting their gaseous origin. There was no statistically significant association between the number of MES and patient age, cardiovascular history and risk factors, or catheterization results. The presence of coronary artery disease was inversely related to the number of MES (15.8 ± 0.3 compared to 21.8 ± 0.2 per patient when a normal angiogram was present; p < 0.05). In conclusion, although asymptomatic microemboli commonly occur during left heart catheterization, the majority of them are probably of gaseous origin, since they occurred predominantly during contrast media injection in this study, and were not related to cardiovascular history or to atheroma risk factors. Because air embolism has been reported to be harmful, attempts to reduce its occurrence during catheter-based procedures could be pertinent.
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