Background— Current guidelines recommend mitral valve surgery for asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular systolic function when exercise pulmonary hypertension (PHT) is present. However, the determinants of exercise PHT have not been evaluated. The aim of this study was to identify the echocardiographic predictors of exercise PHT and the impact on symptoms. Methods and Results— Comprehensive resting and exercise transthoracic echocardiography was performed in 78 consecutive patients (age, 61±13 years; 56% men) with at least moderate degenerative mitral regurgitation (effective regurgitant orifice area =43±20 mm2; regurgitant volume =71±27 mL). Exercise PHT was defined as a systolic pulmonary arterial pressure (SPAP) >60 mm Hg. Exercise PHT was present in 46% patients. In multivariable analysis, exercise effective regurgitant orifice was an independent determinant of exercise SPAP (P<0.0001) and exercise PHT (P=0.002). Resting PHT and exercise PHT were associated with markedly reduced 2-year symptom-free survival (36±14% versus 59±7%, P=0.04; 35±8% versus 75±7%, P<0.0001). After adjustment, although the impact of resting PHT was no longer significant, exercise PHT was identified as an independent predictor of the occurrence of symptoms (hazard ratio=3.4; P=0.002). Receiver-operating characteristics curves revealed that exercise PHT (SPAP >56 mm Hg) was more accurate than resting PHT (SPAP >36 mm Hg) in predicting the occurrence of symptoms during follow-up (P=0.032). Conclusions— Exercise PHT is frequent in patients with asymptomatic degenerative mitral regurgitation. Exercise mitral regurgitation severity is a strong independent predictor of both exercise SPAP and exercise PHT. Exercise PHT is associated with markedly low 2-year symptom-free survival, emphasizing the use of exercise echocardiography. An exercise SPAP >56 mm Hg accurately predicts the occurrence of symptoms.

Exercise Pulmonary Hypertension in Asymptomatic Degenerative Mitral Regurgitation: Mechanisms and impact on Symptoms.

Mitral regurgitation (MR) is the most prevalent valvular heart disease and, when left untreated, results in reduced quality of life, heart failure, and increased mortality. Mitral valve transcatheter edge-to-edge repair (M-TEER) has matured considerably as a non-surgical treatment option since its commercial introduction in Europe in 2008. As a result of major device and interventional improvements, as well as the accumulation of experience by the interventional cardiologists, M-TEER has emerged as an important therapeutic strategy for patients with severe and symptomatic MR in the current European and American guidelines. Herein, we provide a comprehensive up-do-date overview of M-TEER. We define preprocedural patient evaluation and highlight key aspects for decision-making. We describe the currently available M-TEER systems and summarise the evidence for M-TEER in both primary mitral regurgitation (PMR) and secondary mitral regurgitation (SMR). In addition, we provide recommendations for device selection, intraprocedural imaging and guiding, M-TEER optimisation and management of recurrent MR. Finally, we provide information on major unsolved questions and "grey areas" in M-TEER. 

Mitral valve transcatheter edge-to-edge repair

In den letzten Jahren finden strukturelle kardiale Interventionen zunehmend Anwendung in der klinischen Routine. Trotz der raschen Einfuhrung und Weiterentwicklung dieser Techniken, ist die Evidenz fur die optimale antithrombotische Therapie nach solchen Interventionen limitiert, da randomisierte Studien zum Vergleich verschiedener antithrombotischer Therapien fur die meisten Einsatzgebiete fehlen. Diese Empfehlung fasst den gegenwartigen Erkenntnisstand zusammen. Basierend auf den zur Verfugung stehenden Daten, werden Behandlungsempfehlungen formuliert, die Arzten und ihren Patienten die Entscheidungsfindung erleichtern sollen.

Antithrombotische Therapie nach strukturellen kardialen Interventionen

Mitral regurgitation (MR) is the most common valvular disease. With a rising incidence in older age, the prevalence of relevant comorbidities inevitably increases. Considering the constantly aging population with high surgical risk, transcatheter therapy of MR is gaining increasing importance. Interventional therapy of either primary or secondary MR represents an alternative to pure drug or surgical therapy. With mitral valve transcatheter edge-to-edge repair, a well-established treatment has evolved in the past two decades. In addition, direct or indirect annuloplasty and ultimately transcatheter mitral valve implantation further expand the armamentarium. The current broad spectrum of interventional therapy options allows for patient-oriented therapy individually targeting different MR pathologies. This review discusses the current landscape of transcatheter therapies for relevant MR.

Current devices and interventions in mitral regurgitation.

Während die Standardschrittmachertherapie seit Jahrzehnten etabliert ist, betonen die neuen ESC-Leitlinien zur kardialen Stimulation und kardialen Resynchronisation die Korrelation von Symptomen im Zusammenhang mit dokumentierten Pausen und einer Stimulationsindikation insbesondere bei Patienten mit Synkopen. Asymptomatische Pausen rechtfertigen nur in Einzelfällen eine Stimulationsindikation. Der Wert implantierbarer Loop-Rekorder wird hervorgehoben. Darüber hinaus enthalten die neuen Leitlinien nur minimale Änderungen bei den Indikationen für die CRT, einschließlich einer Herabstufung für LSB und QRS-Komplex 130–149 ms und für ein CRT-Upgrade sowie ein Upgrade der CRT im Einklang mit dem Pace-and-ablate-Konzept. Außerdem werden zum ersten Mal Empfehlungen für die Stimulation nach TAVI vorgestellt. Neue Formen der Stimulation wie die sondenlose Stimulation und die Stimulation des Reizleitungssystems werden nun diskutiert, wobei die Empfehlungen für die sondenlose Stimulation und die His-Stimulation oder die Linksschenkelstimulation noch begrenzt sind. 

Schrittmacher- und kardiale Resynchronisationstherapie

In der Legende der Abb. 1 des Originalbeitrags wurde die Abkurzung „TMVR“ falsch aufgelost. Richtig muss es heisen: „TMVR kathetergestutzte Mitralklappenrekonstruktion“. Nachfolgend finden Sie die Abbildung mit der korrekten Legende. Wir bitten, diesen Fehler zu entschuldigen und die korrigierte …

/pdf/erratum-zu-interventionelle-therapie-von-av-2fnfx126d5.pdf

Erratum zu: Interventionelle Therapie von AV-Klappenerkrankungen – Kriterien für die Zertifizierung von Mitralklappenzentren. Positionspapier der Deutschen Gesellschaft für Kardiologie

Die Mitral- und Trikuspidalklappeninsuffizienz sind haufige Herzklappenerkrankungen. Sie gehen als unabhangige Risikofaktoren mit einer erhohten Sterblichkeit bei Herzinsuffizienz einher. Die kathetergestutzte Rekonstruktion der Klappen stellt eine mittlerweile relevante Alternative zur rein medikamentosen bzw. chirurgischen Behandlung dar. Wahrend die kathetergestutzte Therapie der Trikuspidalklappeninsuffizienz in ersten Registern Effektivitat und Sicherheit demonstrierte, liegen fur die kathetergestutzte Therapie der Mitralklappeninsuffizienz mittlerweile mehrere randomisierte Studien vor. Dieses Papier stellt die Ergebnisse aktueller Studien dar und gibt Empfehlungen zur Indikation interventioneller Behandlungsverfahren bei Mitral- und Trikuspidalklappeninsuffizienz. Zur Sicherung der Qualitat dieser Verfahren werden von der Deutschen Gesellschaft fur Kardiologie die Kriterien fur die Zertifizierung von Zentren zur kathetergestutzten Therapie der Mitralklappeninsuffizienz aktualisiert.

Interventionelle Therapie von AV-Klappenerkrankungen – Kriterien für die Zertifizierung von Mitralklappenzentren

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Erratum zu: Interventionelle Therapie von AV-Klappenerkrankungen – Kriterien für die Zertifizierung von Mitralklappenzentren. Positionspapier der Deutschen Gesellschaft für Kardiologie

Interventionelle Therapie von AV-Klappenerkrankungen – Kriterien für die Zertifizierung von Mitralklappenzentren