Author + information
- Received June 15, 2015
- Revision received August 31, 2015
- Accepted September 10, 2015
- Published online January 25, 2016.
- Johannes Patzelt, MD∗,
- Yingying Zhang, MD∗,
- Peter Seizer, MD∗,
- Harry Magunia, MD†,
- Andreas Henning, MD∗,
- Veronika Riemlova, MD∗,
- Tara A.E. Patzelt, Dr Oec Publ‡,
- Marc Hansen, Dipl Ing§,
- Michael Haap, MD‖,
- Reimer Riessen, MD‖,
- Henning Lausberg, MD¶,
- Tobias Walker, MD¶,
- Joerg Reutershan, MD†,
- Christian Schlensak, MD¶,
- Christian Grasshoff, MD†,
- Dan I. Simon, MD#,
- Peter Rosenberger, MD†,
- Juergen Schreieck, MD∗,
- Meinrad Gawaz, MD∗∗ ( and )
- Harald F. Langer, MD∗∗ ()
- ∗University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany
- †University Hospital, Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany
- ‡ERBE Elektromedizin GmbH, Tuebingen, Germany
- §Abbott Vascular, Wiesbaden, Germany
- ‖University Hospital, Intensive Care Unit, Eberhard Karls University Tuebingen, Tuebingen, Germany
- ¶University Hospital, Department of Cardiovascular Surgery, Eberhard Karls University Tuebingen, Tuebingen, Germany
- #Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
- ↵∗Reprint requests and correspondence:
Dr. Harald F. Langer OR Dr. Meinrad Gawaz, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Otfried-Mueller-Straße 10, 72076 Tuebingen, Germany.
Objectives This study sought to evaluate a ventilation maneuver to facilitate percutaneous edge-to-edge mitral valve repair (PMVR) and its effects on heart geometry.
Background In patients with challenging anatomy, the application of PMVR is limited, potentially resulting in insufficient reduction of mitral regurgitation (MR) or clip detachment. Under general anesthesia, however, ventilation maneuvers can be used to facilitate PMVR.
Methods A total of 50 consecutive patients undergoing PMVR were included. During mechanical ventilation, different levels of positive end-expiratory pressure (PEEP) were applied, and parameters of heart geometry were assessed using transesophageal echocardiography.
Results We found that increased PEEP results in elevated central venous pressure. Specifically, central venous pressure increased from 14.0 ± 6.5 mm Hg (PEEP 3 mm Hg) to 19.3 ± 5.9 mm Hg (PEEP 20 mm Hg; p < 0.001). As a consequence, the reduced pre-load resulted in reduction of the left ventricular end-systolic diameter from 43.8 ± 10.7 mm (PEEP 3 mm Hg) to 39.9 ± 11.0 mm (PEEP 20 mm Hg; p < 0.001), mitral valve annulus anterior-posterior diameter from 32.4 ± 4.3 mm (PEEP 3 mm Hg) to 30.5 ± 4.4 mm (PEEP 20 mm Hg; p < 0.001), and the medio-lateral diameter from 35.4 ± 4.2 mm to 34.1 ± 3.9 mm (p = 0.002). In parallel, we observed a significant increase in leaflet coaptation length from 3.0 ± 0.8 mm (PEEP 3 mm Hg) to 5.4 ± 1.1 mm (PEEP 20 mm Hg; p < 0.001). The increase in coaptation length was more pronounced in MR with functional or mixed genesis. Importantly, a coaptation length >4.9 mm at PEEP of 10 mm Hg resulted in a significant reduction of PMVR procedure time (152 ± 49 min to 116 ± 26 min; p = 0.05).
Conclusions In this study, we describe a novel ventilation maneuver improving mitral valve coaptation length during the PMVR procedure, which facilitates clip positioning. Our observations could help to improve PMVR therapy and could make nonsurgical candidates accessible to PMVR therapy, particularly in challenging cases with functional MR.
This study was supported by grants from the German research foundation (KFO 274), the Volkswagen foundation (Lichtenberg program), the “Juniorprofessorenprogramm of the county Baden-Wuerttemberg,” and the German Heart foundation. Dr. Hansen is an employee of Abbott Vascular. J. Schreieck has received speaker fees from Medtronic and St. Jude Medical. Dr. Langer was reimbursed by Abbott Vascular for training courses in the percutaneous mitral valve repair procedure. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 15, 2015.
- Revision received August 31, 2015.
- Accepted September 10, 2015.
- American College of Cardiology Foundation