Johannes Patzelt1, Yingying Zhang1, Peter Seizer1, Harry Magunia2, Andreas Henning1, Veronika Riemlova1, Tara A E Patzelt3, Marc Hansen4, Michael Haap5, Reimer Riessen5, Henning Lausberg6, Tobias Walker6, Joerg Reutershan2, Christian Schlensak6, Christian Grasshoff2, Dan I Simon7, Peter Rosenberger2, Juergen Schreieck1, Meinrad Gawaz8, Harald F Langer9. 1. University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany. 2. University Hospital, Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany. 3. ERBE Elektromedizin GmbH, Tuebingen, Germany. 4. Abbott Vascular, Wiesbaden, Germany. 5. University Hospital, Intensive Care Unit, Eberhard Karls University Tuebingen, Tuebingen, Germany. 6. University Hospital, Department of Cardiovascular Surgery, Eberhard Karls University Tuebingen, Tuebingen, Germany. 7. Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio. 8. University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany. Electronic address: meinrad.gawaz@med.uni-tuebingen.de. 9. University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany. Electronic address: harald.langer@med.uni-tuebingen.de.
Abstract
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.
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.
Authors: Alexander Dietl; Christine Prieschenk; Franziska Eckert; Christoph Birner; Andreas Luchner; Lars S Maier; Stefan Buchner Journal: Cardiovasc Ultrasound Date: 2018-01-09 Impact factor: 2.062
Authors: Johannes Patzelt; Miriam Ulrich; Harry Magunia; Reinhard Sauter; Michal Droppa; Rezo Jorbenadze; Annika S Becker; Tobias Walker; Ralph Stephan von Bardeleben; Christian Grasshoff; Peter Rosenberger; Meinrad Gawaz; Peter Seizer; Harald F Langer Journal: J Am Heart Assoc Date: 2017-12-02 Impact factor: 5.501
Authors: Johannes Patzelt; Miriam Ulrich; Annika Becker; Karin A L Müller; Rezo Jorbenadze; Michal Droppa; Wenzhong Zhang; Sarah Mandel; Lisa Habel; Henning Lausberg; Janine Pöss; Tobias Geisler; Oliver Borst; Peter Rosenberger; Christian Schlensak; Meinrad Gawaz; Jürgen Schreieck; Peter Seizer; Harald F Langer Journal: PLoS One Date: 2018-10-19 Impact factor: 3.240
Authors: Reinhard J Sauter; Johannes Patzelt; Matthias Mezger; Henry Nording; Jan-Christian Reil; Mohammed Saad; Peter Seizer; Juergen Schreieck; Peter Rosenberger; Harald F Langer; Harry Magunia Journal: Int J Cardiol Heart Vasc Date: 2019-08-30
Authors: Hou Bo; David Heinzmann; Christian Grasshoff; Peter Rosenberger; Christian Schlensak; Meinrad Gawaz; Jürgen Schreieck; Harald F Langer; Johannes Patzelt; Peter Seizer Journal: Clin Cardiol Date: 2019-09-09 Impact factor: 2.882