International Journal of Cardiology 187 (2015) 532–533
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiac resynchronization therapy in a patient with percutaneous mitral annuloplasty and prior aortic valve surgery Atila Iyisoy, Cengiz Ozturk ⁎, Murat Unlu, Turgay Celik, SaitDemirkol, Hamidullah Haqmal Gulhane Military Medical Academy School of Medicine, Department of Cardiology, Etlik, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 31 March 2015 Accepted 1 April 2015 Available online 3 April 2015 Keywords: Percutaneous mitral annuloplasty Cardiac resynchronization device Aortic valve replacement
Dear Editor, Systolic heart failure is commonly complicated by functional mitral regurgitation (FMR) via the dilatation of mitral annulus in the absence of structural mitral valve abnormalities [1] and it is associated with poor prognosis [2]. Whereby cardiac surgery in symptomatic patients with systolic dysfunction and FMR is associated with an increased procedural risk [3]. As a novel technique, percutaneous valve interventions have been developing recently such as Carillon device [4]. We report a case that we implanted a cardiac resynchronization device (CRT-D) after previous percutaneous mitral annuloplasty with the Carillon system. A 64-year-old male with ischemic heart failure, aortic valve replacement and severe FMR was referred to our clinic. Left ventricular dilatation, systolic dysfunction (ejection fraction 20%), and severe FMR were confirmed by echocardiography. The patient underwent percutaneous mitral annuloplasty with the Carillon system (Cardiac Dimensions Inc, Kirkland, WA, USA). Under fluoroscopy, 9 F guiding catheter was introduced into the coronary sinus. After the coronary sinus angiography, the distal anchor of the device was released. After the application of adequate tension, which resulted in a decrease in the degree of MR on echocardiography, the device proximal anchor was implanted. Before completion of the procedure, coronary angiography was performed to ensure lack of coronary artery compression by the device. ⁎ Corresponding author at: Department of Cardiology, Gulhane School of Medicine, Tevfik Saglam St., 06018 Etlik, Ankara, Turkey. E-mail address: [email protected] (C. Ozturk).
http://dx.doi.org/10.1016/j.ijcard.2015.04.014 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Four months after Carillon device implantation, patient was still symptomatic (NYHA class III). Due to wide QRS, left bundle brunch block and severe systolic dysfunction, we decided implantation of an implantable cardioverter-defibrillator device with CRT function. Coronary sinus catheterization was very easy due to the visibility of proximal anchor of Carillon device. After the coronary sinus angiography, posterolateral branch was detected and left ventriculary lead implanted in this branch (Fig. 1). Six months after the CRT-D implantation, we checked the patients status. The echo parameters of FMR further improved as a result of CRT and Carillon device which EF was 0.40 and patient were asymptomatic (NYHA I–II). FMR is a common finding in systolic heart failure patients [1,2]. Even though prognostic importance of FMR, low referral and high refusal rates for mitral surgery due to increased operative risk of these patients [3] and especially in patients with prior valve surgery. The efficacy and safety of percutaneous mitral annuloplasty with the Carillon device in the treatment of FMR in systolic heart failure patients have been evaluated in the AMADEUS [5] and TITAN [6] trials. TITAN trial confirmed considerable improvement of FMR as assessed by both echocardiography and functional tests that be constant to 24 months
Fig. 1. The fluoroscopic window of the patient after Carillon device and CRT.
A. Iyisoy et al. / International Journal of Cardiology 187 (2015) 532–533
after the procedure. Additionally, an apparent decrease in the left ventricular diastolic volume indicates reverse remodeling as a result of the Carillon device implantation [6]. Several randomized trials showed that CRT reduce symptoms, decrease neurohormonal activation, reverse remodeling, and improve left ventricular function and prognosis in many patients with moderate to severe heart failure due to systolic dysfunction and cardiac dyssynchrony [7–11]. Whether an additional beneficial effect of CRT in patients with Carillon devices remains to be established. To the best of our knowledge, this is the first demonstration of successful CRT after Carillon mitral annuloplasty in patients with prior aortic valve surgery. The combination of these therapies shows both its feasibility and a possible synergistic effect. CRT after successful Carillon mitral annuloplasty may have a synergistic effect in high risk patients with FMR and prior aortic valve surgery. Future clinical trials are warranted. Conflict of interest There is no conflict of interest. References [1] M. Merlo, S.A. Pyxaras, B. Pinamonti, G. Barbati, A. Di Lenarda, G. Sinagra, Prevalence and prognostic significance of left ventricular reverse remodeling in dilated cardiomyopathy receiving tailored medical treatment, J. Am. Coll. Cardiol. 57 (2011) 1468–1476.
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[2] P. Lancellotti, P.L. Gerard, L.A. Pierard, Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation, Eur. Heart J. 26 (2005) 1528–1532. [3] T. Kitai, Y. Okada, Y. Shomura, T. Tani, S. Kaji, T. Kita, Y. Furukawa, Timing of valve repair for severe degenerative mitral regurgitation and long-term left ventricular function, J. Thorac. Cardiovasc. Surg. 148 (2014) 1978–1982. [4] M. Bartkowiak, P. Bugajski, I. Jedlinski, R. Kalawski, Mitral valve repair in a patient with previous percutaneous annuloplasty with a CARILLON device, Interact. Cardiovasc. Thorac. Surg. 12 (2011) 1054–1056. [5] T. Siminiak, U.C. Hoppe, J. Schofer, et al., Effectiveness and safety of percutaneous coronary sinus-based mitral valve repair in patients with dilated cardiomyopathy (from the AMADEUS trial), Am. J. Cardiol. 104 (2009) 565–570. [6] T. Siminiak, C.W. Wu, M. Haude, et al., Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN trial, Eur. J. Heart Fail. 14 (2012) 931–938. [7] J.G. Cleland, J.C. Daubert, E. Erdmann, et al., The effect of cardiac resynchronization on morbidity and mortality in heart failure, N. Engl. J. Med. 352 (2005) 1539–1549. [8] M. Jiang, B. He, Q. Zhang, Comparison of CRT and CRT-D in heart failure: systematic review of controlled trials, Int. J. Cardiol. 158 (1) (Jun 28 2012) 39–45, http://dx.doi. org/10.1016/j.ijcard.2010.12.091 (Epub 2011 Jan 22. Review). [9] Y. Huang, W. Wu, Y. Cao, N. Qu, All cause mortality of cardiac resynchronization therapy with implantable cardioverter defibrillator: a meta-analysis of randomized controlled trials, Int. J. Cardiol. 145 (3) (Dec 3 2010) 413–417, http://dx.doi.org/10. 1016/j.ijcard.2010.05.016 (Epub 2010 Jun 12. Review). [10] G.M. Calvagna, G. Torrisi, C. Giuffrida, S. Patanè, Pacemaker, implantable cardioverter defibrillator, CRT, CRT-D, psychological difficulties and quality of life, Int. J. Cardiol. 174 (2) (Jun 15 2014) 378–380, http://dx.doi.org/10.1016/j.ijcard.2014.03.187 (Epub 2014 Apr 6). [11] N. António, L. Elvas, L. Gonçalves, L.A. Providência, Cardiac resynchronization therapy in the elderly: a realistic option for an increasing population? Int. J. Cardiol. 155 (1) (Feb 23 2012) 49–51, http://dx.doi.org/10.1016/j.ijcard.2011.01.079 (Epub 2011 Feb 21).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiac resynchronization therapy in a patient with percutaneous mitral annuloplasty and prior aortic valve surgery Atila Iyisoy, Cengiz Ozturk ⁎, Murat Unlu, Turgay Celik, SaitDemirkol, Hamidullah Haqmal Gulhane Military Medical Academy School of Medicine, Department of Cardiology, Etlik, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 31 March 2015 Accepted 1 April 2015 Available online 3 April 2015 Keywords: Percutaneous mitral annuloplasty Cardiac resynchronization device Aortic valve replacement
Dear Editor, Systolic heart failure is commonly complicated by functional mitral regurgitation (FMR) via the dilatation of mitral annulus in the absence of structural mitral valve abnormalities [1] and it is associated with poor prognosis [2]. Whereby cardiac surgery in symptomatic patients with systolic dysfunction and FMR is associated with an increased procedural risk [3]. As a novel technique, percutaneous valve interventions have been developing recently such as Carillon device [4]. We report a case that we implanted a cardiac resynchronization device (CRT-D) after previous percutaneous mitral annuloplasty with the Carillon system. A 64-year-old male with ischemic heart failure, aortic valve replacement and severe FMR was referred to our clinic. Left ventricular dilatation, systolic dysfunction (ejection fraction 20%), and severe FMR were confirmed by echocardiography. The patient underwent percutaneous mitral annuloplasty with the Carillon system (Cardiac Dimensions Inc, Kirkland, WA, USA). Under fluoroscopy, 9 F guiding catheter was introduced into the coronary sinus. After the coronary sinus angiography, the distal anchor of the device was released. After the application of adequate tension, which resulted in a decrease in the degree of MR on echocardiography, the device proximal anchor was implanted. Before completion of the procedure, coronary angiography was performed to ensure lack of coronary artery compression by the device. ⁎ Corresponding author at: Department of Cardiology, Gulhane School of Medicine, Tevfik Saglam St., 06018 Etlik, Ankara, Turkey. E-mail address: [email protected] (C. Ozturk).
http://dx.doi.org/10.1016/j.ijcard.2015.04.014 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Four months after Carillon device implantation, patient was still symptomatic (NYHA class III). Due to wide QRS, left bundle brunch block and severe systolic dysfunction, we decided implantation of an implantable cardioverter-defibrillator device with CRT function. Coronary sinus catheterization was very easy due to the visibility of proximal anchor of Carillon device. After the coronary sinus angiography, posterolateral branch was detected and left ventriculary lead implanted in this branch (Fig. 1). Six months after the CRT-D implantation, we checked the patients status. The echo parameters of FMR further improved as a result of CRT and Carillon device which EF was 0.40 and patient were asymptomatic (NYHA I–II). FMR is a common finding in systolic heart failure patients [1,2]. Even though prognostic importance of FMR, low referral and high refusal rates for mitral surgery due to increased operative risk of these patients [3] and especially in patients with prior valve surgery. The efficacy and safety of percutaneous mitral annuloplasty with the Carillon device in the treatment of FMR in systolic heart failure patients have been evaluated in the AMADEUS [5] and TITAN [6] trials. TITAN trial confirmed considerable improvement of FMR as assessed by both echocardiography and functional tests that be constant to 24 months
Fig. 1. The fluoroscopic window of the patient after Carillon device and CRT.
A. Iyisoy et al. / International Journal of Cardiology 187 (2015) 532–533
after the procedure. Additionally, an apparent decrease in the left ventricular diastolic volume indicates reverse remodeling as a result of the Carillon device implantation [6]. Several randomized trials showed that CRT reduce symptoms, decrease neurohormonal activation, reverse remodeling, and improve left ventricular function and prognosis in many patients with moderate to severe heart failure due to systolic dysfunction and cardiac dyssynchrony [7–11]. Whether an additional beneficial effect of CRT in patients with Carillon devices remains to be established. To the best of our knowledge, this is the first demonstration of successful CRT after Carillon mitral annuloplasty in patients with prior aortic valve surgery. The combination of these therapies shows both its feasibility and a possible synergistic effect. CRT after successful Carillon mitral annuloplasty may have a synergistic effect in high risk patients with FMR and prior aortic valve surgery. Future clinical trials are warranted. Conflict of interest There is no conflict of interest. References [1] M. Merlo, S.A. Pyxaras, B. Pinamonti, G. Barbati, A. Di Lenarda, G. Sinagra, Prevalence and prognostic significance of left ventricular reverse remodeling in dilated cardiomyopathy receiving tailored medical treatment, J. Am. Coll. Cardiol. 57 (2011) 1468–1476.
533
[2] P. Lancellotti, P.L. Gerard, L.A. Pierard, Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation, Eur. Heart J. 26 (2005) 1528–1532. [3] T. Kitai, Y. Okada, Y. Shomura, T. Tani, S. Kaji, T. Kita, Y. Furukawa, Timing of valve repair for severe degenerative mitral regurgitation and long-term left ventricular function, J. Thorac. Cardiovasc. Surg. 148 (2014) 1978–1982. [4] M. Bartkowiak, P. Bugajski, I. Jedlinski, R. Kalawski, Mitral valve repair in a patient with previous percutaneous annuloplasty with a CARILLON device, Interact. Cardiovasc. Thorac. Surg. 12 (2011) 1054–1056. [5] T. Siminiak, U.C. Hoppe, J. Schofer, et al., Effectiveness and safety of percutaneous coronary sinus-based mitral valve repair in patients with dilated cardiomyopathy (from the AMADEUS trial), Am. J. Cardiol. 104 (2009) 565–570. [6] T. Siminiak, C.W. Wu, M. Haude, et al., Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN trial, Eur. J. Heart Fail. 14 (2012) 931–938. [7] J.G. Cleland, J.C. Daubert, E. Erdmann, et al., The effect of cardiac resynchronization on morbidity and mortality in heart failure, N. Engl. J. Med. 352 (2005) 1539–1549. [8] M. Jiang, B. He, Q. Zhang, Comparison of CRT and CRT-D in heart failure: systematic review of controlled trials, Int. J. Cardiol. 158 (1) (Jun 28 2012) 39–45, http://dx.doi. org/10.1016/j.ijcard.2010.12.091 (Epub 2011 Jan 22. Review). [9] Y. Huang, W. Wu, Y. Cao, N. Qu, All cause mortality of cardiac resynchronization therapy with implantable cardioverter defibrillator: a meta-analysis of randomized controlled trials, Int. J. Cardiol. 145 (3) (Dec 3 2010) 413–417, http://dx.doi.org/10. 1016/j.ijcard.2010.05.016 (Epub 2010 Jun 12. Review). [10] G.M. Calvagna, G. Torrisi, C. Giuffrida, S. Patanè, Pacemaker, implantable cardioverter defibrillator, CRT, CRT-D, psychological difficulties and quality of life, Int. J. Cardiol. 174 (2) (Jun 15 2014) 378–380, http://dx.doi.org/10.1016/j.ijcard.2014.03.187 (Epub 2014 Apr 6). [11] N. António, L. Elvas, L. Gonçalves, L.A. Providência, Cardiac resynchronization therapy in the elderly: a realistic option for an increasing population? Int. J. Cardiol. 155 (1) (Feb 23 2012) 49–51, http://dx.doi.org/10.1016/j.ijcard.2011.01.079 (Epub 2011 Feb 21).
