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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses percutaneous approaches to mitral regurgitation (MR), percutaneous devices for aortic valve disease, the optimal treatment of MR, organic MR, as well as functional MR.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Evalvular disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPercutaneous Approaches to Mitral Regurgitation (MR)\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003ETwo trials, EVEREST I and II (Endovascular Valve Edge-to-Edge REpair STudy), examined the efficacy and safety of clip devices in treating patients with moderate to severe MR. EVEREST I, a non-randomized trial which is now complete, can be cautiously compared with data from the Society of Thoracic Surgeons (STS) database. Notably, patients enrolled in EVEREST I were older, had more diabetes, and more heart failure than those in the STS database.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EAfter 30 days, 95% of the 92 patients in EVEREST I had no adverse events, and the one death was unrelated to treatment. These data show that the device decreases MR; 70% of the 82 patients available for follow-up had an MR reduced to \u22641+. Finally, says Peter Block, MD, Professor of Medicine in the Department of Cardiology at Emory University, \u201cthe good news is that the surgical options are not taken away.\u201d Therefore, if a clip implant is unsuccessful, a patient retains the option of surgery. EVEREST II is a randomized trial that will allow more direct comparisons between surgical and percutaneous edge to edge repair efficacy; investigators are anxiously awaiting these results.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EAdditional devices in development include the coronary sinus device from Viacor, the Mitralign system, the Edwards self expanding device and the Ample device.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPercutaneous Devices for Aortic Valve Disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EAlthough patients with aortic stenosis typically benefit from surgical replacement, an increasing number of individuals are poor candidates due to age and other factors. A percutaneous device, the Cribier-Edwards valve, is deployed through a patient\u0027s circulatory system and opened in the heart. John Webb, MD, Director of Interventional Cardiology at St. Paul\u0027s Hospital in Vancouver, and colleagues conducted a study to determine the efficacy and safety of this procedure. A femoral approach was used on about 60 patients and an apical approach was used on about 20 patients. Data is currently available only on the first 50 femoral patients. At 30 days, the predicted mortality was 28% in these patients with multiple co-morbidities, whereas the actual observed mortality was only 12%. There appears to be a learning curve, says Dr. Webb; the first 25 patients suffered from 16% mortality whereas the last 25 patients had a rate of only 8% (The Vancouver Registry).\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EThe CoreValve self-expanding bioprosthetic valve has also recently had some impressive results. Initial trials show that the implantation of this small 21 French-sized catheter may reduce mortality and morbidity rates in patients with AS. Given the high incidence of peripheral vascular disease in this patient population, the apical approach appears to be an attractive option.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMitral Regurgitation: State-of-the-Art Management\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EOptimal treatment of mitral regurgitation (MR) requires the determination of disease etiology, severity and mechanism. Organic MR is caused by inherent mitral disease, such as rheumatic disease. Conversely, in functional MR, the papillary muscles, chordae, and valve leaflets are structurally normal; the disease is caused either by ischemic or idiopathic left ventricular (LV) dilation.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOrganic MR\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EWhether to repair or replace a valve is not based solely on the skills of the surgeon or diagnostician, but also on predicted outcome. \u201cWith the advent of repair techniques, the threshold for patients referred for surgery has decreased,\u201d says Michael Argenziano, MD, Director of the Surgical Arrhythmia Program, New York-Presbyterian Hospital\u0027s Columbia Medical Center.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EAlthough it is almost impossible to compare the outcomes of replacement and repair techniques due to lack of clinical trial data, decreased mortality and morbidity is associated with repair. Importantly, however, patients more likely to get repairs are younger and have fewer co-morbidities. Despite patient characteristics, longevity of the repaired valve is clearly superior.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe etiology of organic MR requires unique procedures. For annular dilatation, Dr. Argenziano recommends ring annuloplasty to reduce the circumference of the annulus. More recently, remodeling of the 3-dimensional annular shape is thought to be important. For posterior leaflet prolapse, quadrangular resection is recommended. \u201cFor anterior leaflet prolapse there are many more techniques\u2026we are not very good at anterior leaflet pathology,\u201d says Dr. Argenziano. Some of these techniques include chordal transposition, chordal shortening, triangular resection and edge-to-edge repair (Alfieri stitch).\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EFunctional MR\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EFunctional MR is not a disease of the valve per se, but rather a disease of the ventricle involving local or global LV remodeling. Functional MR is also dynamic. For example, some patients have only mild MR at rest which increases during exercise. This dynamic component, defined as \u0026gt;13mm\u003Csup\u003E2\u003C\/sup\u003E increase in the effective regurgitant orifice (ERO), is associated with a 5-fold increased risk of mortality.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EMedical treatment is the mandatory first step in patients with functional MR. These agents can reduce loading conditions and can be useful by inducing progressive inverse LV remodeling. Angioplasty is indicated in selected patients with pure ischemic MR, while cardiac resynchronization therapy is useful in patients with LV dysynchrony. CABG and surgical MV repair may be performed in selected patients. Finally, edge-to-edge repair (clip) and coronary sinus approaches to annuloplasty are two percutaneous options on the horizon for patients not fit for surgery. In order to determine which therapies are best for which patients, more data from prospective registries and randomized trials are needed.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2006 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/6\/5\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm4od\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}