title: Effects of Mechanical Ventilation on Heart Geometry and Mitral Valve Leaflet Coaptation During Percutaneous Edge-to-Edge Mitral Valve Repair.
abstract: OBJECTIVE
  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.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Johannes
authors.initials: J
authors.lastname: Patzelt
authors.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Yingying
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Seizer
authors.affiliation: University Hospital, Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Harry
authors.initials: H
authors.lastname: Magunia
authors.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Henning
authors.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Veronika
authors.initials: V
authors.lastname: Riemlova
authors.affiliation: ERBE Elektromedizin GmbH, Tuebingen, Germany.
authors.forename: Tara A E
authors.initials: TA
authors.lastname: Patzelt
authors.affiliation: Abbott Vascular, Wiesbaden, Germany.
authors.forename: Marc
authors.initials: M
authors.lastname: Hansen
authors.affiliation: University Hospital, Intensive Care Unit, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Haap
authors.affiliation: University Hospital, Intensive Care Unit, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Reimer
authors.initials: R
authors.lastname: Riessen
authors.affiliation: University Hospital, Department of Cardiovascular Surgery, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Henning
authors.initials: H
authors.lastname: Lausberg
authors.affiliation: University Hospital, Department of Cardiovascular Surgery, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Walker
authors.affiliation: University Hospital, Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Joerg
authors.initials: J
authors.lastname: Reutershan
authors.affiliation: University Hospital, Department of Cardiovascular Surgery, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Schlensak
authors.affiliation: University Hospital, Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Grasshoff
authors.affiliation: Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Dan I
authors.initials: DI
authors.lastname: Simon
authors.affiliation: University Hospital, Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Rosenberger
authors.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
authors.forename: Juergen
authors.initials: J
authors.lastname: Schreieck
authors.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany. Electronic address: meinrad.gawaz@med.uni-tuebingen.de.
authors.forename: Meinrad
authors.initials: M
authors.lastname: Gawaz
authors.affiliation: University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany. Electronic address: harald.langer@med.uni-tuebingen.de.
authors.forename: Harald F
authors.initials: HF
authors.lastname: Langer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000768:Anesthesia, General; D006328:Cardiac Catheterization / Q000295:instrumentation; D002496:Central Venous Pressure; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D061646:Operative Time; D011175:Positive-Pressure Respiration / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome
keywords: PEEP; PMVR; hemodynamics; mechanical ventilation; mitral valve coaptation; mitral valve regurgitation