The Valve Wire Archive

Seven-Year Valve Durability With Transcatheter or Surgical Aortic Valve Replacement: An Ad Hoc Analysis of the PARTNER 3 Randomized Clinical Trial.

IMPORTANCE: As transcatheter aortic valve replacement (TAVR) is considered for younger and lower-risk populations, the durability of bioprosthetic valves is increasingly important. Limited data exist on long-term (7 years and beyond) valve durability. OBJECTIVE: To report 7-year valve durability outcomes for low-risk patients with symptomatic severe aortic stenosis treated with TAVR vs surgery. DESIGN, SETTING, AND PARTICIPANTS: Between March 2016 and October 2017, a total of 1000 patients were enrolled at 71 centers in the US and Canada and randomized to undergo TAVR vs surgery. The patient population for the present analysis consisted of all patients who underwent valve implantation (495 with TAVR and 453 with surgery). The last 7-year follow-up occurred in March 2025. INTERVENTIONS: Patients were randomized to balloon-expandable TAVR with the SAPIEN 3 valve or surgery with any commercially available valve. MAIN OUTCOMES AND MEASURES: The main outcomes of this analysis were stage 2 or 3 bioprosthetic valve dysfunction (BVD) related to structural valve deterioration (SVD), thrombosis, or endocarditis; all-cause bioprosthetic valve failure (BVF); BVF related to SVD; and aortic valve reintervention at 7 years. Analyses are presented as cumulative incidence rates with death as a competing risk. RESULTS: The mean (SD) age of the study population was 73.5 (6.0) years, and 657 participants (69.3%) were male. Of 671 patients who were still alive and enrolled in the study at 7-year follow-up, 537 (80.0%) were available for echocardiographic analysis. Cumulative incidence rates of stage 2 or 3 SVD-related BVD (7.3% vs 7.6%; hazard ratio [HR], 0.96; 95% CI, 0.59-1.57; P = .88), all-cause BVF (6.9% vs 7.5%; HR, 0.91; 95% CI, 0.55-1.49; P = .69), SVD-related BVF (3.9% vs 5.3%; HR, 0.72; 95% CI, 0.39-1.36; P = .31), and valve reintervention (6.0% vs 5.5%; HR, 1.09; 95% CI, 0.62-1.90; P = .77) were low and similar for TAVR and surgery, respectively. Stage 2 or 3 thrombosis-related BVD (subclinical and clinical) occurred more frequently with TAVR (5.2% vs 0.9%; HR, 5.52; 95% CI, 1.92-15.85; P < .001), although most events occurred within 3 years and few progressed to BVF. Rates of stage 2 or 3 endocarditis-related BVD were also low and similar (0.4% in the TAVR group vs 0.5% in the surgery group; HR, 0.85; 95% CI, 0.12-6.07; P = .87). The proportion of patients alive and free of all-cause BVF was 73.4% (331/451) with TAVR vs 74.8% (288/385) with surgery (P = .69). CONCLUSIONS AND RELEVANCE: In this ad hoc analysis of a randomized clinical trial among low-risk patients with symptomatic severe aortic stenosis randomized to TAVR or surgery, both TAVR and surgery demonstrated comparable and sustained valve durability, with low and similar rates of SVD, all-cause BVF, and reintervention through 7 years. These findings may inform discussions of valve replacement strategies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02675114.

Temporal Trends in Mitral Valve Repair Procedures and Outcomes Among Older U.S. Adults.

BACKGROUND: Mitral valve (MV) transcatheter edge-to-edge repair (M-TEER) has reshaped the management of mitral regurgitation in high surgical risk patients. As M-TEER adoption expands, understanding concurrent changes in procedural utilization, patient characteristics, and clinical outcomes is important. OBJECTIVES: The objective of the study was to evaluate temporal trends in procedural utilization, comorbidity burden, and mortality among Medicare beneficiaries undergoing MV repair. METHODS: Medicare beneficiaries undergoing MV repair between 2017 and 2021 were analyzed. Procedure volumes, Elixhauser Comorbidity Index, and mortality at 30-days, 30-days postdischarge, 1-year, and 2-years were assessed. Temporal mortality trends were analyzed using adjusted Cox models with calendar year as a continuous variable. RESULTS: Among 81,215 beneficiaries, 39,097 underwent M-TEER and 42,118 surgical MV repair. M-TEER utilization increased from 15.0 to 27.6 per 100,000 beneficiaries (+84.0%), whereas surgical MV repair decreased from 29.1 to 20.7 per 100,000 (-28.9%), resulting in a 9.5% overall increase in MV repair use. The Elixhauser Comorbidity Index increased overall (+7.8%), remained stable among M-TEER patients (-0.2%), and decreased among surgical MV repair patients (-5.1%). Overall, adjusted mortality decreased at 30-days (adjusted HR [aHR]: 0.92; 95% CI: 0.89-0.94; P < 0.001), postdischarge 30-days (aHR: 0.93; 95% CI: 0.89-0.97; P < 0.001), 1-year (aHR: 0.98; 95% CI: 0.97-1.00; P = 0.013), and 2-years (aHR: 0.98; 95% CI: 0.97-0.99; P < 0.001). CONCLUSIONS: Between 2017 and 2021, M-TEER utilization increased substantially whereas surgical MV repair declined, resulting in increased overall MV repair utilization. Over the same period, adjusted short-term and midterm mortality improved despite a higher overall comorbidity index.

Staged Transcatheter Treatment of Combined Aortic and Mitral Regurgitation: A Downstream Approach.

BACKGROUND: Concomitant severe aortic (AR) and mitral regurgitation (MR) affects up to 25% of patients with aortic valve disease and portends poor prognosis. Evidence on a sequential downstream approach in native AR is limited. CASE SUMMARY: We report 4 patients with high surgical risk (mean age 82 years, Society of Thoracic Surgeons score >8) with severe AR and MR treated with transcatheter aortic valve replacement for native AR. In 2 patients with secondary MR, AR correction was followed by reverse remodeling and downstaging of MR from severe to moderate, avoiding mitral transcatheter edge-to-edge repair. In the remaining 2 patients, MR remained severe, and staged mitral transcatheter edge-to-edge repair was performed. DISCUSSION: These cases support the hypothesis that MR etiology, rather than AR correction alone, determines whether MR regresses after isolated AR treatment. TAKE-HOME MESSAGE: MR etiology and post-transcatheter aortic valve replacement reassessment may guide a staged transcatheter strategy, sparing unnecessary mitral intervention in inoperable patients with combined AR/MR.

Prevention of Left Ventricular Outflow Tract Obstruction During High-Risk Transcatheter Mitral Valve Replacement.

BACKGROUND: Transcatheter mitral valve replacement can carry a left ventricular outflow tract (LVOT) obstruction in patients with small neo-LVOT. CASE SUMMARY: A 74-year-old woman with a degenerated 27-mm surgical mitral bioprosthesis presented with severe symptomatic mitral stenosis and biventricular failure. She was deemed high risk for redo surgery. After heart team discussion, she underwent extracorporeal membrane oxygenation-supported valve-in-valve transcatheter mitral valve replacement with balloon-assisted translocation of the anterior mitral leaflet modification and intraleaflet deployment of a 26-mm balloon-expandable valve using a left ventricular pacing guidewire and 13-F steerable sheath. DISCUSSION: Mechanical circulatory support combined with leaflet modification may enable transcatheter mitral valve replacement in patients with high-risk anatomy and prohibitive surgical risk. TAKE-HOME MESSAGES: Balloon-assisted translocation of the anterior mitral leaflet modification with mechanical circulatory support may be feasible in selected patients at high risk of LVOT obstruction. A left ventricular pacing guidewire can facilitate valve delivery and rapid pacing while avoiding right ventricular instrumentation, while a steerable sheath supports controlled traversal of a calcified leaflet.

Transcatheter Edge-to-Edge Mitral Valve Repair for Severe Degenerative Mitral Regurgitation With Coexisting Cor Triatriatum Sinistrum.

BACKGROUND: Cor triatriatum sinistrum (CTS) is a rare congenital malformation, and its coexistence with degenerative mitral regurgitation (MR) in older adults is exceptionally rare and creates substantial technical challenges for transcatheter interventions. CASE SUMMARY: We report a 78-year-old woman presenting with progressive dyspnea, palpitations, and lower limb edema secondary to severe MR caused by posterior mitral leaflet prolapse. Preprocedural imaging incidentally identified a complete, nonfenestrated CTS membrane. Three clips were sequentially implanted at the prolapse site, downgrading MR from severe to trace. The final mean transmitral gradient was 3 mm Hg. The patient achieved rapid symptom resolution and was discharged 7 days postprocedure. DISCUSSION: This case establishes the feasibility of mitral transcatheter edge-to-edge repair in patients with CTS through meticulous preprocedural planning and controlled transmembranous access. It broadens the therapeutic landscape for anatomically complex, surgically prohibitive older adults with valvular disease. TAKE-HOME MESSAGE: The mitral transcatheter edge-to-edge repair is feasible and safe in MR with CTS.

Preserve the Heart Team: Surgical Backup Is Not Optional in TAVR.

Surgical Bailout During TAVR: A Contemporary Analysis of the Centers for Medicare and Medicaid Services Database.

BACKGROUND: Surgical bailout during transcatheter aortic valve replacement (TAVR) may be necessary to manage emergent TAVR complications. With discussions of performing TAVR in U.S. hospitals without in-hospital cardiac surgery support, analysis of TAVR bailout on a national level is needed. OBJECTIVES: This study sought to analyze the annual trends and outcomes of TAVR bailout. METHODS: This study included Medicare beneficiaries who underwent TAVR between 2016 and 2024. Annual trends of bailout were analyzed. The primary outcome was 30-day mortality. Additionally, the impact of hospital surgical aortic valve replacement (SAVR) volume on TAVR bailout mortality was assessed with multivariable analysis. RESULTS: TAVR bailout occurred in 0.56% (2,240/400,862) of TAVRs. The annual incidence of TAVR bailout decreased from 0.92% (261/28,430) in 2016 to 0.40% (216/54,301) in 2024 (P < 0.001). The median follow-up time after TAVR was 952 days (IQR: 414-1,615 days). The 30-day mortality rate of TAVR bailout was 26.3% (588/2,240). Landmark analysis demonstrated higher mortality of TAVR bailout compared to TAVR without bailout up to 1 year after TAVR (P < 0.001), but similar mortality was seen after 1 year (P = 0.53). When compared across low-, intermediate-, and high-volume SAVR hospitals in a multilevel hierarchal model, 30-day mortality was similar (27% [102/383] vs 29% [163/566] vs 25% [322/1,291], respectively; P = 0.28). CONCLUSIONS: In contemporary data, the annual incidence of TAVR surgical bailout is decreasing, but the short-term mortality remains high. However, patients who survived 1 year after TAVR had similar long-term mortality to patients without surgical bailout. These data support the need for continued cardiac surgical support in TAVR centers to manage emergent complications.

Five-Year Follow-Up of Transcatheter Aortic Valve Replacement With Self-Expanding Intra-Annular Versus Commercially Available Valves.

BACKGROUND: Long-term outcomes of the self-expanding intra-annular Portico transcatheter aortic valve are not known. OBJECTIVES: This study aimed to report the 5-year outcomes of the PORTICO IDE randomized controlled trial. METHODS: This multicenter trial randomized (1:1) patients with severe symptomatic aortic stenosis at high/extreme surgical risk to transcatheter aortic valve replacement (TAVR) with the self-expanding intra-annular valve (study valve) or Food and Drug Administration-approved commercially available valves (CAVs; balloon-expandable or self-expanding supra-annular platforms). Assessments of the primary safety endpoint (30 days) and the primary efficacy endpoint (1 year) have been previously reported. Prespecified clinical outcomes and hemodynamic valve parameters are presented through 5 years. RESULTS: We randomized 750 eligible patients (mean age: 83 years, 52.7% female) to the study valve (n = 381) or CAV (n = 369). Compared with CAV, the study valve showed similar 5-year all-cause mortality or stroke (55.6% vs 51.3%, P = 0.42). Cardiovascular mortality was numerically higher in the study valve group compared with the CAV group (33.4% vs 25.8%; P = 0.06). Naïve permanent pacemaker implantation was higher in the study valve group (36.6%) than the CAV group (20.3%; P < 0.0001) at 5 years. At 5 years, the study valve showed a lower mean transvalvular gradient (7.2 ± 3.0 vs 9.5 ± 6.5 mm Hg, P = 0.008), but similar valve area (1.78 ± 0.45 vs 1.71 ± 0.51 cm2, P = 0.40) compared to CAV. CONCLUSIONS: In patients at high or extreme surgical risk, TAVR with the self-expanding intra-annular transcatheter heart valve had similar 5-year overall survival, stroke rates, and valve function compared with commercially available valves.

Predictors of Procedural and Clinical Outcomes Following Transcatheter Tricuspid Edge-to-Edge Repair: An Expert Overview.

Tricuspid transcatheter edge-to-edge repair alleviates symptoms, but survival benefit remains inconsistent. The authors conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020-compliant systematic review and meta-analysis (CRD42024600438) to identify multivariable predictors of procedural success and adverse outcomes. PubMed, Scopus, the Cochrane Library, and Google Scholar were searched (from January 2008 to March 2025) for adjusted predictors of mortality, heart failure hospitalization, major adverse cardiovascular events, and procedural success. Random-effects meta-analysis was performed when ≥2 independent cohorts reported comparable estimates. Fifty-nine studies met the inclusion criteria. Baseline tricuspid regurgitation severity (OR: 2.50; 95% CI: 1.33-4.71), nonanteroseptal jet location (OR: 2.46; 95% CI: 1.08-5.60), and increasing coaptation gap (HR: 1.19 per mm; 95% CI: 1.07-1.33) predicted residual tricuspid regurgitation. Residual tricuspid regurgitation ≥3+ was the only predictor suitable for pooled synthesis across endpoints and was associated with all-cause mortality (HR: 2.19; 95% CI: 1.60-3.00) and major adverse cardiovascular events (HR: 1.84; 95% CI: 1.37-2.48) (I2 = 0%-2%.) Renal dysfunction, impaired right ventricular function and remodeling, pulmonary hypertension, and right ventricular-pulmonary arterial uncoupling reflect advanced disease substrate and demonstrated consistent associations with adverse outcomes. Among surgical risk models, the European System for Cardiac Operative Risk Evaluation II score showed limited discrimination, whereas the TRI-SCORE performed better; tricuspid transcatheter edge-to-edge repair-specific clinical models remain limited, and validated procedural prediction models are emerging. Limited data suggest that an intermediate disease profile may derive the greatest benefit, but this finding is confined to single-registry analyses. Further work is required to define optimal disease-stage thresholds and develop integrated risk models incorporating procedural outcome predictors.

UNICORN TAVR in Native Complex Congenital Aortic Stenosis at High Risk of Coronary Obstruction.

BACKGROUND: Coronary artery obstruction is a rare but serious complication of transcatheter aortic valve replacement (TAVR). Undermining iatrogenic coronary obstruction with a radiofrequency needle (UNICORN) is a novel technique of intraleaflet TAVR valve deployment for mitigating this risk. There is limited experience in native aortic valve anatomy, particularly in congenital aortic stenosis. CASE SUMMARY: A 26-year-old man in cardiogenic shock secondary to severe congenital aortic stenosis was successfully treated with emergency TAVR, with leaflet modification using the UNICORN technique due to the high risk of coronary obstruction. DISCUSSION: UNICORN is a novel technique for preventing coronary obstruction in TAVR. Here we describe the first case of UNICORN in congenital aortic stenosis in cardiogenic shock at prohibitive surgical risk. TAKE-HOME MESSAGES: UNICORN can be used successfully in carefully selected native valves at risk of coronary obstruction during TAVR. Use of leaflet modification techniques such as UNICORN enables intervention in a broader cohort of patients unfit for surgery.

Balloon Rupture After Subannular Slippage During Transcatheter Aortic Valve Replacement in Extremely Calcified Anatomy.

BACKGROUND: Direct implantation of balloon-expandable transcatheter aortic valves without predilatation is increasingly performed. In patients with extreme asymmetric aortic valve calcification, this strategy may lead to rare but serious mechanical complications. CASE SUMMARY: A 77-year-old man with symptomatic severe aortic stenosis and extreme asymmetric valvular and subannular calcification underwent transfemoral transcatheter aortic valve replacement using a 29-mm balloon-expandable valve without predilatation. During valve deployment, the balloon slipped toward the left ventricular outflow tract and ruptured. Despite this complication, the valve was fully deployed with no paravalvular regurgitation. After heart team discussion, urgent surgical extraction of the ruptured balloon was performed, as percutaneous retrieval was not considered suitable. DISCUSSION: Balloon rupture during transcatheter aortic valve replacement is an exceptionally rare but potentially life-threatening complication. Extreme asymmetric calcification with subannular extension may predispose to balloon slippage and rupture. Careful preprocedural computed tomographic assessment, selective predilatation, and readiness for either percutaneous retrieval or immediate surgical bailout are essential in high-risk anatomy.

Persistent Hypoxia After Tricuspid Valve Replacement.

BACKGROUND: Transcatheter tricuspid valve replacement (TTVR) is a novel therapy for symptomatic severe tricuspid regurgitation in high-risk surgical patients. Platypnea-orthopnea syndrome has not previously been described as a complication of TTVR. CASE SUMMARY: A 76-year-old woman with symptomatic severe tricuspid regurgitation underwent successful TTVR but developed persistent hypoxia despite negative pulmonary work-up. Her hypoxia followed a platypnea-orthodeoxia pattern. Echocardiography revealed a patent foramen ovale (PFO) with right-to-left shunting. She then underwent successful percutaneous PFO closure, with resolution of her hypoxia. DISCUSSION: Acute post-TTVR anatomic and hemodynamic changes can include right atrial distortion and right ventricular dysfunction in the absence of pulmonary hypertension. These changes may acutely worsen right-sided pressures, leading to right-to-left shunting through an existing PFO. TAKE-HOME MESSAGES: Persistent hypoxia with a platypnea-orthodeoxia pattern immediately after TTVR should prompt thorough work-up including evaluation for PFO. Percutaneous PFO closure can address platypnea-orthodeoxia syndrome in this setting.

Rapid Clinical and Renal Recovery after Transcatheter Tricuspid Valve Replacement.

BACKGROUND: Severe tricuspid regurgitation (TR) is associated with heart failure symptoms and end-organ dysfunction. Many patients are considered too high risk for surgical intervention, prompting the development and increased use of transcatheter valve replacement/repair systems. CASE SUMMARY: We report the case of an 85-year-old White male with symptomatic heart failure and signs of worsening end-organ dysfunction due to torrential TR who underwent transcatheter tricuspid valve replacement (TTVR) using the Edwards Evoque system. After TTVR, the patient experienced immediate and significant improvement of heart failure symptoms. Furthermore, congestion diminished substantially. Additionally, he demonstrated significant improvement of kidney function. Signs of liver congestions also improved rapidly. DISCUSSION: This case demonstrates that treatment of severe TR using a TTVR system, even in an older, high-risk patient, can significantly improve not only clinical symptoms but also end-organ dysfunction. TAKE-HOME MESSAGE: TTVR should be considered in patients with severe TR and end-organ dysfunction.

Sex-Specific Outcomes in Patients Undergoing Mitral Valve Transcatheter Edge-to-Edge Repair: The REPAIR Study.

BACKGROUND: Mitral valve transcatheter edge-to-edge repair (M-TEER) is an established treatment for patients with mitral regurgitation (MR) at prohibitive surgical risk. Sex-specific M-TEER outcomes are mainly derived from small, historic, MR etiology-specific, or MitraClip-treated cohorts. OBJECTIVES: The objective of the study was to evaluate sex-specific outcomes in patients undergoing PASCAL M-TEER. METHODS: REgistry of PAscal for mItral Regurgitation is an investigator-initiated, multicenter M-TEER registry. Outcomes included Mitral Valve Academic Research Consortium-defined technical success, optimal result at discharge (residual MR ≤ 1+ and mean transmitral pressure gradient <5 mm Hg), and 1-year all-cause mortality. RESULTS: Among 2,601 patients, 1,150 (44.2%) were females and 1,451 (55.8%) were males. MR etiology distribution was similar between sexes (primary: 33.5% vs 32.4%; secondary: 48.9% vs 52.1%; mixed: 17.6% vs 15.6%; P = 0.219). Technical success was achieved in 97.0% vs 97.7% (P = 0.395). An optimal result was achieved more often in males (55.7% vs 65.9%; P < 0.001), driven by higher postprocedural gradients in females (mean transmitral valve pressure gradient ≥5 mm Hg: 24.0% vs 14.0%; P< 0.001), whereas residual mild or less MR was similar (71.3% vs 74.6%; P = 0.066). One-year mortality was 11.0% (95% CI: 8.7%-13.2%) vs 12.1% (95% CI: 10.1%-14.1%; P = 0.266). Residual mild or less MR was independently associated with lower 1-year mortality (adjusted HR: 0.57; 95% CI: 0.38-0.84; P = 0.005), whereas gradients <5 mm Hg were not (adjusted HR: 0.63; 95% CI: 0.40-1.01; P = 0.056). CONCLUSIONS: PASCAL M-TEER resulted in similar technical success rates and 1-year mortality across sexes, despite females achieving an optimal result less frequently, due to higher postprocedural gradients. MR reduction to mild or less was the primary determinant of improved survival, consistent across sexes.

Valve-in-Valve Transcatheter Aortic Valve Replacement After a Valve-in-Valve Transcatheter Mitral Valve Replacement.

BACKGROUND: Bioprosthetic valve failure is frequently treated with transcatheter therapies in high-surgical risk patients. Management of patients with concurrent bioprosthetic multivalvular dysfunction may require more complex decision-making and planning compared to those with isolated valve disease. CASE SUMMARY: An 84-year-old patient presented with symptomatic diastolic heart failure, with evidence of both mitral and aortic bioprosthetic valve failure on echocardiogram. He underwent sequential mitral and aortic valve-in-valve (ViV) procedures. DISCUSSION: This case highlights technical challenges and considerations for ViV transcatheter aortic valve replacement (TAVR) in patients with prior transcatheter mitral valve replacement (TMVR). TAKE-HOME MESSAGES: In patients with challenging left ventricular outflow tract anatomy, it is desirable to perform aortic ViV before mitral ViV procedures to minimize interaction of the TAVR system with the mitral prosthesis. In situations where the aortic ViV is performed after the mitral valve has been treated, anatomic challenges of a narrow left ventricular outflow tract and close proximity of the TMVR to the aortic valve can be overcome with careful procedural planning and advanced techniques.

Combined Snare and Buddy-Balloon Strategy for Failed Valve Crossing in Valve-in-Valve Transcatheter Aortic Valve Replacement.

BACKGROUND: Retrograde valve crossing during valve-in-valve transcatheter aortic valve replacement (ViV TAVR) may fail despite modern delivery systems. CASE SUMMARY: A 67-year-old man with a degenerated 27-mm Magna Ease bioprosthesis and unfavorable aortic geometry (kinked ascending aorta at a prior surgical graft site) underwent ViV TAVR, where retrograde valve crossing failed despite multiple stiff guidewires and snare traction alone. Successful delivery of a 29-mm Evolut FX+ was ultimately achieved by combining gooseneck-snare traction for coaxial realignment with a partially inflated Tyshak buddy balloon acting as a mechanical ramp across the surgical valve frame. DISCUSSION: This case demonstrates a structured, stepwise approach to managing failed valve crossing in ViV TAVR, highlighting the mechanical roles of snare traction and balloon-mediated coaxial alignment. TAKE-HOME MESSAGE: A combined snare and buddy-balloon strategy can facilitate valve delivery when conventional retrograde crossing fails during ViV TAVR.

Aortic Root and Tricuspid Annulus Reconstruction for Transcatheter Valve Replacement-Associated Infective Endocarditis in an Octogenarian.

BACKGROUND: Prosthetic valve endocarditis after transcatheter aortic valve replacement (TAVR) is a rare and life-threatening complication, particularly in elderly patients. CASE SUMMARY: An 88-year-old man with a previous TAVR was readmitted 2 months after the procedure with fever (38.6 °C). Blood cultures were positive for methicillin-resistant Staphylococcus epidermidis. We performed extensive surgical debridement and reconstruction of the aortic root and tricuspid annulus, followed by a Bentall procedure and tricuspid valve replacement. The postoperative course was favorable, with good early recovery and normally functioning prostheses at follow-up. DISCUSSION: This case illustrates that, even in octogenarian patients with prohibitive surgical risk and extensive multivalvular involvement, aggressive surgical management guided by a multidisciplinary heart team may provide favorable outcomes when medical therapy alone fails to control infection. TAKE-HOME MESSAGES: TAVR-associated prosthetic valve endocarditis may present with extensive perivalvular and multivalvular involvement. Surgical treatment, although rarely performed in this setting, can be lifesaving when guided by careful patient selection and multidisciplinary evaluation.

Transcatheter Aortic Valve Replacement in Functionally Dependent Patients: Analysis Using a Government-Adjudicated Long-Term Care Certification.

BACKGROUND: Evidence to guide treatment for functionally dependent elderly patients with severe aortic stenosis is limited, making clinical decisions challenging. OBJECTIVES: The aim of this study was to evaluate the safety and outcomes of transcatheter aortic valve replacement (TAVR) in functionally dependent elderly patients. Japan's government-mandated Long-Term Care Insurance (LTCI) grades were used as an objective measure of frailty and social dependency. METHODS: We retrospectively analyzed consecutive patients with verified LTCI data undergoing TAVR at a single high-volume center between 2019 and 2023. Outcomes included all-cause and cardiovascular mortality, heart failure rehospitalization, NYHA functional class, and the VARC-3 (Valve Academic Research Consortium-3) unfavorable outcome. RESULTS: A total of 649 patients with verified LTCI status were retrospectively analyzed. Of these, 101 (15.6%) and 179 (27.6%) were certified as requiring support and long-term care, respectively. Among the 3 groups, the long-term care group was older, more predominantly female, and exhibited higher levels of frailty, higher surgical risk, and more severe heart failure symptoms. Technical success exceeded 98% across all groups. Long-term care patients displayed a 2-fold higher risk of 2-year all-cause mortality (adjusted HR: 2.03; 95% CI: 1.35-3.09), whereas the support group had similar risk to the independent group (adjusted HR: 1.11; 95% CI: 0.62-1.98). Cardiovascular mortality and heart failure rehospitalization were similarly low across all strata. The VARC-3 unfavorable outcome occurred in 8.7%, 6.9%, and 14.0% of the independent, support, and long-term care groups, respectively (P = 0.096). CONCLUSIONS: TAVR was technically safe and potentially provided benefit even in care-dependent elderly patients. Functional dependence alone should not preclude referral for TAVR.

Percutaneous Closure of a Giant Secundum Atrial Septal Defect Using 2 Sutured Occluders.

BACKGROUND: Giant secundum atrial septal defects (ASDs) are generally considered unsuitable for transcatheter closure and often require surgical repair. Innovative percutaneous strategies may provide an alternative in prohibitive-risk patients. CASE SUMMARY: A 75-year-old man with a giant secundum ASD (64.5 × 38.8 mm), severe mitral and tricuspid regurgitation, pulmonary hypertension, atrial fibrillation, cirrhosis, and chronic kidney disease was deemed inoperable. After staged mitral and tricuspid transcatheter edge-to-edge repair, the ASD was successfully closed using two 38-mm septal occluder devices sutured together ex vivo and simultaneously deployed, resulting in stable device position without residual shunt. DISCUSSION: This case demonstrates a novel percutaneous strategy for closure of exceptionally large ASDs exceeding currently available occluder size limits. TAKE-HOME MESSAGE: Percutaneous closure of giant ASDs may be feasible in selected prohibitive-risk patients using coupled occluder devices.

Transcatheter Mitral Valve Replacement Using a Dedicated Mitral Valve System.

BACKGROUND: Mitral valve regurgitation is a highly prevalent disease in elderly population that causes significant morbidity and mortality. CASE SUMMARY: A 77-year-old male presented with worsening functional class and asthenia. A transthoracic and transesophageal echocardiography showed severe mitral regurgitation (MR). The patient underwent transcatheter mitral replacement procedure. DISCUSSION: The treatment of severe MR in patients with high surgical risk remains a clinical challenge. Transcatheter mitral edge-to-edge repair is an established therapy in secondary MR; however, transcatheter mitral valve replacement (TMVR) may be an option in some patients with non-optimal anatomic features such as degenerative MR. Cardiac computed tomography planification is needed to guide the procedure and reduce potential complications. TAKE-HOME MESSAGES: TMVR is a feasible and effective alternative in patients with severe degenerative MR, high surgical risk, and unfavorable anatomy for edge-to-edge repair. The Cardiovalve system enables fully transfemoral transseptal TMVR with a low-profile design, achieving effective MR reduction while minimizing the risk of left ventricular outflow tract obstruction.

TAVR in a Small Surgical Bioprosthesis With a Kinked Aortic Graft Using an Intra-Annular Self-Expanding Valve.

OBJECTIVE: To demonstrate transcatheter aortic valve-in-valve replacement in a small surgical bioprosthesis with a kinked aortic root graft using an intra-annular self-expanding valve. KEY STEPS: Balloon valve fracture to enable implantation of a larger balloon-expandable valve was excluded because of prior root replacement. A supra-annular self-expanding valve with a single-spine shaft was considered unfavorable for the kinked aortic graft. A 23-mm Navitor Vision valve was successfully deployed over a Lunderquist guidewire, with pre- and postdilatation using a 21-mm True balloon. POTENTIAL PITFALLS: Use of a small balloon-expandable valve could have resulted in unfavorable hemodynamics and increased risk of valve dislodgement during advancement of a naked valve across the kinked aortic graft. A supra-annular self-expanding valve with a single-spine shaft could have posed difficulty crossing the kinked graft in the small surgical bioprosthesis. TAKE-HOME MESSAGE: A small degenerated surgical bioprosthesis with a kinked aortic graft can be successfully treated with an intra-annular self-expanding valve.

Balloon-Assisted Leaflet Laceration Using Modified UNICORN Technique in Native Valve TAVR.

OBJECTIVE: Coronary obstruction due to displacement of calcified native valve leaflets over the coronary ostia is a life-threatening complication of transcatheter aortic valve replacement (TAVR). Undermining iatrogenic coronary obstruction with radiofrequency needle (UNICORN) has emerged as an innovative electrosurgical method for preventing coronary obstruction, primarily in valve-in-valve TAVR. A native-valve modification is described. KEY STEPS: First, the target leaflet is traversed using transcatheter electrosurgery with angiographic and echocardiographic guidance. Then a series of balloon valvotomies are performed followed by leaflet laceration with a large noncompliant balloon before implantation of the balloon-expandable transcatheter heart valve. POTENTIAL PITFALLS: Malalignment in traversing the target aortic leaflet can lead to ineffective splay or damage to nearby structures. TAKE-HOME MESSAGE: The modified UNICORN TAVR technique is an alternative to bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction when bulky leaflet calcification is present at the leaflet tip, while also preserving superior coronary access compared with the snorkel technique.

High-Risk Valve-in-Valve TAVR With Chronic Type B Aortic Dissection.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a challenge in patients with chronic aortic dissection given risk of intraoperative dissection extension. There are limited prior case reports. CASE SUMMARY: A 45-year-old man with a history of repaired type A dissection and aortic valve replacement with residual type B dissection presented in cardiogenic shock due to severe prosthetic valve stenosis. Because of his surgical risk and rapid decompensation, a valve-in-valve TAVR was successfully performed, followed by resolution of cardiogenic shock. DISCUSSION: We demonstrate a successful valve-in-valve TAVR in a patient with known type B dissection in the setting of hemodynamic deterioration. TAKE-HOME MESSAGES: TAVR is uniquely challenging in patients with type B aortic dissection but is feasible in the acute setting. Femoral access requires special attention to ensure entry into the true lumen.

Redo Transcatheter Aortic Valve Replacement for Degenerated Valve With High-Risk Coronary Anatomy.

OBJECTIVES: Here we describe a step-by-step, imaging-guided technical approach to redo transcatheter aortic valve replacement (TAVR) in a degenerated ACURATE Neo2 valve (Boston Scientific) with high-risk right coronary artery (RCA) anatomy and highlight strategies to prevent coronary obstruction during valve-in-valve implantation. KEY PROCEDURAL STEPS: A 76-year-old man who previously underwent TAVR using a 27-mm ACURATE Neo2 valve presented with heart failure due to severe prosthetic aortic regurgitation. Preprocedural computed tomography demonstrated a critically high-risk anatomy for RCA obstruction, with the coronary ostium originating between the upper and lower crowns of the Neo2 frame and limited sinus of Valsalva accommodation. Because of his prohibitive surgical risk, redo TAVR was performed using a 26-mm SAPIEN 3 valve (Edwards Lifesciences). The procedure incorporated meticulous computer tomography-based planning, prophylactic RCA wiring for coronary protection, and stepwise, high and controlled valve deployment with real-time positional adjustments to achieve precise alignment at the Neo2 upper crown. POTENTIAL PITFALLS: Valve-specific ACURATE Neo2 geometry increases coronary obstruction risk, making careful imaging, valve selection, and coronary protection essential.

Transcatheter Edge-to-Edge Repair in a Patient With Severe Degenerative Mitral Regurgitation and Mirror-Image Dextrocardia.

BACKGROUND: Managing severe degenerative mitral regurgitation (MR) in patients with mirror-image dextrocardia is challenging given the rare, complex anatomy. Transcatheter edge-to-edge repair (TEER) offers a minimally invasive alternative for patients at high surgical risk. CASE SUMMARY: A 76-year-old woman with dextrocardia presented with NYHA functional class III heart failure due to severe MR from anterior leaflet flail. Given prohibitive surgical risk, she successfully underwent TEER with 2 MitraClip XTR devices. Adaptations for the mirrored anatomy included a modified transseptal puncture site and reversed catheter maneuvering. Postprocedural MR was reduced to trivial without stenosis, with rapid symptomatic improvement. DISCUSSION: This case confirms the feasibility of TEER for degenerative MR in dextrocardia. TAKE-HOME MESSAGE: TEER for degenerative MR in dextrocardia is critically dependent on preprocedural planning and specific intraoperative modifications to accommodate the reversed anatomy, expanding minimally invasive options for high-risk patients with complex cardiac conditions.

Electrosurgical Leaflet Modification in TAVR Adoption and Adaptation Across the Asia-Pacific Region.

Modification of Calcified Native and Surgical Bioprosthetic Aortic Valves: Lessons From the Bench.

BACKGROUND: Leaflet modification (LM) techniques, including electrosurgical and mechanical BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) and intraleaflet deployment, are important in the lifetime management of aortic valve disease. However, benchtop assessment is limited. OBJECTIVES: The aim of this study was to provide a benchtop assessment of LM in native valves and bioprosthetic surgical aortic valves (SAVs). METHODS: Features of calcific native aortic valves (n = 100) and naive SAVs (7 types) were assessed. Calcific native cusps (n = 13) and SAV leaflets (n = 14) stratified by calcific load were modified by electrosurgical or mechanical BASILICA or intraleaflet deployment with assessment of splay, laceration patterns, and embolic debris. The impact of leaflet length and valve-in-valve implantation on splay area was analyzed. RESULTS: In native cusps, calcification in traversal and laceration zones was common (89% and 97%, respectively). LM was feasible across calcification severities, although increasing calcification was associated with laceration difficulty (P = 0.028), leaflet tears (P = 0.02), and increased embolic debris (P < 0.05). Leaflet splay decreased with shortening of leaflet length (68.9% ± 10.7% at 5 mm; R2 = 0.72) and increased with simulated valve expansion in a limited analysis. In SAVs, neoskirt heights and features varied. LM was feasible across SAV leaflet calcification levels. No overall association between calcification and debris was observed; however, in a restricted subset, higher calcification was associated with increased debris (P = 0.035). SAV leaflet splay decreased with leaflet length (80.2% ± 8.8% at 5 mm; R2 = 0.84) and generally increased with simulated valve expansion, but this varied by SAV type. CONCLUSIONS: Features of native aortic valves and SAVs impact the efficacy of LM. LM is feasible across a spectrum of calcific disease. Further study is required.

UNICORN During Transcatheter Aortic Valve Replacement in Native and Bioprosthetic Aortic Valves: A Multicenter Study.

BACKGROUND: UNICORN (undermining coronary obstruction with radiofrequency "needle") has been adopted by some operators to prevent coronary obstruction during transcatheter aortic valve replacement (TAVR). More clinical data are needed to evaluate UNICORN outcomes. OBJECTIVES: The aim of this study is to describe preliminary outcomes of UNICORN during TAVR. METHODS: Nine sites contributed consecutive patients undergoing UNICORN TAVR from March 2024 to May 2025. Primary success was UNICORN TAVR without composite periprocedural coronary obstruction, reintervention, or death. Primary safety endpoints were intraprocedural hypotension plus overall 30-day safety, which included 30-day death, stroke, coronary obstruction requiring reintervention, stage 3 or 4 acute kidney injury, life-threatening bleeding, major vascular complication, and valve-related reintervention. Two UNICORN techniques, intraleaflet deployment and full-leaflet tearing, were used. RESULTS: Fifty-three patients (8 native aortic valves, 30 surgical valves, and 15 transcatheter valves) were included. Left-sided and right-sided UNICORN procedures were performed in 30 (57%) and 19 (36%), respectively. UNICORN was bilateral in 4 (8%). Eleven (21%) underwent contralateral BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction), and 3 (6%) received contralateral snorkel-stent protection. Forty patients (76%) underwent intraleaflet deployment, and 13 (24%) underwent full-leaflet tearing. Primary success occurred in 51 patients (96%). Two (4%) experienced coronary obstruction and required rescue percutaneous coronary intervention. Overall 30-day safety was observed in 46 patients (87%), with strokes in 3 (6%), life-threatening bleeding in 2 (4%), and major vascular complications in 2 (4%). Intraprocedural hypotension occurred in 12 (23%). There were no deaths, valve-related reinterventions, or stage 3 to 4 acute kidney injury at 30 days. CONCLUSIONS: UNICORN during TAVR was successful in preventing coronary obstruction. Intraprocedural hypotension requiring vasopressor support was frequent. UNICORN should be considered in cases in which lower risk options are unlikely to be successful.

The ELASTA-T Technique for TTVR After Failed T-TEER: An Operator-Oriented Guide to Planning, Execution, Pitfalls.

Failure of tricuspid transcatheter edge-to-edge repair (T-TEER) with persistent severe tricuspid regurgitation (TR) is an increasingly encountered clinical scenario in contemporary structural heart disease treatment. In this setting, transcatheter tricuspid valve replacement (TTVR) is emerging as an effective therapeutic option for recurrent TR after T-TEER. However, the presence of pre-existing tricuspid edge-to-edge devices significantly alters valve geometry, creating a fixed multiple-orifice configuration that may impair coaxial device crossing, generate asymmetrical expansion forces, and compromise anchoring conditions during valve implantation. ELASTA-T (Electrosurgical LAceration and STAbilization of T-TEER devices with a TTVR system) has been developed as a catheter-based strategy to selectively detach one leaflet from the T-TEER device while preserving attachment to the opposing leaflet, thereby restoring a functionally single-orifice configuration prior to valve implantation. This paper provides a comprehensive, practical, operator-oriented technical framework for performing ELASTA-T before TTVR using the EVOQUE system. The authors describe a structured approach integrating preprocedural planning to define T-TEER device position, commissural relationships, leaflet geometry, and subvalvular anatomy. Detailed step-by-step procedural guidance is provided, including dual-catheter valve crossing, snaring system creation, electrosurgical "flying V" and "flying U" wire preparation, controlled leaflet-T-TEER device laceration, and subsequent transcatheter tricuspid valve deployment. Key technical considerations, procedural pitfalls, and troubleshooting strategies are also discussed to improve safety and reproducibility. Through this structured approach, the aim of this review is to describe this emerging procedural technique and facilitate its adoption among structural heart operators.

Percutaneous Closure of Left Ventricular Apex Perforation After Transcatheter Aortic Valve Replacement Valve-in-Valve.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) valve-in-valve (ViV) is a less invasive alternative to redo surgery for high-risk patients with failed bioprosthetic aortic valves. Left ventricular (LV) perforation is a rare but potentially life-threatening complication, typically requiring surgical repair. Percutaneous closure is seldom reported. CASE SUMMARY: An 80-year-old man with NYHA functional class III symptoms from severe degenerative transvalvular bioprosthetic aortic regurgitation underwent TAVR ViV. Postprocedure transthoracic echocardiogram and computed tomography scan revealed a small, contained LV apex perforation, likely iatrogenic from guidewire manipulation. This was successfully closed percutaneously using an Amplatzer Vascular Plug II. DISCUSSION: This case highlights importance of high-quality post-TAVR ViV transthoracic echocardiography and safety of percutaneous closure of LV apex perforation compared with surgical repair. TAKE-HOME MESSAGES: LV apex perforation is a rare but serious complication of TAVR. Percutaneous closure may avoid high-risk surgery in suitable cases.

Feasibility of Robotic Hybrid CABG and Transcarotid TAVI for Severe Aortic Stenosis and Coronary Disease.

BACKGROUND: Managing severe aortic stenosis and multivessel coronary disease is challenging in patients with elevated surgical risk and hostile iliofemoral anatomy. CASE SUMMARY: A 70-year-old man with severe aortic stenosis, multivessel coronary disease, and advanced peripheral artery disease presented with decompensated heart failure. Given prohibitive transfemoral access and elevated surgical risk, a single-admission staged hybrid strategy was pursued. The patient underwent robotic hybrid coronary aortic bypass grafting (RHCABG), followed 48 hours later by transcarotid transcatheter aortic valve implantation (TAVI). Both procedures succeeded, yielding an uncomplicated recovery and marked functional improvement. DISCUSSION: This case demonstrates the feasibility of combining RHCABG with alternative-access transcatheter valve replacement for high-risk patients unsuitable for conventional surgery. TAKE-HOME MESSAGES: Combining RHCABG and transcarotid TAVI is feasible for high-risk patients. Transcarotid access is a valuable TAVI alternative given hostile iliofemoral anatomy. Single-admission staged hybrid procedures may reduce overall morbidity and recovery time.

Successful Balloon Valvuloplasty for Paravalvular Leak 4 Months After TAVR in a Bicuspid Aortic Valve.

BACKGROUND: Late detection of paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) presents unique treatment challenges, especially in bicuspid valves, likely because of valve geometry and the mechanism of percutaneous anchoring. CASE SUMMARY: A 70-year-old man underwent TAVR for bicuspid aortic stenosis using a balloon-expandable valve. Moderate to severe PVL was detected 4 months later. A multidisciplinary team evaluated the PVL etiology, patient anatomy, and available treatment options including valve-in-valve and plug closure. A partially fused commissural raphe causing focal underexpansion was identified as the origin of PVL, and late balloon valvuloplasty was performed successfully. DISCUSSION: Unlike surgical-valve PVL, where percutaneous plug closure is the main treatment option, post-TAVR PVL offers additional approaches. Multimodality imaging helps define mechanism, feasibility, and risk. TAKE-HOME MESSAGES: Late balloon valvuloplasty is a safe option for underexpanded TAVR in bicuspid valves. Assessment of calcified raphe anatomy and the underexpansion site guides procedural risk and informs treatment selection.

Leaflet Splitting to Prevent TAVR-Induced Coronary Obstruction in Stented vs Stentless Surgical Bioprosthetic Valves.

BACKGROUND: Transcatheter electrosurgical leaflet splitting prevents coronary artery obstruction (CAO) following transcatheter aortic valve replacement (TAVR), particularly in valve-in-valve interventions. Morphologic and fluoroscopic differences between stented and stentless valves may affect outcomes, but comparative data are limited. OBJECTIVES: The aim of this study was to compare procedural characteristics and outcomes of BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic CAO) and TAVR in stented vs stentless surgical bioprosthetic valves. METHODS: A total of 131 patients undergoing BASILICA and valve-in-valve TAVR from the multicenter EURO-BASILICA registry were included. Patients were stratified by valve type (stented vs stentless), and outcomes were described according to Valve Academic Research Consortium 3 recommendations. RESULTS: Overall, 115 patients (87.8%) had stented valves and 16 (12.2%) had stentless valves. Risk for CAO was comparable, but stentless valves had longer leaflets (17.0 vs 14.0 mm; P < 0.001). Procedures in stentless valves required more contrast medium (174.0 vs 91.0 mL; P < 0.001) and longer fluoroscopy (61.7 vs 41.0 min; P = 0.023) and showed a trend toward longer procedure time. Technical success was similar, but stentless valves were associated with a significantly higher rate of target leaflet-related CAO (44.4% vs 7.1%; P < 0.001), which was mainly partial and non-flow-limiting (33.3% vs 3.9%; P < 0.001). In-hospital complications and 30-day outcomes were similar. No late CAO or myocardial infarction occurred during 1-year follow-up. CONCLUSIONS: BASILICA is technically feasible for both stented and stentless valves. However, stentless valves had a higher rate of partial CAO after BASILICA and TAVR and may therefore require additional or alternative coronary artery protection measures in selected patients.

Aortic Valve Leaflet Modification: A Working Group Position Statement on Best Practices and Step-by-Step Guide.

Coronary artery obstruction is a potential life-threatening complication of transcatheter aortic valve replacement (TAVR) in all settings including native, valve-in-valve, and redo-TAVR. Risk of obstruction can be identified on preprocedural computed tomography. BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) effectively prevents TAVR-induced coronary obstruction. Perceived technical complexity, limited availability of purpose-built devices, and scarce training opportunities have hindered the adoption of BASILICA and related techniques. This document synthesizes international experience to provide contemporary best-practice guidance for BASILICA and related leaflet modification strategies. This state-of-the-art review details transcatheter electrosurgery principles; how to determine risk and computed tomographic risk analysis and plan the procedures; a step-by-step guide to electrosurgical BASILICA; tips and tricks for uncommon challenges; scenarios in which BASILICA is unlikely to succeed; and variant techniques such as intraleaflet valve deployment, alternative measures, and dedicated devices. These contemporary best practices can help operators gain or maintain proficiency.

Sex-Specific and Time-Dependent Outcomes After TAVR Versus SAVR: A Meta-Analysis of Randomized Trials.

BACKGROUND: Sex differences in outcomes after transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) have been reported, but their variation over time and across surgical risk strata remains uncertain. OBJECTIVES: The objective of the study was to evaluate sex-specific and time-dependent outcomes of TAVR vs SAVR and the influence of baseline surgical risk. METHODS: PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched through January 18, 2026. Randomized controlled trials reporting sex-stratified, mortality-inclusive primary endpoints with ≥1-year follow-up were included. Pooled risk ratios (RRs) were estimated using random-effects models, with prespecified analyses by sex and surgical risk and exploratory meta-regression. RESULTS: Nine trials (N = 9,583; 44.2% women) were included. In women, TAVR was associated with lower risk at 1 and 2 years vs SAVR (1 year: RR: 0.67; 95% CI: 0.55-0.81; 2 years: RR: 0.80; 95% CI: 0.69-0.94), with no significant difference at 5 years (RR: 1.03; 95% CI: 0.89-1.18). In men, no significant differences were observed across time points. By surgical risk, early benefit with TAVR in women was more evident in intermediate-high-risk patients, whereas at 5 years a higher risk with TAVR was observed in men; no clear sex differences were seen in low-risk patients. Meta-regression showed no significant effect modification by age, surgical risk, or atrial fibrillation prevalence. CONCLUSIONS: Outcomes after aortic valve replacement vary by sex, surgical risk, and time. TAVR was associated with early benefit in women, particularly in intermediate-high-risk patients, with convergence over longer follow-up, whereas men showed no significant differences across time points, with higher risk observed with TAVR at 5 years in intermediate-high-risk patients. (Sex Differences in Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement: An Updated Meta-Analysis of Randomized Controlled Trials; CRD420261287967).

Multicenter Experience of Aortic Valve Leaflet Modification in TAVR: From the Asia-Pacific Electrosurgery Working Group.

BACKGROUND: Safety and efficacy of leaflet modification in transcatheter aortic valve replacement (TAVR) to reduce coronary obstruction risk have been demonstrated in North American and European populations, but real-world data from the Asia-Pacific remain limited. OBJECTIVES: The authors aimed to report the real-world procedural and clinical outcomes of bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) and undermining iatrogenic coronary obstruction with radiofrequency needle (UNICORN) leaflet modification techniques during TAVR in Asia-Pacific. METHODS: This multicenter retrospective observational registry included consecutive patients undergoing aortic valve leaflet modification during TAVR across 7 centers in the Asia-Pacific from April 2019 to January 2026. Primary outcome was procedural success, defined as successful leaflet traversal, leaflet modification, and transcatheter heart valve implantation without coronary obstruction, emergent surgery, stroke, or mortality in 30 days. Secondary outcomes included 30-day major adverse events per the Valve Academic Research Consortium 3 definitions. RESULTS: Among 100 patients, 72.2% were female with a median age of 80.0 years. BASILICA was performed in 67.0%, UNICORN in 30.0%, and BASILICA-UNICORN in 3.00%. Annual case volume increased nearly 10-fold during the study period. Index valves were predominantly small (≤21 mm) surgical bioprostheses. Procedural success was achieved in 85.1% of BASILICA patients and 96.7% of UNICORN patients. Coronary obstruction occurred in 2.99% of BASILICA patients. CONCLUSIONS: Transcatheter electrosurgical leaflet modification techniques are associated with acceptable short-term outcome in high-risk patients undergoing TAVR in the Asia-Pacific region.

Transcatheter Tricuspid Valve Replacement for Severe Tricuspid Regurgitation Post-Left Ventricular Assist Device.

BACKGROUND: The presence of severe tricuspid regurgitation (TR) in patients supported with durable left ventricular assist devices (LVADs) is associated with increased morbidity and mortality. The role of transcatheter interventions remains limited, but represents a promising therapeutic frontier. CASE SUMMARY: A 62-year-old woman with chemotherapy-induced cardiomyopathy underwent HeartMate 3 LVAD implantation, complicated by progressive right ventricular (RV) dilation, severe annular dilation, and torrential secondary TR with marked leaflet malcoaptation. Despite guideline-directed medical therapy and chronic inotropic support, she developed refractory RV failure with a ventricularized right atrial waveform on catheterization. Given prohibitive surgical risk, transfemoral transcatheter tricuspid valve replacement (TTVR) with a 56-mm Edwards EVOQUE valve was performed, resulting in near-complete TR elimination, improved RV-pulmonary artery coupling, and clinical recovery. DISCUSSION: This case illustrates TTVR as a viable therapy for refractory TR and RV failure in select LVAD-supported patients. TAKE-HOME MESSAGE: TTVR offers a definitive alternative for post-LVAD severe TR when surgical repair is not feasible.

Treatment of Acute M3 Thrombosis.

BACKGROUND: The Edwards SAPIEN M3 transcatheter mitral valve replacement (TMVR) has demonstrated safety and efficacy in the treatment of symptomatic patients with mitral valve disease for whom commercially available surgical or transcatheter treatment options are deemed unsuitable. We present a case of acute M3 thrombosis due to oral anticoagulation nonadherence, complicated by cardiogenic shock, successfully treated with valve-in-valve intervention. CASE SUMMARY: A 58-year-old woman with recent M3 TMVR presented with cardiogenic shock, and was found to have prosthetic valve thrombosis with elevated gradients across the mitral valve and heavy clot burden causing severe mitral stenosis. After worsening hemodynamic parameters with thrombolytic therapy alone, emergent valve-in-valve TMVR was performed with successful implantation of a 29-mm Edwards SAPIEN S3 Ultra Resilia valve inside the Encircle M3 valve. DISCUSSION: We demonstrate the effective management of a rare but serious complication of TMVR with prosthetic valve thrombosis successfully treated with valve-in-valve reintervention. TAKE-HOME MESSAGES: Valve thrombosis remains a clinically significant complication in next-generation transcatheter mitral valve systems, emphasizing the need for vigilant anticoagulation management and early diagnostic consideration. For patients with high surgical risk who present with acute thrombosis, ad hoc valve-in-valve reintervention is an effective treatment option.

Mitral Valve Entrapment of Preshaped Guidewire During TAVI.

CASE SUMMARY: We report a case of acute mitral regurgitation caused by a stiff guidewire entrapment in the subvalvular apparatus during transcatheter aortic valve implantation. Early detection by the multidisciplinary Heart Team enabled prompt conversion to successful minimally invasive surgery for mitral repair. TAKE-HOME MESSAGE: Mitral injury due to guidewire entrapment is a rare, life-threatening transcatheter aortic valve implantation complication. Key to success is the early recognition of pathognomonic echocardiographic features and immediate surgical bailout. Minimally invasive surgery is a safe, effective rescue strategy. Maintaining a hybrid environment with a scrubbed cardiac surgeon is essential to optimize outcomes in such high-risk, unexpected scenarios.

Managing Aortic Regurgitation and Dynamic Aortic Thrombus in a Patient With Left Ventricular Assist Device.

BACKGROUND: Patients with end-stage heart failure undergoing durable left ventricular assist device (dLVAD) implantation are at risk of developing de novo or progressive aortic regurgitation (AR) during long-term support. CASE SUMMARY: We report a dLVAD patient with significant AR, in whom transcatheter aortic valve replacement was unsuitable because of an enlarged aortic annulus and aortic thrombus. A complex hybrid approach included open thrombus removal from the ascending aorta under short circulatory arrest, temporary interventional occlusion of a not-accessible dLVAD outflow-graft, and surgical aortic valve replacement (SAVR). DISCUSSION: Aortic thrombus in dLVAD patients carries the risk of coronary, cerebral or peripheral embolism. In addition to this contraindication, SAVR was favored over transcatheter aortic valve replacement because of an aortic annulus diameter >28 mm, according to the institutional treatment algorithm. TAKE-HOME MESSAGE: In a dLVAD patient with AR and aortic thrombus, an individualized hybrid strategy enabled effective outflow-graft occlusion facilitating safe thrombus evacuation and SAVR.

Impact of Aortic Annulus Size on Outcomes After Aortic Valve Replacement: The PARTNER 3 Trial.

BACKGROUND: There are limited studies comparing the impact of transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) by annular size. OBJECTIVES: The aim of this post hoc analysis from the PARTNER (Placement of Aortic Transcatheter Valves) 3 trial was to assess the relationship between annular size and outcomes among patients with severe aortic stenosis (AS) who underwent TAVR or SAVR. METHODS: Low-risk patients with severe, symptomatic AS were randomized to TAVR using the balloon-expandable SAPIEN 3 valve or SAVR. Patients were stratified by computed tomographic angiography-derived aortic annular area (small, ≤430 mm2; large, >430 mm2). The primary endpoint was the composite of death, stroke, or rehospitalization. Interactions among annular size, treatment strategy, and adjudicated 5-year clinical outcomes were assessed. RESULTS: Of the 925 patients with available computed tomographic angiography-derived annular size, 293 had small and 632 had large aortic annuli, respectively. Median follow-up duration was 5.2 years (Q1-Q3: 5.0-6.0 years). Five-year rates of the primary endpoint were similar for TAVR and SAVR in the overall cohort, results that were consistent for patients with small (21.2% vs 31.0%; OR: 0.60; 95% CI: 0.35-1.02) and large (23.5% vs 25.5%; OR: 0.90; 95% CI: 0.62-1.29) annuli, without effect modification by annular size (P for interaction = 0.22). Rates of bioprosthetic valve failure were similar and low at 5 years, without effect modification by annular size. Five-year health status was also similar between treatment modalities across annulus strata (P for interaction = 0.12). CONCLUSIONS: TAVR with the SAPIEN 3 valve led to similar 5-year clinical and health status outcomes compared with SAVR, irrespective of annular size. (PARTNER 3 Trial: Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis [P3]; NCT02675114).

From High-Risk to High-Reward: Surgical Rescue After TAVR: Prosthetic Valve Endocarditis.

Bioprosthetic Valve Fracture During Valve-in-Valve TAVR in a Degenerated Braile Aortic Valve.

BACKGROUND: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) in degenerated surgical bioprostheses, including less characterized valves such as those manufactured by Braile Biomédica, may be limited by constrained expansion and high residual gradients, particularly in small surgical valves. CASE SUMMARY: An 89-year-old man presented with acute heart failure due to degeneration of a 23-mm Braile surgical aortic bioprosthesis with inherently small true internal diameter. ViV-TAVR with a 23-mm self-expanding valve resulted in a high residual gradient despite appropriate positioning. Given the absence of alternative therapeutic options, intentional high-pressure postdilatation using a noncompliant balloon was performed. This achieved bioprosthetic valve fracture (BVF), confirmed by fluoroscopy and computed tomography, leading to optimal transcatheter valve expansion, marked gradient reduction, and clinical improvement. DISCUSSION: This case provides imaging-confirmed evidence of BVF in a degenerated Braile valve performed in the clinical setting, establishing the structural behavior of this specific prosthesis in human anatomy. TAKE-HOME MESSAGES: Small surgical bioprostheses with limited or poorly characterized true internal diameter are at high risk for severe residual gradients after ViV-TAVR. BVF, guided by multimodality imaging, can be a decisive strategy to optimize transcatheter valve expansion and hemodynamics.

Leaflet-to-Ring Edge-to-Edge Repair With Paravalvular Leak Closure for Dehisced Surgical Mitral Annuloplasty.

BACKGROUND: Percutaneous mitral valve repair after surgical annuloplasty is not well described but represents an important therapeutic option for patients with prohibitive risk for redo surgery. CASE SUMMARY: An 85-year-old man with symptomatic severe mitral regurgitation and hemolysis following prior mitral annuloplasty with a SimpliciT incomplete flexible band presented with anterior leaflet prolapse, a markedly deficient posterior leaflet, and posterior ring dehiscence. He underwent a combined percutaneous strategy of mitral transcatheter edge-to-edge repair (M-TEER) with anterior leaflet-to-annuloplasty ring clipping and paravalvular leak (PVL) closure using a vascular plug, resulting in reduction of mitral regurgitation from severe to mild-to-moderate and resolution of hemolysis. DISCUSSION: Annuloplasty ring dehiscence is generally considered unfavorable for transcatheter mitral valve replacement with current-generation devices, leaving limited percutaneous treatment options for patients with recurrent mitral regurgitation after surgery. This case demonstrates the feasibility of combining M-TEER with PVL closure to address complex mixed intravalvular and paravalvular regurgitation in high-risk patients. TAKE-HOME MESSAGES: Combined M-TEER and PVL closure is an effective solution for recurrent mitral regurgitation in selected patients with deficient leaflet anatomy and annuloplasty ring dehiscence when guided by careful imaging and multidisciplinary heart team planning.

Sex-Related Differences in Outcomes and Thresholds for Intervention in Primary Mitral Regurgitation: A Systematic Review and Meta-Analysis.

BACKGROUND: Evidence on sex differences in outcomes after interventions for primary mitral regurgitation (PMR) remains conflicting. The authors performed a dedicated meta-analysis to examine whether guideline-recommended thresholds for intervention may contribute to these discrepancies. METHODS: Electronic databases were searched for studies reporting long-term outcomes of patients undergoing surgical or transcatheter interventions for PMR, stratified by sex. The primary endpoint was all-cause mortality, and the secondary endpoint was major adverse cardiovascular events. Reconstructed time-to-event individual patient data were used to derive frailty-adjusted Cox models and restricted mean survival time. To investigate whether sex-based differences in baseline characteristics had a modulating effect on differences in all-cause mortality, meta-regression was performed on individual patient data-derived HRs using a linear mixed-effects model. RESULTS: Across 17 studies (N = 25,690), women comprised the minority (n = 9,632, 37.5%) and were significantly older (mean difference: 3.2 years, 95% CI: 2.2-4.3) with a greater proportion of heart failure symptoms (OR: 1.8; 95% CI: 1.6-2.1). At 15.7 years of follow-up, women had significantly greater risk of all-cause mortality compared with men (HR: 1.15; 95% CI: 1.07-1.24), corresponding to a survival deficit of 5.8 months (95% CI: 3.7-7.7). Similar results were observed in sensitivity analyses restricted to surgical intervention studies (HR: 1.18; 95% CI: 1.10-1.27). Female sex was also associated with significantly increased major adverse cardiovascular events (n = 2,775) (HR: 1.37; 95% CI: 1.11-1.70; Δ restricted mean survival time: 8.5 months, 95% CI: 2.4-14.5). Age, ≥ moderate tricuspid regurgitation (TR), and concomitant tricuspid valve repair (TVr) emerged as significant moderators of sex differences in mortality after intervention for PMR (P < 0.001, P = 0.03, and P < 0.001, respectively). A greater proportion of ≥ moderate TR and TVr in women conferred increased mortality relative to men. Neither left ventricular nor left atrial parameters significantly moderated sex differences in all-cause mortality (all P > 0.05). CONCLUSIONS: At the time of PMR intervention, women are older, have more symptoms, and worse long-term outcomes compared with men. Older female age alongside higher prevalence of ≥ moderate TR and TVr explained a significant proportion of this heterogeneity in sex-related all-cause mortality, whereas differences in left ventricular and left atrial parameters had no significant influence. A careful appraisal of current guidelines to ensure equality of health care outcomes between sexes is warranted.

Valve-in-Valve Implantation for Early Failure of a Transcatheter Tricuspid Valve.

BACKGROUND: Transcatheter tricuspid valve replacement (TTVR) is increasingly used for severe tricuspid regurgitation in high-risk patients. Early prosthetic dysfunction may occur, but management strategies remain poorly described. CASE SUMMARY: A 79-year-old woman presented with cardiogenic shock 6 months after Topaz TTVR. Echocardiography and computed tomography showed leaflet thickening involving 2 of 3 leaflets with a mean gradient of 9 mm Hg. Endocarditis was excluded, and anticoagulation optimization failed. Because of persistent catecholamine dependence and prohibitive surgical risk, the heart team selected transcatheter valve-in-valve implantation. Bench testing using a computed tomography-derived 3-dimensional printed model guided a 29-mm Sapien 3 valve implantation, reducing the gradient to 1 mm Hg with no residual regurgitation. DISCUSSION: Valve-in-valve implantation may be an effective rescue strategy after failed TTVR. Patient-specific bench testing improves procedural planning and procedural safety. TAKE-HOME MESSAGES: Early dysfunction of TTVR prostheses requires prompt multimodality evaluation. Bench-guided transcatheter valve-in-valve implantation can safely avoid high-risk redo surgery.

Cross-Organ Recovery After Transcatheter Tricuspid Valve Replacement With Diuretic and Antiviral Discontinuation: Beyond Cardiac Function.

BACKGROUND: Transcatheter tricuspid valve replacement (TTVR) is an emerging option for patients with severe tricuspid regurgitation (TR) at prohibitive surgical risk. Severe TR is associated with systemic venous congestion, multiorgan dysfunction, and high mortality, yet isolated tricuspid surgery is rarely performed. CASE SUMMARY: A 68-year-old woman with prior double mechanical valve replacement, chronic kidney disease, and hepatitis B, treated with entecavir, presented with dyspnea and edema. Imaging revealed torrential TR with a 43-mm annulus. Because of high surgical risk, she underwent successful TTVR. TR abolition allowed cessation of diuretics and antiviral therapy after normalization of hepatic tests and viral load. DISCUSSION: This case illustrates how TTVR-mediated venous decongestion can reverse renal and hepatic alterations and enable cessation of supportive therapies. TAKE-HOME MESSAGES: TTVR can abolish TR, improve right-heart hemodynamics, and provide systemic benefits beyond cardiac function. Venous decongestion may enable cross-organ recovery and allow withdrawal of diuretics and antiviral therapy.

Early Degeneration of a Next-Generation Mitral Bioprosthesis in the Tricuspid Position Treated With Valve-in-Valve.

BACKGROUND: Bioprosthetic tricuspid valve replacement is increasingly performed, but long-term durability data are limited. The Edwards Mitris Resilia valve, designed for the mitral position, has been used off-label in the tricuspid position, with scarce evidence of outcomes. CASE SUMMARY: We report 2 patients who developed early (<2-year) structural valve degeneration of the Mitris Resilia bioprosthesis in the tricuspid position. Both presented with symptomatic severe intraprosthetic tricuspid regurgitation. Given the prohibitive surgical risk of redo sternotomy, we opted for valve-in-valve (ViV) transcatheter tricuspid valve replacement (TTVR) using the Edwards Sapien 3 Ultra Resilia transcatheter heart valve. Both procedures were successful, with no residual regurgitation or paravalvular leak. DISCUSSION: To our knowledge, this is the first reported series of early Mitris Resilia structural valve degeneration in the tricuspid position. The cases highlight potential concerns about the durability of bioprostheses in the tricuspid position, especially in congenital heart disease or redo settings. Valve-in-valve tricuspid valve replacement with balloon-expandable transcatheter valves proved to be feasible, safe, and effective, preventing high-risk surgical reoperation. Early intervention is crucial to avoid irreversible right ventricular dysfunction.

Combining Transcatheter Edge-to-Edge Repair and Commissural Plug Occlusion for Complex Degenerative Mitral Regurgitation.

BACKGROUND: Degenerative mitral regurgitation involving the commissures remains a challenging anatomical subset for transcatheter repair. CASE SUMMARY: An 86-year-old male with high surgical risk presented with symptomatic, severe degenerative mitral regurgitation due to A3 prolapse extending to the posteromedial commissure and a measured mitral valve area of 3.8 cm2. The heart team was elected for transcatheter edge-to-edge repair. Despite successful implantation of a single clip in the A3-P3 region, moderate residual commissural regurgitation persisted. The small native valve area and insufficient leaflet length after the first clip precluded safe placement of a second device. As a bailout strategy, a vascular plug was deployed to specifically occlude the residual commissural leak. DISCUSSION: This simultaneous hybrid approach successfully reduced mitral regurgitation to mild, demonstrating a novel solution for managing complex anatomical challenges where conventional transcatheter edge-to-edge repair is insufficient. TAKE-HOME MESSAGES: Commissural involvement combined with a small mitral valve area and limited leaflet length may render conventional multiclip transcatheter edge-to-edge repair unfeasible, increasing the risk of residual regurgitation. This hybrid transcatheter strategy, combining edge-to-edge repair with targeted plug occlusion, can expand the treatable spectrum of complex degenerative mitral regurgitation in high-surgical-risk patients.

Transcatheter Mitral Valve-in-Valve Replacement With Microaxial Flow-Pump Support for Bioprosthetic Valve Failure.

BACKGROUND: Structural deterioration of bioprosthetic mitral valves is a common cause of late valve failure, requiring surgical or transcatheter replacement of the failed prosthesis. In rare cases, hemodynamic compromise may lead to cardiogenic shock, requiring mechanical circulatory support and making treatment particularly challenging. CASE SUMMARY: A 76-year-old man with prior bioprosthetic mitral valve replacement presented with cardiogenic shock. A microaxial flow pump was implanted. Echocardiography revealed severe transvalvular mitral regurgitation due to leaflet tear. Because of prohibitive surgical risk, the heart team opted for transcatheter mitral valve-in-valve replacement. The procedure resulted in immediate hemodynamic stabilization and weaning from mechanical support within 24 hours. DISCUSSION: This case demonstrates the feasibility of transcatheter mitral valve replacement combined with microaxial flow-pump support in cardiogenic shock as a potential rescue therapy in selected patients. TAKE-HOME MESSAGE: Timely transcatheter intervention may be life-saving in cardiogenic shock due to bioprosthetic mitral valve failure.

Transcatheter Edge-to-Edge Repair of a Functionally Trileaflet Mitral Valve.

BACKGROUND: A trileaflet configuration of the mitral valve is an uncommon anatomical finding that presents unique challenges for transcatheter repair. CASE SUMMARY: A 67-year-old man with a history of atrioventricular canal defect and prior mitral valve repair presented with symptomatic severe mitral valve insufficiency due to impaired leaflet coaptation from a cleft dividing the A2 scallop, creating a functionally trileaflet mitral valve. Given elevated surgical risk and patient preference to avoid reoperation, transcatheter edge-to-edge repair with the 2 PASCAL ACE system devices (Edwards Lifesciences) was successfully performed allowing restoration of coaptation and reduced mitral insufficiency to trace severity with a final transmitral mean gradient of 3 mm Hg. DISCUSSION: This case highlights the adaptability of transcatheter edge-to-edge repair in unconventional mitral valve anatomy. TAKE-HOME MESSAGE: Complex trileaflet or cleft mitral valves should not preclude transcatheter repair when guided by appropriate imaging and device strategy.

Transcatheter Closure of Post-Myocardial Infarction Ventricular Septal Rupture Using an Atrial Septal Defect Occluder.

OBJECTIVE: To describe the procedural strategy and technical considerations for transcatheter closure of post-myocardial infarction ventricular septal rupture (VSR) using an atrial septal defect (ASD) occluder in a patient unsuitable for surgical repair. KEY STEPS: An elderly, frail patient with postinfarction VSR and cardiogenic shock was stabilized with an intra-aortic balloon pump. Given the high surgical risk, transcatheter closure was performed after a 14-day delay to allow infarcted tissue stabilization. Multimodality imaging was used to assess defect morphology and rim adequacy. An ASD occluder was deployed under echocardiographic guidance, reducing shunt flow and improving hemodynamics. POTENTIAL PITFALLS: Wire entrapment in the tricuspid subvalvular apparatus may cause tricuspid regurgitation. Careful wire manipulation and appropriate snaring techniques are essential. Adequate rim assessment is also critical. TAKE-HOME MESSAGE: Transcatheter VSR closure using an ASD occluder is a feasible alternative in selected inoperable patients, particularly when dedicated VSD devices are unavailable.

Single-Access Retrieval of a Ruptured Balloon During Balloon-Expandable TAVI.

BACKGROUND: Balloon-expandable valves are among the most commonly used platforms for transfemoral transcatheter aortic valve implantation (TAVI). Although deployment-related complications are uncommon, balloon rupture with distal fragment retention is a rare but technically demanding scenario with no standardized retrieval protocol. CASE SUMMARY: A 79-year-old patient underwent a transfemoral TAVI with a balloon-expandable valve. Balloon rupture during deployment resulted in partial retention of the distal balloon segment. The patient remained hemodynamically stable without annular or aortic injury. The retained fragment was successfully retrieved through the same femoral access site using a snare-based technique, without contralateral large-bore access or surgical conversion. DISCUSSION: Same-access snaring through the ipsilateral E-sheath-after correcting the deformed tip to restore coaxial alignment-allows safe, controlled extraction of the retained balloon fragments through a single-access site. Recognizing and correcting sheath tip deformation before snare advancement is a critical technical prerequisite. TAKE-HOME MESSAGES: Balloon rupture during balloon-expandable TAVI may result in retained balloon fragments. Same-access snaring through the ipsilateral E-sheath is a feasible and safe first-line strategy. Sheath deformation must be recognized and corrected to ensure successful extraction without escalation to additional access or surgery.

Infective Endocarditis of Transcatheter Aortic Valve Replacement and Transcatheter Edge-to-Edge Repair Devices.

Infective endocarditis following transcatheter aortic valve replacement and mitral valve transcatheter edge-to-edge repair poses a significant clinical challenge, necessitating a multidisciplinary approach for timely diagnosis and appropriate management that may include surgical intervention for patients of less than prohibitive risk. Although advances in imaging modalities, including 18F-fluorodeoxyglucose positron emission tomography/computed tomography, show promise in enhancing diagnostic accuracy, standardized guidelines for management are lacking, especially regarding the appropriateness of antimicrobial suppression therapy. Future research should focus on refining diagnostic criteria, optimizing therapeutic strategies, and improving patient outcomes in these populations.

Retrieval Strategies for Embolized Left Atrial Appendage Closure Devices.

BACKGROUND: Device embolization (DE) is a rare but potentially life-threatening complication of left atrial appendage occlusion (LAAO). As landmark trials broaden the eligible population for LAAO, operator preparedness for DE management becomes increasingly critical. CASE SUMMARY: We present 4 cases of LAAO DE managed with distinct retrieval strategies: 1) open surgical retrieval with concurrent AtriClip ligation for an endothelialized left atrial device; 2) sequential transseptal then retrograde arterial snaring for intraprocedural migration to the abdominal aorta; 3) transseptal retrieval using a dedicated ONO system with cerebral embolic protection for partial left atrial dislodgment; and 4) retrograde large-bore arterial retrieval for delayed aortic embolization. CONCLUSIONS: Percutaneous retrieval is feasible in most cases when tailored to embolization location. Surgical backup remains indispensable. Prevention requires rigorous preprocedural imaging, accurate sizing, and routine postimplant surveillance. TAKE HOME MESSAGE: LAAO embolization has high mortality, accurate device sizing as well as follow up imaging in paramount.

Transaortic TAVR and MICS-CABG in a Patient on Dialysis With RCA Restenosis.

BACKGROUND: Severe aortic stenosis in patients undergoing dialysis often coexists with diffuse vascular and coronary calcifications, complicating access and revascularization. CASE SUMMARY: A man in his 80s undergoing maintenance hemodialysis presented with heart failure and dialysis intolerance. Echocardiography revealed severe aortic stenosis, coronary angiography showed 99% ostial right coronary artery in-stent restenosis, and computed tomography demonstrated a shaggy descending aorta with unsuitable transfemoral and nonfemoral access routes but a relatively preserved ascending aorta. The heart team performed simultaneous transaortic transcatheter aortic valve replacement and minimally invasive coronary artery bypass grafting using a saphenous vein graft to the posterior descending artery. A 29-mm Evolut FX (Medtronic) valve was successfully implanted. DISCUSSION: This strategy avoided sternotomy, cardiopulmonary bypass, hostile peripheral access, and repeat ostial percutaneous coronary intervention. TAKE-HOME MESSAGE: Simultaneous transaortic transcatheter aortic valve replacement and minimally invasive coronary artery bypass grafting may be useful when standard access and durable percutaneous coronary intervention are unsuitable.

Endovascular Salvage of Late Type IA Endoleak After Ascending Aortic TEVAR for Ruptured Penetrating Ulcer.

BACKGROUND: Ascending aortic penetrating atherosclerotic ulcers (PAUs) are rare acute aortic syndromes, where guidelines recommend surgical repair. In surgically ineligible patients, endovascular repair has been described; however, data on management of postoperative complications are limited. CASE SUMMARY: A frail 75-year-old woman presented with dyspnea, 1 month after emergency endovascular repair of a ruptured ascending aortic PAU. Computed tomography aortography (CTA) demonstrated a late type IA endoleak with associated pseudoaneurysm. Given her prohibitive surgical risk, a staged approach was initially used by creating a scaffold with transcatheter aortic valve implantation and deployment of an atrial septal defect occluder across the pseudoaneurysm's neck, followed by patent foramen ovale occluder implantation, coil packing, and thrombin injection. This achieved complete endoleak exclusion and pseudoaneurysm sealing, confirmed on serial CTAs. The patient remains well after 1 year. DISCUSSION: This is the first case of successful endovascular repair of a type IA endoleak and pseudoaneurysm, following endovascular repair of the ascending aorta. TAKE-HOME MESSAGE: Complex ascending aortic complications can be managed endovascularly.

Snare-Assisted Transseptal Antegrade Transcatheter Aortic Valve Replacement: Turning Back the Clock.

BACKGROUND: Transfemoral access remains the preferred route for transcatheter aortic valve replacement (TAVR); however, severe peripheral artery disease (PAD) and unfavorable anatomy can result in the preclusion of conventional access. Transseptal antegrade TAVR may offer another avenue in such cases. CASE SUMMARY: An 81-year-old man with severe symptomatic aortic stenosis, extensive peripheral artery disease, porcelain aorta, prior coronary artery bypass graft, and prohibitive surgical risk had no feasible conventional access. As such, a transseptal antegrade TAVR approach was pursued. During advancement of a balloon-expandable valve system through the left atrium and mitral valve, navigation toward the aortic annulus was difficult. Retrograde snare capture of the valve nose cone enabled traction, coaxial positioning, and successful deployment of a 29-mm SAPIEN 3 Ultra RESILIA valve with excellent hemodynamics and trace paravalvular regurgitation. DISCUSSION: Retrograde snare assistance facilitated valve delivery when antegrade advancement was insufficient. TAKE-HOME MESSAGE: In carefully selected patients, transseptal antegrade TAVR with retrograde snare-assisted delivery may be an alternative strategy.

Redo T-TEER for Severe Tricuspid Regurgitation After Prior Surgical or Transcatheter Repair.

Transcatheter Edge-to-Edge Repair Under Argatroban in IABP-Supported Acute Mitral Regurgitation With Suspected Heparin-Induced Thrombocytopenia.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a prothrombotic immune-mediated complication that complicates cardiac surgery because cardiopulmonary bypass requires systemic heparinization. We report a case of acute severe mitral regurgitation (MR) complicated by clinically suspected HIT, in which conventional surgical repair was not feasible. CASE SUMMARY: A 59-year-old man presented with acute severe MR due to chordal rupture and developed cardiogenic shock requiring intra-aortic balloon pump support. While awaiting surgery, his platelet count decreased from 262,000/μL to 23,000/μL. The 4Ts score was 6, and PF4/heparin antibody testing was positive, supporting clinically suspected HIT. Because cardiopulmonary bypass requiring systemic heparinization was considered prohibitively high risk, M-TEER was performed under continuous argatroban infusion. Two PASCAL Ace implants were successfully deployed, reducing MR from severe to trivial without thrombotic or bleeding complications. The patient recovered rapidly with immediate IABP removal and early extubation. DISCUSSION: This case demonstrates that M-TEER under argatroban anticoagulation can be a feasible alternative when conventional surgery is precluded by suspected HIT and the anticipated challenges of anticoagulation during cardiopulmonary bypass. TAKE-HOME MESSAGE: M-TEER under argatroban may serve as a rescue strategy for critically ill patients with acute severe MR and suspected HIT when surgical management is not feasible.

Transcatheter Aortic Valve Replacement for Severe Bicuspid Aortic Valve Stenosis: A Systematic Review and Meta-Analysis.

BACKGROUND: Comparative outcomes of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) stenosis remain uncertain. OBJECTIVES: The authors synthesized evidence comparing: 1) TAVR outcomes in BAV vs tricuspid aortic valve (TAV) stenosis; and 2) TAVR vs surgical aortic valve replacement (SAVR) among patients with BAV stenosis. METHODS: MEDLINE, Scopus, and Cochrane CENTRAL were searched through January 31, 2026 (CRD420261304542). Random-effects models pooled risk ratios (RRs) with 95% CIs. Exploratory meta-regression assessed study-level modifiers and temporal trends in 1-year mortality. RESULTS: Fifty-two studies were included. In 39 studies comparing TAVR in BAV vs TAV, BAV was associated with higher paravalvular leak (RR: 1.44; 95% CI: 1.18-1.77; P < 0.001), aortic root injury (RR: 1.83; 95% CI: 1.10-3.04; P = 0.020), 30-day stroke (RR: 1.27; 95% CI: 1.02-1.59; P = 0.035), and 30-day mortality (RR: 1.25; 95% CI: 1.00-1.55; P = 0.047), but lower 1-year mortality (RR: 0.84; 95% CI: 0.75-0.94; P = 0.002). The Society of Thoracic Surgeons score-but not BAV anatomy-predicted 1-year mortality (RR: 1.31; 95% CI: 1.08-1.59; P = 0.006). BAV outcomes improved in recent studies (RR per year, 0.93; 95% CI: 0.87-1.00; P = 0.048). In 13 studies comparing TAVR vs SAVR in BAV, TAVR had higher paravalvular leak (RR: 7.08; 95% CI: 2.28-21.98; P < 0.001) and lower major bleeding (RR: 0.27; 95% CI: 0.17-0.44; P < 0.001) but similar 30-day stroke (P = 0.288) and mortality (P = 0.452). CONCLUSIONS: TAVR for BAV stenosis was associated with procedural risk than TAVR for TAV stenosis but lower 1-year mortality. Compared with SAVR, TAVR showed procedural trade-offs without early mortality differences.

Transcatheter Aortic Valve Replacement for Failed Small Surgical Bioprostheses.

BACKGROUND: Data on the prognostic impact of failed surgical bioprosthetic size following valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) remain limited. OBJECTIVES: This study aimed to assess the impact of failed bioprosthetic size and subsequent prosthesis-patient mismatch (PPM) on midterm outcomes of ViV TAVR. METHODS: We analyzed patients who underwent ViV TAVR for degenerated surgical bioprostheses in the OCEAN-TAVI (Optimized transCathEter vAlvular iNtervention-transcatheter aortic valve implantation) registry. Patients were divided into 2 groups according to the true internal diameter (ID) of bioprostheses: the small bioprosthesis (SB) group (ID ≤20 mm) and the non-small bioprosthesis (NB) group (ID >20 mm). The primary endpoint was a composite of cardiovascular death or heart failure hospitalization at 3 years. Factors associated with severe measured PPM were also examined. RESULTS: Among 367 consecutive patients undergoing ViV TAVR (244 patients in the SB group vs 123 patients in the NB group), 30-day mortality was 0.5%. Severe PPM occurred in 16.9% of the entire cohort and was more prevalent in the SB group (21.3% in the SB group vs 8.3% in the NB group; P = 0.001). The SB group had a higher risk of cardiovascular death or heart failure hospitalization at 3 years (19.1% in the SB group vs 9.8% in the NB group; adjusted HR: 3.48; 95% CI: 1.11-10.87). The SB patients with severe PPM had the highest risk of the primary outcome at 3 years (SB with PPM 39.2% vs NB without PPM 11.0%; adjusted HR: 6.65 [95% CI: 1.95-22.71] compared with the NB group without PPM). Factors associated with severe PPM included larger body surface area, balloon-expandable valve implantation, and true ID ≤20 mm. CONCLUSIONS: ViV TAVR for small surgical bioprostheses was associated with worse clinical outcome, particularly in those with severe PPM. (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation [OCEAN-TAVI]; UMIN000020423).

Late Sinus of Valsalva Sequestration After Transcatheter Aortic Valve Implantation in Native Aortic Valve.

BACKGROUND: Coronary artery obstruction by sinus of Valsalva sequestration is a rare, life-threatening complication that occurs during or after the transcatheter aortic valve implantation procedure. CASE SUMMARY: An 82-year-old woman with severe symptomatic aortic stenosis underwent uncomplicated transfemoral transcatheter aortic valve implantation with a 23-mm Sapien S3 Ultra valve. Three months later, the patient presented to the hospital for chest pain and was found to have a non-ST elevation myocardial infarction. Diagnostic coronary angiography showed difficult left main coronary engagement despite the presence of thrombolysis in myocardial infarction (TIMI) grade 3 flow. Computed tomography angiography revealed a low-density filling defect within the left coronary sinus consistent with sinus sequestration causing partial left-system obstruction. Surgical revascularization (left internal mammary artery-left anterior descending artery and saphenous vein graft-obtuse marginal) with coronary artery bypass grafting was performed successfully. DISCUSSION: This case represents the second-only reported case of late sinus sequestration in a native aortic annulus. Risk factors include low coronary heights, narrow sinuses, and shallow sinotubular junction. Electrocardiography-gated cardiac computed tomography imaging remains crucial for diagnosis and for differentiating sinus insufficiency from sequestration. TAKE-HOME MESSAGE: Late coronary obstruction after transcatheter aortic valve implantation may occur due to sinus sequestration even in native valves; prompt computed tomography evaluation is critical for diagnosis and management.

TAVR for Elderly Patient With Bicuspid Aortic Stenosis, Severe Horizontal Heart, and Ascending Aorta Dilation.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has advanced from an emerging technology to a standard therapeutic option for high-risk patients with symptomatic severe aortic stenosis (AS). Procedural risk correlates strongly with aortic root anatomy. In elderly patients with bicuspid aortic valves, concomitant horizontal cardiac orientation and ascending aortic dilation confer markedly higher procedural risk. CASE SUMMARY: We report an elderly patient with a bicuspid aortic valve, severe horizontal aortic root angulation (88°), and ascending aortic dilation (approximately 60 mm). The presence of an ascending aortic aneurysm supported the indication for surgical intervention.Given the substantial technical complexity and perioperative risk of open-heart surgery, TAVR was selected as a safer alternative. DISCUSSION: This case demonstrates that TAVR remains feasible in elderly patients with complex anatomy unsuitable for surgery, despite increased procedural challenges and risk. TAKE-HOME MESSAGES: In elderly patients with severe AS and anatomically complex aortic pathology, TAVR should be considered a clinically viable treatment strategy.

Impact of Health-Related Social Needs on Transcatheter and Surgical Aortic Stenosis Treatment.

Surgical Bailout and Retrieval of Maldeployed Transcatheter Tricuspid Valve: Technical Considerations.

OBJECTIVE: To discuss the surgical considerations after a maldeployed Evoque transcatheter tricuspid valve replacement system. KEY STEPS: 1) Secure the delivery system at the groin to prevent further device displacement. 2) Safely access the chest and establish cardiopulmonary bypass; arresting the heart is not required. 3) Release each ventricular anchor sequentially in a rotational pattern. 4) Inspect the native tricuspid valve and decide intraoperatively on repair versus replacement. POTENTIAL PITFALLS: Failure to secure the delivery system may risk further device embolization. Central bicaval cannulation may crowd surgical field and make device removal more challenging. Failure to individually free each anchor risks damage to valve leaflets or chordae. Ice-cold saline for nitinol frame risks ventricular arrhythmia in a beating-heart setting and is not necessary. TAKE-HOME MESSAGES: Transcatheter tricuspid valve replacement maldeployment may warrant emergent surgical conversion. Although not technically challenging, patient comorbidities, prior operations, and location of the device all need to be considered.

5-Year Follow-Up After Transcatheter Mitral Valve Replacement Using the Cardiovalve System.

BACKGROUND: Severe mitral regurgitation (MR) in high-risk patients often precludes surgical repair, and suboptimal anatomy may limit edge-to-edge repair. Transcatheter mitral valve replacement (TMVR) has emerged as an alternative; however, long-term durability data remain limited. FIRST IN HUMAN/EARLY REPORTS SUMMARY: We report a 75-year-old man with ischemic MR (Carpentier IIIb), treated with transfemoral TMVR using the Cardiovalve device within the Cardiovalve FIM study (NCT03958773). The procedure was successful, with no MR postprocedural and only minor periprocedural complications. DISCUSSION: At 5-year follow-up, the patient remained clinically stable (NYHA functional class I) with preserved valve function, and absence of degeneration, thrombosis, or left ventricular outflow tract obstruction. This represents the longest reported follow-up of Cardiovalve to date and suggests sustained clinical and hemodynamic benefit. NOVELTY: This is the first report of a 5-year follow-up after transfemoral TMVR with Cardiovalve, demonstrating excellent durability and safety. TAKE-HOME MESSAGE: Cardiovalve TMVR offers a promising long-term option for high-risk MR patients with sustained clinical and echocardiographic success over 5 years.

Chordal-Zone Free Externalization of Retrograde Wire to Facilitate BASILICA and Transcatheter Electrosurgical Procedures.

While Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction (BASILICA) technique is effective for preventing coronary obstruction, challenges with left ventricular outflow tract (LVOT) snaring of the traversal wire and chordal entrapment risk may occur. We describe the Chordal-zone Free Externalization of Retrograde Wire (CLEAR) technique in three patients undergoing valve-in-valve transcatheter aortic valve replacement with BASILICA. After leaflet traversal, a steerable microcatheter positioned below the aortic valve directed the wire retrogradely from the LVOT to the aortic root for snaring, avoiding deep LVOT penetration. All procedures were successful with no coronary obstruction. In one case, chordal entrapment was detected and corrected without the need for LVOT re-entry. The CLEAR technique simplifies wire externalization, reduces chordal entrapment risk, and allows easier adjustment if snaring fails. This initial experience demonstrates CLEAR technique is feasible and safe when integrated in BASILICA procedure.

TEER Beyond Contraindication: Resolving Recurrent Cerebral Infarction in a Patient With Degenerative Mitral Regurgitation.

BACKGROUND: Degenerative mitral regurgitation (MR) is a common valvular heart disease, with transcatheter edge-to-edge repair (TEER) an alternative option for high-risk patients. Non-bacterial thrombotic endocarditis (NBTE), a rare condition with sterile valvular excrescences, often causes cerebrovascular embolism and is thought to be the contraindication to TEER. CASE SUMMARY: A 52-year-old man with multiple comorbidities presented to the hospital with recurrent cerebral infarctions, massive MR and NBTE. TEER and carotid embolic protection device implantation were performed to ameliorate MR, avoid the recurrence of cerebral embolism and delay the time for surgical valve replacement. DISCUSSION: The patient's history of ANCA-associated vasculitis, nephritis and glucocorticoid use made surgical treatment risky. TEER is feasible for severe degenerative MR with NBTE, especially with carotid protection, which reduces embolism risk and postpones valve replacement. TAKE-HOME MESSAGE: This case demonstrates the feasibility of TEER with concurrent NBTE and recurrent cerebral infarction when paired with carotid embolic protection.

CT-Guided Preprocedural Assessment of TEER in Mitral Prolapse: When Calcification Limits TEE.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) relies on accurate preprocedural imaging. Severe mitral leaflet calcification may impair transesophageal echocardiographic assessment and complicate procedural planning. CASE SUMMARY: A 74-year-old female presented with a 6-month history of exertional dyspnea and decreased exercise tolerance. Transthoracic echocardiography demonstrated mitral valve prolapse in A3 with severe mitral regurgitation (MR), leaflet calcification, left atrial enlargement, and preserved left ventricular ejection fraction of 73.7%. Owing to prohibitive surgical risk, TEER was recommended. Preprocedural transesophageal echocardiography (TEE) was limited by leaflet calcification, preventing accurate leaflet length and grasping zone measurement. Cardiac computed tomography (CT) was therefore performed and used for detailed anatomical assessment and procedural planning. TEER was successfully performed with significant reduction in mitral regurgitation and symptomatic improvement. DISCUSSION: This case illustrates the complementary role of cardiac CT in TEER planning when echocardiography is suboptimal due to heavy calcification. TAKE-HOME MESSAGES: Cardiac CT enables precise anatomical characterization in challenging TEER cases.

Early Experience With Septal Scoring Along the Midline Endocardium in the Asia-Pacific Region.

Septal Scoring Along the Midline Endocardium (SESAME) is a novel transcatheter electrosurgical technique for septal reduction that has been reported in the United States and Europe, but experience in the Asia-Pacific region has not been previously described. We report four cases of SESAME procedures performed in the Asia-Pacific region, encompassing diverse clinical scenarios including standalone treatment for hypertrophic obstructive cardiomyopathy (HOCM) in patients with persistent symptoms despite prior alcohol septal ablation or lack of suitable septal branches, and as an adjunct to transcatheter aortic valve replacement (TAVR) in patients with concomitant severe aortic stenosis and septal hypertrophy. The procedures were successfully completed in all cases with reduction in left ventricular outflow tract (LVOT) gradients. One patient developed high-grade atrioventricular block requiring permanent pacemaker implantation. At follow-up ranging from 1 to 3 months, patients demonstrated improved LVOT gradients and functional status. This case series demonstrates the feasibility of SESAME in the Asia-Pacific region for various indications including standalone HOCM treatment and prevention of LVOT obstruction in conjunction with TAVR. Further multicenter studies are needed to evaluate the long-term outcomes and safety profile of this emerging technique in diverse patient populations.

Transapical TAVR in Native Aortic Regurgitation With Chronic Type A Dissection.

BACKGROUND: Severe native aortic regurgitation complicated by chronic Stanford type A dissection represents an extreme-risk scenario in which surgery may be prohibitive and transfemoral transcatheter aortic valve replacement may increase procedural risk. CASE PRESENTATION: An elderly frail patient with symptomatic severe native aortic regurgitation and localized chronic ascending aortic dissection was deemed unsuitable for surgery. Preprocedural computed tomography demonstrated a short dissection segment above the annulus without sinus or coronary involvement and without imaging features of instability. HOW WE DID IT: To minimize mechanical stress on the dissected ascending aorta, a transapical approach was selected to avoid arch manipulation and enable straight-line coaxial valve delivery. A leaflet-anchoring valve was implanted under fluoroscopic and transesophageal echocardiographic guidance with rapid pacing to ensure controlled deployment. OUTCOME: The procedure was completed without dissection progression or significant paravalvular regurgitation. Follow-up imaging confirmed durable valve function and stable dissection morphology. TAKE-HOME MESSAGE: In carefully selected nonsurgical patients with severe native AR and localized chronic type A dissection, transapical TAVR may represent a mechanism-based rescue strategy by avoiding arch manipulation and enabling controlled valve deployment.

Mitral Edge-to-Edge Repair Resolves Hemolytic Anemia After Surgical Mitral Valve Repair.

BACKGROUND: Hemolytic anemia after surgical valve repair is rare but potentially life-threatening and has mostly commonly been described in the context of paravalvular regurgitation. CASE SUMMARY: A 78-year-old woman with prior surgical mitral valve (MV) repair presented with progressive dyspnea and severe hemolytic anemia. Echocardiography revealed severe eccentric, valvular mitral regurgitation (MR) caused by anterior leaflet prolapse with a high-velocity regurgitant jet striking the annuloplasty ring. The patient underwent transcatheter mitral edge-to-edge repair (M-TEER), achieving reduction of MR to mild and resolution of hemolysis. DISCUSSION: This case highlights hemolysis as a rare complication after surgical MV repair and the utility of M-TEER for patients at prohibitive surgical risk. TAKE-HOME MESSAGES: M-TEER may represent a safe and effective option for managing hemolytic anemia due to recurrent MR. Besides paravalvular regurgitation, valvular regurgitation in the context of prior surgical MV repair should be recognized as a potential cause of hemolytic anemia.

Post-Myocardial Infarction Ventricular Septal Defect Percutaneous Closure.

BACKGROUND: Ventricular septal rupture is an uncommon but serious complication of late post-myocardial infarctions (MI) with an exceedingly high mortality. The American College of Cardiology and American Heart Association still advise immediate surgical closure of ventricular septal rupture. CASE SUMMARY: We described a novel minimally invasive transcatheter approach to post-MI ventricular septal defect (PMIVSD) closure through a venovenous loop for an 82-year-old woman. DISCUSSION: A PMIVSD is typically treated surgically and offers reasonable outcomes in patients who survive an initial healing phase. Transcatheter approaches serve as a potential treatment option for select high-risk surgical candidates. TAKE-HOME MESSAGES: Transcatheter closure is a viable alternative in high-risk PMIVSD patients unsuitable for surgery. A venovenous loop offers a safe and effective route for percutaneous VSD closure.

Transcatheter Tricuspid Valve Replacement Using Conscious Sedation and Intracardiac Echocardiography.

BACKGROUND: Transcatheter aortic valve replacement is routinely performed with a "minimalist approach" using conscious sedation. Conversely, transcatheter tricuspid valve replacement (TTVR) is performed with general anesthesia using transesophageal echocardiography. Performing TTVR using conscious sedation and intracardiac echocardiography (ICE) alone has not been described. CASE SUMMARY: We present a patient with NYHA functional class III symptoms secondary to severe tricuspid regurgitation. Our team deemed the patient at high risk for surgical therapy and decided that TTVR with the Evoque system would be ideal. With monitored anesthesia care, imaging was performed using three-dimensional ICE. Evoque positioning and deployment was uneventful, with normal anchoring and trivial central tricuspid regurgitation. DISCUSSION: It is feasible to perform Evoque TTVR with a minimalist approach using conscious sedation and ICE. TAKE-HOME MESSAGE: In select patients, TTVR with Evoque using conscious sedation and ICE alone is possible.

Transcatheter aortic valve-in-valve implantation for residual prosthetic valve dysfunction and paravalvular leak after healed Enterococcus faecalis prosthetic valve endocarditis: a case report.

BACKGROUND: Prosthetic valve endocarditis (PVE) is associated with substantial morbidity and mortality, particularly when complicated by severe prosthetic valve dysfunction and paravalvular leak. Although redo surgery remains the standard treatment, some patients may be unsuitable for surgical intervention because of prohibitive operative risk. CASE SUMMARY: A 64-year-old man with previous surgical bioprosthetic aortic valve replacement had a history of Enterococcus faecalis PVE and received targeted antimicrobial therapy. Following targeted antimicrobial therapy with documented microbiological control, he presented with cardiogenic shock due to severe residual prosthetic valve dysfunction, including severe prosthetic stenosis, severe central transprosthetic regurgitation, and severe paravalvular leak. Given his prohibitive surgical risk, the multidisciplinary Heart Team selected transfemoral valve-in-valve transcatheter aortic valve implantation as a rescue strategy. The procedure resulted in marked haemodynamic improvement with only mild residual regurgitation. At 1-year follow-up, the patient remained clinically stable with a well-functioning prosthetic valve and no evidence of recurrent infection. DISCUSSION: This case demonstrates that valve-in-valve transcatheter implantation may be considered as a rescue option in carefully selected patients with controlled prosthetic valve endocarditis and residual prosthetic valve dysfunction who are unsuitable for redo surgery. Multimodality imaging and multidisciplinary Heart Team evaluation are essential for individualized decision-making in this challenging clinical scenario.

Transjugular LuX-Valve Plus transcatheter tricuspid valve replacement for torrential tricuspid regurgitation in a patient with a giant right atrium and multiple prior valve interventions: a case report.

BACKGROUND: Transcatheter tricuspid valve replacement (TTVR) is an option for selected patients with severe tricuspid regurgitation (TR) who are at high surgical risk, but experience remains limited in those with extreme right-heart anatomy, including a giant right atrium and a markedly enlarged elliptical tricuspid annulus. CASE SUMMARY: A 62-year-old man was admitted with progressive dyspnoea and lower-extremity oedema (NYHA class IV). He had previously undergone mechanical mitral valve replacement and transcatheter aortic valve replacement. Echocardiography and computed tomography angiography (CTA) showed torrential TR, a giant right atrium (11.59 × 7.73 cm), preserved right ventricular systolic function, and a markedly elliptical annulus with a perimeter-derived diameter of 55.5 mm. Persistent TR despite satisfactory left-sided prosthetic valve function prompted transcatheter evaluation. Redo surgery was prohibitive and transcatheter edge-to-edge repair was unsuitable. The Heart Team selected LuX-Valve Plus because its leaflet graspers and septal anchor provide radial force-independent multipoint fixation. A 79.2-mm bend-point-to-annulus distance exceeded the proposed 45-70 mm range, requiring a slightly lateral jugular entry angle and complicating depth control and coaxial alignment. The mechanical mitral prosthesis limited visualization by transoesophageal echocardiography (TEE) but served as a fluoroscopic landmark; TEE and fluoroscopy enabled successful implantation. At 1 month, NYHA class improved to II, with stable prosthetic haemodynamics, no obvious transvalvular regurgitation, and trivial paravalvular leak; findings remained stable at 6-7 weeks. DISCUSSION: This case highlights the feasibility of transjugular LuX-Valve Plus TTVR in extreme right-heart anatomy and emphasizes the importance of anatomy-driven device selection, tailored delivery and imaging strategies, and individualized postprocedural management.

Acute leaflet opening restriction caused by endarterectomy-like iliac artery intimal detachment entrapped within a self-expanding transcatheter aortic valve: a case report.

BACKGROUND: Acute transcatheter heart valve (THV) dysfunction immediately after transcatheter aortic valve implantation (TAVI) is uncommon but can be catastrophic. Mechanical obstruction by migrated vascular tissue is exceptionally rare. CASE SUMMARY: An 80-year-old woman with symptomatic very severe aortic stenosis and high surgical risk underwent transfemoral TAVI with a 23-mm self-expanding Evolut FX valve (Medtronic, Minneapolis, MN, USA). Preprocedural computed tomography showed severe circumferential calcification of the left common iliac artery (CIA) with a preserved lumen (6.8 × 4.9 mm) and a small aortic annulus (area, 244.9 mm2; perimeter, 55.9 mm). After valve deployment, invasive haemodynamics showed no reduction in the transvalvular pressure gradient (mean/peak, 58/97 mmHg before vs. 63/98 mmHg after deployment). Transoesophageal echocardiography demonstrated a tubular structure restricting leaflet opening. Balloon post-dilatation resulted in transient echocardiographic improvement but was complicated by balloon rupture, and a mobile intravalvular structure persisted. Emergency surgical conversion was performed. Intraoperatively, a calcified tubular structure with a lumen-like appearance was found on the guidewire and was impinging on the THV leaflets. The THV was explanted, and surgical aortic valve replacement was performed. Histology confirmed calcified vascular intimal tissue, consistent with detachment from the left CIA. The postoperative course was uneventful, and the patient was discharged home. DISCUSSION: In severely calcified iliofemoral access, endarterectomy-like intimal detachment can occur during device passage and, rarely, can migrate into a self-expanding THV, causing acute leaflet opening restriction. Early recognition using multimodality imaging and timely surgical bailout may be life-saving.

Mitral transcatheter edge-to-edge repair with inverse leaflet grasping in the setting of prior atrial septal defect closure: a case report.

BACKGROUND: According to the 2025 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery guidelines, transcatheter edge-to-edge repair has a Class IIa recommendation in patients with primary mitral regurgitation at high surgical risk following Heart Team evaluation. Procedural complexity may be increased by prior septal closure devices and challenging leaflet anatomy. We describe a modified technical approach that enabled successful treatment in this setting. CASE SUMMARY: A 75-year-old woman with a history of atrial septal defect closure presented with advanced heart failure symptoms due to severe primary mitral regurgitation from posterior leaflet prolapse. Because of frailty and comorbidities, surgical repair was not feasible, and an interventional approach was recommended. Transseptal puncture was technically challenging due to an Amplatzer occluder and required a posterior-superior puncture site. Conventional leaflet capturing with the PASCAL Ace device was unsuccessful because of pronounced prolapse and localized chordal restriction. A modified sequence, called inverse leaflet grasping, was employed: clasps were fixed in a horizontal position, while the paddles remained elongated during posterior leaflet engagement, followed by paddle closure. This manoeuvre allowed secure capture and effective reduction of regurgitation after the first device, followed by implantation of a second device using conventional technique. The patient improved clinically and remained stable at 6-month follow-up with mild residual mitral regurgitation. DISCUSSION: This case illustrates that mitral transcatheter edge-to-edge repair is feasible even in anatomically complex scenarios. Inverse leaflet grasping may serve as a bailout technique when conventional leaflet capturing fails. The report underlines the importance of tailored interventional strategies in line with current ESC guidelines.

Intraoperative transoesophageal echocardiographic detection of guidewire malposition and incomplete valve expansion in valve-in-valve transcatheter aortic valve implantation for Trifecta bioprosthesis failure: a case report.

BACKGROUND: Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is widely used for failed surgical bioprostheses; however, procedural pitfalls remain, particularly in valves prone to early structural deterioration. CASE SUMMARY: An 84-year-old woman with a failed 21 mm Trifecta bioprosthesis underwent ViV-TAVI. Although the guidewire crossed smoothly and fluoroscopy appeared reassuring, incomplete valve expansion occurred. Intraoperative transoesophageal echocardiography revealed that the guidewire had passed between degenerated leaflets rather than through the true central orifice. After repositioning under transoesophageal echocardiography guidance, full symmetric valve expansion and optimal haemodynamics were achieved. DISCUSSION: This case highlights the risk of false procedural reassurance during ViV-TAVI and underscores the importance of actively confirming central guidewire trajectory, particularly in failed Trifecta bioprostheses.

Plug-based bail-out strategy for leaflet tear after mitral transcatheter edge-to-edge repair: a case report.

BACKGROUND: Mitral transcatheter edge-to-edge repair (TEER) is a safe and widespread treatment approach for severe mitral regurgitation (MR). However, rare but serious device-related complications, including single leaflet device attachment, perforation, and leaflet tear, may occur, often requiring surgical correction. CASE SUMMARY: An 82-year-old man with congestive heart failure and ischaemic cardiomyopathy underwent mitral TEER using MitraClip XTW clip for severe functional MR. Two days after the procedure, MR recurrence due to a leaflet tear was observed. Given the patient's advanced age and reduced left ventricular function, our cardiac team decided to perform a transcatheter bail-out procedure. First, the tear was converted to a hole shape by implanting a PASCAL Ace device (Edwards Lifesciences) lateral to the XTW, as this device has a lower risk of leaflet damage compared to the MitraClip device. Then, Amplatzer Vascular Plug II (AVP II) was deployed into the hole, with its mid-lobe positioned in contact with the devices and leaflets. After releasing the AVP II, the MR jet reduced to mild. CONCLUSION: An optimal bail-out strategy for leaflet tears has not yet been established. When it is difficult to sufficiently cover the leaflet tear using only an additional TEER device, the use of a plug with additional TEER devices can be considered a bail-out strategy.

Great debate: surgical aortic valve replacement is first choice for aortic stenosis in patients with a life expectancy beyond 5 years.

Transcatheter aortic valve implantation (TAVI) is increasingly used for the treatment of aortic stenosis. Recently published guidelines favour now TAVI in all patients 70 years or older who have tricuspid valves and suitable anatomy. However, while a number of randomized controlled trials confirm that TAVI and surgical aortic valve replacement (SAVR) provide equivalent outcomes up to 5 years, data beyond 5 years are still scarce and real-world registry data report indeed conflicting results. Higher rates of complications after TAVI such as pacemaker requirement and paravalvular regurgitation, which have been shown to be associated with worse outcome may become more relevant after 5 years and still favour surgery on long-term. In addition, long-term durability data for TAVI are still insufficient. Thus, the question whether SAVR should still be the first choice for patients with a life expectance beyond 5 years is therefore justified. This debate summarizes the pros and cons for this claim.

Transapical transcatheter mitral valve implantation in a patient with mitral annular defect due to a patch dehiscence after aortic valve replacement: a case report.

BACKGROUND: Transcatheter mitral valve implantation (TMVI) has emerged as a therapeutic option for high-risk patients with severe mitral regurgitation (MR) who are unsuitable for surgery. The Tendyne system, with its dual-frame design consisting of an atrial cuff and an external frame, has shown promising in complex anatomical settings. However, experience with Tendyne TMVI remains limited in patients with post-surgical MR caused by mitral leaflet perforation and a concomitant mechanical aortic valve prosthesis. CASE SUMMARY: An 80-year-old woman with a prior mechanical aortic valve replacement (St. Jude Medical, 21 mm) for bicuspid aortic stenosis presented with severe mixed MR. At the index operation, a Manouguian aortic root enlargement using a pericardial patch had been performed to prevent prosthesis-patient mismatch. During follow-up, patch dehiscence resulted in perforation of the anterior mitral leaflet, while concomitant annular dilatation generated an additional regurgitant jet, resulting in severe mixed MR. Given the prohibitive risk of redo cardiac surgery (EuroSCORE II 25.24%), the multidisciplinary Heart Team recommended a transcatheter treatment strategy. Following Heart Team evaluation, transapical TMVI with a Tendyne prosthesis (29S LP) was performed. The procedure achieved complete elimination of MR without residual paravalvular leak or interference with the mechanical aortic valve. Notably, the external stent frame of the prosthesis successfully sealed the mitral leaflet perforation, eliminating the need for additional closure devices. DISCUSSION: This case underscores the importance of imaging-guided, multidisciplinary Heart Team planning in optimizing procedural outcomes for patients with challenging post-surgical anatomy. Transcatheter mitral valve implantation might be a feasible option for patients with MR after cardiac surgery at prohibitive surgical risk.

Transcatheter aortic valve implantation-related acute ascending aortic dissection diagnosed intraoperatively using transoesophageal echocardiography: a case series.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been widely adopted as a less invasive treatment for aortic stenosis (AS). Although rare, acute ascending aortic dissection associated with TAVI is a life-threatening complication that necessitates prompt intraoperative diagnosis. This case series reports two cases of acute ascending aortic dissection occurring during TAVI performed under general anaesthesia. CASE SUMMARY: Cases 1 and 2 involved an 87-year-old woman and a 90-year-old man, respectively, both of whom underwent transfemoral TAVI for severe AS. In both cases, procedural difficulty was encountered, including valve pop-up and resistance during device passage. Before overt haemodynamic deterioration became apparent, intraoperative transoesophageal echocardiography revealed an intimal flap and false lumen in the ascending aorta, leading to the diagnosis of acute ascending aortic dissection. Both patients underwent prompt surgical intervention. Case 1 underwent surgical aortic valve replacement (SAVR) and ascending aortic replacement, whereas Case 2 underwent SAVR and total arch replacement. Both patients were discharged ambulatory without neurological sequelae. DISCUSSION: Unlike fluoroscopy and angiography, which provide only intermittent assessment, transoesophageal echocardiography enables continuous intraoperative evaluation and can simultaneously detect findings directly relevant to haemodynamic status, including an intimal flap, false lumen, acute aortic regurgitation, and pericardial effusion. This case series suggests that additional transoesophageal echocardiography assessment prompted by procedural difficulty may contribute to the early diagnosis of serious complications and facilitate prompt conversion to surgical intervention.

Impella™-protected PCI in a post-CABG patient with advanced biventricular dysfunction and mitral regurgitation.

Patients with advanced coronary artery disease (CAD), severely reduced left ventricular (LV) ejection fraction, and prior coronary artery bypass grafting (CABG) present with complex revascularization challenges requiring individualized, multidisciplinary decision-making and pre-procedural strategy planning. Protected percutaneous coronary intervention (PCI) using percutaneous temporary mechanical circulatory support, such as the Impella™ microaxial flow pump, may enable complex revascularization in carefully selected patients at high risk of peri-procedural haemodynamic compromise. We describe a male patient with advanced ischaemic cardiomyopathy, severe functional mitral regurgitation, and complex multivessel CAD, including chronic total occlusion (CTO) of the left anterior descending artery, following prior CABG. After Heart Team discussion and in the context of prohibitive surgical risk, a staged strategy was carefully planned pre-procedurally and then pursued with mitral transcatheter edge-to-edge repair, followed by prophylactic Impella-assisted PCI. Under haemodynamic support, retrograde CTO PCI via a patent saphenous vein graft was performed with drug-eluting stent implantation and intravascular ultrasound-confirmed optimization, achieving TIMI 3 flow. The patient remained haemodynamically stable, with an uneventful post-procedural course and no vascular or cardiac complications. This case illustrates how a staged Impella-protected PCI strategy can facilitate revascularization in post-CABG patients with advanced LV dysfunction and be integrated into a timely, planned, and patient-tailored approach accounting for ventricular function, valvular disease, and complex coronary anatomy when surgery is not feasible.

Post-procedural computed tomography comparison of predicted and actual neo-left ventricular outflow tract after one-session double valve-in-valve implantation: a case report.

BACKGROUND: Left ventricular outflow tract (LVOT) obstruction is a serious complication of transcatheter mitral valve replacement and mitral valve-in-valve (ViV) procedures. Computed tomography (CT)-based virtual valve implantation predicts the neo-LVOT area, but it assumes idealized seating and may not fully reflect procedural interaction during double-valve intervention. CASE SUMMARY: A 74-year-old woman with degenerated surgical mitral and aortic bioprostheses presented with NYHA class IV heart failure. Full-cycle ECG-gated 4D-CT identified the minimum predicted neo-LVOT at 43% of the R-R interval (300.9 mm2). A one-session transapical double ViV procedure was performed. The aortic ViV was performed first because CT simulation showed that the aortic balloon would expand between the two strut posts of the surgical mitral prosthesis; implanting the mitral valve first could have exposed the newly deployed mitral prosthesis to compression during subsequent aortic balloon expansion. Post-procedural 4D-CT, evaluated using the same workflow and compared at 43%, showed a neo-LVOT area of 280.6 mm2, a 20.3 mm2 reduction, with approximately 1.2 mm asymmetric ventricular protrusion of the mitral prosthesis. Echocardiography showed normal valve-in-valve function and no haemodynamic LVOT obstruction. DISCUSSION: This case demonstrates that CT-based planning correctly identified procedural feasibility, while post-procedural CT revealed measurable geometric variability. The finding remained well above high-risk thresholds and should be interpreted as a hypothesis-generating geometric observation rather than clinically significant obstruction.

Fully percutaneous emergency management of an acute myocardial infarction complicated by papillary muscle rupture treated with percutaneous revascularization and mitral transcatheter edge-to-edge repair: a case report.

BACKGROUND: Papillary muscle rupture (PMR) in a rare and life-threatening complication of a myocardial infarction (MI). In our case we describe a complete percutaneous emergency management of this complication with coronary angioplasty followed to successful MitraClip repair. CASE SUMMARY: We report a case of a 62-year-old man with MI and severe mitral regurgitation. We performed percutaneous revascularization and intra-aortic balloon pump (IABP) was placed. After a transthoracic and transoesophageal echo evaluation, a PMR was diagnosed. Due to intractable pulmonary oedema, we proceed to emergency mitral edge-to-edge repair with two MitraClip just 2 h later. Mitral regurgitation was reduced to mild, and patient was extubated. CONCLUSION: This case reports a completely percutaneous management of an MI complicated by PMR in prohibitive surgical risk patient. Emergency treatment of MI and PMR with coronary angioplasty and MitraClip is feasible and could be a bail-out option in high surgical risk patients.

Tricuspid transcatheter edge-to-edge repair in local anaesthesia guided by three-dimensional intracardiac echocardiography: a case report.

BACKGROUND: Tricuspid transcatheter edge-to-edge repair (T-TEER) effectively reduces tricuspid regurgitation (TR) severity and improves symptoms and functional outcome in patients with TR and high surgical risk. Procedural guidance using intracardiac echocardiography (ICE) is a promising alternative in case of impaired imaging quality or contraindications for transoesophageal echocardiography (TEE) but also to defer any form of anaesthesia. The present case report aims to display the feasibility of an ICE-only guided T-TEER procedure in local anaesthesia and respective set-up. CASE SUMMARY: A multimorbid 74-year-old man with severe mixed secondary TR was admitted for elective T-TEER. He suffered from NYHA III dyspnoea, chronic lower leg oedema and had two heart failure hospitalizations in the last 14 months. Local heart team recommended T-TEER due to the high individual surgical risk. TR was successfully reduced to trace by ICE-only guided T-TEER with implantation of two devices, one in anteroseptal and one in posteroseptal position in conventional clover technique. The patient was discharged without any notable complications. DISCUSSION: The present case report demonstrates the feasibility of an ICE-only guided T-TEER, exclusively conducted in local anaesthesia. High-quality intraprocedural imaging guidance was essential for achieving procedural success.

Endoscopic mitral and tricuspid valve repair in a patient with dextrocardia, hypoplastic right lung, and scimitar syndrome: a case report.

BACKGROUND: The treatment of primary mitral and secondary tricuspid regurgitation (MR, TR) in the setting of lung agenesis poses major technical challenges, and data on the feasibility of endoscopic tricuspid valve repair in adult congenital anatomy remain limited. CASE SUMMARY: We report the case of a 76-year-old male with severe primary MR due to Barlow's disease, torrential secondary TR, biatrial dilatation, persistent atrial fibrillation, and post-capillary pulmonary hypertension. Anatomical anomalies included dextrocardia, hypoplastic right lung, and scimitar vein syndrome. The patient had a history of surgical correction of an aortic coarctation at the age of 32 with residual stenosis but no proof of residual gradients in invasive assessment. Transcatheter repair was deemed unsuitable due to the massive dextrocardia, extensive leaflet pathology, and annular dilatation. The patient underwent endoscopic mitral and tricuspid repair with dual arterial and venous cannulation to avoid malperfusion of the upper body during extracorporeal circulation. Mitral valve repair included a surgical edge-to-edge repair, along with an implantation of an annuloplasty ring; secondary TR was repaired by ring annuloplasty too. Postoperatively, the patient experienced prolonged weaning and renal support. He was ultimately transferred to rehabilitation for uneventful recovery. Discharge echocardiography revealed good surgical results for the mitral valve and a residual moderate-to severe TR. DISCUSSION: The present case highlights that an endoscopic approach for the treatment of mitral and tricuspid valve pathologies can be used in selected patients with dextrocardia. Tricuspid annuloplasty may reduce but not abolish tricuspid regurgitation in a combination of primary, congenital, and secondary aetiologies.

A case report of the coagulation management of an adult with moderate haemophilia A undergoing transcatheter aortic valve implantation.

BACKGROUND: Haemophilia A is an X-linked bleeding disorder resulting from factor VIII deficiency. While surgical management requires the correction of factor VIII levels by the administration of factor VIII concentrate, antiplatelet therapy after lower-risk cardiac surgery/procedures (such as transcatheter aortic valve implantation-TAVI) is not yet standardized. This report describes the management of a patient with moderate haemophilia A undergoing TAVI for severe aortic stenosis. CASE SUMMARY: A 76-year-old man with untreated haemophilia A was admitted with traumatic bleeding. After initial stabilization, he developed acute heart failure due to newly discovered severe aortic stenosis. TAVI procedure was performed by transfemoral access according to multidisciplinary team-discussion; a bio-prosthetic valve was successfully implanted. We outline the peri-procedural haemostatic management, which included factor VIII replacement therapy to achieve guideline-recommended activity levels, followed by progressive dose reduction. In view of the high bleeding risk and absence of significant coronary artery disease, antiplatelet therapy was limited to a short course. The procedure was successful, with no bleeding complications. DISCUSSION: In our patient, replacement therapy with rFVIII was initiated with a target FVIII activity between 80 and 100 IU/dL. During the procedure, unfractionated heparin was administered to achieve an ACT target 29 of 200 s. Post-operatively, FVIII replacement therapy was maintained above 60 IU/dL for the first 30-72 h, followed by 40-50 IU/dL from day 4 to day 7. Subsequently, it was decided to continue low-dose FVIII replacement for 32 additional 7 days. This strategy led to a successful management of both cardiological and hematological aspects. CONCLUSION: Although evidence is limited to case reports, TAVI appears to be feasible and safe in patients with haemophilia A. Maintaining high factor VIII activity levels and minimizing antithrombotic exposure through multidisciplinary evaluation can effectively reduce haemorrhagic risk. Our case, in line with previous reports, resulted in no bleeding complications.

TENDYNE mitral valve implantation complicated by heparin-induced thrombocytopenia in a patient with NSCLC: a case report.

BACKGROUND: Transcatheter mitral valve replacement (TMVR) is an emerging therapeutic option [SA1.1] for patients with complex mitral valve disease who are at high surgical risk. The TENDYNE transcatheter mitral valve system enables treatment in anatomically challenging cases but may be associated with early device thrombosis prior to endothelialization. We report a complex cardio-oncology case of a 52-year-old man with severe combined mitral valve disease and concomitant potentially curable non-small cell lung cancer who underwent TMVR following induction chemo-immunotherapy to optimize oncologic timing. CASE SUMMARY: The early postoperative course was complicated by heparin-induced thrombocytopenia (HIT) type II, resulting in progressive thrombosis of the left atrium and prosthetic valve despite therapeutic anticoagulation with argatroban. Imaging demonstrated significant prosthetic obstruction requiring urgent surgical thrombectomy, explantation of the transcatheter valve, and bioprosthetic mitral valve replacement. After multidisciplinary perioperative management, including tailored anticoagulation strategies, the patient recovered and was discharged in stable condition. DISCUSSION: This case highlights the interplay between TMVR-associated thrombogenicity, HIT-driven hypercoagulability, and the complexity of treatment sequencing in cardio-oncology patients, emphasizing the importance of individualized, interdisciplinary decision-making.

Clinical improvement of functional mitral and tricuspid regurgitation following transcatheter aortic valve implantation with the NAVITOR VISION system: a case report.

BACKGROUND: Concomitant mitral regurgitation (MR) and tricuspid regurgitation (TR) are frequently encountered in patients with severe aortic stenosis (AS) and are associated with adverse clinical outcomes after transcatheter aortic valve implantation (TAVI). However, the impact of transcatheter heart valve selection on post-procedural multi-valvular haemodynamics remains incompletely understood. CASE SUMMARY: An 87-year-old woman with symptomatic low-flow, low-gradient AS complicated by moderate-to-severe MR and severe TR was admitted with refractory heart failure despite intensive medical therapy. Given her advanced age, frailty, and high surgical risk, transfemoral TAVI was performed using a 23-mm Navitor™ Vision valve (Abbott Structural Heart, Santa Clara, CA, USA).Valve selection was guided by the presence of a small aortic annulus and the need to balance optimal haemodynamic performance with minimization of potential mitral valve interaction. The procedure was successfully completed without significant residual transvalvular gradient or paravalvular leakage. Following TAVI, relief of afterload was achieved, leading to improvement in functional MR and TR, with discontinuation of inotropic support. Follow-up echocardiography demonstrated a reduction in both MR and TR, accompanied by a decrease in right ventricular systolic pressure. CONCLUSION: We report a case of symptomatic low-flow, low-gradient AS with concomitant MR and TR that was successfully treated with TAVI using a Navitor Vision valve. In patients with small annuli and complex multi-valvular disease, careful transcatheter heart valve selection and procedural optimization may facilitate favourable haemodynamic outcomes and reverse remodelling.

Simultaneous TAVR and TMVR-in-MAC guided by 3D modelling and prosthesis modification: a case report.

BACKGROUND: Severe aortic stenosis (AS) with concomitant mitral annular calcification (MAC) presents substantial procedural and surgical challenges, and simultaneous transcatheter treatment remains rare. This case adds to the emerging literature by demonstrating a hybrid approach using transfemoral transcatheter aortic valve replacement (TAVR) and transapical transcatheter mitral valve replacement (TMVR)-in-MAC supported by patient-specific 3D-printed simulation and prosthesis modification. CASE SUMMARY: A 68-year-old woman with severe obesity, diabetes, chronic kidney disease, prior thoracic surgery, and a pacemaker presented with progressive dyspnoea. Echocardiography showed severe AS and functional mitral stenosis due to extensive MAC. Given prohibitive surgical risk, the Heart Team pursued a percutaneous strategy. A transfemoral self-expanding aortic transcatheter heart valve (THV) was partially deployed for annular anchoring, followed by transapical TMVR with a balloon-expandable valve modified with a polyethylene terephthalate skirt. Pre-procedural simulation with a patient-specific 3D-printed model guided implant depth and informed the decision for prosthesis modification. Both valves were implanted successfully with no paravalvular leak; a moderate left ventricular outflow tract (LVOT) gradient was noted. DISCUSSION: Simultaneous TAVR and TMVR in MAC is rare and technically challenging. This case shows that patient-specific 3D-printed modelling can support procedural planning and device modification, enabling a feasible hybrid transcatheter strategy with favourable clinical outcomes in a high-risk patient.

Transcatheter edge-to-edge repair with DragonFly

BACKGROUND: Transcatheter edge-to-edge repair (TEER) has emerged as an alternative treatment for severe mitral regurgitation (MR). However, complex anatomical features of mitral valve pose significant technical and procedural challenges for TEER. In patients whose effective regurgitation reduction requires multiple clips, a small mitral valve area (MVA) limits TEER by increasing the risk of post-procedural elevated transvalvular gradients and iatrogenic stenosis. CASE SUMMARY: A 90-year-old man presented with progressive tightness of breath that remained refractory to drug-based medical therapy. Echocardiography revealed severe mixed mitral regurgitation characterized by C1 segment prolapse and atrial functional mitral regurgitation with a small MVA of 4.09 cm2. Given his advanced age and prohibitive surgical risk (Society of Thoracic Surgeons [STS] score for repair: 10.49%), the multidisciplinary Heart Team elected to perform TEER using the DragonFlyTM system. The procedure was successfully performed under transoesophageal echocardiographic (TEE) guidance with the sequential implantation of two clips. The second clip utilized a 'Stepless self-locking' strategy to carefully balance the reduction of regurgitation against the transmitral pressure gradient elevation. Regurgitation was reduced from grade 4 + to 1 + with a final mean gradient of 4 mmHg and no evidence of significant mitral stenosis. The patient experienced a marked improvement in functional status during the follow-up period. DISCUSSION: This case highlights the importance of individualized anatomical assessment and tailored device selection in managing patients with MR and complex, challenging structure. Precise clip sizing and stepwise deployment strategies can successfully balance MR reduction while preserving MVA. Such tailored approaches are essential to prevent iatrogenic complications and optimize clinical outcomes in high-risk populations.

Case report: combined transcatheter paravalvular leak closure and valve-in-valve transcatheter aortic valve replacement for treatment of severe regurgitation complicating transcatheter aortic valve replacement.

BACKGROUND: Concurrent transvalvular regurgitation (TVR) and paravalvular leak (PVL) complicating transcatheter aortic valve replacement (TAVR0 is rare, and optimal management is not well described. CASE SUMMARY: A 74-year-old man with LVEF of 40% and prior TAVR (34-mm Medtronic Evolut) presented 8 years post-implantation with New York Heart Association (NYHA) class IV acute decompensated heart failure. Transthoracic echocardiography (TTE) identified severe bioprosthetic aortic regurgitation; transoesophageal echocardiography (TEE) delineated concomitant severe TVR and PVL. Computed tomographic angiography (CTA) identified a discrete paravalvular tunnel between two calcific annular nodules. Given the prohibitive surgical risk, he underwent single-session transcatheter PVL closure with an Amplatzer ductal occluder followed by valve-in-valve TAVR with an Edwards SAPIEN 3 Ultra RESILIA valve. AR pressure half-time improved from 217 to 436 ms, and invasive aortic diastolic pressure normalized from approximately 40-65 mm Hg. At 30-day follow-up, symptoms had improved to NYHA class II, with trace residual PVL and no TVR on TTE. DISCUSSION: To the best of our knowledge, this represents one of the first reported cases of a combined single-session percutaneous approach, consisting of transcatheter PVL closure and valve-in-valve TAVR, to address mixed-mechanism bioprosthetic aortic regurgitation. TEE and CTA are essential for mechanism delineation. A combined transcatheter approach is feasible and effective in high-risk patients.

Transcatheter aortic valve implantation vs surgical aortic valve replacement for aortic stenosis: the saga continues.

Clinical applications of Impella 5.5 for acute severe bioprosthetic aortic regurgitation: a bridge to destination therapy report-case series and review.

BACKGROUND: Acute severe bioprosthetic aortic regurgitation complicated by cardiogenic shock represents a high-risk clinical scenario requiring urgent intervention. Conventional medical therapy is often insufficient, and options for mechanical circulatory support remain limited because severe aortic regurgitation is traditionally considered a relative contraindication to transvalvular support devices. CASE SUMMARY: We describe two cases of acute severe bioprosthetic aortic regurgitation presenting with cardiogenic shock in which Impella 5.5 was utilized as temporary mechanical circulatory support to stabilize patients and facilitate definitive treatment. In the first case, Impella 5.5 support enabled successful bridge to valve-in-valve transcatheter aortic valve replacement. In the second case, Impella 5.5 was used as a bridge to redo surgical aortic valve replacement. In both cases, haemodynamic stabilization and end-organ recovery allowed progression to destination therapy. DISCUSSION: These cases demonstrate that, in carefully selected patients with acute severe bioprosthetic aortic regurgitation and cardiogenic shock, Impella 5.5 may serve as a feasible bridge to definitive valve intervention. Although severe aortic regurgitation has traditionally limited the use of transvalvular mechanical support, these experiences suggest a potential role for Impella 5.5 in individualized management strategies. Further studies are needed to better define patient selection, safety, and outcomes.

Mitral valve posteromedial papillary muscle head rupture presenting after liposomal doxorubicin chemotherapy for metastatic lung liposarcoma: a case report.

BACKGROUND: Doxorubicin-induced cardiotoxicity classically manifests as dose-dependent left ventricular systolic dysfunction. Herein, we describe an unusual case of acute mitral papillary muscle rupture following cumulative anthracycline therapy, presenting despite a preserved ejection fraction. CASE SUMMARY: A 78-year-old woman with metastatic liposarcoma and multiple cardiovascular risk factors developed acute dyspnoea 1 week after completing liposomal doxorubicin (cumulative absolute dose 534 mg). She previously received 5-fraction stereotactic body radiation therapy to the lower lung lobes in September 2024 (9 months prior), targeting fields in close geographic proximity to the diaphragmatic and inferior heart walls. Surveillance echocardiograms from 2022 to 2025 showed a preserved left ventricular ejection fraction (65%-75%). At presentation, cardiac biomarkers showed a normal brain natriuretic peptide and flat, minimally elevated troponins. Transoesophageal echocardiography confirmed an acute rupture of the posteromedial papillary muscle head and associated chordae causing severe (4+) mitral regurgitation. Open surgical intervention was deferred due to advanced malignancy and goals of care. Her acute heart failure was optimized medically with intravenous loop diuretics, low-dose lisinopril for afterload reduction, and metoprolol succinate, while home amlodipine and hydrochlorothiazide were discontinued. She stabilized and is undergoing evaluation for transcatheter edge-to-edge repair. DISCUSSION: While a direct causal link is unproven, this case highlights a rare structural complication. We present this 'two-hit' model as a hypothesis-generating observation, suggesting that chemotherapy-induced structural changes might compound underlying ischaemic or radiation-induced vulnerabilities. As such, advanced imaging modalities may offer value in future efforts to implement risk-adapted surveillance.

Deep learning-derived biological age from preoperative chest radiographs predicts mortality following surgical and transcatheter procedures for structural heart disease beyond EuroSCORE II.

AIMS: Accurate risk stratification before structural heart disease interventions is essential for clinical decision-making. Traditional risk models, such as the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), were designed for surgical patients and show inconsistent performance in transcatheter cohorts. Biological age, reflecting cumulative physiological decline, may offer prognostic value beyond chronological age and established risk scores. METHODS AND RESULTS: In this retrospective study of 1269 patients [non-transcatheter aortic valve implantation (TAVI) n = 751, TAVI n = 518] treated at the German Heart Center Munich, biological age was estimated from pre-operative chest radiographs using CXR-Age, a validated deep learning model. Analyses were conducted separately for surgical (non-TAVI) and transcatheter (TAVI) groups. For 30-day mortality, biological age outperformed EuroSCORE II in both subgroups [area under the receiver operating characteristic curve (AUC): non-TAVI 0.874 vs. 0.785, P < 0.001; TAVI 0.952 vs. 0.745, P = 0.004] and remained independently predictive after adjustment [TAVI OR 1.58 per year, 95% confidence interval (CI) 1.27-2.12]. While STS-PROM was the strongest single predictor for non-TAVI patients (AUC 0.949), it was similar to EuroSCORE II for TAVI patients (AUC 0.729). Notably, patients whose biological age exceeded their chronological age by more than 10 years faced higher major complication rates (17.3% vs. 9.2%; P = 0.016). CONCLUSION: Biological age distinguished risk across both populations, suggesting that deep learning-based biological age estimation from routine chest radiographs could serve as an automated, accessible complement to existing risk models.

Surgical implantation of an aortic over-expanded transcatheter heart valve: a rescue strategy for calcified and aneurysmatic annulus.

Detection of progression of asymptomatic severe aortic stenosis using Apple Watch-estimated maximal oxygen consumption (VO

BACKGROUND: Symptomatic aortic stenosis (AS) constitutes a class I indication for aortic valve intervention, either by surgical or transcatheter aortic valve replacement (TAVR). Progressive AS can reduce maximal oxygen consumption (MVO2), yet this parameter is not routinely evaluated in clinical practice. CASE SUMMARY: We present a case of a 68-year-old with hypertension and hyperlipidaemia, initially diagnosed with moderate AS [aortic valve area (AVA) 1.3 cm2, mean gradient 23 mmHg, peak velocity 3.2 m/s]. He was asymptomatic and maintained a high level of physical activity, including treadmill running. Over the course of 3 years, the patient used an Apple Watch® to monitor estimated VO2 max. Despite stable exercise tolerance, his recorded VO2 max decreased progressively from 36 to 26 mL/kg/min. Concerned by the trend, he sought our evaluation. Repeat echocardiography showed severe AS (AVA 0.6 cm2, mean gradient 43 mmHg, peak velocity 4.29 m/s) with preserved left ventricular ejection fraction (LVEF 60%-65%). The patient subsequently underwent TAVR with a 26 mm Edwards Lifesciences Sapien 3 Ultra Valve®. At 1-year follow-up, his Apple Watch-derived VO2 max improved to 41 mL/kg/min. Echocardiography confirmed a well-seated prosthesis with a mean gradient of 9 mmHg. DISCUSSION: This case illustrates the potential utility of consumer wearable technology (Apple Watch) for detecting progressive asymptomatic AS using estimated VO2 max feature. Continuous tracking of estimated VO2 max may serve as an adjunct parameter to guide timing of intervention in selected patients.

Transcatheter closure of a ruptured sinus of Valsalva aneurysm-a minimally invasive approach to a rare cardiac emergency: a case report.

BACKGROUND: Sinus of Valsalva aneurysm (SVA) is a rare but clinically significant cardiac anomaly, arising congenitally or through acquired causes. Typically, asymptomatic until rupture, this condition can precipitate acute or subacute heart failure via a pathological left-to-right shunt. While surgical repair has long been considered the definitive treatment, advances in high-resolution imaging and percutaneous device technology have established transcatheter closure as a compelling, minimally invasive alternative in anatomically suitable patients. CASE SUMMARY: We present a case of a ruptured noncoronary sinus of Valsalva aneurysm creating a left-to-right shunt into the right ventricle. Despite the potentially life-threatening haemodynamic implications, the patient maintained stability. Multimodal imaging-including transoesophageal echocardiography and computed tomography angiography-precisely delineated the defect and informed procedural strategy. The patient underwent a successful percutaneous transcatheter closure using a patent ductus arteriosus occluder device, with no procedural complications. Follow-up evaluation confirmed complete defect occlusion and preservation of aortic valve integrity, with no residual shunting. CONCLUSION: This case underscores the expanding role of transcatheter interventions in the management of ruptured SVAs, highlighting the importance of meticulous imaging and patient selection to achieve excellent clinical and structural outcomes. It contributes to the growing evidence supporting minimally invasive alternatives to surgery in selected structural heart diseases.

Valve-in-valve transcatheter pulmonary valve replacement in carcinoid heart disease: a case report.

BACKGROUND: Carcinoid heart disease (CHD) commonly affects right-sided heart valves, often leading to progressive right heart failure (RHF) and structural valve deterioration. CASE SUMMARY: A 30-year-old male with CHD and prior bioprosthetic tricuspid and pulmonic valve replacements presented with New York Heart Association Class III symptoms and RHF. Imaging revealed significant degeneration of both valves. Given the high surgical risk (EuroSCORE II 9.12%), the Heart Team opted for transcatheter pulmonary valve replacement (TPVR). Despite challenging anatomy, a Melody valve (Medtronic) was successfully implanted, resulting in improved haemodynamics and no significant residual regurgitation. DISCUSSION: Bioprosthetic failure in CHD poses significant treatment challenges. This case underscores the growing role of TPVR as a less invasive and effective alternative to surgery in high-risk patients, with advanced imaging playing a pivotal role in planning and execution.

Bailout transcatheter mitral valve implantation for extensive valvular and atrial calcifications during triple-valve surgery in a patient with long-lasting renal replacement therapy: a case report.

BACKGROUND: We present a successful case of triple-valve surgery, including bailout open-heart transcatheter mitral valve implantation, in a haemodialysis patient with extensive intracardiac calcifications. CASE SUMMARY: A middle-aged woman with exercise-induced dyspnoea and an end-stage kidney disease on renal replacement therapy was admitted to the emergency department for severe hypotension and bradycardia. A high-degree AV block was diagnosed. Multimodal imaging exams also revealed a triple severe valvular disease (mitral stenosis, aortic stenosis, and tricuspid regurgitation) with an unclear cardiac mass enclosed within the left atrial wall. To avoid potentially dangerous decalcification for valve replacement, a combined traditional surgical approach and transcatheter valve implantation have been successfully applied. DISCUSSION: The current case confirms that open-heart transcatheter valve implantation at the mitral position in the presence of marked calcifications involving the valve apparatus, atrial, and ventricular walls is a valuable option, potentially avoiding dangerous decalcification, achieving effective mitral valve stenosis relief, and shortening surgical times.

Transcatheter edge-to-edge repair for severe mitral regurgitation in a patient with a massive left atrium: a case report.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) poses significant technical challenges in patients with a massive left atrium (LA), where conventional anatomical criteria often deem the procedure unsuitable. CASE SUMMARY: A 77-year-old man, at prohibitive surgical risk, presented with a giant LA (113 × 129 × 133 mm) and severe mitral regurgitation (MR). After pacemaker implantation, TEER was performed. Despite suboptimal echocardiographic windows and challenging leaflet capture, a tailored posteroinferior transseptal puncture 4.67 cm above the mitral annular plane provided a stable trajectory, enabling successful navigation and deployment of three MitraClip devices (Abbott, Santa Clara, CA, USA). The procedure achieved an excellent outcome with a mean gradient of 5 mmHg and only mild residual MR. Marked left atrial reverse remodelling and symptomatic improvement were observed at 1-month follow-up. DISCUSSION: This case demonstrates that TEER is a viable and effective intervention for patients with extreme LA enlargement, challenging conventional anatomical selection criteria. Success hinges on technical precision-particularly an optimized transseptal puncture-and prioritizing favourable haemodynamic outcomes over rigid anatomic thresholds.

Emerging Longer-Term Evidence on Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis in Low-Risk Patients: A Call for Caution

The expanding use of transcatheter aortic valve implantation (TAVI) in low-risk patients with severe aortic stenosis, including populations underrepresented in pivotal trials and often beyond established guideline recommendations, makes extended follow-up from TAVI versus surgical aortic valve replacement (SAVR) trials central to assessing valve durability and late adverse events and to informing lifetime management strategy. Although Evolut Low Risk 6- to 7-year follow-up showed no statistically significant difference in the primary composite of death or disabling stroke, the signals of later mortality accrual, more myocardial infarction events, and higher aortic valve reintervention rates with TAVI raise concerns about durability and stability of the early treatment effect.

The Society of Thoracic Surgeons Risk Model for Surgical Aortic Valve Replacement After Transcatheter Aortic Valve Replacement

Recent evidence suggests cardiac surgery after transcatheter aortic valve replacement (TAVR) carries additional risk. Herein we describe validation of a risk model for surgical aortic valve replacement (SAVR) after prior TAVR and risk distribution over time.

Graft-Assisted Transapical Transcatheter Aortic Valve Replacement with Concomitant Robotic Minimally Invasive Direct Coronary Artery Bypass

This is a case of a 55-year-old male with multivessel coronary artery disease and severe aortic stenosis. The patient presented with multiple recent hospitalizations for heart failure and had been turned down for heart transplantation approximately one year prior. The heart team determined that the patient was high-risk for sternotomy due to recent chest radiation and high-risk for transfemoral approach due to severe peripheral vascular disease. Ultimately, the patient underwent robotic minimally invasive direct coronary artery bypass with concomitant graft-assisted transapical transcatheter aortic valve replacement.

Hospital-Level Variation in Transcatheter versus Surgical Aortic Valve Replacement Among Patients Younger than 65 Years

Current guidelines do not recommend transcatheter aortic valve replacement (TAVR) in adults younger than 65 years with isolated aortic stenosis and a life expectancy >10 years.

Anomalous Left Circumflex Artery in Valve Interventions: Surgical and Transcatheter Challenges

Anomalous origin of the left circumflex coronary artery (AOLCX) following a retro-aortic course is at risk of compression during valve interventions. Although typically benign, iatrogenic injury can cause catastrophic ischemia. As transcatheter aortic valve replacement (TAVR) expands to lower-risk populations, understanding mechanisms of injury in both surgical and transcatheter settings is crucial.

Emerging Longer-Term Evidence on Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis in Low-Risk Patients: A Call for Caution.

The expanding use of transcatheter aortic valve implantation (TAVI) in low-risk patients with severe aortic stenosis, including populations underrepresented in pivotal trials and often beyond established guideline recommendations, makes extended follow-up from TAVI versus surgical aortic valve replacement (SAVR) trials central to assessing valve durability and late adverse events and to informing lifetime management strategy. Although Evolut Low Risk 6- to 7-year follow-up showed no statistically significant difference in the primary composite of death or disabling stroke, the signals of later mortality accrual, more myocardial infarction events, and higher aortic valve reintervention rates with TAVI raise concerns about durability and stability of the early treatment effect. In PARTNER 3, 7-year outcomes appeared broadly similar when comparing the reported composite endpoints, but their interpretation is limited by heterogeneous endpoint construction, non-prespecified hierarchical analysis, incomplete follow-up, and the influence of post hoc vital-status ascertainment on late mortality estimates. In an intermediate-risk population, PARTNER 2A showed lower 10-year survival and higher aortic valve reintervention rates with TAVI than with SAVR. Together with the presented UK-TAVI, meta-analyses, and large observational studies, these findings underscore uncertainty about durability and reintervention burden of TAVI and future treatment strategies. By integrating extended follow-up from pivotal trials with other new data, this review calls for a more rigorous and transparent long-term evidence framework before further expanding TAVI, particularly in younger, low-risk patients. Treatment decisions should remain individualized within a structured Heart Team framework, with explicit discussion of expected survival, anatomical suitability, valve durability, reintervention options, and lifetime-management implications.

Optimal Management for Moderate Aortic Stenosis at the Time of Coronary Artery Bypass Grafting.

BACKGROUND: Established guidelines recommend consideration for concomitant surgical aortic valve replacement (SAVR) at time of coronary artery bypass grafting (CABG) in patients with moderate aortic stenosis (AS) to avoid future reoperation for AS progression. The advent of transcatheter aortic valve replacement allows for treatment of AS without mediastinal entry. This questions the optimal treatment choice of moderate AS in patients undergoing CABG. We compared outcomes of CABG with or without SAVR in patients with moderate AS. METHODS: Patients ≥65 years old with moderate AS who underwent CABG or CABG+SAVR from 2011-2022 were identified from the Society of Thoracic Surgeons adult cardiac surgery database. Exclusions included cardiogenic shock, endocarditis, severe aortic insufficiency, and non-sternotomy cases. Analyzed outcomes included perioperative complications, mid-term mortality, and readmission for heart failure or aortic valve (AV) intervention. RESULTS: Among 18,247 patients, 9,325(51.1%) underwent CABG+SAVR and 8,922(48.9%) underwent isolated CABG. The isolated CABG cohort had lower operative mortality and postoperative complications. Risk adjusted mid-term outcomes showed similar all-cause mortality. Patients who underwent isolated CABG were at an increased risk for mid-term readmission for heart failure and AV intervention. Rate of AV intervention at 8 years for isolated CABG patients compared to CABG+SAVR was 25.9% versus 2.4%, respectively. CONCLUSIONS: Deferring SAVR during CABG in patients with moderate AS may lower operative risk without affecting mid-term mortality but increases heart failure readmissions and later AV interventions. Further studies are needed to determine if delaying the AV intervention translates to reduced prosthetic valve degeneration without increasing long-term morbidity and mortality.

Outcomes After Ross, TAVR, and SAVR in Younger Adults.

Graft-Assisted Transapical Transcatheter Aortic Valve Replacement with Concomitant Robotic Minimally Invasive Direct Coronary Artery Bypass.

This is a case of a 55-year-old male with multivessel coronary artery disease and severe aortic stenosis. The patient presented with multiple recent hospitalizations for heart failure and had been turned down for heart transplantation approximately one year prior. The heart team determined that the patient was high-risk for sternotomy due to recent chest radiation and high-risk for transfemoral approach due to severe peripheral vascular disease. Ultimately, the patient underwent robotic minimally invasive direct coronary artery bypass with concomitant graft-assisted transapical transcatheter aortic valve replacement.

SAVR and TAVR in Dialysis-Dependent Patients: Are We Improving Survival Beyond Medical Management?

Management of TAVI Candidates With Metal Allergy: Minimally Invasive Aortic Valve Replacement With a Metal-Free Bioprosthesis.

An 87-year-old woman with severe aortic stenosis required intervention. Patch testing demonstrated nickel and cobalt hypersensitivity, ruling out transcatheter valve implantation. After multidisciplinary review, minimally invasive aortic valve replacement through a right anterior thoracotomy was chosen, thereby avoiding median sternotomy and stainless steel wires. A 21-mm Avalus bioprosthesis (Medtronic)-engineered without a metallic stent-was implanted successfully. Recovery was smooth. Extubation occurred within hours, and the patient was discharged from the hospital on postoperative day 5. At 1 year, prosthetic performance and clinical status were excellent. This experience illustrates a practical path when transcatheter treatment is contraindicated by documented metal allergy: minimally invasive surgery with a metal-free valve.

Transcatheter Aortic Valve Explant Experience From a High-Volume Structural Heart Center.

BACKGROUND: When transcatheter aortic valve replacement (TAVR) fails and repeat TAVR is not possible, TAVR explantation remains a viable strategy. However, results from multicenter studies have shown high morbidity and mortality. This study aimed to examine early and late outcomes after TAVR explantation at a high-volume structural heart center. METHODS: At a single center performing >600 TAVR procedures annually, the institutional The Society of Thoracic Surgeons registry was queried to identify all patients undergoing surgical aortic valve replacement with a history of TAVR between 2011 and 2024. Institutional trends, operative details, and outcomes at 30-days and 5-years were compared between TAVR explantation with isolated surgical aortic valve replacement (SAVR; n = 14) and TAVR explantation with SAVR plus concomitant procedures (n = 40). RESULTS: TAVR implantations and explantations increased significantly over time (P < .001). The median time to TAVR explantation was 455 days (interquartile range, 145-1094 days), and the median surgeon TAVR explantation experience was 4 cases (interquartile range, 1-11 cases). Overall, 30-day mortality (7.4%) and 30-day morbidity and mortality (25.9%) were relatively low despite high rates of concomitant procedures (74.1%). There were no differences in 30-day mortality (P = .52) or 5-year survival (hazard ratio, 1.78; 95% CI, 0.38-8.40; P = .47) between the isolated SAVR and concomitant procedures groups. CONCLUSIONS: The risk of morbidity and mortality was relatively low in patients undergoing TAVR explantation in a single high-volume center, a finding highlighting the potential need to centralize care for this complex procedure.

Revisiting the SURPLUS Procedure-A Hybrid Solution to the Complex Aortic Root.

Valve-in-valve transcatheter aortic valve (TAV) replacement (TAVR) is becoming increasingly more common in patients with bioprosthetic valve failure. However, solutions for high-risk patients with prior TAVR deployment remain challenging, and TAV-in-TAV may not be feasible because of the risk for coronary occlusion. We revisit the SURPLUS procedure, surgical resection of prosthetic valve leaflets under direct vision, with hybrid placement of a TAV-in-TAV for a patient who had prior valve-in-valve TAVR complicated by left main coronary artery occlusion warranting emergent left main snorkel placement, now with moderate to severe aortic insufficiency complicated by heart failure.

The Society of Thoracic Surgeons Risk Model for Surgical Aortic Valve Replacement After Transcatheter Aortic Valve Replacement.

BACKGROUND: Recent evidence suggests cardiac surgery after transcatheter aortic valve replacement (TAVR) carries additional risk. Herein we describe validation of a risk model for surgical aortic valve replacement (SAVR) after prior TAVR and risk distribution over time. METHODS: Patients undergoing SAVR (7/2014-3/2025) were extracted from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Patients were excluded for no prior TAVR, concomitant arch/descending aortic procedures, other major surgery, or missing operative mortality data. Patients undergoing proximal aortic or other valve surgery were included. De novo, parsimonious models were built for all 8 STS outcomes. RESULTS: Among 651,398 SAVR patients during the study period, 5,708 had SAVR after TAVR with 2,298 (40.3%) isolated SAVR-after-TAVR and 3,410 (59.7%) concomitant procedures. The risk model for SAVR-after-TAVR had excellent discrimination for operative mortality (AUC 0.82) and morbidity or mortality (AUC 0.73). Calibration was excellent across risk deciles for all demographic and surgical subgroups. Of isolated SAVR-after-TAVR cases that might qualify for redo-TAVR (excluding endocarditis, root enlargement and emergent cases), 53.3% (753/1,334) had predicted risk of mortality <3%, and the operative mortality rate decreased over time from 13.1% to 3.5%. Given improvement over time, era was included as an interaction term in the model for isolated SAVR cases, leading to stable observed-to-expected ratios. CONCLUSIONS: Mortality rates for SAVR-after-TAVR have decreased. The risk model has excellent performance and demonstrates a large cohort of TAVR explant patients can be classified as low risk. The new risk model allows for accurate risk estimates to inform clinical decision-making.

Isolated Transcatheter and Surgical Aortic Valve Replacement in the Evolut Low-Risk Trial: 5-Year Comparative Outcomes.

BACKGROUND: We aim to compare the 5-year outcomes of patients who received isolated transcatheter aortic valve replacement (TAVR) versus those who underwent isolated surgical aortic valve replacement (SAVR) from the Evolut Low Risk Trial. METHODS: In the Evolut Low Risk trial, 1,414 low-risk patients with severe aortic stenosis underwent TAVR using a self-expanding, supra-annular CoreValve, Evolut R, or PRO bioprosthesis or SAVR. This post hoc analysis excluded 250 patients, those with concomitant procedures (e.g., percutaneous coronary intervention and coronary artery bypass grafting performed) and those who experienced crossover between treatment arms. Five-year clinical and echocardiographic outcomes are reported. RESULTS: A total of 1,164 patients underwent an isolated procedure (667 TAVR, 497 SAVR). At 5 years, the composite of all-cause mortality or disabling stroke was similar between the isolated groups (15.5% TAVR, 14.6% SAVR; P=.84). All-cause mortality (13.5% TAVR, 12.8% SAVR; P=.85) and cardiovascular mortality (6.9% TAVR, 8.3% SAVR; P=.36) were also comparable. New permanent pacemaker implantation was higher with TAVR (27.3% vs 8.9%, P<.001). The 5-year rate of aortic valve reintervention was 3.0% for TAVR and 2.2% for SAVR (P=.51). Moderate or greater paravalvular regurgitation (PVR) occurred in 0.5% of TAVR patients and none of the SAVR patients (P=.52) at 5 years. CONCLUSIONS: This post hoc analysis of the Evolut Low Risk Trial in patients undergoing isolated TAVR or SAVR demonstrates similar rates of all-cause mortality, reintervention, and ≥moderate PVR at 5 years, supporting Evolut TAVR as a suitable treatment option in carefully selected low-risk patients undergoing isolated valve replacement.

Anomalous Left Circumflex Artery in Valve Interventions: Surgical and Transcatheter Challenges.

BACKGROUND: Anomalous origin of the left circumflex coronary artery (AOLCX) following a retro-aortic course is at risk of compression during valve interventions. Although typically benign, iatrogenic injury can cause catastrophic ischemia. As transcatheter aortic valve replacement (TAVR) expands to lower-risk populations, understanding mechanisms of injury in both surgical and transcatheter settings is crucial. METHODS: A narrative review was performed focusing on anatomical risks, injury mechanisms, and management of AOLCX. Forty-five relevant publications were synthesized to integrate technical and anatomical evidence. RESULTS: Left circumflex artery compromise is determined by the vessel's proximity to the aortic and mitral annuli. In surgery, deep sutures or prosthetic rings are the primary causes. In TAVR, mechanisms involve retro-aortic compression and ostial occlusion, necessitating pre-procedural assessment of coronary height, sinus dimensions, calcification, and annular proximity. Preventive strategies include surgical mobilization, prophylactic bypass, and guidewire protection. Bailout strategies include bypass and emergency stenting. For aortic stenosis, procedure selection between surgery and TAVR should be individualized based on age, calcification and anatomical metrics. Late complications such as delayed coronary obstruction necessitate longitudinal surveillance. CONCLUSIONS: Pre-procedural computed tomography angiography is essential to quantify anatomical risk. A Heart Team approach is required to select the optimal intervention and implement mechanism-specific protection. Long-term clinical and imaging surveillance is warranted to prevent both acute and delayed left circumflex artery compromise.

Transcatheter vs. Surgical Aortic Valve Replacement in Low- to Intermediate-Risk Patients: Do DEDICATE trial outcomes translate to real-world populations?

To assess the transportability of the randomized DEDICATE trial results, comparing SAVR with TAVR in low- to intermediate-risk patients, to an external Dutch population derived from the Netherlands Heart Registration (NHR).

Morbidity and Mortality Outcomes of Surgical Versus Transcatheter Aortic Valve Replacement in Dialysis-Dependent Patients

To compare morbidity and mortality outcomes of isolated surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) among patients on dialysis over 5 years.

Impact of Membranous Septum Length and Valve Calcification on Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement

Conduction abnormalities requiring permanent pacemaker implantation (pPMI) following surgical aortic valve replacement (SAVR) are associated with worse postoperative outcomes. Although membranous septum (MS) length measured on preprocedural computed tomography (CT) is a known predictor for pPMI following transcatheter aortic valve replacement, its impact in SAVR is not fully understood.

Transcatheter vs. Surgical Aortic Valve Replacement in Low- to Intermediate-Risk Patients: Do DEDICATE trial outcomes translate to real-world populations?

OBJECTIVE: To assess the transportability of the randomized DEDICATE trial results, comparing SAVR with TAVR in low- to intermediate-risk patients, to an external Dutch population derived from the Netherlands Heart Registration (NHR). METHODS: Data sources included the DEDICATE-RCT data (TAVR-trial, SAVR-trial) and the NHR (SAVR-registry). The primary endpoint was composite of all-cause mortality or stroke at one year; secondary endpoints were mortality and stroke. As-treated TAVR-trial and SAVR-trial patients were propensity-score (PS) matched to SAVR-registry patients. Model-based and weighting-based transportability analyses were performed. RESULTS: After applying trial criteria, 3,389 SAVR-registry patients were eligible and 1,211 trial patients were included (654 TAVR; 557 SAVR). Trial-eligible SAVR-registry patients were younger and had fewer comorbidities. PS-matching of TAVR-trial to SAVR-registry yielded 1,150 patients, and matching of SAVR-trial to SAVR-registry yielded 892 patients. In PS-matched cohorts, SAVR-trial patients experienced more composite events (HR 1.63 [1.02-2.62],p=0.04) and strokes (HR 2.96 [1.37-6.37],p=0.01) than SAVR-registry patients, with comparable mortality (HR 1.15 [0.65-2.02], p=0.63). TAVR-trial (vs. SAVR-registry) patients had lower 1-year mortality (HR 0.46 [0.24-0.87], p=0.02). Transported absolute risk reduction (ARR) of 1-year mortality of TAVR was attenuated when the trial was reweighted to resemble the registry (ARRtransported: 2.2% [0.1-4.2]; ARRtrial: 3.7% [1.4-6.7]). CONCLUSION: In PS-matched analyses, SAVR-registry patients showed lower combined mortality/stroke and stroke rates than SAVR-trial participants, suggesting caution in transporting trial-derived relative effects to this population. For mortality the relative trial-effects could be reproduced, but absolute benefit of TAVR was diminished in the registry population.

Transcatheter versus surgical aortic valve replacement for severe aortic stenosis in low-risk adults: a network meta-analysis.

PURPOSE: To compare the safety and efficacy of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in low-risk severe aortic stenosis, and to assess the differential impact of balloon-expandable (BE) and self-expanding (SE) valve platforms on clinical outcomes. METHODS: A systematic search across seven databases was performed through May 2024. Frequentist and Bayesian network meta-analyses were conducted across three pre-specified time horizons: 30 days, 1 to 2 years, and 3 or more years. Results are reported as odds ratios (OR) with 95% confidence intervals (CI). Egger's regression testing and randomized controlled trial (RCT)-only sensitivity analyses were performed. RESULTS: Thirty-one studies (37,741 patients) were included. All TAVR types demonstrated comparable short-term and intermediate-term mortality to SAVR, with TAVR-BE ranking most favourably by Surface Under the Cumulative Ranking (SUCRA) (81.2% and 87.7%); these rankings should be interpreted alongside the non-significant effect estimates. In exploratory ≥3-year analyses (k=10 studies, consistent with RCT-only sensitivity analyses), TAVR-Mixed showed significantly higher mortality than SAVR (OR 1.963 [95% CI 1.620 to 2.378]; p<0.001), while TAVR-BE and TAVR-SE showed no significant difference. TAVR-BE significantly reduced 30-day rehospitalization (OR 0.625; p=0.007), stroke (OR 0.534; p=0.001), atrial fibrillation, acute kidney injury, and major bleeding versus SAVR. All TAVR platforms shortened hospital stay by approximately 4 days. SAVR was associated with significantly lower rates of paravalvular regurgitation and permanent pacemaker implantation at all time horizons. CONCLUSION: In low-risk severe aortic stenosis, TAVR, particularly with balloon-expandable valves, appears to offer comparable short-term and intermediate-term survival with superior procedural safety versus SAVR. In exploratory ≥3-year analyses, SAVR was associated with lower mortality specifically within the heterogeneous TAVR-Mixed cohort; TAVR-BE and TAVR-SE showed no significant mortality difference from SAVR at this horizon, underscoring the importance of platform-specific and individualised decision-making. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-026-02245-1.

Trends in Aortic Valve Reintervention: Incidence and Outcomes after Failed TAVI Among Medicare Patients.

OBJECTIVE: With the growing use of TAVI, data on TAVI failure and outcomes after reintervention remain limited. This study describes trends in reinterventions and associated outcomes, including mortality and heart failure (HF) hospitalization in elderly patients. METHODS: Using the Medicare database, we identified 324,701 patients who underwent TAVI during 2013-2022. Trends in aortic valve reinterventions-including TAVI-in-TAVI and surgical explants-were analyzed using Joinpoint regression to report annual percent change (APC). A Cox proportional hazards model was used to estimate the association between the year of reintervention and the risk of outcomes as hazard ratios (HRs). RESULTS: Between 2013 and 2022, 2,387 patients underwent aortic valve reintervention after TAVI (61.3% TAVI-in-TAVI and 38.7% surgical aortic valve replacement (SAVR)). The number of aortic valve reinterventions increased from 49 in 2013 to 505 in 2022 (APC:22.1%, p<0.001). There was an initial decline in the TAVI-in-TAVI incidence rate per 1,000 person-years (APC:-27.6% from 2013-2019), followed by a significant increase (APC:35.2% from 2019-2022). Meanwhile, the incidence rate remained unchanged for explant until 2017, after which it increased (APC:18.3%, p<0.001). After reintervention, 8.7% of patients died within 30 days, and 18.7% within one year. The adjusted risk of mortality (HR: 0.96 [95%CI: 0.93-0.99], p=0.01) and HF hospitalization (sHR: 0.87 [95%CI: 0.83-0.91], p<0.001) declined significantly over time. CONCLUSION: Reinterventions, mainly surgical explants, have increased after TAVI. However, associated mortality and HF hospitalization have declined, reflecting an improvement in the management of failed TAVI in elderly patients. Further research into rising explant rates is warranted.

The 2026 American Association for Thoracic Surgery (AATS) Expert Consensus Document: Management of Atrial Functional Mitral Regurgitation.

OBJECTIVE: Atrial functional mitral regurgitation (AFMR) represents a distinct pathophysiologic entity characterized by mitral regurgitation secondary to left atrial dilation and annular remodeling, in the absence of significant left ventricular disease. With the increasing prevalence of atrial fibrillation and heart failure with preserved ejection fraction, AFMR has emerged as an important and potentially underrecognized etiology of mitral regurgitation. This expert consensus statement provides an evidence- and experience-based framework for the evaluation and management of AFMR, encompassing diagnosis, medical and rhythm therapy, surgical and transcatheter interventions, and postoperative management. METHODS: The American Association for Thoracic Surgery convened an international multidisciplinary panel of cardiac surgeons, cardiologists, and electrophysiologists with expertise in atrial and mitral valve disease. The panel conducted a systematic literature review and iterative Delphi consensus process to develop recommendations, graded according to class of recommendation (CoR) and level of evidence (LoE). RESULTS: Consensus was achieved on 18 statements, organized into five sections: (1) Definition, pathophysiology, and diagnostic evaluation of AFMR. (2) Medical and rhythm management strategies. (3) Surgical treatment and concomitant procedures. (4) Transcatheter and hybrid interventions. (5) Postoperative rhythm and anticoagulation management CONCLUSIONS: AFMR represents a distinct form of secondary mitral regurgitation driven by atrial remodeling. This document summarizes current expert consensus to guide diagnosis, timing, and choice of intervention, and highlights the need for multidisciplinary collaboration and prospective research to optimize outcomes.

Contemporary Surgical Outcomes and Repair Rates in Degenerative Mitral Regurgitation: Real World Insights from the International MITRACURE Registry.

OBJECTIVE: Degenerative mitral valve (MV) disease is the leading mitral regurgitation (MR) etiology in Western countries, representing a significant health burden. With the rise of transcatheter therapies, real-world data on surgical management, repair rates, outcomes, and center-level practices are increasingly needed. METHODS: From MITRACURE, a multicenter registry of 40 centers across Canada and France of consecutive adult patients who underwent surgery for MR in 2019, we selected the subset of patients with degenerative MR. RESULTS: MV surgery was performed in 2,135 patients with degenerative MR (70% male, 65±12 years); 37% were in NYHA III/IV, only 17% were considered asymptomatic, and early intervention was performed in only 4%. MV repair rate was 80%, with a 6% intraoperative repair failure rate. In-hospital mortality was 2.3%, 1.4% for repair vs 6.2% for replacement, P<0.0001. Major complications occurred in 20%, higher for replacement and combined procedures. Independent predictors of mortality included NYHA III/IV, type of surgery, and EuroSCORE II. Repair rates declined with age, comorbidities, and complex anatomy, and increased with center volume (68%, 77%, and 84% in low, intermediate, and high-volume centers, respectively; P<0.0001). Sex was not associated with repair rates after adjustment. CONCLUSIONS: In this large real-world cohort from two publicly funded healthcare systems, many patients with degenerative MR were referred late for surgery, and early intervention was rare. While in-hospital mortality was low overall, outcomes varied across subgroups. MV repair declined with age and MV anatomical complexity. High-volume centers had better outcomes, supporting earlier referral, structured pathways, and surgical centralization to optimize care.

Morbidity and Mortality Outcomes of Surgical Versus Transcatheter Aortic Valve Replacement in Dialysis-Dependent Patients.

OBJECTIVE: To compare morbidity and mortality outcomes of isolated surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) among patients on dialysis over 5 years. METHODS: Patients with CKD on dialysis undergoing isolated SAVR or TAVR between 2005 and 2025 were identified from the TriNetX Research Network. Cohorts were matched on demographics and relevant comorbidities. Baseline characteristics were compared using Chi-square and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Early outcomes were analyzed using logistic regression. Long-term outcomes at 1, 3, and 5 years were assessed using Kaplan-Meier survival analysis and Cox proportional hazards regression. RESULTS: After matching, 224 patients were included in each group with adequate balance. At 1 month, pooled 3-point major adverse cardiovascular and cerebrovascular events (MACCE; mortality, ischemic stroke, and acute MI) was significantly higher in the SAVR cohort (HR 1.96, 95%CI 1.18-2.47). Mortality did not significantly differ between cohorts at 1 year; however, it was significantly lower at 3 (HR=0.70, 95%CI 0.52-0.95) and 5 years (HR=0.71, 95%CI 0.54-0.94) with SAVR. Risk of atrial fibrillation was higher with SAVR at 1 month (OR=1.64; 95%CI 1.09-2.47). Other cardiovascular comorbidities were similar between the cohorts over the follow-up duration. CONCLUSION: In dialysis-dependent patients, SAVR is associated with higher early MACCE, but improved long-term survival compared with TAVR.

Surgical aortic valve replacement with Y-incision aortic annular enlargement provided better hemodynamics than transcatheter aortic valve replacement.

OBJECTIVE: We aimed to examine early outcomes of surgical aortic valve replacement (SAVR) with Y-incision aortic annular enlargement (Y-AAE) versus transcatheter AVR (TAVR) in native aortic valve stenosis. METHODS: From August 2020 to March 2024, 362 patients with severe native aortic valve stenosis underwent SAVR + Y-AAE with bioprosthetic valves (n = 70) or TAVR (n = 292) with ejection fraction ≥50%, Society of Thoracic Surgeons predicted risk of mortality score ≤8, and minimal aortic annular diameter ≤25 mm by computed tomography. Nearest-neighbor 1:3 propensity score matching was conducted across all preoperative variables. RESULTS: The minimal aortic annular diameter by CT was 22 mm (IQR, 20, 23 mm) in the TAVR group and 21 mm (IQR, 19, 23 mm) in the SAVR + Y-AAE group. The TAVR group had median implanted valve sizes of Edwards LifeSciences Sapien 26 mm (IQR, 25, 29 mm) and Medtronic Evolut 29 mm (29, 34 mm), whereas the SAVR + Y-AAE group had a median implant size of 29 mm (27, 29 mm). Compared with the TAVR group, the SAVR + Y-AAE group had similar operative mortality (0% vs 2%; P > .99) and lower postoperative pacemaker implantation rate (1.4% vs 10.3%; P = .03). At 24 to 36 months postoperative, the SAVR + Y-AAE group had significantly larger effective orifice area (2.7 vs 1.9 cm2), lower aortic valve mean gradients (5 vs 9.5 mm Hg), greater dimensionless index (0.67 vs 0.54), lower rates of aortic insufficiency (3.0% vs 26%), and less moderate/severe prosthesis-patient mismatch (0% vs 20.1%). The left ventricular mass index regression was greater in SAVR + Y-AAE patients (42% vs 22%; P = .05). The SAVR + Y-AAE 3-year survival was 96% versus 79% for TAVR in the propensity-score matched cohort (P = .12). The hazard ratio of SAVR + Y-AAE for early mortality was 0.15 (95% CI, 0.02-1.13; P = .066). CONCLUSIONS: Low- and intermediate-risk patients with aortic valve stenosis should be considered for SAVR + Y-AAE for excellent hemodynamics and early outcomes.

Redo surgical aortic valve replacement versus valve-in-valve transcatheter aortic valve replacement with balloon valve fracture: Short-term clinical outcomes.

OBJECTIVE: To evaluate short-term outcomes of redo surgical aortic valve replacement (SAVR) versus valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) with bioprosthetic valve fracture (ViVBVF) in patients with bioprosthetic structural valve deterioration undergoing reintervention. METHODS: This retrospective single-center study was conducted between 2015 and 2025. Data were obtained from institutional registries. A total of 128 consecutive patients met the inclusion criteria (75 with redo-SAVR and 53 with ViVBVF). Patients requiring concomitant cardiac procedures, mechanical valves, or unsuitable anatomy for ViV were excluded. The primary endpoints were 30-day mortality, stroke, and readmission; secondary endpoints included echocardiographic changes and postoperative complications. Overlap propensity score weighting to adjust baseline differences was performed. RESULTS: Compared to the redo-SAVR patients, the ViVBVF patients were older and had a higher predicted risk of mortality. The rates of 30-day mortality, stroke, and readmission were similar in the 2 groups. ViVBVF achieved significantly greater reductions in mean gradient (-26.0 mm Hg vs -17.4 mm Hg; P =.003), peak gradient (-39.2 mm Hg vs -23.3 mm Hg; P =.004), and peak velocity. After matching, 30-day mortality was higher after redo-SAVR (8.9% vs 0%; P < .001). The ViVBVF group showed a greater reduction in peak velocity but more frequent pacemaker implantation. CONCLUSIONS: In patients with bioprosthetic valves requiring reintervention, ViVBVF offers greater gradient reduction, with a perioperative safety advantage suggested in the adjusted analysis.

A decade of cardiac surgery after transcatheter aortic valve replacement: Short-term clinical outcomes at a high-volume center.

BACKGROUND: The growing adoption of transcatheter aortic valve replacement (TAVR) in younger and lower-risk patients has increased the number of patients with other cardiac diseases requiring surgical intervention. Such surgeries pose unique technical challenges due to the presence of the TAVR, often requiring explantation. Despite increasing clinical relevance, outcomes of these operations remain poorly characterized. We sought to assess the incidence, indications, and short-term results of cardiac surgery following TAVR at a high-volume institution. METHODS: This was a retrospective single-center analysis of patients undergoing any cardiac surgery post-TAVR between 2015 and 2024. Primary endpoints were perioperative all-cause mortality and stroke; secondary endpoints included cardiopulmonary bypass and cross-clamp times, as well as in-hospital and 30-day outcomes. RESULTS: Among 10,898 surgeries, 61 (0.5%) involved patients with prior TAVR (median age, 72 years; 59% male), including 85% with hypertension, 28% with diabetes, 43% with chronic lung disease, and 15% with cerebrovascular disease. The median time between TAVR and surgery was 20 months, and 57% of the surgeries were urgent or emergent/salvage procedures. Major indications included TAVR dysfunction (28%), infective endocarditis (26%), and aortic pathology (13%). Common procedures were TAVR explant and surgical aortic valve replacement (n = 49), mitral surgery (n = 19), aortic root/arch surgery (n = 12), and multivessel coronary artery bypass grafting (n = 5). The median aortic cross-clamp and cardiopulmonary bypass times were 121 minutes and 160 minutes, respectively. The mortality rate was 13%. Other outcomes included stroke (3%), prolonged ventilation (31%), tracheostomy (7%), de novo dialysis (8%), need for postoperative blood products (61%), cardiac reintervention (10%), discharge to rehabilitation facility (34%), and readmission (13%). CONCLUSIONS: Cardiac surgery post-TAVR is uncommon and associated with significant morbidity and mortality. Prosthesis dysfunction and endocarditis are the leading indications, and TAVR explant remains a common although highly morbid intervention.

Acute and midterm outcomes of patients undergoing right-sided heart valve surgery for carcinoid heart valve disease.

OBJECTIVES: Carcinoid heart syndrome is a rare manifestation of metastatic neuroendocrine tumor that causes right heart valve dysfunction and subsequent symptomatic right heart failure, reducing long-term survival. In addition to symptomatic treatment, therapeutic strategies include surgical or interventional valve replacement for tricuspid and pulmonary valve regurgitation. METHODS: Between 2011 and 2022, 12 patients with symptomatic right heart failure and carcinoid heart syndrome underwent elective valve surgery at our institution and were retrospectively included in this study. Procedural data, early clinical outcomes, survival, and time to reintervention were analyzed. The median follow-up period was 33 months, ranging from 2 to 131 months. RESULTS: All patients underwent tricuspid bioprosthetic valve replacement with concomitant pulmonary valve replacement in 4 patients. A 3-dimensional endoscopic approach via right anterolateral minithoracotomy was conducted in 33.3% (4 out of 12) of cases, whereas a full median sternotomy was performed in 66.7% (8 out of 12). Beating-heart technique without crossclamping of the aorta was used in 58.3% (7 out of 12) of cases. Postoperative rethoracotomy for bleeding was required in 2 patients, and 1 patient developed acute kidney injury. No patients experienced permanent pacemaker implantation or stroke. One patient died during hospitalization due to acute hepatic failure in the presence of a preoperatively elevated Model for End-Stage Liver Disease score of 13, resulting in an in-hospital mortality rate of 8.3%. At final follow-up, overall survival was 41.7% (5 out of 12). Five patients required valve reintervention due to bioprosthetic degeneration associated with progression of the underlying neuroendocrine tumor, occurring 11 to 44 months after the index procedure. Two patients underwent surgical redo procedures (1 repeat tricuspid valve replacement and 1 repeat pulmonary valve replacement). One patient underwent pulmonary balloon valvuloplasty followed by 2 valve-in-valve procedures using balloon-expandable transcatheter heart valves. In addition, 2 patients underwent combined valve-in-valve interventions of both the tricuspid and pulmonary valves. Four of the 5 patients undergoing reintervention died during subsequent follow-up. CONCLUSIONS: The results from our single-center study provide descriptive information on current treatment approaches for this rare cardiovascular disease. Surgical valve replacement for carcinoid heart syndrome is technically feasible and associated with satisfactory early clinical outcomes. However, reinterventions are frequently required, largely driven by progression of neuroendocrine tumor disease. Consequently, the influence of valve intervention on long-term survival remains uncertain, and valve durability appears limited, as reflected by the high rate of repeat procedures. These findings underscore the necessity for close follow-up with dedicated heart valve units, enabling early detection of disease progression and bioprosthetic valve degeneration and ensuring optimized care through a multidisciplinary treatment approach.

Pushing the Age Limit: Mitral Valve Surgery Is Safe and Effective in Octogenarians.

OBJECTIVE: Octogenarians represent a growing patient population who require intervention for mitral valve disease. With the advent of transcatheter mitral approaches, the role of surgery, particularly valve repair, is under scrutiny. Co-morbidity burden, poor tissue quality, and limited life expectancy have been cited as obstacles to benefiting from valve repair attempts. This study aims to capture outcomes of mitral valve surgery in octogenarians and compare outcomes of surgical valve repair and replacement. METHODS: All patients ≥ 80 years old who underwent surgical mitral valve operations at a high-volume valve center were included in analysis. Analysis of all patients and sub-analysis of patients with degenerative mitral regurgitation (DMR) was conducted. Outcomes evaluated included operative mortality and mid-term survival. RESULTS: Between 2015-2024, a total of 221 octogenarians underwent mitral surgery including 158 (71%) undergoing mitral valve repair and 63 (29%) who underwent replacement for any etiology. Overall operative mortality was 5% (12/221) (STS Risk Score [STS-PROM]: 5%) and was lower following mitral repair versus replacement (3% vs. 11%, p=0.04). On a sub-analysis of 168 DMR patients (141 [84%] repair, 27 [16%] replacement), operative mortality was 1.2% (2/168), with no difference by procedure type. Valve repair was associated with improved mid-term survival for up to 4 years post-surgery (p=0.02). CONCLUSIONS: Mitral surgery can be performed safely and effectively in appropriately selected octogenarians. Valve repair, when feasible, can promote improved mid-term survival.

Twenty-five years of the

OBJECTIVE: To analyze research trends and key contributors in The Journal of Thoracic and Cardiovascular Surgery over 25 years (2000-2024) using bibliometric methods. METHODS: A total of 9190 articles from Web of Science were analyzed using CiteSpace, VOSviewer, and Bibliometrix to assess publication trends, citation metrics, author/institution/country contributions, co-citation networks, and keyword co-occurrence. RESULTS: Annual publications increased from 329 (2000) to 659 (2014), then stabilized at an average of 319 ± 32 (2015-2024). Impact factor peaked at 6.44 in 2021. The United States led with 4695 publications, followed by Japan and Canada. Harvard University topped institutional output (662 publications), whereas Blackstone EH was the most influential author (h-index: 65). The 20 most-cited articles were predominantly clinical studies focused on surgical techniques and outcomes. Co-citation analysis identified aortic surgery, cardiac valve surgery, and coronary artery surgery as major domains. Citation burst analysis revealed transcatheter aortic valve replacement as the most dynamic recent frontier, with Mack MJ and Popma JJ showing strongest citation bursts. Cardiac surgery was the most frequent key word (300 occurrences), followed by non-small cell lung cancer and coronary artery bypass. Recent emerging terms include acute kidney injury, coronavirus disease, and surgical aortic valve replacement. CONCLUSIONS: This 25-year bibliometric analysis reveals The Journal of Thoracic and Cardiovascular Surgery as a leading platform for cardiothoracic surgery research with sustained growth and increasing scholarly impact. The field demonstrates strong North American institutional dominance, with transcatheter aortic valve replacement emerging as the primary research frontier. Future directions should emphasize international collaboration, research in low- and middle-income regions, transcatheter technologies, and translational research integration.

A novel dual-orifice mitral bioprosthesis: Proof-of-concept in an ovine model.

OBJECTIVE: Conventional large mitral bioprostheses may cause left ventricular outflow tract obstruction. A dual-orifice mitral bioprosthesis was designed for both surgical and transcatheter valve replacement. METHODS: Pulsatile flow testing was used to measure the effective orifice area (EOA). Computational fluid dynamics analysis was conducted to assess thrombogenic and hemolysis risk. An ovine model was used to evaluate procedural safety, hemodynamic performance, and leaflet calcification. RESULTS: Pulsatile flow testing showed that the EOAs of surgical dual-orifice valve (17K, 18K, 19K, 20K, 21K) were 2.0 ± 0.2, 2.1 ± 0.3, 2.4 ± 0.4, 2.5 ± 0.1, and 2.7 ± 0.3 cm2 under 5 L/min cardiac output, respectively. The mean hemolysis index and platelet activation state of 19K surgical dual-orifice valve under 7 L/min cardiac output were 1.3 × 10-8 and 2.2 × 10-8 in the computational fluid dynamics analysis, respectively. Six ovine underwent implantation of the 19K surgical dual-orifice valve and were followed for 20 weeks. The mean pressure gradient and EOA were 3.7 ± 0.8 mm Hg and 2.7 ± 0.3 cm2 immediately after implantation and 5.0 ± 2.3 mm Hg and 2.5 ± 0.2 cm2 at 20 weeks, respectively. One ovine was implanted the 19K transcatheter dual-orifice valve and followed up for 125 days. The mean pressure gradient was 5.0 mm Hg immediately after implantation and 3.0 mm Hg at the end point. CONCLUSIONS: The dual-orifice mitral bioprosthesis may represent an alternative design for mitral valve replacement, especially for patients with large mitral annuli. This findings also show the potential of this design in transcatheter mitral valve replacement.

Outcomes of surgical and transcatheter aortic valve replacement in patients with large and extra-large aortic annuli.

OBJECTIVE: The study objective was to evaluate outcomes after aortic valve replacement in patients with large or extra-large annuli. METHODS: We conducted a retrospective cohort study of adults undergoing isolated transcatheter aortic valve replacement or surgical aortic valve replacement from 2021 to 2025 at a single quaternary care center. Eligible patients had large (annular area ≥575 mm2 or perimeter ≥85 mm) or extra-large (annular area ≥683 mm2 or perimeter ≥94.2 mm) trileaflet aortic annuli on preprocedural computed tomography. RESULTS: A total of 414 patients underwent aortic valve replacement, including 353 transcatheter aortic valve replacements and 61 surgical aortic valve replacements. The median age was 78.8 years (interquartile range, 73.4-83.8), and 20 patients (4.8%) were female. Extra-large annuli were present in 109 patients (26%). Transcatheter aortic valve replacement recipients were older (median 80.2 vs 68.0 years, P < .001) and had a higher burden of comorbidities, including heart failure, atrial fibrillation, diabetes, and prior myocardial infarction (all P < .001). Early 30-day mortality was low, occurring in 3 patients who received transcatheter aortic valve replacement (0.9%) and none of the patients who received surgical aortic valve replacement (0%, P = .470). Compared with an age- and sex-matched US population, patients who received surgical aortic valve replacement had numerically lower mortality (standardized mortality ratio, 0.29, 95% CI, 0.04-2.03), whereas patients who received transcatheter aortic valve replacement experienced higher-than-expected mortality (standardized mortality ratio, 1.69, 95% CI, 1.35-2.11). Heart failure rehospitalization was significantly more frequent after transcatheter aortic valve replacement even after adjustment for baseline characteristics (hazard ratio, 5.09, 95% CI, 1.88-13.80, P = .001). CONCLUSIONS: Aortic valve replacement in patients with large or extra-large annuli is safe, with low early mortality. Differences in long-term outcomes primarily reflect differences in baseline patient risk profiles rather than treatment strategy.

Mortality and morbidity benefits of surgical versus transcatheter aortic valve replacement in patients ≤60 years: Findings from a national cohort.

OBJECTIVE: To compare outcomes of surgical aortic valve replacement (SAVR) with transcatheter aortic valve replacement (TAVR) in patients aged ≤60 years throughout the United States. METHODS: Patients aged ≤60 years with aortic stenosis undergoing either first-time SAVR or TAVR between January 2006 and December 2025 were identified from TriNetX, an administrative real-world database. The primary outcome was all-cause mortality over 5 years. Cardiac-related outcomes were also assessed. Results were analyzed after propensity matching for age, sex, presence of bicuspid aortic valve, lower respiratory disease, liver fibrosis/cirrhosis, liver failure, kidney disease, dialysis dependence, and previous cardiac surgery. RESULTS: Among 9841 patients, 7896 underwent SAVR, whereas 1945 underwent TAVR. Matching resulted in 1666 patients per cohort. Before matching, patients who underwent SAVR were younger, more likely to have bicuspid aortic valves, and had lower rates of lower respiratory disease, liver or kidney disease, dialysis use, and previous cardiac surgery. After matching, SAVR was associated with comparable mortality risk at 1 month but lower mortality risks at 1 year (odds ratio, 0.69; 95% CI, 0.53-0.92) and 5 years (hazard ratio [HR], 0.58; 95% CI, 0.48-0.69). By the end of follow-up, SAVR was associated with decreased risks of acute myocardial infarction (HR, 0.65; 95% CI, 0.49-0.86), endocarditis (HR, 0.55; 95% CI, 0.37-0.82), complete atrioventricular block (HR, 0.45; 95% CI, 0.30-0.66), pacemaker implantation (HR, 0.61; 95% CI, 0.45-0.83), paravalvular leak (HR, 0.39; 95% CI, 0.26-0.87), and reintervention (HR, 0.54; 95%, CI 0.38-0.78). CONCLUSIONS: Among patients aged ≤60 years, SAVR is associated with lower mortality and morbidity rates over TAVR.

Four-year clinical and echocardiographic outcomes after tricuspid valve replacement using a novel bovine pericardial valve bioprosthesis.

OBJECTIVE: To describe our experience and evaluate the clinical outcomes and hemodynamic performance of a new bovine pericardial valve bioprosthesis when used off-label for tricuspid valve replacement (TVR). METHODS: We retrospectively reviewed 82 consecutive patients who underwent 83 TVR procedures (1 patient required early reoperation for paravalvular leak) with the new bioprosthesis between July 2021 and April 2025 at our institution. The mean clinical follow-up was 2.3 ± 1.1 years (94% completed), and the mean echocardiographic follow-up was 2.0 ± 1.1 years (75% completed). The primary end point was bioprosthetic valve dysfunction; secondary end points were survival, perioperative outcomes, major complications, and hemodynamic performance. RESULTS: Mean age was 66.6 ± 14.0 years; 51.2% (42/82) were female. New York Heart Association class III-IV symptoms were present in 65.2% (45/69). Principal indications were annular dilatation (65.7%, 46/70) and TriClip failure (11.4%, 8/70). Mean Society of Thoracic Surgeons and TRI-SCORE were 6.9 ± 11.4 and 11.8 ± 7.1, respectively. Sternotomy was performed in 41.0% (34/83) and minimally invasive access in 59.0% (49/83). Concomitant procedures included left-sided valvular surgery (47.0%, 39/83) and left atrial appendage closure (26.5%, 22/83). The most common prosthesis size was 33 mm (67.5%, 56/83). As the primary end point, no valve thrombosis was observed and 2.6% (2/77) developed severe central tricuspid regurgitation (TR) requiring percutaneous reintervention. New moderate intraprosthetic TR occurred in 13.3% (6/45) of patients. Thirty-day mortality was 15.9% (13/82). Major complications included new pacemaker implantation (19.3%, 16/83), reoperation for bleeding (7.2%, 6/83), and cerebrovascular events (7.2%, 6/83). Echocardiography showed stable mean gradients (3.2 ± 1.3 mm Hg at discharge; 3.0 ± 1.2 mm Hg at latest follow-up). Otherwise, 1.3% (1/77) underwent redo TVR for early paravalvular leak. Bioprosthetic endocarditis occurred in 5.2% (4/77), all treated conservatively. Actuarial 4-year survival was 63% and freedom from valvular reintervention was 92%. CONCLUSIONS: The new bioprosthesis implanted in the tricuspid position in this high-risk cohort demonstrated stable hemodynamics; however, 2 cases of valvular dysfunction needing reintervention occurred at 2 years, with 6 cases of stable moderate central TR observed at follow-up. These complications highlight the need for longer follow-up to establish durability and guide patient selection and postoperative care.

Konno aortic valve replacement in adults: Enabling larger prosthetic valve implantation and adequate aortic root enlargement for coronary clearance.

OBJECTIVE: Surgical aortic valve replacement in patients with severe aortic stenosis and small annuli remains challenging owing to prosthesis-patient mismatch and the limited feasibility of subsequent valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). The Konno procedure enables annular and left ventricular outflow tract (LVOT) enlargement; however, outcomes in adults remain insufficiently defined. METHODS: Between January 2023 and October 2025, 193 patients underwent surgical aortic valve replacement at our institution, of whom 19 (10%) received the Konno procedure for annulus diameter ≤19 mm, high likelihood of prosthesis-patient mismatch, or anticipated ViV-TAVR with estimated high risk of coronary obstruction. Operative results, echocardiographic and electrocardiographic parameters, and computed tomography measurements of the aortic root were assessed before and after surgery. RESULTS: Patients were aged 59 ± 19 years and 84% were women. Bioprostheses were implanted in 12 patients (63%) and mechanical valves in seven (37%), with enlargement permitting prosthesis implantation 2 to 3 sizes larger. Septal myectomy was performed in 6 patients. No in-hospital mortality occurred. Computed tomography demonstrated enlargement of the sinus of Valsalva (+7.0 mm) and sinotubular junction (+6.9 mm), consistent with ViV-TAVR feasibility. Echocardiography confirmed relief of LVOT obstruction; however, right ventricular diameter tended to increase, tricuspid annular plane systolic excursion declined, and QRS duration increased from 90 to 114 milliseconds, indicating intraventricular conduction delay. CONCLUSIONS: Konno aortic valve replacement facilitates implantation of larger prostheses, relieves LVOT obstruction, and optimizes root anatomy for future ViV-TAVR. Conduction disturbances and right ventricular functional decline warrant long-term surveillance.

Surgical aortic valve replacement after transcatheter aortic valve replacement: How an orthopedic device can help cardiac surgeons.

Impact of Membranous Septum Length and Valve Calcification on Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement.

OBJECTIVES: Conduction abnormalities requiring permanent pacemaker implantation (pPMI) following surgical aortic valve replacement (SAVR) are associated with worse postoperative outcomes. Although membranous septum (MS) length measured on preprocedural computed tomography (CT) is a known predictor for pPMI following transcatheter aortic valve replacement, its impact in SAVR is not fully understood. METHODS: We evaluated 425 patients who underwent SAVR and had preoperative CT imaging. Patients with aortic root surgery, endocarditis, prior aortic valve intervention, or prior pPMI were excluded. MS length was measured using the infra-annular method. The primary endpoint was pPMI for symptomatic atrioventricular block during the same period of care. Factors associated with pPMI were evaluated using logistic regression and Fadden's pseudo-R2 analyses. RESULTS: Thirty-two patients (7.5%) received pPMI. Median time to pPMI was 5 (4-7) days. Preexisting complete right bundle branch block (CRBBB), higher aortic valve calcium score, and shorter MS length were significantly associated with pPMI (all P<0.05). MS length demonstrated the greatest explanatory value (pseudo-R2=0.08), compared with aortic valve calcium score (0.03) and CRBBB (0.04). A multivariable model incorporating MS length and calcium score in addition to CRBBB provided the best overall fit and explained the largest proportion of variance. CONCLUSIONS: Short MS length and high aortic valve calcium score on preoperative CT were associated with increased risk of pPMI following SAVR. These findings support the expanding role of CT-based anatomical assessment in surgical planning and underscore the need for prospective studies to refine risk stratification and guide operative strategies.

Long-term follow-up of surgical versus transcatheter aortic valve replacement in patients younger than 70 years.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical aortic valve replacement (SAVR) in intermediate- and low-risk patients with severe aortic stenosis. However, most randomized trials have enrolled patients older than 70 years with limited follow-up, and evidence on long-term outcomes in younger populations remains insufficient. Our objective was to compare long-term clinical outcomes between propensity-matched TAVR and SAVR patients aged <70 years. METHODS: A total of 959 patients (SAVR: 808, TAVR: 151) were included, resulting in 132 propensity-matched patients per group. The primary outcome was a composite of all-cause death, stroke, and procedure- or valve-related hospitalization at 30 days, 2 years, 5 years, and up to 10 years. A flexible parametric survival model was used to evaluate the hazard ratio (HR) for reintervention and its time dynamics. RESULTS: Baseline characteristics were balanced between matched groups (mean age 64.9 years; Society of Thoracic Surgeons Predicted Risk of Mortality score 2.9%). At 10 years, primary outcome rates were similar (SAVR: 50.8% vs TAVR: 42.9%; HR, 1.01; 95% CI, 0.66-1.53; P = .95). Patients who underwent SAVR had greater rates of acute kidney injury, bleeding, and new-onset atrial fibrillation during hospitalization (P < .01), whereas permanent pacemaker rates were similar (P = .140). Reintervention was more frequent after TAVR (10.6% vs 3.7%; P = .03), and flexible parametric survival model showed a greater risk of reintervention in TAVR (HR, 3.63; 95% CI, 0.73-1.78; P = .01). CONCLUSIONS: At long-term follow-up, all-cause mortality, stroke, and rehospitalization rates were similar between TAVR and SAVR in patients younger than 70 years with aortic stenosis. However, patients who underwent TAVR had greater rates and risk of reintervention, which did not affect mortality.

Clinical outcomes following simultaneous supra-aortic and aortovisceral artery bypass in patients with type V Takayasu arteritis.

OBJECTIVE: Type V Takayasu arteritis (TAK) is the most extensive form of this large-vessel vasculitis, frequently necessitating complex surgical management due to its multiterritory arterial involvement. This study aims to evaluate the clinical efficacy and safety of 1-stage supra-aortic and aortovisceral artery (SAVA) bypass in patients with Numano type V TAK. METHODS: We retrospectively reviewed all patients diagnosed with type V TAK undergoing simultaneous SAVA bypass at 6 tertiary centers in China between February 2017 and April 2024. These patients were selected from a multicenter surgical database of 264 patients with TAK. Demographics and characteristics were collected. The primary end point was mortality within 30 days after surgery; secondary end points included graft patency, major surgery-related complications, and overall survival. All patients were prospectively followed, and outcomes were analyzed. RESULTS: A total of 12 patients, with 115 SAVA segments affected by TAK, underwent reconstruction of 42 arteries. These reconstructions utilized 14 autologous great saphenous vein grafts and 28 prosthetic grafts with a mean operative time of 514 ± 101 minutes. The 30-day survival rate was 100%. During a mean follow-up duration of 47.4 ± 28.5 months, 4 cases of graft restenosis were detected, of which 1 was successfully resolved via surgical thrombectomy and 3 were managed conservatively. No late mortality or major complications was observed. Postoperatively, systolic blood pressure decreased significantly, and patients achieved sustained symptom relief with improved health-related quality of life. CONCLUSIONS: With appropriate perioperative management and surgical planning, the simultaneous reconstruction of SAVA in type V TAK can be performed safely and effectively.

Objective analysis of frailty-based 10-year outcomes of transcatheter and surgical aortic valve replacement.

OBJECTIVE: To compare the long-term outcomes of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) by adjusting not only for conventional risk scores but also for frailty, cognitive function, nutritional status, and comorbidities. METHODS: This retrospective single-center study included 1258 patients (SAVR, n = 446; TAVI, n = 812) who underwent isolated elective procedures for AS between January 2014 and December 2024. Propensity score matching (1:1) was performed based on 19 baseline variables including age, Society of Thoracic Surgeons risk score, Clinical Frailty Scale, Mini-Mental State Examination, and Geriatric Nutritional Risk Index. The primary endpoint was a composite of all-cause mortality and cardiac readmission over a follow-up period of up to 10 years. RESULTS: After matching, 114 patient pairs were obtained. The SAVR group had longer intensive care unit and hospital stays. However, there were no significant differences in 30-day mortality, stroke, pacemaker implantation, or readmission rates. Over long-term follow-up, a significantly better survival rate was seen in the SVAR group compared to the TAVI group (hazard ratio [HR], 0.16; 95% confidence interval [CI], 0.49-0.58; P = .005), while the readmission rate was similar in the 2 groups (HR, 1.0; 95% CI, 0.40-1.69; P = .93). CONCLUSIONS: After comprehensive adjustment for frailty, cognitive function, and nutritional status, SAVR demonstrated superior long-term survival compared to TAVI, with comparable readmission rates. Personalized treatment strategies for AS should incorporate broader patient-specific factors to guide optimal therapeutic decision making.

Fate of dilated ascending aorta after transcatheter aortic valve replacement.

OBJECTIVE: Poststenotic ascending aortic dilation has been extensively studied, with most studies focusing on surgical aortic valve replacement outcomes. Very few studies have evaluated outcomes after transcatheter aortic valve replacement (TAVR). This study evaluated changes of poststenotic ascending aortic dilation after TAVR, as well as the incidence of aortic intervention. METHODS: Patients with aortic stenosis who underwent TAVR over a 5-year study period were evaluated at a single institution. All patients with ascending aortas ≥4.0 cm were included. Continuous variables were analyzed using parametric or nonparametric tests, as appropriate, and a linear regression model was used to evaluate an estimate of the progression of aortic size over time. RESULTS: In all, 115 of 1184 (9.7%) patients undergoing TAVR had a dilated ascending aorta, including 6.1% who had a bicuspid aortic valve, with 25.2% female. The average Society of Thoracic Surgeons risk score was 8.1 ± 4.2%. Median follow-up was 2.49 years (interquartile range, 0.4-6.1 years). The average aortic size preoperatively was 4.3 ± 0.3 cm. Patients with bicuspid valves had a larger mean aortic size compared with those with a tricuspid valve (4.5 ± 0.5 cm vs 4.2 ± 0.3 cm, P = .05). The average postoperative size was 4.01 ± 0.5 cm, which was smaller compared with the preoperative size (P < .001). However, a linear regression model showed no evidence that aortic size becomes smaller over continued follow-up. Importantly, only 2 patients had to undergo an aortic intervention after TAVR. CONCLUSIONS: For patients with aortic stenosis and a moderate dilated ascending aorta, TAVR appears to be safe in those with a dilated ascending aorta at intermediate follow-up.

Beyond annuloplasty: Anatomy-based tricuspid valve repair for right ventricular dysfunction.

OBJECTIVES: Functional tricuspid regurgitation in the setting of right ventricular (RV) remodelling remains one of the least standardized challenges in valvular surgery. Surgeons are often confronted with complex anatomy and limited formal training in advanced tricuspid reconstruction. This review seeks to consolidate the evolving surgical knowledge base and provide a structured reference for the full spectrum of repair strategies beyond annuloplasty. METHODS: A targeted literature review was performed to identify key reports on surgical tricuspid valve interventions. These were synthesized narratively to outline the principles, indications, and anatomical rationale for current techniques, including edge-to-edge repair, leaflet augmentation, papillary muscle relocation, approximation, suspension, bundling, and annular repositioning. RESULTS: Collectively, these approaches form a growing surgical armamentarium aimed at restoring normal leaflet geometry and subvalvular alignment in the setting of RV dilatation. Understanding the interplay between annular, leaflet, and subvalvular distortion is essential for achieving functional and durable repair that can rival evolving transcatheter options. CONCLUSIONS: This review unifies previously scattered concepts into a practical framework for anatomy-guided tricuspid reconstruction, offering surgeons an accessible reference for managing complex, RV-dependent tricuspid valve disease.

TAVR timing: Waiting more than 6 months may hurt survival odds

&lt;p&gt;When heart patients are diagnosed with severe AS, how quickly do they need to undergo TAVR? That was the focus of a new analysis published in &lt;em&gt;Open Heart&lt;/em&gt;.&lt;/p&gt;

Bailout cardiac surgery in patients undergoing transcatheter aortic valve replacement: a comprehensive analysis of post-marketing safety reports

Background: Bailout cardiac surgery during transcatheter aortic valve replacement (TAVR) is uncommon but remains associated with substantial morbidity and mortality. Although registries have described its incidence and major causes, they often provide limited detail regarding device-related failure mechanisms, attempted transcatheter rescue, and the clinical pathway leading to surgical conversion. We aimed at analyzing post-marketing safety reports from the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to characterize the mechanisms, management strategies, and reported outcomes of bailout surgery during or shortly after TAVR. Methods: We retrospectively analyzed FDA MAUDE reports received from July 1, 2016, through June 30, 2026. Eligible reports described unplanned urgent or emergent open cardiac surgery during or immediately after TAVR. Candidate reports were screened, adjudicated, and deduplicated at the clinical-event level. Events were classified by precipitating complication, transcatheter rescue, operative pathway, and reported outcome. Associations were evaluated using permutation tests, Fisher exact tests with Benjamini?Hochberg correction, adjusted regression models, and sensitivity analyses. Results: After screening 43,239 initial reports, we identified 376 bailout-surgery events, with survival status was documented in 254, including 104 deaths and 150 survivors, corresponding to 40.9% reported mortality. Valve embolization, migration, or malposition was the most frequent complication phenotype (32.4%), whereas ventricular perforation or laceration was associated with the highest mortality (74.1%; OR, 4.86; 95% CI, 1.97?11.99). Mortality differed across complication phenotypes (p<0.001) and operative pathways (p<0.001), but not across transcatheter rescue pathways (p=0.355). Valve explantation with SAVR was associated with lower reported mortality (18.9%; OR, 0.29; 95% CI, 0.12?0.69), whereas unspecified surgery or access/support alone was associated with higher mortality (56.9%; OR, 3.04; 95% CI, 1.80?5.12). Ancillary analyses identified potential platform-specific differences in complication and management patterns, while bailout timing was not independently associated with mortality after adjustment. Conclusions: In this MAUDE analysis, bailout cardiac surgery after TAVR was most commonly precipitated by valve embolization, migration, or malposition, whereas ventricular perforation or laceration was associated with the highest reported mortality. Outcomes differed across complication and operative pathways but not across transcatheter rescue strategies or bailout timing after adjustment. These findings identify clinically relevant post-marketing safety signals but should not be interpreted as incidence estimates, comparative device risks, or causal treatment effects.

TAVR is safe for patients with large aortic annuli—heart failure remains a concern

&lt;p&gt;As always, heart team discussions play a vital role when choosing between TAVR and SAVR for patients with large or extra-large aortic annuli.&amp;nbsp;&lt;/p&gt;

Surgery outperforms TAVR in young heart patients, new data confirm

&lt;p&gt;Researchers tracked data from nearly 10,000 patients 60 years old or younger who underwent SAVR or TAVR. Propensity score matching was used to focus on two groups of approximately 1,500 patients.&lt;/p&gt;

Long-Term Reintervention, Clinical Valve Failure, and Outcomes After Transcatheter Aortic Valve Replacement: A National Real-World Study

Background As transcatheter aortic valve replacement (TAVR) expands to younger patients with longer life expectancy, understanding long-term reintervention and clinically significant valve failure has become increasingly important. Objectives To evaluate temporal trends in TAVR outcomes, characterize the incidence and timing of aortic valve reintervention, compare outcomes after redo-TAVR (TAVR-in-TAVR) versus surgical explantation, and assess freedom from clinically significant valve failure requiring repeat intervention after TAVR versus surgical bioprosthetic aortic valve replacement (SAVR). Methods We performed a retrospective cohort study using the Epic Cosmos. Adults undergoing index TAVR between February 2010 and May 2026 were identified. Primary outcomes included aortic valve reintervention and 30-day major adverse cardiovascular events (MACE). Reintervention incidence was estimated using competing-risk methods with death as the competing event. Propensity-score matching compared redo-TAVR with surgical explantation and TAVR with SAVR. A prespecified 1-year landmark analysis evaluated clinically significant valve failure requiring repeat intervention. Results Among 300,927 patients undergoing TAVR, annual procedural volume increased more than tenfold between 2016 and 2025. Thirty-day MACE decreased from 31.8% before 2017 to 18.6% after 2022 (P<0.001), while mortality declined from 3.0% to 1.4% (P<0.001). During follow-up, 3,315 patients underwent redo-TAVR and 347 underwent surgical explantation. The cumulative incidence of reintervention was 1.1%, 1.2%, 1.5%, and 2.7% at 3, 5, 7, and 10 years, respectively, with significantly lower rates in contemporary procedural eras (Gray test, P<0.001). Compared with surgical explantation, redo-TAVR was associated with lower 30-day mortality, stroke, acute kidney injury, and major bleeding. However, among propensity-matched hospital survivors, surgical explantation was associated with superior long-term survival (hazard ratio: 0.64; 95% CI: 0.44 - 0.93; P=0.018). In the landmark analysis, clinically significant valve failure requiring repeat intervention occurred earlier after TAVR than after SAVR despite a lower overall cumulative incidence of repeat intervention following TAVR. Conclusions Contemporary TAVR is associated with progressively improving procedural outcomes and a low incidence of repeat aortic valve intervention. Redo-TAVR offers lower perioperative risk than surgical explantation, whereas surgical explantation is associated with superior long-term survival among selected patients. Earlier clinically significant valve failure requiring repeat intervention after TAVR underscores the importance of lifetime management strategies as TAVR expands to younger populations.

Less-invasive heart valve procedure now an option for more patients, including those at lower surgical risk - ClickOnDetroit | WDIV Local 4

Less-invasive heart valve procedure now an option for more patients, including those at lower surgical risk&nbsp;&nbsp;ClickOnDetroit | WDIV Local 4

PARTNER 3: 7-Year TAVR vs. SAVR Outcomes in Low-Risk Patients - American College of Cardiology

PARTNER 3: 7-Year TAVR vs. SAVR Outcomes in Low-Risk Patients&nbsp;&nbsp;American College of Cardiology

PARTNER 3: 7-Year TAVR vs. SAVR Outcomes in Low-Risk Patients - American College of Cardiology

PARTNER 3: 7-Year TAVR vs. SAVR Outcomes in Low-Risk Patients&nbsp;&nbsp;American College of Cardiology

New PARTNER 3 update links TAVR to early benefits over SAVR - Cardiovascular Business

New PARTNER 3 update links TAVR to early benefits over SAVR&nbsp;&nbsp;Cardiovascular Business

New PARTNER 3 update links TAVR to early benefits over SAVR

&lt;p&gt;Low-risk patients face comparable outcomes after TAVR and SAVR, researchers wrote, making it important to highlight even the smallest differences between these two approaches.&amp;nbsp;&lt;/p&gt;

TAVR vs. Redo Open Heart Surgery for Aortic Valve Stenosis: How to Choose the Right One for You - Yahoo Health

TAVR vs. Redo Open Heart Surgery for Aortic Valve Stenosis: How to Choose the Right One for You&nbsp;&nbsp;Yahoo Health

Seven-year study finds non-surgical valve replacement holds up as well as open-heart surgery - Medical Xpress

Seven-year study finds non-surgical valve replacement holds up as well as open-heart surgery&nbsp;&nbsp;Medical Xpress

Pulmonary Valve Catheter Delivery System Recall: Medtronic Removes Harmony Delivery Catheter System (DCS)

The distal tip in certain lots of the Medtronic Harmony Delivery Catheter System (DCS) may detach which can require endovascular retrieval or surgical intervention.

A Nerve-Dependent NGF Receptor Switch Controls Corneal Epithelial Renewal In Neurotrophic Keratopathy

Corneal epithelial integrity depends on continuous epithelial renewal by limbal epithelial stem cells (LESCs), a process tightly linked to sensory innervation. Loss or impairment of innervation causes neurotrophic keratopathy (NK), a sight-threatening degenerative disease for which rhNGF, the only FDA-approved pharmacologic therapy, often has limited efficacy in advanced or refractory disease. The mechanistic basis for this limited response remains unclear. Using surgical, genetic, and pharmacologic approaches in a rodent model of NK with corneal Schwann cell ablation or structural and functional denervation, together with primary human LESCs, we examined how denervation alters NGF receptor signaling during epithelial repair. In innervated corneas, NGF promoted epithelial regeneration through TrkA. Denervation, however, increased expression of a second NGF receptor, anti-regenerative p75NTR, and activation of its effector JNK, and reduced the activity of the TrkA effector AKT in LESCs. In this altered receptor context, denervation-induced elevation of endogenous NGF amplified p75NTR signaling, thereby explaining the failure of topical rhNGF to rescue severely denervated NK phenotype corneas. Conversely, selective TrkA activation, either with the clinical-stage agonist tavilermide, or pharmacologic or genetic inhibition/ablation of p75NTR, restored AKT signaling and rescued epithelial healing in denervated corneas independent of reinnervation. These findings identify a nerve-dependent NGF receptor switch as a key regulator of corneal epithelial renewal and establish receptor-selective modulation as a mechanistically rational therapeutic strategy for treating NK. One Sentence SummaryCorneal denervation shifts limbal epithelial stem cell signaling from pro-regenerative TrkA-AKT toward anti-regenerative p75NTR-JNK, explaining the limited efficacy of recombinant human nerve growth factor (rhNGF; cenegermin), the only approved pharmacologic therapy for neurotrophic keratopathy, in severely denervated corneas and identifying receptor-selective modulation as a mechanistically distinct therapeutic strategy.

TAVR Matches Surgical Valve Durability at 7 Years - Medscape

TAVR Matches Surgical Valve Durability at 7 Years&nbsp;&nbsp;Medscape

Prevalence of epilepsy in children with structural heart disease: A systematic review and meta-analysis

Background: Children with structural heart disease (SHD), particularly congenital heart disease (CHD), are increasingly recognised as being at risk of adverse neurological outcomes. Although advances in cardiac surgery and perioperative care have markedly improved survival, epilepsy has emerged as an important long-term complication. Reported prevalence estimates vary considerably across studies, and the overall burden remains uncertain. This systematic review and meta-analysis aimed to estimate the pooled prevalence of epilepsy among children with SHD and explore differences according to geographic region, lesion characteristics, and surgical exposure. Methods: This systematic review and meta-analysis was conducted in accordance with PRISMA 2020 and MOOSE guidelines and registered in PROSPERO (CRD420261378572). PubMed/MEDLINE, Scopus, and ProQuest were searched for observational studies published between January 2000 and December 2025. Eligible studies included children aged 0-18 years with SHD or CHD reporting epilepsy prevalence or incidence. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. A random-effects meta-analysis was performed to estimate pooled prevalence with 95% confidence intervals (CI). Results: Eight cohort studies comprising 21,731 children were included. Studies were conducted across North America, Europe, and Asia and predominantly involved surgically managed CHD populations. The pooled prevalence of epilepsy was 3.0% (95% CI 1.3%-4.8%), substantially higher than estimates reported in the general paediatric population. Heterogeneity was considerable (I{superscript 2} = 98.0%; p < 0.001). The 95% prediction interval ranged from 0% to 8.1%, indicating substantial variability across populations. Narrative subgroup synthesis suggested higher epilepsy prevalence among children with cyanotic and complex lesions and among surgically managed cohorts, particularly those exposed to cardiopulmonary bypass and perioperative neurological complications. Most studies were rated as having low risk of bias, and sensitivity analyses demonstrated stable findings. Conclusions: Children with SHD have a substantially increased burden of epilepsy compared with the general paediatric population. Complex lesions, perioperative neurological injury, and cardiac surgical exposure may contribute to epileptogenesis. Long-term neurological surveillance and multidisciplinary neurodevelopmental follow-up should be integrated into routine care for children with SHD.

Emergency Valve-in-Valve Transcatheter Aortic Valve Implantation in a Patient With a Degenerated Surgical Xenograft and High Body Mass Index Presenting With Recurrent Pulseless Electrical Activity Arrest - Cureus

Emergency Valve-in-Valve Transcatheter Aortic Valve Implantation in a Patient With a Degenerated Surgical Xenograft and High Body Mass Index Presenting With Recurrent Pulseless Electrical Activity Arrest&nbsp;&nbsp;Cureus

Emergency Valve-in-Valve Transcatheter Aortic Valve Implantation in a Patient With a Degenerated Surgical Xenograft and High Body Mass Index Presenting With Recurrent Pulseless Electrical Activity Arrest - Cureus

Emergency Valve-in-Valve Transcatheter Aortic Valve Implantation in a Patient With a Degenerated Surgical Xenograft and High Body Mass Index Presenting With Recurrent Pulseless Electrical Activity Arrest&nbsp;&nbsp;Cureus

Sex-specific outcomes after TAVR and SAVR: Key takeaways from a new meta-analysis - Cardiovascular Business

Sex-specific outcomes after TAVR and SAVR: Key takeaways from a new meta-analysis&nbsp;&nbsp;Cardiovascular Business

Sex-specific outcomes after TAVR and SAVR: Key takeaways from a new meta-analysis

&lt;p&gt;TAVR was associated with early benefits for women. After five years, however, outcomes were comparable across the board.&lt;/p&gt;

TAVR vs. SAVR: Outcomes Differ By Sex and Over Time - American College of Cardiology

TAVR vs. SAVR: Outcomes Differ By Sex and Over Time&nbsp;&nbsp;American College of Cardiology

High-intensity ultrasound technology for calcified valve leaflets makes debut in Europe

&lt;p&gt;The new technology was designed for patients who may not be able to undergo SAVR or TAVR.&lt;/p&gt;

New 10-Year TAVI Data Generally ‘Reassuring’ But Highlight Challenges

New 10-Year TAVI Data Generally ‘Reassuring’ But Highlight Challenges cmacahilig@crf.org Tue, 06/16/2026 - 13:17 Todd Neale High mortality in elderly patients followed over a decade might complicate the lessons learned compared with SAVR.

Cardiovascular Outcomes with GLP-1 Receptor Agonists in Patients with Type 2 Diabetes or Obesity Undergoing Surgical Aortic Valve Replacement

Abstract Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated cardiovascular benefit in type 2 diabetes and obesity, with recent observational data suggesting favorable associations after transcatheter aortic valve replacement. Whether similar associations exist after surgical aortic valve replacement (SAVR) is unknown. Methods: Retrospective propensity-matched cohort analysis using the TriNetX U.S. Collaborative Network. Adults with type 2 diabetes or obesity (BMI [&ge;]30 kg/m2) undergoing SAVR were categorized by GLP-1 RA exposure (any use within 3 months before through 1 year after SAVR) versus no use. One-to-one matching was performed on 44 covariates. Primary outcomes were 1-year all-cause mortality, heart failure, acute kidney injury, acute myocardial infarction, cerebral infarction, and atrial fibrillation. Sensitivity analyses included 30-day landmark restriction and falsification outcomes. Results: After matching, 1,984 patients were retained per cohort. GLP-1 RA use was associated with lower 1-year risks of all-cause mortality (4.8% vs 10.4%; HR, 0.44; 95% CI, 0.34-0.56), acute kidney injury (6.9% vs 10.1%; HR, 0.65; 95% CI, 0.49-0.85), myocardial infarction (3.0% vs 5.1%; HR, 0.57; 95% CI, (0.40-0.82), heart failure (11.3% vs 15.7%; HR, 0.68; 95% CI, (0.51-0.90), and atrial fibrillation or flutter (10.1% vs 13.9%; HR, 0.69; 95% CI, 0.54-0.90; all P[&le;]006). Cerebral infarction did not differ. In landmark analysis, mortality, heart failure, and acute kidney injury associations persisted; myocardial infarction and atrial fibrillation associations were attenuated. Falsification outcomes were null. Conclusions: Perioperative GLP-1 RA use was associated with lower 1-year cardiovascular event rates after SAVR. These hypothesis-generating findings support prospective randomized investigation.

Edwards Lifesciences Wins FDA Approval for First Tricuspid Surgical Valve Replacement - Medical Device and Diagnostic industry

Edwards Lifesciences Wins FDA Approval for First Tricuspid Surgical Valve Replacement&nbsp;&nbsp;Medical Device and Diagnostic industry

FDA clears first dedicated tricuspid surgical valve - Cardiovascular Business

FDA clears first dedicated tricuspid surgical valve&nbsp;&nbsp;Cardiovascular Business

How to evaluate risk when TAVR patients require surgery later in life

&lt;p&gt;Robert Hawkins, MD, discussed an updated risk calculator—and the latest data on SAVR after TAVR—for a new video interview with Cardiovascular Business.&lt;/p&gt;

Edwards gets FDA approval for surgical tricuspid valve - MedTech Dive

Edwards gets FDA approval for surgical tricuspid valve&nbsp;&nbsp;MedTech Dive

Edwards gets FDA nod for Triformis Resilia surgical tricuspid valve replacement - MassDevice

Edwards gets FDA nod for Triformis Resilia surgical tricuspid valve replacement&nbsp;&nbsp;MassDevice

TAVR or SAVR? A closer look at those decisions | New Impella 5.5 data | First patient enrolled in massive heart failure trial - Cardiovascular Business

TAVR or SAVR? A closer look at those decisions | New Impella 5.5 data | First patient enrolled in massive heart failure trial&nbsp;&nbsp;Cardiovascular Business

TAVR or SAVR? Cardiologists and heart surgeons highlight the care that goes into each decision - Cardiovascular Business

TAVR or SAVR? Cardiologists and heart surgeons highlight the care that goes into each decision&nbsp;&nbsp;Cardiovascular Business

Comparing TA-TAVR and SAVR in severe aortic regurgitation: outcomes and valve haemodynamics.

TAVR “vs” SAVR In The Modern Era - Conexiant

Comparing TA-TAVR and SAVR in severe aortic regurgitation: outcomes and valve haemodynamics.

TAVR “vs” SAVR In The Modern Era - Conexiant

Long-term outcomes of transcatheter mitral valve repair in patients with cancer: a systematic review and meta-analysis.

Surgical and transcatheter mitral valve interventions are the mainstay of treatment for mitral regurgitation (MR). Their impact in patients with cancer has recently gained attention in observational studies but remains poorly characterized. We performed a systematic review and meta-analysis to evaluate outcomes of mitral valve interventions, with particular focus on M-TEER, in patients with active or prior cancer. PubMed and Scopus were systematically searched according to the PRISMA 2020 Statement. This systematic review was prospectively registered in PROSPERO (CRD420261368392). Studies reporting outcomes of transcatheter or surgical mitral valve interventions in patients with cancer were eligible. The primary outcome was all-cause mortality. Secondary outcomes included short-term mortality, procedural success, heart failure worsening or hospitalization, and reintervention. Hazard ratios (HRs) were pooled using random-effects models when appropriate. When HRs were not directly available, they were reconstructed according to established methods for time-to-event data synthesis. Eight observational studies met the inclusion criteria. Seven studies evaluated M-TEER, accounting for the vast majority of patients included in the quantitative analyses (1522 patients with cancer and 4716 controls), whereas only one study assessed surgical mitral valve intervention. In the pooled analysis of M-TEER studies, cancer was associated with a significantly higher risk of all-cause mortality during follow-up (HR 1.72, 95% CI 1.03-2.90; I2 = 74.8%). This association remained consistent across prespecified subgroup and sensitivity analyses. No significant differences were observed in 30-day mortality or procedural success between patients with and without cancer. Data on heart failure outcomes and reintervention were insufficient for quantitative synthesis. This study provides a quantitative synthesis of available evidence regarding long-term outcomes after M-TEER in patients with cancer. Patients with cancer undergoing M-TEER have higher long-term mortality than those without cancer, despite similar procedural success and short-term outcomes. These findings suggest the observed excess mortality occurs in patients with cancer but the available evidence does not establish the factors responsible for this association, which could be mediated by frailty, CV comorbidity, treatment-related comorbidity mitral regurgitation (MR) characteristics, or other residual confounders. Of note, studies comparing matched cohorts found a non-significant difference in HR for long-term mortality. Current evidence is limited by observational data and residual confounding. Prospective cardio-oncology studies are needed to improve patient selection and identify individuals most likely to benefit from transcatheter mitral valve intervention.

Computational fluid dynamics assessment of hemodynamic effects of catheter navigation during transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a widely adopted, minimally invasive alternative to surgical aortic valve replacement. Despite its clinical success, TAVI can induce hemodynamic complications, which can be investigated using computational fluid dynamics (CFD). In this study, CFD was applied to evaluate the hemodynamic impact of catheter insertion during the TAVI procedure. METHODS: CFD simulations were conducted in SimVascular to assess blood flow alterations at different stages of catheter insertion, from the iliac access to the ascending aorta, focusing on four critical phases of catheter advancement. Hemodynamic parameters were systematically analyzed across all simulated models. RESULTS: Catheter insertion induced a pronounced local pressure drop and elevated wall shear stress (WSS) at the access-side iliac artery. Outlet flow analysis showed redistribution across branches, with reduced flow on the access side and compensatory increases in the contralateral femoral artery and the other branches. Oscillatory shear index (OSI) and turbulent kinetic energy (TKE) were reduced at the access site, whereas higher OSI and TKE were observed in the contralateral iliac artery. Local hemodynamics and WSS near the catheter tip were found to be sensitive to the catheter's longitudinal position. CONCLUSION: This proof-of-concept study demonstrates that CFD can effectively capture catheter-induced hemodynamic disturbances during TAVI delivery, providing a foundation for patient-specific risk assessment and procedural optimization.

Relationship between a small aortic annulus and clinical and quality-of-life outcomes in patients undergoing TAVR.

BACKGROUND: A small aortic annulus is associated with impaired hemodynamics after transcatheter aortic valve replacement (TAVR). The impact on long-term clinical or patient-centered outcomes remains unclear. AIMS: To evaluate the association between aortic annulus size and long-term clinical outcomes and patient-reported health status after TAVR. METHODS: In this post-hoc analysis of the multicenter SCOPE I randomized trial, patients were categorized according to computed tomography-derived annular size (small ≤ 430 mm2, larger > 430 mm2). Outcomes included clinical events, disease-specific health status assessed with the Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) and an integrated patient-centered outcome defined as being alive with good health status (KCCQ-OS ≥ 75 without a decline > 10 points from baseline). RESULTS: Among 732 patients, 323 (44.1%) had a small and 409 (55.9%) larger annulus. Patients with a small annulus were more frequently women and had slightly higher surgical risk. Despite higher transvalvular gradients and a higher prevalence of prosthesis-patient mismatch, patients with a small annulus had no differences in all-cause mortality (18.6% vs 25.4%), heart-failure hospitalization (14.9% vs 15.6%), or patient-reported health status at 3 years, and a comparable probability of being alive with good health status (46.5% vs 43.2%; OR 0.95, 95% CI 0.63-1.44, p = 0.81). In an exploratory factorial analysis, a small annulus treated with a balloon-expandable valve was associated with a lower probability of this integrated outcome (RR 0.59, 95% CI 0.41-0.85; p for interaction = 0.004). CONCLUSIONS: Patients with small aortic annuli experience comparable long-term survival and quality-of-life recovery after TAVR. Exploratory analyses suggest that valve type may influence patient-centered outcomes in this population.

Surgical Explantation of Transcatheter Aortic Valves: A Contemporary Analysis of Indications and Outcomes.

Transcatheter aortic valve replacement (TAVR) has transformed the treatment of severe aortic stenosis across all surgical risk profiles. However, as TAVR expands into younger, lower-risk populations with longer life expectancies, the management of late bioprosthetic failure has emerged as a critical clinical challenge. While valve-in-valve TAVR offers a less-invasive reintervention strategy, absolute anatomical contraindications frequently render it infeasible, necessitating surgical explantation. Driven primarily by structural valve deterioration, acute device failure, and prosthetic valve infective endocarditis, TAVR explantation presents a uniquely hostile operative field. Unlike traditional redo-surgical aortic valve replacement, the endothelialized and fibrotic integration of transcatheter stent frames into the aortic root and subvalvular apparatus significantly complicates extraction. These procedures often require complex, unplanned concomitant reconstructive procedures. Consequently, explantation carries a substantial morbidity and mortality burden that significantly eclipses native redo-surgical aortic valve replacement, with a stark volume-outcome relationship highlighting the necessity of institutional expertise. This review synthesizes contemporary data from high-volume international registries to evaluate the evolving landscape of TAVR explantation, detailing the primary indications, anatomical hurdles, and clinical outcomes. Ultimately, we emphasize the necessity of rigorous, computed tomography-based lifetime management protocols at the time of the index procedure and the regionalization of explant operations to specialized multidisciplinary structural heart centers to mitigate the severe surgical risks of transcatheter valve failure.

The Predictive Value of The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) Score for One-Month Prognosis and First-Year Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has become a viable option for patients with severe aortic valve stenosis across a broad range of surgical risk in recent years. The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score, a novel indicator of malnutrition and inflammation, has been discovered to be inversely linked with prognosis in several cancer types. The purpose of this study is to examine the performance of the HALP score in predicting one-month major adverse cardiac events and one-year mortality in patients treated with TAVI. METHODS: This study included 395 consecutive patients treated with TAVI, separated into two groups based on their HALP scores: low and high. Our study's primary endpoint was all-cause death within a year after discharge following the TAVI operation. The secondary endpoint was a composite endpoint that included periprocedural complications and events in one month. RESULTS: Patients with a low median HALP score had a higher risk of one-month composite events and one-month death. In multivariate analysis, chronic kidney disease (odds ratio [OR]: 4.67, 95% confidence interval [CI]: 2.36 - 9.25, P < 0.001) and HALP score < 3.4 (OR: 1.235, 95% CI: 1.091 - 1.397, P < 0.001) were independent predictors of first-year mortality. Kaplan-Meier analysis for computing cumulative survival found that patients with low HALP scores based on a receiver operating characteristic curve cutoff of 3.4 had increased mortality rates throughout short-term follow-up. CONCLUSION: The HALP score may be a significant independent predictor of short-term prognosis and mortality in patients treated with TAVI, beyond conventional risk-scoring tools for better disease management.

Gutter Rotation Technique for Percutaneous Ipsilateral Retrieval of a Ruptured SAPIEN-3 Balloon.

Balloon rupture during transcatheter aortic valve replacement (TAVR) with balloon-expandable valves is a rare but potentially serious complication that may result in incomplete valve expansion, difficult device retrieval, and vascular injury. We report the case of an 88-year-old woman with severe calcific aortic stenosis who underwent TAVR using a 20-mm SAPIEN 3 transcatheter heart valve. Balloon rupture during valve deployment resulted in partial valve expansion and significant paravalvular leak. Conventional retrieval attempts were unsuccessful because the crumpled balloon became entrapped within the posterior expandable segment ("gutter") of the Edwards E-sheath. A novel Gutter Rotation Technique, involving counter-clockwise rotation of the E-sheath with simultaneous clockwise rotation of the Commander delivery system, redirected the balloon toward the rigid portion of the sheath, enabling successful ipsilateral percutaneous retrieval without surgical or contralateral intervention. Valve expansion was subsequently optimized with balloon post-dilatation. This technique may represent a feasible bailout maneuver in selected cases of Type 1 or Type 2 balloon rupture and warrants further evaluation.

Evolution of Aortic Valve Replacement Across Two Eras: Institutional Changes in Transcatheter and Surgical Practice and Outcomes.

Objectives: Conventionally, the gold standard for aortic valve disease has been surgical aortic valve replacement (SAVR). Advances in transcatheter aortic valve replacement (TAVR) have since produced marked improvements in both outcomes and procedural volume. We sought to characterize this evolution by comparing the earliest and most recent 100 procedures of each modality at a single high-volume institution. Methods: We retrospectively compared four cohorts of 100 consecutive isolated procedures: 100 TAVRs from 2012 (the earliest period of complete and verifiable registry capture) and 100 first-time SAVRs from a contemporaneous period (2011), each versus the 100 most recent procedures of the same modality (TAVR 2024; SAVR 2024-2025). The SAVR cohorts were limited to first-time, isolated replacement; the TAVR cohorts to native-valve procedures. The primary endpoint was the 30-day composite of death or stroke. Secondary endpoints included new permanent pacemaker implantation, paravalvular leak, vascular access route, anesthetic technique, and length of stay. Results: For TAVR, the 30-day composite of death or stroke fell from 10% to 1% (p = 0.010), with fewer in-hospital deaths (6% to 0%; p = 0.029) and less new dialysis (4% to 0%; p = 0.059). A paravalvular leak of at least mild severity fell from 27% to 3% (p < 0.001), with none as moderate or greater in either era. New pacemaker implantation decreased from 15% to 6% (p = 0.056). Within the same comparison, general anesthesia decreased from 100% to 23%, non-transfemoral access from 29% to 2%, median ICU stay from 43 to 0 h, and hospital stay from 6 to 1 day (all p < 0.001). SAVR outcomes remained similar (composite 2% to 0%, p = 0.497; pacemaker 1% to 0%; and paravalvular leak 0% to 4%), while prolonged ventilation (11% to 1%; p = 0.007) and hospital stay (8 to 5 days; p < 0.001) improved. The SAVR population became younger (74 to 64 years; p < 0.001), and isolated first-time surgery was markedly less frequent, requiring 18.9 versus 5.7 months to accrue 100 consecutive cases. Conclusions: In this two-era institutional comparison, recent-era TAVR outcomes were markedly better, while SAVR outcomes remained excellent in both eras within a recent population that was younger and in whom eligible isolated first-time surgery was less frequent. Because the eras differed substantially in patient risk profile, these unadjusted within-modality comparisons describe a real-world redistribution of aortic stenosis care between two increasingly complementary treatments rather than isolating the effect of any single procedural or technological factor.

A pathobiologic classification of aortic stenosis: Moving beyond the degenerative-bicuspid-rheumatic paradigm.

BackgroundAortic stenosis is traditionally categorised as degenerative calcific, congenital bicuspid, or rheumatic. Contemporary molecular biology, multimodality imaging, and transcatheter valve therapy demonstrate that aortic stenosis represents a spectrum of mechanistically distinct diseases converging upon a shared haemodynamic endpoint. A four-category pathobiologic classification is proposed linking disease mechanism to operative strategy and procedural risk stratification.MethodsA narrative mechanistic review was performed using contemporary international guidelines, foundational biological studies, and key clinical series. Pathophysiology, characteristic imaging phenotype, and procedural implications were integrated into a clinically applicable framework for use by multidisciplinary heart valve teams.ResultsAortic stenosis arises via common downstream pathways - valve interstitial cell activation, inflammation, extracellular matrix remodelling, and mineralisation - through mechanistically distinct initiating processes. Four phenotypes are identified: (a) congenital structural-biomechanical disease; (b) fibro-calcific inflammatory-osteogenic disease; (c) autoimmune/inflammatory valvulitis; and (d) metabolic/mineralisation-associated disease. Each demonstrates characteristic anatomical morphology, rate of haemodynamic progression, and differential suitability for transcatheter or surgical intervention.ConclusionsAortic stenosis is a final common phenotype of multiple distinct biological processes. A pathobiologic classification improves procedural planning, risk stratification, and therapeutic selection in the era of transcatheter valve therapy, and supports precision-based individualised patient management.

Clinical Outcomes of a Dedicated TAVR Device for Native Aortic Regurgitation: Insights From a Multicenter Real-World Experience.

BACKGROUND: The JenaValve Trilogy Transcatheter Heart Valve System (Trilogy) is a CE-marked transcatheter aortic valve replacement device designed for the treatment of symptomatic aortic regurgitation. Despite its unique indication, data from large cohorts remain limited. This study aimed to evaluate procedural characteristics and clinical outcomes in all-comers patients with symptomatic aortic regurgitation undergoing transfemoral transcatheter aortic valve replacement with the Trilogy valve. METHODS: This multicenter retrospective analysis included patients with symptomatic aortic regurgitation who underwent Trilogy implantation between June 2021 and June 2025 at 8 European centers. Baseline, procedural, and follow-up data were collected according to local protocols, and outcomes were defined per VARC-3 (Valve Academic Research Consortium-3). RESULTS: A total of 363 patients (median age, 81 years [interquartile range, 75-84]; 45% female patients; median European System for Cardiac Operative Risk Evaluation II, 3.4%; median left ventricular ejection fraction, 50%) were included. Transfemoral access was used in 359 (99%), and technical success was achieved in 98%. Valve embolization occurred in 5 patients: 2 managed with a second valve, 2 surgically, and 1 required valve-in-valve reintervention. Two additional technical failures involved hemodynamic instability and a vascular complication. At discharge, 86% had none or trace leakage, and the mean transvalvular gradient was 4 mm Hg. Permanent pacemaker implantation was required in 22%. In-hospital mortality was 0.3%. At 30 days, functional status had improved markedly, with 88% of patients in New York Heart Association class I or II. Kaplan-Meier estimated all-cause mortality at 6 months, 1, 2, and 3 years was 4.1%, 7.0%, 15.8%, and 25.9%, respectively, among patients with available follow-up. CONCLUSIONS: In this large analysis, transfemoral transcatheter aortic valve replacement with the Trilogy valve demonstrated high procedural success and favorable hemodynamic valve performance. These findings are encouraging and suggest a potential role for the Trilogy valve in patients with symptomatic aortic regurgitation who are unsuitable for surgery.

Transcatheter vs Surgical Replacement of Degenerated Bioprosthetic Aortic Valve: A Meta-Analysis of Propensity-Score-Matched Studies.

INTRODUCTION: Degeneration of bioprosthetic aortic valves is a common late complication. While redo surgical aortic valve replacement (redo-SAVR) has traditionally been the standard of care, transcatheter valve-in-valve implantation (ViV-TAVR) has emerged as a less invasive alternative. This meta-analysis aimed to compare outcomes between ViV-TAVR and redo-SAVR using propensity-score-matched studies. METHODS: A systematic search of Cochrane CENTRAL, Scopus, MEDLINE (via PubMed) Embase, and Scopus was conducted from inception through to 1 September 2024. Propensity-score matched cohort studies comparing ViV-TAVR and redo-SAVR were included. Risk ratios (RRs) and mean differences (MDs) or standardised mean differences (SMD), as appropriate, were pooled using a random-effects model. RESULTS: Thirteen propensity score-matched studies encompassing 16,223 patients (8,463 ViV-TAVR; 7,760 redo-SAVR) with a weighted mean follow-up of 16.6 months were included. Compared to redo-SAVR, ViV-TAVR was associated with significantly lower short-term all-cause mortality (RR: 0.47; 95% confidence interval [CI]: 0.34-0.66; p<0.0001), major bleeding (RR: 0.45; 95% CI: 0.33-0.59), acute kidney injury (RR: 0.56; 95% CI: 0.38-0.84), and shorter hospital stay (SMD: -0.79; 95% CI: -1.00 to -0.57). ViV-TAVR was also associated with a significantly lower incidence of new-onset atrial fibrillation (RR: 0.22; 95% CI: 0.13-0.37) but higher post-procedural mean transvalvular gradients (SMD: 0.45; 95% CI: 0.20-0.69). No significant differences were observed in 1- or ≥2-year mortality, stroke/transient ischaemic attack, myocardial infarction, permanent pacemaker implantation, or early readmission. Results remained consistent across sensitivity and subgroup analyses. CONCLUSION: ViV-TAVR offers significant short-term benefits over redo-SAVR, including lower early mortality and shorter hospitalisation. Long-term clinical outcomes remain comparable, while postprocedural mean gradients are higher after ViV-TAVR, underscoring the need for randomised trials and individualised patient selection to guide treatment decisions for degenerated bioprosthetic valves.

Machine Learning for Mortality Prediction in Infective Endocarditis: A Systematic Review and Meta-Analysis.

Infective endocarditis (IE) continues to be an often fatal condition despite improvements in cardiac surgical procedures and antibiotic therapy, and conventional scoring tools show poor generalizability. Machine learning (ML) addresses these limitations by capturing complex, nonlinear clinical relationships, outperforming conventional scores in predictive accuracy, though prior ML work in IE has focused on diagnosis. A PRISMA-compliant systematic review and meta-analysis of PubMed (Supplemental Digital Content, https://links.lww.com/CIR/A251) and Scopus (through April 2026) evaluated supervised ML models predicting all-cause mortality in adult IE patients; study quality and reporting were appraised using PROBAST and TRIPOD. Eight studies (5503 patients, mean age 53.85) were included in qualitative synthesis, of which 5 contributed area under the receiver operating characteristic curve (AUC) or C-index estimates for pooling via random-effects models, stratified into in-hospital/early and 6-month mortality subgroups. Seven studies were retrospective, and 1 was prospective. ML models, especially ensemble approaches such as Random Forest and gradient boosting, demonstrated strong discriminative performance across all cohorts, with AUC reflecting the ability to distinguish patients who died from those who survived, and outperformed conventional models. Pooled AUC was 0.85 (95% confidence interval [CI], 0.81-0.89) for in-hospital/early mortality (I2 = 35.3%) and 0.85 (95% CI, 0.82-0.88) for 6-month mortality (I2 = 0%). Dominant predictor domains varied by clinical context; multisystem physiologic markers characterized general IE cohorts, dynamic and laboratory variables enhanced intensive care unit-based predictions, and procedural and anatomical factors defined surgical and transcatheter aortic valve replacement model performance. Risk of bias was identified in 4 studies. ML models showed strong discriminative performance for IE mortality prediction, with ensemble methods outperforming conventional approaches by capturing its multivariate heterogeneity. Clinical adoption remains limited; future efforts should prioritize multicenter prospective validation, longitudinal data integration, and development of interpretable frameworks for bedside adoption.

TAVR Explant in the Era of Lifetime Valve Management: Indications, Operative Challenges, and Contemporary Outcomes.

PURPOSE OF REVIEW: This review summarizes contemporary evidence on transcatheter aortic valve replacement (TAVR) explantation, emphasizing epidemiology, indications, operative challenges, outcomes, risk prediction, and implications for lifetime valve management. RECENT FINDINGS: As TAVR expands to younger and lower-risk patients, explantation is becoming an increasingly relevant component of lifetime valve care. Recent systematic reviews, registries, national databases, and center experiences show that TAVR explant is technically complex, frequently requires concomitant procedures, and carries early mortality that exceeds conventional risk predictions. TAVR-in-TAVR is feasible in selected patients with structural valve degeneration but may be limited by infection, small annulus, coronary obstruction risk, or impaired future coronary access. TAVR explant should be considered during index valve selection. Heart Team planning should incorporate durability, coronary access, annular size, redo-TAVR feasibility, and surgical explant complexity, particularly in younger patients.

Outcomes of surgical aortic valve replacement with coronary artery bypass grafting versus transcatheter aortic valve replacement with percutaneous coronary intervention.

BACKGROUND: Aortic stenosis (AS) often coexists with coronary artery disease (CAD). Although transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) is frequently performed, comparative data with surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG) remain limited. This study compared outcomes of TAVR plus PCI versus SAVR plus CABG in patients with severe AS and CAD. METHODS: Data were obtained from the TriNetX Research Network, a large real-world retrospective database. Patients undergoing TAVR plus PCI or SAVR plus CABG between January 2015 to December 2022 were identified. After propensity score matching, 2483 patients were included in each group. Thirty-day outcomes included all-cause mortality, stroke, and permanent pacemaker (PPM) implantation. In addition, all-cause mortality at 1 and 3 years was determined. RESULTS: At 30 days, SAVR plus CABG was associated with higher all-cause mortality (4.2% vs 2.7%; p = 0.005) and higher incidence of stroke (5.5% vs 3.8%, p = 0.003) compared to TAVR plus PCI; however, PPM was lower in SAVR plus CABG (5.2% vs. 8.4%; p < 0.001). At 1-year, all-cause mortality was similar between SAVR plus CABG and TAVR plus PCI (10.4% vs. 11.1% [p = 0.70], respectively). At 3 years, SAVR plus CABG demonstrated lower all-cause mortality compared with TAVR plus PCI (18.7% vs 26.2%; p < 0.001). CONCLUSION: In patients with severe AS and CAD, SAVR with CABG is associated with higher short term all-cause mortality and stroke with lower PPM implantation compared to TAVR with PCI. Despite worse early outcomes, SAVR with CABG demonstrated superior long-term survival at 3 years.

Routine versus selective use of a femoral protection wire in transfemoral TAVI: a single-centre analysis of vascular complications.

BACKGROUND: Transfemoral transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe aortic stenosis in patients with elevated surgical risk. However, vascular complications remain a major source of morbidity and mortality. The protection wire technique was introduced to prevent major access-related complications, but its role in contemporary TAVI practice is uncertain. AIMS: To evaluate whether routine protection wire use reduces vascular complications in contemporary transfemoral TAVI. METHODS: We performed a retrospective, single-centre analysis of 1476 consecutive patients undergoing transfemoral TAVI between January 2020 and August 2023. Until November 2021, protection wire placement was standard-of-care (Group 1, n = 801); thereafter procedures were performed without routine protection wire use (Group 2, n = 675). Vascular complications were defined according to VARC-3 criteria. Multivariable logistic regression was used to identify independent predictors of minor and major vascular complications. RESULTS: The composite of minor and major vascular complications occurred more frequently in Group 1 than in Group 2 (18.6% vs. 10.8%, p < 0.001). In Group 1, 34.8% of access-related complications were associated with the protection wire access. Major vascular complications were numerically less frequent in Group 2 (2.5% vs. 4.2%). Omission of routine protection wire placement was independently associated with a lower risk (OR 0.52, 95% CI 0.38-0.72, p < 0.001). CONCLUSION: In contemporary transfemoral TAVI, routine protection wire use was not associated with reduced major vascular complications and was linked to a higher rate of minor access site injuries. These findings support a restrictive rather than routine use of protection wires in current practice.

Contemporary Evaluation and Management Strategies for Tricuspid Regurgitation.

BACKGROUND: Tricuspid regurgitation (TR) is a common but historically under-recognized valvular heart disease. Although mild to moderate TR was long considered benign, accumulating evidence indicates that clinically significant TR is associated with right ventricular failure, hepatic congestion, recurrent hospitalization, and increased mortality. AIMS: This review aims to provide a comprehensive overview of contemporary evaluation and management strategies for TR across its clinically relevant spectrum, with particular emphasis on severe disease and secondary mechanisms when discussing intervention. METHODS: Current literature was synthesized with a focus on TR classification, underlying mechanisms, imaging and hemodynamic assessment, risk stratification, device-related TR, and evolving therapeutic strategies, including both surgical and transcatheter approaches. RESULTS: Management paradigms have shifted toward earlier recognition and intervention, with echocardiography remaining central to diagnosis and procedural planning. While medical therapy is primarily supportive, advances in transcatheter edge-to-edge repair, annuloplasty systems, and transcatheter valve replacement have significantly expanded treatment options, particularly for patients at high surgical risk. Key determinants of therapeutic decision-making include pulmonary artery pressure, right ventricle-pulmonary artery coupling, right-sided chamber remodeling, surgical risk, and anatomic suitability. CONCLUSION: TR represents a complex and rapidly evolving area of cardiology that requires individualized assessment based on anatomy, hemodynamics, comorbidities, and the quality of available evidence. Ongoing clinical trials and emerging therapies are expected to further refine treatment algorithms and future guideline recommendations.

In-hospital mortality after transcatheter aortic valve implantation versus surgical aortic valve replacement in maintenance hemodialysis patients: a Japanese nationwide retrospective cohort study.

Patients with maintenance dialysis are at high risk for adverse outcomes after aortic valve replacement and have been largely excluded from major trials comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Comparative evidence in this population remains limited. We aimed to compare in-hospital outcomes between TAVI and SAVR in patients undergoing maintenance hemodialysis using a nationwide Japanese database. We conducted a retrospective cohort study of maintenance hemodialysis patients who underwent TAVI or SAVR between February 2021 and March 2023 using the Japanese Diagnosis Procedure Combination database. The primary outcome was in-hospital mortality. Secondary outcomes included length of hospital stay and in-hospital aortic valve reintervention. Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline differences. Among 1,649 patients, 966 underwent TAVI and 683 underwent SAVR. In-hospital mortality was lower in the TAVI group than in the SAVR group (3.0% vs 5.9%). After IPTW, TAVI was associated with lower in-hospital mortality (odds ratio 0.44, 95% confidence interval 0.24-0.79). Length of hospital stay was shorter in the TAVI group (median 14.0 days) than the SAVR group (29.0 days). In-hospital aortic valve reintervention was rare. In a sensitivity analysis restricted to hospitals performing both procedures, the association favored TAVI but was attenuated (OR 0.75, 95% CI 0.34-1.65). In patients receiving maintenance hemodialysis, TAVI was associated with lower in-hospital mortality and shorter hospital stay compared with SAVR.

Intraprocedural echocardiographic guidance in transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis across all surgical risk groups. Traditionally performed under general anesthesia with transesophageal echocardiography (TEE) guidance, TAVI has evolved toward a minimalist approach using local anesthesia and conscious sedation (LACS), supported by transthoracic echocardiography (TTE) or fluoroscopy alone. Despite this shift, intraprocedural imaging remains valuable as it offers real-time imaging guidance throughout the procedures, allowing for rapid and accurate assessment of complication and procedural results. Echocardiographic modalities used during TAVI include TTE, TEE (adult-, mini-, or micro-TEE) and intracardiac echocardiography (ICE), each with its own advantages and limitations. While TTE is widely used in uncomplicated cases, its image quality may be suboptimal, leading to missing complications and underestimation of paravalvular leak (PVL). In contrast, TEE provides superior spatial resolution, enabling comprehensive real-time assessment and improved PVL detection and other complications. Moreover, 3D TEE offers accurate assessment of the aortic annulus and aids in sizing of the prosthesis when computed tomography is suboptimal or unavailable. ICE is an attractive alternative as it provides real-time high-resolution images and can be performed under LACS by the same operator, although it is costly with single use and requires additional venous access. ICE may be particularly helpful in patients with challenging TTE windows, or in those with contraindications for TEE. We propose an upfront intraprocedural TEE strategy in patients with high-risk anatomies undergoing TAVI, and those with poor TTE window or renal impairment in whom minimal contrast usage is preferred. Mini-TEE (with a smaller probe) is the preferred modality for intraprocedural guidance, which has 3D imaging with good resolution, and is well tolerated under LACS. In conclusion, imaging strategies in TAVI should be individualized. While minimalist approaches are feasible, TEE remains indispensable in complex cases to optimize outcomes and minimize complications.

Percutaneous Mechanical Aspiration of Left-Sided Intracardiac Masses for Prohibitive Surgical Candidates: A Single-Center Experience.

BACKGROUND: Percutaneous mechanical aspiration (PMA) of intracardiac masses is mostly described for right-sided lesions. Left-sided masses are typically managed medically or surgically, with limited data regarding transcatheter removal. PMA is currently considered off-label; however, it may have advantages to debulk lesions and reduce morbidity in high risk patients. METHODS: We performed an observational study of 7, prohibitive surgical candidates who underwent transseptal PMA of mitral valve (MV) masses. Baseline characteristics, echocardiographic findings, procedural details, and in-hospital and short-term outcomes were collected. The primary procedural efficacy end point included procedural success defined by ≥70% mass removal and procedure-related mortality. The primary composite safety end point included in-hospital mortality, cerebrovascular accident, increased valvular regurgitation, and major structural complications. RESULTS: A total of 7 patients were included. The mean age was 77.9 ± 6.1 years; 71% were women, and the median predicted Society of Thoracic Surgery mortality score was 19.5%. All patients had echocardiographic evidence of large (>1 cm) left-sided masses involving the MV or adjacent structures. The primary efficacy end point was seen in 100% of cases. The primary composite outcome was seen in 14.3%, driven by worsening MV regurgitation. Procedure and fluoroscopy durations demonstrated a downward trend with increased experience. All patients survived to discharge and 30-day survival was 85.7%, with 1 noncardiac death. CONCLUSIONS: Transseptal PMA is feasible for debulking of MV masses in prohibitive surgical candidates. In this early experience, the technique achieved success with low procedural morbidity and encouraging short-term outcomes. Larger studies are needed to define patient selection criteria and long-term efficacy.

Transcatheter Aortic Valve Replacement in Patients With Symptomatic, Severe Aortic Regurgitation: 1-Year Outcomes of the J-Valve Transfemoral Early Feasibility Study.

BACKGROUND: Clinically significant native aortic regurgitation (AR) increases with age. Surgical aortic valve replacement has been the only curative guideline-recommended therapy, while transcatheter options remain limited by anatomic constraints. METHODS: The J-Valve early feasibility study (NCT06034028) evaluated the safety and effectiveness of transfemoral J-Valve transcatheter heart valve implantation in patients with symptomatic, severe native AR. The prospective single-arm study enrolled 25 patients with symptomatic, severe, native AR deemed high risk for surgical aortic valve replacement at 8 centers. Clinical and echocardiographic assessments were performed at baseline, 30 days, 6 months, and 1 year with independent core laboratory and clinical events committee adjudication. The primary effectiveness end point was a non-hierarchical composite of all-cause mortality or disabling stroke at 30 days. RESULTS: Mean age was 80.6 ± 4.3 years; 76% were male; 100% were New York Heart Association (NYHA) class II/III; mean Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score was 5.6 ± 4.5%. Successful implantation occurred in 92% (23/25). The primary end point occurred in 2 patients (8.0%). All-cause mortality was 4.0% at 30 days and 1 year, with no cardiovascular-related deaths. Two strokes (1 disabling) (8.2%) and 2 new pacemaker implantations (10%) occurred within 30 days. At 1 year, none/trace AR was present in 95.5% (21/22) and mild AR in 4.5% (1/22), with a mean gradient of 5.5 ± 1.7 mm Hg, and an effective orifice area of 2.48 ± 0.53 cm2. Reverse left ventricular (LV) remodeling was evident at 30 days with sustained reductions in LV end-diastolic and end-systolic volume indices to 1 year. NYHA class improved in 72.7% (16/22) of patients, with 95.5% (21/22) in NYHA class I/II at 1 year. CONCLUSIONS: This study demonstrates preliminary safety and effectiveness of the J-Valve in high-risk patients with severe AR, with favorable 1-year outcomes and stable hemodynamic performance.

Electrosurgical Septal Leaflet Liberation and Transcatheter Tricuspid Valve Replacement for Failed Postero-Septal Tricuspid Transcatheter Edge-to-Edge Repair.

Sodium-Glucose Cotransporter-2 Inhibitors in Valvular Heart Disease: From Mechanistic Insights to Clinical Application.

Valvular heart disease encompasses a diverse group of hemodynamic disorders that are frequently associated with heart failure, recurrent hospitalizations, and substantial morbidity despite advances in transcatheter and surgical therapies. Sodium-glucose cotransporter-2 (SGLT2) inhibitors have emerged as a cornerstone of cardiovascular and renal disease management, demonstrating consistent benefits across a broad range of patient populations. Beyond their established effects in heart failure, diabetes mellitus, and chronic kidney disease, accumulating evidence suggests that SGLT2 inhibitors may favorably influence key biological pathways involved in valvular heart disease, including inflammation, oxidative stress, fibrosis, endothelial dysfunction, and adverse cardiac remodeling. Preclinical and translational studies have provided mechanistic support for a potential role of SGLT2 inhibition in modifying valvular and myocardial disease processes. Emerging clinical evidence suggests possible benefits across several forms of valvular heart disease, including degenerative aortic stenosis, functional mitral regurgitation, tricuspid regurgitation, rheumatic mitral stenosis, and bioprosthetic valve degeneration. In addition, growing interest has focused on the integration of SGLT2 inhibitors into contemporary structural heart practice, particularly among patients undergoing transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and other structural interventions. This narrative review summarizes the mechanistic rationale, current clinical evidence, and practical considerations surrounding the use of SGLT2 inhibitors in valvular heart disease and structural heart interventions. We discuss the strengths and limitations of the existing literature, identify important gaps in knowledge, and highlight future directions for research aimed at defining the role of SGLT2 inhibitors as an adjunctive therapy in structural heart disease.

Simultaneous Transcatheter Aortic Valve Replacement and Endovascular Aneurysm Repair in a Patient With Peripheral Artery Disease Requiring Surgical Vascular Access: A Case Report.

Aortic stenosis, abdominal aortic aneurysm, and peripheral artery disease are common comorbidities with shared risk factors. As the population ages, more patients will require intervention to reduce morbidity and mortality from these entities. We present a 78-year-old woman with severe aortic stenosis, abdominal aortic aneurysm (8.1 × 4.9 × 4.8 cm), and severe peripheral artery disease. Simultaneous transcatheter aortic valve replacement and endovascular aneurysm repair were performed, with surgical cutdown of the right common femoral artery and then a right femoral endarterectomy required. The patient was discharged home 2 days later. A multidisciplinary approach with careful preoperative planning was key.

Totally endoscopic beating-heart redo tricuspid valve replacement using a frame-preserving strategy: a case report.

BACKGROUND: Redo tricuspid valve surgery for structural bioprosthetic degeneration is technically challenging and carries substantial operative risk, particularly after previous sternotomy. Totally endoscopic approaches may reduce re-entry-related morbidity, but experience in redo tricuspid surgery remains limited. In selected cases, preserving a well-incorporated bioprosthetic frame may avoid extensive annular dissection. CASE PRESENTATION: A 46-year-old man presented with progressive right-sided heart failure 11 years after tricuspid bioprosthetic valve replacement for infective endocarditis. Echocardiography showed severe intra-prosthetic regurgitation and stenosis with calcified, retracted leaflets. Transcatheter valve-in-valve therapy was considered but not selected because of the patient's young age, durability concerns, limited availability, and cost. Totally endoscopic beating-heart redo tricuspid valve replacement was performed through a right mini-thoracotomy under peripheral cardiopulmonary bypass. The degenerated leaflets were excised, the sewing ring was preserved, and a 29-mm mechanical prosthesis was implanted onto the retained frame. Recovery was uneventful, and valve function was normal at 6 months. CONCLUSION: This frame-preserving, totally endoscopic approach is feasible in selected patients, although further experience is needed.

[TAVI Program in Centers without an On-Site Cardiac Surgical Department: Outcomes and Feasibility].

Aortic valve stenosis is a serious condition with high morbidity and mortality if untreated. Since 2002, transcatheter aortic valve implantation (TAVI) has revolutionized treatment, offering a less invasive alternative with excellent outcomes. Increased demand necessitates expanded treatment capacity, especially due to long waiting times and associated risks. While cardiac surgery centers provide emergency support, improved technology and lower complication rates now allow TAVI in centers without on-site surgery, given proper collaboration with surgical facilities. This study evaluates the feasibility of TAVI in such settings. At Meir Medical Center, 149 patients underwent TAVI with no mortality or emergency surgeries. These findings support expanding TAVI access to non-surgical centers without compromising outcomes.

Balloon Aortic Valvuloplasty as a Bridge Therapy in Acute Valve Syndrome: A Narrative Review of Evidence Gaps and Future Directions.

Acute valve syndrome represents a high-acuity, decompensated presentation of severe aortic stenosis (AS), often manifesting as acute heart failure, cardiogenic shock, or cardiac arrest. Transcatheter aortic valve replacement (TAVR) remains the only durable therapy for severe AS in patients with prohibitive surgical risk, yet acute valve syndrome patients may be too unstable for standard preprocedural planning. Balloon aortic valvuloplasty (BAV) has re-emerged as a bridge strategy that can provide rapid hemodynamic stabilization and permit subsequent valve replacement. Registry analyses report lower mortality in emergent TAVR compared with BAV, but these comparisons are confounded by procedural indication and unmatched AS severity. Smaller hemodynamically characterized cohorts suggest that selected patients who stabilize after BAV and proceed to TAVR may achieve outcomes comparable to direct TAVR, although these studies remain underpowered for definitive inference. In this narrative review, we evaluate evidence comparing BAV-bridged strategies with emergent TAVR, identify key evidence gaps, and discuss how acute hemodynamic status may inform Heart Team decision-making.

Lifetime Planning of Aortic Stenosis Treatment Starts Before the First Valve.

CT-guided lifetime planning in severe aortic stenosis. Preprocedural CT should guide not only valve implantation, but the first lifetime treatment decision. In patients with longer expected survival, CT can identify whether TAVR-first is likely to preserve coronary access and future TAVR-in-TAVR feasibility, or whether SAVR-first should be considered when surgical risk is acceptable. Abbreviations: CT, computed tomography; SAVR, surgical aortic valve replacement; TAVR, transcatheter aortic valve replacement.

Beyond Propensity Matching: Interpreting Outcomes of Surgical Aortic Valve Replacement Versus Transcatheter Aortic Valve Replacement in Patients With Reduced Ejection Fraction.

Valve-In-Valve Transcatheter Aortic Valve Replacement: Advances in Planning, Technique, and Lifetime Management.

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as a key reintervention strategy for failed surgical bioprostheses. Meticulous preprocedural planning with computed tomography, fluoroscopy, and transesophageal echocardiography is essential for optimal outcomes. Emerging artificial intelligence-based technologies may help mitigate associated risks such as coronary obstruction and patient-prosthesis mismatch and assist with lifetime management planning for valvular heart disease. Transcatheter valve underexpansion can be addressed through bioprosthetic valve fracture in select cases. ViV-TAVR is likely to continue to grow in prevalence given an aging population, its minimally invasive nature compared to redo surgical aortic valve replacement, and its favorable safety profile.

Transcatheter Aortic Valve Replacement for Native Aortic Regurgitation.

Aortic regurgitation (AR) is a common valvular heart disease with an estimated prevalence of greater than 4% among patients aged greater than 65 years in some series. If left untreated, AR is associated with progression to left ventricular dysfunction and death. Surgical aortic valve replacement is considered the gold standard for the management of symptomatic AR. Several dedicated transcatheter heart valves (THVs) are currently in development. In this review, we highlight the current evidence and future studies evaluating outcomes of dedicated THVs for transcatheter aortic valve replacement in AR.

Transcatheter Aortic Valve Replacement with a Self-expanding Prosthesis.

Self-expanding transcatheter valves have evolved significantly into mature therapeutic platforms supported by randomized evidence across the spectrum of surgical risk. The most consistent advantages of self-expanding transcatheter aortic valve replacement remain excellent hemodynamics, especially in small annuli, and the technical flexibility conferred by controlled deployment and recapturability. The principal historical liabilities-pacemaker implantation, paravalvular leak, and coronary reaccess-have improved substantially with new devices and refined implantation technique, although none has been eliminated.

Balloon-Expandable Transcatheter Aortic Valve Replacement: A Comprehensive Review of Current Evidence and Clinical Outcomes.

This article outlines the transformative impact of transcatheter aortic valve replacement (TAVR) since its first successful human use in 2002, redefining the management of severe aortic stenosis. Traditionally treated with surgical aortic valve replacement, many elderly patients with comorbidities were unsuitable for surgery. TAVR has emerged as a less invasive and widely adopted alternative, expanding from high-risk to low-risk populations with strong clinical outcomes. Its rapid global uptake and potential role in earlier intervention highlight its clinical significance. The article also introduces the 2 main valve platforms, balloon-expandable and self-expanding, focusing on their design and evolving applications.

Advances in surgical treatment for valvular heart disease: a narrative review of 2025 studies.

BACKGROUND AND OBJECTIVE: The field of surgical treatment for valvular heart disease (VHD) has progressed rapidly in 2025. This review aims to summarize the year's key research, focusing on comparisons of mainstream techniques for aortic, mitral, and tricuspid valve diseases, innovations in repair techniques, and advances in emerging technologies, to provide evidence-based support for individualized clinical decision-making. METHODS: A structured search of PubMed database was performed to identify randomized controlled trials (RCTs), registry studies, and meta-analyses published in 2025, and the evidence was synthesized narratively. KEY CONTENT AND FINDINGS: In the aortic valve arena, long-term follow-up from the PARTNER 3 and Evolut Low Risk trials confirmed the non-inferiority of transcatheter aortic valve replacement (TAVR) in low-risk patients. However, real-world data suggested higher long-term risks with TAVR in patients with bicuspid aortic valves (BAV) and younger patients, whereas women demonstrated greater benefit. The indication for early intervention in asymptomatic severe aortic stenosis (AS) was reinforced. Aortic valve repair and the Ross procedure accumulated more robust evidence for long-term survival and quality of life in younger patients. In the mitral valve domain, the MITRACURE study highlighted gaps between real-world practice and guidelines, including delayed referral and suboptimal repair rates for mitral regurgitation (MR). The advantages of repair for degenerative disease were further solidified, though techniques for posterior leaflet prolapse and management strategies for atrial functional regurgitation (AFMR) require optimization. Transcatheter edge-to-edge repair (TEER) was increasingly used in high-risk patients but yielded inferior long-term outcomes compared to surgery, and surgical rescue after failed TEER carried high risk. For the tricuspid valve, comparative effectiveness of transcatheter vs. surgical repair and the timing of intervention emerged as key research foci. Emerging technologies such as polymer valves, partial heart transplantation, and artificial intelligence (AI)-assisted analysis demonstrated preliminary potential. CONCLUSIONS: The 2025 evidence reinforces a paradigm shift from risk-score-based decision-making toward individualized valve care. Transcatheter techniques have expanded their indications, but surgery remains irreplaceable in young, low-risk, and BAV patients, as well as in degenerative MR. Real-world gaps in guideline adherence, delayed referral, and suboptimal repair rates require urgent attention. Emerging technologies show early promise, although their long term durability and clinical value await further validation.

The value of preoperative risk scores prior to tricuspid valve interventions: The TRI-SCORE and beyond.

Tricuspid regurgitation (TR) is increasingly recognized as a condition associated with poor clinical outcomes, including reduced quality of life, progressive right-sided heart failure, and increased mortality. Its heterogeneous etiologies and systemic consequences, affecting both cardiac and extracardiac organs such as the kidneys and liver, make patient management particularly challenging. Accurate risk stratification and timely intervention are therefore essential. The 2025 European Society of Cardiology and European Association for Cardio-Thoracic Surgery Guidelines acknowledge the multifaceted nature of TR and emphasize the need for evaluation in expert centers through multidisciplinary Heart Team discussions. In this context, the TRI-SCORE, initially developed to predict in-hospital mortality after isolated tricuspid valve (TV) surgery, has been incorporated into the guideline decision-making algorithm as a key risk assessment tool to support therapeutic selection. This simple eight-variable model demonstrated excellent prognostic predictive performance and has been validated across several international cohorts of patients conservatively treated or who underwent a surgical or transcatheter intervention. Compared with other surgical scores such as EuroSCORE II, Model for End-Stage Liver Disease (MELD)/MELD-XI, or the Society of Thoracic Surgeons isolated TV surgery model, the TRI-SCORE is disease-specific, simple, and offers superior predictive value. It helps identify patients most likely to benefit from intervention, providing a practical framework for integrating disease stage, procedural risk, and expected benefit. Both surgical and transcatheter therapies may improve prognosis when performed early, whereas delayed referral at advanced stages offsets their potential benefit. The systematic use of TRI-SCORE within the Heart Team can therefore refine patient selection, guide the timing of intervention, and support personalized, lifetime management of TR.

Three decades evolution of the lifetime management approach to tricuspid valve disease: a multidisciplinary European perspective from a high-volume heart valve center.

BACKGROUND: The treatment of tricuspid valve (TV) disease has increased over the last decades. This study evaluates trends, patient characteristics, and outcomes of surgical and transcatheter TV interventions over 30 years. METHODS: All consecutive adult patients undergoing TV surgery or transcatheter intervention at the Heart Center Leipzig were included in this unadjusted descriptive analysis. Patients with TV endocarditis were excluded. Surgical data covered 1996-2024, transcatheter edge-to-edge repair (T-TEER) 2016-2024, and transcatheter TV replacement (TTVR) 2021-2025. All information was obtained from the institutional database. RESULTS: A total of 982 patients were analyzed: 450 (46%) surgical, 498 (51%) T-TEER, and 34 (3%) TTVR patients. Surgical patients were younger (67 vs. 79 vs. 81 years, respectively, P<0.001) and had fewer comorbidities than those treated interventionally. Higher-grade TR was more common in T-TEER and TTVR cohorts. Device leads crossing the TV were present in 109 (24%) surgical, 147 (30%) T-TEER, and seven (21%) TTVR patients (P=0.13). Reoperations accounted for 165 (37%) surgical cases, while prior cardiac operations were documented in 148 (30%) T-TEER and 7 (21%) TTVR patients. Surgery after T-TEER was infrequent (n=4, 1%). One-year survival was 88% after surgery, 83% after T-TEER, and 94% after TTVR (log-rank P=0.036). Among surgical patients, 335 (74%) did not require any re-hospitalizations during the first year postoperatively. Surgical reoperations showed survival comparable to primary procedures (actuarial survival at 9 years, 55% vs. 59%, respectively; log-rank P=0.07). Surgical TV replacement was associated with worse survival than surgical TV repair (at 9 years. 55% vs. 65%, respectively; log-rank P=0.03). CONCLUSIONS: Surgical TV repair yields better outcomes than replacement. Long-term survival after reoperation parallels that of primary TV surgery. Surgical and transcatheter therapies address distinct patient populations. Multidisciplinary heart team evaluation remains essential for optimal management of TV disease.

The current state of isolated tricuspid valve surgery: how it complements transcatheter tricuspid valve interventions.

Tricuspid valve insufficiency represents a prevalent health burden for many patients worldwide but remains highly undertreated. This is especially true for isolated tricuspid disease, where surgical intervention remains underutilized. Despite historically elevated periprocedural risk, isolated tricuspid valve surgery (iTVS) today can provide an effective and reliable solution to tricuspid disease. Successful iTVS requires careful evaluation of valve anatomy, pathophysiology, and patient risk profile. Available risk calculators can be useful tools in determining patient risk and surgical candidacy. Additionally, intervening within the treatment window before late right ventricular disease and distortion with end-organ damage is integral to success. The application of minimally invasive surgical approaches can further improve outcomes. Furthermore, tricuspid valve repair has been shown to improve long-term survival. For patients who are not candidates for surgery, transcatheter modalities have increased awareness and provide a promising treatment alternative for tricuspid regurgitation (TR) reduction and symptom control, albeit with limited durability data. Currently, surgical and transcatheter interventions address separate populations with distinct risk profiles. Hence, treatment success is dependent on matching the right patient with the right procedure. Patients with suitable anatomy and lower risk profiles should be considered for surgical approaches, particularly if repair may be feasible.

Clinical and Echocardiographic Outcomes After Implantation of the ALLEGRA Transcatheter Valve Using the Fully Repositionable IMPERIA Delivery System: One-Year Results of the EMPIRE I Study.

BACKGROUND: The EMPIRE I study assessed the early (30 days) safety and efficacy of a new fully repositionable delivery system (IMPERIA) for the commercially available ALLEGRA transcatheter aortic valve in patients with either severe native aortic stenosis or a degenerated surgical bioprosthesis. AIM: To report the final 1-year results of the EMPIRE I study. METHODS: EMPIRE I is a pre-market, prospective, multi-center, single-arm study conducted at 11 centers in 3 European countries. There were independent data safety and clinical events committees and an independent echocardiographic core laboratory. In this analysis, VARC-3 definitions of all clinical endpoints and echocardiographic parameters were employed. RESULTS: The study recruited 121 patients with severe native aortic stenosis and 16 with degenerated surgical bioprosthesis. At 1 year, the incidence of bioprosthetic valve dysfunction in the native population was 5.9%. No patients developed structural valve deterioration or endocarditis, and there were no patients with haemodynamic valve deterioration or bioprosthetic valve failure. In the valve-in-valve sub-group, 2/14 (14.3%) patients had moderate patient prosthesis mismatch at 30 days with no evidence of new bioprosthetic valve dysfunction at 1 year. In the native population, new permanent pacemaker implantation was 14.3% at 30 days and remained unchanged at 1 year. Cardiovascular mortality was 6.8% in the native population and 0% in the valve-in-valve patients. At 1-year, all-cause mortality was 10.8% (95% CI 6.4%-17.8%) in the native aortic stenosis population and 0% in the valve-in-valve patients. CONCLUSION: After 1 year of follow-up, the results of the EMPIRE 1 study show excellent haemodynamic performance, a low rate of bioprosthetic valve dysfunction, and no bioprosthetic valve failure in patients treated with the ALLEGRATM trans-catheter aortic valve implanted using the new IMPERIATM fully repositionable delivery system.

A Word of Caution: Aorto-Right Ventricular Fistula, an Uncommon Pitfall of Perceval Sutureless Valve.

BACKGROUND: An aorto-right ventricular fistula (ARVF) secondary to membranous septum rupture is an exceptionally rare complication after surgical aortic valve replacement (SAVR). While sutureless prostheses such as the Perceval valve have gained wide acceptance due to reduced cross-clamp times and procedural simplification, the reported adverse events predominantly include conduction disturbances and paravalvular leaks. Structural septal disruption remains sparsely described. We report a case of an early ARVF after Perceval implantation and review the pathophysiological and procedural mechanisms implicated in septal injury following sutureless and transcatheter aortic valve interventions. CASE DESCRIPTION: A 66-year-old woman with severe bicuspid aortic valve stenosis underwent SAVR via a median sternotomy using a Perceval XL prosthesis after meticulous annular decalcification and sizing. Immediate intraoperative transesophageal echocardiography (TEE) confirmed optimal seating without any paravalvular regurgitation. Within 24 h, the patient developed a complete atrioventricular block followed by cardiogenic shock. A repeat TEE revealed a large ARVF with significant left-to-right shunt. Emergent re-exploration identified a membranous septum tear. The Perceval prosthesis was explanted, the defect was closed with a reinforced patch repair, and a 27 mm Inspiris Resilia bioprosthesis was implanted. Peripheral veno-arterial ECMO support was required temporarily. The patient recovered and remained free of prosthetic dysfunction at the two-year follow-up. DISCUSSION: Membranous septum rupture after AVR has an estimated incidence of 0.4-1.5% in TAVR cohorts but is virtually unreported with Perceval valves. The mechanisms are thought to be chronic radial stress from oversized or malpositioned prostheses. Case reports with TAVR devices emphasize oversizing as a risk factor. Predictive factors for septal injury in sutureless AVR mirror those for conduction disturbances: valve oversizing, shallow infra-annular septal length, heavy calcification, and prior valve surgery. Preventive measures, such as strict sizing protocols, the avoidance of balloon dilation, and optimized implantation depth, have reduced conduction complications and may mitigate septal trauma. The treatment choice, whether percutaneous or surgical closure, depends on hemodynamic stability, defect size and anatomy, and operative risk. CONCLUSIONS: Early ARVF after Perceval implantation is exceedingly rare but potentially catastrophic. Strict adherence to sizing principles, awareness of septal anatomy, and prompt management, percutaneous in selected stable cases or surgical in acute large defects, are essential to optimize outcomes in sutureless AVR.

Percutaneous electrosurgical leaflet laceration to prevent coronary obstruction during TAVI for severe aortic regurgitation.

Preliminary Outcome of Transcatheter Aortic Valve Implantation at Centers Without On-Site Cardiac Surgery.

In many countries, patients' access to transcatheter aortic valve implantation (TAVI) is limited by reimbursement issues or delayed admission to heart valve centers, thus increasing the risk of adverse events in wait-listed patients. The TAVI AT HOME (TAH) is a single-arm, multicenter study aiming to evaluate the safety and efficacy of transfemoral TAVI performed at centers without on-site cardiac surgery by expert operators. The primary endpoint is 30-day all-cause mortality. This study focuses on the run-in phase of the registry, which was required by the ethics committee to perform an interim safety analysis. The outcome of 20 TAH patients enrolled at three Italian centers from May 2023 to May 2024 was compared to 41 TAVI cases included in the permanent local registry, matching the TAH inclusion/exclusion criteria. The two groups had similar baseline characteristics. Significantly more patients in the TAH group were deemed at prohibitive risk (85.0% vs. 56.1%; p = 0.026) but had similar surgical risk scores. A self-expanding device was used in most cases (60.7%). Technical success did not differ between groups (95.0% in the TAH vs. 85.4%, p = 0.409). No deaths at 30 days (primary endpoint) were observed. The 1-year survival rate did not differ between groups. After interim data analysis, the ethics committee authorized the completion of the TAH enrollment and extension to other centers. The TAH approach might represent an alternative model to allow timely access to TAVI without compromising safety and effectiveness.

Lifetime management of primary mitral regurgitation through integrated surgical and transcatheter reinterventions.

Lifetime management of primary mitral regurgitation requires integrating surgical and transcatheter strategies. This review evaluates initial interventions, emphasizing early timing and repair durability, and outlines subsequent reintervention pathways. Synthesizing contemporary evidence, it highlights how a multidisciplinary Heart Team must design the index procedure to preserve future therapeutic options and ensure structured longitudinal care across the patient lifespan.

Impact of Previous Cardiac Surgery on Outcomes After Tricuspid Valve Transcatheter Edge-to-Edge Repair: Insights from EuroTR.

BACKGROUND: Data on the association of previous cardiac surgery (PCS) with outcomes following tricuspid valve transcatheter edge-to-edge repair (T-TEER) are limited. OBJECTIVES: This study aimed to evaluate the impact of PCS on outcomes after T-TEER. METHODS: This analysis included patients from the EuroTR registry (European Registry of Transcatheter Repair for Tricuspid Regurgitation; NCT0630726) who underwent T-TEER for clinically relevant tricuspid regurgitation (TR) between 2016 and 2024 and had available information on cardiac surgical history. Study endpoints were procedural TR reduction, improvement in NYHA functional class, all-cause mortality, and the composite of death or heart failure hospitalization (HFH) at 2 years. RESULTS: Among 2929 patients, 27.2% had a history of PCS. These patients exhibited a higher comorbidity burden and more advanced right heart remodeling. TR severity at baseline was comparable between groups (P = 0.095), whereas residual TR at discharge and follow-up was higher in patients with PCS (both P < 0.001). PCS independently predicted residual TR ≥ 3 + at discharge (OR: 1.41; 95% CI: 1.11-1.79; P = 0.01). T-TEER was associated with an improvement in NYHA class in patients with and without PCS (≥ 1-class reduction: 66.2% in PCS vs. 59.6% in non-PCS patients; P = 0.15). At 2 years, PCS patients had higher all-cause mortality (HR: 1.25; 95% CI: 1.04-1.50; P = 0.02) and a higher incidence of the composite endpoint of death or HFH (HR: 1.24; 95% CI: 1.05-1.46; P = 0.01). CONCLUSIONS: PCS is an independent predictor of outcomes in patients undergoing T-TEER, identifying a subgroup with less pronounced TR reduction and lower long-term survival despite significant functional improvement.

Transcatheter aortic valve replacement in low-to-medium surgical risk patients: time for a reappraisal?

Stroke after transcatheter aortic valve implantation: incidence, temporal trends and predictors.

BACKGROUND: Stroke remains one of the most serious complications of transcatheter aortic valve implantation (TAVI). This study evaluated temporal trends in 30-day stroke after TAVI, explored potential contributors to these trends and examined associations with mortality. METHODS: All patients undergoing TAVI in Sweden between 2008 and 2023 were identified from the SWEDEHEART registry. The primary endpoint was 30-day ischaemic or haemorrhagic stroke. Temporal trends were analysed using Bayesian binomial regression. To investigate potential contributors to the observed trends, sequential models were fitted, adjusting for patient case-mix and centre-level procedural volume. Predictors of 30-day stroke were explored using a hierarchical Bayesian logistic regression with a centre-level random intercept. Mortality was assessed using Kaplan-Meier estimates and a multivariable Bayesian Cox model with a 30-day landmark. RESULTS: Among 11 957 patients, 374 (3.1%) experienced a stroke within 30 days and 310 during index hospitalisation. The incidence of 30-day stroke declined from 5.3% in 2008 to 3.2% in 2023 (OR 0.97 per year; 95% credible interval 0.95-1.00; probability of direction 98.2%). The temporal decline was partly explained by changes in patient case-mix, particularly declining EuroSCORE (European System for Cardiac Operative Risk Evaluation) II. Centre procedural volume did not modify temporal trends as this trend was similar across low-volume, medium-volume and high-volume centres. In exploratory analyses, prior stroke, female sex, porcelain aorta and self-expanding valves were associated with a higher probability of 30-day stroke, whereas TAVI-in-SAVR (transcatheter aortic valve implantation in surgical aortic valve replacement) procedures were associated with a lower stroke risk. Stroke within 30 days was associated with markedly higher 30-day and 1-year mortality. CONCLUSIONS: In this nationwide cohort, the incidence of early stroke after TAVI declined over time, partly reflecting changes in patient selection towards lower-risk profiles, with additional improvements in TAVI practice likely contributing. Despite this, early stroke remains strongly associated with excess mortality, underscoring the need for continued refinement of procedural strategies and targeted risk mitigation.

Surgical Versus Transcatheter Aortic Valve Replacement in Bicuspid Aortic Stenosis: 1-Year Clinical Outcomes in Patients Aged 65 Years and Older.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has shown noninferiority to surgical aortic valve replacement (SAVR). However, patients with bicuspid aortic stenosis are often excluded from these studies. More insights between these procedures in this population is crucial for treatment selection. METHODS: In this multicenter observational study, patients with bicuspid aortic stenosis undergoing TAVR or SAVR were analyzed using propensity score matching. The primary outcome was a composite of all-cause mortality, stroke, rehospitalization, or valve dysfunction at 1 year. RESULTS: A total of 997 patients with bicuspid aortic stenosis underwent TAVR or SAVR. In the matched cohort of 256 pairs, the median age was 75.0 years (interquartile range, 71.0-78.0), 234 (44.9%) were women, and the median EuroScore II was 1.83% (interquartile range, 1.34-2.86). One-year cumulative incidence of the primary outcome was 15.0% in TAVR compared with 12.0% in SAVR (hazard ratio [HR], 1.35 [95% CI, 0.83-2.19], P=0.23). Mortality (4.3% versus 5.0%, P=0.72) and rehospitalization (4.8% versus 6.4%, P=0.45) were similar between groups. Although rates of valve dysfunction (2.9% versus 0.5%, P=0.06) and stroke (5.3% versus 2.3%, P=0.10) were numerically lower in the surgical group at 1 year, both the risk of stroke (subdistribution HR, 3.01, P=0.02) and valve dysfunction (subdistribution HR, 4.16, P=0.03) were significantly higher in the TAVR group at 2 years. CONCLUSIONS: TAVR in patients with bicuspid aortic stenosis showed a similar 1-year primary outcome rate compared with SAVR, though TAVR exhibited higher rates of valve dysfunction and stroke. These findings underscore the need for randomized trials to define the optimal treatment strategy for this population.

FOOPAS Study: Functional Assessment and Prognostic Value in Aortic Valve Replacement for Patients ≥ 75 Years.

Background: Because of demographic changes, the number of older patients undergoing cardiac interventions has increased. The most common indication in this group is aortic valve stenosis, treated with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVR), with good outcomes. Our study investigated whether the heart team's choice of intervention (TAVI, SAVR, or conservative) is influenced by geriatric assessment results. Methods: This study was a single-centre, prospective, longitudinal case-control study conducted over 12 months and did not affect routine diagnostic examinations or clinical decisions. After risk stratification and clinical evaluation, patients were assigned to undergo TAVI, SAVR, or conservative management. Cardiological evaluation and geriatric assessment were performed for up to 12 months. Results: Of 135 patients (mean age 81 ± 4.6 years), 60% underwent TAVI, 29% SAVR, and 11% conservative therapy. Age, Frailty Score, cognition, and nutritional status were significantly associated with the heart team's decision, whereas EuroSCORE II remained the only independent predictor of one-year mortality (OR 1.58, 95% CI 1.13-2.19, p = 0.007). One-year mortality was 9.9% (n = 11). Compared to the literature, one-year mortality was lower than expected, particularly in the intervention group. Conclusions: Single assessment tools did not have the power to predict mortality. Similar to other trials, a combination of different scores can assess the risk of mortality.

Objective Assessment of Functional Capacity Improvement Following Transcatheter Tricuspid Valve Interventions.

Transcatheter tricuspid valve interventions have recently emerged as effective therapeutic options for patients with severe tricuspid regurgitation (TR) and heart failure at high surgical risk. Despite evidence of post-procedural clinical improvement, data regarding changes in functional capacity remain limited. In this prospective, observational study we enrolled high-risk patients with at least severe TR and heart failure undergoing transcatheter tricuspid valve repair by the PASCAL® device or replacement with the EVOQUE® system. Functional capacity was evaluated by cardiopulmonary exercise testing (CPET), in addition to clinical, laboratory, and echocardiographic parameters, at baseline and 3 months post-procedure. The primary endpoint was the change in peak oxygen consumption (VO₂) by CPET at 3 months versus baseline. Secondary endpoints included changes in other CPET parameters, TR severity by transthoracic echocardiography, New York Heart Association (NYHA) class, daily furosemide dose, and pro-brain natriuretic peptide (pro-BNP) levels. A total of 10 patients were enrolled, with successful device implantation obtained in all cases. Peak VO₂ improved significantly from 14.7±3.7 at baseline to 16.4±2.9 ml/kg/min at 3 months (p=0.009). Peak oxygen pulse increased from 85.1±20.2% to 103.7±23.3% (p=0.022), and ventilation maximum rose from 39.9±10.3 L/min to 45.7±10.9 L/min (p=0.035). TR severity was reduced (p=0.002), NYHA class improved (p=0.016), and daily furosemide dose decreased (p=0.016). Although pro-BNP levels declined, this reduction was not statistically significant. No adverse event occurred during follow-up. In conclusion, among patients with severe TR and heart failure, TR reduction by transcatheter tricuspid valve interventions was associated with improved CPET-derived functional capacity, better functional class and reduced diuretic requirement during short-term follow-up.

Prognostic Impact of Baseline Albumin-Bilirubin Score on Mortality After Transcatheter Edge-to-Edge Mitral Repair.

Background and Objectives: Transcatheter edge-to-edge repair (TEER) has emerged as an effective treatment option for patients with severe mitral regurgitation who are at high surgical risk. However, clinical outcomes after TEER remain heterogeneous and are influenced not only by cardiac parameters but also by systemic comorbidities and multiorgan dysfunction. The albumin-bilirubin (ALBI) score, derived from serum albumin and bilirubin levels, has recently been proposed as a simple marker of hepatic dysfunction and cardio-hepatic interaction. This study aimed to evaluate the prognostic value of baseline ALBI score in predicting long-term mortality after TEER. Materials and Methods: In this single-center retrospective cohort study, 106 consecutive patients with symptomatic moderate-to-severe or severe mitral regurgitation who underwent TEER between January 2019 and December 2025 were included. Baseline ALBI score was calculated using pre-procedural serum albumin and bilirubin levels. Cox proportional hazards regression analysis was used to identify predictors of long-term mortality. Variable selection was performed using least absolute shrinkage and selection operator (LASSO) regression, followed by ridge-penalized multivariable Cox modeling to minimize overfitting. The incremental prognostic value of ALBI was assessed using concordance index (C-index) comparison between predictive models. Receiver operating characteristic (ROC) analysis and Kaplan-Meier survival analysis were also performed. Results: During a median follow-up of 17.9 months, 30 patients (28.3%) died. Higher baseline ALBI scores were significantly associated with increased mortality risk. In multivariable analysis, ALBI score (HR 3.35, 95% CI 1.46-7.71; p = 0.004), left atrial volume index (LAVI) (HR 1.02, 95% CI 1.01-1.03; p = 0.005), and log-transformed B-type natriuretic peptide (BNP) (HR 1.37, 95% CI 1.02-1.86; p = 0.039) remained independent predictors of mortality. Addition of the ALBI score improved model discrimination, increasing the C-index from 0.845 to 0.886. ROC analysis demonstrated good predictive performance of the ALBI score (area under the curve [AUC] = 0.877), with an optimal cut-off value of -1.67. Conclusions: Baseline ALBI score is independently associated with long-term mortality after TEER and may provide potential incremental prognostic information. However, the observed improvement is modest and should be interpreted cautiously. These findings support a potential role of ALBI as a complementary marker, which requires validation in larger prospective studies.

Meta-Analysis of Transcatheter Versus Surgical Aortic Valve Replacement in Low Surgical Risk Patients: An Update.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly considered as an alternative to surgical aortic valve replacement (SAVR) for low-risk patients with aortic stenosis. However, its long-term efficacy remains uncertain. OBJECTIVE: To compare clinical outcomes and procedural complications of TAVR versus SAVR in low-risk patients with aortic stenosis. METHODS: We updated our 2019 systematic review by searching MEDLINE, EMBASE, and Cochrane Central (May 2019-April 2025) for randomized controlled trials (RCTs) comparing TAVR and SAVR in low-risk patients with aortic stenosis. We extracted outcomes at 30 days, 12 months, and ≥ 5 year follow-up. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated using random-effects models. Risk of bias was assessed using the Cochrane Risk of Bias (RoB) 2 tool. RESULTS: Five RCTs (n=4,532) were included. TAVR reduced 30-day all-cause mortality (RR: 0.45, 95% CI: 0.37-0.55), cardiovascular mortality (RR: 0.45, 95% CI: 0.38-0.54), atrial fibrillation (RR: 0.21, 95% CI: 0.10-0.41), and life-threatening bleeding (RR: 0.28, 95% CI: 0.13-0.58), but increased pacemaker implantation (RR: 3.10, 95% CI: 1.23-7.82). Mortality benefits persisted at 12 months. At ≥ 5 years, results were inconclusive due to wide CIs across outcomes, including all-cause death (RR: 0.99, 95% CI: 0.72-1.35), cardiovascular death (RR: 0.93, 95% CI: 0.64-1.35), atrial fibrillation (RR: 0.44, 95% CI: 0.16-1.22), endocarditis (RR: 0.70, 95% CI: 0.33-1.45) and aortic reintervention (RR: 1.21, 95% CI: 0.59-2.49). CONCLUSIONS: TAVR shows early clinical benefits in low-risk patients with aortic stenosis, but long-term outcomes compared to SAVR remain uncertain. Individualized heart team decision-making remains essential.

Current and Emerging Treatments for Isolated Aortic Stenosis and Concomitant Mitral Stenosis: A Comprehensive Narrative Review.

Aortic stenosis (AS) and mitral stenosis (MS) are progressive valvular heart diseases associated with substantial morbidity and mortality once symptoms develop. Over the past decade, the management of isolated AS has undergone profound evolution, driven by refinements in surgical aortic valve replacement, the adoption of minimally invasive techniques, and the rapid expansion of transcatheter aortic valve replacement across all surgical risk categories. In contrast, patients with concomitant AS and MS represent a complex and understudied population, frequently excluded from randomized trials and only marginally addressed in contemporary clinical practice guidelines. The management requires individualized guideline-directed decision-making led by a multidisciplinary Heart Team. The paucity of high-quality data in combined AS-MS underscores the need for dedicated prospective studies and international registries. The aim of this narrative review is to describe current strategies to treat AS both when isolated and concomitant with MS. We also discuss the need for updated, specific guidelines.

The Legacy of the First Valve: Outcomes of Redo Surgical Aortic Valve Replacement After Prior Transcatheter Versus Prior Surgical Aortic Valve Replacement-A Narrative Review.

Transcatheter Aortic Valve Replacement (TAVR) has transformed aortic stenosis management across the full risk spectrum, but expansion into younger populations makes valve failure and reintervention central to lifetime planning. There are two pathways to follow when TAVR fails: redo transcatheter implantation and surgical explantation with surgical aortic valve replacement (SAVR), termed TAVR-SAVR. This narrative review synthesizes evidence from four studies (35,677 patients, 2011-2024) examining the association between prior valve type and redo SAVR outcomes versus redo SAVR after prior surgical prosthesis (SAVR-SAVR). TAVR-SAVR volume grew at up to 144.6% annually, projected to surpass SAVR-SAVR by approximately 2029 based on linear extrapolation from limited registry and single-center data. Operative mortality was 12.3-17% in TAVR-SAVR versus 1.1-9% in SAVR-SAVR, persisting after propensity matching in both comparative studies (11.3% vs. 6.7%, OR 1.7; and 12.0% vs. 1.1%, OR 12.5). Observed-to-expected mortality ratios exceeded 1.0 across all risk strata, including low-risk patients (O/E up to 5.48), while SAVR-SAVR demonstrated a remarkably low ratio of 0.22-0.33. Renal failure, failure to rescue, and prolonged ventilation were significantly higher following TAVR-SAVR; stroke and pacemaker rates were comparable. Paradoxically, shorter bypass and cross-clamp times in TAVR-SAVR despite worse outcomes are consistent with cumulative organ injury, rather than operative complexity, as a predominant contributor to excess mortality, though this mechanistic explanation remains hypothetical. STS risk models, developed for standard surgical populations, showed limited applicability in this population, with observed mortality consistently exceeding predicted values. These findings raise important considerations regarding TAVR-first strategies in operable patients aged 65-80 years, although causality cannot be established from observational data alone. In the era of expanding TAVR indications, the legacy of the first valve cannot be ignored.

Change in Frailty After Transcatheter and Surgical Aortic Valve Replacement for Aortic Stenosis-A Systematic Review and Meta-Analysis.

BACKGROUND: Frailty is common among patients awaiting intervention for aortic stenosis (AS) by transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). Although the association between pre-procedure frailty and poor outcomes is well-established, it remains unclear whether aortic valve interventions can lead to changes in frailty. METHODS: Ovid MEDLINE, SCOPUS, CINAHL and Cochrane databases were searched for studies that reported frailty assessments before and after TAVI and/or SAVR. Data from these studies were used to calculate a standardised score for change in frailty following either TAVI or SAVR, as part of a pooled random effects meta-analysis, with Hedges' adjusted g value. RESULTS: Of 4,093 records screened, nine relevant studies were identified. Among 1,598 TAVI and 200 SAVR patients, no overall changes to frailty were observed, although there was considerable heterogeneity among studies. Improvements to frailty were observed in a sensitivity analysis of lower-risk TAVI cohorts (Society of Thoracic Surgeons predicted risk of mortality [STS-PROM] ≤5%). Higher-risk TAVI and SAVR cohorts (STS-PROM >5%) did not show improvements in frailty post-aortic valve intervention. CONCLUSIONS: Overall, neither TAVI nor SAVR leads to significant changes in frailty measurements, although data are highly heterogeneous. Further research into the possible role of additional frailty interventions, particularly in higher-risk patients with AS undergoing TAVI or SAVR, should be considered.

Severe Low Flow Aortic Stenosis with Preserved Ejection Fraction: Latest Diagnostic and Therapeutic Approach.

Paradoxical low-flow, low-gradient aortic stenosis (pLF-LG AS) represents a distinct phenotype of severe aortic stenosis characterized by a reduced aortic valve area with low transvalvular gradients despite preserved left ventricular ejection fraction and reduced forward flow. It is associated with concentric remodeling, impaired longitudinal systolic function, and diastolic dysfunction, resulting in reduced stroke volume and potential underestimation of disease severity. This state-of-the-art review synthesizes evidence from registries, observational studies, randomized trial subgroup analyses, guideline recommendations, and mechanistic investigations. Diagnosis requires an integrative multimodality approach combining Doppler echocardiography, low-dose dobutamine stress echocardiography, and computed tomography-based aortic valve calcium scoring to differentiate true-severe from pseudo-severe disease. In symptomatic patients with confirmed severe pLF-LG AS, aortic valve replacement is associated with improved survival, although the magnitude of clinical benefit remains variable. Transcatheter aortic valve implantation represents an effective treatment option in selected patients; however, phenotype-specific comparative data versus surgical valve replacement remain limited. Overall, pLF-LG AS requires accurate diagnostic confirmation and individualized, Heart Team-guided management to optimize clinical outcomes.

Impact of angiographic valve expansion on the hemodynamic outcome in valve-in-valve transcatheter aortic valve replacement.

BACKGROUND: The durability of surgical aortic valve replacement prostheses can be limited due to structural valve deterioration over the years. Because of increased patient age and surgical risk, many of these patients are treated with valve-in-valve transcatheter aortic valve replacement (TAVR). Full expansion of the valve is often difficult to achieve in these patients, which might negatively affect the hemodynamic outcome. AIM: The aim was to investigate whether incomplete expansion of valve-in-valve TAVR correlates with an unfavorable hemodynamic outcome. METHODS: A retrospective monocentric study with 152 patients who received a valve-in-valve TAVR between 2014 and 2024 at the University Heart Centre Freiburg-Bad Krozingen, Germany, was performed. The expansion and implantation depth of the TAVR prostheses were measured in the angiographic recordings and correlated with the postinterventional hemodynamic outcome. RESULTS: 69.7% of the patients received self-expanding and 28.9% balloon-expandable TAVR prostheses during the valve-in-valve procedure. Under-expansion in the waist area of self-expanding valve prosthesis was associated with increased postinterventional mean pressure gradients. Post-dilation significantly improved the waist expansion in self-expanding valve prostheses (median increase 7.8%, p < 0.0001). Further, a correlation between implantation depth and waist expansion was observed in self-expanding valves (Spearman r - 0.4481, p < 0.0001), but not in balloon-expandable valves. CONCLUSION: Under-expansion of the waist area of self-expanding valve-in-valve TAVR was associated with an unfavorable hemodynamic outcome. A periinterventional measurement of the angiographic images after valve release might be useful to assess a relevant under-expansion and to assist in the indication for post-dilation. CLINICAL TRIALS REGISTER: The study has been registered in the German Clinical Trials Register (DRKS-ID: DRKS00029242), date: 27/03/2023.

Valve-in-Valve Transcatheter Mitral Valve Replacement Versus Redo Surgical Mitral Valve Replacement: Meta-Analysis of Early and Late Outcomes.

BACKGROUND: Bioprosthetic mitral valve degeneration is traditionally treated with redo surgical mitral valve replacement (redo-SMVR), but valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) offers a less invasive alternative. METHODS: Systematic review and meta-analysis of studies comparing ViV-TMVR and redo-SMVR. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane databases (inception to September 2025) were searched. Meta-analyses were conducted with random-effects models to assess patient-relevant outcomes; Kaplan-Meier-derived time-to-event data were pooled to assess late outcomes. RESULTS: Thirteen observational studies met our eligibility criteria, including 15 941 patients (ViV-TMVR: 5465; redo-SMVR: 10476). In comparison with redo-SMVR, ViV-TMVR was associated with lower risk of in-hospital mortality (risk ratio [RR], 0.72 [95% CI, 0.57-0.90]; P=0.004), stroke (RR, 0.49 [95% CI, 0.29-0.83]; P=0.008), bleeding (RR, 0.43 [95% CI, 0.20-0.94]; P=0.035), acute kidney injury (RR, 0.57 [95% CI, 0.42-0.77]; P<0.001), permanent pacemaker implantation (RR, 0.30 [95% CI, 0.19-0.49]; P<0.001), and shorter hospital length of stay (mean difference,-5.09 days [95% CI, -6.56 to -3.63]; P<0.001). There was no statistically significant difference between the groups in terms of 5-year survival (hazard ratio [HR], 0.92 [95% CI, 0.81-1.05]; P=0.256); however, the landmark analysis revealed that ViV-TMVR was associated with lower risk of death in the initial 6 months (HR, 0.69 [95% CI, 0.58-0.83]; P<0.001) but a higher risk beyond 6 months (HR, 1.47 [95% CI, 1.20-1.79]; P<0.001). CONCLUSIONS: In patients amenable to ViV-TMVR, this procedure shows a lower initial risk of death and complications, but higher mortality after 6 months in comparison with redo-SMVR. These findings highlight the importance of striking a balance between upfront surgical risk and estimated life expectancy when selecting interventions.

Determinants and outcomes of transcatheter aortic valve implantation and surgical aortic valve replacement in patients under 75 with prior cardiac surgery: insights from the Netherlands Heart Registration.

BACKGROUND: A history of prior cardiac surgery (PCS) determines treatment decision and long-term outcomes in patients requiring aortic valve replacement. This study examined patient profiles, treatment-decisions and long-term outcomes of patients under 75 years with PCS undergoing transcatheter and surgical aortic valve implantation/replacement (TAVI, SAVR) in the Netherlands. METHODS: Data from 1,284 patients (ages 50-75 years) with PCS undergoing TAVI or SAVR between 2015 and 2020 were analyzed using data from the Netherlands Heart Registration. Logistic and cox regression identified determinants of treatment selection and long-term mortality. Determinants were considered impactful if they had an odds ratio (OR) or hazard ratio (HR) of ≥ 1.5 or ≤ 0.7 and a prevalence of ≥ 5%. RESULTS: Of 1,284 patients, 690 underwent TAVI (54%) and 594 SAVR (46%). Prior index surgery most frequently involved coronary artery bypass grafting (CABG) (57% in the TAVI group vs 40% in the SAVR group; p < 0.001) and previous aortic valve surgery (25% vs 51%; p < 0.001). TAVI patients were significantly older (median 71 vs. 67 years, p < 0.001) and had a higher EuroSCORE II (median 5.7 vs. 4.4, p = 0.003) than SAVR patients. SAVR was the preferred strategy for intermediate-risk patients (62%), while TAVI was favored in high- and prohibitive-risk patients (62% and 94%, respectively). In descending order of odds ratio, the strongest independent determinants of TAVI selection were left ventricular ejection fraction ≤ 30% ((OR: 4.8; 95% CI: 2.6-8.8), poor mobility ((OR: 3.4; 95% CI: 1.6-7.0) and obesity/cachexia (OR 2.7; 95% CI: 1.6-4.4); the key determinants of SAVR selection were pure native aortic regurgitation (OR: 0.1; 95% CI: 0.1-0.3) and failing surgical bioprosthesis (OR: 0.7; 95% CI: 0.5-1.0. Thirty-day, 1- and 5 year survival after TAVI and SAVR was 97% and 96%, 83% and 91%, and 56% and 83%, respectively (p-value < 0.001). Left ventricular ejection fraction ≤ 30% and chronic lung disease were important mortality determinants for both procedures, with higher odds ratios for mortality in SAVR as compared to in TAVI patients. CONCLUSIONS: In the Netherlands, TAVI and SAVR rates were comparable among patients < 75 years with PCS. Higher-risk patients were directed toward TAVI except for those presenting with pure native aortic regurgitation and bioprosthesis failure who mainly received SAVR. Severe left ventricular dysfunction and chronic lung disease were key mortality predictors for both procedures.

The Evolution of Transcatheter Aortic Valve Replacement: From Novel to Normal.

Over the past decade, transcatheter aortic valve replacement (TAVR) has become a transformative intervention for patients with aortic stenosis (AS). With a minimally invasive approach, TAVR reduces overall risks to the patient compared to the traditional surgical aortic valve replacement. Improvements in technology, training, and access to registered TAVR-designated sites, as well as the high success rate of the procedure, have turned TAVR from a novel approach into the preferred, first-line treatment for patients with AS. The purpose of this review article is to educate RNs and advanced practice RNs (APRNs, including NPs, clinical nurse specialists, anesthetists, and midwives) on the current evidence-based approaches to evaluation, diagnosis, and management of AS before and after TAVR, as well as the evolving role of TAVR in the treatment of AS. Given that TAVR has become the mainstay of treatment for AS, there is a need for RNs and APRNs to be experts in the evidence-based practice guidelines for evaluation, diagnosis, and treatment of this potentially deadly disease.

The impact of frailty on postoperative complications and resource utilization in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).

Patients with severe aortic stenosis undergoing transcatheter aortic valve implantation are usually older adults with multiple comorbidities and often frail. Frailty reflects increased vulnerability to adverse outcomes and is an important factor in this population; however, its impact on postoperative complications and healthcare resource utilization remains uncertain. We investigated the association between preoperative frailty and postoperative outcomes using a nationwide electronic medical records database in Japan. We included patients aged 65 years or older who underwent transcatheter aortic valve implantation between April 2013 and December 2021. Frailty was assessed with the Hospital Frailty Risk Score, with a score of 5 or higher indicating frailty. The primary outcome was acute kidney injury within seven days. Secondary outcomes included major adverse kidney events, blood transfusion within 30 days, and hospital length of stay. Among 781 patients, 237 (30.3%) were classified as frail. Acute kidney injury occurred in 8.8% of non-frail and 12.7% of frail patients. After adjustment for age, sex, comorbidities, baseline estimated glomerular filtration rate, surgical approach, anesthesia type, and hospital size, the odds ratio for acute kidney injury in frail patients was 1.42 (95% confidence interval, 0.83-2.45; P = 0.20). Hospital stay was significantly longer in frail patients, with an adjusted mean difference of 3.45 days. Preoperative frailty was not significantly associated with acute kidney injury or other complications but was associated with prolonged hospitalization. Frailty screening before transcatheter aortic valve implantation may help identify patients at risk of extended hospital stay and guide perioperative care.

Severe Iatrogenic Tricuspid Regurgitation.

Tricuspid regurgitation (TR) is a valvular heart disease mostly associated with structural heart disease or pulmonary hypertension (PH). Rare cases of TR secondary to exposure to specific medications, such as dopamine agonists, have been described. A 50-year-old woman presented with a pituitary microprolactinoma (without surgical indication) and a history of pulmonary embolism (PE) in 2021 (risk factors included bromocriptine, which was switched to cabergoline). An echocardiogram performed one year after the PE showed no significant abnormalities. She was maintained on rivaroxaban 10 mg due to suspected chronic PE on CT angiography. She remained asymptomatic until April 2023, when she developed predominantly right-sided heart failure with dyspnoea, peripheral oedema, and ascites. She was admitted for intravenous diuretic therapy and investigation of PH, with mild symptomatic improvement. Diagnostic work-up revealed right chamber dilatation and severe TR due to annular dilatation with tethering of the subvalvular apparatus and thickened leaflets on transthoracic echocardiography, confirmed by transoesophageal echocardiography and cardiac magnetic resonance imaging. Ventilation-perfusion scintigraphy excluded chronic PE, and right heart catheterisation ruled out PH. After exclusion of alternative causes of severe TR and considering the valvular morphology and exposure to cabergoline, the drug was discontinued. Due to persistent NYHA class II heart failure symptoms, the patient underwent tricuspid valvuloplasty via minithoracotomy and has remained asymptomatic since. This case describes new-onset severe TR with right-sided heart failure in the absence of PH or chronic PE. Withdrawal of cabergoline and optimisation of volume resulted in modest clinical improvement, followed by surgical intervention with full functional recovery. This case highlights the importance of regular clinical and echocardiographic surveillance in patients receiving long-term dopamine agonist therapy, particularly cabergoline, due to the risk of valvulopathy, enabling early diagnosis and timely therapeutic intervention.

Technological Innovations and Research Frontiers in Interventional Therapy for Mitral Regurgitation.

Mitral regurgitation (MR) is a common valvular heart diseasewhose prevalence continues to increase with population aging, posing a serious threat to human health in the advanced stages of the disease. Sole reliance on medication and traditional surgical treatments can no longer meet the therapeutic needs of all patients. Transcatheter interventional therapy is gradually emerging as a promising new treatment option. Recently, technologies for the transcatheter interventional treatment of MR have advanced rapidly, with expanding indications and a continuous stream of new devices. The field has entered a phase of accelerated development in the treatment of structural heart disease, demonstrating broad clinical prospects. This article reviews the key technologies and developmental trends in the current transcatheter interventional treatments for MR, aiming to provide a theoretical basis and rationale for the safe and standardized implementation and broader adoption of these technologies.

Contemporary Transcatheter Approaches to Mitral Regurgitation.

Mitral regurgitation (MR) is a prevalent and prognostically relevant valvular disease, especially in patients with heart failure, in whom MR contributes to adverse remodeling, increased symptom burden, and higher mortality. Surgical repair or replacement remains the standard of care for suitable candidates, but many patients are excluded because of advanced age, comorbidities, or high surgical risk. Transcatheter methods have emerged as transformative alternatives, including mitral transcatheter edge-to-edge repair (MTEER) with devices such as MitraClip and PASCAL, annuloplasty-based devices such as Carillon and Cardioband, and transcatheter mitral valve replacement (TMVR) with devices such as Tendyne, Intrepid, and others under development. Data from randomized trials and registries have established that MTEER lowers hospital readmission rates and improves mortality in carefully selected secondary MR subjects, and that device upgrades improve procedural success and anatomical versatility. Annuloplasty provides targeted repair for functional MR with annular dilation, whereas TMVR offers an alternative for anatomically complex cases or those ineligible for MTEER, albeit with distinct procedural risks. Management of severe mitral annular calcification remains difficult and demands meticulous pre-procedural planning and customized device strategies. Careful patient selection based on MR etiology, proportionality, ventricular function, and anatomical suitability is essential for optimizing outcomes in this rapidly evolving field.

Transcatheter Aortic Valve Replacement for Severe Aortic Regurgitation in a Young Adult With Takayasu Arteritis: A Case Report.

Takayasu arteritis (TAK) is a rare large-vessel vasculitis that can cause severe aortic regurgitation (AR) and heart failure in young adults. While surgical aortic valve replacement remains the standard treatment, transcatheter aortic valve replacement (TAVR) has emerged as a viable alternative in high-risk patients. We present the case of a 23-year-old woman with juvenile idiopathic arthritis (JIA) and TAK who developed refractory heart failure secondary to severe AR. Initial echocardiography revealed a left ventricular ejection fraction (LVEF) of 40%. Given active vasculitis, prohibitive surgical risk, and acute decompensation despite medical therapy, emergent TAVR was performed. The patient demonstrated remarkable clinical improvement with LVEF normalization to 56% at one-year follow-up. This case illustrates that TAVR can be successfully performed for severe AR in young adults with TAK when surgical risk is prohibitive, emphasizing the importance of aggressive perioperative inflammation control, multidisciplinary care, and individualized treatment strategies in vasculitis-associated valvular disease.

Multicenter Evaluation of an Edge-to-Edge Repair System in High-Risk Patients With Degenerative Mitral Regurgitation.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) has become an effective alternative for treating degenerative mitral regurgitation (DMR) in patients at high surgical risk. The SQ-Kyrin-M TEER system (SQ-Kyrin-M system) is a novel TEER device developed in China. This study aimed to evaluate the feasibility, safety, and 12-month clinical efficacy of the SQ-Kyrin-M system in patients with high-risk degenerative mitral regurgitation. METHODS: In this prospective, multicenter, single-arm study (ClinicalTrials.gov: NCT06467110), 120 patients with symptomatic DMR (grade ≥3+) had the device implanted. The primary endpoint was the clinical success rate at 12 months. Secondary endpoints included technical, device, and procedural success rate; New York Heart Association (NYHA) class improvement; Kansas City Cardiomyopathy Questionnaire (KCCQ) score change; and mitral regurgitation (MR) reduction. Safety endpoints encompassed all-cause mortality, cardiovascular mortality, and major adverse event rate. RESULTS: A total of 120 patients received the TEER procedure across 25 participating sites in China; the mean age was 71.9 years, and the mean Society of Thoracic Surgeons (STS) risk score was 9.3. At 12 months, the Kaplan-Meier estimates were 82.5% for clinical success, 7.6% for all-cause mortality, and 10.8% for major adverse events; MR ≤2+ and MR ≤1+ were achieved in 91.7 and 70.4% of the patients, respectively; 88.9% of patients were in NYHA class I or II; and KCCQ score had improved by 18.9 points. Favorable left ventricular remodeling was observed with sustained reductions in left ventricular end-diastolic and end-systolic volumes. CONCLUSIONS: This study demonstrates that the SQ-Kyrin-M system is a safe and effective therapeutic option for DMR patients.

Transcatheter and surgical management of tricuspid valve disease: multidisciplinary lifetime management considerations.

Tricuspid valve disease (TVD) has long been underrecognized compared with left-sided valvular disorders, yet it represents a major determinant of cardiovascular morbidity and mortality. Tricuspid regurgitation (TR), the predominant manifestation of TVD, is being recognized with increasing frequency as populations age and the burden of left-sided heart disease rises. While mild TR is often physiological, moderate and severe TR are associated with adverse outcomes, independent of left ventricular function or pulmonary pressures. Secondary TR, driven by right atrial or right ventricular remodeling, constitutes the majority of cases, whereas primary TR due to intrinsic valvular pathology is less frequent. Cardiac implantable electronic device (CIED)-related TR represents a distinct and increasingly prevalent mechanism that often requires dedicated management considerations. Historically, management of TVD has often been delayed until the onset of advanced right heart failure or end-organ dysfunction, resulting in poor outcomes. Contemporary evidence emphasizes the importance of early recognition, precise etiologic characterization, and timely intervention within a multidisciplinary framework. Surgical repair, particularly annuloplasty, remains the reference standard in suitable candidates, offering durable results when performed before irreversible right ventricular remodeling develops. Transcatheter tricuspid valve interventions have expanded therapeutic options for high-risk or inoperable patients, demonstrating symptomatic and hemodynamic improvement in early studies. Optimal management of TVD follows a lifetime approach, integrating multimodality imaging, risk stratification, and individualized treatment strategies. General physicians and cardiologists play a key role in early detection, while coordinated collaboration among imaging specialists, electrophysiologists, heart failure experts, interventional cardiologists, cardiac surgeons, and anesthesiologists is essential for comprehensive care. Ultimately, a patient-centered lifetime management strategy initiated early and adapted to disease progression offers the best opportunity to preserve right heart function, improve survival, and maintain quality of life in patients with TVD.

How to mirror tricuspid transcatheter edge-to-edge repair (TEER) to mitral TEER in terms of procedural imaging and device workflow: a step-by-step primer.

Transcatheter edge-to-edge repair (TEER) has emerged as a pivotal therapy for mitral and tricuspid regurgitation in patients at high surgical risk. Although anatomical similarities between the mitral and tricuspid valves have allowed the use of the same clip delivery system (CDS) for both procedures, important anatomical differences and imaging challenges necessitate distinct procedural strategies. In this keynote lecture, we compare the technical aspects and imaging guidance of mitral and tricuspid TEER and highlight key maneuvers that optimize procedural success and safety. We focus on the Abbott MitraClip and TriClip systems given both are Food and Drug Administration (FDA) approved in the United States and we have extensive experience with both systems. This stepwise procedural review outlines the nuances of CDS manipulation in both mitral and tricuspid TEER, emphasizing directional response, trajectory optimization, clip alignment, leaflet grasping, and deployment techniques. Differences in imaging requirements and catheter steering are addressed with reference to transesophageal echocardiography (TEE), intracardiac echocardiography (ICE), and fluoroscopic landmarks. CDS flexion and advancement from the atrium to the valve follow similar principles in both TEER procedures; however, CDS rotation produces opposite directional effects relative to the septum. In mitral TEER, the CDS is steered from lateral to medial, whereas in tricuspid TEER, it is directed from septal to lateral. Using the Abbott MitraClip system, trajectory and orientation adjustments rely primarily on the M and + knobs for mitral TEER, and on the F and S/L knobs for tricuspid TEER. ICE serves as a critical adjunct to TEE in tricuspid TEER due to limited acoustic windows. Grasp optimization involves leaflet-specific torque and individual gripper manipulation. Mitral and tricuspid TEER require distinct navigation strategies and imaging approaches, but can be standardized and mirrored in parallel for better understanding between both procedures. Mastery of these valve-specific techniques, along with continued innovation in imaging and CDS design, will be essential to improving the safety and efficacy of tricuspid TEER.

Cardiac Surgery 2025 Reviewed.

For the 12th consecutive time, we systematically reviewed the cardio-surgical literature for the past year, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach for a results-oriented summary. In 2025, the discussion on the value of randomized and observational evidence continued, showing converging results in the treatment of coronary artery disease and further diverging results in the field of invasive aortic valve therapies. Across randomized trials, meta-analyses, and registries, coronary artery bypass grafting (CABG) consistently provides superior long-term outcomes compared with percutaneous coronary intervention in complex coronary artery disease, driven primarily by sustained reductions in future myocardial infarctions. In addition, atrial fibrillation after CABG was shown to be more frequent than expected, but its long-term burden was negligible, while prolonged dual antiplatelet therapy after CABG for acute coronary syndrome offered no benefit but increased bleeding risk. The "valve treatment arena" in 2025 was heavily affected by the new guidelines, which clarified many aspects in mitral and tricuspid valve treatment but generated great controversy for aortic stenosis treatment. The latter was based on a reduction of the age cut-off for transcatheter aortic valve implantation to 70 years (unsupported by new data) and the selective reliance on only randomized studies (despite contradictory risk-adjusted registry evidence). Across mitral and tricuspid valve disease, publications showed improvements in symptoms and quality of life without survival benefits with transcatheter therapies and the most consistent long-term outcomes with surgery, particularly when appropriately timed and performed in experienced centers. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation, but it provides up-to-date information for patient-specific decision-making.

Medical therapies to prevent the development and progression of calcific aortic valve stenosis: a contemporary review.

INTRODUCTION: Aortic stenosis (AS), the leading cause of valvular heart disease related mortality, affects 12% of individuals over 75 years and is set to expand as the population ages. Once symptoms develop, severe symptomatic AS carries an average survival of approximately two years. The only management currently available is aortic valve replacement (AVR), either surgically or via transcatheter aortic valve implantation, but this addresses only the end stage of the disease process which is often associated with irreversible myocardial remodeling. There are currently no pharmacotherapies proven to treat AS. The development of this condition is an active pathophysiological process which involves complex metabolic signaling cascades providing myriad potential therapeutic targets. AREAS COVERED: This review looks at recent and ongoing clinical trials of novel pharmacotherapies for AS, including lipid lowering therapy, nitrous oxide pathway targeting, vitamin K supplementation, renin-angiotensin-aldosterone system blockade, repurposing diabetic pharmacotherapies, colchicine, and transthyretin stabilizers. EXPERT OPINION: AS is an active, pathological disease which should be amenable to pharmacological modulation. A wide spectrum of pharmacotherapeutic agents are currently being investigated and the authors of this review are optimistic that we might be on the cusp of a breakthrough.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Symptomatic Severe Aortic Stenosis and Prior Mediastinal Radiation: A Meta-Analysis of Short-Term and 1-Year Outcomes.

Mediastinal radiation potentiates aortic stenosis and complicates its treatment. We compared the short and midterm-outcomes with transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with prior mediastinal radiation. Electronic databases were searched from inception through December 2024. Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes were pooled as mean differences (MDs) with respective 95% confidence intervals (CIs). Six observational studies were identified, including 2458 TAVR patients and 1873 SAVR patients. In the short-term, TAVR was associated with lower rate of mortality (RR: 0.54; 95% CI: 0.34-0.88), atrial fibrillation (RR: 0.31; 95% CI: 0.15-0.65), acute kidney injury (RR: 0.75; 95% CI: 0.59-0.95), bleeding (RR: 0.37, 95% CI: 0.33-0.42), and shorter length of hospital stay (MD: -4.30; 95% CI: -5.45 to -3.15). One-year mortality was comparable between the 2 groups (RR: 1.04; 95% CI: 0.50-2.13). This meta-analysis of observational studies of patients with prior mediastinal radiation demonstrated that TAVR was associated with better short-term outcomes compared to SAVR. While 1-year mortality appeared similar between the 2 interventions, this finding should be interpreted with caution. However, randomized controlled trials are needed to validate these findings.

Transcatheter and hybrid closure of muscular ventricular septal defects using the KONAR-MF™ occluder: a multicentre paediatric experience in India.

BACKGROUND: The KONAR-MF™ occluder, with its flexible medium-profile design, has broadened the feasibility of transcatheter closure of muscular ventricular septal defects, particularly in infants. OBJECTIVE: To assess feasibility, safety, techniques, and outcomes of muscular ventricular septal defect closure using the KONAR-MF™ occluder in a multicentre paediatric cohort. METHODS: A retrospective review was conducted at three tertiary paediatric cardiac centres (2018-2024). Patient demographics, ventricular septal defect characteristics, procedural approaches, and follow-up outcomes were analysed. Device implantation was performed via retrograde, antegrade, transseptal, or hybrid approaches under fluoroscopic and echocardiographic guidance. RESULTS: Fifty patients (54 devices) were included (median age: 48 months [interquartile range 12-96]; weight: 12 kg [interquartile range 7.5-23]), including 14 infants (9 < 7 kg). Indications were failure to thrive (46%), heart failure (28%), recurrent infections (12%), and postoperative residual ventricular septal defect (14%). The mean ventricular septal defect size was 5.8 ± 2 mm. Median fluoroscopy time was 18 minutes (range: 3-71). Residual shunts were present in 18% immediately, reducing to 9% at one week and resolving by three months. Mild, transient tricuspid regurgitation occurred in 14%. Over a median 9-month follow-up (range 1-60), no cases of heart block or haemolysis occurred. One embolisation required surgical retrieval. Pulmonary artery pressure decreased significantly (37 ± 13.4 to 19 ± 3.8 mmHg, p < 0.001). CONCLUSIONS: Transcatheter closure of muscular ventricular septal defects with the KONAR-MF™ occluder is safe, effective, and versatile across paediatric age groups, including infants and postoperative cases. High success rates, minimal complications, and favourable short- to mid-term outcomes support its use in routine practice.

Navigating Vascular Access Strategies for Transcatheter Aortic Valve Replacement in Patients With Peripheral Artery Disease: A Literature Review.

Transcatheter aortic valve replacement (TAVR) is the preferred treatment for severe aortic stenosis (AS) in high-risk surgical patients. The transfemoral (TF) access is the gold standard due to its minimally invasive nature and favorable outcomes. However, peripheral artery disease (PAD), common in TAVR candidates, can complicate TF access due to calcification, tortuosity, and vessel narrowing. This literature review evaluates vascular access strategies for TAVR in patients with PAD, highlighting recent advances that support expanded use of TF access. A narrative literature review was conducted in scientific databases up to 14 April 2025. Studies reporting on access strategies for TAVR in patients with PAD were included. The SANRA scale was utilized to ensure methodological quality. TF access remains the preferred route for TAVR, associated with lower mortality and complication rates compared to alternative approaches. Tools like the Hostile Score has further strengthened pre-procedural planning by quantifying iliofemoral complexity and helping clinicians determine the safest and most feasible access route. Advances in technology have enhanced TF feasibility in patients with PAD, enabling device delivery despite complex anatomy. When TF access is not viable, alternative routes remain feasible but are linked to increased risks, including stroke and vascular complications. Expanding the eligibility for TF access through vessel preparation and imaging-guided planning can improve safety and outcomes in PAD patients undergoing TAVR. A personalized approach based on anatomy feasibility, supported with risk stratification tools and multidisciplinary collaboration is essential to selecting the optimal vascular access strategy.

Image-Based Medical Navigation Systems for Cardiac Interventions: Recent Technological Advances.

BACKGROUND: The application of catheter-based treatments for a growing range of structural heart diseases (SHD) has significantly increased over the past five years, driven by technological advances in medical navigation systems, particularly those based on medical imaging. Multimodal cardiac imaging plays a crucial role in these systems by combining complementary anatomical, morphological, and functional information, thereby increasing diagnostic accuracy and improving the effectiveness of cardiovascular interventions and clinical outcomes. However, multimodal imaging poses challenges, including intermodality misalignment and the need to determine optimal integration methods for data from different imaging modalities. METHODS: This article reviews the state-of-the-art image-based medical navigation systems used in catheter-based cardiac procedures. The review covers the period from 2019 to 2023 and includes a total of 44 articles. The methodologies in these studies are grouped into six main categories: Image Enhancement and Tracking, Image Fusion and Reconstruction, 3D Modeling/Printing, Extended Reality, and Artificial Intelligence (AI). RESULTS: Most studies involve multimodality imaging, combining or transferring information across different modalities. The review emphasizes that current multimodal imaging techniques enhance the accuracy of procedures such as left atrial appendage closure (LAAC), transcatheter aortic valve implantation (TAVI), and catheter ablation therapy. These techniques rely on combinations of imaging modalities such as fluoroscopy, ultrasound, and computed tomography (CT) to enable real-time guidance and precise navigation during minimally invasive interventions. CONCLUSION: By integrating data from multiple sources, these systems improve diagnostic reliability and procedural success, meeting the complex demands of SHD treatment. Despite advances, real-time surgical guidance remains a major challenge, underscoring the need for continued research in this area.

Automated Alerts to Improve Timely Evaluation and Treatment of Valvular Heart Disease: The ALERT Trial.

BACKGROUND: Severe aortic stenosis (AS) and mitral regurgitation (MR) are frequently undertreated and characterized by persistent sex, racial and ethnic, socioeconomic, and geographic disparities despite effective valve therapies. Whether automated electronic clinician notification (ECN) alerts improve the evaluation and treatment of AS and MR across health systems is unknown. OBJECTIVES: The purpose of this study was to evaluate whether ECN alerts improve guideline-directed evaluation and treatment of significant AS and MR across multiple health systems. METHODS: ALERT is a multisystem, cluster-randomized clinical trial including clinicians ordering echocardiograms across 5 U.S. health systems encompassing 35 hospitals between August 2024 and September 2025. Clinicians were randomized 1:1 to receive an ECN alert identifying significant AS or MR with accompanying care recommendations or to no alert with usual care. The primary endpoint was a hierarchical composite of time to surgical or transcatheter valve intervention, followed by time to multidisciplinary heart team clinic evaluation within 90 days, analyzed using the stratified win-ratio method. Secondary outcomes included individual components of the composite. RESULTS: A total of 765 clinicians ordering 2,016 echocardiograms were included. In the win-ratio analysis of the primary endpoint, ECN alert was superior to usual care (win ratio: 1.27; 95% CI: 1.05-1.54; P = 0.007), including higher rates of valve intervention (13.4% vs 9.6%; P = 0.005) and multidisciplinary heart team evaluation (22.7% vs 17.9%; P = 0.005) and shorter times to both endpoint components. Effect sizes were similar in AS (win ratio: 1.29) and MR patients (win ratio: 1.23). No evidence of heterogeneity was noted by valve pathology (Pint = 0.821) or across prespecified subgroups (age, sex, race, social deprivation index, inpatient vs outpatient setting, provider specialty, and rurality; Pint > 0.100 for all) and sensitivity analyses yielded consistent results across modified intention-to-treat, intention-to-treat, and per-protocol populations. CONCLUSIONS: In this multisystem cluster randomized trial, automated ECN alerts improved timely guideline-directed evaluation and valve intervention for clinically significant AS and MR. These findings suggest that electronic health record-integrated clinical decision support may represent a scalable strategy to reduce undertreatment and improve access to specialized valve care. (Addressing Under-treatment and Health Equity in AS and MR Using an Integrated EHR Platform; NCT06099665).

ADAPTING INTERVENTIONAL ECHOCARDIOGRAPHY TO NEW TECHNIQUES: ECHOCARDIOGRAPHIC GUIDANCE FOR TRANSCATHETER MYOTOMY USING SEPTAL SCORING ALONG THE MIDLINE ENDOCARDIUM (SESAME).

Septal Scoring Along the Midline Endocardium (SESAME) is a recently developed electrosurgical, percutaneous myotomy technique. It was designed to prevent iatrogenic left ventricular outflow tract (LVOT) obstruction following transcatheter mitral valve replacement (TMVR) in patients with prohibitive surgical risk. SESAME can also be used to reduce LVOT obstruction in cases of obstructive hypertrophic cardiomyopathy (oHCM). Based on over 200 SESAME procedures at three experienced centers, we present a best practice step-by-step echocardiography-guided approach, emphasizing key anatomical and procedural features. Given the complexity of the electrosurgical approach, protocol-driven imaging is essential to ensure procedural safety and optimize outcomes.

Angio-Seal plug-based versus dual ProGlide for transfemoral hemostasis in transcatheter aortic valve replacement: a systematic review and meta-analysis.

Transcatheter aortic valve replacement (TAVR) carries risks of vascular and bleeding complications. We aimed to study the effectiveness of Angio-Seal combined with Perclose ProGlide versus dual Perclose ProGlide following transfemoral TAVR. We searched PubMed, Cochrane Library, Scopus, and WOS from inception until November 2024 for studies comparing Parclose ProGlide with Angio-Seal versus dual Parclose ProGlide in transfemoral TAVR. The primary outcome was major vascular complications, while other secondary outcomes were bleeding complications, the need for additional vascular closure device (VCD), minor vascular complications, unplanned surgical intervention, mortality, hematoma, pseudoaneurysm, and dissection. Dichotomous outcomes were pooled and analyzed using odds ratio (OR) with 95% confidence interval (CI) via the DerSimonian-Laird random-effect model. Seven studies (two RCTs and five observational studies) comprising 1,766 patients were included. In RCT-only analyses, single Perclose ProGlide combined with Angio-Seal showed no significant difference compared with dual Perclose ProGlide in major vascular complications (OR = 0.54, 95% CI [0.28-1.04], P = 0.07) or major/life-threatening bleeding (OR = 0.66, 95% CI [0.25-1.74], P = 0.40). However, it significantly reduced the need for additional vascular closure devices (OR = 0.11, 95% CI [0.05-0.24], P < 0.01) and minor vascular complications (OR = 0.52, 95% CI [0.38-0.72], P < 0.01). For dual Perclose ProGlide combined with Angio-Seal, no RCTs were available; observational evidence suggested a reduction in major/life-threatening bleeding compared to dual Perclose ProGlide (OR = 0.43, 95% CI [0.21 to0.92], p = 0.03), while there was no significant difference between the two groups upon excluding Costa et al. (EuroIntervention, 17:728-735, 2021) (OR = 0.56, 95% CI [0.26 to 1.21], p = 0.14). Based on the available RCTs, the combination of single Perclose ProGlide with Angio-Seal during transfemoral TAVR significantly reduces the need for additional vascular closure devices. It may also reduce minor vascular complications, but this effect is not consistently robust. The pooled analysis of observational studies suggests a potential benefit of dual Perclose ProGlide combined with Angio-Seal for major/life-threatening bleeding. However, this finding was not robust in sensitivity analyses and no RCTs have evaluated this strategy.

Computed tomography (CT) planning for Redo-transcatheter aortic valve implantation (TAVI): a step-by-step approach and structured reporting.

The expansion of transcatheter aortic valve implantation (TAVI) indications to younger and lower-risk patients has led to an increasing incidence of late transcatheter valve failure. In this setting, redo-TAVI (TAV-in-TAV) has emerged as a less invasive alternative to surgical valve explantation, albeit with specific anatomical and technical challenges, particularly related to the risk of coronary obstruction. Computed tomography (CT) plays a pivotal role in preprocedural planning by enabling detailed characterisation of the index valve, identification of the failure mechanism, assessment of commissural and coronary alignment, accurate internal valve measurements, and definition of the neoskirt plane. This pictorial essay presents a step-by-step CT-based approach to redo-TAVI planning, illustrating the main implantation strategies and their relationship with the coronary risk plane. In addition, a structured reporting template is proposed to standardise CT interpretation and support multidisciplinary Heart Team decision-making.

Comparing mitral transcatheter edge-to-edge repair and surgical intervention in mitral regurgitation: A meta-analysis.

Surgery remains the standard treatment for severe mitral valve regurgitation (MR), but growing evidence highlights the potential role of mitral valve percutaneous edge-to-edge repair (M-TEER). This meta-analysis aims to compare 12-month all-cause mortality between M-TEER and surgical intervention (SMVI). A systematic search (October 2024) of PubMed, Cochrane, Scopus, and Web of Science identified randomized control trials (RCTs) and propensity-matched observational studies comparing 12-month all-cause mortality in MR patients treated with M-TEER or SMVI. An inverse variance random-effects meta-analysis assessed outcomes using risk ratios (RR) and 95% confidence intervals (CI). Two RCTs (MATTERHORN and EVEREST II) and three observational studies totaling 1,782 patients, were included in the final analysis. A non-significant trend of higher mortality at 30 days was observed in the SMVI group (RR: 0.72; CI: 0.26-2.00), along with higher complication rates mainly due to bleeding. At 12 months follow-up, SMVI was associated with a significantly lower risk of all-cause mortality (RR: 1.41; CI: 1.11-1.81), while the M-TEER group had more patients with MR grade 3 or higher (RR: 4.05; CI: 1.54-10.67), with a non-significant trend of higher rate of MR reintervention (RR 2.51; CI 0.83-7.66) at 12 months. Based on current evidence, M-TEER should continue to be reserved for patients with prohibitive high surgical risk. While propensity-matched cohorts were pooled for the study estimates, the limited available data from randomized trials, combined with heterogeneity in patient populations, particularly regarding MR etiology, underscores the need for further studies.

[Open Atrial Transcatheter Mitral Valve Replacement for Mitral Annular Calcification: First Case Report in Chile].

Severe mitral annular calcification represents a significant challenge for valve replacement, particularly in elderly patients with comorbidities, in whom conventional surgical approaches are associated with high morbidity and mortality. In such cases, percutaneous and minimally invasive transatrial approaches have emerged as therapeutic alternatives. The latter, unlike the former, allows direct visualization of the annulus, resection of the anterior leaflet, and more accurate prosthesis positioning, reducing malposition, embolization, paravalvular leak, and left ventricular outflow tract obstruction. We present the case of an 81-year-old woman with severe mitral stenosis and extensive annular calcification, who underwent transcatheter mitral valve replacement via open transatrial access. The surgical technique and postoperative course up to hospital discharge are described. This is the first reported case in Chile using this technique, providing evidence of its feasibility in patients with severe mitral annular calcification and high surgical risk.

Prognostic value of the hemoglobin-albumin-lymphocyte-platelet (HALP) score for long-term mortality after transcatheter aortic valve implantation.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe aortic stenosis in elderly and high-risk patients; however, long-term mortality remains substantial. Conventional surgical risk scores show limited prognostic performance in this population, in whom frailty and impaired nutritional and inflammatory status are common. The hemoglobin-albumin-lymphocyte-platelet (HALP) score integrates these domains, but its prognostic value in TAVI has not been established. AIM: To evaluate whether the preprocedural HALP score predicts long-term all-cause mortality after TAVI. MATERIAL AND METHODS: This retrospective single-center study included 785 consecutive patients who underwent TAVI between January 2018 and January 2024. HALP scores were calculated from routine laboratory parameters. Clinical, echocardiographic, and procedural data were collected. Independent predictors of mortality were assessed using Cox regression analysis. The optimal HALP cut-off was determined by maximally selected rank statistics, and survival was analyzed using Kaplan-Meier analysis. RESULTS: During a median follow-up of 21.8 months, 62 (8%) patients died. Non-survivors had significantly lower HALP scores and a higher prevalence of chronic kidney disease and atrial fibrillation. In multivariable analysis, lower HALP scores independently predicted mortality (HR = 0.94; 95% CI: 0.91-0.98; p = 0.002), along with chronic kidney disease and paradoxical low-flow, low-gradient aortic stenosis. A HALP cut-off of 36.82 effectively discriminated long-term survival (log-rank p < 0.0001). CONCLUSIONS: Preprocedural HALP score is an independent predictor of long-term mortality after TAVI and may aid preprocedural risk stratification.

Transcatheter aortic valve implantation in centers without a cardiac surgery department: a meta-analysis of contemporary evidence.

INTRODUCTION: The prevalence of aortic stenosis (AS) is increasing, resulting in a growing demand for aortic valve interventions. Current guidelines recommend transcatheter aortic valve implantation (TAVI) only in centers with on-site cardiac surgery (CS) backup. However, procedural advancements have reduced the need for emergent cardiac surgery (ECS), prompting a debate about the necessity of backup for this procedure. This meta-analysis evaluated the safety of TAVI performed in centers without CS backup. MATERIAL AND METHODS: The study was conducted in accordance with the MOOSE guidelines. The protocol was registered at PROSPERO (CRD420251044095). PubMed, CENTRAL, and Scopus were systematically searched up to November 2025. Studies comparing outcomes of TAVI performed with and without on-site CS or reporting outcomes of TAVI in non-CS centers were included. The outcomes were in-hospital mortality, 30-day death, need for ECS, and stroke. Meta-analyses of comparative studies and pooled proportions were performed using random-effects models. Risk of bias was evaluated using the ROBINS-I tool. RESULTS: Eight observational studies were analyzed, including 22,203 patients (19,373 with and 2830 without on-site CS). No significant difference in in-hospital mortality was observed between groups (relative risk [RR] = 1.1, 95% CI: 0.6-1.9, p = 0.8). Thirty-day mortality was also similar (RR = 1.2, 95% CI: 0.5-2.6, p = 0.72). ECS did not occur (0%; 95% CI: 0-1), with an RR of 0.8 (95% CI: 0.2-2.4, p = 0.7). Stroke rates did not differ (RR = 1.1, 95% CI: 0.8-1.5). Pooled in-hospital mortality in non-surgical centers was 3% (95% CI: 1-4%), and 30-day mortality was 4% (95% CI: 2-6%). Sensitivity analyses in propensity score-matched populations confirmed findings with reduced heterogeneity and consistent results. CONCLUSIONS: TAVI performed in centers without on-site cardiac surgery demonstrated comparable outcomes to those with surgical backup, suggesting that selected programs may safely operate under this model. These findings support reconsidering current guideline restrictions to enhance access and equity in TAVI delivery.

Patient-Reported Outcome Measures (PROMs) and Frailty Assessments Before and After Transcatheter Aortic Valve Implantation (TAVI): A Review of Current Evidence.

Transcatheter aortic valve implantation (TAVI) has become a paradigm shift in the treatment of elderly and frail patients with severe aortic stenosis, offering a minimally invasive alternative to conventional surgical aortic valve replacement. As the indications for TAVI expand to include lower-risk patients, there is a growing need for sophisticated patient assessment methodologies that capture the complex interplay between physical and functional status, quality of life, and treatment outcomes. This review aims to synthesize the current evidence on the use of patient-reported outcome measures (PROMs) and frailty assessments before and after TAVI, with a focus on their utility in predicting treatment outcomes and improving patient-centered care. A comprehensive literature search was conducted to identify studies published in peer-reviewed journals that investigated the use of PROMs and frailty assessments in the context of TAVI. The review found that PROMs and frailty assessments are increasingly being used to evaluate the pre- and post-procedural status of patients undergoing TAVI. These assessments have been shown to predict treatment outcomes, including mortality, morbidity, and quality of life, and to inform treatment decisions. The review also highlights the importance of integrating PROMs and frailty assessments into routine clinical practice to optimize patient outcomes and improve patient-centered care. In conclusion, this review demonstrates the growing body of evidence supporting the use of PROMs and frailty assessments in the context of TAVI. By incorporating these assessments into routine clinical practice, healthcare providers can better identify patients at risk of poor outcomes, optimize treatment strategies, and improve patient-centered care. Future research should focus on developing and validating PROMs and frailty assessments that are specific to the TAVI population and on exploring the impact of these assessments on treatment outcomes and healthcare utilization.

A Randomized Trial Evaluating Automated Notifications for the Identification and Treatment of Aortic Stenosis and Mitral Regurgitation: The ALERT Study.

BACKGROUND: Aortic stenosis (AS) and mitral regurgitation (MR) are common cardiac conditions associated with significant morbidity and mortality if left untreated. Despite the availability of effective therapies, many patients with severe AS and MR do not receive timely interventions, with disparities particularly affecting minority populations, women, and those in rural areas. METHODS: The Addressing undertreatment and heaLth Equity in aortic stenosis and mitral regurgitation using an integrated ehR plaTform (ALERT) study is a multicenter, prospective, cluster-randomized controlled trial designed to evaluate the impact of automated electronic health record notifications on the management of severe AS and MR. This cluster-randomized controlled trial involves at least 5 US hospital systems. Providers are randomized to receive automated notifications or not receive notifications, based on echocardiogram report findings. The primary end point is a hierarchical composite of transcatheter or surgical valve intervention (valve intervention) or multidisciplinary heart team clinic visit within 90 days. The study aims to randomize at least 600 providers and 1500 total patients 1:1 into each study arm, hypothesizing that automated notifications increase the proportion of patients receiving appropriate evaluation and treatment. RESULTS: The results of the study are pending completion of enrollment and should be available in Q2 2026. CONCLUSIONS: The ALERT study leverages integrated electronic health record platforms to address undertreatment in severe AS and MR, with the potential to improve patient outcomes and reduce disparities in care.

Cecal Bascule in a Cardiac Surgical Patient.

A cecal bascule is a specific type of volvulus that confers a high degree of mortality if it is not addressed. Timely and proper diagnosis is critical, as it generally requires surgical correction. Given the rarity of this phenomenon, it is important for clinicians to be aware of this complication to facilitate treatment. In this case report, we discuss the diagnosis and management of a patient who experienced a cecal bascule postoperatively after cardiac surgery. Prompt diagnosis allowed the patient to obtain appropriate treatment, and he was ultimately discharged after a positive outcome.

Staged TAVR and TEER for complex multivalvular disease in advanced heart failure: a case report.

BACKGROUND: Multivalvular heart disease complicated by advanced heart failure in elderly patients represents a major therapeutic challenge, particularly in the presence of complex anatomy, severe ventricular remodeling, and high surgical risk. Staged transcatheter strategies may offer a less invasive and individualized therapeutic alternative. An elderly patient with end-stage heart failure and severe ventricular remodeling was diagnosed with Sievers type I bicuspid aortic valve with mixed stenosis and severe regurgitation, complicated by functional moderate-to-severe mitral regurgitation. Given the patient's high surgical risk (STS-PROM 12%; EuroSCORE II 15%), a staged transcatheter strategy was adopted. Transfemoral TAVR was first performed with good prosthetic valve function and clinical improvement. Due to persistent symptomatic functional MR, subsequent transcatheter edge-to-edge repair (TEER) was performed three months later, resulting in significant MR reduction, symptomatic improvement, and favorable hemodynamic outcomes at follow-up. DISCUSSION: This case demonstrates the feasibility and clinical value of a staged transcatheter strategy in high-risk elderly patients with complex multivalvular disease and advanced heart failure. Sequential intervention allows reassessment of residual valve pathology, reduces procedural complexity, and lowers procedural risk compared with simultaneous multivalvular intervention. TAKE-HOME MESSAGE: A staged transcatheter strategy combining TAVR followed by TEER represents a safe, feasible, and effective therapeutic option for selected high-risk patients with complex multivalvular disease and advanced heart failure, offering individualized treatment and meaningful symptomatic improvement when surgical risk is prohibitive.

Differential impact of institutional procedural volume on outcomes of transcatheter and surgical strategies for concomitant aortic stenosis and coronary artery disease: a nationwide registry study.

Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist in elderly patients. Surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG) has been the standard treatment. However, transcatheter aortic valve replacement (TAVR) combined with percutaneous coronary intervention (PCI) currently offers a less invasive alternative. This study describes in-hospital and functional outcomes in elderly patients with AS and CAD undergoing TAVR + PCI or SAVR + CABG, and evaluates procedural volume influence. This retrospective cohort study analyzed 12,393 patients from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination database (2012-2022) who underwent TAVR + PCI (n = 1,487) or SAVR + CABG (n = 10,906) during hospitalization for AS. The primary endpoint was in-hospital mortality rate. Secondary outcomes included functional recovery, assessed using the Barthel Index (BI). Multivariate logistic regression models were adjusted for demographics, comorbidities, and procedural volume. Patients in the TAVR + PCI group were older (85.1 vs. 75.5 years) and had higher frailty. However, in-hospital mortality was lower in TAVR + PCI (3.3% vs. 5.1%, p = 0.002), with greater improvements in BI scores at discharge (+ 5.9 vs. - 1.9, p < 0.001). SAVR + CABG outcomes improved significantly at high-volume Centers (adjusted OR for mortality in the lowest vs. highest quartile: 2.067, p < 0.001). In contrast, TAVR outcomes were consistent regardless of institutional procedural volume. TAVR + PCI was associated with favorable short-term outcomes and functional recovery in elderly AS patients with CAD, despite older age and greater frailty. Institutional experience strongly influences SAVR outcomes, but appears less critical in TAVR, suggesting that TAVR can be safely performed at more hospitals.

Approaches to transcatheter aortic valve replacement failure: is more focus on prevention required?

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis across all surgical risk strata. As its use expands to younger, lower-risk patients, the durability of transcatheter heart valves and the clinical consequences of prosthetic failure have become critically important. Despite a growing literature on reintervention strategies, systematic prevention of TAVR failure remains comparatively underemphasized. AREAS COVERED: We searched PubMed and the Cochrane Library (2000-2026, English language) for studies on TAVR failure and its prevention. This review examines the mechanisms of TAVR failure, including structural valve deterioration, paravalvular leak, prosthesis-patient mismatch, subclinical leaflet thrombosis, valve endocarditis, and device migration; appraises current management, including valve-in-valve TAVR, redo surgical aortic valve replacement, and medical therapy; and reviews prevention strategies spanning patient selection, procedural optimization, antithrombotic management, structural surveillance, coronary access preservation, and lifetime planning. EXPERT OPINION: The evidence base has focused disproportionately on reintervention rather than prevention. Greater emphasis on structured lifetime management planning at index TAVR, individualized antithrombotic strategies, and evidence-based surveillance is needed. Several proposed measures, however, including routine anticoagulation for subclinical leaflet thrombosis and routine CT or artificial-intelligence-based surveillance, are not yet supported by outcome data and require prospective validation.

Transcatheter Aortic Valve Replacement in Patients Aged 65 Years and Younger: Unresolved Issues and Future Directions.

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has become the predominant treatment for severe aortic stenosis across all surgical risk categories. However, its role in patients aged 65 years and younger remains uncertain, and current guideline recommendations continue to favor surgical aortic valve replacement (SAVR) in this population. Despite this, contemporary real-world data demonstrate a marked increase in TAVR utilization among younger patients, creating an important gap between guidelines and clinical practice. METHODS: This review synthesizes contemporary observational evidence evaluating TAVR in patients ≤65 years, with a focus on patient selection, clinical outcomes, and lifetime management considerations. RESULTS: Available studies demonstrate that younger patients undergoing TAVR often represent a highly selected and clinically complex population with greater comorbidity burden, higher surgical risk, and shorter life expectancy than age-matched SAVR recipients, yet substantial hospital-level variation in TAVR utilization exists even after risk adjustment. Mid-term observational data suggest higher mortality and heart failure readmission rates following TAVR compared with SAVR, although these findings are likely influenced by substantial baseline differences between treatment groups. No randomized controlled trial has specifically compared TAVR and SAVR in patients ≤65 years. Furthermore, long-term issues including valve durability, coronary access, redo-TAVR feasibility, and THV optimization remain incompletely understood. CONCLUSIONS: TAVR recipients ≤65 are often a clinically distinct group characterized by significantly heavier comorbidity burdens than SAVR recipients of the same age with standard surgical risk models possibly underestimating the true clinical risk. Despite this, significant hospital-level variation in TAVR utilization persists even after risk adjustment, suggesting that institutional practice patterns and other non-clinical factors continue to influence treatment selection.

Imprecision of annular sizing in low-risk patients with aortic stenosis and its impact on transcatheter aortic valve size.

Aortic stenosis (AS), the most prevalent heart valve disease, is treatable through Surgical Aortic Valve Replacement (SAVR) or Transcatheter Aortic Valve Implementation (TAVI). Precise valve sizing is crucial for optimal clinical outcomes, minimizing risks like paravalvular leakage, conduction abnormalities, and patient-prosthesis mismatch. SAVR valve sizing is intraoperative, while Multidetector Computed Tomography (MDCT) measurements serve as the gold standard for TAVI sizing. The recent expansion of TAVI to low-risk patients reflects heightened confidence in its safety and efficacy. However, little is known about annular sizing imprecision in low-risk TAVR patients and its impact on valve size. This study aims to evaluate the inter- and intra-observer variability of MDCT-based measurements (annular area, perimeter, and diameter) and their impact on TAVI valve sizing. A secondary objective involves assessing intraoperative annular measurements against MDCT measurements. Fifty low-surgical-risk patients underwent SAVR. Preoperative MDCT, evaluated by three experienced cardiac MDCT operators, measured aortic annular parameters. Inter- and intra-observer variability were compared with intraoperative aortic valve sizers and predefined TAVI valve sizes. Among fifty low-risk patients with AS, strong correlation (Pearson > 0.90) was observed for all MDCT measurements between operators. However, interindividual differences led to diverse TAVI valve sizing in 40% of patients. No specific operator emerged as an outlier. Intraoperative annular diameter consistently measured smaller than MDCT-derived measurements. MDCT aortic annular measurements in AS patients exhibit strong correlation between operators. Yet, inter-operator discrepancies significantly impact TAVI valve sizing in a high percentage of patients, emphasizing the need for improved standardization.

Safety and efficacy of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in patients with bicuspid aortic stenosis: A Systematic review and meta-analysis.

BackgroundBicuspid aortic valve (BAV) disease is a leading cause of aortic stenosis (AS). Surgical aortic valve replacement (SAVR) has traditionally been regarded as the best therapeutic option for bicuspid AS. However, the distinctive anatomical characteristics of BAV make the treatment with transcatheter aortic valve replacement (TAVR) challenging, so this population was often excluded from the trials. We aimed to compare TAVR and SAVR in terms of safety and efficacy in the population with bicuspid AS.MethodsWe conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies, searched from PubMed, Cochrane, Scopus, and Web of Science (from inception until September 2025). Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes as mean differences (MDs), each with 95% confidence intervals (CIs).ResultsA total of 78,677 patients were included in one RCT, 12 retrospective cohort studies, and one prospective cohort study. TAVR, compared to SAVR, was associated with significantly higher rates of permanent pacemaker implantation (PPI) (O.R. = 2.29, 95% C.I. [1.51, 3.47], P < 0.01) and shorter length of hospital stay (M.D. = -2.24, 95% C.I. [-3.96, -0.52], P = 0.01) and lower bleeding rates (O.R. = 0.31, 95% C.I. [0.14, 0.69], P < 0.01). However, there were no significant differences in all-cause mortality (ACM) (P = 0.948), acute kidney injury (AKI) (P = 0.28), stroke incidence (P = 0.475), and vascular complications (P = 0.31). The PPI and stroke rate results were consistent during in-hospital and short-term follow-ups. However, subgroup analysis by follow-up duration revealed that long-term stroke incidence was significantly higher in the TAVI group.ConclusionTAVR offers benefit by minimizing significant bleeding and hospital length of stay. However, the benefits should be balanced against the considerably increased risk of PPI and PVL. Further RCTs are needed to confirm these findings.

Current Trends and Future Challenges in Transcatheter Aortic Valve Implantation (TAVI): A Narrative Review.

The advent of transcatheter aortic valve implantation (TAVI) has redefined the treatment of aortic stenosis over the last two decades, evolving from a therapy reserved for patients that were deemed to be of prohibitive surgical risk to the standard of care for a large group of patients presenting with symptomatic disease. With improvements in technology, operator and institutional experience and longer-term outcome data, recent guidelines have supported the broadening of indications to low-risk and asymptomatic patients in addition to other pathologies including the management of failed surgical bioprosthetic valves and aortic regurgitation. The rapid developments in the field have resulted in a rapid expansion of TAVI. The focus has moved from the technical aspects of the procedure itself that are now well established to the lifetime management of patients with aortic stenosis, particularly younger patients with regard to valve durability, planning for a further intervention after TAVI and associated considerations including future coronary access. Beyond aortic stenosis, TAVI technology is also increasingly being utilized for the management of failed surgical bioprostheses, bicuspid valve disease, aortic incompetence and mitral/tricuspid disease and these represent future areas of focus in the field.

Tricuspid annular diameter as a predictor of persistent significant tricuspid regurgitation following transcatheter atrial septal defect closure: A prospective single center study.

BACKGROUND: Functional tricuspid regurgitation (TR) is frequently present in adults with secundum atrial septal defect (ASD) due to chronic right-sided volume overload and right heart remodeling. AIMS: The aim of this study is to evaluate changes in TR severity, tricuspid annular and right ventricular (RV) reverse remodeling 12 months after transcatheter ASD closure, including RV systolic function assessed by conventional parameters and RV free wall longitudinal strain (RVFWLS). We also evaluated baseline echocardiographic predictors of persistent ≥ moderate TR at follow-up. METHODS: We prospectively enrolled 200 adult patients (150 women, 50 men) with the median age of 35 years (interquartile range 25.0-48.5) undergoing transcatheter closure of secundum ASD. Transthoracic echocardiography was performed before the procedure and at 12-month follow-up to assess TR severity, RV and tricuspid annular dimensions and RV systolic function, including RVFWLS. Persistent TR was defined as ≥ moderate TR at 12 months. Baseline predictors of persistent TR were evaluated using univariate and multivariable logistic regression analyses. RESULTS: The severity of TR was reduced after 12 months (P <0.001), with a significant increase in the number of patients without TR from 0% to 19% and a decrease in the incidence of severe TR (7% vs. 1%). An improvement in the semi quantitative and quantitative parameters of TR was noted, including the width of the vena contracta (median 3.0 vs. 2.0 mm), the effective regurgitant orifice area (median 0.20 vs. 0.18 cm²), and the regurgitant volume (median 15.0 vs. 12.0 ml) (P <0.001). Reverse remodeling was observed in the form of a decrease in the diameter of the tricuspid valve annulus (median 35.0 vs. 33.0 mm; P <0.001) and the diameter of the proximal part of the RV outflow tract (median 32.0 vs. 28.0 mm; P <0.001). RV systolic function also improved, as evidenced by improvements in echocardiographic parameters: RVFWLS, tricuspid annular plane systolic excursion, s', fractional area change, and Right Ventricular Index of Myocardial Performance (P <0.001). At 12 months, 80 patients (40%) had persistent ≥ moderate TR. In multivariable analysis, baseline tricuspid annular diameter (odds ratio, 4.53; 95% confidence interval [CI], 2.26-9.10; P <0.001) and baseline TR regurgitant volume (odds ratio, 1.28; 95% CI, 1.15-1.43; P <0.001) independently predicted persistent ≥ moderate TR. Receiver operating characteristic analysis demonstrated excellent discrimination for predicting clinically significant TR (area under the curve 0.97; 95% CI, 0.951-0.989), with an optimal annular diameter cut off of 39 mm. CONCLUSIONS: Transcatheter ASD closure is associated with significant improvement in functional TR and right heart reverse remodeling at 12 months, accompanied by improved RV systolic function. Annular diameter >39 mm identifies patients at increased odds of persistent significant TR after device closure and may support consideration of surgical ASD closure with concomitant tricuspid annuloplasty.

Dysphagia: A Novel Risk Factor for Poor Outcomes Following Cardiovascular Procedures.

BACKGROUND: Dysphagia, an increasingly recognized clinical marker of frailty, is prevalent among older adults yet its impact on cardiovascular postprocedural outcomes remains undetermined. This study evaluated the association between dysphagia and adverse outcomes following major cardiac interventions. METHODS: Using the TriNetX database (2020-2024), we retrospectively identified adults with and without dysphagia who underwent coronary artery bypass graft, implantable cardioverter-defibrillator placement, transcatheter aortic valve replacement, surgical aortic valve replacement, or mitral transcatheter edge-to-edge repair. Cohorts were propensity matched based on demographics and comorbidities; a sensitivity analysis incorporated additional frailty markers. The 90-day and 1-year risks of mortality, stroke, aspiration pneumonia, infectious pneumonia, hypoxemia, intubation, foreign body in respiratory tract, and esophagogastroduodenoscopy were measured. Kaplan-Meier analyses on survival probability were performed. Hazard ratios (HRs) for mortality, and risk ratios for all outcomes with 95% CIs were calculated. RESULTS: Propensity matched cohorts of patients with and without dysphagia (coronary artery bypass graft, n=5152; implantable cardioverter-defibrillator, n=4112; transcatheter aortic valve replacement, n=4066; surgical aortic valve replacement, n=1982; mitral transcatheter edge-to-edge repair, n=710) were well balanced. Dysphagia was associated with significantly increased 90-day mortality following coronary artery bypass graft (HR, 1.321), implantable cardioverter-defibrillator implantation (HR, 1.398), transcatheter aortic valve replacement (HR, 1.736), and surgical aortic valve replacement (HR, 1.341) (all P<0.01) but not mitral transcatheter edge-to-edge repair. Dysphagia also increased the 1-year risk of stroke, hypoxemia, infectious pneumonia, and intubation across all procedures. CONCLUSIONS: Dysphagia is associated with increased short-term morbidity and mortality following common cardiovascular procedures. Incorporating dysphagia screening into perioperative workflows may improve patient selection and resource allocation, supporting its inclusion in guideline-directed risk assessment and perioperative optimization pathways.

A critique on methodological aspects of a novel survival prediction model after isolated surgical aortic valve replacement in the transcatheter aortic valve replacement era.

Validation of aortic valve calcification quantification on contrast-enhanced computed tomography against ex vivo gravimetric analysis: comparison of fixed Hounsfield unit thresholds and deep learning segmentation.

BACKGROUND: Accurate quantification of aortic valve calcification (AVC) on contrast-enhanced computed tomography angiography (CTA) is pivotal for planning surgical and transcatheter aortic valve replacement. The optimal Hounsfield unit (HU) threshold for calcification detection on contrast-enhanced images remains unresolved, and every prior validation study has relied on non-contrast Agatston scoring-itself an imaging estimate-as the reference standard. This study validated two widely used fixed HU thresholds (450 HU and 850 HU) and a self-configuring nnU-Net deep learning model against ex vivo gravimetric calcium weight as an absolute physical ground truth. METHODS: Four hundred patients were included in a retrospective cohort study with a pre-specified temporal validation split: 300 with CT-confirmed AVC and 100 with normal aortic valves. Fifty chronologically later AVC patients who underwent elective open surgical aortic valve replacement (SAVR) within seven days of clinically indicated pre-operative contrast-enhanced CTA formed the locked surgical validation cohort; their excised native leaflets underwent standardised high-temperature ashing (550 °C, 12 h) and analytical weighing (precision 0.1 mg) to obtain gravimetric calcium mass. The remaining 350 cases served exclusively for nnU-Net development (280 training / 70 internal validation). CT-derived calcium mass-equivalent estimates were quantified on the validation cohort and compared with gravimetric weight using Pearson and Spearman correlation and Bland-Altman analysis. RESULTS: The nnU-Net achieved the strongest observed correlation with gravimetric weight (Pearson r = 0.967; bias + 6.2 mg; RMSE 13.7 mg), significantly outperforming the 450 HU threshold for correlation (r = 0.864; bias + 36.2 mg; RMSE 42.1 mg; Steiger p < 0.001) and showing a non-significant trend toward stronger correlation than 850 HU (r = 0.929; bias + 17.5 mg; RMSE 23.9 mg; Steiger p = 0.085). Compared with 850 HU, nnU-Net provided lower bias and RMSE, although the difference in Pearson r did not reach statistical significance. The 450 HU method exhibited significant proportional bias (p = 0.024), whereas neither 850 HU nor nnU-Net did. The nnU-Net achieved a mean Dice coefficient of 0.873 and intersection-over-union of 0.812. CONCLUSIONS: Against physically weighed calcium, nnU-Net deep learning segmentation provided the most favourable overall performance profile on contrast-enhanced CTA, with the lowest bias and RMSE and the strongest observed correlation. The improvement in Pearson correlation over 850 HU represented a non-significant trend, whereas the error and agreement metrics favoured nnU-Net. Among fixed thresholds, 850 HU substantially outperformed 450 HU, offering direct physical-rather than surrogate imaging-evidence to support 850 HU as the preferred fixed threshold in standard contrast-enhanced protocols.

Untreated mild-moderate mitral regurgitation after isolated aortic valve replacement for aortic stenosis.

BACKGROUND: Postoperative persistent/worsening mitral regurgitation (MR) is reported to be a prognostic marker in patients undergoing isolated aortic valve replacement (AVR). However, there is little evidence regarding the surgical indication for coexisting mild-to-moderate MR in patients undergoing isolated surgical AVR. This study evaluates the relationship between untreated mild-to-moderate MR and postoperative significant MR after surgical AVR. METHODS: Between 2016 and 2021, 430 patients with severe aortic stenosis underwent isolated surgical AVR with untreated mild-to-moderate MR. The primary endpoint was significant (moderate or greater) MR at 1 year after surgery. Composite endpoint (mortality and heart failure readmission) was also retrospectively reviewed. The mean follow-up duration was 5.0 ± 2.0 years. RESULTS: At 1 year after surgery, 22 patients (5%) presented with moderate or greater MR. Multivariable analysis showed aortic valve peak velocity (OR, 0.44; 95% CI, 0.22-0.89; P= .021), moderate MR (OR, 11.9; 95% CI, 3.80-38.5; P = < 0.001), and left atrial dimension index (OR, 1.12; 95% CI, 1.02-1.25; P= .020) at baseline were risk factors for postoperative significant MR. The freedom from composite endpoint were significantly lower in patients with multiple risk factors for MR than those without (log-rank P= .041). CONCLUSIONS: In patients undergoing isolated surgical AVR with untreated mild-to-moderate MR, preoperative aortic velocity, left atrial dimension, and moderate MR were associated with postoperative significant MR, as well as increased heart failure readmission rates. These risk factors need to be considered in coexisting mild-to-moderate MR when treating aortic valvular lesion. CLINICAL REGISTRATION NUMBER: Approved by the Clinical Research Ethics Committee of Osaka University Hospital: Approval No.: 20,222 (T2).

A Comparison of 2- and 3-Dimensional Echocardiographic Measurement of the Mitral Valve Leaflet Lengths.

OBJECTIVES: Accurate echocardiographic assessment of mitral valve (MV) anatomy and function is essential for guiding therapeutic decision making in patients with mitral regurgitation. This is particularly critical for transcatheter mitral edge-to-edge repair, in which open surgical inspection is not feasible and procedural success is heavily dependent on periprocedural echocardiographic imaging. Measurements on the order of millimeters determine procedure feasibility and risk of complications. The authors hypothesized that 3-dimensional (3D) imaging with multiplanar reconstruction (MPR) would improve quantitative assessment of the MV leaflet lengths. DESIGN AND SETTING: A retrospective analysis of patients scheduled for elective cardiac surgery with adequate transesophageal echocardiographic 2-dimensional (2D) mid-esophageal views and full-volume 3D datasets was performed at a single institution. PARTICIPANTS: Seventy-five adult patients participated in this study. INTERVENTIONS: Two- and three-dimensional diastolic leaflet lengths of the middle segment of the anterior leaflet (A2), anterior-lateral scallop of the posterior leaflet (P1), middle scallop of the posterior leaflet (P2), and posterior-medial scallop of the posterior leaflet (P3) were measured and compared using Bland-Altman and Pearson correlation statistics. Interobserver variability was evaluated in a subset of 15 patients. MEASUREMENTS AND MAIN RESULTS: Correlations between 2D and 3D imaging were moderate (r = 0.41-0.74, p < 0.0001 for all). While the mean biases (differences) between 2D and 3D measures of A2 and P2 were small (0.03 and -0.07 cm, respectively), the coefficients of variation (CoVs) ranged from 19.4% to 23.7% for A2 and from 41.4% to 44.3% for P2. The mean biases between 2D and 3D measures of P1 and P3 were 0.05 and 0.04 cm, respectively, with CoVs of 59.9% and 49.6%, respectively. Interobserver variability analysis showed that 3D MPR measures of A2 (CoV, 7.3%) and P2 (CoV, 17.3%) were significantly lower (p = 0.004 and p = 0.02, respectively) than 2D measures from the mid-esophageal 4-/5-chamber and mid-esophageal long-axis windows of A2 (20.4% and 38.2%, respectively) and P2 (43.6% and 53.6%, respectively). CONCLUSIONS: There were significant differences between 2D and 3D measurements of diastolic mitral leaflet lengths. While this study did not define the gold-standard measurement technique, it showed that 3D MPR with 3D feedback for precise leaflet identification of A2 and P2 resulted in improved precision based on interobserver variability and significantly lower CoV. Overall, the variability reported in this study indicates the need for well-defined standardized methods of image acquisition, image interpretation, and analysis of the MV.

Modified Right Vertical Infra-Axillary Thoracotomy Technique: A 2 to 5 cm Incision Approach for Repair of Various Congenital Heart Diseases in All Age Groups.

OBJECTIVE: To evaluate the surgical outcomes of the modified right vertical infra-axillary thoracotomy (MRVIAT) technique for the treatment of various congenital heart diseases (CHDs) across all age groups. METHODS: A retrospective analysis was performed on 1,513 patients with CHD who underwent surgery using the MRVIAT technique between January 2022 and June 2024. Incisions were 2 to 5 cm, and peripheral extracorporeal circulation was not used. Twelve primary surgical procedures were executed across all age groups. RESULTS: All 1,513 patients successfully underwent surgery without the need for conversion to a median sternotomy or any in-hospital mortality. The median patient age was 1.1 years (range, 0.1 to 57 years), with 62 patients aged 18 years or older. The median weight was 9 kg (range, 1.8 to 101.6 kg), with 859 patients (56.8%) weighing ≤10 kg, 588 patients (39.9%) weighing between 10 kg and 50 kg, and 66 patients (4.4%) weighing ≥50 kg. Two patients (0.1%) required early reoperation: 1 (0.1%) due to third-degree atrioventricular block and 1 (0.1%) due to postoperative bleeding. Other postoperative complications included mild residual shunt in 20 patients (1.3%), pneumothorax in 2 patients (0.1%), wound infection in 3 patients (0.2%), and pulmonary infection in 4 patients (0.3%). The median follow-up period was 1.3 years (range, 0.3 to 2.5 years). During follow-up, no surgery-related thoracic deformities were noted. CONCLUSIONS: The MRVIAT technique is a safe and viable method for treating CHD patients across all age groups. This technique, which involves a smaller, less prominent incision, offers a promising alternative to median sternotomy methods.

10-Year Randomized Outcomes of Transcatheter or Surgical Aortic Valve Replacement in Intermediate-Risk Aortic Stenosis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical aortic valve replacement for symptomatic severe aortic stenosis, but long-term, comparative clinical outcomes and echocardiography data are lacking. OBJECTIVES: Our goal was to compare 10-year clinical and echocardiographic outcomes after balloon-expandable TAVR or surgery in intermediate-risk surgical patients in the PARTNER 2A randomized trial. METHODS: Between 2011 and 2013, patients with severe, symptomatic aortic stenosis at intermediate surgical risk were randomized at 57 centers to TAVR with the balloon-expandable SAPIEN XT system (Edwards Lifesciences) or to surgery. Randomization was stratified by anatomical suitability for transfemoral (TF) or transthoracic (transapical/transaortic [TA/TAo]) access. Ten-year outcomes were evaluated in the valve implant population and included all-cause mortality, aortic valve reintervention, and core laboratory-adjudicated echocardiographic outcomes. To obtain 10-year data, patient reconsent at 5 years was required, and vital status sweeps were implemented to improve data completeness for all-cause mortality. RESULTS: Among 1,910 randomized patients who received a valve, 974 underwent TAVR (TF: 749/974 [76.9%]) and 936 had surgery. Mean patient age was 81.6 years, 45.4% were women, and the mean Society of Thoracic Surgeons score was 5.8%. At 10 years, vital status was available for 881 of 974 patients (90.5%) and 838 of 936 patients (89.5%). All-cause 10-year mortality with vital status sweeps was 86.1% after TAVR and 82.8% after surgery (HR: 1.13; 95% CI: 1.02-1.25; P = 0.02). When stratified by access route, rates of all-cause mortality for TAVR and surgery in the TF group were similar (83.9% vs 82.1%, respectively; P = 0.27), whereas mortality was higher for TAVR in the TA/TAo group (93.2% vs 85.1%; P < 0.01; P for interaction = 0.03). Cumulative incidence rates of aortic valve reintervention at 10 years were 6.3% for TAVR and 1.6% for surgery (P < 0.001). Of the 24 TAVR and 35 surgical patients with available echocardiographic data at 10 years, mean gradients were 12.6 mm Hg and 12.7 mm Hg, respectively. CONCLUSIONS: At the 10-year follow-up, TAVR in intermediate-risk patients with the SAPIEN XT prosthesis compared with surgery was associated with lower survival rates, with differences predominantly observed in the TA/TAo access cohort. TAVR with the XT valve was also associated with significantly higher rates of aortic valve reintervention. (PARTNER II Trial: Placement of AoRTic TraNscathetER Valves II - XT Intermediate and High Risk [PII A]; NCT01314313).

10-Year Outcomes of SAPIEN 3 Transcatheter Aortic Valve Replacement or Surgery in Intermediate-Risk Patients.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis. However, long-term outcomes data are lacking for TAVR, particularly with newer-generation transcatheter heart valves. OBJECTIVES: The purpose of this study was to compare 10-year outcomes of intermediate-risk patients who underwent TAVR with the third-generation, balloon-expandable SAPIEN 3 valve in the PARTNER 2 SAPIEN 3 Intermediate-risk Registry (P2S3i) with those who underwent surgery in the PARTNER 2A (P2A) randomized trial. METHODS: Intermediate-risk patients were enrolled in the P2A trial from 2011 through 2013 and in the P2S3i registry in 2014. These prospective, multicenter studies used the same eligibility criteria and stratified patients based on suitability for transfemoral or transthoracic (transapical/transaortic) access. Ten-year outcomes were evaluated, including all-cause mortality, aortic valve reintervention, and core laboratory-adjudicated echocardiographic outcomes. Patient reconsent was required at 5 years for extended 10-year follow-up, and vital status sweeps were implemented to improve data completeness for all-cause mortality. To account for potential baseline differences and reduce confounding, P2S3i TAVR patients were propensity score-matched 1:1 to P2A surgical patients. RESULTS: Among 2,005 patients who received a valve, 1,069 underwent TAVR in P2S3i and 936 underwent surgery in P2A. After propensity score matching (N = 783 patients in each group), baseline characteristics were similar between groups: mean age was approximately 82 years, 43% were female, and mean Society of Thoracic Surgeons score was 5.5%. At 10 years, all-cause mortality rate was 83.4% after TAVR and 82.3% after surgery, respectively (HR: 1.01 [95% CI: 0.91-1.13]; P = 0.82). Aortic valve reintervention rates adjusted for competing mortality were 2.0% for TAVR and 1.9% for surgery (P = 0.47). Among 32 TAVR and 30 surgical patients with available echocardiographic data at 10 years, mean gradients were 11.0 mm Hg and 12.6 mm Hg, respectively. CONCLUSIONS: At 10 years, TAVR with the SAPIEN 3 valve and surgery resulted in similar rates of mortality and aortic valve reintervention, and similar hemodynamics in intermediate-risk patients with symptomatic severe aortic stenosis. This analysis highlights challenges associated with extended long-term follow-up of clinical trials, including differential loss to follow-up and the competing risk of mortality in elderly populations. (PARTNER 2A Trial; NCT01314313; PARTNER 2 SAPIEN 3 Intermediate-Risk Registry; NCT03222128).

10-year experience with transcatheter aortic valve explants in a high-volume center.

OBJECTIVE: Indications for transcatheter aortic valve replacement (TAVR) are expanding into younger, lower-risk patients, and TAVR explants are increasing. We report our 10-year single-center experience and outcomes following TAVR explant. METHODS: All TAVR explants performed between January 2015 and September 2025 were retrospectively reviewed. Patients were stratified into early-explant (≤30 days from index TAVR) and late-explant (>30 days) groups. Late-explant patients were further categorized as lower-risk (SAVR after TAVR risk score ≤ 8) or high-risk (>8). The primary endpoint was operative mortality; secondary endpoints included observed-to-expected (O/E) mortality and midterm survival. RESULTS: Sixty-six TAVR explants were performed: 9 (13.6%) early and 57 (86.4%) late. Among late explants, 40 (70.2%) were lower-risk and 17 (29.8%) high-risk. Median time to explant in this cohort was 37.3 months (IQR:17.2-66.1). Indications were structural valve degeneration (33.3%), endocarditis (30%), valve thrombosis (6.1%), non-structural dysfunction (16.7%) and acute causes (13.6%). Within the late-explant cohort, only 13 patients (22.8%) had an isolated aortic valve replacement; most required concomitant procedures. Operative mortality was 22.2% for early and 15.8% for late explants. Among late cases, operative mortality was higher in the high-risk group (41.2% vs 5%, p = 0.002), with a substantially increased O/E mortality ratio (2.81 vs 1.40). Survival at 1, 2, and 3 years was 82.8%, 78.4%, and 65.8% in the lower-risk group versus 45.3% at all time points in the high-risk group. CONCLUSIONS: TAVR explantation carries operative mortality higher than anticipated, particularly in high-risk patients. A TAVR-first strategy in younger and lower-risk populations warrants careful consideration within a lifetime management framework.

Paradoxical sparing of cerebral circulation in massive TAVR-associated endocarditis.

BACKGROUND: Prosthetic valve endocarditis (PVE) after transcatheter aortic valve replacement (TAVR) is an uncommon but life-threatening complication associated with high embolic risk. CASE PRESENTATION: A 82-year-old woman with prior TAVR presented with fever and malaise and was diagnosed with PVE due to Streptococcus Mutans. Transesophageal echocardiography revealed a large, highly mobile vegetation attached to the transcatheter valve, floating in the systolic jet of blood flow. Computed tomography demonstrated progressive splenic infarction and embolic involvement of the kidneys and mesenteric circulation, while no cerebral embolization occurred. At surgery, the previously visualized vegetation was no longer present, suggesting interval embolization. The transcatheter valve was explanted using cardiopulmonary bypass and cardioplegia. Radical debridement and annular enlargement with bovine pericardium were performed, followed by implantation of a surgical bioprosthesis using infection-conscious techniques. The patient recovered uneventfully. Post hoc analysis may suggest that proximal origin of the supra-aortic vessels (type III aortic arch configuration with the innominate artery originates below the horizontal plane of the inner curvature of the aortic arch) in the setting of an elongated aorta in this patient may explain the absence of cerebral embolization. This could possibly be relevant in combination with the centrally located floating vegetation, which was ejected along the strong central flow stream and consequently embolized to the abdominal organs. However, this excludes a generalization of the statement, and therefore the classic surgical principle of early surgery in patients with huge floating vegetations should be applied in similar cases. CONCLUSIONS: This case illustrates the embolic potential of large, mobile vegetations in TAVR-associated endocarditis and supports early surgical intervention in accordance with both American and European infective endocarditis guidelines. The absence of cerebral embolization in the presence of massive systemic emboli should not be mistaken for anatomical protection.

Two-year outcomes of transcatheter aortic valve replacement with the vitaflow libertyTM system in high-surgical-risk patients with severe aortic stenosis.

BACKGROUND: Mid-term clinical evidence for the VitaFlow LibertyTM transcatheter aortic valve system in anatomically complex populations is limited. METHODS: This was a prospective, multicenter, single-arm Objective Performance Criteria study performed at 22 Chinese sites, with follow-up at 30 days, 6 months, 1 year, and annually through 5 years. The prespecified primary endpoint of the parent study was 1-year all-cause mortality. Other clinical events were adjudicated according to Valve Academic Research Consortium-2 definitions. RESULTS: A total of 163 patients underwent transcatheter aortic valve replacement (TAVR) with the VitaFlow LibertyTM system. The mean age was 76.8 ± 5.0 years, 65.0% were male, the mean STS-PROM score was 7.87 ± 2.70, and 46.6% had bicuspid aortic valve anatomy. At 2 years, all-cause mortality was 13.5%, any stroke occurred in 7.6%, and new permanent pacemaker implantation was required in 19.5%. Mean aortic valve gradient improved from 59.22 ± 19.76 mmHg at baseline to 9.04 ± 6.07 mmHg at 2 years, and effective orifice area improved from 0.57 ± 0.21 cm2 to 2.00 ± 0.51 cm2. Moderate paravalvular leak was present in 4.5% of patients at 2 years. CONCLUSIONS: TAVR with the VitaFlow LibertyTM system demonstrated favorable 2-year safety and efficacy in a challenging population, with sustained hemodynamic performance. TRIAL REGISTRATION: NCT04414878.

Clinical outcomes of TAVR with self-expanding valves for non- or minimally calcified aortic regurgitation.

INTRODUCTION: Surgical intervention for aortic regurgitation (AR) is often deferred for high-risk patients. Our study evaluated patient outcomes with non- or minimally calcified AR undergoing TAVR with self-expanding valves, regardless of anatomical features, including those with LVAD support. METHODS: A retrospective observational cohort study was conducted at a single academic center from 01/01/2012 to 12/01/2024. Eligible patients were those with greater than moderate AR, high/inoperable surgical risk, aortic valve calcium score < 400. Primary outcomes were all-cause and cardiovascular (CV)-related mortality rates at 1 and 12 months. Secondary outcomes included rehospitalization rates, procedural complications, in-hospital events, and Valve Academic Research Consortium-3 (VARC) success rates at 1 month. RESULTS: 25 patients who underwent TAVR were included, 13 were female with mean age 67 ± 14 years. The majority (76%) of patients presented with severe AR with a mean aortic valve calcium score of 61.5 ± 109.2. No intraprocedural death or conversion to open surgery occurred. Only one all-cause mortality occurred within 30 days, with Kaplan-Meier survival rate of 96% and 84%, at 1 month and 12 months, respectively. Heart failure-related hospitalization occurred in less than 10% of patients at 12 months. Technical success rate was 80%, with ventricular device migration occurring in five patients (20%), two of which were on LVAD support. In those cases, a second balloon-expandable valve was implanted achieving ≤ mild AR. All patients achieved mild or less residual AR at 12 months. CONCLUSION: Off-label TAVR use with self-expanding valves for AR is achievable with favorable safety and efficacy in select patients with and without LVADs.

Left and right heart remodeling at 1 year after transcatheter versus surgical aortic valve replacement: A speckle-tracking echocardiography study.

OBJECTIVES: Speckle-tracking echocardiography (STE) identifies subclinical myocardial dysfunction after aortic valve replacement. We compared strain-based remodelling and prognostic values after transcatheter (TAVR) versus surgical (SAVR) aortic valve replacement. METHODS: We analyzed preoperative (preop) and postoperative (postop) left atrial volume index (LAVI), LV global longitudinal strain (LV-GLS), RV free wall strain (RV-FWS), RV global longitudinal strain (RV-GLS) and tricuspid annular plane systolic excursion (TAPSE) in 373 (TAVR n = 195; SAVR n = 178). Multivariable logistic regression assessed echocardiographic predictors of one-year clinical outcomes. RESULTS: LV ejection fraction and LV-GLS remained stable in both groups. RV function deteriorated post-SAVR compared to TAVR (p < 0.001), with marked declines in TAPSE and RV-GLS (both p < 0.001). Preop LAVI predicted mortality (adjusted OR 1.03, 95% CI 1.02-1.05; p = 0.001) and AF recurrence (OR 1.04, 95% CI 1.02-1.06; p = 0.001). Stroke was predicted by preop RV-GLS (OR 0.91; p = 0.031) and TAPSE (OR 1.12; p = 0.013). Postop LAVI (OR 1.06; p = 0.001), RV -FWS (OR 1.06; p = 0.016), RV-GLS (OR 1.10; p = 0.006), and TAPSE (OR 0.93; p = 0.035) also remained significant predictors. Furthermore, postop LV-GLS was associated with mortality (OR 1.08; p = 0.013) and AF recurrence (OR 1.16; p = 0.001). CONCLUSIONS: Preop and postop strain parameters, particularly LAVI, LV-GLS, and RV longitudinal metrics, provide substantial prognostic value. Divergent RV remodelling patterns support integrating routine echocardiographic strain assessment for longitudinal risk stratification.

Prison Break: Extraction of a Plug Jailed Between Two Mechanical Valves.

Paravalvular leak (PVL) occurs in up to 17% of prosthetic valve replacements, mainly in the mitral position. Surgery is the gold standard but carries high morbidity in patients with a history of previous sternotomies. Transcatheter closure of PVL offers a minimally invasive alternative with a very high success rate. Device migration, while uncommon, can be catastrophic when impinging on mechanical prosthetic valve performance. We report the case of a 37-year-old woman with prior mechanical mitral and aortic valve replacements, complicated by recurrent heart failure due to a mitral PVL resulting from suture dehiscence. Initial transcatheter closure with two Amplatzer Vascular Plug III devices achieved a substantial reduction of regurgitation. Four months later, she presented with acute pulmonary edema caused by migration of one device into the left ventricular outflow tract, intermittently obstructing a mechanical aortic valve leaflet. Given her prohibitive surgical risk, percutaneous retrieval was undertaken, followed by immediate re-closure of the PVL during the same procedure, successfully restoring valve function and hemodynamic stability. This case illustrates the complexity of late PVL management after mechanical mitral valve replacement and highlights the potential risk of device migration. While surgery remains the gold standard, percutaneous intervention represents the only viable option in patients at prohibitive surgical risk. To our knowledge, this is the first reported case of successful percutaneous retrieval of an embolized device through a mechanical prosthesis, followed by re-closure of the PVL within the same procedure. This experience underscores the feasibility of advanced bailout strategies in carefully selected patients.

Racial trends in outcomes and access to treatment for mitral regurgitation: a South London population cohort study.

BACKGROUND: Racial disparities in valvular heart disease are well-documented, yet evidence specific to mitral regurgitation (MR) remains fragmented. This study examined racial differences in mortality and treatment access among patients with moderate-severe MR within a universal healthcare system. METHODS: This retrospective cohort study utilised digital health records from a South London tertiary centre using natural language processing (NLP), including demographic, clinical, echocardiographic and socioeconomic data. Adult patients with moderate or greater MR diagnosed between 2010 and 2023 were stratified by ethnicity (White, Black, Asian). Primary outcomes were all-cause mortality and surgical/transcatheter intervention rates. Multivariable Cox regression and competing risk analyses adjusted for demographics, MR characteristics, comorbidities and socioeconomic deprivation. RESULTS: The cohort (n=6665) comprised 5331 (80.0%) White, 958 (14.4%) Black and 376 (5.6%) Asian patients with under-represented minority proportions relative to local demographics. Black patients presented younger (65.4 vs 72.2 years; p <0.001) with greater socio-economic deprivation (median IMD decile 3 vs 5), higher comorbidity burden and predominantly secondary MR (91% vs 85%; p <0.001). Crude mortality rates were 103.8, 88.1 and 80.4 per 1000 person-years for White, Black and Asian patients respectively. After adjustment, ethnicity was not independently associated with mortality (Black vs White: HR 0.90; 95% CI 0.80 to 1.00; p=0.06) or intervention (OR 0.81; 95% CI 0.59 to 1.11; p=0.18). Socioeconomic deprivation was independently associated with mortality (HR 0.97/IMD decile increase; p <0.001) and intervention rates. Crude intervention rates were lower in Black than in White patients (6.9% vs 12.7%), this difference attenuated after adjustment for MR aetiology, comorbidities and socioeconomic deprivation and did not persist as an independent association (OR 0.81; 95% CI 0.59 to 1.11; p=0.18). CONCLUSION: MR appears under-detected among minority patients relative to local demographics and occurs at a younger age and with a greater prevalence of secondary MR and comorbidity. Once identified, clinical factors and socioeconomic deprivation rather than ethnicity itself drive outcomes and treatment access, with no statistically independent association between ethnicity and either mortality or intervention, although modest but clinically relevant differences cannot be excluded given the cohort sizes. These findings highlight the need for enhanced valve disease detection in diverse communities alongside strategies addressing socioeconomic determinants of cardiovascular health.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients Aged 50 to 65 Years: A Propensity Score-Matched Five-Year Study.

Introduction Comparative long-term outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in younger patients remain incompletely defined, particularly beyond early follow-up. This study evaluated short-, mid-, and long-term outcomes between TAVR and SAVR in patients aged 50 to 65 years using a multicenter retrospective cohort. Methods Patients with aortic stenosis aged 50-65 years undergoing TAVR or SAVR were identified using the TriNetX database. Patients were matched 1:1 using propensity score matching (PSM). Outcomes were assessed at 30 days, 1 year, and 5 years. The primary endpoint was a composite of all-cause mortality or stroke; secondary endpoints included hospitalization, major bleeding, acute kidney injury (AKI), cardiogenic shock, and valve dysfunction. Hazard ratios (HRs) with 95% confidence intervals (CIs) were used to estimate the overall effect size. Results PSM yielded 1,041 well-balanced pairs. At 30 days, TAVR was associated with a lower risk of the primary composite endpoint (3.0% vs. 5.6%; HR 0.53; 95% CI 0.34-0.82; p=0.004), all-cause mortality (HR 0.50; p=0.03), major bleeding (HR 0.29; p<0.001), AKI (HR 0.39; p<0.001), and cardiogenic shock (HR 0.28; p<0.001). At 1 year, the composite endpoint, mortality, and stroke did not differ significantly between groups; major bleeding remained lower with TAVR (HR 0.50; p<0.001). At 5 years, TAVR was associated with higher risks of the primary composite endpoint (18.6% vs. 15.5%; HR 1.27; 95% CI 1.03-1.57; p=0.02) and all-cause mortality (13.7% vs. 8.3%; HR 1.81; 95% CI 1.39-2.37; p<0.001), while major bleeding remained lower (HR 0.65; p<0.001). Conclusion TAVR demonstrated early safety but a higher long-term risk of mortality and composite adverse outcomes at 5 years compared with SAVR.

Impact of Balloon Post-Dilatation Strategy During Transcatheter Aortic Valve Implantation on the Cardiac Conduction System.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become a well-established treatment for patients with severe aortic stenosis who are at intermediate or high surgical risk. Despite procedural advances, post-procedural conduction disturbances remain among the most common complications, particularly new-onset left bundle branch block (LBBB). This study aimed to investigate the impact of balloon pre- and post-dilatation on the cardiac conduction system during TAVI. METHOD: A retrospective analysis was conducted on 447 consecutive patients who underwent successful TAVI between June 2021 and June 2025. After excluding patients with baseline bundle branch block or permanent pacemaker rhythm, 282 patients were included. Standard 12-lead electrocardiograms were evaluated before and after TAVI. Post-procedural QRS prolongation was defined as QRS >120 ms, and logistic regression analysis was performed to identify predictors. RESULT: The mean age was 76.5 ± 6.9 years, and 63.8% of patients were female. Larger prosthesis diameter (OR = 1.173, 95% CI 1.082-1.271; P < .001) and post-dilatation (OR = 2.147, 95% CI 1.235-3.733; P = .007) were independently associated with QRS prolongation. Post-dilatation specifically correlated with new-onset LBBB but not with right bundle branch block (RBBB), intraventricular conduction delay, or high-grade atrioventricular (AV) block. No significant predictors were identified for permanent pacemaker implantation. CONCLUSION: Balloon post-dilatation during TAVI is an independent risk factor for the development of new-onset LBBB. Patients with pre-existing conduction abnormalities, such as RBBB or first-degree AVr block, should be monitored closely after post-dilatation, as LBBB may adversely affect left ventricular function and long-term clinical outcomes.

Mitral Transcatheter Edge-to-Edge Repair in Non-Surgical Candidates with Hypertrophic Obstructive Cardiomyopathy: Clip It, or Ablate It?

Hypertrophic cardiomyopathy (HCM), with or without obstructive phenomena, remains underdiagnosed and undertreated. This condition often involves pathological changes in the mitral valve leaflets and apparatus, which can lead to relevant mitral regurgitation (MR). The mechanism of MR is mostly related to the systolic anterior motion (SAM) of the anterior mitral leaflet. The treatment of patients with hypertrophic obstructive cardiomyopathy (HOCM) with persistent symptoms despite optimal pharmacological therapy includes septal myectomy or transcoronary ablation of septal hypertrophy (TASH). Percutaneous edge-to-edge repair of the mitral valve represents an innovative alternative therapy with promising results regarding clinical symptoms and echocardiographic findings. In this article, we provide a concise, critical overview of the current evidence on this technique in HOCM and delineate future perspectives and unresolved issues.

In-hospital outcomes of valve-in-valve vs. native valve transcatheter aortic valve implantation in Brazil: A propensity-matched analysis.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) has become the standard of care for elderly patients with severe aortic stenosis. While valve-in-valve TAVI (ViV-TAVI) offers a less invasive alternative to redo surgery in patients with degenerated surgical heart valves (SHV), evidence remains limited. METHODS: This is a retrospective study based on a Brazilian clinical registry of TAVI patients between January 2009 and December 2021. We compared ViV-TAVI patients with native aortic valve (NV-TAVI) patients. Temporal trends, procedural, and in-hospital outcomes were evaluated. We performed propensity score matching (PSM) and multivariable regression to adjust comparisons. RESULTS: Among 3194 patients from 25 centers, 135 underwent ViV-TAVI. The ViV volume increased slightly over time in proportion to NV-TAVI. After PSM, there were 127 ViV and 248 NV-TAVI patients. ViV patients had lower device success (71.7% vs. 87.9%; OR 0.35; 95% CI 0.20-0.60; p < 0.01) and permanent pacemaker implantation (4.7% vs. 12.9%; OR 0.35; 95% CI 0.13-0.79; p < 0.01) compared with NV-TAVI. Valve embolization was more frequent in ViV-TAVI (3.9% vs. 0.8%; OR 4.44; 95% CI 1.03-25.59; p = 0.04). Among ViV patients, no difference in embolization risk was detected (OR 1.11; 95% CI 0.18-11.80; p = 0.91) between radiopaque vs. radiolucent SHV. Major vascular complications, major or life-threatening bleeding, stroke, and in-hospital mortality did not differ significantly between groups. CONCLUSION: During the study period, a modest but significant increase was observed in the number of ViV-TAVI procedures. Device success and PPI were lower, and valve embolization was more frequent in ViV-TAVI compared with NV-TAVI. In-hospital safety outcomes did not differ between groups.

Indications and outcomes of non-emergent cardiac surgery following transcatheter aortic valve replacement.

OBJECTIVES: This study examined the indications, frequency, and outcomes of cardiac surgery following transcatheter aortic valve replacement (TAVR) at a single institution. As TAVR volumes increase, understanding the nature and outcomes of subsequent cardiac operations is critical, particularly as the procedure expands to younger, lower-risk populations. METHODS: We analyzed outcomes of 61 patients who underwent cardiac surgery after TAVR at our institution from August 2011 to September 2023, excluding periprocedural complications and staged procedures. Patients were stratified into two groups: those requiring surgical aortic valve replacement (SAVR) with or without concomitant procedures (n = 33) and those undergoing non-SAVR cardiac operations (n = 28). Data were collected from a prospectively maintained cardiovascular surgery database and electronic health records. Indications for surgery, operative characteristics, and outcomes were analyzed, with survival assessed using Kaplan-Meier estimates. RESULTS: The median interval between TAVR and cardiac surgery was 19 months. Indications for SAVR included infective endocarditis (36%), nonstructural valve deterioration (36%), structural valve deterioration (12%), and valve thrombosis (6%). Non-SAVR operations primarily addressed mitral valve disease (43%) and coronary artery disease (29%). Operative mortality was 6.6%, with no deaths in the endocarditis subgroup. Postoperative complications included prolonged mechanical ventilation (18%), new-onset renal failure (7%), and stroke (2%). Kaplan-Meier survival estimates were 83% at 1 year and 50% at 5 years. CONCLUSIONS: Although complex, cardiac operations in patients who have undergone TAVR can be performed with acceptable mortality rates. Structural valve deterioration, paravalvular leak, and endocarditis were the primary indications for SAVR, while mitral valve and coronary artery disease predominated in non-SAVR cases. These findings highlight the importance of considering nonaortic valve pathologies in TAVR planning, particularly as the procedure expands to younger, lower-risk populations.

Balloon - Assisted Transaxillary Artery Closure (BATAC); A novel vascular closure approach in patients undergoing TAVI via percutaneous transaxillary access.

BACKGROUND: Transaxillary (TAx) access has shown comparable outcomes to transfemoral access in selected studies of transcatheter aortic valve implantation (TAVI). Although TAx-TAVI has mainly been performed via surgical cutdown under general anesthesia, a fully percutaneous approach under local anesthesia with mild sedation has recently emerged as a less invasive option. OBJECTIVES: We present Balloon - Assisted Transaxillary Artery Closure (BATAC) approach and report our early clinical experience. METHODS: This observational study included consecutive adult patients with severe aortic stenosis who underwent simplified TAx-TAVI. Procedures were performed via left or right axillary access under ultrasound-guidance. Two ProStyles were pre-deployed, and the access sheath was progressively upsized over Amplatz Super Stiff wire. During closure, the Armada balloon was inflated at 2 atm via the ipsilateral arterial access at the site of the arteriotomy. With the balloon inflated, the ProStyle suture knots were sequentially advanced one-by-one under fluoroscopic guidance all the way to the arterial wall adjacent to the inflated balloon ensuring no entrapment within the surrounding soft tissue. RESULTS: Twelve patients underwent TAx-TAVI using this technique. Technical success was met in all patients, and device success in 91.7%. There were no in-hospital deaths, cerebrovascular events, major vascular complications, life-threatening bleeding, or need for vascular surgery. One patient developed cardiac tamponade requiring pericardial drainage, without transfusion. One minor access-site bleeding episode was managed conservatively. CONCLUSIONS: A simplified percutaneous axillary artery closure strategy following TAx-TAVI was associated with excellent early procedural and clinical outcomes in this small cohort. Larger studies are warranted to validate these findings.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Pre-Existing Permanent Pacemaker or Implantable Cardioverter-Defibrillator: A Nationwide Propensity-Matched Analysis.

Patients with severe aortic stenosis and a pre-existing permanent pacemaker (PPM) or implantable cardioverter-defibrillator represent a distinct subgroup in whom the usual pacemaker disadvantage of transcatheter aortic valve replacement (TAVR) is largely neutralized. We used the National Inpatient Sample 2016-2022 to compare isolated TAVR versus surgical aortic valve replacement (SAVR) in adults with aortic stenosis and pre-existing PPM/implantable cardioverter-defibrillator. After exclusions, 8776 hospitalizations were identified (8141 TAVR; 635 SAVR), and 501 well-balanced propensity-matched pairs were formed. The primary outcome was in-hospital all-cause mortality; secondary outcomes included major adverse cardiovascular and cerebrovascular events, procedural complications, length of stay, and discharge disposition. In the matched cohort, in-hospital mortality was lower after TAVR than SAVR (0.80% vs 2.59%; matched odds ratio 0.31, 95% confidence interval, 0.10-0.94; P = 0.049). TAVR was also associated with a lower major adverse cardiovascular and cerebrovascular events, stroke/transient ischemic attack, acute kidney injury, major bleeding/transfusion, cardiogenic shock, respiratory failure, lead revision, nonroutine discharge, and shorter length of stay, without excess new-pacemaker procedures. These findings support TAVR as a favorable strategy in selected patients already carrying cardiac rhythm devices.

Ventricular Migration of Transcatheter Valve During Transcatheter Aortic Valve Replacement After Valve-Sparing Root Replacement: A Case Report.

Transcatheter aortic valve replacement is increasingly used off-label for native aortic regurgitation in high surgical risk patients, although the absence of annular calcification-particularly after prior valve-sparing aortic root replacement-complicates valve anchoring and increases migration risk. We report a 66-year-old man with severe symptomatic aortic regurgitation after valve-sparing aortic root replacement and hemiarch repair who underwent transcatheter aortic valve replacement. Following deployment of a 29-mm Evolut FX+ valve (Medtronic), valve migration into the left ventricular outflow tract caused severe regurgitation and instability. A second 26-mm SAPIEN 3 Ultra valve (Edwards Lifesciences) was successfully implanted to stabilize the prosthesis, restoring competence and enabling uneventful recovery.

Emergency Valve-in-Valve Transcatheter Aortic Valve Implantation in a Patient With a Degenerated Surgical Xenograft and High Body Mass Index Presenting With Recurrent Pulseless Electrical Activity Arrest.

Degeneration of bioprosthetic aortic valves is a recognised late complication that may present with severe stenosis, regurgitation, or acute haemodynamic compromise. Redo surgical aortic valve replacement in patients with obesity and multiple comorbidities carries substantial perioperative risk, making valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) an important alternative. We report a middle-aged man with obesity and a prior bovine xenograft aortic valve replacement who presented with progressive heart failure, severe prosthetic aortic stenosis, and recurrent pulseless electrical activity arrest. He was stabilised with vasopressor support and emergency balloon aortic valvuloplasty before undergoing successful left transfemoral ViV-TAVI with coronary protection and common femoral artery repair. His postoperative course was complicated by delayed vascular infection and bleeding, requiring further surgical and endovascular intervention. This case highlights the role of urgent ViV-TAVI in critically unwell patients, the technical challenges of reintervention in obesity, and the importance of multidisciplinary management in complex structural heart disease.

International Age and Use Criteria for Transcatheter and Surgical Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have transformed the management of severe aortic stenosis across a wide range of patient risk profiles. As populations age and indications extend to lower-risk and younger patients, determining the appropriate role of age in selecting TAVR versus SAVR has become increasingly complex. Current guidelines emphasize individualized decision-making, yet age-based referral patterns remain common in clinical practice. This review examines how age thresholds are applied in contemporary guidance from the United States (US), Europe, and the Asia-Pacific region. Additionally, this review evaluates whether chronological age alone is a defensible basis for referral or treatment selection. This evidence-based narrative review queried PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) from January 1, 2013, through December 31, 2025, using the search terms: ("aortic stenosis" AND ("TAVR" OR "transcatheter aortic valve implantation (TAVI)" OR "SAVR")) AND ("age" OR "appropriateness"). English-language abstracts and full texts were screened in duplicate. Eligible studies included randomized controlled trials, national or continental registries, health economic simulations, and clinical practice guidelines that reported age-stratified outcomes or recommendations. Single-case reports, editorials, and animal studies were excluded. Of the 1628 titles screened, 87 full texts were reviewed, and 45 studies were retained. Across regions, guidelines converge on a core principle: age is informative but insufficient in isolation. U.S. guidance generally favors SAVR in patients younger than 65 years or those with a life expectancy greater than 20 years, and favors transfemoral TAVR in patients older than 80 years or with a life expectancy shorter than 10 years. European guidance typically favors SAVR in patients younger than 75 years and TAVR in those older than 75 years. Meanwhile, Asia-Pacific recommendations adopt a similarly individualized approach but place greater emphasis on bicuspid anatomy, rheumatic disease, local health system infrastructure, and cost. Recent data support a cautious approach in younger patients. In observational U.S. analyses of patients younger than 65 years, TAVR use increased substantially despite guideline preference for surgery, and TAVR was associated with higher long-term mortality or higher pacemaker and readmission burdens in selected cohorts. Contemporary randomized data suggest broadly similar outcomes between TAVR and SAVR in older or intermediate-age populations; however, uncertainty persists in younger low-risk patients, particularly those with bicuspid anatomy and long projected survival. Age-based cutoffs should be interpreted as decision anchors rather than rigid rules. The most defensible framework integrates age with life expectancy, valve durability, anatomy, frailty, comorbidity burden, coronary artery disease, feasibility of future valve-in-valve therapy, and patient preferences within a multidisciplinary heart team. Expansion of TAVR into younger populations should remain measured until more robust long-term durability and lifetime management data become available.

Long-Term Outcomes of a Self-Expanding Transcatheter Heart Valve.

BACKGROUND: Data on long-term outcomes and durability of the ACURATE neo valve are limited. This study aimed to obtain long-term outcome and echocardiographic data among ACURATE neo recipients. METHODS: Consecutive patients undergoing transfemoral transcatheter aortic valve implantation for severe native aortic stenosis from 4 centers using the ACURATE neo valve between 2012 and 2018 (n = 961) were included. Exclusion criteria for the durability analysis were 30-day mortality, valve-in-valve implantation or surgical aortic valve replacement within 30 days, and lack of echocardiographic follow-up (FU) beyond 30 days, leaving 758 patients included in the durability cohort. Primary endpoints were the cumulative incidence of late bioprosthetic valve failure (BVF), structural valve deterioration (SVD), and Kaplan-Meier estimates of all-cause mortality. RESULTS: In the overall cohort (median age of 82 years, 61.3% females, median and maximum FU time of 5.0 and 11.3 years), estimates of all-cause mortality at 1, 5, and 8 years were 13.6, 43.1, and 67.3%, respectively. In the durability cohort, the cumulative incidence was 3.5% for moderate SVD, 2.1% for severe SVD, and 3.2% for BVF at 8 years. Paired FU echocardiography beyond 5 years (n = 243, median FU time of 6.4 years) showed mean aortic valve gradients and effective orifice area of 9 mmHg and 1.8 cm2 post-transcatheter aortic valve implantation and 6 mmHg and 1.7 cm2 at final FU echo. CONCLUSIONS: In this multicenter observational cohort treated with the ACURATE neo platform, 8-year survival was 32.7%, and the cumulative incidence of severe SVD (2.1%) and BVF (3.2%) was limited. These findings provide long-term durability estimates in an elderly, real-world population.

Contrasting Impacts of Social Deprivation and Ethnicity on Transcatheter Aortic Valve Replacement vs Surgical Aortic Valve Replacement.

BACKGROUND: The association between social deprivation and cardiac valvular procedural outcomes is not well established. We sought to distinguish the relationship between social deprivation and outcomes after transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR). METHODS: Demographics, patient comorbidities, procedural details, and outcomes for adults undergoing TAVR and SAVR between April 2017 and March 2022 were obtained from clinical and administrative databases and linked to neighbourhood-level measures of social deprivation using the Ontario Marginalization Index in Ontario, Canada. Our outcomes were 30-day mortality, 30-day readmission, 1-year mortality, and 1-year readmission. Separate Cox proportional hazard models for postprocedural mortality and cause-specific hazard models for postprocedural readmission were used to determine the association between social deprivation and postprocedural outcomes after TAVR vs SAVR. RESULTS: We identified 6218 TAVR procedures and 3342 isolated SAVR procedures within our study period. After multivariable adjustment, TAVR was associated with lower 30-day mortality (hazard ratio [HR] 0.58; 95% confidence interval [CI] [0.37, 0.92]; P = 0.02), lower 30-day readmission rates (HR 0.75; 95% CI [0.63, 0.89]; P = 0.001), and a higher 1-year readmission rate (HR 1.14; 95% CI [1.02, 1.27]; P = 0.01), compared to SAVR. When the 3 index domains by treatment interactions were included in the analysis, the associations between TAVR and SAVR and these outcomes were not modified by the degree of neighbourhood social deprivation. CONCLUSIONS: TAVR is associated with lower 30-day mortality and 30-day readmission rates and higher 1-year readmission compared to SAVR. These associations were not modified by markers of social deprivation.

Iron deficiency and risk of acute kidney injury after TAVI: a machine learning analysis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become the preferred therapeutic option for patients with severe aortic stenosis (SAS) at high or intermediate surgical risk. Despite its minimally invasive nature, TAVI is frequently associated with post-procedural complications, among which acute kidney injury (AKI) represents a major clinical concern. Early identification of patients at increased risk for AKI remains a critical unmet need. METHODS: This retrospective, observational, single-center study enrolled consecutive patients with severe aortic stenosis who underwent TAVI between December 2022 and December 2023. The primary endpoint was to identify independent predictors of acute kidney injury (AKI) within 48 hours after TAVI. Secondary endpoint was to identify independent predictors of hospitalization for heart failure (HHF) during follow-up. Predictive modeling was conducted using the eXtreme Gradient Boosting (XGBoost) algorithm, with interpretability enhanced via SHapley Additive exPlanations (SHAP). RESULTS: A total of 116 patients were included (mean age 76±6.5 years; 57% male). Comorbidities were common, including heart failure (41%), coronary artery disease (32%), atrial fibrillation (41%), diabetes mellitus (29%), and chronic kidney disease (34%). Median EuroSCORE II was 2.1 (IQR 1.5-3.9). Median ferritin was 99.5 ng/mL (IQR 40-129), mean hemoglobin 12.3±1.7 g/dL and mean eGFR was 69.9±24.9 mL/min/1.73 m2. After TAVI procedure, AKI occurred in 9% of patients within 48 h. According to the SHAP analysis, ferritin and TSAT emerged as the two most influential features in AKI prediction. The machine learning model achieved high sensitivity (96%) and an F1-score of 0.98, suggesting strong clinical utility for early risk stratification. CONCLUSIONS: In patients undergoing TAVI, iron deficiency, as reflected by low ferritin and TSAT levels, emerged as independent predictors of early post-procedural AKI.

Emergency mitral valve transcatheter edge-to-edge repair in cardiogenic shock due to papillary muscle rupture.

UNLABELLED: Cardiogenic shock secondary to papillary muscle rupture carries high mortality and often precludes surgical repair. We present a case of acute mitral regurgitation following myocardial infarction managed with emergent transcatheter edge-to-edge repair (TEER) under combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and transvalvular assist device (Impella, Abiomed, Danvers, MA, USA) support. Real-time echocardiographic guidance required transient VA-ECMO flow reduction to optimize right atrial visualization and Impella adjustment to prevent device interference. Sequential clip deployment achieved significant mitral regurgitation reduction and hemodynamic improvement. This case highlights the feasibility, imaging challenges, and multidisciplinary coordination required for successful TEER in refractory cardiogenic shock. LEARNING OBJECTIVE: We illustrate the feasibility and technical nuances of performing transcatheter edge-to-edge mitral valve repair in cardiogenic shock due to papillary muscle rupture under combined veno-arterial extracorporeal membrane oxygenation and Impella support. This case emphasizes the critical role of real-time multimodality echocardiographic guidance, hemodynamic optimization through temporary device flow adjustments, and coordinated multidisciplinary decision-making in achieving procedural success when conventional surgical repair is not feasible.

Insights into a rare clinical phenomenon: Isolated native valve endocarditis subsequent to transcatheter prosthetic valve implantation.

INTRODUCTION: Prosthetic valve endocarditis (PVE) is a known complication of prosthetic valve implantation (PVI). Native valve endocarditis (INVE) without concurrent PVE, or isolated native valve endocarditis (INVE), after PVI is largely unheard of in literature. This review aims to identify the factors that predispose to INVE along with management and complications of INVE. METHODS: A review of four major databases was carried out to identify the incidence of INVE after various PVIs. INVE was compared to PVE in terms of patient demographics, PVI characteristics, pathogen types, management approaches, and outcomes. RESULTS: INVE was found in 119/645 (18.4%) cases after transcatheter aortic valve implantation (TAVI) and 9/138 (6.5%) cases after surgical aortic valve implantation (SAVI). INVE case distributions in the TAVI cohort were 87/119 (73.1%) on mitral valves and 32/119 (26.9%) on right heart valves. Corevalve implants were more closely linked to INVE than to transcatheter aortic valve implant endocarditis (TAVIE) at 67/119 (56.3%) vs 240/526 (45.6%) (OR = 1.55, CI 1.02-2.29, p = 0.036). Surgery was performed less frequently in INVE than TAVIE at 9/119 (7.6%) vs 130/526 (24.7%) (RR = 0.31, CI 0.16-0.58, p = 0.001). In hospital mortalities were less frequent in INVE than TAVIE at 22/119 (18.5%) vs 170/526 (32.3%) (RR 0.65, CI 0.45-0.94, p = 0.015). CONCLUSION: INVE makes up a measurable proportion of endocarditis cases after TAVI and frequently manifests on mitral valves. Compared to TAVIE, INVE is more likely to occur after Corevalve PVI, is amenable to medical therapy, and has lower rate of in hospital mortality. Surgical and non-aortic PVI based INVE is less frequently reported on and warrants investigation.

Percutaneous salvage of a failed 14F suture-mediated femoral closure using dual collagen-mediated vascular closure devices.

Transcatheter aortic valve replacement is performed via percutaneous femoral access; however, vascular complications can occur owing to the use of large-bore sheaths. We describe a novel technique for managing a failed suture-mediated percutaneous closure of a 14F arteriotomy using two collagen-based closure devices. We achieved hemostasis without loss of access and avoided an open surgical repair. This highlights the utility of dual MYNX (MYNX vascular closure device) as a rescue strategy for closing large diameter arteriotomies. Our experience suggests that this technique may be a salvage option in cases of suture-mediated closure failure, avoiding open repair.

Postural and workflow impacts from the implementation of a cardiovascular surgery/procedure instrument platform within an image-guided interventional environment.

BACKGROUND/OBJECTIVES: Image-guided surgical procedures have spatial constraints that complicate workflow, contributing to repetitive awkward turning and leaning postures. These postures, coupled with lead aprons for radiation protection, can cause Work-Related Musculoskeletal Disorders in the spine/shoulders. This study evaluates an intervention table for equipment in front of operators to reduce spatial constraints and physical risks. METHODS: Nine attending clinicians (8 male) and 3 fellows (2 male) performed Transcatheter Aortic Valve Replacement (TAVRs) at a quaternary academic hospital at baseline and with an intervention table. Postural data, turning patterns, and subjective workload were collected. RESULTS: 120 cases were collected (67 baseline, 53 intervention). The intervention table significantly reduced high-risk postures for the neck and the torso for attendings; while increasing risky postures for both shoulders compared to baseline. CONCLUSIONS: The intervention table may help neck and torso postures, with the trade-off being increased risks to the arms and shoulders.

Meta-Analysis of TAVR Versus SAVR in Bicuspid Valve: Mortality, Complications, and Long-Term Outcomes.

INTRODUCTION: Bicuspid Aortic Valve (BAV) is the most common congenital heart disease and often causes aortic stenosis in younger adults. There are few prospective randomized trials comparing Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement (SAVR) in BAV patients, since these patients are usually excluded from major studies because of their complex anatomy. A meta-analysis to compare clinical outcomes between TAVR and SAVR in people with BAV was conducted. METHODS: PubMed, Google Scholar, and SCOPUS were searched for studies published up to December 2023 that compared TAVR and SAVR in patients with BAV. The main outcomes that were examined were mortality, atrial fibrillation, permanent pacemaker implantation, stroke, respiratory complications, and acute kidney injury. Forward and backward citation searches were also used. Random-effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals, and heterogeneity was assessed using the I² statistic. Sensitivity analyses were performed by removing one study at a time. RESULTS: The analysis included seven studies with a total of 96,430 BAV patients. Of these, 41,110 had TAVR and 55,320 had SAVR. Patients who had TAVR were less likely to experience in-hospital respiratory complications, bleeding or need for transfusion, and new-onset atrial fibrillation. However, they were more likely to need a permanent pacemaker. There were no significant differences between the groups in short-term mortality, stroke, or acute kidney injury. DISCUSSION: Lower peri-procedural morbidity with TAVR likely reflects its minimally invasive nature, whereas higher pacemaker rates may relate to bicuspid valve anatomy and conduction system vulnerability. CONCLUSION: TAVR appears to be a reasonable alternative to SAVR in carefully selected BAV patients, but randomized trials and long-term follow-up remain necessary.

Balloon-Expandable Transcatheter Aortic Valve Implantation for LVAD-Associated Native Aortic Insufficiency: A Single-Center Experience.

BACKGROUND: Aortic insufficiency (AI) during long-term left ventricular assist device (LVAD) support creates a maladaptive recirculatory loop that impairs forward flow, increases left ventricular filling pressures, leading to progressive congestion, and accelerates right ventricular dysfunction. Surgical correction carries high risk, making transcatheter aortic valve implantation (TAVI) an alternative strategy, although outcomes are challenged by complex annular geometry and the absence of calcific anchoring. METHODS: We performed a retrospective single-center analysis of consecutive LVAD-supported patients undergoing TAVI for native AI. Annular sizing was area-based with a predefined oversizing strategy of approximately 15-30%, adjusted to annular geometry. Balloon-expandable valves were implanted using controlled deployment under rapid pacing and temporary LVAD flow reduction. Outcomes were assessed according to VARC-3 definitions. RESULTS: Fourteen patients underwent TAVI. The cohort demonstrated high anatomical complexity, including annular eccentricity (median 0.21 [IQR 0.19-0.23]), horizontal aorta (42.9%), and flared left ventricular outflow tract (LVOT) morphology (50%). Median annular area was 528 mm2 (IQR 487-574), with area-derived diameter 25.9 mm (IQR 24.9-27.0). Mean oversizing was 21.9% (median 20.0%; range 15.1-30.3%). Technical and VARC-3 device success were achieved in 71.4%. Second valve implantation occurred in 28.6%. Procedural mortality was 0%. In-hospital mortality (21.4%) was related to low cardiac output and multi-organ dysfunction rather than device failure. No survivor had moderate or greater residual AI at discharge. CONCLUSIONS: In anatomically complex LVAD patients, an anatomy-driven balloon-expandable TAVI strategy achieved elimination of clinically significant AI with zero procedural mortality. In our interpretation, mortality reflected the advanced stage of heart failure at the time of intervention rather than acute device-related failure.

The current and future in transcatheter treatment of aortic stenosis: from the 'beyond the guidelines' session at cardiovascular research technologies 2026.

The introduction of transcatheter aortic valve replacement (TAVR) over two decades ago has fundamentally reshaped the management and treatment landscape for the treatment of severe aortic stenosis by introducing a less invasive approach compared to a surgical aortic valve replacement (SAVR). The field continues to rapidly evolve as clinical studies expand the indications for TAVR across all surgical risk strata. However, it is unclear whether TAVR can be safely applied to patients with complex aortic valve and root pathologies as well as match the long-term durability demonstrated by SAVR. Thus, optimizing patient selection to maximize net clinical benefit, by defining the indications and limitations of TAVR, continue to be areas of active research and discourse. To this end, the annual 'Beyond the Guidelines' session at the 2026 Cardiovascular Research Technologies (CRT) convened an expert panel to highlight the current state of evidence, summarize the accumulated evidence in current domains of clinical equipoise where investigative efforts are focused, and identify key areas of clinical unmet need. This article summarizes the expert panel discussions of current evidence supporting the latest societal guidelines on management of severe aortic stenosis, the accumulation of investigative evidence in established clinical domains of equipoise including TAVR for aortic stenosis in asymptomatic patients; those with bicuspid aortic valves, treatment of transcatheter aortic valve failure, and expert opinions on emerging areas of unmet need where future investigative efforts may need to be focused.

Comparative environmental life cycle assessment between transfemoral transcatheter aortic valve implantation and isolated surgical aortic valve replacement.

BACKGROUND: Comparisons between transfemoral transcatheter aortic valve implantation (TF-TAVI) and surgical aortic valve replacement (SAVR) in severe aortic stenosis have demonstrated a consistent mortality benefit, lower 1 year costs and greater quality-adjusted life years in favour of TF-TAVI. However, the differences in the environmental impact of these two interventions have not yet been sufficiently investigated. The aim of the present study was to compare the intraprocedural environmental impact of these two procedures and to identify emission hotspots in order to mitigate their environmental impact. METHODS: In this prospective, observational, single-centre study, usage data were collected from 15 TF-TAVI and 15 SAVR procedures. All products, energy and water consumed during the procedures were identified and were used in a comprehensive comparative environmental life cycle assessment to quantify the intraprocedural environmental impact of these two interventions. RESULTS: Material use in SAVR amounted to 17.7 kg compared with 8.7 kg in TF-TAVI, consisting of 84% and 69% plastics, respectively. Electricity use in TF-TAVI was 52% less than in SAVR; in both interventions, energy consumption was dominated by the use of electronic devices. In SAVR, water consumption was 30 times higher than in TF-TAVI (5800 vs 194 L), mainly due to the heating cooling system of the cardiopulmonary bypass in SAVR. In all 10 calculated environmental impact categories, SAVR had a greater life-cycle impact. Its carbon footprint was 181.2 kg CO2-eq, compared with 68.6 kg CO2-eq per TF-TAVI. CONCLUSIONS: TF-TAVI outperformed SAVR in all environmental impact categories and had a carbon footprint of 38% that of SAVR. In TF-TAVI, 51% less material, 52% less energy and 97% less water were used. Despite these impressive results, there is still room for improvement in the environmental impact of TF-TAVI by using fewer disposable items, powering down idle imaging systems and introducing reusable/remanufactured valve delivery systems.

Impact of the 2019 Low-Risk Indication Expansion on Transcatheter Aortic Valve Replacement Utilization, Outcomes, and Disparities: A National Interrupted Time Series Analysis.

In August 2019, the U.S. Food and Drug Administration extended the indication for transcatheter aortic valve replacement (TAVR) to low-surgical-risk patients with severe aortic stenosis. We evaluated the impact of this policy on national utilization, clinical outcomes, and access equity using an interrupted time series analysis of 81,142 unweighted TAVR hospitalizations (405,710 survey-weighted) from the National Inpatient Sample (2016-2022) across 2955 hospitals. The primary exposure was the third-quarter 2019 low-risk expansion, and the primary outcome was in-hospital mortality. Segmented linear regression measured level and slope changes at the policy inflection point; secondary analyses included Oaxaca-Blinder decomposition of racial mortality disparities and inverse probability of treatment weighting. Annual TAVR volume increased 134%, from 33,545 in 2016 to 78,405 in 2022, while mean patient age fell from 79.7 to 78.2 years, and the low-risk proxy prevalence tripled from 2.0% to 6.0%. In-hospital mortality declined from 1.58% to 0.84%, with a significant favorable postexpansion slope change ( P < 0.001); stroke, permanent pacemaker implantation, vascular complications, and length of stay also improved (all P < 0.001), whereas acute kidney injury was unchanged. Access increased modestly for racial minorities and lower-income patients. The 2019 low-risk expansion was associated with substantial volume growth, a shift toward younger, lower-acuity patients, and improved or stable outcomes, but emerging racial disparities warrant targeted surveillance.

Long-term valve durability and clinical outcomes after transcatheter versus surgical aortic valve replacement in low-risk patients: a systematic review and meta-analysis of randomized trials.

Transcatheter aortic valve replacement (TAVR) has extended its use to low-surgical-risk populations, yet long-term comparative data against surgical aortic valve replacement (SAVR) are still limited, particularly concerning durability and the need for reintervention. We conducted a search of PubMed/MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov through March 2026 for randomized trials comparing TAVR with SAVR in patients with low surgical risk and severe aortic stenosis, specifically those with at least three years of follow-up. Outcomes were pooled as risk ratios (RR) using Mantel-Haenszel random-effects models, and durability and mortality outcomes were analyzed as time-to-event hazard ratios (HR) to accommodate different follow-up durations. Prespecified subgroup analyses by valve platform were performed. Four trials involving 3,014 patients (follow-up ranging from 3 to 10 years) were included. Cardiovascular mortality (HR 1.11, 95% CI 0.86-1.42; P = 0.43) and all-cause stroke (HR 1.09, 95% CI 0.73-1.64; P = 0.67) did not differ significantly between TAVR and SAVR. Aortic valve reintervention was higher with TAVR in risk-ratio analysis (RR 1.58, 95% CI 1.16-2.16) but did not reach statistical significance in the prespecified time-to-event analysis (HR 1.29, 95% CI 0.81-2.05). The excess reintervention risk was confined to the self-expanding valve platform. Permanent pacemaker implantation was significantly more frequent after TAVR (RR 2.08, 95% CI 1.48-2.93; P < 0.0001), with a significant interaction by valve platform (self-expanding RR 2.57 vs balloon-expandable RR 1.40; P = 0.02 for interaction). Bioprosthetic valve failure showed a nonsignificant trend favoring TAVR (HR 0.80, 95% CI 0.54-1.17). The only available 10-year randomized data (NOTION trial) showed significantly less severe structural valve deterioration with TAVR than with SAVR. The results suggest that TAVR and SAVR are equivalent in terms of cardiovascular mortality and stroke outcomes. However, pacemaker implantation rates were higher with TAVR and were strongly dependent on the valve platform used. The observed excess in reinterventions was confined to self-expanding valves and did not show robust support in the time-to-event analysis. The unique 10-year data from the self-expanding platform indicate less severe structural valve deterioration compared to SAVR, suggesting that durability should not be generalized across different device families. These findings advocate for individualized, platform-aware decision-making in clinical practice.

A critical appraisal of "A novel survival prediction model after isolated surgical aortic valve replacement in the transcatheter aortic valve replacement era".

Maeda et al. recently proposed a model to predict long-term survival after isolated surgical aortic valve replacement (SAVR) in the transcatheter aortic valve replacement (TAVR) era. While the model shows encouraging discrimination and calibration, several methodological and clinical limitations may restrict its broader applicability. The authors selected the final six-variable model primarily on the basis of maximal five-year C-statistic, without formal sample size justification or contemporary shrinkage-based criteria. Validation was restricted to internal resampling within the same registry, limiting evidence for transportability. Important prognostic domains, notably frailty and key anatomical and comorbidity variables, were not incorporated, and performance was not directly compared with established risk scores. Reporting only partially aligns with modern prediction model guidelines and omits decision curve analysis, leaving clinical utility uncertain. Overall, the model represents a valuable step but requires methodological refinement and external validation before guiding lifetime management between SAVR and TAVR.EBM Rating: Level V evidence. The article represents expert opinion derived from the author's clinical experience and interpretation of existing literature, without original experimental, randomized, controlled, cohort, or comparative analytic data.

Differential Effects of GLP-1 Receptor Agonist and SGLT2 Inhibitor Add-on Therapy on Outcomes Following Cardiac Surgery: A Propensity Score-Matched Analysis.

Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors (SGLT2is) reduce cardiovascular events in nonsurgical populations, yet their comparative effects as combination versus monotherapy after cardiac surgery remain unknown. Using the TriNetX US Collaborative Network (115 million patients, 67 healthcare organizations), we conducted a retrospective propensity score-matched cohort study of adults undergoing coronary artery bypass grafting or open valve surgery between January 2018 and January 2026, excluding transcatheter aortic valve replacement. Two prespecified analyses compared combination therapy (GLP-1 RA plus SGLT2i) with each monotherapy. One-to-one nearest-neighbor matching (caliper 0.1) balanced age, sex, race, ethnicity, comorbidities, and glycemic control. The primary outcome was all-cause mortality at 365 days, with prespecified subgroup analyses by heart failure (HF) and chronic kidney disease (CKD) status and sensitivity analyses at 180 and 600 days. After matching, Analysis 1 (combination vs GLP-1 RA monotherapy) included 6974 patients, and Analysis 2 (combination vs SGLT2i monotherapy) included 12,682 patients. Combination therapy was not associated with reduced mortality versus GLP-1 RA monotherapy overall (HR, 0.93; P = 0.587) but was associated with lower mortality versus SGLT2i monotherapy (HR, 0.60; P < 0.001), along with lower atrial fibrillation and major adverse cardiovascular events. The Analysis 1 mortality benefit emerged only in HF and CKD subgroups, with an acute kidney injury signal at 600 days. GLP-1 RA add-on therapy was associated with broad mortality reduction after cardiac surgery, whereas SGLT2i add-on benefit was confined to patients with HF or CKD, with potential renal risk in unselected patients. Prospective trials are warranted.

The Shifting Boundary Between Invasive and Non-Invasive Angiographic Investigation in Contemporary Cardiology and Cardiac Surgery: An Up-to-Date Narrative Review.

Background: Invasive coronary angiography has historically been the reference standard for coronary, valvular, and structural heart disease. Over the past decade, coronary computed tomography angiography (CCTA), CT-derived fractional flow reserve (CT-FFR), photon-counting detector computed tomography (PCCT), and cardiac magnetic resonance (CMR) have expanded the range of clinical questions answerable without an intra-arterial catheter, but this shift has been uneven across clinical domains. Methods: We performed a narrative review and synthesis of randomized trials, registries, society guidelines, and consensus documents (2009-2026) identified through PubMed and major cardiovascular guideline databases, written from a joint cardiology and cardiac-surgical standpoint. Results: The boundary has shifted asymmetrically, by which we mean a domain-dependent rather than uniform displacement of invasive angiography. Non-invasive imaging is now established as the first-line approach for stable chest pain at low-to-moderate pretest probability, for pre-transcatheter aortic valve replacement (TAVR) and structural procedural planning, and for aortic disease. It remains contested for stable multivessel disease and pre-coronary artery bypass grafting (CABG) planning, where CCTA- or CT-FFR-only planning is still investigational. Invasive angiography stays first-line for ST-elevation myocardial infarction (STEMI), cardiogenic shock, and complex percutaneous coronary intervention (PCI), where diagnosis and therapy are inseparable. Conclusions: Invasive and non-invasive modalities are complementary rather than competing. The appropriate first-line investigation depends on the disease domain, pretest probability, anatomical complexity, imaging quality, and whether diagnosis and treatment can be separated. We propose a complexity-stratified, heart-team framework and identify the surgical research gaps that remain.

A Comparison of Percutaneous Mitral Valve Repair and Surgical Mitral Valve Intervention: A Systematic Review and Meta-Analysis.

BACKGROUND & AIM: Transcatheter edge-to-edge repair (TEER) has expanded options for high-risk patients with severe mitral regurgitation (MR), however its longer-term performance relative to surgical mitral valve repair (SMVR) remains uncertain. This systematic review and meta-analysis compares the clinical outcomes of TEER versus SMVR in adults with MR. METHODS: We performed a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-guided systematic review and random-effects meta-analysis of randomised and comparative observational studies including adults with primary or secondary MR treated with TEER (MitraClip therapy) or SMVR. Primary outcomes were mortality, reintervention and recurrent ≥3+ MR; secondary outcomes included stroke, acute kidney injury (AKI) and permanent pacemaker implantation. Subgroup analyses explored modification by MR aetiology, study design and surgical strategy. RESULTS: Twenty-one studies (70,641 patients; 24,820 TEER, 45,821 SMVR) met the inclusion criteria. TEER recipients were older, more comorbid and had higher baseline risk. In-hospital and 30-day mortality were similar between strategies. At 1 year, mortality was significantly higher after TEER (risk ratio [RR] 1.58, 95% confidence interval [CI] 1.10-2.28). Within 1 year, reintervention was almost three-fold more frequent after TEER (RR 2.98, 95% CI 2.14-4.14), and recurrent ≥3+ MR was substantially higher both at approximately 1 year (RR 4.80, 95% CI 1.97-11.72) and 3 years (RR 6.51, 95% CI 2.60-16.29). TEER was associated with a lower 1-year stroke risk, while pooled AKI and pacemaker outcomes did not differ significantly. CONCLUSIONS: TEER is a short-term alternative for high-risk patients but demonstrates higher long-term recurrence and reintervention. SMVR remains superior for durability and survival. Further studies are needed to evaluate TEER in high-risk surgical cohorts.

Long-Term Outcomes After Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) is a more prevalent procedure than surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). With increasing TAVR utilization in young and low-risk patients, understanding long-term outcomes of TAVR is critical. Three randomized TAVR vs SAVR trials in patients with severe AS were identified with outcomes reported beyond 5 years: the NOTION (10-year outcomes), PARTNER 3 (7-year outcomes), and Evolut Low-Risk (6 year overall outcomes and 7 year reintervention data) trials. Primary trial outcomes, all of which were composite outcomes including all-cause mortality, stroke, myocardial infarction, and/or valve-, procedure-, or heart failure-related readmission, demonstrated similar outcomes between TAVR and SAVR (NOTION: 65.5% vs 65.5%, P=0.9; PARTNER 3: 34.6% vs 37.2%, HR 0.87 [95% CI 0.70-1.08]; Evolut Low Risk: 23.3% vs 20.4%, P=0.43). Amongst secondary outcomes, the cumulative incidence of TAVR reintervention was similar to SAVR reintervention in the NOTION trial (4.3% vs 2.2%, P=0.3) and the PARTNER 3 trial (6.7% vs 6.0%, HR 1.11 [0.63-1.94]), but TAVR reintervention was higher than SAVR reintervention in the Evolut Low-Risk trial (9.8% vs 6.0%; p=0.02). Study limitations include small cohort size (145 undergoing TAVR) of older patients undergoing TAVR with early generation self-expanding TAVRs in the NOTION trial and no data yet beyond 7 years in the PARTNER 3 and Evolut Low-Risk trials. Despite limitations, these data highlight the criticality in extremely careful patient selection for TAVR to optimize long term outcomes in the era of lifetime management of AS.

Study Design of the EDGEFIRM Trial: TEER Versus GDMT in Atrial Functional Mitral Regurgitation and HFpEF.

BACKGROUND: Over the past decade mitral valve transcatheter edge-to-edge repair (M-TEER) has become an established interventional treatment option for functional mitral regurgitation. One subtype that has recently gained increasing scientific attention is atrial functional mitral regurgitation (aFMR) occurring in patients with heart failure with preserved ejection fraction (HFpEF). Randomized trials to date have largely excluded patients with HFpEF, leading to limited data in this cohort. METHODS: The randomized evaluation of transcatheter edge-to-edge repair in patients with atrial functional mitral regurgitation and heart failure with preserved ejection fraction compared with GDMT (EDGEFIRM) is a prospective, open-label, randomized, multicentre trial evaluating the additive effect of M-TEER in patients with aFMR and HFpEF compared to guideline directed medical therapy (GDMT) only. Eligible patients must be symptomatic under stable GDMT with significant aFMR (> grade II or grade II with hemodynamic relevance) and HFpEF and considered high risk for surgical therapy by Heart Team evaluation. Randomization will be conducted in a 2:1 manner M-TEER + GDMT vs. GDMT only. The primary combined endpoint consists of cardiovascular mortality, heart failure hospitalization/worsening heart failure, improvement < 10 points in KCCQ-Score after one year. Secondary endpoints include reduction of mitral regurgitation, device safety, functional capacity as well as the individual components of the combined endpoint. CONCLUSION: The EDGEFIRM trial aims to evaluate the additive effect of M-TEER compared with GDMT only in patients with symptomatic aFMR and HFpEF.

Health Status Outcomes 7 Years After Transcatheter or Surgical Aortic Valve Replacement in Low-Surgical Risk Patients With Aortic Stenosis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) results in early improvements in health status outcomes relative to surgical aortic valve replacement (SAVR) in low-surgical risk patients with symptomatic severe aortic stenosis. However, long-term data comparing the detailed health status outcomes of these 2 treatments are lacking. OBJECTIVE: The purpose of this study was to compare long-term health status outcomes between TAVR and SAVR in low-risk patients and explore heterogeneity of treatment effect. METHODS: The PARTNER 3 (Placement of Aortic Transcatheter Valves) trial randomized patients with severe aortic stenosis and low surgical risk 1:1 to TAVR with a balloon-expandable valve vs SAVR. Health status was evaluated with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Short Form-36 Heath Survey at baseline and 1 month, 6 months, and annually from years 1 to 7. Between treatment group differences in health status scores over time were examined with mixed effects models for repeated measures adjusted for baseline. RESULTS: The analytic cohort included 943 patients enrolled in the PARTNER 3 trial who had baseline KCCQ assessments and underwent their assigned procedure (494 TAVR, 449 SAVR; mean age: 73.5 ± 5.9 years; 69.2% men; mean Society of Thoracic Surgeons-Predicted Risk of Mortality: 1.9% ± 0.6%; mean KCCQ-overall summary [KCCQ-OS] score: 70.9 ± 20.5). TAVR and SAVR both resulted in significant improvements in KCCQ and Short Form-36 Heath Survey summary scores relative to baseline through 7-year follow-up. KCCQ-OS scores were substantially higher at 1 month after TAVR vs SAVR (mean treatment difference: +16.2 points; 95% CI: 14.3-18.1) and remained modestly higher through 2 years of follow-up (mean difference at 2 years: +1.9 points; 95% CI: 0.2-3.7), but there were no significant between-group differences in years 3-7. At 7 years, ∼60% of patients in both treatment groups had an excellent outcome (alive, KCCQ-OS ≥75; no KCCQ-OS decline ≥10 from baseline). CONCLUSIONS: Patients with severe aortic stenosis at low surgical risk had substantial improvement in patient-reported health status with either TAVR or SAVR that was sustained through 7 years. Patients had earlier recovery with TAVR, but health status outcomes after 2 years were similar between treatment groups. (PARTNER 3 Trial: Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis; NCT02675114).

Comparative Analysis of Antithrombotic Strategies Following Valve-in-Valve Transcatheter Aortic Valve Implantation Using Real-World Registry Data.

BACKGROUND: Valve-in-valve transcatheter aortic valve implantation is a less invasive alternative to redo surgery for failed surgical bioprostheses, but optimal antithrombotic management is uncertain. OBJECTIVES: To compare outcomes across antithrombotic regimens after valve-in-valve procedures in real-world practice. METHODS: In the Australasian Cardiac Outcomes Registry (2018-2025), 1,050 adults were grouped by discharge regimen: single antiplatelet therapy, dual antiplatelet therapy, oral anticoagulation, or oral anticoagulation plus antiplatelet therapy. Outcomes included 30-day and 12-month mortality, stroke/TIA, life-threatening or major bleeding, major adverse cardiac and cerebrovascular events, and echocardiographic valve performance. RESULTS: Thirty-day mortality was higher with oral anticoagulation (1.7%) and combination therapy (3.6%) than with single or dual antiplatelet therapy (both 0%; p < 0.001). The 30-day MACCE rate was greater with oral anticoagulation (4.5%) and combination therapy (4.4%) than with single (1.5%) or dual antiplatelet therapy (0.4%) (p = 0.003); stroke/TIA and bleeding were infrequent and similar across groups. At 12 months, MACCE remained highest with oral anticoagulation (11.8%) and combination therapy (10.7%) compared with single (5.0%) and dual antiplatelet therapy (3.2%) (p = 0.001). Mortality at 12 months was numerically higher with oral anticoagulation or combination therapy (5.2% and 4.4%) than with single or dual antiplatelet therapy (1.8% and 2.4%) (p = 0.116). At 30 days, transvalvular gradients were lower in patients receiving oral anticoagulation-containing regimens; however, no significant differences in gradients, valve area, ejection fraction, or regurgitation were observed at 12 months. In multivariable analysis, combination therapy was independently associated with higher odds of 12-month MACCE compared with SAPT (OR 2.76, 95% CI 1.03-7.37; p = 0.043). Higher STS score and greater frailty were also independently associated with 12-month MACCE. CONCLUSIONS: In this observational cohort of patients undergoing valve-in-valve TAVI, oral anticoagulation-containing regimens were associated with higher early mortality and higher 12-month MACCE rates than antiplatelet-only strategies. However, these associations should be interpreted cautiously, as they likely reflect in part the greater baseline comorbidity burden of patients prescribed anticoagulation rather than a direct treatment effect. No sustained haemodynamic benefit was observed at 12 months. Individualised antithrombotic therapy and prospective randomised studies are warranted.

Transcatheter Versus Mechanical and Bioprosthetic Surgical Aortic Valve Replacement in Retrospective Patient Cohorts with Aortic Stenosis <75 Years.

Background: Comparisons between transcatheter and surgical aortic valve replacement (TAVR or SAVR) in younger aortic stenosis (AS) patients are scarce. The aim of the study was to evaluate the 5-year outcomes of AS patients <75 years undergoing TAVR or SAVR. Methods: This was a single-center study that retrospectively included AS patients <75 years who underwent transfemoral TAVR or SAVR from a Chinese real-world database (2014-2023). The primary outcome was defined as the composite of all-cause death, stroke, and cardiovascular rehospitalization at 5 years post-procedure. Robust risk adjustment was performed using inverse probability weighting (IPTW), multilevel regression models, and competing-risk analysis. Sensitivity analyses included comparison between TAVR and mechanical or bioprosthetic SAVR separately in the overall cohort and patients with bicuspid aortic valve (BAV). Results: A total of 1646 patients undergoing TAVR (n = 808) or SAVR (n = 838) were finally included. At baseline, TAVR patients had an older age [(67.9 ± 5.2) vs. (56.5 ± 9.6) years, p < 0.001] and a higher surgical risk score [(3.1 ± 1.5) vs. (2.1 ± 1.0) %, p < 0.001] than SAVR patients, which was well balanced after IPTW. The 5-year adjusted risk of the primary outcome was similar (TAVR 45.9% vs. SAVR 43.4%, weighted hazard ratio, 1.00, 95% confidence interval, 0.64-1.54, p = 0.986), which stayed comparable between TAVR and mechanical or bioprosthetic SAVR separately. In BAV patients (n = 516), the risk of death was 8.3% in the TAVR group and 3.4% in the SAVR group (p = 0.349). The risk of bioprosthetic structural valve deterioration at 5 years was comparable between groups in the overall cohort (5.7% vs. 8.4%, p = 0.478) and BAV patients (7.8% vs. 13.2%, p = 0.345). Conclusions: In this retrospective study of patients aged <75 years, the risk-adjusted 5-year major clinical outcomes were statistically similar between TAVR and SAVR. However, given the inherent historical imbalances, these exploratory findings should be interpreted with caution, and dedicated prospective studies are still needed in younger and BAV populations.

The SALZBURG Score: A Simple Clinical Tool for Long-Term Risk Stratification After Self-Expanding Transcatheter Aortic Valve Implantation.

BACKGROUND: Long-term survival after transcatheter aortic valve implantation (TAVI) remains difficult to estimate, and established risk scores perform suboptimally in this setting. We aimed to develop and externally validate a simple bedside score for prediction of long-term mortality after transfemoral TAVI. METHODS: In this multi-center study, 585 consecutive patients undergoing transfemoral TAVI with self-expanding valve systems comprised the derivation cohort, while 117 patients formed an independent external validation cohort. Predictors of 3-year all-cause mortality were identified using LASSO-Cox regression and multivariable Cox modeling. Model performance was assessed by discrimination, calibration, decision curve analysis, and net reclassification improvement. RESULTS: Six routinely available variables-age >80 years, male sex, eGFR <60 ml/min, atrial fibrillation, anemia, and diabetes mellitus-were incorporated into the SALZBURG Score (0-11 points). In the derivation cohort, the score predicted 3-year mortality with an AUC of 0.66 (95% CI 0.61-0.71), outperforming EuroSCORE II (0.56; p=0.002), the STS Score (0.57; p=0.005), and the TAVR-Risk Score (0.62; p=0.035), while showing similar discrimination compared with TAVI2-SCORe (0.63; p=0.166). Calibration was good across predefined risk groups, and risk reclassification improved compared with established surgical and TAVI-specific risk models. In the external validation cohort, discrimination remained stable (C-index 0.62; 95% CI 0.54-0.69). CONCLUSIONS: The SALZBURG Score is a simple and externally validated bedside tool for estimating long-term mortality risk after transfemoral TAVI using routinely available clinical variables. Pending validation in larger contemporary TAVI cohorts, it may serve as a complementary tool to support individualized long-term risk assessment and multidisciplinary Heart Team discussions.

Heyde Syndrome Complicated by Pulmonary Embolism Before Transcatheter Aortic Valve Replacement: A Clinical Dilemma Between Bleeding and Thrombosis.

BACKGROUND Heyde syndrome is an uncommon clinical entity characterized by severe aortic stenosis (AS) and acquired von Willebrand syndrome, typically presenting with recurrent gastrointestinal bleeding secondary to angiodysplasia. Although most reported cases involve isolated gastrointestinal bleeding, the coexistence of thromboembolic events is exceedingly rare and poses a significant therapeutic challenge in balancing hemostatic and anticoagulant strategies. CASE REPORT We report a 70-year-old woman who initially presented with massive hematochezia and subsequently developed dyspnea, requiring hospitalization. Physical examination revealed a prominent systolic murmur over the aortic area. Transthoracic echocardiography confirmed severe AS, with an aortic valve area of 0.8 cm² and a mean transvalvular pressure gradient of 71 mm Hg. Together with profound anemia (hemoglobin 44 g/L) and markedly reduced von Willebrand factor ristocetin cofactor activity (vWF: RCo, 25.3%), these findings supported the diagnosis of Heyde syndrome. During the preprocedural evaluation for transcatheter aortic valve replacement (TAVR), acute pulmonary embolism was incidentally identified on computed tomography pulmonary angiography. After hemostatic stabilization, anticoagulant therapy was cautiously initiated, resulting in complete resolution of the pulmonary embolism after 1 month. Given the elevated surgical risk (EuroSCORE II, 8.05%), the patient underwent successful TAVR. Following the procedure, the transvalvular pressure gradient normalized (mean, 13.8 mm Hg), with restoration of normal vWF activity. CONCLUSIONS This case underscores the therapeutic complexity of simultaneously managing hemorrhagic and thrombotic risks in Heyde syndrome. TAVR remains the definitive treatment for acquired von Willebrand syndrome, while a staged, individualized anticoagulation approach is crucial in patients with concomitant thromboembolic complications. Correcting the underlying AS remains the cornerstone of management.

Mortality predictors in cancer patients undergoing transcatheter aortic valve implantation for aortic stenosis: a systematic review and meta-analysis.

BACKGROUND: The coexistence of cancer and aortic stenosis is increasingly common in elderly patients, presenting unique challenges for management. Transcatheter aortic valve implantation (TAVI) offers a less invasive alternative to surgical valve replacement, but the impact of various clinical factors on post-TAVI mortality in cancer patients remains unclear. OBJECTIVE: To systematically review and meta-analyze the predictors of mortality in cancer patients undergoing TAVI for aortic stenosis. METHODS: A comprehensive literature search was conducted in Scopus, PubMed, Web of Science, and Embase up to May 2025. Studies assessing mortality predictors in cancer patients post-TAVI were included. Data extraction and quality assessment were performed independently by two reviewers. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analyses addressed within-study correlation assumptions, and heterogeneity was assessed using I² and τ² statistics. RESULTS: Five high-quality case-control studies, encompassing over 7,000 patients, were included. Advanced NYHA class (III/IV), prior myocardial infarction, atrial fibrillation, COPD, diabetes mellitus, and higher STS scores were robustly associated with increased mortality. Active cancer conferred a significantly higher mortality risk (HR 1.64, 95% CI: 1.17-2.30), while preserved left ventricular ejection fraction and renal function were linked to improved survival. Most predictors remained stable across sensitivity analyses, although the impact of cancer status varied with correlation assumptions. CONCLUSION: Both traditional cardiovascular and cancer-specific factors significantly influence mortality in cancer patients undergoing TAVI. These findings underscore the need for individualized, multidisciplinary risk assessment and highlight the importance of further research to refine patient selection and optimize outcomes in this growing patient population.

Low-Flow, Low-Gradient Aortic Stenosis in Transthyretin Cardiac Amyloidosis: Diagnostic and Therapeutic Challenges-A Case Report.

Background: In low-flow, low-gradient aortic stenosis (LFLG AS), restricted aortic valve opening may represent either fixed valvular obstruction or flow-dependent incomplete leaflet opening due to reduced forward flow. Aortic stenosis (AS) and transthyretin cardiac amyloidosis (ATTR-CM) may coexist, making it difficult to distinguish myocardial disease-driven low-flow physiology from clinically relevant valvular obstruction. Case Presentation: An 88-year-old man presented with decompensated heart failure and paradoxical LFLG AS. Dobutamine stress echocardiography (DSE) failed to restore normal flow, and the calculated aortic valve area remained within the severe range despite stress. Computed tomography showed a low aortic valve calcium score (AVCS) of 313 Agatston units, leaving true-severe versus pseudo-severe AS indeterminate. Further evaluation confirmed wild-type ATTR-CM. Because the contribution of AS to heart failure was uncertain, the patient was initially managed with optimized heart failure therapy. Approximately two years later, he was readmitted with recurrent acute decompensated heart failure, severe left ventricular systolic dysfunction, dobutamine dependency, end-organ congestion, and a classical LFLG AS phenotype. Although AS severity remained indeterminate, a clinically relevant valvular afterload component could not be excluded. At that time, tafamidis was not immediately available because of local access limitations. Because left ventricular assist device implantation and heart transplantation were not feasible and surgical aortic valve replacement carried prohibitive risk, transcatheter aortic valve implantation (TAVI) was performed after discussion by the Heart Team. Left ventricular ejection fraction improved early after TAVI, from 19.9% before the procedure to 29.4% at 3 days and 44.1% at 35 days. At 1-year follow-up, left ventricular ejection fraction remained improved at 51%, and more than two years after TAVI, the patient continues regular outpatient follow-up without recurrent heart failure hospitalization. Conclusions: In ATTR-CM with LFLG AS, DSE and AVCS may not definitively determine AS severity. Carefully selected TAVI, combined with ATTR-directed and optimized heart failure therapy, may be associated with early left ventricular functional recovery and sustained clinical improvement.

Evaluating the UNICA system for the treatment of severe tricuspid regurgitation.

Despite significant advances in transcatheter tricuspid valve repair and replacement (TTVR), a substantial proportion of patients with severe tricuspid regurgitation (TR) remain ineligible for currently available therapies due to anatomical constraints, advanced disease, or prohibitive procedural risk. Heterotopic valve implantation strategies, in which prosthetic valves are positioned outside the native tricuspid annulus, have emerged as alternative approaches for this challenging population. The UNICA system represents a novel single-stent, double valve heterotopic platform designed for patients with symptomatic severe TR who are unsuitable for surgical or transcatheter annular interventions. Early clinical experience suggests high technical success, short procedural times, favorable short-term safety, and meaningful improvements in functional status and quality of life. Mechanistically, the system offers potential advantages over existing TTVR devices by bypassing complex annular anatomy and simplifying procedural execution. Nevertheless, further prospective data is required to define long-term durability, optimal patient selection, and comparative effectiveness.

Left Internal Jugular Vein Access for Mitral Transcatheter Edge-to-Edge Repair: A Case Report and Review of Literature for Alternative Venous Access Routes.

BACKGROUND: The increasing indications of transcatheter edge-to-edge repair (TEER) have led to its use in more diverse populations, including patients with complex comorbidities where standard transfemoral access may not be feasible. In these cases, utilizing the right internal jugular vein (IJV) access has been reported as a safe and practical alternative route. Herein, we report the first case of mitral TEER via left IJV access, using PASCAL system. CASE PRESENTATION: A 50-year-old woman with long-standing chronic kidney disease and two previously failed renal transplants suffered repeated admissions for acute pulmonary edema. Echocardiography confirmed severe functional mitral regurgitation (MR) and global left ventricular systolic dysfunction. Due to extremely high surgical risk, the multidisciplinary heart team opted for mitral TEER. Unexpectedly, pre-procedural imaging demonstrated complete occlusion of the inferior vena cava with prominent collateral circulation and total occlusion of the right IJV. After extensive team discussion, access via the left IJV was selected. Transseptal puncture (TSP) was performed with the VersaCross radiofrequency system, the septum was dilated using a 6 mm Mustang balloon, and a PASCAL P10 device was successfully implanted between the A2 and P2 segments, resulting in reduction of MR severity from severe (4+) to mild (1+). The procedure concluded without complications and hemostasis was secured. At 2-month follow-up the patient remained stable with no recurrent decompensations. CONCLUSION: Left IJV is a feasible alternative access for mitral-TEER when other venous accesses are not feasible. Proper pre-procedural planning and local expertise is essential to overcome the technical challenges related to TSP and steering the guiding catheter against the complex anatomical orientation of the left innominate vein.

Comparison of robot-assisted surgical and transcatheter closure of secundum atrial septal defect: A single-center retrospective study.

BACKGROUND: Atrial septal defect (ASD) closure can be performed using either transcatheter or robot-assisted surgical approaches. This study aimed to compare the clinical outcomes, procedural characteristics, and complications associated with these two techniques in a large patient cohort. METHODS: A retrospective analysis was conducted on 635 patients who underwent ASD closure via either robot-assisted surgery (Group I, n=290) or transcatheter closure (Group II, n=345). Preoperative, perioperative, and postoperative data, including procedural times, complications, and follow-up outcomes, were evaluated. In addition, patients treated after 2019 were analyzed as a subgroup and categorized as Group Is (robot-assisted surgery, n=101) and Group IIs (transcatheter closure, n=105). RESULTS: Patients in Group I had significantly longer procedural times and hospital stays than those in Group II (p<0.001). Postoperative tricuspid regurgitation was more frequent in the transcatheter group (p=0.003). Device migration occurred in 3.2% of transcatheter cases. Overall neurological events occurred in 0.7% of Group I patients and 2.6% of Group II patients (p=0.06). No significant difference in postoperative arrhythmia rates was observed between the groups. In the subgroup analysis of patients treated after 2019, the mean hospital stay was 2.36±0.5 days in Group Is and 2.21±0.6 days in Group IIs (p=0.07). Ventilation time was 3.6±1.4 hours versus 3.1±1.9 hours (p=0.05), and intensive care unit stay was 7.8±2.9 hours versus 7.2±3.0 hours (p=0.20), respectively. CONCLUSION: Both transcatheter and robot-assisted surgical ASD closure are safe and effective when patients are appropriately selected. Robot-assisted surgery offers the additional advantage of concomitant tricuspid valve annuloplasty and demonstrates improved outcomes with increasing surgical experience. Larger prospective multicenter studies are needed to further validate these findings.

The Expanding Therapeutic Armamentarium for Mitral Regurgitation: Surgical and Transcatheter Interventions.

Background: Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases, with a rising global incidence. The 2025 European Society of Cardiology (ESC) guidelines introduced updated pathophysiological and morphological concepts for secondary MR, distinguishing ventricular and atrial mechanisms. Concurrent advances in cardiovascular imaging and therapeutic technologies have transformed the diagnostic and management landscape of MR. Methods: This review summarizes current evidence on the diagnosis and treatment of MR, with a focus on the updated ESC classification, multimodality cardiovascular imaging, minimally invasive surgical techniques, and contemporary transcatheter repair strategies. Recent literature was evaluated to highlight advances in anatomical assessment and individualized therapeutic approaches. Results: Multimodality imaging provides comprehensive evaluation of mitral valve anatomy, ventricular remodeling, and disease mechanisms, enabling accurate patient selection and procedural planning. Surgical management has evolved from conventional repair or replacement to minimally invasive approaches, including video-assisted right thoracotomy and robotic-assisted surgery, which have demonstrated favorable perioperative and clinical outcomes. In parallel, transcatheter interventions have expanded the therapeutic armamentarium for patients at high surgical risk or with complex anatomy. These include direct and indirect annuloplasty, transcatheter edge-to-edge repair, and emerging catheter-based repair technologies targeting specific structural abnormalities of the mitral valve apparatus. Conclusions: Contemporary management of MR requires an integrated understanding of disease pathophysiology, advanced imaging, and patient-specific anatomical characteristics. The combination of minimally invasive surgical techniques and rapidly evolving transcatheter interventions has broadened treatment options and supports a tailored, multidisciplinary approach to improve clinical outcomes and expand access to effective therapy for patients with severe MR.

Prognostic value of preoperative CT-derived fractional flow reserve after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis.

BACKGROUND: Patients with aortic stenosis (AS) often have concomitant coronary artery disease (CAD), and coronary CTA (CCTA) is performed for anatomical evaluation to inform coronary revascularization decision-making prior to aortic valve replacement (AVR). However, the role of coronary hemodynamic assessment in pre-AVR is not well established. We aim to evaluate the prognostic value of preoperative CT angiography-derived fractional flow reserve (CT-FFR) in patients with severe AS undergoing transcatheter (TAVR) or surgical aortic valve replacement (SAVR). METHODS: This consecutive retrospective observational cohort (July 2023-January 2025) included patients with severe AS referred to TAVR or SAVR. CT-FFR was obtained fully-automatic using an on-site machine learning algorithm, and a low value was defined as CT-FFR ≤ 0.80. The composite endpoint was a patient-oriented composite of all-cause mortality and major adverse cardiac events (MACE) (nonfatal myocardial infarction, unstable angina, cardiac death, cardiovascular-driven admission or heart failure admission). RESULTS: Among 329 patients (mean age 61.4 ± 13.1 years), composite endpoint occurred in 14.3% and all-cause mortality in 4.0% over a median follow-up of 17 months. After adjustment, CT-FFR ≤ 0.80 remained independently associated with the composite endpoint (HR 3.83; 95% CI 2.04-7.20; P < 0.001) and with MACE (HR 4.84; 95% CI 2.40-9.78; P < 0.001), but was not independently associated with all-cause mortality (P = 0.071). Adding CT-FFR to clinical models substantially improved risk discrimination for MACE (C-index 0.74) and significantly improved reclassification (NRI 0.346; P < 0.001), whereas adding anatomical CCTA alone provided minimal incremental value. CONCLUSION: In patients with severe AS undergoing TAVR or SAVR, preoperative CT-FFR was associated with an increased risk of post-AVR adverse cardiac events. The prognostic value of CT-FFR was consistent across both TAVR and SAVR populations and may improve individual-level risk reclassification.

The Hidden Burden of Iatrogenic Atrial Shunting in Severe Tricuspid Regurgitation: A Case Report.

BACKGROUND: Iatrogenic atrial septal defects (iASDs) following transseptal puncture are usually benign. However, in the presence of severe tricuspid regurgitation (TR), even small defects may become hemodynamically significant, leading to hypoxemia and worsening right heart failure. AIMS: To describe the clinical and hemodynamic consequences of a persistent iASD after heterotopic caval valve implantation in a patient with severe TR and the outcome of percutaneous ASD closure. METHODS AND RESULTS: We present the case of an 82-year-old woman with severe TR and a persistent iASD following atrial fibrillation ablation, who developed progressive exertional desaturation evolving into resting hypoxemia. Because of prohibitive surgical and transcatheter risk for tricuspid valve repair or replacement, a heterotopic caval valve implantation was performed as a palliative strategy to reduce systemic congestion. Although the procedure was technically successful, hypoxemia worsened due to increased right-to-left shunting. Percutaneous ASD closure resulted in immediate normalization of systemic oxygenation and substantial improvement in symptoms and exercise capacity. CONCLUSIONS: Heterotopic caval valve may increase right atrial pressure and unmask or exacerbate right-to-left shunting in patients with pre-existing interatrial defects. Comprehensive hemodynamic evaluation and a tailored, stepwise management strategy are essential.

First Report of Left-Sided Transvenous Pacemaker Implantation Through a Bicaval TricValve Prosthesis.

BACKGROUND: The transcatheter bicaval system is a heterotopic therapy option for patients with torrential tricuspid regurgitation (TR) at prohibitive surgical risk. Experience with permanent pacing in patients with bicaval prostheses remains extremely limited. CASE SUMMARY: An 83-year-old woman with chronic obstructive pulmonary disease, permanent atrial fibrillation, transfusion-dependent anemia, prior non-ST elevation myocardial infarction, and previous MitraClip implantation for severe mitral regurgitation presented with advanced right-sided heart failure and massive functional TR due to a 17 mm coaptation gap. Transcatheter tricuspid edge-to-edge repair was not feasible, and she underwent transcatheter bicaval system implantation with two nitinol stent-mounted bioprostheses in the superior and inferior vena cava, resulting in marked symptomatic improvement. Ten months later, she developed symptomatic bradycardia requiring permanent pacing. A single-chamber pacemaker was successfully implanted via the left subclavian vein after venography confirmed safe drainage of the left brachiocephalic vein into the superior vena cava, allowing safe passage of the pacing lead through the prosthetic stent struts. Electrical parameters were excellent, and 10-month follow-up confirmed stable function without lead or valve damage. DISCUSSION: This is, to our knowledge, the first published report of successful left-sided pacemaker implantation through a tricuspid bicaval prosthesis. Alternative pacing strategies, including conduction system pacing and leadless pacemakers, were carefully considered but deemed unsuitable because of anatomical and clinical constraints. Our case demonstrates that left-sided implantation can be performed safely when venographic anatomy allows. Careful pre-procedural imaging and meticulous lead navigation are essential to ensure prosthesis integrity and durable pacing performance.

Sequential transcatheter closure of sinus venosus and secundum atrial septal defects using covered stents and a septal occluder, a two-step strategy: a case report.

BACKGROUND: Superior sinus venosus atrial septal defect (SVASD) is an uncommon congenital anomaly frequently associated with partial anomalous pulmonary venous drainage (PAPVD). Surgical repair has traditionally been the standard treatment; however, transcatheter strategies have recently emerged as viable alternatives in selected patients. CASE PRESENTATION: We describe a 22-year-old Persian male with SVASD and PAPVD who underwent a staged transcatheter intervention. Initially, two PTFE-covered stents were deployed at the superior vena cava-right atrial junction to redirect pulmonary venous flow and exclude the defect. Due to residual shunting and persistent symptoms, a second procedure was performed, during which a septal occluder device was implanted to close the residual SVASD and a concomitant secundum ASD. The combined approach achieved effective defect closure and symptomatic improvement. CONCLUSION: This case illustrates the feasibility of a minimally invasive, staged endovascular strategy for complex SVASD with PAPVD. In carefully selected patients, this approach may represent an alternative to surgery.

Prosthesis-patient mismatch with intra-annular self-expanding valves: an analysis of the PORTICO IDE trial.

BACKGROUND: Aortic valve replacement in small aortic annuli is associated with an increased risk of impaired haemodynamics. AIMS: We sought to evaluate haemodynamic outcomes and prosthesis-patient mismatch (PPM) in aortic stenosis (AS) patients treated with Portico, Evolut, and SAPIEN 3 transcatheter aortic valves (TAVs) in small (diameter ≤23 mm) and large (diameter >23 mm) aortic annuli. METHODS: PORTICO IDE was a prospective, multicentre, international, premarket randomised controlled trial comparing Portico to Evolut and SAPIEN 3 TAVs. An independent core laboratory evaluated the mean transvalvular pressure gradient (MG) and the effective orifice area (EOA), and PPM was calculated based on the core lab results. RESULTS: A total of 675 patients with severe AS at high or extreme surgical risk were included (Portico: 362 patients; Evolut: 109; SAPIEN 3: 204). At 30 days, the EOA and rates of severe PPM in small aortic annuli were similar between Portico and Evolut (EOA 1.65 cm2 vs 1.78 cm2; p=0.09; PPM 3.3% vs 3.0%; p=1.0) with a higher MG (8.5 mmHg vs 6.9 mmHg; p=0.034) for Portico. No significant differences were observed between Portico and Evolut for large aortic annuli (MG 8.3 mmHg vs 7.4 mmHg; p=0.069; EOA 1.93 cm2 vs 2.02 cm2; p=0.18; PPM 5.4% vs 3.2%; p=0.83). Portico was superior to SAPIEN 3 in both small (MG 8.5 mmHg vs 13.7 mmHg; p<0.0001; EOA 1.65 cm2 vs 1.40 cm2; p<0.0001; PPM 3.3% vs 26.3%; p<0.0001) and large annuli (MG 8.3 mmHg vs 10.9 mmHg; p<0.0001; EOA 1.93 cm2 vs 1.67 cm2; p<0.0001; PPM 5.4% vs 10.9%; p=0.0014). At 5 years, the rate of structural valve deterioration in patients with small aortic annuli was significantly lower in patients treated with Portico (2.2%) versus SAPIEN 3 (13.9%; p=0.03). CONCLUSIONS: Haemodynamic performance was similar for the intra-annular Portico and supra-annular Evolut. Portico haemodynamics outperformed the balloon-expandable SAPIEN 3 for PPM and mean gradient in both small and large aortic annuli.

Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR): How It Started, How It's Going, and Where It's Going.

Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR) has come a long way since the first-in-human implant by Prof Cribier & colleagues in 2002. Initially a consideration for inoperable/high-surgical-risk patients, TAVI is now indicated in patients with severe tricuspid aortic stenosis and suitable anatomy aged 70 or higher. This has been made possible due to improvements in preprocedural planning, performance upgrades to and evolution of transcatheter heart valve (THV) systems and increasing operator experience. Younger age at index implantation, complexities of redo TAVI planning and methods to improve THV durability are the next frontiers. This review summarizes these advancements while emphasizing preprocedural planning, current guidelines, and individualized device selection, with a brief note on polymeric heart valves-developed to overcome the disadvantageous bioprosthetic dysfunction seen with current THVs.

Dual Coronary Sinus Lead Strategy to Avoid Tricuspid Valve Traversal in Biventricular Pacing.

Patients requiring permanent pacing after tricuspid valve intervention present challenges due to the need to cross tricuspid valve prostheses. We report three cases of successful dual coronary sinus (CS) lead implantation for biventricular pacing following a range of tricuspid interventions-surgical tricuspid annuloplasty, transcatheter edge-to-edge repair, and transcatheter tricuspid valve replacement. The approach avoided tricuspid valve traversal, was technically feasible and resulted in satisfactory pacing performance without procedural complications. Dual CS lead configurations were individualized based on CS anatomy and pacing characteristics. The degree of QRS narrowing achieved varied according to lead location and ventricular activation patterns, highlighting the importance of individualized lead placement strategies and device programming. Dual CS lead pacing may represent a viable alternative for biventricular pacing in selected patients with prior tricuspid valve interventions. Larger studies are needed to evaluate long-term outcomes and define the optimal role of this approach among available pacing strategies in this patient population.

GLP-1 Receptor Agonists in Cardiac Surgery: From Metabolic Drug to Potential Perioperative Cardioprotective Agent.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have rapidly evolved from glucose-lowering agents to central players in cardiovascular risk reduction. Evidence from landmark randomized controlled trials has established their capacity to reduce major adverse cardiovascular events, promote anti-inflammatory signaling, attenuate ischemia-reperfusion injury, and improve myocardial metabolic efficiency. As the prevalence of obesity, type 2 diabetes mellitus, and heart failure in the cardiac surgical population grows, GLP-1 RAs are increasingly encountered in the perioperative setting. Yet the cardiac surgery literature has yet to synthesize their emergent role coherently. This is a narrative review; no systematic review or meta-analysis was performed. This narrative review integrates mechanistic, clinical, and translational evidence to reframe GLP-1 RAs as potential perioperative cardioprotective agents in patients undergoing cardiac surgery. We examine receptor-level biology, evidence from the GLOBE randomized trial, observational data linking GLP-1 RA use to reduced postoperative atrial fibrillation after coronary artery bypass grafting, the rationale for the forthcoming REVERSE-TAVR trial, and evolving perioperative management guidelines. Key evidence gaps are identified, including the absence of prospective data in open cardiac surgery, aortic surgery, and high-acuity populations. We propose a research agenda and conceptual framework to guide future investigation into GLP-1 RAs as a new dimension of perioperative cardioprotection. The current evidence is hypothesis-generating; a definitive perioperative cardioprotective benefit has not yet been demonstrated in cardiac surgery populations, and these agents are presented here as potential rather than proven cardioprotective tools.

[Transcatheter Aortic Valve Implantation Using a Balloon-expandable Valve in Small Size Surgical Aortic Valve for Structural Valve Deterioration].

We report a case of transcatheter aortic valve-in-surgical aortic valve( TAV in SAV) implantation for structural valve deterioration of a small bioprosthetic valve. An 81-year-old woman presented with heart failure 19 years after aortic valve replacement using a 19-mm bioprosthetic valve. Imaging studies revealed severe prosthetic valve stenosis. Considering high surgical risk and anatomic feature of misalignment between the axis of ascending aorta and bioprosthetic valve, balloon-expandable transcatheter heart valve implantation was successfully performed via femoral approach without complications. Postoperative echocardiography showed improved hemodynamic condition and the patient became less symptomatic. During TAV in SAV for small bioprosthetic valve, valve selection should be individualized based on anatomical and clinical characteristics.

Intracardiac Neoplastic Extension of a Malignant Solitary Fibrous Tumor Mimicking a Giant Left Atrial Thrombus.

Intracardiac masses in patients with advanced malignancy pose a major diagnostic and therapeutic challenge, as neoplastic intravascular extension can closely mimic thrombus. We report a patient with metastatic malignant solitary fibrous tumor (SFT) who presented with a giant multilobulated left atrial mass (>5 cm) initially suspected to represent thrombus. Transthoracic and transesophageal echocardiography demonstrated a highly mobile mass prolapsing through the mitral valve into the left ventricle during diastole, with no right-sided involvement, no significant valvular pathology, and no history of atrial fibrillation or structural heart disease. Given the imminent risk of systemic embolization or mitral valve obstruction, therapeutic anticoagulation was started, and the mass was surgically resected after multidisciplinary discussion. Histopathology demonstrated an intravascular malignant neoplasm of epithelioid cells, with severe nuclear atypia, brisk mitotic activity, and a hemangiopericytoma-like vascular pattern; tumor cells were STAT6-positive, confirming metastatic malignant SFT. This case illustrates the diagnostic difficulty of distinguishing thrombus from neoplastic intravascular extension in cancer patients and underscores the complementary roles of echocardiography and histopathological confirmation in guiding urgent, multidisciplinary management of highly mobile left atrial masses.

Ebstein Anomaly: Imaging, Pathophysiology, and Therapeutics.

Ebstein anomaly is a rare congenital malformation defined by failed delamination and apical displacement of the tricuspid valve, which produces an atrialized segment of the right ventricle and variable right ventricular dysfunction. Its clinical expression is wide, ranging from severe neonatal cyanosis and heart failure, which carry high perinatal mortality, to incidental detection in adulthood. Because anatomy and physiology vary widely among patients, imaging is central to diagnosis, risk stratification, and treatment planning. Transthoracic echocardiography remains the first-line study and establishes the diagnosis through apical leaflet displacement, leaflet tethering, and right atrial dilation; three-dimensional and transesophageal echocardiography refine the assessment of leaflet morphology and the atrialized right ventricle. Cardiac magnetic resonance imaging quantifies right ventricular and right atrial volumes, ejection fraction, regurgitant volume, and myocardial fibrosis, and increasingly informs the timing of surgery; computed tomography is a complement when magnetic resonance is contraindicated or extracardiac anatomy must be defined. Management is guided by current European and North American congenital heart disease guidelines and is matched to symptom burden and anatomy. Transplacental non-steroidal anti-inflammatory drugs may relieve the circular shunt in selected fetuses. Cone reconstruction has become the preferred surgical repair, with valve replacement reserved for valves deemed unsuitable. Catheter-based options, including device closure of interatrial communications, accessory-pathway ablation, and transcatheter tricuspid valve-in-valve implantation, address specific problems in higher-risk patients, although dedicated transcatheter replacement remains investigational in this population. Long-term care depends on serial imaging to detect residual regurgitation, progressive ventricular dysfunction, and arrhythmia. This review summarizes the anatomy, pathophysiology, multimodality imaging, and contemporary therapy of Ebstein anomaly, with emphasis on how imaging findings translate into clinical decisions.

Forgotten but Striking: Complete Tricuspid Valve Degeneration Unmasked by Lancisi's Sign.

Tricuspid regurgitation (TR) is increasingly recognized as an important cause of right-sided heart failure and adverse clinical outcomes. Although severe TR typically presents with a holosystolic murmur, advanced disease may produce atypical findings that obscure the diagnosis. Lancisi's sign, characterized by prominent systolic jugular venous pulsations, remains an important but underrecognized bedside clue to severe TR. We present the case of a 60-year-old man with a remote history of presumed infective endocarditis who presented with progressive dyspnea, anasarca, and peripheral edema. Physical examination revealed marked systolic jugular venous pulsations consistent with Lancisi's sign but no audible cardiac murmur. Transthoracic echocardiography demonstrated complete degeneration of the tricuspid valve leaflets, torrential TR, massive right-sided chamber dilation, and right atrial ventricularization. Doppler interrogation confirmed rapid pressure equalization between the right atrium and right ventricle. Given the advanced right-sided remodeling and evidence of end-organ involvement, the patient was deemed unsuitable for surgical or transcatheter intervention and was managed medically. This case highlights the diagnostic value of careful physical examination and illustrates how severe TR may present without its classic auscultatory findings. Early recognition of bedside signs such as Lancisi's sign may facilitate timely diagnosis before progression to irreversible right-sided heart failure.

Valve-in-Ring TMVR Following Antegrade Base-to-Tip LAMPOON With ELASTIC on VA-ECMO Support: A Case Report.

Transcatheter mitral valve replacement (TMVR) in failed surgical rings with an Alfieri stich represents a therapeutic challenge. A 70-year-old man with prior robotic surgical mitral valve repair with an incomplete ring and an Alfieri stich presented with acute decompensated heart failure and was found to have severe mitral regurgitation and pulmonary hypertension. He was deemed not to be suitable for redo surgery. Preprocedural computed tomography demonstrated anterior mitral leaflet length of 29 mm, indicative of high-risk for dynamic left ventricular outflow tract obstruction. This case described the successful combination of antegrade laceration of the anterior mitral valve leaflet to prevent outflow obstruction and electrosurgical laceration of Alfieri stitch to facilitate valve-in-ring TMVR while on venoarterial extracorporeal membrane oxygenation support to prevent hemodynamic compromise during high-risk valve-in-ring TMVR.

Cost-Effectiveness of Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo-Surgical Aortic Valve Replacement for Degenerated Bioprosthetic Aortic Valve.

BACKGROUND: Degenerated bioprosthetic aortic valves are associated with substantial morbidity, mortality, and health care resource use. Treatment options include redo-surgical aortic valve replacement (redo-SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). ViV-TAVR has been associated with shorter length of stay, but its higher device costs have raised uncertainty about its overall economic value. We constructed a decision-analytic model to compare the cost-effectiveness of ViV-TAVR vs redo-SAVR for the management of degenerated bioprosthetic aortic valves. METHODS: Cost-effectiveness was evaluated by calculating deaths averted and incremental cost-effectiveness ratios (ICERs). The main outcome was ICER defined as US dollars/deaths averted. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. RESULTS: In the probabilistic analysis, the mean total cost of ViV-TAVR was $88,829 (95% CI, $88,554-$89,104) with a 2-month survival probability of 0.97 (95% CI, 0.969-0.970). For redo-SAVR, the mean cost was $91,411 (95% CI, $91,163-$91,659) with a 2-month survival probability of 0.96 (95% CI, 0.959-0.961). ViV-TAVR was the dominant strategy, resulting in a mean ICER of -$259,323 per death averted (95% CI, -$304,599 to -$220,679). ViV-TAVR was cost effective in 57% to 58% of simulations for willingness-to-pay thresholds ranging from $0 to $150,000. CONCLUSIONS: ViV-TAVR is an economically dominant strategy for the management of degenerated bioprosthetic aortic valves, yielding lower costs and marginally improved short-term survival relative to redo-SAVR. However, given a moderate degree of decisional uncertainty, trial-level comparative data and longer-term modeling are required to refine these estimates.

Surgical Aortic Valve Replacement Following Transcatheter Aortic Valve Implantation Degeneration in a Patient with Prior David Procedure: A Case Report.

This is the first reported case of a self-expanding aortic valve explanted from the ascending aorta consisting of a Dacron prosthesis. We describe a 75-year-old male with bicuspid aortic valve regurgitation initially treated with a David procedure. Following degeneration, a "valve-in-repaired-valve" transcatheter aortic valve implantation (TAVI) was performed. Six years later, he presented with dyspnea, severe insufficiency, and paravalvular leakage. An interdisciplinary team opted for redo surgery. The patient underwent successful redo aortic valve replacement with an EpicMax bioprosthesis via resternotomy. Despite a complex postoperative course, he recovered well. This case underscores key challenges in lifetime management, including TAVI durability, sizing, and reoperative strategies.

Comparing outcomes of TAVI and SAVR in low or intermediate risk symptomatic severe aortic stenosis: a systematic review and meta-analysis.

OBJECTIVES: To compare the mortality and clinical outcomes of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with low- or intermediate-risk symptomatic severe aortic stenosis through an updated systematic review and meta-analysis of randomized controlled trials. METHODS: This systematic review was performed using PubMed, Medline, Embase, and Cochrane databases for RCTS between 2017 and 2024 which evaluated mortality outcomes in patients with low to intermediate risk AS who received TAVI vs. SAVR. Relative risks (RRs) with 95 % confidence intervals (CIs) were pooled using random effects models. RESULTS: TAVI showed a numerically lower but statistically insignificant mortality risk compared to SAVR (RR: 0.88, 95 % CI: 0.62-1.25, p=0.49). TAVI was associated with a higher risk of PPM insertion (RR: 2.19, 95 % CI: 1.55-3.16, p<0.001, i2: 80 %), aortic valve re-intervention (RR: 2.51, 95 % CI: 1.40-4.51, p<0.001; I2=0 %), new-onset bundle branch block (RR: 2.10, 95 % CI: 1.21-3.67, p<0.01; I2=84 %), and vascular site complications (RR: 4.77, 95 % CI: 2.11-10.81, p<0.001; I2=62 %). Atrial fibrillation incidence was lower with TAVI (RR: 0.29, 95 % CI: 0.23-0.38, p<0.001; I2=73). There was no significant difference in the rates of post-procedural myocardial infarction, stroke and endocarditis between TAVI and SAVR. CONCLUSIONS: TAVI has mortality outcomes comparable to SAVR in low to intermediate risk patients. TAVI offers advantages in atrial fibrillation reduction, but is associated with increased risk of PPM insertion, vascular complications, new-onset bundle branch block, aortic valve re-intervention. Individualized treatment decisions remain important for optimizing outcomes in low to intermediate risk patients. PROSPERO REGISTRATION NUMBER: CRD42024547882.

Nickel Allergy in Cardiothoracic Surgery: A Case Report.

BACKGROUND: Metal hypersensitivity represents a rare but important challenge in cardiothoracic surgery, particularly during prosthesis selection for aortic valve replacement. CASE DESCRIPTION: A 63-year-old woman with critical bicuspid aortic stenosis and moderate left ventricular dysfunction was found to have severe hypersensitivity to multiple metal alloys, including nickel, palladium, and iridium. Following multidisciplinary evaluation, standard surgical aortic valve replacement was considered unsafe. A transfemoral transcatheter aortic valve implantation using a cobalt-chromium transcatheter valve was successfully performed without complications. CONCLUSION: This case highlights the importance of individualized, multidisciplinary decision-making when managing patients with significant metal hypersensitivity.

Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients: A Systematic Review of Long-Term Outcomes.

The role of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS) continues to expand, yet uncertainty remains regarding the long-term outcomes in low-risk populations compared with surgical aortic valve replacement (SAVR). This systematic review examined long-term mortality, stroke, postoperative complications, and valve durability across randomized and observational studies. Randomized data showed similar long-term survival and stroke rates between TAVR and SAVR, while observational studies suggested worse late outcomes following TAVR. TAVR was consistently associated with fewer postoperative complications, whereas durability and re-intervention findings varied across studies. Overall, these results suggest that while TAVR offers meaningful advantages, treatment decisions should be individualized to balance a patient's comorbidities with long-term procedural outcomes.

Thoracic endovascular aortic repair for iatrogenic descending aortic pseudoaneurysm after aborted transcatheter aortic valve implantation.

Iatrogenic aortic injury is a rare but life-threatening complication of transcatheter aortic valve implantation (TAVI). Descending thoracic aortic pseudoaneurysms are particularly uncommon and challenging to manage. We report an 88-year-old woman with prior type A dissection treated with a Bentall procedure and Carpentier-Edwards Perimount bioprosthesis, who developed severe valve stenosis. An initial transfemoral TAVI failed due to unfavorable descending thoracic aortic anatomy. One year later, angiography revealed a descending thoracic aortic pseudoaneurysm, which was likely related to the prior procedure. Given the high surgical risk, staged management was performed: thoracic endovascular aortic repair followed by successful transapical valve-in-valve TAVI.

A hybrid biofabrication platform for patient-specific aortic phantoms: from surgical rehearsal to device testing.

Fabricating high-fidelity, patient-specific aortic phantoms that possess both complex pathological features and physiological compliance remains a significant challenge for single-method manufacturing techniques. This study presents a complete virtual-to-physical prototyping workflow, enabled by a novel Hybrid Additive Manufacturing Platform (HAMP), for translating clinical imaging data into high-fidelity, patient-specific aortic phantoms. Building upon a validated brush-spin-coating technique capable of precise wall thickness control (±0.1 mm), the HAMP synergistically integrates 3D printing and casting. This integration overcomes the limitations of single-method techniques, uniquely enabling the creation of phantoms with (i) controllable interlayer delamination for mimicking dissection, (ii) enclosed multi-chamber structures for endoleak simulation, (iii) seamless integration of dissimilar materials, and (iv) the replication of complex intra-wall pathologies such as intramural hematoma. The platform's capability was rigorously demonstrated through the successful fabrication and application of four distinct classes of aortic phantoms. These high-fidelity models were directly employed in: fundamental biomechanical studies to visualize dissection propagation; advanced surgical training for complex procedures like ex vivo fenestration; emergency preoperative planning, where a patient-specific model was delivered in under 30 h; and industrial medical device testing using parametric, ISO-compliant models. In each scenario, the phantoms provided functional, anatomically accurate representations suitable for the intended evaluation-whether physical testing, surgical rehearsal, or hydrodynamic assessment. In summary, the HAMP demonstrates a rapid virtual-to-physical prototyping workflow. By enabling the on-demand creation of complex, multi-material, patient-specific phantoms, it provides a versatile tool that bridges digital data and physical reality, addressing needs across research, clinical training, and device development.

Surgical management of concomitant lung cancer and cardiovascular diseases: a multidisciplinary perspective.

Lung cancer and cardiovascular diseases (CVDs) frequently coexist due to shared risk factors such as aging, smoking, and chronic inflammation. The growing prevalence of elderly surgical candidates with concomitant lung cancer and CVDs presents unique diagnostic and therapeutic challenges. This review explores current strategies for managing such patients, emphasizing the importance of individualized, multidisciplinary treatment planning. Advances in minimally invasive pulmonary resection and parenchymal -sparing surgery-such as segmentectomy-have expanded surgical options, especially in frail patients. Simultaneously, improvements in cardiovascular therapies, including transcatheter aortic valve implantation (TAVI), thoracic endovascular aortic repair (TEVAR), and off-pump coronary artery bypass grafting (OPCAB), have enabled safer, staged approaches. Guideline-directed preoperative risk assessment from Japanese, American, and European societies underscores the need for tailored sequencing of cardiac and oncologic interventions. In general, a staged approach with initial cardiac stabilization followed by pulmonary resection is preferred. However, simultaneous surgery, especially OPCAB combined with pulmonary resection, may be feasible in carefully selected patients. Additionally, the cardiac toxicity of immune checkpoint inhibitors and EGFR-TKIs must be considered when planning neoadjuvant treatment. Integrating cardiovascular expertise into thoracic oncology is crucial to optimizing outcomes in this complex population.

Association Between Aortic Valve Mean Gradient and TAVR Outcomes: A Perspective From a Nationwide Registry.

BACKGROUND: Patients with severe aortic stenosis with very low resting aortic valve mean gradient (MG) are underrepresented in transcatheter aortic valve replacement (TAVR) studies. We investigated the association of resting aortic valve MG with post-TAVR outcomes in a large nationwide cohort. METHODS: We included patients from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with a self-expanding Evolut TAVR (until December 2022) and eligible for 1-year follow-up without prior balloon aortic valvuloplasty, TAVR, or surgical aortic valve replacement. RESULTS: Among 80 429 patients (mean age, 80.7±7.9; women, 53.9%; high/extreme surgery risk, 51.2%) stratified into 6 echocardiographic resting aortic valve MG groups (10-<20, 20-<25, 25-<30, 30-<35, 35-<40, ≥40 mmHg), 1 year, all-cause mortality increased progressively across decreasing MG subgroups (from 9.3%, ≥40 mmHg to 20.9%, 10-<20 mmHg; P<0.001; 10.8% entire cohort), as did hospital readmission. Kansas City Cardiomyopathy Questionnaire scores increased progressively across increasing MG subgroups (P<0.001 at all time points). The Valve Academic Research Consortium 3 Kansas City Cardiomyopathy Questionnaire ordinal outcome improved substantially/moderately for all subgroups (1 year ≥52% patients). After multiple imputation for missing covariate data, Cox regression adjusting for clinically relevant baseline factors demonstrated a significant association between baseline MG and 1-year mortality (hazard ratio, 0.93 [95% CI, 0.91-0.94]; P<0.001). CONCLUSIONS: Baseline aortic valve MG is an important predictor of 1-year all-cause mortality in patients with severe aortic stenosis undergoing TAVR. Most patients undergoing TAVR had considerably improved quality-of-life assessments regardless of resting MG. Additional studies should elucidate mechanisms associated with MG-mortality risk and whether improved patient selection can further improve outcomes.

Multidisciplinary Heart Team Model to Deliver Advanced Cardiovascular Care in a Public Safety-Net Hospital.

BACKGROUND: Implementation of guideline-supported Multidisciplinary Heart Teams (MHT) for the management of complex cardiovascular disease has not been described in a public safety-net hospital setting. In May 2023, an MHT was established at Los Angeles General Medical Center to deliver comprehensive cardiovascular care to an underserved population in a resource-constrained setting. METHODS: We conducted a retrospective review of all cases discussed by a comprehensive MHT at Los Angeles General Medical Center from May 24, 2023 through January 21, 2026. The MHT convenes weekly in a hybrid format, using a privacy-compliant centralized platform for longitudinal care coordination. Referral pathways extend to affiliated safety-net clinics and hospitals. RESULTS: During the study period, the MHT discussed 494 patients, including 369 (74.7%) with any valvular disease, 78 (15.8%) with complex coronary disease, 29 (5.9%) with congenital heart disease, and 33 (6.7%) with endocarditis. The patient cohort reflected a high prevalence of health care disparities, with 93.9% reporting a race or ethnicity other than non-Hispanic White, a high proportion with publicly funded (69.0% Medicaid) or uninsured (3.6%) status, and frequent substance use disorders (28.1%). The MHT generated consensus recommendations including cardiac surgery (99 [20.0%]), transcatheter intervention (122 [24.7%]), complex percutaneous coronary intervention (30 [6.1%]), and medical management (149 [30.2%]). In-hospital mortality was low among patients who underwent surgical or percutaneous procedure (9 [3.6%]). Programmatic growth included development of a transcatheter valve repair program and increased complexity of cardiac surgical case volume. CONCLUSIONS: Establishment of an MHT in a resource-constrained public safety-net hospital was feasible and sustainable. Our model may serve as a blueprint to deliver guideline-concordant cardiovascular therapies to underserved populations.

Transcatheter Edge-to-Edge Repair With MitraClip G4 System Compared With PASCAL System in Patients With Functional Mitral Regurgitation: A Propensity Score-Matched Analysis.

BACKGROUND: Functional mitral regurgitation (FMR), resulting from left ventricular dysfunction or left atrial dilation, is associated with heart failure and increased mortality. Mitral transcatheter edge-to-edge repair is an established treatment for patients with severe symptomatic FMR who are at high surgical risk. However, comparative data on the 2 most commonly used mitral transcatheter edge-to-edge repair systems, MitraClip G4 and PASCAL, remain limited. This study compared the safety and efficacy of both devices in patients with FMR. METHODS: Consecutive patients with severe symptomatic FMR who underwent mitral transcatheter edge-to-edge repair using MitraClip G4 or PASCAL between 2021 and 2023 at a single center were included. Coprimary end points were 1-year survival and freedom from heart failure hospitalization. Secondary end points included MR reduction and New York Heart Association functional class. Propensity score matching was performed to adjust for baseline differences. RESULTS: The study included 319 patients, of whom 150 (47.0%) were treated with MitraClip G4 and 169 (53.0%) with PASCAL. After propensity score matching, 116 matched pairs were analyzed. Procedural success, defined as MR grade ≤2, was achieved in 98.1% of the MitraClip G4 group and 97.3% of the PASCAL group (P=0.61). At 1 year, no significant differences were observed between groups regarding residual MR (P=0.83), New York Heart Association class (P=0.41), or freedom from heart failure hospitalization (P=0.41). Estimated 1-year survival was 86.7% for MitraClip G4 and 87.8% for PASCAL (P=0.84). CONCLUSIONS: In patients with FMR, MitraClip G4 and PASCAL demonstrated similarly high procedural success, durable MR reduction, and comparable clinical outcomes at 1 year.

Novel Bailout for Pulsta Valve Embolization: Microporous Endograft Fixation at the SVC-RA Junction in Repaired Tetralogy of Fallot With Severe Pulmonary Regurgitation.

This report describes a 47‑year‑old woman with a history of repaired tetralogy of Fallot presenting with a massively dilated native right ventricular outflow tract (RVOT) and enlarged pulmonary arteries. She underwent bilateral branch pulmonary artery valve implantation using self-expanding Pulsta valves. Early embolization of the left pulmonary artery valve necessitated a complex percutaneous rescue, including balloon anchoring, through-and-through wiring, and stepwise relocation. Following a subsequent embolization into the right ventricle resulting in tricuspid entrapment, emergent surgical retrieval was recommended but declined by the patient's family. Consequently, the migrated prosthesis was ultimately managed via definitive fixation at the superior vena cava-right atrium (SVC-RA) junction using an off-label, fenestrated thoracic covered stent. This approach successfully avoided emergent redo sternotomy, illustrating a novel and effective transcatheter bailout strategy for embolized pulmonary valves in challenging RVOT anatomies when surgical intervention is refused.

Early Multicenter Outcomes of Dedicated Transcatheter Aortic Valve Replacement for Left Ventricular Assist Device-Associated Pure Aortic Regurgitation.

BACKGROUND: Aortic regurgitation (AR) is a frequent and clinically relevant complication in patients with left ventricular assist devices (LVAD), impairing circulatory support and worsening outcomes. Surgical aortic valve replacement often carries prohibitive risk in this population, while conventional transcatheter aortic valve replacement (TAVR) is limited by the lack of annular calcification. The JenaValve Trilogy is the first transfemoral TAVR system with regulatory approval for AR. Evidence on its use in LVAD patients remains scarce. METHODS: We conducted a retrospective multicenter registry of LVAD recipients undergoing JenaValve Trilogy implantation for pure AR between 2020 and 2026 at five high-volume centers in Germany and the United States. Patient characteristics, procedural details, and outcomes were analyzed. The primary endpoint was device success according to Valve Academic Research Consortium-3 (VARC-3) criteria at 30 days. Secondary endpoints included peri-procedural complications, mortality, and device-related reinterventions at follow-up. RESULTS: Thirty patients (median age 66 years, 36.7% female, median LVAD support time: four years) were included. One patient did not meet criteria for technical success, and one experienced a fatal hemorrhagic stroke on postoperative day 2, rendering device success 93.3% (28/30). 30-day mortality was 3.3% (1/30). At a median follow-up of 273 days (IQR 30-491), survival was 93.3% (28/30). CONCLUSION: This first multicenter experience demonstrates that JenaValve Trilogy provides a feasible and safe treatment option for clinically significant AR in LVAD patients at prohibitive surgical risk, with high device success and favorable short-term outcomes.

Valve-Preserving Repair of Very Late Type A Aortic Dissection Following Self-Expanding TAVI in an Octogenarian Patient: Case Report and Focused Narrative Review of the Literature.

Introduction: Acute type A aortic dissection (ATAAD) is a rare but potentially catastrophic complication following transcatheter aortic valve implantation (TAVI). Most reported cases occur during or shortly after the procedure and are attributed to procedural aortic injury. Very late presentations occurring years after successful TAVI are exceptionally uncommon, and evidence regarding their optimal management remains limited. Case Presentation: An 86-year-old man presented with acute chest pain four years after transfemoral implantation of a self-expanding Evolut R 29-mm transcatheter heart valve. Transthoracic echocardiography revealed pericardial effusion with signs of impending cardiac tamponade. Computed tomography angiography confirmed Stanford type A acute aortic dissection involving the ascending aorta. Emergency surgical repair was performed through replacement of the ascending aorta and hemiarch using a vascular graft. The previously implanted transcatheter valve was preserved because it remained structurally intact and functionally normal. The postoperative course was uneventful, and the patient was discharged on postoperative day 9 with preserved prosthetic valve function (mean gradient 11 mmHg, peak velocity of 2.1 m/s, EOA 1.8 cm2, EF 50%, TAPSE 18 mm and no evidence of paravalvular or intraprosthetic regurgitation). Discussion: To better contextualize this rare presentation, a focused review of the literature on delayed and late ATAAD after TAVI was performed. Only a limited number of cases were identified, highlighting the exceptional rarity of this complication. Reported management strategies included conservative treatment, endovascular interventions, and open surgical repair, with considerable heterogeneity in outcomes. Compared with previously published reports, the present case is notable for the exceptionally long interval between TAVI and dissection onset and for the successful valve-preserving surgical repair. These findings suggest that emergency surgery with preservation of a functioning transcatheter valve may be a feasible option in carefully selected patients. Conclusions: Very late ATAAD after TAVI is an exceptionally rare but life-threatening condition. This case demonstrates that valve-preserving surgical repair can be successfully performed even in selected octogenarian patients. As the population of long-term TAVI survivors continues to expand, awareness of late aortic complications, prompt diagnosis, and referral to specialized aortic centers remain essential for achieving favorable outcomes.

Remodel the Failed Trifecta or Not: That Is a Question.

Using a high-pressure balloon to do bioprosthetic valve remodeling (BVR) for a failed surgical non-fracturable aortic valve is thought to improve the expansion of a transcatheter heart valve (THV) during valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). However, the risks and benefits of this approach remain under debate. We present two cases of failed bioprosthetic aortic valves (Trifecta 19 mm and 21 mm, Abbott Vascular) receiving ViV-TAVR using balloon-expandable valves (Sapien 3 20-mm, Edwards Lifesciences). In one patient, an ATLAS GOLD balloon catheter (20 mm, BD, Franklin Lakes, New Jersey, USA) was used to do BVR. In the other patient, a double-tap technique with the same volume balloon post-dilatation was performed without BVR. Both procedures were successful, with notable clinical improvement. The post-TAVR computed tomography and transthoracic echocardiogram were performed 1 month after the procedure which demonstrated comparable hemodynamic results; however, the THV deformation was more pronounced in the patient who underwent BVR. Importantly, the THV-to-coronary ostium distance in this patient decreased unexpectedly from 5 mm to near 0 mm over right coronary artery. These cases illustrate that using a high-pressure balloon to perform BVR in a non-fracturable surgical valve had limited impact on THV expansion at the annular level. Conversely, unpredictable over-expansion of the THV in the outflow portion may pose an increased risk to the coronaries, even when the valve-to-coronary distance is long prior to the valve-in-valve TAVR procedure.

Contemporary Management of Failed Tricuspid Valve Prosthesis.

Failure of tricuspid valve prostheses is an increasingly encountered and complex clinical problem. Patients often present with advanced comorbidities, progressive right ventricular dysfunction, and prohibitive surgical risk. Despite growing burden, high-quality evidence and clear guideline-directed strategies remain limited. This narrative review summarizes contemporary approaches to the management of failed tricuspid valve prostheses, which include traditional redosurgical re-intervention, minimal invasive and beating-heart surgical techniques, and transcatheter valve-in-valve and valve-in-ring implantation, as well as emerging therapies for failed transcatheter tricuspid devices. Redo tricuspid valve surgery has historically carried substantial perioperative risk, although outcomes have improved at experienced centers, particularly with less invasive surgical approaches. Transcatheter valve-in-valve and valve-in-ring procedures demonstrate a high procedural success rate and favorable early outcomes in selected patient profiles with failed bioprosthetic valves or annuloplasty rings. However, durability beyond short to mid-term remains uncertain, especially in younger individuals. Given the heterogeneity of the prosthesis types and patients' profiles, the management should be individualized. A multidisciplinary Heart Team approach that integrates surgical risk, right ventricular function, prosthesis characteristics, and anatomic considerations is essential to optimize outcomes in this high-risk patient population. Given the limited and heterogeneous nature of currently available evidence, this review was designed as a clinically focused narrative review rather than a formal systematic review or meta-analysis.

Outcomes of single versus double Perclose suture device use after transfemoral transcatheter procedures using large-bore arterial access: A meta-analysis and systematic review.

BACKGROUND: In large-bore transfemoral procedures such as transcatheter aortic valve replacement and endovascular aneurysm repair, the comparative effectiveness of single (SP) versus the default double Perclose (DP) strategies for arterial closure remains uncertain. METHODS: We performed a systematic literature search in PubMed, Scopus, Web of Science, and the Cochrane Library from January 2014 to April 2026 to identify studies comparing SP and DP devices for large-bore transfemoral arterial access closure. Outcomes included device/technical success, need for unplanned surgical or catheter-based intervention, 30-day mortality, any vascular complication, major bleeding, arterial dissection, and arterial stenosis. Random-effects meta-analysis using inverse-variance weighting was performed, and heterogeneity was assessed using the I2 statistic. RESULTS: We identified 14 studies published or available between 2015 and 2026, comprising 6487 patients before matching or adjustment (SP 3518; DP 2969). Post-matching adjusted cohorts comprised 5077 patients (SP 2691; DP 2386). Comparing SP with DP, device/technical success was similar (RR 1.02, 95% CI 1.00-1.03; P = 0.07), as was the need for unplanned surgical/catheter intervention (RR 0.77, 95% CI 0.54-1.09; P = 0.14). There were no significant differences in overall vascular complications (RR 0.78, 95% CI 0.59-1.04; P = 0.09), major bleeding (RR 0.83, 95% CI 0.51-1.36; P = 0.46), arterial stenosis (RR 0.81, 95% CI 0.55-1.20; P = 0.30), or 30-day mortality (RR 0.99, 95% CI 0.65-1.50; P = 0.96). However, SP was associated with a lower risk of arterial dissection (RR 0.32, 95% CI 0.15-0.70; P = 0.004). CONCLUSION: In large-bore transfemoral transcatheter procedures, a single Perclose strategy was associated with a lower risk of arterial dissection compared to double Perclose and no significant difference for other major outcomes and complications.

Redo-Transcatheter Aortic Valve Implantation Versus Surgical Explantation in Patients With Previous Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis.

BACKGROUND: As transcatheter aortic valve implantation (TAVI) expands to younger and lower-risk populations, failed transcatheter heart valves are increasingly encountered, yet the optimal reintervention strategy remains uncertain. This meta-analysis aimed to compare the outcomes of redo-TAVI (TAVI-in-TAVI) versus surgical transcatheter heart valve explantation with surgical aortic valve replacement (TAVI-explantation) after transcatheter heart valve failure. METHODS: PubMed/Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched from inception to September 10, 2025 for comparative studies. The primary outcome was all-cause mortality (in-hospital, 30-day, and 1-year). Secondary outcomes included cerebrovascular events, major adverse cardiac events, permanent pacemaker implantation, greater-than-mild paravalvular leak, major bleeding, length of stay, and 30-day readmission. As the primary analysis, reconstructed individual patient-level data were analyzed using Firth penalized logistic regression adjusting for study, and complementary random-effects meta-analyses were also used. RESULTS: Eight observational studies including 6166 patients (3743 redo-TAVI; 2425 TAVI-explantation) were analyzed. Compared with TAVI-explantation, redo-TAVI was associated with lower in-hospital mortality (odds ratio [OR], 0.20 [95% CI, 0.11-0.35]; P<0.0001), 30-day mortality (OR, 0.28 [95% CI, 0.23-0.34]; P<0.0001), and 1-year mortality (OR, 0.70 [95% CI, 0.62-0.80]; P<0.0001). No significant differences were observed in cerebrovascular events or permanent pacemaker implantation rates. Redo-TAVI was associated with lower major bleeding (OR, 0.35 [95% CI, 0.24-0.50]; P<0.0001), fewer 30-day readmissions (OR, 0.53 [95% CI, 0.30-0.92]; P=0.023), and shorter hospitalization (Mean Difference -6.29 days [95% CI, -8.66 to -3.93), but a higher risk of greater-than-mild paravalvular leak (OR, 80.12 [95% CI, 11.30-10 153]; P<0.0001). CONCLUSIONS: Redo-TAVI was associated with lower early and 1-year mortality, reduced bleeding, and shorter hospitalization compared with TAVI-explantation, with similar cerebrovascular event and permanent pacemaker implantation rates but higher paravalvular leak risk. These findings support redo-TAVI as the preferred reintervention strategy in anatomically suitable patients, whereas randomized trials and longer-term follow-up are needed to refine lifetime management strategies after transcatheter heart valve failure.

Staged Therapeutic Approach to Concomitant Severe Aortic Stenosis and Atrial Septal Defect: Addressing Dual Mechanisms of Heart Failure-Case Report and Literature Review.

BACKGROUND: Severe aortic stenosis (AS) remains the most prevalent primary valvular disease in Europe and North America, causing heart failure (HF), with pulmonary hypertension (PH) occurring in up to 75% of symptomatic patients. The coexistence of AS and atrial septal defect (ASD) is rare and may generate dual mechanisms of PH, complicating both diagnosis and management. Case summary and review: We report a 78-year-old patient with symptomatic severe AS and right heart failure, in whom an unrecognized secundum ASD with significant left-to-right shunt was identified as a major contributor to persistent HF and right ventricular (RV) dysfunction. Due to prohibitive surgical risk, a staged interventional strategy was decided: transcatheter aortic valve implantation (TAVI), followed by cardiac catheterization and ultimately by percutaneous ASD closure. Marked clinical benefit with the reduction of the RV dimensions and improved systolic function were observed at one year follow-up. A focused review of the literature was conducted to contextualize the pathophysiological mechanisms, diagnostic challenges, and therapeutic strategies in patients with coexisting AS and ASD. CONCLUSIONS: This case emphasizes the importance of comprehensive hemodynamic assessment in AS complicated by PH and HF, particularly in the presence of congenital anomalies such as ASD.

Four-Dimensional Cine Cinematic Rendering of Structural Heart and Mechanical Circulatory Support Devices: An Illustrative Technical Experience.

Patients with implanted cardiac devices are a rapidly growing imaging population, and electrocardiogram-gated cardiac computed tomography (CT) is increasingly used to characterize device geometry, multi-device relationships, and dynamic behavior across the cardiac cycle. Cinematic rendering (CR) is a photorealistic three-dimensional (3D) visualization technique for cardiac CT whose established contribution in this population is communicative: it conveys 3D device geometry and material distinctions within a single rendered volume. We describe a demonstrative case series extending CR across the cardiac cycle-time-resolved "4D cine" CR-to depict dynamic device behavior and time-resolved multi-device interaction in a single volume; this is an illustrative technical experience rather than a systematic evaluation of diagnostic performance. Illustrative examples include an EVOQUE transcatheter tricuspid valve rendered together with concurrent surgical mitral and transcatheter aortic valves, a left atrial appendage occlusion device, a normally positioned Impella catheter, and a HeartMate 3 left ventricular assist device (LVAD). Across cases, 4D cine CR feasibility scaled inversely with metallic burden-the aggregate volume and radiodensity of metallic device components within the scan field-with renderings informative for low-metal nitinol and catheter devices but substantially degraded by streak artifact in high-metal LVAD housings. This relationship was observed qualitatively in a small selected series and is offered as an initial observation rather than an established characteristic of the technique. We discuss current limitations and emerging directions such as photon-counting detector CT, metal artifact reduction, and artificial-intelligence-assisted post-processing that may extend 4D cine CR in this population.

Comparative outcomes of balloon-expandable versus self-expanding transcatheter aortic valves: insights from a large-scale German registry.

BACKGROUND: While transcatheter aortic valve replacement (TAVR) has become an established alternative to surgical aortic valve replacement (SAVR), the comparative outcomes of balloon-expandable (BE) and self-expanding (SE) valve technologies remain an area of ongoing investigation. METHODS: Using the German DESTATIS database, we analyzed 48,565 transfemoral TAVR procedures performed between 2021 and 2022. Outcomes were compared between BE (n = 23,412) and SE (n = 25,153) valves using a double/debiased machine learning estimator to account for potential confounding. Key endpoints included in-hospital mortality, major bleeding, stroke, acute kidney injury, mechanical ventilation > 48 h, postoperative delirium, permanent pacemaker implantation (PPI), length of hospital stay, and reimbursement. RESULTS: Descriptively, SE valves were associated with significantly lower in-hospital mortality (1.6% vs. 2.0%, p < 0.001) and major bleeding (1.4% vs. 2.1%, p < 0.001) but a higher risk of stroke (2.4% vs. 1.9%, p < 0.001). A trend towards higher risk of PPI was observed (p = 0.078). After adjustment, patients with SE valves are at lower risk for in-hospital mortality (RR 0.85, p = 0.049) and major bleeding (RR 0.78, p = 0.006), but had a higher risk of stroke (RR 1.35, p < 0.001) and permanent pacemaker implantation (RR 1.09, p = 0.028). Subgroup analysis indicated that older and high-risk patients, particularly those aged ≥ 85 years, showed a stronger association with lower in-hospital mortality for SE valves, whereas younger patients exhibited a trend favouring BE valves. BE valves were also associated with a modestly higher reimbursement (€209 per case, p = 0.004). CONCLUSION: In this large, real-world cohort, self-expanding valves were associated with lower in-hospital mortality and major bleeding but a higher risk of stroke and permanent pacemaker implantation compared with balloon-expandable valves. Because prosthesis choice in routine practice is highly individualized and driven by anatomical and procedural factors not captured in administrative data, these associations are hypothesis-generating and cannot support device-selection recommendations.

Invasive and echocardiographic gradients of self- and balloon-expandable valves in failing aortic bioprostheses.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an established treatment for a failing aortic bioprosthesis. The hemodynamics of TAVI in degenerated transcatheter or surgical aortic valves (TAV-in-TAV or TAV-in-SAV) are unknown. We aimed to investigate hemodynamic differences between self- and balloon-expandable TAV-in-TAV and TAV-in-SAV groups, and transthoracic echocardiography-derived (TTE) versus invasive transaortic pressure gradients. METHODS: Patients ≥ 18 years with a self-expanding EVOLUT (SEV) or balloon-expandable SAPIEN3 (BEV) valve for TAV-in-TAV or TAV-in-SAV were included. Transaortic gradients were determined invasively and by TTE within 48 h post-intervention. RESULTS: We identified 56 patients with SEV (n = 36) or BEV (n = 20) TAV in a failing aortic bioprosthesis. Fourteen cases involved failing transcatheter valves and 42 surgical bioprostheses. Invasive mean gradients were similar after BEV and SEV (median (25th-75th percentile): 6.0 (1.5-6.5) vs 7.0 (2.0-10.0) mm Hg, p = 0.109). Mean gradients by TTE were higher for BEV than SEV at discharge (16.0 (10.8-19.8) versus 10.0 (7.0-12.0) mm Hg, p = 0.003) and 12-month follow-up (13.0 (11.0-15.5) versus 9.0 (7.0-12.3) mm Hg, p = 0.025). The discrepancy between TTE and invasive mean gradients was significantly larger for BEV than SEV (13.0 (6.3-14.0) vs 3.0 (1.5-8.3) mm Hg, p = 0.001) and most pronounced in TAV-in-SAV (BEV 13.0 (6.3-17.0) vs SEV 3.0 (1.0-8.5) mm Hg, p = 0.004). CONCLUSION: Mean gradient after TAV in a failing bioprosthesis is similar for BEV and SEV, when measured invasively, but higher with BEV than SEV by TTE. The discordance between invasive and TTE-derived mean gradients is the largest in BEV.

Interventional treatment options for elderly patients with mitral regurgitation.

The prevalence of mitral regurgitation (MR), particularly degenerative MR (DMR), rises with advancing age. Elderly patients frequently carry increased surgical risk due to frailty and comorbidities, leading to a prohibitive risk of conventional surgery. For such patients, mitral transcatheter edge-to-edge repair (M-TEER) provides a minimally invasive alternative to surgical repair. Data from large registries, including TRAMI (Transcatheter Mitral Valve Interventions) and EXPAND (The MitraClip™ EXPAND Study of the Next Generation of MitraClip™ Devices), demonstrate high procedural success, low 30-day mortality (2-3%) and stroke rates (<1%), and durable improvements in functional status and quality of life (QoL) in elderly cohorts. Although definitions of "elderly" vary between studies (≥75, ≥80, or ≥85 years) and benefits are consistently observed, elderly was defined  ≥75 years within this review. For selected patients unsuitable for M-TEER, transcatheter mitral valve replacement (TMVR) can achieve effective MR elimination, with reported 1-year mortality ranging from 7% to 17% in early transfemoral, transseptal experiences and up to 29% after transapical TMVR. This review summarizes current evidence on safety, functional outcomes, QoL, survival, emerging replacement strategies, and conservative management in elderly patients with MR.

Safety and efficacy of transaortic transcatheter aortic valve implantation via right mini-thoracotomy.

OBJECTIVES: Transcatheter aortic valve Implantation (TAVI) via the transfemoral approach is widely used. However, patients with unsuitable peripheral arterial anatomy require alternative transthoracic access. In such patients, the right mini-thoracotomy transaortic (Rt-TAo) approach offers a less invasive option than conventional sternotomy. Therefore, this study aimed to evaluate the procedural and 2-year clinical outcomes of transfemoral (TF) TAVI versus Rt-TAo TAVI. METHODS: Patients who underwent TAVI via the TF approach or Rt-TAo approach between January 2012 and November 2023 were retrospectively reviewed. Baseline characteristics and clinical outcomes were compared, and propensity score matching was performed to adjust for baseline differences. The primary endpoints were in-hospital mortality, stroke, other periprocedural morbidities, and postprocedural length of hospitalization. Secondary endpoints included overall survival, freedom from cardiac-related death, and major adverse cardiac and cerebrovascular events (MACCE) at 2 years. RESULTS: A total of 767 consecutive patients were included in the analysis, of whom 694 underwent TF TAVI and 73 underwent Rt-TAo TAVI. Before matching, the Rt-TAo group had higher baseline prevalences of comorbidities and Society of Thoracic Surgeon risk scores. After matching, the Rt-TAo group had a longer procedural time, higher transfusion requirements, and longer lengths of intensive care unit and total hospital stays. However, the 2 groups had similar rates of periprocedural stroke, coronary obstruction, annular rupture, access-related complications, and in-hospital mortality. The 2 groups had similar 2-year rates of survival and freedom from MACCE. CONCLUSIONS: The Rt-Tao TAVI is a safe and feasible alternative for patients with unsuitable peripheral arterial access, demonstrating comparable 2-year outcomes to TF TAVI.

Valve-Specific Anatomy and Structural Determinants of Susceptibility to Infective Endocarditis: A Review.

Background/Objectives: Infective endocarditis (IE) is a life-threatening cardiovascular infection with in-hospital mortality of 15-30% despite modern therapy. Contemporary IE demonstrates non-random valve involvement: aortic and mitral 35-45%, tricuspid 5-10% (30-50% in intravenous drug users [IVDU]), and pulmonary < 1%. These patterns implicate valve-specific anatomy and hemodynamics as central determinants of susceptibility. This narrative review examines the reported distribution of IE across the aortic, mitral, tricuspid and pulmonary valves and summarises the anatomical, haemodynamic, structural, microbial and patient-related factors associated with valve-specific susceptibility. Methods: A structured narrative review of English-language literature was conducted using PubMed/MEDLINE, Embase, Scopus, and Google Scholar (January 1990-March 2026). Search terms included "infective endocarditis," "valve anatomy," "hemodynamics," "bicuspid aortic valve," "prosthetic valve endocarditis," and "transcatheter aortic valve replacement (TAVR) endocarditis." We included anatomical studies, clinical cohorts, surgical series, imaging research, and international guidelines. Evidence was synthesized narratively using Oxford Centre for Evidence-Based Medicine (CEBM) levels. Results: IE susceptibility follows a biologically coherent gradient determined by the interaction between valve anatomy, hemodynamic stress, endothelial injury, and structural substrate. The aortic valve is most vulnerable because of high shear stress, congenital abnormalities such as bicuspid aortic valve, and direct continuity with the cardiac fibrous skeleton, predisposing to peri-annular extension. Mitral valve IE is largely conditional upon pre-existing structural disease, particularly mitral valve prolapse, rheumatic heart disease, and mitral annular calcification, and is characterized by a high risk of systemic embolization. Tricuspid valve IE reflects the interaction between low-pressure hemodynamics and acquired patient-specific modifiers, including intravenous drug use, cardiovascular implantable electronic devices, and congenital heart disease. Pulmonary valve IE remains uncommon because of favorable native hemodynamics but occurs predominantly in repaired congenital heart disease, right ventricular outflow tract reconstruction, and prosthetic pulmonary valves. Across all valve types, multimodality imaging and anatomical assessment consistently influence complication detection, surgical planning, and long-term surveillance. Conclusions: IE involvement is unevenly distributed among the cardiac valves. Aortic and mitral involvement predominate, tricuspid involvement is strongly influenced by injection drug use and intracardiac devices, and pulmonary-valve IE remains rare and is principally associated with congenital abnormalities or prosthetic material. These patterns highlight the possible contributions of haemodynamic stress, pre-existing structural abnormalities, and age-related valvular changes to the greater susceptibility of left-sided valves.

Midterm outcomes after TAVR or SAVR in low-risk patients with severe aortic stenosis in the real clinical practice in Japan.

The clinical trials in low risk patients have clearly demonstrated clinical outcomes of transcatheter aortic-valve replacement (TAVR) comparable to those of surgical aortic-valve replacement (SAVR) in patients with severe aortic stenosis (AS). However, data are lacking on the appropriate treatment selection for patients with severe AS and low surgical risk in Japanese routine clinical practice. Among 3369 patients enrolled in the CURRENT AS Registry-2 between April 2018 and December 2020, the current study population include 826 patients with low Society of Thoracic Surgeons (STS) score and not on hemodialysis who actually underwent TAVR (439 patients) or SAVR (387 patients). After propensity score matching, there remained 162 patients in each group. The primary outcome was a composite of all-cause death, disabling stroke, or heart failure hospitalization. The cumulative 3-year incidence of the primary outcome was not significantly different between the TAVR and SAVR groups (19.5% and 17.4%, P = 0.82). Even after adjusting for age and institution, there was no excess risk of TAVR relative to SAVR for the primary outcome (adjusted HR: 1.05, 95% CI: 0.50-2.20, P = 0.91). In low-risk patients with severe AS, TAVR compared to SAVR was associated with comparable clinical outcomes for a composite of all-cause death, disabling stroke and heart failure hospitalization.

Mid-Term Outcomes and Echocardiographic Predictors of TTVR: Insights from the TRAVEL Study.

BACKGROUND: The mid-term prognosis after transcatheter tricuspid valve replacement (TTVR) is poorly defined, and echocardiographic predictors remain uncertain. OBJECTIVES: To describe mid-term all-cause mortality, 30-day major adverse events (MAEs), and echocardiographic risk markers of TTVR. METHODS: Consecutive patients undergoing TRAVEL (Transcatheter right atrial-ventricular valve replacement With LuX-Valve) at three centers were retrospectively analyzed. Firth Cox regression was applied for mortality, and Firth logistic regression was used for exploratory MAE analyses. RESULTS: A total of 62 patients (median age 66.5 years [61.0-72.8], 83.8% female) were included. Over a mean follow-up of 46.2 months, seven deaths (11.2%) occurred, corresponding to mid-term survival of 88.8%. Within 30 days, 14 patients (22.6%) experienced MAEs, including three deaths (4.8%), major bleeding in eight (12.9%), surgical re-exploration in seven (11.3%), repeat open-heart tricuspid valve replacement in one (1.6%), and permanent pacemaker implantation in six (9.7%). TR was reduced to mild or less in 95.2% at 1 year. CONCLUSIONS: In this LuX-Valve TTVR cohort, 30-day MAEs mainly reflected perioperative or device-related complications rather than a direct signal of baseline RV dysfunction or remodeling. LuX-Valve implantation showed favorable mid-term survival and clinically meaningful procedural effectiveness; RV-centered echocardiographic markers should be considered hypothesis-generating and require validation in larger cohorts.

Infective endocarditis following transcatheter valvular interventions (transcatheter aortic valve implantation and transcatheter edge-to-edge repair).

Infective endocarditis (IE) following transcatheter valvular interventions, including transcatheter aortic valve implantation and transcatheter edge-to-edge repair, is an uncommon but life-threatening complication associated with major diagnostic and therapeutic challenges. As indications for structural interventions continue to expand, the burden of device-related IE is expected to increase. This expert opinion, jointly developed by the Association of Valvular Heart Disease and the Association of Cardiovascular Intervention of the Polish Cardiac Society, summarizes contemporary evidence regarding the epidemiology, clinical presentation, diagnosis, treatment, and prevention of transcatheter valve-related IE. Transcatheter aortic valve implantation-related IE occurs at an estimated incidence of 0.3-2.0 per 100 person-years and is associated with high in-hospital and long-term mortality, whereas transcatheter edge-to-edge repair-related IE is less frequent but similarly associated with poor outcomes. Clinical presentation is frequently atypical, particularly in elderly and in patients with multimorbidity, resulting in delayed diagnosis. Echocardiography remains the first-line imaging modality but is often limited by prosthesis-related artifacts. Multimodality imaging, particularly electrocardiography-gated cardiac computed tomography and in selected cases positron emission tomography, substantially improves diagnostic accuracy and detection, especially of perivalvular complications. Management relies on prolonged pathogen-directed intravenous antibiotic therapy, but surgical intervention should be considered in all patients, with a significant indication for surgery in patients with uncontrolled infection, heart failure, embolic complications, or extensive tissue destruction. Preventive measures, including maintaining strict periprocedural asepsis and targeted antibiotic prophylaxis, remain essential. IE after transcatheter valvular interventions therefore represents a rare but devastating complication requiring high clinical vigilance, multidisciplinary management, and individualized treatment strategies to improve outcomes.

Aortic valve stenosis in 2026: from emerging mechanisms to clinical drug development.

Calcific aortic valve stenosis (AS) is the most prevalent valvular heart disease in high-income countries, affecting 9.4 million persons globally. While surgical and transcatheter aortic valve replacement have transformed outcomes, they address end-stage disease rather than the underlying pathobiology. The development of pharmacological therapies to slow or halt AS progression would represent a paradigm shift in disease management. Recent advances have substantially expanded our understanding of AS pathogenesis. Large-scale genome-wide association studies have identified over 260 risk loci, with the LPA locus confirming lipoprotein(a) as the most robustly validated genetic risk factor. Single-cell transcriptomics have revealed unexpected cellular heterogeneity and novel mechanisms including macrophage-to-mesenchymal transition. Emerging insights into metabolic reprogramming, epigenetic regulation, innate immunity and clonal hematopoiesis have identified multiple therapeutic targets. Despite these pathophysiological advances, no pharmacological therapy has yet demonstrated efficacy in adequately powered randomized trials. Statin therapy and skeletal bone metabolism-targeted agents have proven ineffective previously and multiple mechanistically diverse approaches are now under investigation. The most promising developments center on lipoprotein(a) reduction with antisense oligonucleotides, with the first dedicated AS trial ongoing. Additional strategies include PCSK9 inhibition, supplementation of omega-3 fatty acids, treatment with colchicine, soluble guanylate cyclase activation with ataciguat, and DPP-4 inhibition. Success in any of these trials would represent the first disease-modifying therapy for AS, with potential to delay valve replacement, preserve myocardial function, and improve outcomes for millions of patients worldwide.

Comparison of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with prior chest radiation: a systematic review and meta-analysis of 11,572 patients.

BACKGROUND: Cardiac complications from prior oncologic therapies and radiation are being increasingly recognized and patients with symptomatic severe aortic valve disease and a history of prior chest radiation represent a high-risk group in which the best management approach has not yet been established. METHODS: A systematic search of PubMed, Scopus, and Cochrane identified studies comparing outcomes of transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) in patients with a history of prior chest radiation. RESULTS: Nine studies comprising 11,572 patients were included in this meta-analysis. There were no significant differences between TAVR and SAVR in postoperative mortality (OR: 0.70; 95% CI 0.44-1.13, p = 0.147) or 1-year mortality (OR: 1.04; 95% CI 0.71-1.53, p = 0.84). TAVR was associated with significantly lower rate of postoperative major bleeding (OR: 0.38; 95%CI: 0.25-0.57, p < 0.01), acute kidney injury (AKI) (OR: 0.51; 95%CI: 0.27-0.97, p: 0.04), postoperative atrial fibrillation (OR: 0.20 95%CI: 0.16-0.24, p: <0.01) and respiratory complications (OR: 0.39; 95%CI: 0.24-0.63, p < 0.01) compared to SAVR. The incidence of postoperative permanent pacemaker insertion (OR: 2.27; 95%CI: 1.79-2.87, p < 0.01) and at least moderate aortic regurgitation (OR: 4.44 (95%CI: 2.93-6.73), p < 0.01) were higher among the patients undergoing TAVR. CONCLUSIONS: TAVR in patients with a history of prior radiation was associated with a lower risk for postoperative complications albeit at an increased risk for pacemaker insertion in the postoperative period compared to SAVR.

Management of Severe Aortic Stenosis in Patients Receiving Dialysis.

Previous reports have comprehensively assessed clinical outcomes of transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in patients with chronic kidney disease (CKD), including those on dialysis. Some studies suggest better short-term outcomes with TAVR, including lower periprocedural mortality, acute-on-chronic kidney injury, bleeding, and shorter length of stay, but similar or worse long-term survival compared with SAVR. While clinical outcomes have been studied, comparative durability and risk of structural valve deterioration (SVD) between transcatheter and surgical bioprosthetic valves in dialysis patients remain poorly defined. The therapeutic approach for the treatment of aortic valve disease in patients with end-stage renal disease is clinically relevant as these patients have short life expectancy and often receive bioprosthetic valves that are at higher risk for accelerated SVD and failure. This review synthesizes current literature describing TAVR and SAVR valve durability in patients with end-stage renal disease, focusing on mechanisms of bioprosthetic SVD, outcomes associated with TAVR and SAVR, and explores strategies for lifelong management of aortic valve disease, including considerations for reintervention.

Cost-effectiveness of transcatheter aortic valve replacement in patients with severe aortic stenosis and low surgical risk: perspective of a middle-income country's public health system.

BACKGROUND: Randomized controlled trials comparing transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis and low surgical risk have demonstrated noninferiority of TAVR regarding all-cause mortality and stroke outcomes in 5- and 10-year follow-up. Nevertheless, TAVR remains a costly intervention, and its widescale adoption may affect healthcare expenditure in low- and middle-income countries. This study aimed to conduct a cost-utility analysis comparing TAVR and SAVR in patients with severe aortic stenosis at low surgical risk, from the perspective of the Brazilian Unified Health System (Sistema Único de Saúde - SUS). METHODS: A Markov model was developed to simulate a hypothetical cohort of patients with severe aortic stenosis over a lifetime horizon. A systematic review was performed to inform efficacy and effectiveness inputs. Cost data were derived from Brazilian patient cohorts who underwent TAVR or SAVR and were expressed in international dollars (Int$). Incremental cost-effectiveness ratios (ICERs) were calculated and sensitivity analyses were performed. RESULTS: The estimated lifetime cost was Int$ 32,341 for TAVR and Int$ 19,778 for SAVR. Lifetime quality-adjusted life-years (QALYs) were 9.90 and 9.71, respectively. The ICER for TAVR was Int$ 64,617 per QALY gained, exceeding the Brazilian willingness-to-pay threshold of Int$ 47,619 per QALY. In probabilistic sensitivity analysis, TAVR was cost-effective in 32.8% of simulations. CONCLUSION: In patients with severe aortic stenosis at low surgical risk, TAVR was unlikely to be cost-effective compared with SAVR from the perspective of the Brazilian Unified Health System, primarily driven by cost differences between strategies.

Transcatheter Tricuspid Valve Replacement for Residual Tricuspid Regurgitation After TEER.

BACKGROUND: Residual or recurrent tricuspid regurgitation (TR) after prior transcatheter tricuspid edge-to-edge (T-TEER) repair occurs in about 12% of patients within 1 year. Since surgical tricuspid valve repair or replacement is of high risk, treatment options remain scarce. Data regarding the feasibility, safety, and treatment strategies using transcatheter valve replacement (TTVR) after T-TEER are sparse. AIMS: Here, we aimed to summarize our early experience in TTVR after failed T-TEER, analyze its feasibility and summarize the results in a distinct algorithm. METHODS: Patients undergoing TTVR (n = 21) at the University Hospital of Duesseldorf were prospectively analyzed and stratified according prior T-TEER procedures with implanted devices. Groups were compared in terms of procedural success, periprocedural complications, and patient outcomes. Individual treatment decisions for patients after T-TEER were analyzed. RESULTS: Five patients had residual/recurrent severe to torrential TR and underwent TTVR after T-TEER, whereas 16 patients were primarily referred for TTVR. Preprocedural wire-based intentional clip excision (WICE) was performed in 60% of these patients. Patients did not differ regarding procedural success (100% in both groups, p = 0.99) and periprocedural complications (0 [TTVR after TEER] vs. 5.6% [primary TTVR], p = 0.99 for the combined endpoint of in-hospital death, stroke, myocardial infarction, re-intervention or surgery, and major bleeding). A pacemaker was required in one patient of each group, p = 0.4). Procedural times were higher among patients with prior T-TEER. Treatment decisions for patients after T-TEER were integrated into a treatment algorithm. CONCLUSION: The valve after clip concept is feasible and the proposed algorithm may support procedural planning.

Tricuspid Valve Infective Endocarditis.

Staphylococcus aureus endocarditis is a severe and life-threatening infection that continues to pose a significant challenge in cardiovascular medicine. Despite advances in healthcare, its management remains complex due to its aggressive nature and potential complications. Although infective endocarditis (IE) predominantly affects the left side of the heart, right-sided IE can also occur, often linked to intravenous drug use, medical device implantation, and vascular access for dialysis. Notably, many patients with native valve S. aureus endocarditis have no prior structural heart disease, suggesting that inflammation may play a critical role in its development. Early diagnosis is crucial and relies on comprehensive clinical evaluation, blood cultures, and echocardiography. Empiric antibiotic therapy should provide broad coverage against common pathogens, with adjustments based on culture results. In certain cases, surgical intervention is required, particularly when complications such as large vegetations, persistent infection, or severe valve dysfunction arise. A multidisciplinary approach involving infectious disease specialists, cardiologists, and cardiothoracic surgeons is essential for optimizing patient outcomes. Timely intervention, individualized treatment strategies, and coordinated care can significantly reduce the risk of complications and improve prognosis.

Evolving Early Outcomes After Transcatheter Aortic Valve Replacement in Asian Patients: Temporal Trends From the OCEAN-TAVI Registry.

BACKGROUND: As transcatheter aortic valve replacement (TAVR) has expanded across a broad range of surgical risk profiles, evaluating temporal changes in outcomes has become increasingly important, particularly in the Asian population where patient characteristics differ from those of the Western population. The aim of the study was to evaluate the temporal trends in short-term outcomes after TAVR over the past decade in a large Asian multicenter registry. METHODS: This retrospective multicenter registry included 13,245 patients who underwent TAVR at 18 centers from 2013 to 2023. Temporal trends in 30-day mortality, 30-day stroke, and 30-day pacemaker implantation (PMI), and paravalvular leakage (PVL) ≥ mild at discharge were assessed using multiple imputation and center-clustered generalized estimating equations. The effect modification by age and surgical risk was prespecified. RESULTS: The median age was 85 years, and the median Society of Thoracic Surgeons (STS) score was 5.6%. Over time, patient profiles shifted toward lower risk, and procedures became less invasive. Consistent across age and Society of Thoracic Surgeons risk strata, the overall risk-adjusted 30-day mortality remained low and did not change significantly over time. In contrast, the risk-adjusted PMI and PVL ≥ mild declined significantly over time, particularly in TAVR using balloon-expandable valves (BEVs). The risk-adjusted incidence of 30-day stroke did not change significantly. CONCLUSIONS: Early mortality after TAVR in the Asian cohort has remained consistently low over the past decade. Although device-related complications such as PMI and PVL improved substantially, periprocedural stroke remained as a key unmet clinical challenge.

Transcatheter bi-caval valve implantation in a post-pacemaker patient with severe tricuspid regurgitation: A case report.

UNLABELLED: Severe tricuspid regurgitation (TR) presents a significant clinical challenge in patients deemed unsuitable for conventional surgical intervention. This case describes a 60-year-old woman with torrential TR and intractable ascites with a dual-chamber pacemaker in situ who presented with refractory right heart failure unresponsive to maximal medical therapy. Transcatheter bicaval valve implantation was performed with computed tomography guidance, deploying 29-mm and 35-mm self-expanding nitinol-pericardial valves in the superior and inferior vena cavae. At six-month follow-up, the patient demonstrated marked clinical improvement with substantial reduction in ascites and resolution of venous congestion, establishing bicaval valve implantation as an effective palliative strategy for alleviating systemic venous hypertension in high-risk patients with end-stage TR and prohibitive surgical risk, despite limited right ventricular structural recovery. LEARNING OBJECTIVE: 1)To recognize the clinical presentation, hemodynamic findings, and diagnostic features of severe, symptomatic tricuspid regurgitation.2)To understand the anatomic and hemodynamic principles underlying transcatheter heterotopic bicaval valve implantation (CAVI) as a palliative strategy in patients with advanced right heart remodeling and prohibitive surgical risk.3)To understand the short- and medium-term symptomatic and hemodynamic outcomes of CAVI.

The Role of Preprocedural CT in Redo Transcatheter Aortic Valve Replacement: A Radiologist's Perspective.

As transcatheter aortic valve replacement (TAVR) has become a viable option across all surgical risk levels, younger patients are anticipated to outlive the durability of their index transcatheter heart valve (THV). When a THV fails, cardiac CT is an important tool to assess the mechanism of THV failure and aids in the differentiation between structural and nonstructural THV dysfunction mechanisms. After the identification of the index THV dysfunction mechanism, CT guides the sizing and selection of the new THV type. While the principles of preprocedural redo TAVR (often called TAV-in-TAV) CT assessment overlap with those for patients undergoing TAVR of surgical bioprosthetic valves, the assessment is different in several ways. These differences are primarily related to the need to evaluate the characteristics of the index THV and the degree of commissural and coronary alignment achieved during the index TAVR procedure, which affect the selection of the type and size of the new THV and determine the risks of coronary obstruction and impeded future coronary access, as well as the potential for leaflet modification. Keywords: Applications-CT, CT Angiography, Transcatheter Aortic Valve Implantation/Replacement, TAVI/TAVR Supplemental material is available for this article. ©RSNA, 2026.

Open superior mesenteric artery thrombectomy of dislodged aortic valve causing acute mesenteric ischemia.

Transcatheter aortic valve replacement is preferred for severe aortic stenosis in elderly, high-risk patients. We report the case of a 96-year-old woman who developed acute mesenteric ischemia from embolization of the native heart valve after transcatheter aortic valve replacement and highlight the key management steps that enabled successful revascularization and bowel preservation, as well as the decision-making between surgical and endovascular mesenteric thrombectomy.

Impact of surgical timing on outcomes after transcatheter aortic valve explantation: insights from a French multicenter retrospective study.

BACKGROUND: Surgical explantation of transcatheter aortic valves (TAV-explant) is an emerging but uncommon procedure, increasingly required as TAVI is performed in younger and lower-risk patients. Contemporary evidence on outcomes, timing, and valve type remains limited. METHODS: We conducted a multicenter retrospective study of patients undergoing surgical TAV-explant. Clinical characteristics, indications, surgical strategies, and outcomes were analyzed. Outcomes were compared according to the interval between index TAVI and explantation (< 1 month, 1-12 months, > 12 months). The indication and the type of initial transcatheter valve (balloon-expandable vs. self-expanding) were also analyzed. The primary outcome was 30-day mortality. RESULTS: A total of 62 patients were included. Indications for TAV-explantation were predominantly bioprosthetic valve dysfunction (45.2%), infective endocarditis. (21%), and procedural failure (33.9%)The 30-day mortality was 16.1% and did not differ according to the delay of explantation (p = 0.816). Overall mortality did not differ according to the indication of explantation, nor by type of explanted valve. Concomitant aortic surgery was required in 18% of cases. Although EuroSCORE II values were elevated in this cohort, this tool underestimated the operative risk, as it was not designed for complex redo surgery. CONCLUSIONS: TAV-explantation is technically feasible but remains associated with substantial early mortality. Outcomes are not influenced by the timing of explantation or by valve type. These findings highlight the limitations of current surgical risk scores and underscore the importance of thorough pre-operative planning and Heart Team evaluation. Continued multicenter data collection is essential to optimize patient selection and refine management strategies.

Transcatheter Management of Severe Aortic Insufficiency in a Left Ventricular Assist Device Recipient with a Small Aortic Annulus-Uncorrected Proof.

We report the case of a 72-year-old woman with a HeartMate III left ventricular assist device who developed severe aortic regurgitation and New York Heart Association Class III symptoms. Given her high surgical risk and the presence of a small aortic annulus (mean diameter 18.4 mm), transfemoral transcatheter aortic valve replacement was performed using a 26-mm Evolut PRO+ self-expanding valve under transesophageal echocardiographic guidance. Temporary reduction of left ventricular assist device (LVAD) speed prevented ventricular migration during deployment. The procedure resulted in complete resolution of regurgitation without complications. This case demonstrates the feasibility and safety of transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic regurgitation in patients with LVADs and small annuli, when meticulous pre-procedural planning and careful intraoperative management are employed.

Valve-in-Valve TAVR in Surgical Stentless Aortic Bioprostheses, a Challenging Scenario.

Background and objectives: Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become an established treatment for failed surgical bioprostheses in patients at high surgical risk. However, procedures performed in degenerated stentless aortic valves remain particularly challenging because of the absence of a radiopaque frame, variable surgical implantation techniques, and a potentially increased risk of coronary obstruction. Evidence in this specific setting is limited. We conducted a systematic review of the literature to identify studies reporting ViV TAVI in degenerated stentless surgical bioprostheses. Materials and methods: Case reports and case series were included when patient-level or clearly identifiable data were available. Baseline characteristics, anatomical features, procedural strategies, and clinical outcomes were extracted and analyzed using a descriptive approach. A total of 54 studies were included, encompassing 294 ViV TAVI procedures performed in failed stentless aortic valves. Results: The mean patient age was 73.9 years, and the average STS-PROM score was 13.45%, reflecting a high-risk population. The most frequently treated prosthesis was the Medtronic Freestyle valve, and the predominant mechanism of failure was regurgitation. Transfemoral access represented the most common approach, while balloon-expandable and self-expanding transcatheter valves were used with similar frequency. Coronary protection strategies were adopted in a minority of procedures, whereas adjunctive procedural techniques such as pre- or post-dilation were relatively common. Device-related complications were mainly driven by coronary obstruction, while cardiac complications included myocardial infarction and unplanned coronary intervention. Overall, VARC-3 device success was achieved in the majority of procedures, with acceptable short-term mortality despite the complexity of the treated population. Conclusions: ViV TAVR in degenerated stentless bioprostheses appears feasible and generally effective but remains associated with specific procedural challenges, particularly related to coronary obstruction risk. Careful anatomical assessment and tailored procedural planning are essential, and larger contemporary studies are needed to better define optimal management strategies in this complex setting.

Categories of Aortic Stenosis: What's New and the Clinical Implications.

Aortic valve stenosis (AS) is assessed by echocardiography in clinical practice. Conventionally, the aortic valve area, peak transaortic valve velocity/gradient and the mean transvalvular gradient determine if the AS is categorized as mild, moderate or severe. Recently, the entity of paradoxical low-flow, low-gradient AS despite normal left ventricular ejection fraction (LVEF) was described and flow (as determined by stroke volume indexed to body surface area) was used to further categorize AS. The new European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) guidelines in 2025 recommended a new phenotype-based classification, which improved the prognostication of AS. There are now five phenotypes: (1) concordant high-gradient AS; (2) low-flow, low-gradient AS with reduced LVEF; (3) low-flow, low-gradient AS with preserved LVEF; (4) normal-flow, low-gradient AS with preserved LVEF; and (5) discordant high-gradient AS. These appear to have different underlying pathophysiology, and hence prognostication and therapy. In addition, categories of AS in the setting of reduced LVEF are further divided based on their responses to dobutamine or exercise stress, which may result in different therapeutic strategies. In the transaortic valvular replacement (TAVR) versus the surgical aortic valve replacement (SAVR) era, the classification of these AS groups may have differing implications on the appropriate interventions. Furthermore, there are investigations on the effect of AS on the left ventricle and other chambers and stages of AS based on the extent of cardiac damage, which may have important prognostic value post-AVR. On the other spectrum, there are new developments in imaging analysis, such as using artificial intelligence. This state-of-the-art paper will comprehensively review the important updates in AS and its clinical implications.

A Valvular Dilemma: The Difficult Choice of a Surgical versus Transcatheter Approach in Repeat Aortic Valve Replacement.

Single Centre Experience With the Balloon-Expandable Myval Transcatheter Aortic Valve System in Patients With Bicuspid Anatomy: 1 Year Follow-Up.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve (BAV) anatomy remains challenging due to anatomical complexity and limited trial data. New-generation balloon-expandable valves, such as Myval, require further evaluation in this subgroup. AIMS: To report 1-year VARC-3 outcomes following TAVI procedure with the Myval transcatheter heart valve (THV) in BAV anatomy. METHODS: From December 2019 to July 2023, 52 consecutive BAV patients at moderate-to-high surgical risk or deemed unsuitable for surgery underwent TAVI with the Myval THV. Outcomes, assessed per VARC-3 definitions, were compared to 217 trileaflet aortic valve (TAV) patients in unmatched and propensity score-matched cohorts. RESULTS: At 1 year, BAV and TAV patients showed no significant differences in all-cause mortality (3.9% vs. 10.2%, p = 0.185), cardiac mortality (0% vs. 2.3%, p = 0.587), or stroke (3.9% vs. 2.8%, p = 0.654) regarding an unmatched comparison. In the matched analysis, all-cause mortality and stroke were 3.9% and 1.9%, respectively, with no cardiac deaths. Endocarditis was rare (1.9% vs. 1.4%, p = 0.579); no valve thrombosis occurred. At 1 year, 94% of matched patients were in NYHA class I. Echocardiographic parameters remained stable; no moderate/severe paravalvular regurgitation was observed in BAV patients. Kaplan-Meier analysis revealed no differences in survival or composite outcomes. Technical and device success rates exceeded 95%; early safety was limited by a high incidence of non-vascular type 2-4 bleeding events. Based on the analyses, the relatively high postprocedural PPI rate (unmatched BAV vs. TAV: 34.0% vs. 30.4%, p = 0.429; matched: 34.0% vs. 24.0%, p = 0.274) is more likely attributable to patient-related characteristics rather than device-related complications, and remained unchanged following hospital discharge. CONCLUSIONS: TAVI with the Myval THV in real-world BAV patients is safe and effective with excellent hemodynamic performance at 1 year follow-up. This may reinforce the use of this device in this anatomically complex population.

Durability of Bioprosthetic and Mechanical Valves Implanted for Aortic Valve Replacement in Pediatric Patients.

BACKGROUND: There is limited published information on bioprosthetic aortic valve durability. The purpose of this study was to assess the durability of bioprosthetic valves used for aortic valve replacement (AVR) in pediatric patients. METHODS: We reviewed all surgical AVR procedures performed from May 02 to July 24 in patients ≤21 years of age using a mechanical valve or bioprosthesis. Long-term valve-related outcomes were assessed with propensity-score-adjusted analysis. RESULTS: During the study period, 180 AVR procedures were performed in pediatric patients (median age, 14.3 years) using a bioprosthetic valve (n=79) or mechanical prosthesis (n=101). Freedom from reintervention was significantly shorter in patients with a bioprosthetic valve (77% at 5 years, 29% at 10 years) than those with a mechanical valve (88% at 5 years, 82% at 10 years; P<0.001). By propensity score-adjusted multivariable Cox regression, a bioprosthetic valve (hazard ratio, 4.66 [95% CI, 2.26-9.62]; P<0.001) and age <12 years at AVR (3.26 [1.81-5.87]; P<0.001) were associated with shorter freedom from reintervention. Endocarditis was diagnosed in 16 patients, and thromboembolic or bleeding complications were reported in 8. CONCLUSIONS: In pediatric patients undergoing AVR, bioprosthetic valves have significantly worse durability than mechanical prostheses, with the disparity most pronounced in younger patients. Valve-related mortality and complications were relatively common. These findings should focus attention on the need for better replacement valves or therapeutic options in young patients with aortic valve disease.

Transapical TAVI in Left Ventricular Apical Aneurysm.

Transcatheter aortic valve implantation (TAVI) was the preferred intervention for patients with severe aortic stenosis at high surgical risk and recently included intermediate and even low surgical risk patients. The transfemoral (TF) route is the standard approach, with alternative access reserved for patients with challenging peripheral artery disease. The transapical (TA) approach is rarely performed, especially in patients with left ventricular (LV) apical aneurysm due to risk of myocardial rupture and bleeding secondary to fibrosed myocardial tissue. We are presenting the first reported case, to our knowledge, of a TA TAVI performed from an LV apical aneurysm despite fibrosed myocardium after failed TF access with severe bicuspid aortic stenosis, advanced ischemic cardiomyopathy, peripheral vascular disease, and chronic obstructive pulmonary disease (COPD). A 29 mm Edwards Sapien S3 Ultra valve was successfully implanted with residual trivial paravalvular regurgitation and stable postoperative recovery. This case highlights the feasibility of TA TAVI in the presence of LV apical aneurysm when no other vascular access route is possible, contrary to the perceived view of the LV aneurysm being thin and friable, which should not preclude a case being done with TA access.

Feasibility and technical considerations of mitral TEER in adults with surgically repaired congenital heart disease: descriptive cohort of OCEAN-mitral registry.

Screening for amyloidosis before aortic valve elective replacement: results from the SAVER study.

AIMS: Concomitant aortic stenosis (AS) and cardiac amyloidosis (CA) result in heart failure and reduced life expectancy. Early detection of CA in AS is an unmet clinical need to prevent disease progression. The SAVER study aims to establish a simple CA screening for AS patients. METHODS AND RESULTS: SAVER is a prospective cohort study enrolling AS patients planned for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). Firstly, patients were assessed for CA-specific symptoms and history on top of AS evaluation. Patients with suspected CA underwent DPD scintigraphy or magnetic resonance imaging. Secondly, we performed multiple-regression analysis to identify optimal parameters for selecting patients at risk of CA. From 2021 to 2023, 1001 patients were enrolled, with 405 (40%) flagged for potential CA. Two hundred six (21%) patients received further diagnostics due to the screening and five (0.5%) patients due to physician discretion, leading to 17 (2%) confirmed CA cases. Key predictors of CA included male sex [OR 23.8 (95% CI 2.6; 216.9)], carpal tunnel syndrome [OR 5.5 (95% CI 1.4; 22.0)], spinal stenosis [OR 4.1 (95% CI 1.1; 14.7)], heaviness or numbness of arms or legs [OR 3.8 (95% CI 1.1; 13.3)], NT-proBNP [OR 6.7 (95% CI 1.8; 25.3)], and sparkling myocardium [OR 4.8 (95% CI 1.3; 17.3)]. The optimized approach reached an AUC of 0.88 (95% CI 0.81-0.96). CONCLUSION: The SAVER approach is the first holistic screening method focusing on CA's multiorgan manifestations in AS. This approach can be implemented in clinical settings to prevent futile outcomes of combined disease.

Transcatheter Repair of Sinus Venosus Defect Using a 12-zig Covered Cheatham-Platinum Stent in Large Superior Vena Cava-Right Atrium Junctions: Early Multicenter Experience.

Sinus venosus defect (SVD) is a rare congenital heart anomaly characterised by an abnormal communication between the atria, often associated with partial anomalous pulmonary venous connection (PAPVC). Traditional surgical repair carries significant risks, prompting exploration into less invasive transcatheter approaches. This study aims to evaluate the efficacy and safety of a 12-zig covered Cheatham-platinum stent for the correction of SVD, particularly in patients with enlarged superior vena caval-right atrial (SVC-RA) junctions unsuitable for standard stenting techniques. A retrospective analysis was conducted on five symptomatic patients treated with the 12-zig CP stent across two institutions. Preprocedural imaging, including echocardiograms, cardiac MRIs, and CT angiograms was performed to assess right ventricular function and define anatomical relationships. The procedures were guided by transoesophageal echocardiography (TOE) and involved balloon sizing to ensure optimal stent placement. All five patients (80% male, median age 59 years) successfully underwent stent implantation. A second stent was required in three cases due to residual leaks, which were effectively sealed, and in one case for stent stability. No procedural complications were reported, and all patients experienced symptomatic improvement at follow-up, with imaging confirming stable stent positions. The 12-zig CP stent demonstrates feasibility in the percutaneous treatment of highly selected patients with SVD, allowing for effective closure in complex anatomies, including large SVC-RA junctions. This study underscores the potential of advanced imaging techniques and tailored interventions in enhancing patient outcomes with complex congenital heart disease previously unsuitable for standard transcatheter approaches.

Comparative Outcomes of Transcatheter Edge-to-Edge Repair and Surgical Mitral Valve Repair or Replacement for Degenerative Mitral Regurgitation: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis.

Traditionally, surgical mitral valve repair or replacement (SMVR) has been the mainstay of treatment for mitral regurgitation (MR), providing a long-lasting way to restore valve competence. On the other hand, transcatheter edge-to-edge repair (TEER) has emerged as an option, especially for high surgical risk patients, demonstrating favorable results from short-term to intermediate-term follow-up. This study aims to evaluate and compare the clinical outcomes of TEER versus SMVR in patients with degenerative mitral regurgitation (DMR). This systematic review was conducted in accordance with the PRISMA guidelines. A comprehensive literature search was conducted until February 2, 2025. Relevant randomized controlled trials (RCTs) and cohort studies were included in the analysis. The data were extracted, and analysis was conducted using Review Manager (RevMan) version 5.3. Eight studies involving a total of 13,308 patients were included in the analysis. TEER showed a statistically significantly higher risk of 1-year mortality (RR 1.82, 95% CI: 1.04-3.19) and mitral reintervention at ≥ 1-year follow-up (RR 4.52, 95% CI: 3.46-5.91). However showing lower risk of new-onset AF (0.21, 95% CI: 0.07-0.67), blood transfusion (RR 0.21, 95% CI, 0.13-0.34), septicemia (RR 0.13, 95% CI: 0.02-0.70), AKI (RR 0.45, 95% CI: 0.24-0.86), shorter hospital stay (MD -4.44 days, 95% CI: -6.60 to -2.27), and ICU stay (MD -1.00 days, 95% CI: -1.13 to -0.88), when compared to the SMVR group. Survival at ≥ 2-year follow-up was significantly favored in the surgery group (RR 0.72, 95% CI: 0.56-0.93). No significant differences were observed regarding 30-day mortality (RR 0.99, 95% CI: 0.77-1.27), MR grade 1 (RR 1.16, 95% CI: 0.60-2.21), stroke (RR 1.06, 95% CI: 0.37-3.03), HF rehospitalization (RR 2.36, 95% CI: 0.82-6.81), and wound infection (RR, 0.45, 95% CI: 0.05-4.27). TEER was associated with a significantly lower rate of postoperative MR grade 0 (RR 0.20, 95% CI: 0.08-0.49), and significantly higher rates of MR grades 2 (RR 4.82, 95% CI: 1.87-12.40), 3 (RR 8.39, 95% CI: 3.69-19.09), and 4 (RR 4.20, 95% CI: 1.45-12.18), indicating inferior MR resolution. Although TEER is associated with a lower risk of septicemia and may reduce the risk of new-onset AF, hospital stay, and ICU stay, current evidence doesn't support the use of TEER as a substitute for surgery in patients with SMVR, as TEER may be associated with higher 1-year mortality and reduced long-term survival. Further controlled trials are needed to validate these findings and identify patient subgroups that may derive the greatest benefit from TEER.

Neosinus and Valve Thrombosis After Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement is regarded as an effective intervention for patients with aortic stenosis and has now been extended to low-risk populations. Leaflet thrombosis is a distinct and concerning form of transcatheter aortic valve dysfunction following transcatheter aortic valve replacement. Emerging studies have consistently shown that the formation of the neosinus after transcatheter aortic valve replacement and the resulting local hemodynamic changes are closely related to the occurrence of leaflet thrombosis. However, there is currently a lack of systematic integration of this evidence. This review aims to systematically summarize 4 key aspects of neosinus thrombosis after transcatheter aortic valve replacement: the incidence of thrombosis, the anatomical and pathological remodeling of the neosinus, the mechanisms of neosinus thrombosis, and the hemodynamic determinants within the neosinus. Local hemodynamics is the dominant and modifiable factor affecting thrombosis. Future research may integrate patient-specific modeling with long-term clinical outcomes to optimize the design and surgical strategies of transcatheter heart valves.

Electrosurgical laceration and stabilisation of tricuspid edge-to-edge repair: the ELASTA-T technique.

Recurrent tricuspid valve regurgitation (TVR) after tricuspid transcatheter edge-to-edge repair (T-TEER) poses a significant challenge, particularly when centrally positioned clips impede subsequent transcatheter tricuspid valve replacement (TTVR). Electrosurgical laceration and stabilisation of T-TEER (ELASTA-T) has been developed to facilitate TTVR by enabling controlled single leaflet device attachment (SLDA). The aim of this manuscript is to provide a step-by-step standardised description of the ELASTA-T strategy, outlining essential procedural principles, the required equipment, and technical steps. ELASTA-T involves intentional detachment of the most centrally placed tricuspid clip using electrosurgical leaflet laceration. A modified coronary guidewire shaped into a "flying V" - based on Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) and Laceration of the Anterior Mitral leaflet to Prevent Outflow ObstructioN (LAMPOON) principles - is positioned across the target leaflet using bilateral femoral vein access, deflectable guiding sheaths, microcatheters, and a snare-assisted venovenous rail. Laceration is performed under fluoroscopic and transoesophageal echocardiographic guidance, with preventive haemodynamic support on standby because of the risk of transient severe TVR. After laceration, the clip is mobilised towards the septal leaflet to avoid interference with valve deployment, followed by immediate implantation of a dedicated transcatheter tricuspid valve (TTV). ELASTA-T allows safe and reproducible SLDA, creating adequate central space for accurate positioning and full expansion of a TTV. Detachment can be reliably confirmed by fluoroscopy and transoesophageal echocardiography. By removing any mechanical obstruction from centrally placed clips, the technique facilitates secure TTVR anchoring and may reduce paravalvular regurgitation. This step-by-step framework may support procedural standardisation and broader adoption, ultimately improving outcomes in this high-risk population.

Surgical and Transcatheter Tricuspid Valve Interventions: An Electrophysiology-Focused Review.

Increasing recognition of the clinical impact of isolated tricuspid regurgitation has led to rapid expansion of surgical and transcatheter tricuspid valve interventions. Given the close anatomic relationship between the tricuspid valve and the atrioventricular conduction system, both surgical and transcatheter approaches carry a significant risk of new conduction disturbances and permanent pacemaker implantation. A three-dimensional understanding of the atrioventricular conduction axis is essential to anticipate and mitigate these complications. This review provides a comprehensive overview of conduction system anatomy and physiology in the context of tricuspid valve interventions, highlighting the mechanisms underlying procedure-related conduction abnormalities. We also discuss contemporary management strategies, including approaches to pre-existing transvalvular leads, valve-sparing pacing alternatives, and the evolving role of electrophysiologists within the multidisciplinary heart team.

Successful explantation of an EDWARDS INTUITY rapid deployment valve with concomitant annular enlargement.

BACKGROUND: Rapid deployment aortic valves, such as the Edwards Intuity valve, shorten implantation times and facilitate less-invasive approaches. The features that enable the valve's rapid deployment pose a technical challenge if explant is required, as in the instance of endocarditis or structural valve deterioration (SVD), because the prosthesis often becomes densely invested in surrounding cardiac structures. Although international reports describe Intuity and Perceval explants, none have been reported from the United States with annular enlargement. CLINICAL PRESENTATION: A 69-year-old woman with a bicuspid aortic valve underwent mini-thoracotomy aortic valve replacement eight years prior with a 23 mm Edwards Intuity valve. Seven years postoperatively she presented with progressive dyspnea and echocardiography showing moderate prosthetic stenosis (valve area 1.3 cm²). After several months of observation, she returned with severe stenosis (mean gradient 60 mmHg, valve area 0.78 cm²). Valve-in-valve transcatheter aortic valve replacement was considered, but surgery was favored given her small valve size and relatively young age. At reoperation, the prosthesis was densely adherent to the aortomitral curtain and left ventricular outflow tract, necessitating transection and careful dissection for safe removal. A Rittenhouse-Manouguian annular enlargement allowed implantation of a 25-mm Edwards Inspiris Resilia valve. She was discharged on postoperative day 5 and follow-up showed excellent recovery in normal sinus rhythm. CONCLUSION: Explantation of the Edwards Intuity rapid deployment valve with Rittenhouse-Manouguian annular enlargement is feasible and safe, offering a surgical option for SVD.

Lifetime management of aortic stenosis: a primer for the generalist.

Aortic stenosis affects millions globally and untreated disease approaches a one-year mortality of 50%. While surgical aortic valve replacement (SAVR) was historically the only life-prolonging treatment, transcatheter aortic valve replacement (TAVR) has revolutionized management, initially for inoperable patients and now extending to lower-risk populations. This review provides an overview of aortic stenosis, from pathophysiology through diagnosis. Disease progression, emerging pharmacological therapies, and surveillance strategies are discussed. Finally, the approach to intervention has evolved from surgical risk-based decision-making to a framework centered on age, life expectancy, and valve durability. Timely recognition and referral to a multidisciplinary heart team remain essential for shared decision making.

In-hospital outcomes and cost-effectiveness of transcatheter aortic valve replacement among younger patients: a double/debiased machine learning approach using electronic health records in Germany.

BACKGROUND: The prevalence of severe symptomatic aortic stenosis is increasing with population aging. Although surgical aortic valve replacement (SAVR) has traditionally been the standard treatment, transfemoral transcatheter aortic valve replacement (TF-TAVR) is increasingly used. The optimal treatment for patients aged 60-75 remains debated. METHODS: This retrospective cohort study analyzed 28,805 German patients who underwent isolated SAVR or TF-TAVR (2018-2022). We applied double/debiased machine learning estimators that combined adaptive lasso variable selection with propensity score-based weighting across 21 baseline characteristics. Cost-effectiveness was assessed via incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves from in-hospital and 1-year perspectives. RESULTS: Compared with SAVR, TF-TAVR was associated with a significant reduction in in-hospital mortality (causal risk ratio [RR] 0.65; p = 0.012), along with lower rates of bleeding (RR 0.29; p < 0.001), postoperative delirium (RR 0.32; p < 0.001), and mechanical ventilation > 48 h (RR 0.39; p < 0.001). No significant difference was observed in acute kidney injury rates (RR 0.89; p = 0.150). However, reimbursement was substantially higher for TF-TAVR (€7071 more per case, p < 0.001). A hypothetical shift from SAVR to TF-TAVR was associated with an ICER of €857,413 (95% CI €472,195-€4,310,651) from the in-hospital perspective and €196,422 (95% CI €123,873-€457,813) from the 1-year perspective. Notably, unadjusted analyses indicated a narrowing cost gap over time: Reimbursement for TF-TAVR decreased by approximately 12% between 2018 and 2022, while SAVR costs remained stable. Consequently, TF-TAVR is becoming increasingly cost-effective. CONCLUSION: Given an estimated life expectancy of 11 to 25 years in this population, the incremental costs per life saved associated with a hypothetical shift from SAVR to TF-TAVR appear justifiable. Nonetheless, individual patient circumstances must always be considered in decision-making.

Effectiveness and safety of REVIVENT-TC system for the left ventricular reconstruction in ischaemic heart failure. A literature review.

BACKGROUND: Surgical ventricular reconstruction (SVR) is not always feasible in patients with ischaemic cardiomyopathy and left ventricular (LV) aneurysm, due to high surgical risk. The Revivent-TC Transcatheter Ventricular Enhancement System is a less invasive alternative option. METHODS: We conducted a systematic literature search using PubMed, Ovid Medline and Google Scholar between January 2013 up to May 2025 to assess the effectiveness and safety of Revivent-TC System. Inclusion criteria included symptomatic patients with ischaemic left ventricular (LV) systolic impairment and anterior or anteroseptal scar, with appropriate anatomy confirmed by cardiac magnetic resonance (CMR), who were treated with the device. Outcomes included echocardiographic parameters, procedural data, adverse events and survival. RESULTS: Eight studies (276 patients) were included: seven observational and the prospective non-randomised dual-arm ALIVE trial. Mean age was 61.8 years; 73% were male with LV ejection fraction (EF) ranging from 22.8% to 35.6%. Procedural success ranged from 96 to 100%, with procedure-related mortality of 2.5%. Conversion to full median sternotomy was required in 1.4% due to complications such as right ventricular (RV) perforation, acute mitral regurgitation and right ventricular (RV) failure. Surgical re-intervention was required in 4.3% of patients. Overall mortality during follow-up was 6.5%. Statistically significant improvement in LVEF and LV volumes was observed across observational studies, persisting up to 5 years post-operatively. Improvements in exercise tolerance, NYHA functional class and quality of life were also observed. However, the ALIVE trial did not demonstrate a significant clinical benefit over guideline-directed medical therapy (win ratio 1.13; p = 0.32), with cardiovascular mortality and HF hospitalisation numerically favouring the control group. CONCLUSIONS: The Revivent-TC system is associated with LV volume reduction and functional improvements in selected patients, offering a less invasive alternative to surgical ventricular reconstruction. However, the evidence base consists predominantly of small observational studies, and the only controlled trial did not demonstrate significant benefit on hard clinical endpoints. Longer-term randomised data, including a guideline-directed medical therapy comparator arm, are needed before definitive conclusions about efficacy can be drawn.

Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis: A Retrospective Cohort Study.

Background: Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) were historically considered contraindicated in severe aortic stenosis (AS) due to theoretical haemodynamic risks. Contemporary evidence increasingly challenges this paradigm, yet data on preoperative use and postoperative outcomes remain limited. We examined the association between preoperative ACEi/ARB use and mortality following aortic valve replacement. Methods: We conducted a retrospective cohort study of 198 consecutive patients undergoing transcatheter (TAVI) or surgical aortic valve replacement (SAVR) at a single tertiary centre between May 2020 and March 2025. Complete one-year follow up was available for 185 patients (93%). The primary outcome was one-year all-cause mortality. Multivariable logistic regression adjusted for age, sex, hypertension, diabetes, LVEF, and procedure type. Results: Of 198 patients, 80 (40%) were receiving ACEi/ARB therapy preoperatively. ACEi/ARB users had a higher prevalence of hypertension (82% vs. 53%, p < 0.001) and diabetes (48% vs. 27%, p = 0.005) but similar age, valve area, and ejection fraction. Unadjusted one-year mortality was lower in the ACEi/ARB group (7% vs. 19%; odds ratio [OR] 0.33, 95% CI 0.12-0.91, p = 0.030). After multivariable adjustment for confounders including age, diabetes, and hypertension, the association did not reach statistical significance (adjusted OR 0.33, 95% CI 0.10-1.12, p = 0.075). Among diabetic patients, unadjusted one-year mortality was numerically lower in the ACEi/ARB group (12% vs. 35%, p = 0.038); however, six subgroup comparisons were performed and this result would not survive Bonferroni correction (threshold p < 0.008). This exploratory finding should be interpreted with caution given the small sample size and absence of adjustment for confounders. Conclusions: Preoperative ACEi/ARB use was associated with lower unadjusted one-year mortality, but this association did not reach statistical significance after multivariable adjustment and residual confounding cannot be excluded. ACEi/ARB use was not associated with increased mortality in this cohort. These hypothesis-generating findings from a single-centre observational study require confirmation in adequately powered prospective trials.

Comments on "Hospital procedural costs of surgical aortic valve replacement versus transcatheter aortic valve replacement in low-risk isolated aortic stenosis: a single-center analysis in Japan".

Cardiac Imaging in Clinical Trials of Intervention in Aortic Valve Stenosis.

Cardiac imaging and in particular transthoracic echocardiography and computed tomography play a major role in the selection of the patients for surgical or transcatheter aortic valve replacement, for the assessment or procedural success and early prosthetic valve hemodynamics following aortic valve replacement, and for the evaluation and follow-up of the prosthetic valve structure and function in the longer-term, which is key to demonstrate the valve durability. The purpose of this review article is thus to present the role of cardiac imaging, and particularly transthoracic echocardiography and computed tomography, in: (1) patient selection for intervention; (2) assessment of procedural and device success, and of intended performance of the valve; and (3) assessment of the long-term success, valve durability, and prognosis, for clinical trials of intervention in patients with aortic stenosis. Transthoracic echocardiography is the primary imaging modality to detect and stage bioprosthetic valve dysfunction. However, multimodality imaging, including transesophageal echocardiography and computed tomography, is often necessary to determine the cause of bioprosthetic valve dysfunction and make the differential diagnosis between prosthesis-patient mismatch, structural valve deterioration, thrombosis, pannus, or endocarditis. The clinical trials in the field of structural heart disease, and particularly in the field of aortic valve intervention, include imaging end points as part of the primary or key secondary end points. Standardized methods and definitions should be applied to adjudicate these imaging end points, and ideally, these trial end points should be analyzed by independent imaging core labs.

Porcelain Aorta in TAVR: Predictor of Adverse Outcomes or Overestimated Risk Factor?

Background and Objectives: Patients with porcelain aorta (PA) pose major surgical challenges during aortic valve replacement, making transcatheter aortic valve replacement (TAVR) the preferred alternative. However, data on the prognostic significance of PA among TAVR recipients are limited. This study sought to evaluate whether PA is associated with adverse short-term outcomes following TAVR. Materials and Methods: Consecutive, surgery-naïve patients who underwent TAVR between 2012 and 2020 at a single institution were retrospectively analyzed. Based on preoperative CT scans, patients were categorized as having either porcelain aorta (PA) or non-calcific aorta (NC). Inverse probability of treatment weighting (IPTW) was used to minimize baseline differences, with standardized mean differences (SMD) < 0.1 indicating adequate covariate balance. Logistic regression addressed residual post-IPTW imbalances. Results: A total of 2037 patients with severe symptomatic aortic stenosis were identified, of whom 40 (2%) had PA. Compared to the NC population, PA patients were more likely to be younger (p = 0.002), had a higher prevalence of heart failure symptoms (p = 0.041) and peripheral artery disease (p = 0.006). After adjustment for preoperative characteristics, no significant differences were observed between groups in post-TAVR mortality (p = 0.498), stroke (p = 0.606), or postoperative creatinine levels (p = 0.827). However, PA patients experienced significantly longer in-hospital (p < 0.001) and ICU (p < 0.001) lengths of stay. Conclusions: In this single-center cohort, PA did not appear to confer additional risk of mortality, stroke or renal failure, although it remained associated with longer postoperative in-hospital and ICU lengths of stays. TAVR appears to be a safe and effective method of AVR when significant circumferential atherosclerotic aortic calcification precludes aortic cross-clamping.

Correspondence on 'Updated 5-year outcomes of transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low- to intermediate-surgical risk', by Marin-Cuartas

Computed Tomography Coronary Angiography as a Gatekeeper for Invasive Coronary Assessment Before Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) has become the predominant treatment strategy for severe aortic stenosis across all surgical risk categories. The coexistence of coronary artery disease (CAD) in 40-75% of TAVI candidates has traditionally mandated pre-procedural invasive coronary angiography (ICA). However, computed tomography coronary angiography (CTCA), which is already integral to TAVI planning for annular sizing and access route evaluation, offers the potential to assess coronary anatomy simultaneously. Accumulating evidence demonstrates that CTCA possesses excellent sensitivity (90-97%) and high negative predictive value (94-99%) for excluding significant proximal CAD, potentially serving as a reliable gatekeeper to avoid unnecessary ICA in a substantial proportion of patients. This approach is particularly attractive given the questionable benefit of routine pre-emptive coronary revascularization in stable TAVI candidates, as demonstrated by the ACTIVATION and NOTION-3 trials. This review synthesizes the current evidence on the diagnostic performance of CTCA, clinical outcomes with CT-guided strategies, technical considerations and limitations, and the evolving paradigm of coronary assessment in the contemporary TAVI era. We propose a practical algorithm integrating CTCA as a first-line screening tool, reserving ICA for patients with suspected significant proximal disease, thereby optimizing resource utilization while maintaining patient safety.

Successful Transcatheter Aortic Valve Implantation in a High-Risk Elderly Patient with Intraoperative Ventricular Tachycardia: A Case Report.

Aortic stenosis (AS) is a common valvular heart disorder in older adults, primarily caused by age-related degenerative changes. In high-risk cases, transcatheter aortic valve implantation (TAVI) has emerged as a viable and less invasive alternative to surgical aortic valve replacement for patients with symptomatic severe AS and an elevated risk of operative mortality. We report a favorable outcome of TAVI performed under monitored anesthesia care in a 76-year-old woman with multiple comorbidities who developed ventricular tachycardia during the procedure conducted under local anesthesia with light sedation.

Growth rate of the ascending aorta and risk of aortic dissection or reintervention in patients with bicuspid or tricuspid aortic valves undergoing valve interventions: a systematic review and meta-analysis.

Introdução: A válvula aórtica bicúspide (VAB) associa-se a disfunção valvular precoce e dilatação progressiva da aorta, podendo evoluir para disseção. A evolução das dimensões da aorta após procedimento de substituição valvular permanece incerta, particularmente quando comparada com a doença da válvula aórtica tricúspide (VAT). Esta revisão sistemática e meta-análise teve como objetivo comparar o crescimento da aorta pós-operatório e o risco de eventos aórticos major entre doentes com VAB e VAT. Métodos: Foi realizada uma pesquisa sistemática nas bases de dados MEDLINE, CENTRAL e Web of Science (até abril de 2025), identificando estudos de coorte prospetivos e retrospetivos que incluíram doentes adultos com VAB ou VAT submetidos a substituição valvular aórtica cirúrgica (SAVR) ou por via percutânea (TAVI). Os estudos tinham de reportar dados longitudinais sobre a taxa de crescimento aórtico (mm/ano) ou a incidência de dissecção aórtica ou reintervenção; foram excluídos aqueles com cirurgia aórtica concomitante. Meta-análises com modelo de efeitos aleatórios estimaram diferenças médias (DM) e razões de risco (RR) com intervalos de confiança (IC) de 95%. Resultados: Foram incluídos quinze estudos (n = 1.772 para crescimento da aorta; n = 2.307 para dissecção aórtica; n = 2.598 para reintervenção aórtica). Não se verificou diferença significativa no crescimento aórtico anual entre VAB e VAT (DM 0,15 mm/ano; IC 95% -0,03 a 0,33; p = 0,09; I² = 82,6%). A meta-regressão confirmou que diferenças de idade entre as coortes de VAB e VAT não modificaram o efeito global neutro na taxa de crescimento aórtico. As análises por subgrupos demonstraram resultados semelhantes entre diferentes desenhos de estudo, mas pequenas diferenças consoante o tipo de procedimento (SAVR DM 0,21 mm/ano, p = 0,07; TAVI DM -0,04 mm/ano, p = 0,53; p = 0,02 para comparação entre SAVR e TAVI). Não foram encontradas diferenças significativas no risco de dissecção aórtica (RR 1,34; IC 95% 0,63-2,83; p = 0,44) nem de reintervenção aórtica (RR 0,95; IC 95% 0,56-1,61; p = 0,84). Conclusões: A dilatação da aorta e as taxas de eventos árticos foram comparáveis entre doentes com VAB e VAT após substituição valvular. Estes resultados desafiam a suposição de longa data de que a morfologia bicúspide acelera intrinsecamente a progressão da aortopatia pós-operatória em todos os doentes.

Transcatheter vs surgical aortic valve replacement in young adults with chronic kidney disease: a national inpatient comparison of in-hospital outcomes.

BACKGROUND: Chronic Kidney Disease (CKD) is a major global health problem, burdening more than 650 million people worldwide and exposing them to the risk of aortic stenosis (AS). The present study responds to the urgent need to assess the safety and effectiveness of aortic valve replacement (AVR) interventions young adults with CKD, who tend to be excluded from randomized trials. METHODS: We analyzed the in-hospital outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in a young adult population with chronic kidney disease (CKD) using the National Inpatient Sample (NIS) database. This large, publicly available United States inpatient healthcare database allowed cross-sectional analysis of hospital admissions during 2018-2020. The population included patients under the age of 65 with a primary or secondary CKD diagnosis who underwent TAVR or SAVR procedures. Baseline factors and in-hospital outcomes, such as mortality rates, hospital costs, and hospital stay, were compared between the TAVR and SAVR groups using statistical analysis, adjusting for these baseline factors. RESULTS: The 11,315 young adults with CKD trial revealed that TAVR was associated with comparable risk of in-hospital death, reduced length of hospital stay, and decreased hospital charges in comparison to SAVR. TAVR was also associated with reduced risk of acute kidney injury, cardiogenic shock, and venous thromboembolism complications. CONCLUSIONS: In conclusion, TAVR presents a favorable alternative to SAVR for young adults with CKD. These findings contribute strong evidence to guide clinical decision-making and improve care for this complex patient population.

[Redo Surgical Aortic Valve Replacement for Dysfunctional Transcatheter Aortic Valve Implanted for Degenerated Surgical Bioprosthesis].

An 81-year-old man underwent surgical aortic valve replacement (SAVR) for stenotic bicuspid valve with a 21-mm CEP bioprosthesis 17 years ago. Four years ago, he underwent valve-in-valve (ViV)transcatheter aortic valve replacement (TAVR) using a self-expandable Evolut R 23-mm valve due to structural valve deterioration (SVD) and redo SAVR was indicated because of repeat SVD and heart failure symptoms. Transcatheter valve and prior surgical valve adhered to the anterior mitral leaflet. Removal of the valve caused perforation, which required repair. Aortic valve replacement was performed using an Epic Plus 21-mm valve. SAVR after TAVR is more invasive and has higher mortality than ViV, but in younger or low-risk patients, treatment should be planned with long-term prognosis in mind.

Ventricular Septal Rupture Despite Early Pharmaco-Invasive Reperfusion in Anterior STEMI With Favorable Surgical Outcome.

Ventricular septal rupture (VSR) is a rare but catastrophic mechanical complication of acute myocardial infarction, even in the contemporary reperfusion era. Although early reperfusion strategies have significantly reduced its incidence, they do not completely eliminate the risk. We report the case of a 76-year-old man with a history of hypertension and no prior structural heart disease who presented with an anterior ST-elevation myocardial infarction (STEMI). He received tenecteplase 2 hours and 37 minutes after symptom onset and was subsequently referred for routine percutaneous coronary intervention (PCI), during which a stent was implanted in the left anterior descending (LAD) artery. During in-hospital monitoring, a new harsh holosystolic murmur was detected. Transthoracic echocardiography revealed an 11-mm interventricular septal defect with left-to-right shunting, which was confirmed by color and spectral Doppler. Despite this mechanical complication, the patient remained hemodynamically stable and did not require vasopressor support. He underwent successful surgical repair using an infarct exclusion technique with a bovine pericardial patch. The postoperative course was favorable, with no need for mechanical circulatory support, extubation within the first 12 hours, no requirement for high-dose vasoactive amines, and no residual shunt on follow-up echocardiography. He was discharged home with outpatient follow-up. This case highlights that post-infarction VSR may occur despite timely pharmaco-invasive reperfusion, particularly in anterior STEMI, and underscores the importance of continued clinical vigilance even after apparently successful reperfusion. Early recognition through physical examination and echocardiography, together with prompt multidisciplinary management, may allow for favorable outcomes in selected patients.

The Initial Middle Eastern Experience With the Alterra Adaptive Pre-Stent: Single-Center Outcomes From Saudi Arabia.

BACKGROUND: The Alterra Adaptive Pre-Stent, used with the Edwards SAPIEN 3 valve, offers a novel transcatheter option for patients with severely dilated right ventricular outflow tracts (RVOTs) previously unsuitable for conventional transcatheter pulmonary valve replacement (TPVR). No prior experience with this system has been reported from the Middle East. METHODS: We report the first Middle Eastern experience with the Alterra Adaptive Pre-Stent from a high-volume congenital heart center. A retrospective, single-center analysis was performed at Prince Sultan Cardiac Center (Riyadh, Saudi Arabia). Between April and July 2025, a total of 10 patients with native (after balloon valvuloplasty) or surgically patched RVOTs underwent TPVR using the Alterra Pre-Stent and Edwards SAPIEN 3 valve. Patient selection, procedural data, and early clinical outcomes were reviewed. RESULTS: All 10 patients (mean age: 30 ± 7.1 years; range: 15-40 years) underwent successful implantation. The mean weight was 66.4 ± 22.7 kg (range: 35-103 kg), and 30% (n = 3) were male. Procedural success was 100%, with accurate device positioning and no significant residual gradient or pulmonary regurgitation. No major complications-including valve embolization, coronary compression, or surgical conversion-occurred. At a median follow-up of 31 days (range: 10-43 days), all patients remained clinically stable with improved functional status. CONCLUSIONS: This is the first reported experience of the Alterra Adaptive Pre-Stent in the Middle East. Early results demonstrate that the device is safe, technically feasible, and effective in selected patients with complex RVOT anatomies, potentially broadening TPVR applicability in the region.

Transcatheter Versus Surgical Aortic Valve Replacement in Severe Aortic Stenosis With Reduced Left Ventricular Ejection Fraction (≤50%): A Systematic Review and Meta-Analysis of Hemodynamic and Clinical Outcomes.

Severe aortic stenosis with reduced left ventricular ejection fraction (LVEF) represents a clinically vulnerable subgroup in whom the comparative benefits and risks of transcatheter aortic valve replacement/implantation (TAVR/TAVI) and surgical aortic valve replacement (SAVR) remain incompletely defined. This systematic review and meta-analysis compared early clinical outcomes and one-year hemodynamic and ventricular recovery outcomes between TAVR/TAVI and SAVR in adults with severe native aortic stenosis and baseline LVEF ≤50% or an extractable reduced-LVEF subgroup. Searches were performed in PubMed/MEDLINE, Scopus, Web of Science, Embase, and SciELO on February 27, 2026, with an updated search on April 1, 2026. Embase was used with awareness that it incorporates ClinicalTrials.gov records, and supplementary registry searches and verification included ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, and the EU Clinical Trials Register. The protocol was prospectively registered in PROSPERO (International Prospective Register of Systematic Reviews) (CRD420261348568). Risk of bias was assessed using RoB 2 (revised Cochrane risk-of-bias tool for randomized trials) for randomized evidence and ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) V2 for nonrandomized comparative studies; certainty of evidence was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Seven comparative studies met eligibility criteria, including randomized subgroup analyses and matched or adjusted observational cohorts; six contributed to at least one pooled quantitative synthesis. Thirty-day all-cause mortality did not show a statistically significant difference between TAVR/TAVI and SAVR (RR 0.85, 95% CI 0.46-1.57; 6 studies; n=1,651). TAVR/TAVI was associated with a lower risk of early stroke (RR 0.48, 95% CI 0.25-0.91; 4 studies; n=1,285). Permanent pacemaker implantation was numerically more frequent after TAVR/TAVI, but the estimate was highly imprecise (RR 2.66, 95% CI 0.49-14.38; 3 studies; n=1,082). At one year, the pooled estimates did not establish a clear difference in mean transprosthetic gradient (MD -1.70 mmHg, 95% CI -11.22 to 7.82; 3 studies; n=654) or LVEF recovery (MD 2.91 percentage points, 95% CI -6.20 to 12.01; 3 studies; n=615). In severe aortic stenosis with reduced LVEF, TAVR/TAVI may reduce early stroke, and short-term mortality appears broadly similar to SAVR; however, evidence for pacemaker implantation, one-year gradients, and LVEF recovery remains very uncertain and should not be interpreted as evidence of equivalence between strategies.

[Assessment of valvular heart disease: the role of imaging from diagnosis to intervention].

Valvular heart disease is common in an aging population and is associated with substantial morbidity and mortality. Modern cardiovascular imaging is central to diagnosis, therapeutic decision-making, and longitudinal follow-up of aortic, mitral, and tricuspid valve disease throughout the entire care pathway - from initial evaluation to specialized intervention. Transthoracic echocardiography (TTE) remains the first-line modality for initial diagnosis and follow-up assessment. Transesophageal echocardiography (TEE) provides detailed morphological evaluation of the valves and is indispensable for surgical and interventional planning, particularly of the atrioventricular valves. Cardiac CT is the current standard for planning transcatheter aortic valve implantation (TAVI) and is gaining importance in percutaneous mitral and tricuspid valve replacement, including simulation-based planning and risk assessment. Cardiac MRI contributes primarily to precise volume quantification and the assessment of ventricular function and myocardial structure. Peri-interventional TEE has become an essential real-time guidance tool in the catheter laboratory, enabling precise device navigation and immediate evaluation of procedural success. The targeted use of complementary imaging modalities is crucial for accurate assessment of valvular pathology, optimal planning and guidance of interventions, and long-term patient follow-up. Imaging is therefore not merely a diagnostic aid but the foundation of modern, increasingly catheter-based valve therapy.

Hypericum monogynum extract inhibits human aortic valve interstitial cell calcification by interfering with the EGFR/PI3K/AKT signaling pathway.

Calcific aortic valve disease (CAVD) is a serious heart valve condition with increasing global prevalence. Currently, transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) represents the only available treatment strategy, as no pharmaceutical therapies for CAVD are approved. The aim of this study was to identify compounds capable of inhibiting osteogenic differentiation of human aortic valve interstitial cells (hVICs), a process critically implicated in CAVD pathogenesis, and to elucidate the underlying molecular mechanism. From an in-house library of 88 compounds screened via dot-blotting, we identified chipericumin D, a natural compound extracted from Hypericum monogynum L., as a candidate exhibiting potent inhibitory activity against hVIC osteogenic differentiation. Network pharmacology analysis, molecular docking, drug affinity responsive target stability (DARTS), cellular thermal shift assay (CETSA), and surface plasmon resonance (SPR) collectively demonstrated direct binding of chipericumin D to the epidermal growth factor receptor (EGFR). Furthermore, chipericumin D suppressed activation of the EGFR/phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT) signaling pathway in hVICs cultured under osteogenic medium (OM) conditions. These findings indicate that chipericumin D is a promising therapeutic candidate for CAVD, and provide preliminary evidence that EGFR constitutes a novel molecular target for CAVD intervention.

Successful Valve-in-Valve-in-Valve Procedure in a Patient With Severe Aortic Prosthesis Dysfunction: A Case Report.

Transcatheter aortic valve implantation (TAVI) has become an established treatment for patients with severe aortic stenosis, particularly those with elevated surgical risk. As indications for TAVI expand and patient survival improves, an increasing number of individuals may outlive their initial transcatheter heart valve (THV), creating new challenges in long-term valve management. Repeat procedures such as valve-in-valve implantation are therefore becoming more common. However, repeated transcatheter valve implantation increases the risk of complications, including patient-prosthesis mismatch (PPM), impaired coronary access, and residual or recurrent aortic regurgitation (AR). We report a rare case of early failure of two balloon-expandable transcatheter valves resulting in severe transvalvular regurgitation and recurrent heart failure. The patient was successfully treated with implantation of a third prosthesis using a self-expanding supra-annular valve in a valve-in-valve-in-valve (ViViV) configuration. This strategy corrected the regurgitation while preserving an adequate effective orifice area. This case highlights the importance of individualized valve selection and demonstrates that switching valve platforms from balloon-expandable to self-expanding devices may provide an effective solution in complex redo TAVI procedures.

From Presyncope to Recovery: Echocardiography-guided Transcatheter Aortic Valve Implantation for Severe Bicuspid Aortic Stenosis.

Bicuspid aortic valve (AV) is the most common congenital cardiac valvular anomaly and often progresses to severe calcific aortic stenosis (AS). Although surgical AV replacement has been the conventional treatment, transcatheter AV implantation (TAVI) is emerging as a viable alternative, especially in patients with high surgical risk or complex anatomy. This case report demonstrates the crucial role of echocardiography in the management of TAVI in a patient with bicuspid AS. A 66-year-old male with a 3-year history of palpitations and recurrent presyncope underwent a comprehensive evaluation for suspected AV disease. Transthoracic echocardiography (TTE) revealed severe bicuspid AS with preserved left ventricular function. Coronary angiography and computed tomography angiography were performed for anatomical and procedural assessment, confirming suitability for TAVI. The procedure was conducted through a transfemoral approach using a 24-mm self-expanding bioprosthetic valve under echocardiographic guidance. TEE provided real-time imaging during valve deployment, while serial TTE was used for postprocedural and follow-up evaluations at 1 and 6 months to assess valve function and complications. This case underscores the central role of echocardiography in the comprehensive management of TAVI for bicuspid AS, from patient selection and intraprocedural guidance to postimplantation monitoring, ultimately optimizing clinical outcomes.

Transcatheter aortic valve-in-valve implantation for failed surgical aortic bioprostheses using the Navitor platform: early outcomes in a consecutive single-center cohort.

INTRODUCTION: Transcatheter heart valve implantation into a failed surgical heart valve (THV-in-SHV) is an established reintervention strategy for degenerated aortic bioprostheses; however, early procedural outcomes, discharge hemodynamics, and standardized safety remain clinically relevant in routine practice. MATERIAL AND METHODS: We retrospectively analyzed consecutive patients who underwent aortic THV-in-SHV with the Navitor platform between 2022 and 2025. The primary endpoint was the mean aortic gradient at discharge. Secondary endpoints included peak gradient, maximum transvalvular velocity (Vmax), paravalvular leak (PVL), Valve Academic Research Consortium-3 (VARC-3) early safety, and time from surgical aortic valve replacement (SAVR) to reintervention according to leaflet mounting. RESULTS: Thirty patients were included (age, 72.5 ± 9.2 years; 73.3% male). At discharge, the mean and peak aortic gradients were 16.8 ± 6.7 mmHg and 30.0 ± 11.7 mmHg, respectively. Paravalvular leak was absent, trace, or mild in 96.7%, with no severe PVL. Early safety according to VARC-3 was achieved in 86.7%. Mortality and stroke occurred in 3.3% each, and bleeding type ≥ 2 occurred in 6.7%. No acute kidney injury (AKI) stage 3, renal replacement therapy (RRT), major vascular complications, device-related intervention, or new permanent pacemaker implantation occurred. Smaller surgical valves were associated with higher residual gradients, whereas outside-mounted bioprostheses showed a shorter time to reintervention than inside-mounted designs. CONCLUSIONS: Aortic THV-in-SHV with the Navitor platform was associated with acceptable discharge hemodynamics, low rates of clinically relevant PVL, and favorable early safety according to VARC-3. Residual gradients were driven primarily by surgical valve size despite the intra-annular design.

TRI-SCORE based risk stratification across contemporary treatment strategies for isolated tricuspid regurgitation: a multicenter retrospective analysis.

BACKGROUND: The TRI-SCORE is a disease-specific risk model developed to predict outcomes after isolated tricuspid valve surgery. Although its prognostic value has been demonstrated across contemporary treatment strategies, independent external validation in multicenter cohorts across a broader clinical and etiological spectrum remains limited. We evaluated the prognostic performance of the TRI-SCORE in patients with isolated ≥ moderate tricuspid regurgitation (TR) treated with medical therapy, surgery, or transcatheter tricuspid edge-to-edge repair (T-TEER). METHODS: In this retrospective multicenter study, 104 patients with isolated ≥ moderate TR treated between 2010 and 2024 were included. Patients underwent medical therapy (n = 31), isolated tricuspid valve surgery (n = 40), or T-TEER (n = 33). The primary endpoint was all-cause mortality, and the secondary endpoint was a composite of all-cause mortality or heart failure hospitalization. Multivariable Cox proportional hazards models included TRI-SCORE and selected clinically relevant covariates. RESULTS: The median age was 77.0 years (IQR, 69.8-83.0), 62% of patients were women, and the median follow-up was 45 months (IQR, 27-63). During follow-up, all-cause mortality occurred in 37 (36%), and the composite endpoint in 40 (38%). One-year all-cause mortality increased across TRI-SCORE categories (7%, 13%, and 33% in the low-, intermediate-, and high-risk groups, respectively; P = 0.03). Baseline TRI-SCORE independently predicted all-cause mortality (HR 1.23; 95% CI 1.08-1.40) and the composite endpoint (HR 1.34; 95% CI 1.17-1.52). At 1 year, TR was reduced to < moderate severity in 60% of medically treated patients, 91% of surgically treated patients, and 68% of T-TEER-treated patients. Although surgery was associated with a lower risk of the composite endpoint (HR 0.39; 95% CI 0.17-0.89), Kaplan-Meier analysis showed no significant survival difference among treatment groups. CONCLUSIONS: In this multicenter real-world cohort of patients with isolated ≥ moderate TR, the TRI-SCORE provided independent prognostic information across medical therapy, surgery, and T-TEER. These findings provide external validation of the TRI-SCORE in a multicenter cohort representing a broader clinical and etiological spectrum than previously evaluated, supporting its use for baseline risk stratification across contemporary management strategies. Treatment comparisons should be interpreted cautiously because of the observational study design.

Pre- and post-dilatation in transcatheter aortic valve implantation with self-expanding valves: a systematic review and meta-analysis.

INTRODUCTION: Pre-dilatation balloon aortic valvuloplasty (PRE-BAV) and post-dilatation (POST-DIL) are commonly used during transcatheter aortic valve implantation with self-expanding valves (SEV-TAVI) to facilitate device delivery and optimize valve expansion, but both may increase procedural complications. METHODS: We conducted a systematic review and meta-analysis to evaluate outcomes associated with PRE-BAV and POST-DIL compared with direct implantation (DIRECT) and valves left as deployed (AS-DEPLOYED), respectively. Eleven studies (nine observational, two randomised; 24,143 patients) were included for PRE-BAV and five observational studies (7,526 patients) for POST-DIL. Key outcomes included mortality, stroke, permanent pacemaker implantation, and moderate or greater paravalvular leak (PVL2+). Random-effects meta-analyses with Hartung-Knapp-Sidik-Jonkman adjustment were used to estimate pooled odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Compared with DIRECT, PRE-BAV was not associated with differences in mortality, stroke, pacemaker implantation, or PVL2+, but randomised data showed a reduced need for POST-DIL (OR 0.43; 95% CI 0.24-0.74). Compared with AS-DEPLOYED, observational series suggested that POST-DIL was linked to higher 30-day mortality (OR 1.39; 95% CI 1.18-1.63), increased PVL2+ (OR 3.76; 95% CI 2.13-6.63), and more frequent surgical conversion (OR 1.22; 95% CI 1.06-1.41), with no differences in stroke or pacemaker implantation. DISCUSSION: PRE-BAV was not associated with increased adverse outcomes and may reduce the need for post-dilatation, whereas the adverse outcomes observed with POST-DIL in observational studies are most likely explained by confounding by indication rather than a causal effect. Further adequately powered randomised trials are needed to define the optimal balloon dilatation strategy in SEV-TAVI. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024610604.

A case report: Transcatheter aortic valve replacement via femoral artery for aortic regurgitation post-CARVAR.

A 26-year-old male patient experienced recurrent severe aortic regurgitation accompanied by left ventricular enlargement and a left ventricular ejection fraction of 17.7% 8 years after undergoing comprehensive aortic root and valve repair (CARVAR). Given the high risks associated with redo sternotomy and the patient's explicit refusal of both redo sternotomy and heart transplantation, a multidisciplinary consultation led to the decision to perform transcatheter aortic valve replacement (TAVR) as a transitional treatment. The transvalvular procedure was performed with snare-assisted valve delivery devices and ultra-high release technique. Postoperative echocardiography demonstrated normal valve function without perivalvular leakage, with significant improvement in cardiac function compared to baseline. This case illustrates that TAVR can serve as an effective transitional therapeutic strategy for high-risk patients with recurrent aortic regurgitation following CARVAR.

Direct Intravascular Observation of Trifecta️ Bioprosthetic Valve Dysfunction Using Nonobstructive General Angioscopy.

Although surgical reintervention remains the standard of care for failed surgical valves, transcatheter aortic valve implantation in surgical aortic valves (TAV-in-SAV) has emerged as a viable alternative with reliable results. The Trifecta valve is one of the most challenging SAVR prostheses for TAV-in-SAV management. Recently, nonobstructive general angioscopy (NOGA) has been used to evaluate the quality of plaques on the inner surface of the aorta under direct visualization, which cannot be evaluated using computed tomography. Here, we describe a case of Trifecta️ bioprosthetic valve dysfunction (BVD) directly observed by NOGA. A 26-mm Evolut FX was implanted, and the procedure was completed without complications. This case highlights the potential adjunctive role of NOGA in the assessment of BVD; however, its incremental clinical benefit and safety profile require further investigation.

Successful Transcatheter Amplatzer Repair of Severe Paravalvular Leak Following Mechanical Mitral Valve Replacement Surgery.

INTRODUCTION: Paravalvular leaks are a rare complication following surgical mitral valve replacement but may result in significant mitral regurgitation. In patients with paravalvular leak, percutaneous repair of the leak is an emerging option for patients who are poor surgical candidates. This report presents a case of a severe symptomatic paravalvular leak postsurgical mitral replacement that was treated with a transcatheter approach resulting in complete resolution of paravalvular regurgitation and symptoms. CASE DESCRIPTION: A 60-year-old male with a history of atrial fibrillation, nonischemic cardiomyopathy, Stage III chronic kidney disease, and heart failure with a mildly reduced ejection fraction that improved after undergoing mechanical mitral valve replacement presented with recurrent shortness of breath a few months after surgery. Transthoracic echocardiography demonstrated severe paravalvular leak, with a subsequent TEE confirming the precise etiology and location. After collaborative evaluation in a multidisciplinary valve clinic, the patient underwent successful transcatheter closure with Amplatzer plugs. DISCUSSION: Transcatheter valve interventions are minimally invasive techniques that have emerged as therapeutic options for patients who are poor surgical candidates. Using this approach to manage PVL is now being studied as a treatment option for patients to avoid redo mitral surgery. This case presents a transcatheter approach to PVL closure in a patient who had undergone a previous surgical mitral valve replacement, resulting in complete resolution of symptoms. The effectiveness of this transcatheter approach signals the need for larger prospective or registry studies to refine transcatheter approaches to manage postsurgical mitral paravalvular leaks.

Transcatheter Mitral Valve Replacement in Failed Mitral Bioprosthesis: Case Report.

Transcatheter valve-in-valve mitral valve replacement (ViV TMVR) is an established therapeutic alternative for selected patients with symptomatic degeneration of a surgical mitral bioprosthesis and high or prohibitive surgical risk. We present a 75-year-old woman with a failed Pericarbon More 29-mm mitral bioprosthesis and severe prosthetic mitral stenosis, which was resolved with transseptal transcatheter ViV TMVR. Baseline echocardiography showed mitral valve area 0.45 cm2 by pressure half-time, mean transmitral gradient 13 mmHg, preserved left ventricular systolic function, estimated systolic pulmonary artery pressure of 55 mmHg, and severe tricuspid regurgitation. ECG-gated computed tomography was performed for proper procedural planning. During the procedure, after dilation of the interatrial septum, an abrupt left-to-right shunt caused hemodynamic compromise. Rapid rescue balloon dilation of the stenotic mitral bioprosthesis and subsequent implantation of a 26-mm SAPIEN 3 valve restored forward transmitral flow, reduced the interatrial shunt to a minimum, and avoided septal occluder implantation. Postprocedural echocardiography showed a mean transmitral gradient of 3.5 mmHg, no intraprosthetic or paravalvular regurgitation, no LVOT obstruction, and a minimal, hemodynamically insignificant residual shunt. At 6-month, 12-month, and 2-year follow-ups, the patient remained asymptomatic with stable prosthetic valve function, although the estimated pulmonary artery pressure remained mildly to moderately elevated and tricuspid regurgitation persisted at a moderate degree. Beyond demonstrating the feasibility of valve-in-valve TMVR, this case highlights that septal dilation in severe prosthetic mitral stenosis can precipitate abrupt hemodynamic deterioration by creating a clinically significant left-to-right interatrial shunt before relief of the mitral obstruction.

A Concomitant Off-Pump Coronary Artery Bypass to TAV-in-TAV in a Patient with a High Risk of Coronary Artery Occlusion.

We report a case of a 90-year-old woman with prior transcatheter aortic valve replacement (TAVR) who presented with symptomatic structural valve deterioration. Imaging revealed a critically short valve-to-coronary distance (< 4 mm), suggesting a high risk for coronary obstruction during valve-in-valve (TAV-in-TAV) procedure. Although preventive techniques such as BASILICA and chimney stenting have been considered, these approaches require advanced technical expertise and are associated with procedural risks. Given the patient's advanced age and high surgical risk, we therefore opted for a hybrid strategy combining TAV-in-TAV with concomitant off-pump coronary artery bypass grafting to the left anterior descending artery for coronary protection. The procedure was successfully completed without complications. Postoperative imaging confirmed good prosthetic valve function, graft patency, and preserved coronary flow. To our knowledge, few reports have described TAV-in-TAV with simultaneous surgical coronary revascularization as a preventive approach for coronary obstruction. This case highlights the potential utility of surgical-transcatheter hybrid strategy in anatomically high-risk patients unsuitable for conventional transcatheter preventive techniques.

State of the art: Transcatheter tricuspid valve intervention.

Tricuspid regurgitation (TR) has a community prevalence of 3%, which increases with age and affects up to 7% of elderly patients. TR is secondary (functional) in 90% of cases (usually resulting from left heart disease and/or pulmonary hypertension), although atrial dilatation is an increasingly recognised cause. Awareness of the poor prognosis associated with increasing TR severity has refocused the quest for effective treatments. Surgical intervention has been hindered by high in-hospital mortality (up to 10%), even in carefully selected cases, and transcatheter tricuspid valve interventions (TTVIs) have emerged as a low-risk alternative for this high-risk cohort. Increasing data demonstrate the clinical safety and efficacy of TTVIs, but uncertainties remain concerning optimal case selection and procedural timing. Herein, we review newly established techniques alongside emerging clinical and procedural outcome data.

Transcatheter dual-device closure for symptomatic iatrogenic atrial septal defect following bioprosthetic mitral valve replacement: a case report.

Iatrogenic atrial septal defect (iASD) is a relatively common complication after cardiac surgical or catheter-based procedures involving transseptal access. While most defects close spontaneously, a subset may persist and become hemodynamically significant, leading to clinical deterioration and necessitating intervention. We report a case of a large, persistent iASD that led to progressive right-sided heart failure following bioprosthetic mitral valve replacement combined with tricuspid annuloplasty. A 69-year-old male underwent bioprosthetic mitral valve replacement and tricuspid annuloplasty. Postoperatively, the patient developed a large, persistent iASD, which contributed to severe right-sided heart failure. The patient also had end-stage liver disease, portal hypertension, and severe coagulopathy, which made reoperation extremely high-risk. After heart team evaluation, a transcatheter closure approach was chosen. Initially, a 24-mm occluder was deployed, but significant residual shunting remained. A planned two-device strategy was then performed, resulting in complete closure of the defect. Post-procedure imaging confirmed the absence of residual shunt, and tricuspid regurgitation significantly improved. The patient's symptoms improved to New York Heart Association NYHA I-II, and at six-month follow-up, the device remained stable, and cardiac function had recovered. This case illustrates that in patients with large, complex, or poorly rimmed iASDs, particularly those who are not suitable candidates for reoperation, the dual-device strategy represents a safe and effective percutaneous alternative.

Artificial Intelligence-Driven Detection, Characterization, and Risk Stratification in Patients with Severe Tricuspid Regurgitation.

BACKGROUND: Tricuspid regurgitation (TR) is prevalent and challenging to manage. There is a high mortality rate associated with isolated surgery and late referral for intervention. Additionally, there has been a recent expansion of transcatheter therapies. In Brazil, there is a lack of data and validation of prognostic tools. OBJECTIVE: To investigate and define clinical, laboratory, and echocardiographic data from patients with severe TR based on variables collected through the training of an artificial intelligence (AI) model. METHODS: This observational, single-center, non-interventional, retrospective study was based on 71,911 echocardiographic reports performed between 2021 and 2024. A natural language processing (NLP) model was developed in Python to identify cases of severe TR, extract variables, and perform automated calculation of the TRI-SCORE and EuroSCORE II, which were subsequently reviewed. A two-tailed p-value < 0.05 was considered statistically significant. RESULTS: A total of 803 patients with severe TR were identified. The mean age was 68.8 ± 13.5 years, and 64.1% were female. Hypertension (71.7%) and atrial fibrillation (69.4%) were the most prevalent comorbidities. Secondary etiology predominated (96.8%), mainly associated with mitral valve disease (68.5%). Surgical risk was high (medians: EuroSCORE II = 13.4%; TRI-SCORE = 7). Mortality was 17.1%. In the secondary mortality analysis, multivariable regression identified independent predictors, such as high-risk TRI-SCORE (relative risk [RR] 2.19; 95% CI 1.14-4.21) and increased creatinine (RR 3.13; 95% CI 1.91-5.14). CONCLUSIONS: In the largest Brazilian cohort of severe TR, constructed with the aid of AI, the disease demonstrated high clinical and prognostic complexity. The application of NLP to large echocardiographic databases proved to be efficient and may support multicenter studies.

Trans-catheter closure of large peri-membranous ventricular septal defect with multiple exits using two occluder devices.

Aneurysmal peri-membranous ventricular septal defects (PM-VSD) may show multiple right ventricular exits separated by tricuspid chordae or trabeculations. Transcatheter PM-VSD closure is increasingly performed as a surgical alternative. An 8-year-old girl with a large PM-VSD, with moderate pulmonary hypertension, presented with dyspnea and recurrent respiratory infections. The defect measured 12 mm with two exits. Closure was successfully achieved using two devices through an antegrade approach with two arteriovenous loops. There was no residual shunt, aortic regurgitation, or conduction block on follow-up. Transcatheter closure of PM-VSDs with multiple exits using two devices is feasible and safe in selected patients.

Transcatheter Edge-to-Edge Repair in Adult Congenital Heart Disease: Anatomic Challenges, Device Adaptations, and Emerging Evidence.

Atrioventricular valvular regurgitation (AVVR) is a principal determinant of morbidity and mortality in adults with congenital heart disease (ACHD), and surgical management carries substantial operative risk owing to prior sternotomies, distorted intracardiac anatomy, impaired ventricular function, and lesion-specific hemodynamic fragility. Transcatheter edge-to-edge repair (TEER)-using MitraClip or TriClip (Abbott) or PASCAL/PASCAL ACE (Edwards Lifesciences)-has emerged as a compelling alternative in high-surgical-risk acquired valvular disease and is rapidly expanding into ACHD. We review the anatomic substrate, device-specific technical considerations, preprocedural imaging requirements, and clinical evidence supporting TEER across the principal ACHD substrates: congenitally corrected transposition of the great arteries (TGA) with systemic tricuspid regurgitation, atrial switch repairs for dextro-TGA, atrioventricular septal defects, and single-ventricle Fontan circulations. We also address procedural challenges unique to ACHD, including venous access anomalies, altered transseptal geometry, absent conventional echocardiographic windows, and iatrogenic stenosis risk in morphologically abnormal valves. Multidisciplinary selection integrating ACHD structural expertise, advanced imaging, and procedural TEER experience is requisite for safe outcomes.

Concomitant Dynamic Left Ventricular Outflow Tract Obstruction and Severe Aortic Stenosis a Case Report and a Literature Review.

We report the case of a 77-year-old woman presenting with a hypertrophic cardiomyopathy phenotype characterized by hemodynamically significant dynamic left ventricular outflow tract obstruction (LVOTO) due to mitral systolic anterior motion (SAM), in association with aortic stenosis (AS). The clinical presentation included an episode of syncope, followed by progressive exertional dyspnea. Initial transthoracic echocardiography revealed marked septal hypertrophy, a calcified aortic valve with elevated transvalvular gradients, and SAM-induced dynamic LVOTO. Sarcomeric hypertrophic cardiomyopathy (HCM) and its phenocopies were subsequently excluded from the study. Transesophageal echocardiography confirmed the coexistence of severe AS and SAM. Given the complexity of the patient's cardiac condition and the presence of a "porcelain aorta," both surgical and transcatheter aortic valve replacement were deemed high risk. We discuss the diagnostic and therapeutic challenges of this "double-threat" scenario - severe aortic stenosis combined with dynamic LVOTO - and review the relevant literature regarding its hemodynamic implications, imaging strategies, and management approaches, including the concept of the "suicide left ventricle".

Successful Mitral Valve Repair for Single Leaflet Device Attachment Following Transcatheter Edge-to-Edge Repair: A Case Report.

An 87-year-old man underwent transcatheter edge-to-edge repair (TEER), one MitraClip NT︎ from anterior commissure (AC), 8 months prior for severe mitral regurgitation (MR) due to functional etiology and A1 chordal rupture, complicated by heart failure. Following improvement in heart failure, he was discharged home independently 2 weeks postprocedure. However, 4 months ago, he experienced worsening heart failure, and echocardiography revealed recurrent severe MR due to single leaflet device attachment (SLDA) at P1, prompting a surgical intervention. Intraoperatively, after establishing cardiopulmonary bypass and inducing cardiac arrest, transseptal access revealed the MitraClip NT︎ firmly adhered to the P1 leaflet and extensive rupture of the A1 chordae. The MitraClip NT︎ and involved leaflet tissue were excised en bloc, the defect was repaired, artificial chordae were implanted, edge-to-edge repair of the AC region was performed, and a prosthetic annuloplasty ring was sutured in place, successfully eliminating regurgitation. Since MitraClip NT︎ becomes encapsulated by fibrous tissue within 2-3 months postimplantation, isolated removal becomes technically difficult in the late phase. Therefore, en bloc resection with the leaflet is necessary in cases of SLDA-related recurrent MR. SLDA involving the posterior mitral leaflet is considered more amenable to mitral valve repair than that involving the anterior mitral leaflet. Patients selected for TEER generally have limited surgical tolerance; thus, minimizing operative and cardiopulmonary bypass times is essential. Surgical approach should be tailored based on leaflet morphology and clip location.

Concomitant transcatheter edge-to-edge treatment for mitral regurgitation and the K-Clip system for tricuspid regurgitation: one case report.

Transcatheter valve repair is an important alternative therapy for patients with severe valvular regurgitation who are at high risk for or contraindicated to undergo surgical procedures. However, there are challenges in bivalve interventional therapy. This case report presents a patient who underwent simultaneous transcatheter edge-to-edge repair (TEER) of the mitral valve and K-Clip™ tricuspid annuloplasty. The postoperative and one-month follow-up results were satisfactory, providing a new treatment approach for such patients.

The effect of diabetes mellitus on aortic valve stenosis and its treatment outcome: A meta-analysis review.

BACKGROUND: Given the importance of diabetes mellitus (DM) and its role in the development of aortic valve stenosis (AVS), as well as its association with adverse outcomes after aortic valve replacement (AVR), the present meta analysis aimed to provide a comprehensive review of previous studies in this field. METHODS: To achieve this objective, a thorough literature search was conducted in PUBMED/MEDLINE, ScienceDirect, CINAHL, EMBASE/SCOPUS, PsycINFO, ClinicalKey, the Cochrane Central Register of Controlled Trials (CENTRAL), ProQuest, Web of Science, and Persian databases such as SID and Magiran. The number of patients, gender ratio, mean age, prevalence of T2DM, AVS, and treatment outcomes after TAVI, TAVR, and SAVR (stroke, early and late mortality) were recorded. RESULTS: This metaanalysis comprised 22 studies involving a total of 760,287 patients with AVS. The pooled prevalence of DM was approximately 31% (95% CI: 26-36%). DM was associated with a significantly higher risk of early mortality, including both inhospital mortality (OR: 2.399) and 30day mortality (OR: 1.45), compared with nonDM patients (p<0.05). However, the increase in late mortality (one year or longer) among DM patients was not statistically significant. Additionally, DM patients showed a significantly elevated risk of stroke compared with nonDM patients (OR: 1.15; 95% CI: 1.03-1.28; p=0.009). CONCLUSION: Overall, DM appears to play a significant role in the development of AVS and is associated with adverse outcomes including mortality and stroke after AVR.

TAVR vs. SAVR in Patients With Severe Aortic Stenosis and Chronic Kidney Disease Undergoing Dialysis: A Comprehensive Meta-Analysis.

BACKGROUND: Patients with chronic kidney disease (CKD) undergoing dialysis who also suffer from severe aortic stenosis (AS) present a complex management challenge. Both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are treatment options, but comparative outcomes in this specific, high-risk population continue to remain unclear. AIM: This study aims to compare TAVR and SAVR postoperative clinical outcomes in patients with severe AS and CKD undergoing dialysis. METHODS: According to PRISMA guidelines, a comprehensive search was conducted across various databases such as PubMed, EMBASE, Scopus, and Google Scholar. Original studies that compared the clinical outcomes between TAVR and SAVR in patients with severe AS and CKD undergoing dialysis were included in the study. RESULTS: Ten studies, all retrospective, involving 28,625 (14,625 TAVR and 14,000 SAVR) patients with severe AS and CKD undergoing dialysis who underwent TAVR or SAVR were included in this study. Patients who underwent TAVR had significantly lower odds of in-hospital mortality (OR 0.49; 0.29, 0.84; p = 0.01) and shorter length of stay (LOS) (SMD -2.59; 95% CI -5.04, -0.14; p ≤ 0.04). However, the TAVR group had significantly higher odds of permanent pacemaker implantation (OR 2.25; 95% CI 1.71-2.94; p < 0.00001). CONCLUSION: In patients with severe AS and CKD undergoing dialysis, TAVR is associated with lower in-hospital mortality and shorter LOS, suggesting a favorable early safety profile and recovery in this population.

Circulating biomarkers improve prediction of postoperative outcome after aortic valve surgery.

BACKGROUND: Predicting adverse outcomes following aortic valve surgery remains challenging. This study aimed to investigate the association between preoperative circulating biomarkers and postoperative mortality and morbidity, with the goal of improving established risk stratification tools. METHODS: Between March 2018 and May 2022, 492 patients underwent surgical aortic valve replacement or repair and were included in a registry. Preoperative blood biomarkers, including hemoglobin, creatinine, high-sensitivity troponin I (hsTrop-I), GOT, GPT, INR, CRP, NT-proBNP and WBC, were sampled at baseline. Logistic regression analysis adjusted for EuroSCORE-II tested associations between biomarker levels and VARC-III adjudicated endpoints. Model fit was assessed using Akaike's Information Criterion, and likelihood ratio tests compared different prediction models. RESULTS: Preoperative hemoglobin (OR 0.70; 95% CI: 0.57, 0.87; p < 0.001), creatinine (OR 4.09; 95% CI: 1.63, 10.26; p = 0.003), high-sensitivity troponin I (OR 1.48; 95% CI: 1.11, 1.95; p = 0.007), GOT (OR 2.49; 95% CI: 1.06, 5.86; p = 0.036), INR (OR 4.74; 95% CI: 1.32, 17.05; p = 0.017), CRP (OR 2.14; 95% CI: 1.53, 3.00; p < 0.001), NT-proBNP (OR 2.06; 95% CI: 1.41, 3.00; p < 0.001), and WBC (OR 5.82; 95% CI: 1.88, 17.97; p = 0.002) were independently associated with 30-day mortality after adjustment for EuroSCORE-II. Models combining biomarkers with EuroSCORE-II outperformed those predicting mortality by EuroSCORE-II or biomarkers alone, as indicated by the lowest Akaike's Information Criterion and likelihood ratio tests. CONCLUSIONS: Combining established risk stratification models with preoperative biomarkers was associated with improved predictive performance for adverse outcomes after aortic valve surgery and may support heart team decision-making when choosing between surgical and transcatheter aortic valve replacement.

Transcatheter and surgical aortic valve replacement for aortic stenosis in France: Trends from 2010 to 2022 and impact of European guidelines and clinical trial results.

BACKGROUND: The PARTNER trials played a key role in the expansion of transcatheter aortic valve replacement (TAVR) for severe aortic valve stenosis (AS), shaping international practice guidelines. We assessed the evolution of AS management in France between 2010 and 2022, and the impact of PARTNER trials and European guideline updates on TAVR use. Characteristics of patients, facilities and TAVR valves, and post-procedure events were also described. METHODS AND FINDINGS: We conducted a nationwide cohort study using the French Health Data System (SNDS), including patients aged 18 years or older hospitalized for AS and receiving a first TAVR or surgical aortic valve replacement (SAVR) from 2010 to 2022. ARIMA models were used to study the impact of PARTNER trials and European guideline updates on TAVR use. Among 255,453 procedures, 109,739 were TAVR (N2010: 1,389; N2022: 16,770). No significant change in the proportion of TAVR was associated with PARTNER trials or European guideline updates (p ≥ 0.125). Median age and EuroSCORE II proxy were 83.0 years and 2.2 in TAVR group and 72.0 years and 1.4 in SAVR group. Approximately 60% of the TAVR and SAVR procedures were performed in public facilities. Latest valve generations replaced progressively earlier ones, with 62.5% being balloon-expandable. Mortality decreased over time in both groups, while length of stay and intensive care unit admissions decreased only in TAVR group. CONCLUSIONS: This 13-year nationwide overview highlights the growing uptake of TAVR in France, likely driven by clinical practice and procedural innovation rather than guidelines. Further analyses will compare efficacy and safety between TAVR and SAVR.

Case Report: Selective metal cell excision during open TAVR implantation preserves coronary access while maintaining valve integrity and function.

BACKGROUND: Coronary access following transcatheter aortic valve replacement (TAVR) remains challenging and should be carefully considered when planning re-intervention for patients with structural valve degeneration. Current management options [valve-in-valve (ViV) TAVR or surgical aortic valve replacement and TAVR explant] both carry significant benefits and limitations. CASE PRESENTATION: A 78-year-old female with a degenerated 23 mm Sapien 3 TAVR presented with severe prosthetic stenosis, moderate paravalvular leak (PVL), and progressive dyspnea. A standard TAVR ViV had a suboptimal risk of not addressing the PVL and worsening prosthesis-patient mismatch, whereas TAVR explantation and SAVR with root enlargement carried an increased surgical risk. INTERVENTION: Open surgical TAVR explantation with direct re-implantation of a 26 mm Sapien Ultra valve, combined with selective metal cells excision facing the left main coronary artery (LMCA) and felt patch repair of the PVL. OUTCOME: The patient achieved immediate resolution of severe stenosis and elimination of PVL, with sustained clinical improvement at six-month follow-up and a more favorable coronary access. CONCLUSION: Selective metal cell excision during open TAVR implantation is a technically feasible approach to prophylactically preserve coronary access while maintaining valve integrity and function. This technique may benefit high-risk patients requiring TAVR explants and root enlargement SAVRs.

Complex mitral annular calcification: why surgical access still matters.

Risk-score performance for detecting transthyretin cardiac amyloidosis in severe aortic stenosis: a prospective cohort study.

INTRODUCTION: The coexistence of transthyretin cardiac amyloidosis (ATTR-CA) and severe aortic stenosis (AS) presents a diagnostic challenge. This study aimed to determine the prevalence of this dual pathology and to assess the effectiveness of diagnostic models in enhancing detection accuracy. METHODS: We conducted a prospective study of 104 consecutive patients with severe AS (aortic valve area <1 cm2). Comprehensive evaluation included clinical and laboratory assessments, electrocardiography, transthoracic echocardiography, planar whole-body bone scintigraphy, and chest single-photon emission computed tomography/computed tomography using technetium-99m-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid tracer. Patients were grouped according to the presence of ATTR-CA, and the diagnostic utility of the RAISE score, its variations, and the T-AMYLO score was evaluated. RESULTS: Nineteen (18%) patients with AS also had ATTR-CA (ATTR-CA-AS). They were significantly older (82.6 ± 7.4 vs. 76 ± 6.9, p < 0.001), more often had arrhythmic and conduction disorders (atrial fibrillation, implanted pacemakers), and had a reduced left ventricular ejection fraction (44.6% vs. 54.7%, p = 0.03). Patients with ATTR-CA-AS more frequently presented with the low-gradient/low-flow phenotype of AS (73.7%, p = 0.009). Both NT-proBNP and troponin levels were significantly higher in patients with ATTR-CA-AS (4174.0 vs. 1,238 pg/mL; p < 0.001; and 59.6 vs. 23.3 ng/L, p < 0.001, respectively). After a 6-month follow-up, a similar number of deaths occurred in both groups, and no surgical aortic valve replacement was performed in the ATTR-CA-AS population. The eRAISE model demonstrated the highest diagnostic accuracy (AUC=0.948). CONCLUSIONS: ATTR-CA is commonly observed in patients with severe AS. Implementing risk scores in routine practice could enhance the diagnostic accuracy of ATTR-CA in patients with AS, given their strong diagnostic performance and ease of assessment.

Improved hemodynamic performance and reduced paravalvular regurgitation with the SAPIEN 3 Ultra RESILIA valve: a propensity-matched single-center TAVR study.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has rapidly evolved into a standardized treatment for severe aortic stenosis, particularly in patients at increased surgical risk. The fifth-generation SAPIEN 3 Ultra RESILIA (S3UR) valve notably incorporates RESILIA-treated tissue as well as an enhanced external skirt in order to reduce structural valve deterioration (SVD) and paravalvular leak (PVL). However, real-world data on its clinical performance remains limited. OBJECTIVES: To evaluate procedural, hemodynamic, and short-term clinical outcomes of the S3UR valve compared to earlier-generation SAPIEN 3 (S3) and SAPIEN 3 Ultra (S3U) platforms in Ronald Raegan UCLA medical center. METHODS: 513 patients who underwent transfemoral TAVR at Ronald Reagan UCLA Medical Center between 2022 and 2024 were analyzed. Of these, 216 received the S3UR valve and 297 received S3U/S3 valves. Propensity-score matching (1:1) yielded 181 well-balanced patient pairs. Primary endpoints included device success per VARC-3 criteria, with secondary endpoints encompassing 30-day safety, echocardiographic performance, and procedural complications. RESULTS: The S3UR group demonstrated significantly lower post-procedural and 30-day mean aortic valve gradients (7.45 ± 3.37 mmHg and 9.06 ± 2.94 mmHg, respectively; p < 0.001) compared to the S3U/S3 group. Rates of moderate PVL were 0% in the S3UR group vs. 8.9-10.1% in S3U/S3 patients (p < 0.001). Procedural success exceeded 98% in both groups, with no significant differences in stroke, mortality, or new pacemaker implantation. Readmission rates trended lower in the S3UR cohort (7.8% vs. 13.9%), though not statistically significant. CONCLUSIONS: The SAPIEN 3 Ultra RESILIA valve demonstrated superior hemodynamic performance and significantly reduced PVL compared to earlier-generation balloon-expandable valves, while maintaining comparable safety and procedural success. These findings add institutional-level evidence to the growing body of data supporting the S3UR valve; however, multicenter prospective studies with longer follow-up are needed to confirm these results and assess long-term durability.

Precision hybrid technique for direct SAPIEN-3 ultra™ implantation in extensive mitral annular calcification.

Mitral valve surgery in patients with extensive mitral annular calcification remains challenging. Different surgical approaches have been described: from a complete decalcification and reconstruction of the mitral annulus to other techniques where a full debridement was avoided to minimize the risk of possible peri-operative complications. In the current era of transcatheter valve implantation, the issue of mitral annulus calcification has been addressed by some with the adoption of a hybrid technique, where a transcatheter aortic valve is implanted in mitral position, during open heart surgery. This technique is emerging as a treatment option for high-risk patients although it is still an off-label procedure and needs further standardization. We describe here our surgical technique to implant a SAPIEN-3 Ultra™ in mitral position, addressing some of the key points in the surgical technique: the appropriate sizing and the phase of deployment of the prosthesis.

Endoscopic techniques in redo mitral and tricuspid valve surgery.

Redo mitral and tricuspid valve surgery presents considerable technical challenges due to dense adhesions, previous surgical alterations, and distortion of normal anatomical landmarks. Traditionally, these complex reoperative procedures have been approached through repeat median sternotomy, a strategy that, while familiar, carries heightened risks of cardiac or great vessel injury during re-entry, increased bleeding, longer operative times, and prolonged recovery. As minimally invasive cardiac surgery has evolved, endoscopic techniques have emerged as a viable and increasingly attractive alternative, offering surgeons enhanced visualization and patients a less traumatic operative experience. In this technical paper, we outline our institutional approach with endoscopic redo mitral and tricuspid valve surgery, emphasizing comprehensive preoperative planning, thoughtful patient selection, and meticulous intraoperative strategy. Critical components of preparation include detailed imaging assessment, analysis of previous operative notes, and formulation of a cannulation strategy tailored to each patient's anatomy and prior interventions. Myocardial protection remains a fundamental priority, and we describe the methods we have found most effective in achieving consistent and safe cardiac preservation in a reoperative setting. Our stepwise operative approach focuses on minimizing dissection, utilizing enhanced visualization, and employing targeted techniques to navigate scar tissue and restored anatomy while preserving procedural safety. In the experience of expert surgeons and teams, endoscopic access has translated into meaningful clinical benefits, including reduced transfusion requirements, shorter intensive care and hospital stays, and excellent early postoperative outcomes compared with traditional redo sternotomy as previously published. With proper preparation, a multidisciplinary team, and intraoperative vigilance, endoscopic redo mitral and tricuspid valve surgery represents a reliable, reproducible, and patient-centered option for complex valve reoperations.

Artificial intelligence in cardiovascular medicine: prevention, diagnosis, and intervention.

Recent evidence in the literature suggests that Artificial intelligence (AI) is rapidly becoming more clinically relevant with expanding applications across cardiovascular medicine and cardiothoracic surgery. Advances in computational power and the widespread digitization of clinical data have enabled AI models to identify complex, nonlinear patterns across multimodal datasets, positioning them as powerful tools for diagnosis, risk stratification, and procedural decision support. This review examines the current and emerging landscape of AI in cardiac care, with a particular focus on valvular heart disease. We synthesize evidence spanning diagnostic applications such as electrocardiographic and echocardiographic interpretation, preoperative planning, and risk prediction for surgical and transcatheter interventions, and real-time intraoperative decision support. Across these domains, AI systems frequently demonstrate performance comparable to or exceeding conventional approaches, particularly in automating standardized tasks and enabling personalized risk assessment. However, most evidence to date derives from retrospective studies, and challenges related to generalizability hold significant barriers to widespread adoption. We further discuss ethical considerations necessary for safe and equitable implementation. Overall, AI shows substantial promise to augment cardiovascular care across the continuum of practice, but its successful translation into routine clinical use will require rigorous prospective validation, transparent model development and interpretability, and carefully designed integration into existing clinical workflows.

The impact of inspiratory muscle training on pulmonary function recovery and pulmonary complications in patients undergoing cardiothoracic surgery: a systematic review and meta-analysis.

OBJECTIVE: To quantify the effects of inspiratory muscle training (IMT) on pulmonary function (PF) recovery and postoperative pulmonary complications (PPCs) including pneumonia and atelectasis in patients undergoing cardiothoracic surgery through systematic evaluation and meta-analysis, providing an evidence-based basis for perioperative respiratory management. METHODS: PubMed, Embase, Cochrane Library, and Web of Science were systematically searched until May 2025, with 7 randomized controlled trials (RCTs) involving 507 adult patients who underwent cardiothoracic surgery retrieved (the study of transcatheter aortic-valve replacement was excluded due to heterogeneous surgical characteristics). The quality of the literature was evaluated using the Cochrane Risk-of-Bias Tool (RoB 2.0). A meta-analysis was conducted using RevMan 5.4 software to compare the differences in predefined outcome measures: forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and the pneumonia incidence between the IMT and control groups. RESULTS: The meta-analysis showed that the IMT group had a higher FEV1 than the control group [mean difference (MD)=0.80 L, 95% confidence interval (CI): 0.09-1.52, P = 0.03], with clinically relevant improvements. Similarly, FVC was better in the IMT group (MD = 0.64 L, 95% CI: 0.11-1.17, P = 0.03), also representing a clinically meaningful benefit. However, there was no difference in FEV1/FVC ratio between the two groups (P = 0.15). The IMT group performed better in the 6-minute walk test (6MWT) (MD = 47.89 m, 95% CI: 1.28-94.51, P = 0.04), indicating improved functional capacity. Regarding PPCs, the incidence of postoperative pneumonia [odds ratio (OR)=0.18, 95% CI: 0.06-0.57, P = 0.004] and atelectasis (OR = 0.37, 95% CI: 0.17-0.81, P = 0.01) in the IMT group were lower than those in the control group. CONCLUSION: IMT can effectively improve PF and reduce the risk of PPCs in patients undergoing cardiothoracic surgery by enhancing the strength and endurance of inspiratory muscles.

Access to transcatheter aortic valve implantation: interregional variability and expert evaluation.

INTRODUCTION AND OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has revolutionised the treatment of severe symptomatic aortic stenosis, providing an alternative to surgical valve aortic replacement, especially in high-risk patients. Despite its benefits, significant interregional variability in TAVI access persists within Spain. This study aimed to analyse disparities in TAVI implementation across different autonomous communities, identifying the key factors underlying this variability. METHODS: We conducted a retrospective observational study using data from the Spanish National Registry of Specialized Care Activity - Minimum Basic Data Set for 2016-2023, including all TAVI performed in Spain. Additionally, a survey was distributed among specialists from 123 centres to assess the factors influencing clinical decision-making, barriers to access, and resource availability. RESULTS: Although the number of TAVI increased across all regions, significant differences were observed in the implantation rates (between 0.63 and 2.28 per 10 000 inhabitants). Survey responses indicated that the primary determinants for TAVI indication were medical team judgment (40.0%) and patient risk stratification (36.5%). The main barriers to expanding TAVI access included rigid patient stratification (25.6%), insufficient early detection (17.8%), and resource limitations (13.3%). Participants emphasized the need for better coordination among health care levels and establishing uniform access criteria. CONCLUSIONS: Although TAVI adoption has increased in Spain, significant regional disparities remain, suggesting factors beyond economics contribute to access variability. Addressing these inequalities requires enhanced coordination across different health care levels, optimized resource allocation, and refined patient selection strategies.

Clinical value of non-electrocardiogram-gated computed tomography angiography for planning transcatheter aortic valve implantation: A retrospective single-centre study.

PURPOSE: Computed tomography angiography (CTA) is a key component of preprocedural planning for transcatheter aortic valve implantation (TAVI). Although current guidelines recommend electrocardiogram (ECG)-gated acquisition of the aortic root, non-ECG-gated CTA protocols are still used in clinical practice. The present study aimed to evaluate the clinical feasibility and safety of a non-ECG-gated CTA protocol for TAVI planning. METHODS: We conducted a retrospective, single-centre observational study including 194 consecutive patients who underwent TAVI between January 2012 and December 2024 and were planned using a non-ECG-gated, single-phase CTA protocol. CTA-derived anatomical measurements were used to guide prosthesis selection and vascular access planning. Clinical outcomes were assessed during the index hospitalization and up to 30 days. RESULTS: CTA measurements were successfully used to guide prosthesis sizing in all patients. Thirty-day all-cause mortality was 3.6%, stroke or transient ischaemic attack occurred in 1.5% of patients, and vascular complications were observed in 6.7%. Conduction disturbances occurred in 38.1% of patients, while new permanent pacemaker implantation was required in 3.1%. Paravalvular leak (PVL) was predominantly mild; no cases of severe PVL were observed, and no patient required surgical or interventional correction for PVL. CONCLUSION: This study demonstrates that a non-ECG-gated CTA protocol appears feasible and may support TAVI planning in selected centres with experienced teams. In this single-centre experience, a non-ECG-gated CTA protocol provided sufficient anatomical information for TAVI planning, with acceptable short-term clinical outcomes. While ECG-gated CTA remains the reference standard, this approach may represent a pragmatic alternative when integrated into a structured workflow.

Clinical Outcomes of Percutaneous Mitral Valve Repair with Mitraclip

BACKGROUND: The MitraClip device is used as an endovascular therapy for mitral valve repair in patients with severe mitral insufficiency and high surgical risk. This therapy was used for the first time in Colombia in 2013, after its authorization by the National Institute of Drug and Food Surveillance. MATERIALS AND METHODS: A quantitative, observational, descriptive, longitudinal study was conducted, with an analytical component stratified by age, in adults who underwent mitral valve repair with MitraClip from March 2013 to June 2022 to determine the clinical outcomes associated with hospitalization, mortality, complications, and health-related quality of life. RESULTS: A total of 94 patients with a mean age of 70.3±10.3 years were evaluated, most of whom were male (65%), hypertensive (80%), and had New York Heart Association class III-IV classification (90.4%) and functional mitral insufficiency (93.6%) classified as severe (74.5%). The recurrence of all-cause hospitalization was 39.4%, of which 88% corresponded to heart failure. The immediate success of the procedure, determined as mitral insufficiency classified as ≤moderate after implantation, was 93.6% (p < 0.001). In-hospital mortality was 2.1%, mortality at 6 months was 12.8% (≤70 years 11.6% vs >70 years 13.7%, p = 0.007), mortality at 1 year was 16%, and mortality at 2 years was 20.2%. The incidence of complications was low, the most frequent one being de novo atrial fibrillation (7.4%), followed by major bleeding requiring transfusion (4.3%). The Kansas City Cardiomyopathy Questionnaire scale was used, with a mean score of 69.9±19.3. CONCLUSION: Percutaneous mitral valve repair with MitraClip is a safe technique that directly affects survival and quality of life. There was a low incidence of complications related to the procedure and the patient's preoperative condition, with results comparable to those of studies carried out in Europe and the United States.

Percutaneous valve intervention for severe mitral regurgitation complicated by lung sepsis.

Severe mitral regurgitation (MR), when complicated by a co-existing lung abscess, is a management challenge, as both conventional cardiac and thoracic surgical interventions may be contraindicated. In the case described below, transcatheter edge-to-edge mitral valve repair (TEER) was utilised to achieve haemodynamic stability, permitting subsequent thoracic surgical lung abscess resection. We report the case of a 60-year-old man with torrential MR secondary to chordal rupture presenting with recurrent pulmonary oedema, complicated by lung sepsis and abscess formation resistant to antibiotic therapy and precluding open valvular repair. The presence of a lung abscess contraindicated open mitral valve repair, and the severity of MR precluded thoracic surgical treatment of the lung abscess, precluding any form of surgical intervention. A successful TEER procedure resulted in a reduction of MR from severe to no more than mild-to-moderate, enabling haemodynamic stabilisation and permitting subsequent thoracic surgical treatment of the lung abscess. Our case demonstrates the possibility of treating severe MR with TEER in the presence of a lung sepsis and abscess, when both conventional cardiac and thoracic surgical interventions were considered contraindicated. This later enabled thoracic surgery and treatment of the lung abscess.

Endoscopic mitral valve surgery: picture from the real world-sub-analysis from the Mini-Mitral International Registry.

BACKGROUND: In the field of minimally invasive mitral valve surgery (MVS), recent technical and technological advances have made endoscopic approaches increasingly popular. However, enthusiasm for endoscopic cardiac surgery has not translated into routine clinical usage likely due to the perceived complexity of the technique and the lack of robust supporting evidence. This study aims to evaluate operative results, and assess the overall effectiveness of endoscopic approaches in current surgical practice using data from the Mini-Mitral International Registry (MMIR). METHODS: This is a retrospective multicenter cohort study based on data from the MMIR, a collaborative effort including 7,957 patients who underwent minimally invasive mitral procedures. For this analysis, patients who did not receive a full endoscopic approach were excluded. Clinical and procedural outcomes were defined according to Mitral Valve Academic Research Consortium (MVARC) standards. Primary outcome measures included the rate of valve repair, in-hospital mortality, and the incidence of postoperative complications. Logistic regression was applied to assess the multivariable association between covariates and in-hospital mortality. RESULTS: Between 2015 and 2022, 2,563 patients underwent full endoscopic mitral surgery [median age 64 years; interquartile range (IQR), 53-73 years]. The etiology of mitral disease was degenerative in 70.5% of patients, functional in 13.7%, rheumatic in 6.6%, endocarditis in 3.3%, failure of previous mitral surgery in 3.8% and failure of previous transcatheter procedure in 1.2%. Mitral valve repair was performed in 2,107 cases (82.2%) and valve replacement in 439 (17.1%). A conversion to full sternotomy was required in 1.7% of cases. The overall in-hospital mortality rate was 2.5% (n=63), with a stroke rate of 1.1% (n=27). These were 1.7% and 0.8%, respectively, in patient who underwent isolated MVS. Risk analysis revealed that patient comorbidities and clinical status, rather than the technical aspects of the endoscopic approach, predominantly determined operative outcomes. Subgroup analysis of patients with degenerative mitral valve disease (n=1,800) revealed a younger cohort (62 years) with a low-risk profile (EuroSCORE II 1.1%). The valve repair rate was 94.9%. Overall, in-hospital mortality and stroke rates were 1.4% and 0.6%, respectively. Among patients who underwent valve repair, 98.8% had no or mild regurgitation at discharge. CONCLUSIONS: Endoscopic MVS is an effective technique for managing a broad range of mitral valve diseases, with excellent valve repair outcomes. The technique demonstrated satisfactory operative mortality and morbidity, even in high-risk patients and complex valve anatomies. Future studies should focus on long-term outcomes and the development of training programs to facilitate wider implementation.