The Valve Wire Archive

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.