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Tricuspid regurgitation (TR) is frequently detected, especially in its secondary form, while primary TR is far less frequent. Similar to mitral regurgitation (MR), primary tricuspid regurgitation should require timely intervention to avoid secondary damage of the RV, which is associated with poor outcome. Current guidelines suggest that secondary TR should be treated at the time of left-sided valve surgery, although a surgical option is rarely offered to high-risk patients with combined heart valve disease. As such, while the transcatheter approach to mitral valve repair/replacement has become a major goal of the transcatheter therapies, the transcatheter tricuspid valve intervention is still at a very early stage. In this review, we provide an overview of the different stages of technical and clinical evolution of transcatheter treatment of patients with TR or MR, highlighting the challenges and the avenues for future research. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the present study was to evaluate the prognostic impact and late evolution of associated tricuspid regurgitation (TR) 2/4+ after aortic valve replacement (AVR).Methods: We evaluated 61 patients who underwent AVR between 2003 and 2012 (35 for aortic stenosis [AS], 26 for aortic regurgitation [AR]) with associated untreated TR 2/4+. Patients with concomitant mitral disease were excluded. Median follow-up was 3.2 years. Serial echocardiographic and clinical data were collected and analyzed.Results: Mean age was 65 ± 13 years; 26% of the patients were in NYHA class III-IV. Left ventricular ejection fraction was 53 ± 11%. Comorbidity included: chronic obstructive pulmonary disease in 5%, chronic renal failure in 13%, coronary artery disease in 20%, history of stroke/TIA in 8%. Thirty-day mortality was 1.6%. Overall actuarial survival was 83 ± 6% at 6.5 years, with a freedom from cardiac death of 90 ± 5%. Freedom from TR ≥3+ was 86 ± 6% at 6.5 years. At last follow-up, 82% of the patients had TR 0-1/4+, 9% had TR 2/4+, 4.5% had TR 3/4+ and 4.5% had TR 4/4+. Occurrence of TR ≥ 3+ at follow-up was associated with increased cardiac mortality (HR 10.5; p = 0.009).Conclusions: preoperative untreated TR 2/4+ improves or remains stable in the majority of patients. The poor outcomes associated with TR > 2+ suggest the need for better methods to identify subjects at risk for TR progression. [ABSTRACT FROM AUTHOR]

Octogenarians affected by mitral regurgitation (MR) are an increasing high-risk population. MitraClip repair is emerging as a promising option for this kind of patients. In this retrospective study, the outcomes of patients aged ≥80 years, affected by isolated degenerative MR, who underwent isolated transcatheter (n = 25) or surgical (n = 35, 29 repairs and 6 replacements) mitral intervention from September 2008 to February 2014 were compared. MitraClip patients had higher mean age (84.5 ± 3.2 vs 81.9 ± 2.0 years, p <0.01), median Logistic Euroscore 19.4 (11.1 to 29.0) versus 8.4 (7.0 to 10.1) (p <0.01), median Society of Thoracic Surgeons predicted mortality 5.3 (3.5 to 6.6) versus 2.7 (2.3 to 3.9) (p <0.01), and more advanced New York Heart Association class (III to IV in 68% vs 37%, p = 0.02). At 30 days, 1 death occurred in the MitraClip group (p = 0.2). MitraClip was associated with significantly less complications (p <0.05) but more residual MR >2 (p <0.01). Two-year actuarial survival rate was 90% for MitraClip versus 97% for surgery (p <0.01). Higher Society of Thoracic Surgeons mortality was associated with reduced follow-up survival rate (p = 0.01). Two-year actuarial freedom from MR >2 was 70% versus 100%, respectively (p <0.01). New York Heart Association class and quality of life improved after MitraClip and were similar to surgical patients. Recurrent MR >2 was not significantly associated with follow-up mortality in this elderly setting. After the introduction of MitraClip, octogenarian patients with isolated degenerative MR receiving mitral treatment significantly increased (p <0.01). In conclusion, MitraClip patients, despite being older, more symptomatic, and affected by more co-morbidities showed significantly reduced postoperative complications. Two-year mortality was higher in the MitraClip group likely because of co-morbidities. Transcatheter mitral repair resulted in more octogenarians being treated compared with the past. [ABSTRACT FROM AUTHOR]

The article discusses issues related to transcatheter therapy of mitral regurgitation. Topics discussed include information on the mitral valve apparatus and reasons for transcatheter therapy. Information is also presented on several approved or in clinical trial therapies and their developers such as the MitraClip from Abbott Vascular and the Accucinch device from Guided Delivery Systems Inc.

Abstract: The 18F Direct Flow Medical (DFM) THV has conformable sealing rings, which minimizes aortic regurgitation and permits full hemodynamic assessment of valve performance prior to permanent implantation. During the DISCOVER trial, three patients who were at risk for receiving contrast media, two due to severe CKD and one due to a recent hyperthyroid reaction to contrast, underwent DFM implantation under fluoroscopic and transesophageal guidance without aortography during either positioning or to confirm the final position. Valve positioning was based on the optimal angiographic projection as calculated by the pre-procedural multislice CT scan. Precise optimization of valve position was performed to minimize transvalve gradient and aortic regurgitation. Prior to final implantation, transvalve hemodynamics were assessed invasively and by TEE. The post-procedure mean gradients were 7, 10, 11mm Hg. The final AVA by echo was 1.70, 1.40 and 1.68cm2. Total aortic regurgitation post-procedure was none or trace in all three patients. Total positioning and assessment of valve performance time was 4, 6, and 12minutes. Contrast was only used to confirm successful percutaneous closure of the femoral access site. The total contrast dose was 5, 8, 12cc. Baseline eGFR and creatinine was 28, 22, 74mL/min/1.73m2 and 2.35, 2.98, and 1.03mg/dL, respectively. Renal function was unchanged post-procedure: eGFR=25, 35, and 96mL/min/1.73m2 and creatinine=2.58, 1.99, and 1.03mg/dL, respectively. In conclusion, the DFM THV provides the ability to perform TAVI with minimal or no contrast. The precise and predictable implantation technique can be performed with fluoro and echo guidance. [Copyright &y& Elsevier]

OBJECTIVES To evaluate the performance and safety of an adjustable semi-rigid annuloplasty ring for mitral regurgitation (MR) in a multicentre study. METHODS Between March 2010 and December 2011, 30 subjects underwent mitral valve (MV) repair using the Cardinal adjustable annuloplasty ring. This device is a semi-rigid ring allowing postimplantation size adjustment, under beating-heart conditions, to optimize leaflet coaptation under echocardiographic guidance. Coaptation length was determined before and after adjustment by transoesophageal echocardiography. RESULTS The study enrolled 21 (70%) male and 9 (30%) female subjects with a mean age of 64 years. The approach was conventional midline sternotomy or mini-invasive right thoracotomy. Leaflet resection was done in 17 subjects, and chordal repair was used in 13. Concomitant procedures included coronary artery bypass grafting in 2 (7%) subjects, atrial ablation in 4 (13%) and tricuspid repair in 4 (13%). There was 1 (3%) early death unrelated to the study device. Intraoperative ring adjustment was performed in 24 of the 30 subjects. Residual MR was detected prior to adjustment in 6 subjects (4 mild and 2 moderate MR). Following adjustment, 5 subjects had no MR and 1 had trace MR. After adjustment, mean coaptation length improved from 7 ± 3 to 10 ± 3 mm (P < 0.0001). All patients who completed 1-year follow-up had less-than-mild MR, with the exception of 1 patient with ring dehiscence (and resultant 2+ MR) and 1 functional MR patient who developed recurrent 2+ MR due to persistent leaflet tethering. CONCLUSIONS MV repair with the Cardinal adjustable annuloplasty ring is a reliable technique that enables the adjustment of the ring diameter on a beating heart under echocardiographic control. Such technology allows the optimization of leaflet coaptation, providing minimal residual MR and durable repair. [ABSTRACT FROM PUBLISHER]

Objectives: The purpose of this article is to report early and mid-term outcomes of the ACCESS-EU study (ACCESS-Europe A Two-Phase Observational Study of the MitraClip System in Europe), a European prospective, multicenter, nonrandomized post-approval study of MitraClip therapy (Abbott Vascular, Inc., Santa Clara, California). Background: MitraClip has been increasingly performed in Europe after approval; the ACCESS-EU registry provides a snapshot of the real-world clinical demographic data and outcomes. Methods: A total of 567 patients with significant mitral valve regurgitation (MR) underwent MitraClip therapy at 14 European sites. Mean logistic European System for Cardiac Operative Risk Evaluation at baseline was 23.0 ± 18.3; 84.9% patients were in New York Heart Association functional class III or IV, and 52.7% of patients had an ejection fraction ≤40%. Results: The MitraClip implant rate was 99.6%. A total of 19 patients (3.4%) died within 30 days after the MitraClip procedure. The Kaplan-Meier survival at 1 year was 81.8%. Intensive care unit and hospital length of stay was 2.5 ± 6.5 days and 7.7 ± 8.2 days, respectively. Single leaflet device attachment was reported in 27 patients (4.8%). There were no MitraClip device embolizations. Thirty-six subjects (6.3%) required mitral valve surgery within 12 months after the MitraClip implant procedure. There was improvement in the severity of MR at 12 months, compared with baseline (p < 0.0001), with 78.9% of patients free from MR, severity of >2+ at 12 months. At 12 months, 71.4% of patients had New York Heart Association functional class II or class I. Six-min-walk-test improved 59.5 ± 112.4 m, and Minnesota-living-with-heart-failure score improved 13.5 ± 20.5 points. Conclusions: In the real-world, post-approval experience in Europe, patients undergoing the MitraClip therapy are high-risk, elderly patients, mainly affected by functional MR. In this patient population, the MitraClip procedure is effective with low rates of hospital mortality and adverse events. [ABSTRACT FROM AUTHOR]

Mitral valve regurgitation (MR) is often diagnosed in patients with heart failure and is associated with worsening of symptoms and reduced survival. While surgery remains the gold standard treatment in low-risk patients with degenerative MR, in high-risk patients and in those with functional MR, transcatheter procedures are emerging as an alternative therapeutic option. MitraClip® is the device with which the largest clinical experience has been gained to date, as it offers sustained clinical benefit in selected patients. Further to MitraClip implantation, several additional approaches are developing, to better match with the extreme variability of mitral valve disease. Not only repair is evolving, initial steps towards percutaneous mitral valve implantation have already been undertaken, and initial clinical experience has just started. [ABSTRACT FROM AUTHOR]

OBJECTIVES Computed tomography (CT) is an increasingly utilized method for the evaluation of patient suitability for transcatheter aortic valve implantation (TAVI). The aim of this study was to analyse the role of CT in the choice of prosthesis and the prevention of residual aortic regurgitation (RAR). METHODS From November 2007 to September 2010, 115 patients (median age 81 years, inter-quantile range (IQR) 76–85; median ejection fraction 55%, IQR 45–60; median logistic EuroSCORE 19.7, IQR 11.0–32.1) undergoing TAVI were evaluated with a pre-procedural CT. An aortic complex was evaluated with multi-planar reconstructions, and we defined significant early RAR as RAR ≥ 2, and prosthesis/annulus mismatch (PAM) as the ratio between prosthesis size and mean annular size. All analyses were conducted for the whole sample and then separately for the two types of prosthesis implanted. RESULTS An Edwards-SAPIEN® prosthesis was implanted in 62 patients (54.7%), and a Medtronic CoreValve® in 52 (45.2%). Aortic annulus minimum and maximum diameters were 22.6 ± 2.1 and 26.0 ± 2.3 mm, respectively. The aortic annulus diameter and the length of the free edge of the aortic cusps were linearly related to a 1:1 ratio (P < 0.0001). Significant RAR (34 patients, 30%) appeared directly related to the annulus diameters (particularly maximum and medium diameters, P = 0.0003 and P = 0.0010, respectively) and cusp length (P = 0.0007) but inversely correlated with PAM (P = 0.0006). Prosthesis/annulus oversizing was associated with a reduction in RAR, with a cut-off of 7% as the limit below which RAR increases; moreover, we observed different cut-off values for the Edwards and CoreValve prostheses, although statistical significance was not reached for the CoreValve (respectively, 2% with P < 0.0001, 11% with P = 0.16). No association was found between PAM and possible PAM-related complications. CONCLUSIONS CT evaluation prior to TAVI showed that RAR was directly correlated with aortic root dimensions (particularly maximum and medium annulus diameters and cusp lengths) and inversely correlated with PAM. Oversizing the prosthesis by at least 7% reduces the risk of RAR. CT is an essential and invaluable tool in the assessment of patients undergoing TAVI. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of the study was to evaluate the technical feasibility and performance of a transcatheter mitral annuloplasty system. METHODS Adult swines (n = 15) underwent left thoracotomy through the 4th–5th intercostal space. A transcatheter device (CardioBand, Valtech-Cardio Ltd) was introduced through an 18F sheath through the left atrium and attached to the annulus between the posterior and anterior commissures using echocardiographic and fluoroscopic guidance, on the beating heart. The sutureless device was implanted using a steerable delivery system to deploy sequential fixation elements. Following implantation, the device length was adjusted on the beating heart to reduce the intercommissural and septolateral dimension, under echocardiographic guidance. Finally, the flexible adjustment tool was withdrawn from the working sheath and the atrial purse-string closed. All but five animals were sacrificed acutely by intent, while the others were sacrificed at 90 days. RESULTS All animals survived the acute implant. One animal died at the third post-operative day due to bleeding. The annuloplasty system was successfully implanted in all animals. A mean of 12 ± 3 fixation elements were deployed. The band length was reduced up to 20% after implantation in each animal. At necropsy, the location of the implant was within a few millimetres of the annulus (3.5 ± 4 mm). In three animals, fixation elements were implanted inadvertently in the leaflets, but no coronary lesions were observed. All animals survived the acute implant. One animal died on the third post-operative day due to bleeding. In the four long-term survivors, the implanted annuloplasty device showed satisfactory healing and no ring dehiscence. CONCLUSIONS Transcatheter minimally invasive, beating-heart implantation of an adjustable annuloplasty band is feasible in the animal model. This approach may be an alternative to open surgical procedures in high-risk patients. [ABSTRACT FROM AUTHOR]

Mitral regurgitation (MR) is the most-common valvular heart disease in the western world. From an etiologic point of view, MR can be either organic (mainly degenerative in western countries) or functional (secondary to left ventricular remodeling in the context of ischemic or idiopathic dilated cardiomyopathy). Degenerative and functional MR are completely different disease entities that pose specific decision-making problems and require different management. The natural history of severe degenerative MR is clearly unfavorable. However, the appropriate and timely correction of degenerative MR is associated with a life expectancy similar to that of the normal population. By contrast, the prognostic impact of the correction of functional MR is still a matter of debate. In this Review, we discuss the optimal treatment of both degenerative and functional MR, taking into account all presently available therapeutic options, including novel percutaneous methods. Since a clear understanding of the etiology and mechanisms of valvular dysfunction is important to guide the timing and choice of treatment, the role of echocardiography in the management of MR is also addressed. [ABSTRACT FROM AUTHOR]

The edge-to-edge technique is a versatile procedure for mitral valve repair. Its technical simplicity has been the prerequisite for the development of a number of transcatheter technologies to perform percutaneous mitral valve repair. The evolution from a standard open heart surgical to percutaneous procedure involved the application of the technique in minimally invasive robotic surgery and direct access (transatrial) off-pump suture-based repair and finally in the fully percutaneous approach with either suture-based or device (clip)-based approach. The MitraClip (Abbott Vascular, Menlo Park, California) is currently available for clinical use in Europe, and it is mainly applied to treat high-risk patients with functional mitral regurgitation. A critical review of the surgical as well as the early percutaneous repair data is necessary to elucidate the clinical role and the potential for future developments of the edge-to-edge repair in the treatment of mitral regurgitation. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study aimed to determine the acute and chronic performance of a new system designed to conduct beating-heart implantation and off-pump adjustment of neochordal length. Methods: In 14 adult sheep (group A) selected to undergo beating-heart cardiopulmonary bypass, the left atrium was opened through a left thoracotomy. Two or more primary chordae in the A2 region were severed to produce a model of a flail leaflet. A chordal adjustment mechanism (V-Chordal, Valtech Cardio Ltd., Or-Yehuda, Israel) was affixed to the head of the papillary muscle. The system includes two adjustable neochordae. The distal end of the neochordae was sutured to the flail segment without estimating the appropriate length. The neochordal length was adjusted off-pump under real-time echo-guidance. The adjustment tool was removed and the atriotomy was closed with a purse-string suture. Control animals (group B, n =4) were implanted with the conventional neochordae. Animals in both groups were sacrificed 3 months after the procedure. Results: In both groups, prior to repair, mitral regurgitation (MR) was severe in all animals. In group A, following adjustment of neochordae, MR was absent in all animals, with the exception of two animals that had residual 2+ MR irresponsive to neochordae adjustments. In group B, MR was 2+ in two of the four animals following repair. At 3 months, mitral competence was stable in all animals. At necropsy, normal healing of the papillary head and leaflet was observed in both the groups. Conclusions: The V-Chordal system simplifies the process of neochordal implantation and precise off-pump adjustment of the neochordal length to correct MR occurring due to a flail leaflet. This technology may improve the technical feasibility for adoption of chordal repair during open or minimally invasive surgical procedures. [Copyright &y& Elsevier]

Abstract: Objective: Trans-catheter aortic valve implantation (TAVI) is an alternative for patients not eligible for surgical aortic valve replacement. When peripheral access is not amenable by the transfemoral route (TF-TAVI), the most-used approaches are the trans-apical (TAp-TAVI) and the trans-axillary (TAx-TAVI). The aim of this study is to report the outcomes in a single-center series of consecutive patients treated by TAVI using the different approaches. Methods: From November 2007 to June 2010, 177 patients underwent TAVI by the same multispeciality valve team. TAp-TAVI was performed in the operative room, while TF-TAVI and TAx-TAVI were done in the catheterization laboratory. Follow-up was 100% complete (mean 6.0±6.8 months). Results: TF-TAVI, TAx-TAVI, and TAp-TAVI were performed in 140 (79.1%), 19 (10.7%), and 16 patients (9.1%), respectively. The groups were not different in terms of age (p =0.6), left ventricular ejection fraction (LVEF) (p =0.6), Log-EuroSCORE (European System for Cardiac Operative Risk Evaluation) (p =0.3), and Society of Thoracic Surgeons (STS) score (p =0.7), while peripheral artery disease was higher in the TAp-TAVI and TAx-TAVI groups compared with the TF-TAVI group (p <0.0001). The Charlson score was 10.7±14.9, 5.8±1.2, and 5.9±1.8 for TAp-TAVI, TAx-TAVI, and TF-TAVI, respectively (p =0.02). In-hospital (30-day) mortality was 1.4% (2/140), 12.5% (2/16), and 5.3% (1/19) for TF, Tap, and TAx, respectively (p =0.03). At follow-up, 6 months’ actuarial survival was 72.2±12.0%, 67.4±17.4%, and 88.4±3.1% for TAp-TAVI, TAx-TAVI, and TF-TAVI, respectively (p =0.3). Conclusions: Similar to findings from recent, larger trials, patients undergoing TF-TAVI in high-risk patients had excellent 6-month results. Although TAx-TAVI was associated with lower hospital mortality, it shared the same 6-month outcomes of TAp-TAVI, probably due to a similar selection bias. [Copyright &y& Elsevier]

Abstract: Objective: Prolonged bleeding during cardiovascular surgery presents a risk for the patient and increases the time and cost of surgery. TachoSil® is a ready-to-use haemostatic agent that consists of an equine collagen patch coated with human fibrinogen and thrombin. This trial evaluated the efficacy and safety (≤30 days post-surgery) of TachoSil surgical patch compared with standard haemostatic fleece for the control of bleeding in patients undergoing cardiovascular surgery. Methods: Patients scheduled for elective surgery on the heart, ascending aorta or aortic arch requiring cardiopulmonary bypass were eligible for this open-label multicentre trial. After primary haemostatic measures, patients were randomised to TachoSil or conventional haemostatic fleece if an area of persisting haemorrhage was identified (target area). After the application of trial treatment, haemostasis was evaluated at 3min (primary endpoint). If haemostasis was not achieved, trial treatment was re-applied and haemostasis assessed at 6min (secondary endpoint). Results: A total of 120 patients were randomised and 119 received trial treatment (TachoSil, n =59; standard treatment, n =60). Twenty-six percent of patients were female and the mean age was 67 years (range: 23–86 years). Baseline characteristics were similar in both the groups. Bleeding occurred mainly from the aorta (56%), right ventricle (16%) or right atrium (13%), more often from a vessel (68%) than tissue (32%), and was assessed to be arterial in 74% of cases. TachoSil was significantly superior to standard haemostatic fleece in controlling bleeding after insufficient primary haemostasis, with 75% (95% confidence interval (CI): 0.64–0.86) of the TachoSil group achieving haemostasis at 3min compared with only 33% (95% CI: 0.21–0.45) of the standard treatment group (p <0.0001). This difference persisted at 6min, with 95% of patients achieving haemostasis in the TachoSil group compared with 72% in the standard treatment group (p =0.0006). Three (5%) TachoSil patients compared with 17 (28%) standard treatment patients failed to achieve haemostasis at 6min and received rescue treatment. TachoSil was well tolerated with adverse events generally similar in the two treatment groups. Conclusions: TachoSil was significantly superior to standard haemostatic fleece material in obtaining effective and fast intra-operative haemostasis in cardiovascular surgical procedures. TachoSil was safe and well tolerated. [Copyright &y& Elsevier]

Abstract: Objective: Mitral valve surgery for organic mitral regurgitation (MR) in the elderly has been debated. In the elderly, quality of life is a better indicator of surgical success than survival. We assessed quality of life of elderly patients submitted to surgery for MR using the Minnesota Living with Heart Failure (MLHF) questionnaire. Methods: Between August 2003 and August 2006, 225 consecutive patients >70 years old underwent surgical treatment of organic MR. Mean age was 77±3.3 years (range 71–87 years). Mean EF was 50±11%. Degenerative disease was the most prevalent (77%) etiology. CABG was associated in 25% of patients. Mean Charlson score was 4.3±1.5 and 101 patients (45%) were NYHA class III and IV. Hospital survivors were followed up and quality of life by MLHF score was assessed. Results: Mitral repair and replacement were equally distributed in this population. Hospital mortality was 2.7%. Late survival was 91±1.9% at 3 years. MLHF was obtained from 204 patients at mean 2±1 years of follow-up. MLHF score was 38±18; there were 135 (66%) patients with MLHF >30. MLHF tended to increase with age at follow-up (p =0.007). Multivariable predictors of MLHF were preoperative atrial fibrillation (p =0.019), diabetes (p =0.03), higher creatinine level (p =0.0009), higher EuroSCORE (p =0.02), residual mitral regurgitation grade at follow-up echocardiography (p <0.0001) and systolic pulmonary artery pressure at follow-up (p =0.04). Type of surgical treatment (repair vs replacement and choice of prosthesis) did not predict MLHF at follow-up, although those who had recurrent MR after repair had the highest scores compared to patients who had repair and durable result and those treated by replacement (MLHF was 51±21, vs 34±16, vs 39±18, respectively, p =0.0013). Conclusions: Quality of life following mitral valve surgery is suboptimal in more than half of elderly patients. MLHF score at follow-up is mostly related to preoperative conditions. Type of surgery does not influence MLHF score, however, quality of life is worse in patients with recurrent/residual MR following repair. [Copyright &y& Elsevier]

Abstract: Objective: Neochordae implantation is a standard method for treatment of mitral valve prolapse. We describe a transcatheter technology enabling transapical endovascular chordal implantation. Methods: Six adult pigs were anesthetized. Two 10F sheaths were introduced in the femoral vessels for monitoring and intracardiac echo. After midline sternotomy, the pericardium was opened, the apex was punctured inside two 2–0 polypropylene purse strings. A 0.035 in J tipped guidewire was introduced in the left ventricle and an ultra stiff 14F sheath (guide catheter) inserted through the apex. A suction-and-suture device was introduced in the left ventricle. The mitral valve was crossed under echo guidance. Using suction, either the anterior (two cases) or posterior (four cases) leaflet was captured and a loop of 4–0 polypropylene was thrown at the edge of the leaflet. The loop, with a pledget, was exteriorized through the introducer. The introducer was removed and the purse-string tied. Under echo guidance, the neochordae suture was pulled and tied over a pledget to evoke leaflet tethering. The animals were sacrificed and gross anatomy reviewed. Results: Leaflet capture was feasible in the intended location in all cases. Following suture tethering, variable degrees of MR were obtained. At gross anatomy, the neochordae were positioned at 1–4mm from the leaflet free edge, and were firmly attached to the leaflets. Conclusions: Transcatheter endovascular neochordae implantation is feasible. A prolapse model is needed to further demonstrate feasibility under pathologic conditions. The apical approach allows easy and direct route to transcatheter beating heart minimally invasive mitral repair. [Copyright &y& Elsevier]

Acute coronary syndromes (ACS) are characterized by multiple unstable coronary plaques and elevated circulating levels of inflammatory biomarkers. The endothelium of internal mammary arteries (IMA), which are atherosclerosis resistant, is exposed to proinflammatory stimuli as vessels that develop atherosclerosis. Our study investigated the IMA endothelial expression of inflammatory molecules in patients with ACS or chronic stable angina (CSA). IMA demonstrated normal morphology, intact endothelial lining, and strong immunoreactivity for glucose transporter 1. E-selectin expression was observed more frequently in IMA of ACS patiention than CSA patients (ACS 61% vs. CSA 14%, P = 0.01). High fluorescence for major histocompatibility complex (MHC) was significantly more frequent on the luminal endothelium (ACS 66.7% vs. CSA 17.6%, P = 0.001 for class I; and ACS 66.7% vs. CSA 6.2%, P = 0.0003 for class II-DR) and on the vasa vasorum (ACS 92.9% vs. CSA 33.3% and 7.7%, P = 0.0007 and P < 0.0001 for class I and class II-DR, respectively) of ACS patients than CSA patients. ICAM-1, VCAM-1, Toll-like receptor 4, tissue factor, IL-6, inducible nitric oxide synthase, and TNF-α expression were not significantly different in ACS and CSA. Circulating C-reactive protein [ACS 4.8 (2.6-7.3) mg/I vs. CSA 1.8 (0.6-3.5) mg/I, P 0.01] and IL-6 [ACS 4.0 (2.6-5.5) pg/ml vs. CSA 1.7 (1.4-4.0) pg/ml, P = 0.02] were higher in ACS than CSA, without a correlation with IMA inflammation. The higher E-selectin, MHC class I and MHC class II-DR on the endothelium and vasa vasorum of IMA from ACS patients suggests a mild, endothelial inflammatory activation in ACS, which can be unrelated to the presence of atherosclerotic coronary lesions. These findings indicated IMA as active vessels in coronary syndromes. [ABSTRACT FROM AUTHOR]

Annular dilation is a common feature of chronic degenerative mitral regurgitation caused by leaflet prolapse. Accordingly, patients undergoing surgical repair usually undergo concomitant reductive annuloplasty to restore a normal annular-to-leaflet relation. With the evolution of transcatheter valve repair technologies, patient selection criteria for those who do not require annuloplasty are needed. A series of patients undergoing mitral repair was analyzed, and the role of annular-to-leaflet mismatch in identifying patients requiring reductive annuloplasty was explored. Preoperative data for 82 patients undergoing mitral repair with annuloplasty for degenerative mitral regurgitation were prospectively collected, including annular intercommissural (IC) and septolateral (SL) dimensions and heights of anterior (ALH) and posterior leaflets. An SL/ALH ratio >1.4 was used to define annular-to-leaflet mismatch. After mitral repair, the ratio between preoperative IC distance and the size of the implanted annular prosthesis (Seguin ring [SR], IC/SR <1.2) was used to identify patients for whom annuloplasty was nonreductive. All patients underwent successful mitral repair. Mean preoperative IC was 46 ± 6 mm, SL was 42 ± 5 mm, and ALH was 31 ± 5 mm. Mean SR was 34 ± 3 mm, with a mean IC/SR ratio of 1.34 ± 0.14. Sixteen patients (19%) had an IC/SR ratio <1.2. IC/SR ratio <1.2 was predicted by a SL/ALH ratio ≤1.4 (p = 0.009). In conclusion, annular dilation is negligible in <20% of surgical candidates. In this subgroup, an isolated leaflet repair may be indicated. SL/ALH ratio is a good indicator of annular-to-leaflet mismatch and could be used as an adjunct to other methods of annular function assessment to select patients for ringless mitral repair. [Copyright &y& Elsevier]

Abstract: The upside-down technique is a method for ‘in situ’ secondary cordae transposition for posterior leaflet lesions. The segmental prolapse of the posterior leaflet is corrected by rotating the resected segment upside-down and reattaching it to the annulus and adjacent leaflet segments. As the procedure is completed, the original annular attachment becomes the new free edge. The secondary chords, originally positioned at the base of the segment, become primary chordae. It is indicated in all cases when quadrangular resection is not feasible such as in case of calcified annulus, posterior leaflet hypoplasia, or when the prolapsing portion is wide. [Copyright &y& Elsevier]

Percutaneous mitral valve repair is under investigation as a novel method to treat mitral valve insufficiency with a catheter-based, closed-heart, nonsurgical approach. Two techniques of mitral valve reconstruction have been adapted from surgery to the percutaneous approach: edge-to-edge repair and annuloplasty. The devices that have been developed to perform these 2 procedures are described, and preliminary clinical experience is presented. Expectations for the future are discussed. [Copyright &y& Elsevier]

Mechanics following partial left ventriculectomy is still poorly understood. A computational cylindrical model of the left ventricle was developed, based on the myocardial fibre behaviour for the evaluation of the mechanical and haemodynamical effects of the operation. A healthy left ventricle with physiological geometry and function and a dilated hypokinetic heart were investigated. Haemodynamic and mechanical data were obtained at baseline and compared with those obtained at different degrees of volume reduction. Data included: ejection fraction (EF); stroke volume (SV); end-systolic and end-diastolic pressure–volume relationships (ESPVR and EDPVR), and efficiency. EF increases following volume reduction in both simulation but, concurrently, SV shows modest improvement (dilated ventricle) or reduction (healthy ventricle) at progressive degrees of resection. The ESPVR and EDPVR slope increases and shifts leftward with the resection extent, but the increase of the ESPVR slope is more pronounced in dilated ventricle. Efficiency is improved in the dilated heart after resections, while does not improve when the healthy-heart volume is reduced. The simulation of partial left ventriculectomy suggests an improvement of systolic performance, counterbalanced by increased diastolic stiffness following inverse remodelling. Efficiency of simulated dilated ventricles is enhanced by volume reduction, suggesting a favourable effect of reduction of the metabolic demand of the failing heart. [Copyright &y& Elsevier]

OBJECTIVES To assess the incremental prognostic value of right ventricular free wall longitudinal strain over conventional risk scores in predicting the peri-operative mortality in patients with severe tricuspid regurgitation (TR) undergoing isolated tricuspid valve (TV) surgery. METHODS We retrospectively enrolled 110 consecutive patients with severe TR who underwent isolated TV surgery between November 2016 and July 2022 at San Raffaele Hospital, Milan, Italy. Exclusion criteria were previous TV surgery, urgent surgery, complex congenital heart disease, active endocarditis and inadequate acoustic window. Baseline clinical data were included, as well as laboratory tests and clinical risk score, as TRI-SCORE and MELD-XI. The clinical outcome was peri-operative mortality, defined as all-cause mortality within 30 days. RESULTS The final cohort included 79 patients. The end-point occurred in 7 patients (9%), who died within 30 days after isolated TV surgery. Receiver operator characteristic curves analysis showed that, among parameters of right ventricular function, right ventricular free wall longitudinal strain was the best parameter to predict peri-operative mortality (AUC: 0.854, 95% CI 0.74–0.96, P  = 0.005, sensitivity 68%, specificity 100%). At univariable analysis, left ventricular ejection fraction, diabetes mellitus, creatinine, estimated glomerular filtration rate, serum sodium, MELD-XI, TRI-SCORE, right ventricular areas, right ventricular global longitudinal strain, right ventricular free wall longitudinal strain, fractional area change and the ratio between right ventricular free wall longitudinal strain/pulmonary arterial systolic pressure were significantly associated with the end-point. The combination of TRI-SCORE and right ventricular Strain, evaluating right ventricular systolic function with speckle-tracking echocardiography, outperformed classic TRI-SCORE in outcome prediction (AUC 0.874 vs 0.787, P  = 0.05). CONCLUSIONS Right ventricular free wall longitudinal strain has an incremental prognostic value over conventional parameters and significantly improves the ability of clinical scores to predict peri-operative mortality in patients undergoing isolated TV surgery. [ABSTRACT FROM AUTHOR]

Background: Closed‐chest transapical valve implantations (aortic, mitral, and tricuspid) and cardiac structural procedures requiring large‐sized introducer sheaths cannot be safely performed with the available technology. We tested a self‐expanding apical closure device in a closed‐chest animal model, using large‐sized introducer sheaths and human‐sized animals to establish the technique for future tests in humans. Methods: Six human‐sized pigs (mean weight: 89.7 ± 3.7 kg) received general anesthesia, intubation, and full heparinization (15,000 IU/animal; expected activated clotting time >200 s). Under fluoroscopy and multimodality imaging guidance with next‐generation fusion imaging prototypes, a 15‐cm long needle and a standard guidewire were percutaneously inserted under the xiphoidal aponeurosis and into the ventricular apex. After the exchange with a stiff guidewire, a 21‐Fr introducer sheath for transapical procedures (outer diameter: 25‐Fr) was placed in the left ventricle through the apex. The self‐expanding closure device was inserted and deployed under fluoroscopic guidance while the 21‐Fr sheath was gently removed. Hemodynamic conditions were monitored for 30 min and then the chest was opened to inspect the closure device and quantify the blood loss in the pericardium. Animals were killed and the hearts were removed and inspected. Results: All six apical closure devices were successfully deployed without adverse events. No death, hemodynamic collapse, or cardiac tamponade occurred during the 30‐min observational period (mean systolic and diastolic pressures: 88 ± 11 and 58 ± 13 mmHg, respectively; mean heart rate: 60 ± 11 beats per minutes). Pre‐ and postdeployment (after protamine administration) mean activated clotting time was 541 ± 263 and 217 ± 62 s, respectively. The plugs provided good sealing with a mean of 27.2 ± 13.86 ml of blood lost in the pericardium. Postmortem inspection showed good plug fixation without myocardial damage. Conclusion: This self‐expanding apical closure device successfully sealed the percutaneous access sites made with large‐sized introducer sheaths in human‐sized animals. This preclinical study suggests that transapical valve and structural procedures requiring large‐sized introducer sheaths can be performed percutaneously. [ABSTRACT FROM AUTHOR]

The article presents a case study of a young man who underwent bicuspid aortic valve repair.

Aim: This analysis aimed to compare the clinical outcomes associated with heart failure (HF) readmissions and to identify associations with HF hospitalizations (HFH) in patients treated with the MitraClip™ NTR/XTR System in the EXPAND study. Methods and results: The global, real‐world EXPAND study enrolled 1041 patients with primary or secondary mitral regurgitation (MR) treated with the MitraClip NTR/XTR System. Echocardiograms were analysed by an independent echocardiographic core laboratory. The study population was stratified into HFH and No‐HFH groups based on the occurrence of HFH 1 year post‐index procedure. Clinical outcomes including MR severity, New York Heart Association (NYHA) functional class, Kansas City Cardiomyopathy Questionnaire (KCCQ) score, and all‐cause mortality were compared (HFH: n = 181; No‐HFH: n = 860). Both groups achieved consistent 1‐year MR reduction to ≤1+ (HFH vs. No‐HFH: 87.3% vs. 89.5%, p = 0.6) and significant 1‐year improvement in KCCQ scores (+16.5 vs. +22.3, p = 0.09) and NYHA functional class. However, more patients in the No‐HFH group had 1‐year NYHA class ≤II (HFH vs. No‐HFH: 67.9% vs. 81.9%, p < 0.01). All‐cause mortality at 1 year was 36.8% in the HFH group versus 10.4% in the No‐HFH group (p < 0.001). The HFH rate decreased by 63% at 1 year post‐M‐TEER versus 1 year pre‐treatment (relative risk 0.4, p < 0.001). Independent HFH associations were MR ≥2+ at discharge, HFH 1 year prior to treatment, baseline NYHA class ≥III, baseline tricuspid regurgitation ≥2+, and baseline left ventricular ejection fraction ≤40%. Conclusions: This study reports the impact of HFH on clinical outcomes post‐treatment in the EXPAND study. Results demonstrate that the occurrence of HFH was associated with worse 1‐year survival, and treatment with the MitraClip system substantially reduced HFH and improved patient symptoms and quality of life. [ABSTRACT FROM AUTHOR]

Nowadays, the necessity of having a cardioplegia circuit capable of being adapted in order to administer different types of cardioplegia is strategically fundamental, both for the perfusionist and for the cardiac surgeon. This allows to avoid cutting tubes, guarantees sterility and, most of all, limits the number of cardioplegia circuits for the different strategies of cardiac arrest. The novel "ReverseTWO cardioplegia circuit system" is the development of the precedent "Reverse system" where mainly the 4:1 and crystalloid cardioplegia were used, It has the advantage of allowing immediate change of cardioplegia set-up versus four types of cardioplegia technique, when the strategy is unexpectedly changed before the beginning of cardiopulmonary bypass (CPB), is safe and enables the perfusionist to use one single custom pack of cardioplegia. Two pediatric roller pumps are usually used in our centre for cardioplegia administration; they have a standardized calibration (the leading with ¼ inch and the follower with 1/8 inch) and the circuit consequently has two different tube diameters for the two different pumps. The presence in the circuit of two different shunts coupled with two different coloured clamps allows the immediate set-up for different cardioplegia administration techniques utilizing a colour-coding mechanism The aim of this manuscript is to present the new ReverseTWO Circuit. This novel system allows to administer four different cardioplegic solutions (4:1, 1:4, crystalloid, ematic) based on multiple tubes, which can be selectively clamped, identified through a color-coding method. The specificity of this circuit is the great versatility, which leads to numerous advantages, such as reduced risk of perfusion accident and reduced costs related not only to the purchase of different cardioplegia kits but also to the storage. https://youtu.be/ovJBE4ok2Ds [ABSTRACT FROM AUTHOR]

The article discusses a study randomized trial which compares undersized annuloplasty versus mitral replacement in the treatment of severe ischaemic mitral regurgitation (MR). The study revealed high recurrence of moderate to severe MR following surgery associated with higher incidence of rehospitalization. It suggests that valve replacement could be a preferable transcatheter mitral valve therapy with the development of transcatheter mitral valve interventions.

Background: The current coronavirus disease 2019 (COVID‐19) pandemic has a huge impact on society and the economy and represents one of the biggest challenges for healthcare systems all over the world. Reports from healthcare institutions in different countries show a variety of crisis exit strategies. Methods: The following is a review and update of the situation and crisis management in Zürich and Switzerland with a special focus on the impact on the cardiac surgery program and extracorporeal membrane oxygenation (ECMO)‐therapy in COVID‐19. Results: Regional and national measures had avoided the collapse of the health system in Switzerland. There was a reduction of over 50% of the surgical and transcatheter caseload during the first wave of the pandemic. Twenty‐three ECMO devices, 150 oxygenators, and more than 300 different cannulas were at our disposal. Between March and May 2020, nine COVID‐19 patients were treated by us with ECMO‐therapy. Three patients were transported by us from distant institutions. Median age at ECMO implantation was 59 years. Two patients died on support. Conclusions: Measures to prevent a collapse of the healthcare system were effective. Our local ECMO‐Program on the ongoing COVID‐19 pandemic has proven to be a useful tool to control mortality and organ failure in critically ill patients. [ABSTRACT FROM AUTHOR]

Objective: The aim was to evaluate the performance of a newly developed magnetically suspended centrifugal pump head intended for use as a ventricular assistance device with a newly developed extracorporeal membrane oxygenator setup. Methods: In an experimental setup, an extracorporeal membrane oxygenator circuit was established in three calves with a mean weight of 68.2 ± 2.0 kg. A magnetically levitated centrifugal pump was tested, along with a newly designed extracorporeal membrane oxygenator console, at three different flow ranges: (a) 0.0 to 5.2 L/min, (b) 0.0 to 7.1 L/min, and (c) 0.0 to 6.0 L/min. For each setup, the animals were supported by a circuit for 6 h. Blood samples were collected just before caridiopulmonary bypass (CPB) after 10 min on bypass and after 1, 2, 5, and 6 h of perfusion for hemolysis determination and biochemical tests. Values were recorded for blood pressure, mean flow, and pump rotational speed. Analysis of variance was used for repeated measurements. Results: Mean pump flows achieved during the three 6 h pump runs for the three pump heads studied were as follows: (a) flow range 0.0 to 5.2 L/min, 3.6 ± 1.5 L/min, (b) flow range 0.0 to 7.1 L/min, 4.9 ± 1.3 L/min, and (c) flow range 0.0 to 6.0 L/min, 3.8 ± 1.5 L/min. Blood trauma, evaluated by plasma hemoglobin and lactate dehydrogenase levels, did not help in detecting any significant hemolysis. Thrombocytes and white blood cell count profiles showed no significant differences between the groups at the end of the 6 h perfusion. At the end of testing, no clot deposition was found in the oxygenator, and there was no evidence of peripheral emboli. Conclusion: The results suggest that the newly developed magnetically suspended centrifugal pump head provides satisfactory hydrodynamic performance in an acute perfusion scenario without increasing hemolysis. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide Type A aortic dissection requires immediate surgical repair. Despite improvements in surgery and anaesthesia, there is still a considerable risk when high-risk patients are concerned. Less invasive endovascular treatments are under evaluation. We investigated the current status of catheter-based treatment for type A aortic dissection with the entry tear located in the ascending aorta. METHODS A PubMed search was supplemented by searching through bibliographies and key articles. Demographics, risk score, stent graft detail, access route, mortality, cause of death, complications, reinterventions and follow-up data were extracted and analysed. RESULTS Thirty-one articles (7 retrospective reports; 24 case reports/series) were included in the study. In total, 104 patients (mean age 71 ± 14 years) received endovascular treatment for acute (63) or chronic (41) type A dissection. A history of a major cardiac or aortic operation was present in 29 patients. The mean EuroSCORE II was 30 ± 20 in 4 reports. A total of 114 stent grafts were implanted: 'off-the-shelf', 65/114; custom made, 12/114; and modified, 7/114. Hospital complications included intraprocedural conversion to open surgery (2/104), stroke (2/104), coronary stenting (2/104), early endoleak (9/104) and repeat aortic endovascular treatment for endoleak (5/104). Hospital mortality was 10% (intraoperative death 2/104). Mean duration of follow-up time was 21 ± 21 months (range 1–81 months); follow-up data were available for 86 patients: 10 patients died of non-aortic-related causes; reintervention for aortic disease (endovascular repair or open surgery) was performed in 8 patients. CONCLUSIONS Catheter-based ascending aorta repair for type A aortic dissection with the entry tear in the ascending aorta can be considered in carefully selected high-risk patients. Further analysis and specifically designed devices are required. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Uncorrected severe mitral regurgitation (MR) due to posterior prolapse leads to left ventricular dilatation. At this stage, mitral valve repair becomes mandatory to avoid permanent myocardial injury. However, which technique among neochoardae implantation and leaflet resection provides the best results in this scenario remains unknown. METHODS We selected 332 patients with left ventricular dilatation and severe degenerative MR due to posterior leaflet (PL) prolapse who underwent neochoardae implantation (85 patients) or PL resection (247 patients) at our institution between 2008 and 2020. A propensity score matching analysis was carried on to decrease the differences at baseline. RESULTS Matching yielded 85 neochordae implantations and 85 PL resections. At 10 years, freedom from cardiac death and freedom from mitral valve reoperation were 92.6 ± 6.1% vs 97.8 ± 2.1% and 97.7 ± 2.2% vs 95 ± 3% in the neochordae group and in the PL resection group, respectively. The MR ≥2+ recurrence rate was 23.9 ± 10% in the neochordae group and 20.8 ± 5.8% in the PL resection group (P  = 0.834) at 10 years. At the last follow-up, the neochordae group showed a higher reduction of left ventricular end-diastolic diameter (44 vs 48 mm; P  = 0.001) and a better ejection fraction (60% vs 55%; P  < 0.001) compared to PL resection group. CONCLUSIONS In this subgroup of patients, both neochordae implantation and leaflet resection provide excellent durability of the repair in the long term. Neochordae implantation might have a better effect on dilated left ventricle. [ABSTRACT FROM AUTHOR]

In terms of pathophysiology, tricuspid regurgitation (TR), right ventricular function and pulmonary artery pressure are linked to each other. Our aim was to analyze whether the echocardiography-derived right ventricular free wall longitudinal strain/pulmonary artery systolic pressures (RVFWLS/PASP) ratio can improve risk stratification in patients with severe tricuspid regurgitation (TR). In this single-center retrospective study, 250 consecutive patients with severe TR were enrolled from December 2015 to December 2018. Baseline clinical and echocardiographic parameters were collected. Echocardiography-derived TAPSE/PASP and RVFWLS/PASP were evaluated. The primary endpoint was all-cause mortality. Out of 250 consecutive patients, 171 meet inclusion criteria. Patients were predominantly female, with several cardiovascular risk factors and comorbidities. RVFWLS/PASP ≤0.34%/mmHg (AUC 0.68, p < 0.001, sensitivity 70%, specificity 67%) was associated with baseline clinical RV heart failure (p = 0.03). After univariate and multivariate analyses, RVFWLS/PASP, but not TAPSE/PASP, independently correlated with all-cause mortality (HR 0.004, p = 0.02). Patients with RVFWLS/PASP >0.26%/mmHg (AUC 0.74, p < 0.001, sensitivity 77%, specificity 52%) showed higher survival rates (p = 0.02). In addition at 24 months follow-up, the Kaplan-Meyer curves showed patients with RVFWLS >14% & RVFWLS/PASP >0.26%/mmHg had the best survival rate compared to patients without. RVFWLS/PASP is independently associated with baseline RV heart failure and poor long-term prognosis in patients with severe TR. The prognostic role of RVFWLS /PASP ratio in severe TR. [Display omitted] [ABSTRACT FROM AUTHOR]

A response from the author of the article related to mitral repair for functional mitral regurgitation (FMR), published in previous issue is presented.

Aims: Mitral valve transcatheter edge‐to‐edge repair is a guideline‐recommended treatment option for patients with secondary mitral regurgitation (SMR). The purpose of this analysis was to report contemporary real‐world outcomes in SMR patients treated with third‐generation MitraClip systems. Methods and results: EXPAND is a prospective, multicentre, international, single‐arm study with 1041 patients treated for mitral regurgitation (MR) with MitraClip NTR/XTR, with 30‐day and 1‐year follow‐up. All echocardiograms were analysed by an independent echocardiographic core lab. Study outcomes included procedural outcomes, durability of MR reduction, and major adverse events including all‐cause mortality and heart failure hospitalizations (HFH). A subgroup of 413 symptomatic patients (age 74.7 ± 10.1 years, 58% male) with severe SMR were included. MR reduction to MR ≤ 1+ and MR ≤ 2+ was achieved in 93.0% and 98.5% of patients, respectively, which was sustained at 1‐year follow‐up. All‐cause mortality was 17.7% at 1‐year‐ follow‐up, and the combined endpoint of all‐cause mortality or first HFH occurred in 34% of patients. This combined endpoint was significantly less frequently observed in MR ≤ 1+ patients (Kaplan–Maier estimates: 29.7% vs. 69.6% for MR ≤ 1+ vs. MR ≥ 2 +; p < 0.0001). New York Heart Association (NYHA) functional class improved significantly from baseline (NYHA ≤ II: 17%) to 1‐year follow‐up (NYHA ≤ II: 78%) (p < 0.0001). While MR reduction was comparable between NTR‐only vs. XTR‐only treated patients, less XTR clips were required for achieving MR reduction. Conclusions: Under real‐world conditions, optimal sustained MR reduction to MR ≤ 1+ was achieved in a high percentage of patients with third‐generation MitraClip, which translated into symptomatic improvement and low event rates. These results appear to be comparable with recent randomized clinical trials. [ABSTRACT FROM AUTHOR]

Using three-dimensional (3D) modalities for optimal pre-procedure planning in transcatheter aortic valve replacement (TAVR) is critical for procedural success. However, current methods rely on visualizing images on a two-dimensional screen, using shading and colors to create the illusion of 3D, potentially impeding the accurate comprehension of the actual anatomy structures. In contrast, a new Mixed Reality (MxR) based software enables accurate 3D visualization, imaging manipulation, and quantification of measurements. The study aims to evaluate the feasibility, reproducibility, and accuracy of dimensions of the aortic valve complex as measured with a new holographic MxR software (ARTICOR®, Artiness srl, Milano, Italy) compared to a widely used software for pre-operative sizing and planning (3mensio Medical Imaging BV, Bilthoven, The Netherlands). This retrospective, observational, double-center study enrolled 100 patients with severe aortic stenosis who underwent cardiac computed tomography (CCT) before TAVR. The CCT datasets of volumetric aortic valve images were analyzed using 3Mensio and newly introduced MxR-based software. Ninety-eight percent of the CCT datasets were successfully converted into holographic models. A higher level of agreement between the two software systems was observed for linear metrics (short, long, and average diameter). In comparison, agreement was lower for area, perimeter, and annulus-to-coronary ostia distance measurements. Notably, the annulus area, annular perimeter, left ventricular outflow tract (LVOT) area, and LVOT perimeter were significantly and consistently smaller with the MxR-based software compared to the 3Mensio. Excellent interobserver reliability was demonstrated for most measurements, especially for direct linear measurements. Linear measurements of the aortic valve complex using MxR-based software are reproducible compared to the standard CCT dataset analyzed with 3Mensio. MxR-based software could represent an accurate tool for the pre-procedural planning of TAVR. • Stereoscopic imaging enables authentic 3D visualization and manipulation. • MxR 3D visualization system provides a user-friendly method for planning TAVR procedures. • Holographic visualization of 3D aortic valve has been proven feasible and accurate. • MxR direct measurements showed a good agreement with 3-Mensio software. • MxR could be a promising tool for structural heart interventions planning. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Our goal was to assess the short- and long-term outcomes of surgical treatment for hypertrophic obstructive cardiomyopathy in patients ≥65 years of age compared to patients < 65 years of age. METHODS Sixty-four patients aged ≥65 years, surgically treated for symptomatic hypertrophic obstructive cardiomyopathy, were compared to a control group of 125 patients <65 years. RESULTS Patients aged ≥65 years were less frequently male (36% vs 68%, P  < 0.001) and had higher EuroSCORE II scores [1.4 (1.1–2.2) vs 0.8 (0.7–1.2), P  < 0.001], lower risk of sudden death, higher pulmonary artery pressure [40 (30–50) vs 30 (30–43), P  = 0.04) and more mitral annulus calcifications (44% vs 14%, P  < 0.001) compared to younger patients. Hospital death was 1%, with no difference between the 2 groups (1.5% vs 0.8%, P  = 0.9). Patients aged ≥65 years had more concomitant coronary bypass grafting (12% vs 5%, P  = 0.05) and a higher incidence of blood transfusions (50% vs 17%, P  < 0.001) and postoperative atrial fibrillation (19% vs 8%, P  = 0.02). Follow-up was 98% complete [median 8.3 (5.3–12.8) years]. The 13-year survival in the group aged ≥65 was 54 (SD: 9) % vs 83 (SD: 5) % in the control group (P  < 0.001), but it was comparable to that expected in the age-sex matched general national population. At 13 years, the cumulative incidence function of cardiac death in the elderly group was 19 (SD: 7)%, mostly unrelated to hypertrophic cardiomyopathy causes. At the last follow-up, 90% of patients were in New York Heart Association functional class I-II and 68% were in sinus rhythm. CONCLUSIONS Selected elderly symptomatic patients with hypertrophic obstructive cardiomyopathy can benefit from surgery, with low hospital mortality and morbidity, relief of symptoms and late survival comparable to that expected in the age-sex matched general population. [ABSTRACT FROM AUTHOR]

Advanced age is a common contraindication for cardiac surgery, particularly in high-risk patients with comorbidities, such as pulmonary and renal impairment, associated coronary artery disease, and neurological disorders. In elderly patients with degenerative mitral regurgitation who are not eligible for conventional surgical valve repair or replacement, percutaneous valve repair is emerging as a viable alternative therapeutic option. Nonsurgical and minimally invasive therapies for degenerative mitral regurgitation are of particular value in this subset of patients, because these interventions are associated with reduced perioperative mortality, clinical improvement, and faster recovery than is possible with surgical procedures. However, given that surgery remains the gold-standard treatment and should still be considered an option regardless of a patient's age, transcatheter mitral valve repair should be performed only in candidates who will gain the most benefit from it. The balance between the risks and benefits, and the value versus the futility of procedures to treat degenerative mitral regurgitation in elderly patients should be assessed by a specialized multidisciplinary care team. In this Review, we discuss the treatment options and indications for degenerative mitral regurgitation in elderly patients. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES With the expanding use of cardiac implantable electronic devices (CIEDs), lead interference with the tricuspid valve (TV) causing significant tricuspid regurgitation (TR) has gained increasing recognition. However, current knowledge about the long-term results of the surgical treatment of TR in this setting is scanty. Therefore, increasing this information was the goal of this study. METHODS A retrospective review of our institutional database was carried out to select all patients with previously implanted CIEDs who underwent tricuspid valve repair and replacement from 2000 through 2019. Kaplan–Meier methods were used to analyse long-term survival. To describe the time course of TR, we performed a longitudinal analysis using generalized estimating equations. RESULTS A total of 151 patients were identified. Mechanical interference with leaflet mobility and coaptation was detected in 103 patients (68%) (CIED-induced group); in the remaining 48 patients (32%), the lead was associated with TR without being the cause of it (CIED-associated group). A total of 105 patients underwent TV repair; in the remaining 46, a TV replacement was necessary. In patients who underwent TV repair, no significant difference in moderate TR recurrence rate was highlighted between CIED-induced and CIED-associated TR. CONCLUSIONS In patients with CIEDs and surgically treated tricuspid regurgitation, TR is CIED-induced in about two-thirds of the cases and CIED-associated in one-third of them. In our experience, TV repair was still possible in 63% of the cases, with good long-term results and no significant durability difference between CIED-induced and CIED-associated TR. [ABSTRACT FROM AUTHOR]

Objectives: Moderate secondary mitral regurgitation is common in patients with severe aortic regurgitation, but whether it has to be addressed at the time of aortic valve surgery remains unclear. With this study, we evaluated the long‐term fate of moderate secondary mitral regurgitation in this specific scenario. Methods: Between January 2004 and January 2018, in 154 patients admitted to our institution for treatment of severe aortic regurgitation, a moderate secondary mitral regurgitation was diagnosed. Ninety‐four patients underwent isolated aortic valve replacement (group 1) and 60 patients underwent also concomitant mitral valve annuloplasty (group 2). Results: One death (1.1%) occurred in group 1, whereas two deaths (3.3%) occurred in group 2 (p =.561). At 11 years, the cumulative incidence function of cardiac death, with noncardiac death as a competing risk was 11.5 ± 5.11% in group 1 and 8.3 ± 5.15% in group 2 (p =.731). The cumulative incidence function of mitral valve reintervention, with death as a competing risk, was 3.7 ± 2.61% in group 1 and 4.5 ± 4.35% in group 2 (p =.620) at 11 years. Secondary mitral regurgitation improved to ≤mild in 66% and 76% of the survivors of group 1 and group 2, respectively (p =.67). Conclusions: In our experience, in patients with moderate secondary mitral regurgitation undergoing aortic valve replacement for severe aortic regurgitation, concomitant mitral valve annuloplasty did not improve the long‐term survival, the incidence of cardiac death and mitral valve reoperation or the evolution of the mitral valve disease. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES This study aimed at assessing mid-term outcomes of patients undergoing isolated tricuspid valve (TV) surgery based on a preoperative baseline clinical and functional classification. METHODS All patients treated with isolated TV repair or replacement from March 1997 to May 2020 at a single institution were retrospectively reviewed and assessed for mid-term postoperative outcome according to a novel classification [stages 1–5 related to the absence or presence and extent of right heart failure (RHF)]. Kaplan–Meier survival curves were used to estimate mid-term survival. Competing risk analysis for time to cardiac death and hospitalizations for RHF were also carried out. RESULTS Among the 172 patients included, 129 (75%) underwent TV replacement and 43 (25%) TV repair. At follow-up (median 4.2 years [2.1–7.5]), there were 23 late deaths. At 5 years, overall survival was 100% in stage 2, 88 ± 4% in stage 3 and 60 ± 8% in stages 4–5 (P = 0.298 and P = 0.001, respectively). Cumulative incidence function of cardiac death at 5 years was 0%, 8.6 ± 3.76% and 13.2 ± 5% for stages 2, 3 and 4 and 5, respectively. At follow-up, cumulative incidence function of re-hospitalizations for RHF was 0% for stage 2, 20 ± 5% for stage 3 and 20 ± 6.7% for stages 4 and 5 (P = 0.118 and P = 0.039, respectively). CONCLUSIONS Both short- and mid-term outcomes support early referral for surgery in isolated TV disease, with excellent survival at 5 years and no further hospitalizations for RHF. [ABSTRACT FROM AUTHOR]

Background: Data to support the routine use of embolic protection devices for stroke prevention during transcatheter aortic valve replacement (TAVR) are controversial. Identifying patients at high risk for peri-procedural cerebrovascular events may facilitate effective patient selection for embolic protection devices during TAVR. Aim: To generate a risk score model for stratifying TAVR patients according to peri-procedural cerebrovascular events risk. Methods and results: A total of 8779 TAVR patients from 12 centers worldwide were included. Peri-procedural cerebrovascular events were defined as an ischemic stroke or a transient ischemic attack occurring ≤24 h from TAVR. The peri-procedural cerebrovascular events rate was 1.4% (n = 127), which was independently associated with 1-year mortality (hazards ratio (HR) 1.78, 95% confidence interval (CI) 1.06–2.98, p < 0.028). The TASK risk score parameters were history of stroke, use of a non-balloon expandable valve, chronic kidney disease, and peripheral vascular disease, and each parameter was assigned one point. Each one-point increment was associated with a significant increase in peri-procedural cerebrovascular events risk (OR 1.96, 95% CI 1.56–2.45, p < 0.001). The TASK score was dichotomized into very-low, low, intermediate, and high (0, 1, 2, 3–4 points, respectively). The high-risk TASK score group (OR 5.4, 95% CI 2.06–14.16, p = 0.001) was associated with a significantly higher risk of peri-procedural cerebrovascular events compared with the low TASK score group. Conclusions: The proposed novel TASK risk score may assist in the pre-procedural risk stratification of TAVR patients for peri-procedural cerebrovascular events. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Mitral regurgitation (MR) due to commissural prolapse or flail represents a pattern of valve dysfunction that can be treated, among other techniques, by suturing the margins of the anterior and posterior leaflets in the commissural area (commissural closure). The very long-term results of this technique have not been reported so far and represent the objective of this study. METHODS A retrospective review of our institutional database was carried on querying for patients who underwent commissural closure and ring annuloplasty within the time frame 1997–2007 to provide a robust long-term assessment. Cumulative incidence function (CIF) using death as a competitive outcome was used to estimate cardiac death and reoperation for mitral valve replacement. To describe the time course of MR, we performed a longitudinal analysis using generalized estimating equations with a random intercept for correlated data. RESULTS A total of 125 patients were included. At 15 years, the CIF for cardiac death, with non-cardiac death as a competitive event, was 8.0 ± 2.57% (95% confidence interval [3.88–13.93]). At 15 years, the CIF for reintervention for a mitral valve replacement with death as a competitive event was 5.0 ± 1.98%, 95% confidence interval [2.04–9.89]. No significant predictors of reintervention for mitral valve replacement were identified. At 5 years, the predicted rate of MR ≥3+ recurrence was 2.53% while it was 8.22% at 15 years. In no case a more than mild mitral stenosis was detected. CONCLUSIONS Severe MR due to commissural prolapse/flail can be effectively treated with commissural closure and ring annuloplasty. In our series, the rate of reoperation in the very long term was extremely low. Similarly, longitudinal analysis demonstrated a very low rate of MR ≥3+ recurrence. [ABSTRACT FROM AUTHOR]