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Aims: This study aimed to compare outcomes after transcatheter mitral valve replacement (TMVR) and mitral valve transcatheter edge‐to‐edge repair (M‐TEER) for the treatment of secondary mitral regurgitation (SMR). Methods and results: The CHOICE‐MI registry included 262 patients with SMR treated with TMVR between 2014 and 2022. The EuroSMR registry included 1065 patients with SMR treated with M‐TEER between 2014 and 2019. Propensity score (PS) matching was performed for 12 demographic, clinical and echocardiographic parameters. Echocardiographic, functional and clinical outcomes out to 1 year were compared in the matched cohorts. After PS matching, 235 TMVR patients (75.5 years [70.0, 80.0], 60.2% male, EuroSCORE II 6.3% [interquartile range 3.8, 12.4]) were compared to 411 M‐TEER patients (76.7 years [70.1, 80.5], 59.0% male, EuroSCORE II 6.7% [3.9, 12.4]). All‐cause mortality was 6.8% after TMVR and 3.8% after M‐TEER at 30 days (p = 0.11), and 25.8% after TMVR and 18.9% after M‐TEER at 1 year (p = 0.056). No differences in mortality after 1 year were found between both groups in a 30‐day landmark analysis (TMVR: 20.4%, M‐TEER: 15.8%, p = 0.21). Compared to M‐TEER, TMVR resulted in more effective mitral regurgitation (MR) reduction (residual MR ≤1+ at discharge for TMVR vs. M‐TEER: 95.8% vs. 68.8%, p < 0.001), and superior symptomatic improvement (New York Heart Association class ≤II at 1 year: 77.8% vs. 64.3%, p = 0.015). Conclusion: In this PS‐matched comparison between TMVR and M‐TEER in patients with severe SMR, TMVR was associated with superior reduction of MR and superior symptomatic improvement. While post‐procedural mortality tended to be higher after TMVR, no significant differences in mortality were found beyond 30 days. [ABSTRACT FROM AUTHOR]

Background: Despite paucity of data, it is common practice to discontinue metformin before invasive coronary angiography due to an alleged risk of Metformin-Associated Lactic Acidosis (M-ALA). We aimed at assessing the safety of metformin continuation in diabetic patients undergoing coronary angiography in terms of significant increase in lactate levels. Methods: In this open-label, prospective, multicentre, single-arm trial, all diabetic patients undergoing coronary angiography with or without percutaneous coronary intervention at 3 European centers were screened for enrolment. The primary endpoint was the increase in lactate levels from preprocedural levels at 72-h after the procedure. Secondary endpoints included contrast associated-acute kidney injury (CA-AKI), M-ALA, and all-cause mortality. Results: 142 diabetic patients on metformin therapy were included. Median preprocedural lactate level was 1.8 mmol/l [interquartile range (IQR) 1.3–2.3]. Lactate levels at 72 h after coronary angiography were 1.7 mmol/l (IQR 1.3–2.3), with no significant differences as compared to preprocedural levels (p = 0.91; median difference = 0; IQR − 0.5 to 0.4 mmol/l). One patient had 72-h levels ≥ 5 mmol/l (5.3 mmol/l), but no cases of M-ALA were reported. CA-AKI occurred in 9 patients (6.1%) and median serum creatinine and estimated glomerular filtration rate remained similar throughout the periprocedural period. At a median follow-up of 90 days (43–150), no patients required hemodialysis and 2 patients died due to non-cardiac causes. Conclusions: In diabetic patients undergoing invasive coronary angiography, metformin continuation throughout the periprocedural period does not increase lactate levels and was not associated with any decline in renal function. Trial registration: The study was registered at Clinicaltrials.gov (NCT04766008). [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve implantation (TAVI) has risen over the past 20 years as a safe and effective alternative to surgical aortic valve replacement for treatment of severe aortic stenosis, and is now a well-established and recommended treatment option in suitable patients irrespective of predicted risk of mortality after surgery. Studies of numerous devices, either newly developed or reiterations of previous prostheses, have been accruing. We hereby review TAVI devices, with a focus on commercially available options, and aim to present a guide for prosthesis tailoring according to patient-related anatomical and clinical factors that may favor particular designs. [ABSTRACT FROM AUTHOR]

Tricuspid regurgitation (TR) negatively affects patient outcomes. Surgical tricuspid valve repair/replacement carries a high operative risk and is not a viable option for many high-risk patients. Percutaneous approaches provide an attractive alternative solution for such patients since they represent a valid alternative to open heart surgery without the significant risks carried by surgery. A number of percutaneous devices are currently under clinical development. This review will discuss about the latest development in the field of percutaneous tricuspid valve repair with possible future developments. [ABSTRACT FROM AUTHOR]

Aims: Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical diseases of the elderly. Up to 16% of older adults with severe AS referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. CA‐AS population suffers from reduced functional capacity and worse prognosis than AS patients. As the prognostic impact of TAVR in patients with CA‐AS has been historically questioned and in light of recently published evidence, we aim to provide a comprehensive synthesis of the efficacy and safety of TAVR in CA‐AS patients. Methods and results: We performed a systematic review and meta‐analysis of studies: (i) evaluating mortality with TAVR as compared with medical therapy in CA‐AS patients and (ii) reporting complications and clinical outcomes of TAVR in CA‐AS patients as compared with patients with AS alone. A total of seven observational studies were identified: four reported mortality with TAVR, and four reported complications and clinical outcomes after TAVR of patients with CA‐AS compared with AS alone patients. In patients with CA‐AS, the risk of mortality was lower with TAVR (n = 44) as compared with medical therapy (n = 36) [odds ratio (OR) 0.23, 95% confidence interval (CI) 0.07–0.73, I2 = 0%, P = 0.001, number needed to treat = 3]. The safety profile of TAVR seems to be similar in patients with CA‐AS (n = 75) as compared with those with AS alone (n = 536), with comparable risks of stroke, vascular complications, life‐threatening bleeding, acute kidney injury, and 30 day mortality, although CA‐AS was associated with a trend towards an increased risk of permanent pacemaker implantation (OR 1.76, 95% CI 0.91–4.09, I2 = 0%, P = 0.085). CA is associated with a numerically higher rate of long‐term mortality and rehospitalizations following TAVR in patients with CA‐AS as compared with those with AS alone. Conclusions: TAVR is an effective and safe procedure in CA‐AS patients, with a substantial survival benefit as compared with medical therapy, and a safety profile comparable with patients with AS alone except for a trend towards higher risk of permanent pacemaker implantation. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is the most common heart arrhythmia, and its prevalence increases with age. Oral Anticoagulant Therapy (OAT) with non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K antagonists (VKAs) is essential to avoid thromboembolic events in AF. However, this treatment is associated with a high risk of bleeding and low adherence in elderly patients. Aim: The aim was to evaluate the real-world use of OAT in a population of patients aged ≥80 years in twenty-three Italian centers and to investigate the tolerance of and patient satisfaction with this therapy. Methods: The ISNEP Study is a multicenter cross-sectional study enrolling patients with AF and aged ≥80 years and treated with either NOACs or VKAs. A written questionnaire was administered to each patient to evaluate the adherence to and patient satisfaction with this therapy. Results: The study included 641 patients with a mean age of 85 (82–87) years. The use of NOACs was reported in 93.0% of cases, with the remaining 7.0% treated with VKAs. A history of stroke events was reported in five (11.1%) and one (0.2%) patients in the VKA and NOAC groups, respectively. The rate of referred ecchymosis/epistaxis was significantly higher in the VKA group compared to the NOAC group (p < 0.001). Patients receiving NOACs reported a substantial improvement in their quality of life compared to the VKA group. Conclusions: A small, but not negligible, proportion of elderly AF patients is still treated with VKAs. Patients treated with NOAC have a higher level of satisfaction with the therapy and complete adherence. [ABSTRACT FROM AUTHOR]

Keywords: Structural heart intervention; aortic stenosis; transcatheter aortic valve implantation; self-expanding bioprosthesis; balloon-expandable bioprosthesis; aortic valve EN Structural heart intervention aortic stenosis transcatheter aortic valve implantation self-expanding bioprosthesis balloon-expandable bioprosthesis aortic valve 497 501 5 08/22/22 20220701 NES 220701 1. Despite the contemporary refinements in valve technologies and implantation techniques, SE valves still demonstrate less accurate positioning compared to BE devices. Transcatheter self-expandable valve implantation for aortic stenosis in small aortic annuli: the TAVI-SMALL Registry. [Extracted from the article]

Tricuspid regurgitation (TR) has a considerable prevalence in the overall population, that further increases in selected categories of patients. Three morphologic types of TR prevail, namely primary, secondary and atrial TR, mostly, but not always, occurring in different subsets of patients. Recent evidences demonstrate a negative impact of TR on outcomes, irrespective of etiology and even when less than severe in grading. Unfortunately, current surgical standards are void of strong prospective evidence of positive impact on clinical outcomes. While on one hand recent advances in diagnosis and risk stratification of patients with TR are shedding light onto the population that may benefit from intervention and its appropriate timing, on the other hand the arrival on stage of percutaneous treatment options is widening even more the therapeutic options for such population. In this review we will address and discuss the available evidence on the prognostic impact of TR in different clinical contexts encountered in practice. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Vascular complications (VC) are the most frequent drawback of transcatheter aortic valve implantation (TAVI), affecting up to 20% of overall procedures. Data on the treatment and their long-term impact are scarce. The goal of this study was to report on the incidence, management and impact on the long-term outcomes of VC following TAVI. METHODS This was a multicentric retrospective analysis of consecutive patients undergoing TAVI. The primary endpoint was freedom from major adverse cardiac and cerebrovascular events at long-term follow-up. Adverse events were evaluated according to Valve Academic Research Consortium-2 criteria. RESULTS A total of 2145 patients were included: VC occurred in 188 (8.8%); of which 180 were limited to the access site. Two-thirds of the VC were minor; 8% required surgical treatment; the remaining were repaired percutaneously. The major adverse cardiac and cerebrovascular events-free survival at 2 years was 83.0% for patients with VC and 86.7% for those without (P  = 0.143), but 71.9% for patients with major compared to 89.0% in those with minor VC (P  = 0.022). Major VC and diabetes mellitus independently predicted worse outcomes at 2 years. The major adverse cardiac and cerebrovascular events-free survival rate and the occurrence of vascular adverse events in the long term among patients with VC at the access site treated by endovascular techniques (covered stent implantation or angioplasty) were similar to those without VC (84.2% vs 86.7%; P  = 0.635). CONCLUSIONS Major but not minor VC impact long-term survival after TAVI. Covered stents implanted to manage VC at the access site have no impact on the long-term clinical outcome of TAVI. [ABSTRACT FROM AUTHOR]

Purpose of the Review: Annular-based strategies for treating tricuspid valve (TV) regurgitation do not always have satisfactory long-term outcomes. Management of failed TV annuloplasty can be challenging and requires a dedicated heart team approach. This review explores the treatment options available for failed TV annuloplasty. Recent findings: Recent developments and novel percutaneous treatment options have emerged as promising alternatives for patients with failed TV annuloplasty. Leaflet-based interventions, valve-in-valve procedures, transcatheter tricuspid valves and new-generation trans-caval valves are all feasible options, which can assure good results whilst minimizing risks for the patient. Summary: Failure of tricuspid annuloplasty is not uncommon amongst patients treated with either a tricuspid ring or suture-based device. The complex anatomy, physiology and clinical risk profile should be carefully evaluated on an individual patient-by-patient basis in order to select the most appropriate clinical and percutaneous treatment strategy. Different transcatheter tricuspid valve repair or replacement techniques may provide an attractive alternative treatment option for managing this challenging patient cohort. [ABSTRACT FROM AUTHOR]

Objectives: To define the incidence of high residual gradient (HRG) after transcatheter aortic valve replacement (TAVR) in BAVs and their impact on short term outcome and 1-year mortality. Background: Transcatheter heart valves (THVs) offer good performance in tricuspid aortic valves with low rate of HRG. However, data regarding their performance in bicuspid aortic valves (BAV) are still lacking. Methods: The BEAT (Balloon vs Self-Expandable valve for the treatment of bicuspid Aortic valve sTenosis) registry included 353 consecutive patients who underwent TAVR (Evolut R/PRO or Sapien 3 valves) in BAV between June 2013 and October 2018. The primary endpoint was device unsuccess with post-procedural HRG (mean gradient ≥ 20 mmHg). The secondary endpoint was to identify the predictors of HRG following the procedure. Results: Twenty patients (5.6%) showed HRG after TAVR. Patients with HRG presented higher body mass index (BMI) (30.7 ± 9.3 vs. 25.9 ± 4.8; p < 0.0001) and higher baseline aortic mean gradients (57.6 ± 13.4 mmHg vs. 47.7 ± 16.6, p = 0.013) and more often presented with BAV of Sievers type 0 than patients without HRG. At multivariate analysis, BMI [odds ratio (OR) 1.12; 95% confidence interval (CI) 1.05–1.20, p = 0.001] and BAV type 0 (OR 11.31, 95% CI 3.45–37.06, p < 0.0001) were confirmed as independent predictors of high gradient. Conclusion: HRG following TAVR in BAVs is not negligible and is higher among patients with high BMI and with BAV 0 anatomy. [ABSTRACT FROM AUTHOR]

Objective: Risk stratification is crucial to optimise treatment strategies in patients with COVID-19. We aimed to evaluate the impact on mortality of an early assessment of cardiac biomarkers in patients with COVID-19.Methods: Humanitas Clinical and Research Hospital (Rozzano-Milan, Lombardy, Italy) is a tertiary centre that has been converted to the management of COVID-19. Patients with confirmed COVID-19 were entered in a dedicated database for cohort observational analyses. Outcomes were stratified according to elevated levels (ie, above the upper level of normal) of high-sensitivity cardiac troponin I (hs-TnI), B-type natriuretic peptide (BNP) or both measured within 24 hours after hospital admission. The primary outcome was all-cause mortality.Results: A total of 397 consecutive patients with COVID-19 were included up to 1 April 2020. At the time of hospital admission, 208 patients (52.4%) had normal values for cardiac biomarkers, 90 (22.7%) had elevated both hs-TnI and BNP, 59 (14.9%) had elevated only BNP and 40 (10.1%) had elevated only hs-TnI. The rate of mortality was higher in patients with elevated hs-TnI (22.5%, OR 4.35, 95% CI 1.72 to 11.04), BNP (33.9%, OR 7.37, 95% CI 3.53 to 16.75) or both (55.6%, OR 18.75, 95% CI 9.32 to 37.71) as compared with those without elevated cardiac biomarkers (6.25%). A multivariate analysis identified concomitant elevation of both hs-TnI and BNP as a strong independent predictor of all-cause mortality (OR 3.24, 95% CI 1.06 to 9.93).Conclusions: An early detection of elevated hs-TnI and BNP predicts mortality in patients with COVID-19. Cardiac biomarkers should be systematically assessed in patients with COVID-19 at the time of hospital admission in order to optimise risk stratification. [ABSTRACT FROM AUTHOR]

Purpose: The WATCHMAN device for Left Atrial Appendage Occlusion (LAAO) has proven to be an effective alternative to oral anticoagulation (OAC) in patients with atrial fibrillation (AF), and has now been adopted in clinical practice. In the present study, we analyzed the safety and efficacy profile of the LAAO procedure at mid-term follow-up.Methods: The TRAPS Registry is an observational, multicenter registry involving four Italian centers. Consecutive patients who had undergone LAAO with WATCHMAN device were enrolled. Clinical, demographic, and procedural data were collected at the time of implantation, and follow-up data were collected to assess the clinical outcome.Results: A total of 151 patients were included in the Registry from May 2012 to October 2015. Implantation of the device was successful in 150/151 patients, with no or minimal (< 5 mm) leakage as assessed by peri-procedural transesophageal echo. In the remaining patient, early device embolization was reported, with no sequelae. Overall, intra-procedural events were reported in 5 (3.3%) patients. During a median follow-up of 16 months (25th and 75th percentile, 10-25), 5 patients died of any cause. The annual rate of all-cause stroke was 2.2% (95% CI, 0.7-5.1), the rate of transient ischemic attack was 1.3% (95% CI, 0.3-3.8), and that of major bleeding 0.4% (95% CI, 0.01-2.4).Conclusions: LAAO for stroke prevention was safely and effectively achieved by implantation of the WATCHMAN device in patients with non-valvular AF. Moreover, regardless of the risk profile of the population, we observed low rates of death and thromboembolic and bleeding events over a median follow-up of 16 months. These findings were obtained in an unselected group of consecutive patients who were variably eligible for chronic OAC therapy. [ABSTRACT FROM AUTHOR]

Ventricular septal rupture (VSR) is a complication of myocardial infarction. Surgery is the only treatment; however, mortality is high, especially if it is performed within 7 days from presentation. The improved outcome with delayed intervention could be related to evolution of the infarct, which allows a more effective surgical repair. However, it is also a representation of survival bias, as an early surgery is usually performed on individuals with hemodynamic instability. We present a case of VSR complicated by cardiogenic shock. An early hemodynamic stabilization was achieved with Impella implantation; the delay in surgery allowed a reduction in surgical risk. [ABSTRACT FROM AUTHOR]

Background: Left atrial catheterization through transseptal puncture is frequently performed in cardiac catheterization procedures. Appropriate transseptal puncture is critical to achieve procedural success.Aims: The aim of the study is to evaluate the feasibility of selective transseptal punctures, using a modified radiofrequency (RF) transseptal needle and transesophageal echocardiography (TEE), in different types of procedures that require specific sites of left atrial catheterization.Setting and Design: This was an observational trial in a cardiac catheterization laboratory of a teaching hospital.Materials and Methods: Patients undergoing different percutaneous procedures requiring atrial transseptal puncture such as atrial fibrillation (AF) ablation, left atrial appendage (LAA) occlusion, and mitral valve repair were included in the study. All procedures were guided by TEE and an RF transseptal needle targeting a specific region of the septum to perform the puncture.Statistical Analysis: The statistical analysis was descriptive only.Results: RF-assisted transseptal punctures were performed in six consecutive patients who underwent AF ablation (two patients), LAA closure (two patients), and mitral valve repair (two patients). In all patients, transseptal punctures were performed successfully at the desired site. No adverse events or complications were observed.Conclusions: Selective transseptal puncture, using TEE and an RF needle, is a feasible technique that can be used in multiple approaches requiring a precise site of access for left atrial catheterization. [ABSTRACT FROM AUTHOR]

Aortic stenosis is the most common valvular heart disease of old age. Patients with severe aortic stenosis who develop symptoms have a very poor prognosis without valve intervention. Surgical aortic valve replacement has historically been the only treatment option for these patients. However a significant minority are considered inoperable or at high surgical risk and therefore are refused or decline surgery. In recent years, transcatheter aortic valve replacement has emerged as an alternative treatment option in these high-risk patients. The aim of this review is to summarize the current role of transcatheter aortic valve replacement in contemporary clinical practice including recent advances in technological and procedural aspects and then discuss future directions. [ABSTRACT FROM AUTHOR]