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OBJECTIVES The aim of this study was to retrospectively compare the characteristics, procedural courses, and outcomes of patients presenting with concomitant mitral regurgitation (MR) and tricuspid regurgitation (TR) in the TriValve (Transcatheter Tricuspid Valve Therapies) and TRAMI (Transcatheter Mitral Valve Interventions) registries. BACKGROUND Transcatheter mitral edge-to-edge valve repair (TMVR) has been shown to be successful in patients with severe MR. Lately, edge-to-edge repair has also emerged as a possible treatment for severe TR in patients at high risk for cardiac surgery. In patients with both severe MR and TR, the yield of concomitant transcatheter mitral and tricuspid valve repair (TMTVR) for patients at high surgical risk is unknown. METHODS The characteristics, procedural data, and 1-year outcomes of all patients in the international multicenter TriValve registry and the German multicenter TRAMI registry, who presented with both severe MR and TR, were retrospectively compared. Patients in TRAMI (n = 106) underwent isolated TMVR, while those in TriValve (n = 122) additionally underwent concurrent TMTVR in compassionate and/or off-label use. RESULTS All 228 patients (mean age 77 +/- 8 years, 44.3% women) presented with significant dyspnea at baseline (New York Heart Association functional class III or IV in 93.9%), without any differences in the rates of pulmonary hypertension and chronic pulmonary disease. The proportion of patients with left ventricular ejection fraction <30% was higher in the TMVR group (34.9% vs. 18.0%; p < 0.001), while patients in the TMTVR group had lower glomerular filtration rates. At discharge, MR was comparably reduced in both groups. At 1 year, overall all-cause mortality was 34.0% in the TMVR group and 16.4% in the TMTVR group (p = 0.035, Cox regression). On multivariate analysis, TMTVR was associated with a 2-fold lower mortality rate (hazard ratio: 0.52; p = 0.02). The rate of patients in New York Heart Association fu

OBJECTIVES The aim of this study was to assess the clinical outcome of baseline massive or torrential tricuspid regurgitation (TR) after transcatheter tricuspid valve intervention (TTVI). BACKGROUND The use of TTVI to treat symptomatic severe TR has been increasing rapidly, but little is known regarding the impact of massive or torrential TR beyond severe TR. METHODS The study population comprised 333 patients with significant symptomatic TR from the TriValve Registry who underwent TTVI. Mid-term outcomes after TTVI were assessed according to the presence of massive or torrential TR, defined as vena contracta width >= 14 mm. Procedural success was defined as patient survival after successful device implantation and delivery system retrieval, with residual TR <= 2+. The primary endpoint comprised survival rate and freedom from rehospitalization for heart failure, survival rate, and rehospitalization at 1 year. RESULTS Baseline massive or torrential TR and severe TR were observed in 154 patients (46.2%) and 179 patients (53.8%), respectively. Patients with massive or torrential TR had a higher prevalence of ascites than those with severe TR (27.3% vs. 20.4%, respectively; p = 0.15) and demonstrated a similar procedural success rate (83.2% vs. 77.3%, respectively; p = 0.21). The incidence of peri-procedural adverse events was low, with no significant between-group differences. Freedom from the composite endpoint was significantly tower in patients with massive or torrential TR than in those with severe TR, which was significantly associated with an increased risk for 1-year death of any cause or rehospitalization for heart failure (adjusted hazard ratio:1.91; 95% confidence interval:1.10 to 3.34; p = 0.022). Freedom from the composite endpoint was significantly higher in patients with massive or torrential TR when procedural success was achieved (69.9% vs. 54.2%, p = 0.048). CONCLUSIONS Baseline massive or torrential TR is associated with an increased risk for all-caus

This second chapter is dedicated to the preoperative screening of patients, when the aortic disease has assumed a degree of severity that requires a thorough understanding in view of the treatment. Which imaging tests are indicated for the diagnosis and quantification of the associated coronary artery disease, as well as mitral and tricuspidal valvulopathies will be discussed. Cardiac tumours and incidental findings and the evaluation of the most relevant non-cardiac co-pathologies are discussed from the point of view of multimodal imaging techniques. Particular attention will be given to the characterisation of the concept of “Frailty”, with state-of-the-art criteria of analysis provided to establish operability, assess the preoperative psychophysical and social conditions. This is to optimise treatment towards a true patient-tailored approach. Finally, rare conditions associated with aortic disease, e.g. amyloidosis, and particular precautions in some settings (e.g. pregnant women, renal failure and the presence of cardiac pacemakers) will be illustrated.

OBJECTIVES The aim of this study was to retrospectively compare the characteristics, procedural courses, and outcomes of patients presenting with concomitant mitral regurgitation (MR) and tricuspid regurgitation (TR) in the TriValve (Transcatheter Tricuspid Valve Therapies) and TRAMI (Transcatheter Mitral Valve Interventions) registries. BACKGROUND Transcatheter mitral edge-to-edge valve repair (TMVR) has been shown to be successful in patients with severe MR. Lately, edge-to-edge repair has also emerged as a possible treatment for severe TR in patients at high risk for cardiac surgery. In patients with both severe MR and TR, the yield of concomitant transcatheter mitral and tricuspid valve repair (TMTVR) for patients at high surgical risk is unknown. METHODS The characteristics, procedural data, and 1-year outcomes of all patients in the international multicenter TriValve registry and the German multicenter TRAMI registry, who presented with both severe MR and TR, were retrospectively compared. Patients in TRAMI (n = 106) underwent isolated TMVR, while those in TriValve (n = 122) additionally underwent concurrent TMTVR in compassionate and/or off-label use. RESULTS All 228 patients (mean age 77 +/- 8 years, 44.3% women) presented with significant dyspnea at baseline (New York Heart Association functional class III or IV in 93.9%), without any differences in the rates of pulmonary hypertension and chronic pulmonary disease. The proportion of patients with left ventricular ejection fraction <30% was higher in the TMVR group (34.9% vs. 18.0%; p < 0.001), while patients in the TMTVR group had lower glomerular filtration rates. At discharge, MR was comparably reduced in both groups. At 1 year, overall all-cause mortality was 34.0% in the TMVR group and 16.4% in the TMTVR group (p = 0.035, Cox regression). On multivariate analysis, TMTVR was associated with a 2-fold lower mortality rate (hazard ratio: 0.52; p = 0.02). The rate of patients in New York Heart Association fu

OBJECTIVES The aim of this study was to assess the clinical outcome of baseline massive or torrential tricuspid regurgitation (TR) after transcatheter tricuspid valve intervention (TTVI). BACKGROUND The use of TTVI to treat symptomatic severe TR has been increasing rapidly, but little is known regarding the impact of massive or torrential TR beyond severe TR. METHODS The study population comprised 333 patients with significant symptomatic TR from the TriValve Registry who underwent TTVI. Mid-term outcomes after TTVI were assessed according to the presence of massive or torrential TR, defined as vena contracta width >= 14 mm. Procedural success was defined as patient survival after successful device implantation and delivery system retrieval, with residual TR <= 2+. The primary endpoint comprised survival rate and freedom from rehospitalization for heart failure, survival rate, and rehospitalization at 1 year. RESULTS Baseline massive or torrential TR and severe TR were observed in 154 patients (46.2%) and 179 patients (53.8%), respectively. Patients with massive or torrential TR had a higher prevalence of ascites than those with severe TR (27.3% vs. 20.4%, respectively; p = 0.15) and demonstrated a similar procedural success rate (83.2% vs. 77.3%, respectively; p = 0.21). The incidence of peri-procedural adverse events was low, with no significant between-group differences. Freedom from the composite endpoint was significantly tower in patients with massive or torrential TR than in those with severe TR, which was significantly associated with an increased risk for 1-year death of any cause or rehospitalization for heart failure (adjusted hazard ratio:1.91; 95% confidence interval:1.10 to 3.34; p = 0.022). Freedom from the composite endpoint was significantly higher in patients with massive or torrential TR when procedural success was achieved (69.9% vs. 54.2%, p = 0.048). CONCLUSIONS Baseline massive or torrential TR is associated with an increased risk for all-caus

Aims: Interventional mitral repair techniques have evolved as safe and effective treatment options for patients with functional mitral regurgitation (FMR) at high or prohibitive surgical risk. Of the techniques available, the MitraClip device and Cardioband mitral repair system have been used most commonly. However, a direct comparison of the two devices, examining their effectiveness at reducing MR, reducing symptoms, and extending life expectancy, has not yet been performed. For this purpose, we compared the outcome of patients after direct annuloplasty by the Cardioband system with patients after edge-to-edge therapy with the MitraClip device in a propensity score-matched analysis. Methods and results: We collected data concerning 123 consecutive patients who were treated with the Cardioband device and 455 consecutive patients treated with the MitraClip from five experienced European centres. Propensity score matching was performed, resulting in two groups with 93 patients each - with no significant differences regarding baseline demographic parameters - who underwent standardised 2D transthoracic echocardiography with assessment at baseline and clinical follow-up at 12 months. The success rate, defined as a reduction of MR to grade 2 or lower, was high in both groups (MR <= 2: MitraClip: 86%, Cardioband: 77%, p=0.18). The Cardioband was better at reducing heart failure symptoms (NYHA <= II: 88%) than the MitraClip (75%) procedure (p=0.046) at 12-month follow-up. All-cause rehospitalisation and mortality within 12 months were lower in Cardioband patients (mortality: OR 0.30, CI: 0.09-0.98, p=0.032; rehospitalisation: OR 0.57, CI: 0.28-0.97, p=0.03). Conclusions: The MitraClip and the Cardioband procedures effectively reduce MR and heart failure symptoms. However, patients undergoing the Cardioband procedure showed a more pronounced improvement with regard to functional NYHA class, rehospitalisation, and mortality, compared to patients undergoing the MitraClip pro

BACKGROUND Tricuspid regurgitation is associated with increased rates of heart failure (HF) and mortality. Transcatheter tricuspid valve interventions (TTVI) are promising, but the clinical benefit is unknown. OBJECTIVES The purpose of this study was to investigate the potential benefit of TTVI over medical therapy in a propensity score matched population. METHODS The TriValve (Transcatheter Tricuspid Valve Therapies) registry collected 472 patients from 22 European and North American centers who underwent TTVI from 2016 to 2018. A control cohort formed by 2 large retrospective registries enrolling medically managed patients with >= moderate tricuspid regurgitation in Europe and North America (n = 1,179) were propensity score 1:1 matched (distance +/- 0.2 SD) using age, EuroSCORE II, and systolic pulmonary artery pressure. Survival was tested with Cox regression analysis. Primary endpoint was 1-year mortality or HF rehospitalization or the composite. RESULTS After matching, 268 adequately matched pairs of patients were identified. Compared with control subjects, TTVI patients had lower 1-year mortality (23 +/- 3% vs. 36 +/- 3%; p = 0.001), rehospitalization (26 +/- 3% vs. 47 +/- 3%; p < 0.0001), and composite endpoint (32 +/- 4% vs. 49 +/- 3%; p = 0.0003). TTVI was associated with greater survival and freedom from HF rehospitalization (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.46 to 0.79; p = 0.003 unadjusted), which remained significant after adjusting for sex, New York Heart Association functional class, right ventricular dysfunction, and atrial fibrillation (HR: 0.39; 95% CI: 0.26 to 0.59; p < 0.0001) and after further adjustment for mitral regurgitation and pacemaker/defibrillator (HR: 0.35; 95% CI: 0.23 to 0.54; p < 0.0001). CONCLUSIONS In this propensity-matched case-control study, TTVI is associated with greater survival and reduced HF rehospitalization compared with medical therapy alone. Randomized trials should be performed to confirm these

Aims: Interventional mitral repair techniques have evolved as safe and effective treatment options for patients with functional mitral regurgitation (FMR) at high or prohibitive surgical risk. Of the techniques available, the MitraClip device and Cardioband mitral repair system have been used most commonly. However, a direct comparison of the two devices, examining their effectiveness at reducing MR, reducing symptoms, and extending life expectancy, has not yet been performed. For this purpose, we compared the outcome of patients after direct annuloplasty by the Cardioband system with patients after edge-to-edge therapy with the MitraClip device in a propensity score-matched analysis. Methods and results: We collected data concerning 123 consecutive patients who were treated with the Cardioband device and 455 consecutive patients treated with the MitraClip from five experienced European centres. Propensity score matching was performed, resulting in two groups with 93 patients each - with no significant differences regarding baseline demographic parameters - who underwent standardised 2D transthoracic echocardiography with assessment at baseline and clinical follow-up at 12 months. The success rate, defined as a reduction of MR to grade 2 or lower, was high in both groups (MR <= 2: MitraClip: 86%, Cardioband: 77%, p=0.18). The Cardioband was better at reducing heart failure symptoms (NYHA <= II: 88%) than the MitraClip (75%) procedure (p=0.046) at 12-month follow-up. All-cause rehospitalisation and mortality within 12 months were lower in Cardioband patients (mortality: OR 0.30, CI: 0.09-0.98, p=0.032; rehospitalisation: OR 0.57, CI: 0.28-0.97, p=0.03). Conclusions: The MitraClip and the Cardioband procedures effectively reduce MR and heart failure symptoms. However, patients undergoing the Cardioband procedure showed a more pronounced improvement with regard to functional NYHA class, rehospitalisation, and mortality, compared to patients undergoing the MitraClip pro

BACKGROUND Tricuspid regurgitation is associated with increased rates of heart failure (HF) and mortality. Transcatheter tricuspid valve interventions (TTVI) are promising, but the clinical benefit is unknown. OBJECTIVES The purpose of this study was to investigate the potential benefit of TTVI over medical therapy in a propensity score matched population. METHODS The TriValve (Transcatheter Tricuspid Valve Therapies) registry collected 472 patients from 22 European and North American centers who underwent TTVI from 2016 to 2018. A control cohort formed by 2 large retrospective registries enrolling medically managed patients with >= moderate tricuspid regurgitation in Europe and North America (n = 1,179) were propensity score 1:1 matched (distance +/- 0.2 SD) using age, EuroSCORE II, and systolic pulmonary artery pressure. Survival was tested with Cox regression analysis. Primary endpoint was 1-year mortality or HF rehospitalization or the composite. RESULTS After matching, 268 adequately matched pairs of patients were identified. Compared with control subjects, TTVI patients had lower 1-year mortality (23 +/- 3% vs. 36 +/- 3%; p = 0.001), rehospitalization (26 +/- 3% vs. 47 +/- 3%; p < 0.0001), and composite endpoint (32 +/- 4% vs. 49 +/- 3%; p = 0.0003). TTVI was associated with greater survival and freedom from HF rehospitalization (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.46 to 0.79; p = 0.003 unadjusted), which remained significant after adjusting for sex, New York Heart Association functional class, right ventricular dysfunction, and atrial fibrillation (HR: 0.39; 95% CI: 0.26 to 0.59; p < 0.0001) and after further adjustment for mitral regurgitation and pacemaker/defibrillator (HR: 0.35; 95% CI: 0.23 to 0.54; p < 0.0001). CONCLUSIONS In this propensity-matched case-control study, TTVI is associated with greater survival and reduced HF rehospitalization compared with medical therapy alone. Randomized trials should be performed to confirm these

For the past few decades, the transaortic septal myectomy (Morrow's procedure) has been the gold standard for treating severe left ventricular outflow tract obstruction in hypertrophic obstructive cardiomyopathy (HOCM) patients. 30-day mortality has been reported at less than 1% in dedicated centers. However, in a subgroup of patients, the interventricular septal obstruction is localized very distally, below the aortic valve plane, and the transaortic approach can be very challenging. A subset of these patients can present with residual obstruction after surgery, due to inadequate length of septal excision, leading to reoperation. The aim of this work is to illustrate an original application of cryoenergy to improve the transaortic exposure of the interventricular septum and thus enable surgeons to perform very distal myectomies in HOCM patients.

The field of mitral valve disease diagnosis and management is rapidly evolving. New understanding of pathophysiology and improvements in the adoption of sophisticated multimodality imaging modalities have led to early diagnosis and to more complex treatment. The most common cause of mitral regurgitation (MR) in the western world is in the primary alteration of the valve, which leads to degenerative leaflet prolapse due to chordal elongation or rupture and annular dilatation. Untreated, significant MR has a negative impact prognosis, leading to reduction of survival. In the setting of degenerative MR, surgical repair currently represents the standard of care. Treatment of asymptomatic patients with severe MR in the Valve Center of Excellence, in which successful repair reaches more than 95% and surgical mortality less than 1%, symbolizes the direction for the next years. Transcatheter mitral valve repair with different devices, more recently the chordal replacement ones, is providing good outcomes and became a therapeutic option in high-risk patients with degenerative MR. In the future, more advances are expected from further development of interventional techniques, careful evaluation and better patient selection. This review will focus on long-term surgical outcomes of mitral valve repair with artificial chordae and on the emerging transcatheter chordal repair devices as therapeutic options for degenerative MR patients.

Objective Thoracoscopic surgical pulmonary vein isolation (sPVI) has been added to the treatment of atrial fibrillation (AF), showing excellent efficacy outcomes. However, data on right ventricular (RV) function following sPVI has never been studied. Our aim was to investigate RV function following sPVI and compare it to patients who underwent endocardial cryoballoon PVI. Methods 25 patients underwent sPVI and were pair-matched according to age, sex, and AF type with 21 patients who underwent cryoballoon PVI. RV function was measured using tricuspid annular plane systolic excursion (TAPSE) and RV strain with 2D speckle tracking. Echocardiography was performed at baseline and at median 6-month follow-up. Results Age was 54 ± 9 years and 84% were male; AF was paroxysmal in 92%. In the sPVI group, TAPSE was reduced with 31% at follow-up echocardiography ( < 0.001) and RV strain showed a 25% reduction compared to baseline ( = 0.018). In the control group, TAPSE and RV strain did not change significantly (-3% and +13%, = 0.410 and = 0.148). Change in TAPSE and RV strain was significantly different between groups ( ≤ 0.001 and = 0.005). Conclusions This study shows that RV function is significantly decreased following sPVI. This effect was not observed in the cryoballoon PVI control group.

Transcatheter valve interventions on the mitral and tricuspid valves entail increasing complexity. Part of the knowledge that has been generated during the development of mitral devices can be transferred to the tricuspid valve (TV). However, a deeper understanding of the peculiar anatomy of the TV and of the right heart chambers, together with differences and similarities between the two valves, is fundamental. This report compares the anatomy of the mitral and tricuspid valves, and its inferences with regard to transcatheter treatments. Condensed Abstract: This report explores anatomical similarities and differences between the mitral and the tricuspid valves, and their implications with regard to transcatheter treatments.

OBJECTIVES: Prosthetic valve endocarditis (PVE) is an uncommon yet dreadful complication in patients with prosthetic valves that requires a distinct analysis from native valve endocarditis. The present study aims to investigate independent risk factors for early surgical outcomes in patients with PVE. METHODS: A retrospective cohort study was conducted in 8 Italian Cardiac Surgery Units from January 2000 to December 2013 by enrolling all PVE patients undergoing surgical treatment. RESULTS: A total of 209 consecutive patients were included in the study. During the study period, the global rate of surgical procedures for PVE among all operations for isolated or associated valvular disease was 0.45%. Despite its rarity this percentage increased significantly during the second time frame (2007-2013) in comparison with the previous one (2000-2006): 0.58% vs 0.31% (P < 0.001). Intraoperative and in-hospital mortality rates were 4.3% and 21.5%, respectively. Logistic regression analysis identified the following factors associated with in-hospital mortality: female gender [odds ratio (OR) = 4.62; P < 0.001], shock status (OR = 3.29; P = 0.02), previous surgical procedures within 3 months from the treatment (OR = 3.57; P = 0.009), multivalvular involvement (OR = 8.04; P = 0.003), abscess (OR = 2.48; P = 0.03) and urgent surgery (OR = 6.63; P < 0.001). CONCLUSIONS: Despite its rarity, PVE showed a significant increase over time. Up to now, in-hospital mortality after surgical treatment still remains high ( > 20%). Critical clinical presentation and extension of anatomical lesions are strong preoperative predictors for poor early outcome.

BACKGROUND: In order to reduce stroke risk, left atrial appendage amputation (LAAA) is widely adopted in recent years. The effect of LAAA on left atrial (LA) function remains unknown. The objective of present study was to assess the effect of LAAA on LA function. METHODS: Sixteen patients with paroxysmal AF underwent thoracoscopic, surgical PVI with LAAA (LAAA group), and were retrospectively matched with 16 patients who underwent the same procedure without LAA amputation (non-LAAA group). To objectify LA function, transthoracic echocardiography with 2D Speckle Tracking was performed before surgery and at 12 months follow-up. RESULTS: Mean age was 57 ± 9 years, 84% were male. Baseline characteristics did not differ significantly except for systolic blood pressure (p = 0.005). In both groups, the contractile LA function and LA ejection fraction were not significantly reduced. However, the conduit and reservoir function were significantly decreased at follow-up, compared to baseline. The reduction of strain and strain rate was not significantly different between groups. CONCLUSIONS: In this retrospective, observational matched group comparison with a convenience sample size of 16 patients, findings suggest that LAAA does not impair the contractile LA function when compared to patients in which the appendage was unaddressed. However, the LA conduit and reservoir function are reduced in both the LAAA and non-LAAA group. Our data suggest that the LAA can be removed without late LA functional consequences.

Transcatheter mitral valve therapies have emerged as an alternative option in high surgical risk or inoperable patients with severe and symptomatic mitral regurgitation (MR). As multiple technologies and different approaches will become available in the field of mitral valve interventions, different challenges are emerging, both patient- (clinical challenges) and procedure-related (technical challenges). This review will briefly explore the current open challenges in the evolving fields of interventional mitral valve treatment.

OBJECTIVE Clinical success of atrial fibrillation (AF) ablation depends on persistent block of electrical conduction across the ablation lines. The fate of ablations performed with temperature-controlled bipolar radiofrequency (RF) is unknown. The purpose of this study was to validate the electrophysiological (EP) efficacy of these lesions, recording pulmonary vein isolation (PVI) after open chest ablation, in the human being. METHODS Ten consecutive mitral patients (mean age: 53 ± 12 years) with concomitant AF were treated with the Cobra Revolution (Estech, San Ramon, CA, USA) bipolar RF device were enrolled for EP assessment. During surgery, pairs of additional temporary wires were positioned on the right PVs (RPV) and on the roof of the left atrium (RLA), before ablation. Pacing thresholds (PTs) were assessed before, after a single encircling ablation and at chest's closure. EP study was repeated before discharge and at 3 weeks. RLA wires served as control. RESULTS Baseline PTs were 0.83 ± 0.81 mA (range 0.2-3 mA) from RPV and 1.13 ± 0.78 mA (range 0.3-3 mA) from RLA. PVI was reached in all patients acutely, and was maintained at 1 week. At 3 weeks, the PTs were 14.3 ± 4.3 mA from RPV (range 7-20 mA) and 3.1 ± 1.3 mA (range 1.5-7 mA) from RLA. All patients were discharged in sinus rhythm. CONCLUSIONS Cobra Revolution temperature-controlled bipolar RF provides complete PVI after a single ablation up to 1 week. This notwithstanding, only 30% of patients were completely isolated (exit block validation) at 3 weeks