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Background: The occurrence of conduction disturbances (CDs) remains the most frequent complication of transcatheter aortic valve replacement (TAVR). However, little is known about the timing of electrocardiogram (ECG) changes and CDs during the TAVR procedure., Objective: The objective of this study was to describe ECG changes throughout the TAVR procedure using the CARA monitor., Methods: This was a multicenter study including 196 prospectively enrolled patients without preexisting CDs undergoing TAVR. All patients were monitored with the CARA system, which uses a 12-lead ECG to measure PQ and QRS intervals, QRS axis, and variations with each heartbeat at every step: baseline, wire insertion, pre-dilatation, valve deployment, post-dilatation, and end of procedure., Results: PQ and QRS intervals progressively increased throughout the procedure, with a cumulative increase from 169.2 ± 20.0 ms to 186.0 ± 31.6 ms (P < .001) for the PQ interval and from 101.3 ± 10.5 ms to 126.0 ± 25.4 ms (P < .001) for the QRS interval, from baseline to the end of the procedure. A significant increase in the number of patients with left axis deviation was observed (7.7% at baseline vs 31.8% at end of procedure; P < .001). A total of 161 (82.1%) patients exhibited at least 1 CD episode (PQ >200 ms, QRS ≥120 ms, advanced heart block) during the procedure, with most episodes occurring during pre-dilatation and valve implantation maneuvers., Conclusion: The CARA system facilitated real-time ECG monitoring, detecting subtle and progressive changes during TAVR. ECG changes occurred at each step, with most patients experiencing CDs, especially during pre-dilatation and valve implantation. The potential clinical impact of monitoring ECG dynamics and timing for early detection of severe CDs should be explored in future studies., Competing Interests: Disclosures Dr Rodés-Cabau reports having received institutional research grants and speaker/consultant fees from Edwards Lifesciences and Medtronic. The rest of the authors have not reported any potential conflict of interest with respect to the content of this article., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Whether patent foramen ovale (PFO) closure benefits older patients with PFO and cryptogenic stroke is unknown because randomized controlled trials (RCTs) have predominantly enrolled patients younger than 60 years of age. Our objective was to estimate anticipated effects of PFO closure in older patients to predict the numbers needed to plan an RCT., Methods: Effectiveness estimates are derived from major observational studies (Risk of Paradoxical Embolism [RoPE] Study and Oxford Vascular Study, together referred to as the "RoPE-Ox" database) and all 6 major RCTs (Systematic, Collaborative, PFO Closure Evaluation [SCOPE] Consortium). To estimate stroke recurrence risk, observed outcomes were calculated for patients older than 60 years in the age-inclusive observational databases (n = 549). To estimate the reduction in the rate of recurrent stroke associated with PFO closure vs medical therapy based on the RoPE score and the presence of high-risk PFO features, a Cox proportional hazards regression model was developed on the RCT data in the SCOPE database (n = 3,740). These estimates were used to calculate sample sizes required for a future RCT., Results: Five-year risk of stroke recurrence using Kaplan-Meier estimates was 13.7 (95% CI 10.5-17.9) overall, 14.9% (95% CI 10.2-21.6) in those with high-risk PFO features. Predicted relative reduction in the event rate with PFO closure was 12.9% overall, 48.8% in those with a high-risk PFO feature. Using these estimates, enrolling all older patients with cryptogenic stroke and PFO would require much larger samples than those used for prior PFO closure trials, but selectively enrolling patients with high-risk PFO features would require totals of 630 patients for 90% power and 471 patients for 80% power, with an average of 5 years of follow-up., Discussion: Based on our projections, anticipated effect sizes in older patients with high-risk features make a trial in these subjects feasible. With lengthening life expectancy in almost all regions of the world, the utility of PFO closure in older adults is increasingly important to explore.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%-3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in-hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low- and high-volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low-volume centers compared to high-volume centers for PTE (24.4% vs. 12.1%, p  = 0.003). Patients with hospitalizations for PTE in low-volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p  < 0.001) and tracheostomy (7.8% vs. 2.6%, p  = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low-volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high-volume centers with multidisciplinary teams should be encouraged for optimal outcomes., Competing Interests: A. V.: Grant funding from the New York Academy of Medicine; A. K.: Institutional funding to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Amgen, CSI, Philips, ReCor Medical, Neurotronic, Biotronik, Chiesi, Bolt Medical, Magenta Medical, Canon, SoniVie, Shockwave Medical, and Merck. In addition to research grants, institutional funding includes fees paid to Columbia University and/or Cardiovascular Research Foundation for consulting and/or speaking engagements in which Dr. Ajay J. Kirtane controlled the content. Personal: Consulting from IMDS; Travel Expenses/Meals from Medtronic, Boston Scientific, Abbott Vascular, CSI, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron; Z. S.: Consulting feeds from Medtronic and Abbott Vascular. The remaining authors declare no conflict of interest., (© 2024 The Authors. Pulmonary Circulation published by John Wiley & Sons Ltd on behalf of Pulmonary Vascular Research Institute.)

The association, if any, between the effective regurgitant orifice area (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients who undergo mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip system (Abbott Vascular, Santa Clara, CA). This study's objective was to determine the association between EROA/LVEDV and 1-year mortality in patients who undergo m-TEER with MitraClip. In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. We studied 525 patients with secondary MR who underwent m-TEER. Most patients were male (63%) and were New York Heart Association class III (61%) or IV (21%). Mitral regurgitation was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely, with median = 0.19 mm 2 /ml, interquartile range [0.12,0.28] mm 2 /ml, and 187 patients (36%) had values <0.15 mm 2 /ml. Postprocedural mitral regurgitation severity was substantially alleviated, being 1+ or less in 74%, 2+ in 20%, 3+ in 4%, and 4+ in 2%; 1-year mortality was 22%. After adjustment for confounders, the logarithmic transformation (Ln) of EROA/LVEDV was associated with 1-year mortality (odds ratio 0.600, 95% confidence interval 0.386 to 0.933, p = 0.023). A higher Society of Thoracic Surgeons risk score was also associated with increased mortality. In conclusion, lower values of Ln(EROA/LVEDV) were associated with increased 1-year mortality in this multicenter registry. The slope of the association is steep at low values but gradually flattens as Ln(EROA/LVEDV) increases., Competing Interests: Declaration of competing interest Dr. Lim reports a relation with Abbott that includes funding grants; a relation with Boston Scientific Corp. that includes funding grants; a relation with Corvia Medical that includes funding grants; a relation with Edwards Lifesciences Corporation that includes funding grants; a relation with Medtronic Inc. that includes funding grants; a relation with Trisol that includes funding grants; a relation with Philips that includes consulting or advisory; a relation with Valgen that includes consulting or advisory; and a relation with Venus that includes consulting or advisory. Dr. Rodriguez reports a relation with Abbott that includes consulting or advisory, funding grants, and speaking and lecture fees. Dr. Zahr reports a relation with Medtronic Inc. that includes board membership, consulting or advisory, and funding grants; a relation with Edwards Lifesciences Corporation that includes funding grants; and a relation with SIEMENS that includes: funding grants. Dr. Ailawadi reports a relation with Medtronic Inc. that includes consulting or advisory; a relation with Abbott that includes consulting or advisory; a relation with Edwards Lifesciences Corporation that includes consulting or advisory; a relation with Gore that includes consulting or advisory; a relation with Anteris that includes consulting or advisory; a relation with AtriCure Inc. that includes consulting or advisory; a relation with CryoLife that includes consulting or advisory; a relation with Philips that includes consulting or advisory; and a relation with Johnson & Johnson that includes consulting or advisory. Dr. Rogers reports a relation with Abbott that includes consulting or advisory and funding grants; a relation with Boston Scientific Corp that includes consulting or advisory and funding grants; and a relation with Baylis Medical Company, Inc. that includes consulting or advisory. Dr. Chen reports a relation with Philips that includes consulting or advisory; a relation with Abbott that includes consulting or advisory; and a relation with Akura Medical that includes consulting or advisory. Dr. Vannan reports a relation with Abbott that includes funding grants and speaking and lecture fees. Dr. Duggal reports a relation with Medtronic Inc. that includes consulting or advisory. Dr. Sodhi reports a relation with Medtronic Inc that includes consulting or advisory; and a relation with Boston Scientific Corp that includes consulting or advisory. Dr. Sorajja reports a relation with 4C Medical Technologies Inc. that includes consulting or advisory; a relation with Anteris that includes consulting or advisory; a relation with Abbott that includes consulting or advisory; a relation with Boston Scientific Corp that includes consulting or advisory; a relation with Edwards Lifesciences Corporation that includes consulting or advisory; a relation with Evolution Medical that includes consulting or advisory; a relation with Foldax that includes consulting or advisory; a relation with GLG that includes consulting or advisory; a relation with Medtronic Inc. that includes consulting or advisory; a relation with Philips that includes consulting or advisory; a relation with SIEMENS that includes consulting or advisory; a relation with Shifamed that includes consulting or advisory; a relation with WL Gore that includes consulting or advisory; a relation with vDyne that includes consulting or advisory; and a relation with xDot that includes consulting or advisory. Dr. Yadav reports a relation with Edwards Lifesciences Corporation that includes consulting or advisory and speaking and lecture fees; a relation with Abbott that includes consulting or advisory and speaking and lecture fees; a relation with Boston Scientific Corp. that includes consulting or advisory and speaking and lecture fees; and a relation with Dasi Simulations that includes board membership. Dr. Chadderdon reports a relation with Medtronic Inc that includes consulting or advisory; a relation with Edwards Lifesciences Corporation that includes consulting or advisory; and a relation with GE Healthcare that includes funding grants. Dr. Chetcuti reports a relation with Medtronic Inc. that includes consulting or advisory and funding grants; a relation with Boston Scientific Corp. that includes consulting or advisory and funding grants; a relation with Jena that includes funding grants; a relation with Abbott that includes funding grants; a relation with Edwards Lifesciences Corporation that includes funding grants; and a relation with Gore that includes funding grants. The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Left ventricular (LV) volume reshaping reduces myocardial wall stress and may induce reverse remodeling in patients with heart failure with reduced ejection fraction. The AccuCinch Transcatheter Left Ventricular Restoration system consists of a series of anchors connected by a cable implanted along the LV base that is cinched to the basal free wall radius. We evaluated the echocardiographic and clinical outcomes following transcatheter left ventricular restoration., Methods and Results: We analyzed 51 heart failure patients with a left ventricular ejection fraction between 20% and 40%, with no more than 2+ mitral regurgitation treated with optimal medical therapy, who subsequently underwent transcatheter left ventricular restoration. Serial echocardiograms, Kansas City Cardiomyopathy Questionnaire scores, and 6-minute walk test distances were measured at baseline through 12 months. Primary analysis end point was change in end-diastolic volume at 12 months compared with baseline. Patients (n = 51) were predominantly male (86%) with a mean age of 56.3 ± 13.1 years. Fluoroscopy showed LV free wall radius decreased by a median of 9.2 mm amounting to a 29.6% decrease in the free wall arc length. At 12 months, the LV end-diastolic volume decreased by 33.6 ± 34.8 mL (P < .01), with comparable decreases in the LV end-systolic volume. These decreases were associated with significant improvements in the overall Kansas City Cardiomyopathy Questionnaire score (16.4 ± 18.7 points; P < .01) and 6-minute hall walk test distance (45.9 ± 83.9 m; P < .01). There were no periprocedural deaths; through the 1-year follow-up, 1 patient died (day 280) and 1 patient received a left ventricular assist device (day 13)., Conclusions: In patients with heart failure with reduced ejection fraction without significant mitral regurgitation receiving optimal medical therapy, the AccuCinch System resulted in decreases of LV volume, as well as improved quality of life and exercise endurance. A randomized trial is ongoing (NCT04331769)., Competing Interests: Conflicts of Interest Nadira Hamid reports Institutional grant support. Ulrich Jorde reports travel support from Ancora Heart. Mark Reisman reports travel support from Ancora Heart. Azeem Latib has nothing to declare. D. Scott Lim has nothing to declare. Susan Joseph has nothing to declare. Alena Kurlianskaya has nothing to declare. Oleg Polonetsky, MD, reports consultancy fees from Ancora Heart, and consultancy or proctoring fees from Edwards Lifesciences and Medtronic. Petr Neuzil has nothing to declare. Vivek Reddy has nothing to declare. Jason Foerst has nothing to declare. Hemal Gada has nothing to declare. Kendra J. Grubb reports advisory board and consulting fees for Medtronic, Boston Scientific, Abbott, Ancora, 4C Medical, and honorarium for Edwards Lifesciences. Guilherme Silva has nothing to declare. Dean Kereiakes has nothing to declare. Satya Shreenivas has nothing to declare. Sean Pinney reports consulting fees from Abbott, CareDx, Medtronic, Procyrion, and Transmedics. Giedrius Davidavicius is a consultant to Ancora Heart. Paul Sorajja has nothing to declare. John Boehmer has nothing to declare. Franz X. Kleber is a consultant to Ancora Heart. Patrick Perier has nothing to declare. Nicolas M. Van Mieghem reports research grant support from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, PulseCath BV, Abiomed, Siemens, and Daiichi Sankyo. Nicolas Dumonteil reports consultancy fees from Ancora Heart, is the co-PI of the CorCinch European study; and reports consultancy and proctoring fees from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic. Martin B. Leon reports institutional clinical research grants from Abbott, Abiomed, Ancora, Boston Scientific, Edwards, and Medtronic. Daniel Burkhoff reports institutional grant support from Ancora Heart to the Cardiovascular Research Foundation., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: There are limited data on the feasibility of Impella-assisted percutaneous coronary intervention (PCI) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR)., Methods: To assess the feasibility of the Impella-assisted PCI in patients with severe symptomatic AS, we retrospectively reviewed the medical records to identify patients who were electively admitted for Impella-assisted PCI with a subsequent TAVR at Weill Cornell Medical Center from 2016 to 2021., Results: During the study period, 15 patients were identified to be eligible for the study, but the Impella failed to cross the aortic valve in 1 patient despite a concomitant balloon aortic valvuloplasty requiring a switch to an intra-aortic balloon pump to assist PCI. A total of 14 patients underwent successful PCI with the Impella CP and were included in the analysis. The median age was 89 years, and women accounted for 43% of the cohort. The median aortic valve area and mean gradient were 0.85 cm 2 and 40 mm Hg, respectively, with a median left ventricular ejection fraction of 51%. The median SYNTAX score was 13. The left main stent was placed in 6 patients (43%), with a rotational atherectomy performed in 10 patients (71%). The balloon aortic valvuloplasty was performed in 2 patients before Impella placement. The TAVR was performed in all 14 patients on a median post-Impella-assisted PCI day of 25. No procedural complications were noted post-TAVR with no in-hospital or 30-day death., Conclusions: In this single-center study of patients with severe AS, the elective Impella-assisted high-risk PCI was feasible and safe before TAVR in selected patients., (© 2023 The Author(s).)

Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices., Competing Interests: Declaration of Competing Interest João Cavalcante received consulting fees from Boston Scientific and Abbott. Matthew Price serves on the advisory board and has received consulting, honoraria, and Speakers Bureau fees from Abbott. Brian Whisenant received consulting fees from Boston Scientific and Abbott. Dee Dee Wang is a principal investigator for investigator-initiated research for Boston Scientific and has received consulting fees from Abbott. Jacqueline Saw, David Holmes, Andrew Goldsweig, James Freeman, Thomas Munger, Issam Moussa, Clifford Kavinsky, Matthew Sherwood, Zoltan Turi, and Mark Reisman reported no financial interests., (Copyright © 2023 Society for Cardiovascular Angiography and Interventions Foundation, Heart Rhythm Society and American College of Cardiology. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest Dr. Finn, Dr. Turco and Dr. Reisman are consultants to RenalPro Medical, Inc. Dr. Chen has no competing interests. CVPath Institute received Grant/Research/Clinical Trial Support from NIH-HL141425, Leducq Foundation Grant, 4C Medical, 4Tech, Abbott Vascular, Ablative Solutions, Absorption Systems, Advanced NanoTherapies, Aerwave Medical, Alivas, Amgen, Asahi Medical, Aurios Medical, Avantec Vascular, BD, Biosensors, Biotronik, Biotyx Medical, Bolt Medical, Boston Scientific, Canon USA,Cardiac Implants, Cardiawave, CardioMech, Cardionomic, Celonova, Cerus EndoVascular, Chansu Vascular Technologies, Childrens National Medical Center, Concept Medical, Cook Medical, Cooper Health, Cormaze Technologies GmbH, CRL/AccelLab, Croivalve, CSI, Dexcom, Edwards Lifesciences, Elucid Bioimaging, eLum Technologies, Emboline, Endotronix, Envision, Filterlex, Imperative Care, Innovalve, Innovative Cardiovascular Solutions, Intact Vascular, Interface Biolgics, Intershunt Technologies, Invatin Technologies, Lahav CRO, Limflow, L&J Biosciences, Lutonix, Lyra Therapeutics, Mayo Clinic, Maywell, MD Start, MedAlliance, Medanex, Medtronic, Mercator, Microport, Microvention, Neovasc, Nephronyx, Nova Vascular, Nyra Medical, Occultech, Olympus, Ohio Health, OrbusNeich, Ossio, Phenox, Pi-Cardia, Polares Medical, Polyvascular, Profusa, ProKidney LLC, Protembis, Pulse Biosciences, Qool Therapeutics, Recombinetics, Recor Medical, Regencor, Renata Medical, Restore Medical, Ripple Therapeutics, Rush University, Sanofi, Shockwave, Sahajanand Medical Technologies, SoundPipe, Spartan Micro, Spectrawave, Surmodics, Terumo Corporation, The Jacobs Institute, Transmural Systems, Transverse Medical, TruLeaf Medical, UCSF, UPMC, Vascudyne, Vesper, Vetex Medical, Whiteswell, WL Gore, Xeltis. Aloke V. Finn received consultant fees/honoraria from Abbott Vascular, Amgen, Biosensors, Boston Scientific, Celonova, Cook Medical, CSI, Lutonix Bard, Sinomed, RenalPro and Terumo Corporation. Drs Turco Chen and Reisman are consults to RenalPro

Importance: The Patent Foramen Ovale (PFO)-Associated Stroke Causal Likelihood classification system combines information regarding noncardiac patient features (vascular risk factors, infarct topography) and PFO features (shunt size and presence of atrial septal aneurysm [ASA]) to classify patients into 3 validated categories of responsiveness to treatment with PFO closure. However, the distinctive associations of shunt size and ASA, alone and in combination, have not been completely delineated., Objective: To evaluate the association of PFO closure with stroke recurrence according to shunt size and/or the presence of an ASA., Design, Setting, and Participants: Pooled individual patient data from 6 randomized clinical trials conducted from February 2000 to October 2017 that compared PFO closure with medical therapy. Patients in North America, Europe, Australia, Brazil, and South Korea with PFO-associated stroke were included. Analysis was completed in January 2022., Exposures: Transcatheter PFO closure plus antithrombotic therapy vs antithrombotic therapy alone, stratified into 4 groups based on the combination of 2 features: small vs large PFO shunt size and the presence or absence of an ASA., Main Outcomes and Measures: Recurrent ischemic stroke., Results: A total of 121 recurrent ischemic strokes occurred in the pooled 3740 patients (mean [SD] age, 45 [10] years; 1682 [45%] female) during a median (IQR) follow-up of 57 (23.7-63.8) months. Treatment with PFO closure was associated with reduced risk for recurrent ischemic stroke (adjusted hazard ratio [aHR], 0.41 [95% CI, 0.28-0.60]; P < .001). The reduction in hazard for recurrent stroke was greater for patients with both a large shunt and an ASA (aHR, 0.15 [95% CI, 0.06-0.35]) than for large shunt without ASA (aHR, 0.27 [95% CI, 0.14-0.56]), small shunt with ASA (aHR, 0.36 [95% CI, 0.17-0.78]), and small shunt without ASA (aHR, 0.68 [95% CI, 0.41-1.13]) (interaction P = .02). At 2 years, the absolute risk reduction of recurrent stroke was greater (5.5% [95% CI, 2.7-8.3]) in patients with large shunt and ASA than for patients in the other 3 categories (1.0% for all)., Conclusions and Relevance: Patients with both a large shunt and an ASA showed a substantially greater beneficial association with PFO closure than patients with large shunt alone, patients with small shunt and ASA, and patients with neither large shunt nor ASA. These findings, combined with other patient features, may inform shared patient-clinician decision-making.

An asymptomatic 63-year-old male with chronic type B aortic dissection underwent repair of an expanding 6.1 cm extent I thoracoabdominal aortic aneurysm. His postoperative course was complicated by respiratory failure from severe acute mitral regurgitation likely due to papillary muscle rupture, which was corrected with transcatheter MitraClip edge-to-edge repair., (© 2022 Wiley Periodicals LLC.)

Background: Severe mitral regurgitation is a progressive disease associated with high morbidity and mortality, and frequent readmissions for heart failure. Surgical mitral valve repair or replacement has been the gold-standard treatment; however, advances in transcatheter edge-to-edge repair (TEER) have provided alternatives for high-risk surgical patients. There are no data on racial disparities in access to high-volume TEER centers., Methods: Data on TEER hospitalizations from New York, New Jersey, Maryland, North Carolina, Washington, Colorado, Arizona, and Florida were analyzed using the State Inpatient Databases for 2016. The baseline characteristics of patients who underwent TEER at high- (≥25 procedures per year) and low-volume centers were identified. The association between race and the likelihood of undergoing TEER at high-volume centers was assessed. The secondary outcomes were mortality and the frequency of home discharges., Results: Of 1567 patients included in the analysis, 1129 underwent TEER at high-volume centers. Patients treated at high-volume centers had a higher prevalence of chronic kidney disease and congestive heart failure. Black and Hispanic patients were 59% (adjusted odds ratio [OR], 0.41; P < .001) and 51% (adjusted OR, 0.49; P < .001) less likely to undergo TEER at high-volume centers, respectively, compared with White patients. Hispanic patients were 3 times more likely to die during index admission than White patients (adjusted OR, 3.32; P = .027). There was geographic clustering of TEER centers, and a higher ratio of White patients to minority patients in zip codes with high-volume TEER centers., Conclusions: Racial minorities patients, particularly Black and Hispanic patients, are less likely to undergo TEER at high-volume centers. Hispanic patients experience higher rates of in-hospital mortality after TEER than White patients., (© 2022 The Authors.)

Objectives: Three-dimensional transesophageal echocardiography (TEE) is widely used to guide decision-making for mitral repair. The relative impact of surgical mitral valve repair (MVr) and MitraClip on annular remodeling is unknown. The aim was to determine the impact of both mitral repair strategies on annular geometry, including the primary outcome of annular circumference and area., Design: This was a retrospective observational study of patients who underwent mitral intervention between 2016 and 2020., Setting: Weill Cornell Medicine, a single, large, academic medical center., Participants: The population comprised 50 patients with degenerative mitral regurgitation (MR) undergoing MVr., Interventions: Elective MVr and TEE., Measurements and Main Results: Patients undergoing MitraClip or surgical MVr were matched (1:1) for sex and coronary artery disease. Mitral annular geometry indices were quantified on intraprocedural three-dimensional TEE. Mild or less MR on follow-up transthoracic echocardiography defined optimal response. Patients undergoing MitraClip were older (80 ± eight v 66 ± six years; p < 0.001) but were otherwise similar to surgical patients. Patients undergoing MitraClip had larger baseline left atrial and ventricular sizes, increased tenting height, and volume (p < 0.01), with a trend toward increased annular area (p = 0.23). MitraClip and surgery both induced immediate mitral annular remodeling, including decreased area, circumference, and tenting height (p < 0.001), with greater remodeling with surgical repair. At follow-up (4.1 ± 9.0 months) optimal response (≤ mild MR) was ∼twofold more common with surgery than MitraClip (81% v 46%; p = 0.02). The relative reduction in annular circumference (odds ratio [OR] 1.05 [1.00-1.09] per cm; p = 0.04) and area (OR 1.03 [1.00-1.05] per cm 2 ; p = 0.049) were both associated with optimal response., Conclusions: Surgical MVr and MitraClip both reduce annular size, but repair-induced remodeling is greater with surgery and associated with an increased likelihood of optimal response., Competing Interests: Conflict of Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To assess the impact of pulmonary hypertension (PH) on outcomes of patients with severe mitral annular calcification (MAC) undergoing transcatheter mitral valve replacement (TMVR)., Background: PH is associated with poor outcomes after mitral valve surgery. Whether the presence of PH in patients with MAC undergoing (TMVR) is associated with poor outcomes, is unknown., Methods: Retrospective evaluation of 116 patients from 51 centers in 11 countries who underwent TMVR with valve in mitral annular calcification (ViMAC) using balloon-expandable aortic transcatheter valves (THVs) from September 2012 to March 2017. Pulmonary artery systolic blood pressure (PASP) by echocardiogram was available in 90 patients. The subjects were stratified based on PASP: No PH = PASP ≤35 mmHg (n = 11); mild to moderate PH = PASP 36-49 mmHg (n = 21) and severe PH = PASP ≥50 mmHg (n = 58). Clinical, procedural, and echocardiographic outcomes were assessed., Results: Mean age was 72.7 (±12.8) years, 59 (65.6%) were female, Society of Thoracic Surgeons score was 15.8 + 11.8% and 90.0% where in New York Heart Association (NYHA) class III-IV. There was no significant difference in all-cause mortality at 30 days (no PH = 27.3%, mild-moderate PH = 19.0%, severe PH = 31.6%; p = 0.55) or at 1 year (no PH = 54.5%, mild-moderate PH = 38.1%, severe PH = 56.1%; p = 0.36). No difference in adverse events, NYHA class or amount of residual mitral regurgitation at 1 year were observed between the groups., Conclusion: This study suggests that the presence of PH in patients with predominantly mitral stenosis with MAC undergoing TMVR does not impact mortality or adverse events. Further studies are needed to fully understand the effect of PH in this group of patients., (© 2022 Wiley Periodicals LLC.)

Objectives: The purpose of this study was to characterize the anatomic relationship between the inferior vena cava (IVC) and tricuspid annulus (TA) and its potential impact on the performance of transcatheter TV interventions., Background: Transcatheter tricuspid valve (TV) interventions are emerging as a therapeutic alternative for the treatment of severe, symptomatic tricuspid regurgitation (TR). Progression of TR is associated with right heart dilatation. These anatomic changes may distort the IVC-TA relationship and impact successful implantation of transcatheter devices., Methods: Fifty patients who presented with symptomatic TR for consideration of transcatheter TV therapy with an available CT were included in the study. Comprehensive transesophageal echocardiogram and CT analyses were performed to assess the right-sided cardiac chambers, TA and IVC-TA relationship., Results: The mean age of the study cohort was 78.4 ± 8.9 years. Torrential TR was present in 54% (n = 27). There was considerable variation in the short axis mid-IVC to mid-TA offset (SAX MID 18.2 ± 7.9 mm, range 4.7-42.1 mm)., Conclusions: The IVC-to-TA relationship exhibits significant variability in patients with symptomatic TR. CT analysis of the tricuspid anatomy, including the relationship to the surrounding structures and the IVC, is essential for planning transcatheter TV interventions. Further studies are needed to define whether the IVC-to-TA relationship is a predictor of technical success in the context of specific transcatheter delivery systems., (© 2022 Wiley Periodicals LLC.)

Competing Interests: Funding Support and Author Disclosures This study was funded by Edwards Lifesciences. Drs. Davidson, Smith, Grayburn, Gray, and Lim have received grant support/consulting fees from Edwards Lifesciences. Dr. Hahn is a speaker and consultant for Edwards Lifesciences and is the Chief Scientific Officer for the Echocardiography Core Laboratory at the Cardiovascular Research Foundation for multiple industry-sponsored trials, for which she receives no direct industry compensation. Drs. Deuschl and Feldman are employees of Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.