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Background: For cancer patients, cardiovascular complications as a consequence of certain oncological therapies are the leading cause of death, apart from the cancer itself. Currently, there are no uniform guidelines for detecting subclinical cardiotoxicity. Hence, the identification of cardiotoxicity arises late in the course of myocardial dysfunction after cardiac damage has occurred already. Early detection, prevention, and treatment of these cardiotoxic effects remain a challenge; therefore, supportive strategies such as physical activity gain in importance. Summary: Exercise therapy, during and after cancer therapy, is considered to be safe, feasible, and effective. While animal models show protective effects, the evidence for the benefits of physical activity on future cardiovascular outcomes in human patients caused by certain cancer treatments is still limited. Consequently, targeted exercise recommendations such as frequency, intensity, time, or type are yet unclear, and certain guidelines, specifically preventing cardiotoxicity, are nonexistent. Low cardiorespiratory fitness is strongly associated with all-cause mortality as well as cardiac dysfunction. In this context, the role of cardiorespiratory fitness as an early predictor in the detection of cardiovascular dysfunction will be discussed. Key Message: Exercise therapy during cancer treatment could have the potential to aid in both the diagnosis and treatment of cardiovascular complications. This narrative review considers the current evidence on the impact of physical activity on cardiovascular outcomes in cancer patients and proposes, according to the present knowledge, a framework for cardioprotective exercise therapies.

ZusammenfassungDie sekundäre Mitralinsuffizienz ist bei Patienten mit Herzinsuffizienz häufig und mit einem schlechten Verlauf assoziiert. Aufgrund des hohen OP-Risikos war die Therapie traditionell auf eine Behandlung der Herzinsuffizienz beschränkt. Die Entwicklung von kathetergestützten Techniken ermöglicht nun die Behandlung mit geringem Risiko. Wenngleich die Studienevidenz immer noch begrenzt ist, erfolgte in den aktuellen Leitlinien der europäischen Fachgesellschaften eine Aufwertung der kathetergestützten Therapie für ausgewählte Patienten mit hohem OP-Risiko und hoher Wahrscheinlichkeit für ein Therapieansprechen. Dennoch bleiben viele Fragen offen, was die Rolle der chirurgischen Behandlung und auch die Patientenselektion für kathetergestützte Therapieverfahren angeht. Hier beschreiben wir den aktuellen Stand der Behandlung der sekundären Mitralinsuffizienz und zeigen Strategien von transuniversitären Verbundprojekten mit dem Ziel, Evidenz für die Behandlung dieser Patienten zu entwickeln.

ZusammenfassungSekundäre Mitral- und Trikuspidalklappeninsuffizienzen treten häufig im Kontext des Herzinsuffizienz-Syndroms auf durch geometrische oder funktionelle Veränderungen der Herzkammern und/oder -vorhöfe trotz strukturell intakter Klappe. Durch Volumenbelastung der Ventrikel können diese entscheidend zur Symptomatik und Progression der Herzinsuffizienz beitragen und sind dadurch von erheblicher prognostischer Bedeutung. Aufgrund des hohen OP-Risikos waren die Therapieoptionen traditionell oft auf eine Behandlung der Herzinsuffizienz beschränkt. Die Entwicklung von kathetergestützten Techniken ermöglicht die Behandlung der sekundären AV-Klappeninsuffizienz mit akzeptablem Risiko und ist aufgrund aktueller Studienergebnisse ein wichtiger Bestandteil der Herzinsuffizienz-Therapie. Im Folgenden geben wir einen Überblick über interventionelle Strategien zur Behandlung der sekundären AV-Klappeninsuffizienzen und deren aktuellen Stellenwert in der klinischen Praxis.

BACKGROUND: In patients with severe mitral regurgitation (MR) who are scheduled for transcatheter mitral valve repair (TMVR), risk stratification is predominantly based on surgical risk scores. AIMS: We sought to characterise and define stages of right heart remodelling in patients undergoing TMVR and evaluate the impact of this staging classification on survival. METHODS: According to echocardiographic parameters, 929 patients undergoing MitraClip treatment were classified into three stages: severe MR without right heart damage (stage 0), with moderate-to-severe tricuspid regurgitation (TR) (stage 1), with right ventricular dysfunction defined as a reduced fractional area change 25 cm(2) and/or indexed right ventricular volume >30 ml/m(2) (stage 2). We compared clinical outcomes and performed a multivariate analysis to evaluate the predictive value of the extent of cardiac damage. RESULTS: Rates of one-year all-cause mortality increased with more advanced stages of right heart remodelling (stage 0: 8% vs stage 1: 9.7% vs stage 2: 18.1%; p

Background: Although depression symptoms are common among heart failure (HF) patients, there is little consensus regarding the relationship between depressive symptoms and NT-proBNP, the key HF marker. Therefore, this study aimed to investigate this relationship and assess the impact of depressive symptoms on the health status and clinical outcomes of HF patients. Methods: 151 patients with HF were enrolled in the study and followed up for one year. Depressive symptoms and health status were assessed by the Hospital Anxiety and Depression Scale (HADS-D) and the Kansas City Cardiomyopathy Questionnaire (KCCQ), respectively. Results: At baseline, the median HADS-D score was 5 (3 - 8) points. Patients with HADS-D scores > 5 points had significantly higher NT-proBNP levels (p = 0.043), and significantly lower KCCQ-OSS and KCCQ-CSS (p < 0.001 for both KCCQ scores). From baseline to the last assessment after one year the percentage changes in the HADS-D scores were significantly positively correlated with the percentage changes in the levels of NT-proBNP (r = 0.22, p = 0.009). It was also significantly negatively correlated with the changes in KCCQ-OSS (r = -0.34, p < 0.001) and KCCQ-CSS (r = -0.19, p = 0.021). Moreover, baseline HADS-D score was an independent predictor of the percentage changes in NT-proBNP from baseline to the last assessment (ß = 3.91, p = 0.03), even after adjustment for age, sex, baseline LVEF and creatinine (ß = 3.99, p = 0.02). In a Cox regression analysis baseline HADS-D score had a significant impact on the cardiovascular mortality, which remained consistent even after adjustment for age, sex, and baseline LVEF, NT-proBNP and creatinine (hazard ratio = 1.18, 95% CI = 1.0 – 1.4, p = 0.048). Conclusions: 1. There is a significant correlation between depressive symptoms, NT-proBNP, and health status in HF patients. 2. Baseline HADS-D score has a significant impact on the cardiovascular mortality in HF patients.

BACKGROUND Men and women differ regarding comorbidities, pathophysiology, and the progression of valvular heart diseases. OBJECTIVES This study sought to assess sex-related differences regarding clinical characteristics and the outcome of patients with severe tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve intervention (TTVI). METHODS All 702 patients in this multicenter study underwent TTVI for severe TR. The primary outcome was 2-year all-cause mortality. RESULTS Among 386 women and 316 men in this study, men were more often diagnosed with coronary artery disease (52.9% in men vs 35.5% in women; P = 5.6 × 10-6). Subsequently, the underlying etiology for TR in men was predominantly secondary ventricular (64.6% in men vs 50.0% in women; P = 1.4 × 10-4), whereas women more often presented with secondary atrial etiology (41.7% in women vs 24.4% in men, P = 2.0 × 10-6). Notably, 2-year survival after TTVI was similar in women and men (69.9% in women vs 63.7% in men; P = 0.144). Multivariate regression analysis identified dyspnea expressed as New York Heart Association functional class, tricuspid annulus plane systolic excursion (TAPSE), and mean pulmonary artery pressure (mPAP) as independent predictors for 2-year mortality. The prognostic significance of TAPSE and mPAP differed between sexes. Consequently, we looked at right ventricular-pulmonary arterial coupling expressed as TAPSE/mPAP and identified sex-specific thresholds to best predict survival; women with a TAPSE/mPAP ratio

Improved imaging modalities contributed to increasing awareness of cardiac amyloidosis. Contemporary data on frequency trends in Germany are lacking.In a retrospective study using health claims data of a German statutory health insurance, patients with diagnostic codes of amyloidosis and concomitant heart failure between 2009 and 2018 were identified.Prevalence increased from 15.5 to 47.6 per 100,000 person-years, and incidence increased from 4.8 to 11.6 per 100,000 person-years, with a continuous steepening in the slope of incidence trend. In patients with amyloidosis and heart failure age and proportion of men significantly increased, whereas the frequency of myeloma and nephrotic syndrome significantly decreased over time. Median (IQR) survival time after first diagnosis was 2.5 years (0.5-6 years), with a 9% (95% CI 2-15%, p = 0.008) reduced risk of death in the second compared to the first 5 years of observation. In the 2 years prior and 1 year after diagnosis, mean total health care costs were 6568 €, 11,872 € and 21,955 € per person and year.The rise in cardiac amyloidosis has continuously accelerated in the last decade. Considering the adverse outcome and high health care burden, further effort should be put on early detection of the disease to implement available treatment.

To investigate the role of left atrial volume index (LAVi) in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (TEER).Outcomes were evaluated in SMR patients of a European multicentre registry according to baseline LAVi. Main analysis was performed for all-cause mortality; residual mitral regurgitation (MR) and New York Heart Association (NYHA) class improvement were analysed for patients available. A total of 1074 patients were included with a median LAVi (interquartile range) of 58 ml/mProcedural success and symptomatic benefit were high throughout the whole range of LAVi. The prognostic impact of left atrial enlargement was relevant in patients with less severe SMR and without pulmonary hypertension, reinforcing the need to identify patients in the early course of backward congestion to achieve good long-term outcome after TEER.

In terms of pathophysiology, tricuspid regurgitation (TR) and right ventricular (RV) function are linked to each other.This study sought to evaluate RV-pulmonary artery (PA) coupling and its impact on clinical outcomes of TR in patients undergoing mitral transcatheter edge-to-edge repair (TEER).We calculated RV-PA coupling ratios in patients undergoing mitral TEER from August 2010 to March 2019 by dividing the tricuspid annular plane systolic excursion (TAPSE) by the echocardiographic estimated PA systolic pressure (PASP). TR was graded as none/trace, mild, moderate, or severe. The primary outcome was all-cause mortality or rehospitalisation within 12 months.Among 744 patients analysed, severe TR was documented in 22.3% of patients and the mean TAPSE/PASP was 0.43±0.25. Technical success of TEER was achieved in 97.2% of participants. Severe TR vs TR ≤moderate (adjusted HR 1.92, 95% CI: 1.39-2.66) and TAPSE/PASP (adjusted HR 0.45, 95% CI: 0.22-0.93) were associated with the outcome. Patients were divided according to the TAPSE/PASP tertile. Compared to patients with TR ≤moderate, patients with severe TR had a higher event rate (TAPSE/PASP0.30: 32.9% vs 45.1%; 0.30≤ TAPSE/PASP0.44: 27.8% vs 41.8%; TAPSE/PASP ≥0.44: 16.0% vs 40.4%), whereas the prognostic significance of TR was attenuated in patients with reduced TAPSE/PASP (i.e., RV-PA uncoupling; interaction term p=0.03). The trends were consistent in the multivariable regression models, spline curves, and sensitivity analysis using post-interventional parameters.RV-PA coupling affects the outcome correlation of TR in patients undergoing mitral TEER. The prognostic impact of TR is attenuated in patients with RV-PA uncoupling.

Background: Recurrent mitral regurgitation (MR) following MitraClip has not been thoroughly investigated. We aimed to examine the predictive factors, morphology, and long-term outcome of recurrent MR after MitraClip. Methods: We assessed data from the Heart Failure Network Rhineland registry from August 2010 to October 2018. Competing risk analyses were performed using the Fine and Gray model to assess the risk of recurrent MR. Results: Among 685 MitraClip patients with a reduction in MR to ≤2+, 61 patients developed recurrent MR within the first 12 months. Flail leaflet (hazard ratio, 3.68; P =0.002) and residual MR (MR grade 2+ versus ≤1+: hazard ratio, 2.56; P =0.03) were the predictors of recurrent MR in primary MR patients, while left atrial volume (per 10 mL increase: hazard ratio, 1.11; P P =0.01) were independently associated with recurrent MR in secondary MR patients. In primary MR patients, loss of leaflet insertion or leaflet tear were the predominant morphologies with recurrent MR. In secondary MR patients, more than half of the patients with recurrent MR did not show any disorder of the clip or leaflets. Patients with recurrent MR were more likely to experience unplanned heart failure hospitalization or heart failure symptom with New York Heart Association scale III/IV (54.1% versus 37.8%; P =0.018) and undergo a repeat mitral valve intervention (9.8% versus 2.2%; P =0.005) during the follow-up. In the landmark survival analysis, patients with recurrent MR tended to have lower long-term survival (58.7% versus 83.9%; P =0.08) than patients without recurrent MR. Conclusions: Flail leaflet and residual MR were the predictors of recurrent MR in primary MR patients, while a larger left atrial volume and residual MR were associated with recurrent MR in secondary MR patients, which may be associated with long-term clinical outcomes of patients after MitraClip.