Search

Background Coronary microvascular function and hemodynamics may play a role in coronary circulation and myocardial remodeling in patients with aortic stenosis (AS). We aimed to evaluate the relationship between myocardial blood flow and myocardial function in patients with AS, no AS, and aortic valve sclerosis. Methods and Results We included consecutive patients who had resting transthoracic echocardiography and clinically indicated positron emission tomography myocardial perfusion imaging to capture their left ventricular ejection fraction, global longitudinal strain (GLS), and myocardial flow reserve (MFR). The primary outcome was major adverse cardiovascular event (all‐cause mortality, myocardial infarction, or late revascularization). There were 2778 patients (208 with aortic sclerosis, 39 with prosthetic aortic valve, 2406 with no AS, and 54, 49, and 22 with mild, moderate, and severe AS, respectively). Increasing AS severity was associated with impaired MFR (P

Background. Tricuspid regurgitation (TR) is a high-prevalence disease associated with poor quality of life and mortality. This quantitative patient preference study aims to identify TR patients’ perspectives on risk-benefit tradeoffs. Methods. A discrete-choice experiment was developed to explore TR treatment risk-benefit tradeoffs. Attributes (levels) tested were treatment (procedure, medical management), reintervention risk (0%, 1%, 5%, 10%), medications over 2 y (none, reduce, same, increase), shortness of breath (none/mild, moderate, severe), and swelling (never, 3× per week, daily). A mixed logit regression model estimated preferences and calculated predicted probabilities. Relative attribute importance was calculated. Subgroup analyses were performed. Results. An online survey was completed by 150 TR patients. Shortness of breath was the most important attribute and accounted for 65.8% of treatment decision making. The average patients’ predicted probability of preferring a “procedure-like” profile over a “medical management-like” profile was 99.7%. This decreased to 78.9% for a level change from severe to moderate in shortness of breath in the “medical management-like” profile. Subgroup analysis confirmed that patients older than 64 y had a stronger preference to avoid severe shortness of breath compared with younger patients ( P

Percutaneous treatment options for high-risk patients with severe, symptomatic aortic regurgitation are currently limited to investigational devices. The J-Valve (JC Medical, Inc) demonstrates promising results in patients with challenging anatomies. We present 2 cases of successful transcatheter aortic valve replacement using the J-Valve in patients with significant aortic angulation., Competing Interests: Ms Simone is an employee for JC Medical. Dr Kereiakes has received consulting fees or honoraria from JC Medical, Inc., and Edwards Lifesciences. Dr Goel has received consulting fees from Medtronic, Boston Scientific, and W.L. Gore & Associates. Dr Garcia is proctor for and has received consulting fees from Edwards Lifesciences All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: The prognostic significance of intraprocedural pulsed-wave Doppler analysis of pulmonary venous flow (PVF) during mitral transcatheter edge-to-edge repair (TEER) remains understudied. We aimed to investigate the prognostic value of systolic dominant-PVF (SD-PVF) morphology post-TEER., Methods: In a retrospective analysis from December 2019 to December 2022, patients undergoing mitral TEER were categorized into SD-PVF and systolic blunting (SB)-PVF groups based on post-TEER morphology. The primary endpoint was a composite of all-cause mortality or heart failure hospitalization at 1 year. We investigated the association of PVF morphology post-TEER with the primary endpoint at 1 year using Cox regression and compared the prognostic accuracy of PVF variables through receiver operating characteristic (ROC) curve analysis., Results: Among 187 patients (mean age 76.4 ± 10.5 years, 51.3% primary etiology), residual mitral regurgitation (MR) ≤mild was observed in 147 (82.4%) patients and 105 (56.2%) had SD-PVF post-TEER. Patients with SD-PVF had a lower incidence of >2+ residual MR after clip deployment, at 30 days (2.1% vs. 13.1%; p = 0.005) and at 1 year (1.4% vs. 9%; p = 0.08). SD-PVF post-TEER was independently associated with the primary endpoint (HR = 0.59, 95% CI = 0.39-0.87; p = 0.009). ROC curve analysis of the prognostic accuracy of SD-PVF demonstrated an AUC of 0.64 (95% CI = 0.54-0.73), comparable to other quantitative measures of PVF., Conclusion: Assessing PVF morphology after clip deployment offers a simple prognostic tool for patients undergoing mitral TEER. Multicenter cohorts will be necessary to further investigate its prognostic value., (© 2024 Wiley Periodicals LLC.)

Background: The impact of mitral annular calcification (MAC) on the clinical outcomes of patients undergoing mitral transcatheter edge-to-edge repair (MTEER) remains unclear. This meta-analysis aims to evaluate the clinical outcomes of MTEER among patients with moderate to severe MAC compared to those with mild or no MAC., Methods: We systematically searched PubMed, EMBASE, and Cochrane CENTRAL databases through March 31st, 2024, comparing clinical outcomes of MTEER among patients with moderate/severe (MAC+) versus no/mild MAC (MAC-). We assessed pooled estimates for procedural success, all-cause mortality, residual mitral regurgitation (MR) ≤ moderate, and New York Heart Association (NYHA) class III/IV status at one year., Results: Among five studies (2533 patients; mean age 76.4 ± 10.9 years, 39.8 % women), MAC+ patients were predominantly women (55.7 % vs 37.5 %, p < 0.001), older (87.9 ± 11.1 vs. 75.9 ± 9.1 years; mean difference (MD) = 3.99, p = 0.011) and had higher STS scores (7.7 ± 6.7 % vs. 4.9 ± 4.6 %; MD = 1.34, p < 0.001). MAC+ patients had comparable procedural success rates, residual MR < moderate, and NYHA III/IV at 1 year. However, all-cause mortality at 1 year was higher for MAC+ patients (Relative Risk = 1.56, 95 % CI = 1.06-2.29)., Conclusions: MTEER is a safe and feasible option for carefully selected patients with MAC and significant MR, offering durable MR reduction and functional status improvement. Significantly higher one-year mortality associated with MAC despite significant MR reduction suggests an increased risk unrelated to valvular dysfunction and highlights the need for further investigation into identifying patients who benefit the most from MTEER., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sachin S. Goel reports a relationship with Abbott that includes: speaking and lecture fees. Michael J. Reardon reports a relationship with Abbott that includes: consulting or advisory. Neil Kleiman reports a relationship with Abbott that includes: funding grants. Dr. Reardon discloses consultancy roles with Medtronic, Boston Scientific, Abbott, and W L Gore & Associates. Dr. Atkins is a consultant for W L Gore & Associates. Dr. Kleiman is a local principal investigator for trials sponsored by Boston Scientific, Medtronic, Abbott, and Edwards Lifesciences. Dr. Goel is a consultant for Medtronic, JC Medical, and W L Gore & Associates and is also on the Speakers Bureau for Abbott Structural Heart. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Background: Transcatheter aortic valve replacement (TAVR) for high surgical risk patients with severe native aortic regurgitation (AR) presents unique challenges. Dedicated devices such as the JenaValve (JenaValve Technology) and J-Valve (JC Medical Inc) show promising results in addressing these challenges., Objectives: This study compares the safety and efficacy of dedicated vs off-label devices among high surgical risk patients with pure native AR., Methods: We systematically searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials through July 11, 2024, for studies on TAVR among patients with pure severe native AR. The primary endpoint was 30-day all-cause mortality. Secondary endpoints were device success, residual AR ≥ moderate, valve embolization/migration, pacemaker implantation, reintervention, and all-cause mortality at 1 year. Summary estimates were constructed using a random effects model., Results: A total of 34 studies encompassing 2,162 patients (mean age 75.4 ± 0.2, 42.8% women) were included in the meta-analysis. Patients undergoing TAVR with dedicated devices had a lower all-cause 30-day mortality rate (3% vs 9%; P < 0.01) and higher device success (93% vs 82%; P < 0.01) compared with off-label devices. The risk of AR ≥ moderate (2% vs 5%; P = 0.03), valve embolization/migration (2% vs 8%; P < 0.01), pacemaker implantation (11% vs 20%; P < 0.01), and reintervention (4% vs 10%; P < 0.01) at 30 days and all-cause mortality at 1 year (6% vs 24%; P < 0.01) were lower in the dedicated device group., Conclusions: Dedicated TAVR devices for native AR show superior device success and reduced mortality, residual AR, and reintervention rates compared with off-label devices. These findings support the use of dedicated devices as a safer alternative for high-risk patients., Competing Interests: Funding Support and Author Disclosures Dr Atkins is a consultant for W. L. Gore & Associates. Dr Reardon is a consultant for Medtronic, Boston Scientific, Abbott, and W. L. Gore & Associates. Dr Kleiman is a local principal investigator for trials sponsored by Boston Scientific, Medtronic, Abbott, and Edwards Lifesciences. Dr Goel is a consultant for Medtronic, JC Medical, Boston Scientific, and W. L. Gore & Associates; and also serves on the Speakers Bureau for Abbott Structural Heart. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Published by Elsevier Inc.)

Background: There is conflicting evidence regarding the effect of residual transmitral mean pressure gradient (TMPG) after mitral transcatheter edge-to-edge repair (M-TEER). Different TMPG cutoffs have been employed in prior studies with varying results., Objectives: The purpose of this study was to examine the association between residual TMPG and M-TEER outcomes., Methods: Consecutive patients undergoing M-TEER at our institution between 2014 and 2022 were included and divided based on quartiles of predischarge TMPG. Outcomes were assessed using Kaplan-Meier analysis and Cox proportional hazard models. We performed subgroup analyses according to mitral regurgitation (MR) mechanism. The primary outcome was all-cause mortality or heart failure hospitalization., Results: We included 283 patients (age 76.7 ± 10.8 years, 42.8% women, 78.4% Caucasian, and baseline TMPG 2.4 ± 1.3 mm Hg). Higher baseline TMPG was a predictor of increased TMPG after M-TEER (coefficient 0.60 [95% CI: 0.40-0.70]; P  < 0.001). In comparison with predischarge TMPG quartiles 1 to 3, those in quartile 4 (7.0 ± 1.1 mm Hg) had an increased risk of 3-year all-cause mortality or heart failure hospitalization (adjHR: 1.53 [95% CI: 1.03-2.26]; P  = 0.034), as well as all-cause mortality alone (adjusted HR [adjHR]: 1.68 [95% CI: 1.09-2.60]; P  = 0.020). Among patients with primary MR, similar findings were seen for the composite endpoint (adjHR: 2.08 [95% CI: 1.15-3.77]; P  = 0.016), and all-cause mortality (adjHR: 2.70 [95% CI: 1.40-5.19]; P  = 0.003). However, this association did not reach statistical significance in secondary MR., Conclusions: In this single-center study, higher residual TMPG after M-TEER was associated with worse outcomes at intermediate- to long-term follow-up. The effect was mainly driven by increased mortality especially in patients with primary MR. Operators should strive to lower residual TMPG before the conclusion of the procedure., Competing Interests: Dr Atkins is a consultant for WL Gore & Associates. Dr Reardon is a consultant for Medtronic, Boston Scientific, Abbott, and WL Gore & Associates. Dr Kleiman is a local principal investigator in trials sponsored by 10.13039/100008497Boston Scientific, 10.13039/100004374Medtronic, 10.13039/100000046Abbott, and 10.13039/100006520Edwards Lifesciences. Dr Goel is a consultant for Medtronic, WL Gore & Associates, and JC Medical; and is on the Speakers Bureau for Abbott Structural Heart. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: Increased left atrial pressure (LAP) has been associated with adverse outcomes after mitral transcatheter edge-to-edge repair (M-TEER). We sought to evaluate outcomes based on differences in postprocedural LAP measured after the final clip deployment., Methods: We included consecutive patients who underwent M-TEER at our institution between 2014 and 2022 with LAP monitoring. Patients were stratified into 3 groups according to tertiles of post-TEER mean LAP. Outcomes were assessed using Kaplan-Meier analysis and Cox proportional hazards models., Results: We included 273 patients (mean age, 76.8±10.8 years; 42.5% women; 78.4% White). The mean post-TEER LAP was 8.7±1.7 mm Hg in tertile 1 (n=85), 14.4±1.6 mm Hg in tertile 2 (n=95), and 21.9±3.8 mm Hg in tertile 3 (n=93). In comparison with tertile 1, both tertiles 2 and 3 were associated with increased risk of all-cause mortality or heart failure hospitalization at 2 years (adjusted hazard ratio [adjHR], 2.27 [95% CI, 1.25-4.12] and adjHR, 3.00 [95% CI, 1.59-5.64], respectively). Among patients with primary mitral regurgitation, higher LAP was associated with increased risk of 2-year all-cause mortality or heart failure hospitalization (tertile 2 versus 1: adjHR, 3.00 [95% CI, 1.37-6.56]; tertile 3 versus 1: adjHR, 5.52 [95% CI, 2.04-14.95]). However, in patients with secondary mitral regurgitation, neither being in tertile 2 (adjHR, 1.53 [95% CI, 0.55-4.24]) nor tertile 3 (adjHR, 2.18 [95% CI, 0.82-5.77]) were associated with the composite outcome compared with tertile 1. Any degree of LAP reduction following M-TEER was associated with lower mortality or heart failure hospitalization compared with no LAP reduction (adjHR, 0.59 [95% CI, 0.39-0.88])., Conclusions: Elevated LAP after M-TEER was associated with increased 2-year risk of mortality or heart failure hospitalization. Exploration of reasons for elevated LAP after M-TEER and ways to lower it warrant further investigation., Competing Interests: Dr Atkins is a consultant for W. L. Gore & Associates; Dr Reardon is a consultant for Medtronic, Boston Scientific, Abbott, and W. L. Gore & Associates; Dr Kleiman is a local principal investigator in trials sponsored by Boston Scientific, Medtronic, Abbott, and Edwards Lifesciences; Dr Goel is a consultant for Medtronic, W. L. Gore & Associates, and JC Medical and is on the Speakers Bureau for Abbott Structural Heart. The other authors report no conflicts.

Background: Pulmonary hypertension (PH) and secondary mitral regurgitation (MR) are associated with adverse outcomes after mitral transcatheter edge-to-edge repair. We aim to study the prognostic value of invasively measured right ventricular afterload in patients undergoing mitral transcatheter edge-to-edge repair., Methods and Results: We identified patients who underwent right heart catheterization ≤1 month before transcatheter edge-to-edge repair. The end points were all-cause mortality and a composite of mortality and heart failure hospitalization at 2 years. Using the receiver operating characteristic curve-derived threshold of 0.6 for pulmonary effective arterial elastance ([Ea], pulmonary artery systolic pressure/stroke volume), patients were stratified into 3 profiles based on PH severity (low elastance [HE]: Ea <0.6/mean pulmonary artery pressure (mPAP)) <35; High Elastance with No/Mild PH (HE-): Ea ≥0.6/mPAP <35; and HE with Moderate/Severe PH (HE+): Ea ≥0.6/mPAP ≥35) and MR pathogenesis (Primary MR [PMR])/low elastance, PMR/HE, and secondary MR). The association between this classification and clinical outcomes was examined using Cox regression. Among 114 patients included, 50.9% had PMR. Mean±SD age was 74.7±10.6 years. Patients with Ea ≥0.6 were more likely to have diabetes, atrial fibrillation, New York Heart Association III/IV status, and secondary MR (all P <0.05). Overall, 2-year cumulative survival was 71.1% and was lower in patients with secondary MR and mPAP ≥35. Compared with patients with low elastance, cumulative 2-year event-free survival was significantly lower in HE- and HE+ patients (85.5% versus 50.4% versus 41.0%, respectively, P =0.001). Also, cumulative 2-year event-free survival was significantly higher in patients with PMR/low elastance when compared with PMR/HE and patients with secondary mitral regurgitation (85.5% versus 55.5% versus 46.1%, respectively, P =0.005)., Conclusions: Assessment of the preprocedural cardiopulmonary profile based on mPAP, MR pathogenesis, and Ea guides patient selection by identifying hemodynamic features that indicate likely benefit from mitral-transcatheter edge-to-edge repair in PH or lack thereof.

Background: Prior studies investigating the impact of residual mitral regurgitation (MR), tricuspid regurgitation (TR), and elevated predischarge transmitral mean pressure gradient (TMPG) on outcomes after mitral transcatheter edge-to-edge repair (TEER) have assessed each parameter in isolation. We sought to examine the prognostic value of combining predischarge MR, TR, and TMPG to study long-term outcomes after TEER., Methods and Results: We reviewed the records of 291 patients who underwent successful mitral TEER at our institution between March 2014 and June 2022. Using well-established outcomes-related cutoffs for predischarge MR (≥moderate), TR (≥moderate), and TMPG (≥5 mm Hg), 3 echo profiles were developed based on the number of risk factors present (optimal: 0 risk factors, mixed: 1 risk factor, poor: ≥2 risk factors). Discrimination of the profiles for predicting the primary composite end point of all-cause mortality and heart failure hospitalization at 2 years was examined using Cox regression. Overall, mean age was 76.7±10.6 years, 43.3% were women, and 53% had primary MR. Two-year event-free survival was 61%. Predischarge TR≥moderate, MR≥moderate, and TMPG≥5 mm Hg were risk factors associated with the primary end point. Compared with the optimal profile, there was an incremental risk in 2-year event-rate with each worsening profile (optimal as reference; mixed profile: hazard ratio (HR), 2.87 [95% CI, 1.71-5.17], P <0.001; poor profile: HR, 3.76 [95% CI, 1.84-6.53], P <0.001). Echocardiographic profile was statistically associated with the 2-year mortality end point (optimal as reference; mixed profile: HR, 3.55 [95% CI, 1.81-5.96], P <0.001; poor profile: HR, 3.39 [95% CI, 2.56-7.33], P =0.02)., Conclusions: The echocardiographic profile integrating predischarge TR, MR, and TMPG presents a novel prognostic stratification tool for patients undergoing mitral TEER.