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Left ventricular (LV) longitudinal function is mechanically coupled to the elasticity of the ascending aorta (AA). The pathophysiologic link between a stiff AA and reduced longitudinal strain and the subsequent deterioration in longitudinal LV systolic function is likely relevant in heart failure with preserved ejection fraction (HFpEF). The proposed therapeutic effect of freeing the LV apex and allowing for LV inverse longitudinal shortening was studied in silico utilizing the Living Left Heart Human Model (Dassault Systémes Simulia Corporation). LV function was evaluated in a model with (A) an elastic AA, (B) a stiff AA, and (C) a stiff AA with a free LV apex. The cardiac model simulation demonstrated that freeing the apex caused inverse LV longitudinal shortening that could abolish the deleterious mechanical effect of a stiff AA on LV function. A stiff AA and impairment of the LV longitudinal strain are common in patients with HFpEF. The hypothesis-generating model strongly suggests that freeing the apex and inverse longitudinal shortening may improve LV function in HFpEF patients with a stiff AA.

During systole, longitudinal shortening of the left ventricle (LV) displaces the aortic root toward the apex of the heart and stretches the ascending aorta (AA). An in silico study (Living Left Heart Human Model, Dassault Systèmes Simulia Corporation) demonstrated that stiffening of the AA affects myocardial stress and LV strain patterns. With AA stiffening, myofiber stress increased overall in the LV, with particularly high-stress areas at the septum. The most pronounced reduction in strain was noted along the septal longitudinal region. The pressure-volume loops showed that AA stiffening caused a deterioration in LV function, with increased end-systolic volume, reduced systolic LV pressure, decreased stroke volume and effective stroke work, but elevated end-diastolic pressure. An increase in myofiber contractility indicated that stroke volume and effective stroke work could be recovered, with an increase in LV end-systolic pressure and a decrease in end-diastolic pressure. Longitudinal and radial strains remained reduced, but circumferential strains increased over baseline, compensating for lost longitudinal LV function. Myofiber stress increased overall, with the most dramatic increase in the septal region and the LV apex. We demonstrate a direct mechanical pathophysiologic link between stiff AA and reduced longitudinal left ventricular strain which are common in patients with HFpEF.

Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation., Competing Interests: Conflict of interest: E.A.: speaker and proctoring fees, research and educational grant from Philips, Edwards, Abbott, GE, and Siemens. E.B.: Proctoring fees from Abbott. M.D.: speaker fees from Pfizer and have participated on advisory boards for Novartis. F.F.: speaker's fees from Philips. P.M.-H.: Shareholder of Neumann Medical Ltd. M.S.: lecturer/proctor for Abbott Vascular, Boston Scientific, Philips Healthcare, and Bioventrix inc. R.S.V.B.: Trials (un-paid): IIT IZKS University of Go¨ttingen, Abbott Vascular, Bioventrix, Boston Scientific, Edwards Lifesciences, Medtronic; Speaker/ Advisory: Abbott Lifesciences, Bioventrix, Boston Scientific, Cardiac Dimensions, Edwards Lifesciences, and Philips. J.-L.Z.: research grants from Abbott. Speaker fee Daichii Sankio, Pfizer. B.A.P.: research grants and lecture fees from GE Healthcare and Hitachi-Aloka., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Tricuspid valve pathophysiology is not well-understood. Emergence of novel transcatheter tricuspid therapies has fueled the requirements for improved imaging visualization techniques and interventional imaging physician skillsets in guiding these complex transcatheter procedures. There is growing understanding on the clinical significance of tricuspid regurgitation which expanded the interest for percutaneous tricuspid valve interventions. The present review concentrates on three essential aspects of tricuspid valve pathophysiology: anatomical considerations for tricuspid interventions, optimal timing of tricuspid interventions by imaging guidance, and the role of interventional imaging physicians' skillset and knowledge in this field., Competing Interests: Author MS was proctor/lecturer for Abbott Vascular, Boston Scientific, Edwards Lifesciences, Philips Healthcare and Bioventrix Inc. Author DW has acted as a consultant for Abbott, Boston Scientific, Edwards Lifesciences, and has received a research grant support from Boston Scientific assigned to employer Henry Ford Health., (Copyright © 2022 Gheorghe, Hegeman, Vrijkorte, Wunderlich, Cavalcante, Wang, Rana, Vannan, Timmers and Swaans.)

Aims: Post-procedure conduction abnormalities (CA) remain a common complication of transcatheter aortic valve implantation (TAVI), highlighting the need for personalized prediction models. We used machine learning (ML), integrating statistical and mechanistic modelling to provide a patient-specific estimation of the probability of developing CA after TAVI., Methods and Results: The cohort consisted of 151 patients with normal conduction and no pacemaker at baseline who underwent TAVI in nine European centres. Devices included CoreValve, Evolut R, Evolut PRO, and Lotus. Preoperative multi-slice computed tomography was performed. Virtual valve implantation with patient-specific computer modelling and simulation (CM&S) allowed calculation of valve-induced contact pressure on the anatomy. The primary composite outcome was new onset left or right bundle branch block or permanent pacemaker implantation (PPI) before discharge. A supervised ML approach was applied with eight models predicting CA based on anatomical, procedural and mechanistic data. CA occurred in 59% of patients ( n  = 89), more often after mechanical than first or second generation self-expanding valves (68% vs. 60% vs. 41%). CM&S revealed significantly higher contact pressure and contact pressure index in patients with CA. The best model achieved 83% accuracy (area under the curve 0.84) and sensitivity, specificity, positive predictive value, negative predictive value, and F1-score of 100%, 62%, 76%, 100%, and 82%., Conclusion: ML, integrating statistical and mechanistic modelling, achieved an accurate prediction of CA after TAVI. This study demonstrates the potential of a synergetic approach for personalizing procedure planning, allowing selection of the optimal device and implantation strategy, avoiding new CA and/or PPI., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Percutaneous therapeutic options for an increasing variety of structural heart diseases (SHD) have grown dramatically. Within this context of continuous expansion of devices and procedures, there has been increased demand for physicians with specific knowledge, skills, and advanced training in multimodality cardiac imaging. As a consequence, a new subspecialty of 'Interventional Imaging' for SHD interventions and a new dedicated professional figure, the 'Interventional Imager' with specific competencies has emerged. The interventional imager is an integral part of the heart team and plays a central role in decision-making throughout the patient pathway, including the appropriateness and feasibility of a procedure, pre-procedural planning, intra-procedural guidance, and post-procedural follow-up. However, inherent challenges exist to develop a training programme for SHD imaging that differs from traditional cardiovascular imaging pathways. The purpose of this document is to provide the standard requirements for the training in SHD imaging, as well as a starting point for an official certification process for SHD interventional imager., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

There has been rapid progress in transcatheter therapies for mitral regurgitation. These developments have elevated the need for the imager to have a core understanding of the functional mitral valve anatomy. Pre- and intraoperative echocardiography for surgical mitral valve repair for mitral regurgitation has defined contemporary interventional imaging in many ways. The central tenets of these principles apply to interventional imaging of transcatheter mitral valve interventions. However, the heightened emphasis on procedural planning and procedural imaging is one of the new challenges posed by transcatheter interventions. This need for accurate and reliable information has required the imager to be agnostic to the imaging modality. Cardiac computed tomography has become critical in procedural planning in this new paradigm. The expanded use of pre-procedural cardiac magnetic resonance to quantify mitral regurgitation and characterize the left ventricle is another illustration of this newer approach. Other illustrations of the new world of interventional imaging include the expanded use of 3-dimensional (3D) transesophageal echocardiography and real-time fusion of echocardiography and fluoroscopy images. Imaging data are also the basis for computational modeling, 3D printing, and artificial intelligence. These technologies are being increasingly explored to improve therapy selection and prediction of procedural outcomes. This review provides an update of the essentials in present interventional imaging for surgical and transcatheter interventions for mitral regurgitation., Competing Interests: Author Disclosures Dr. Wang is a consultant for Edwards Lifesciences, Boston Scientific, and Materialise; receives research grant support from Boston Scientific assigned to employer Henry Ford Health system; and holds a patent on LVOT prediction modeling software assigned to Henry Ford Health System. Dr. Wang is a member of the CLASP IITR Steering Committee and of the PARADIGM Steering Committee. Dr. Swaans is a consultant and lecturer for Abbott Vascular, Boston Scientific, Philips Healthcare, and Bioventrix. Dr. Adams’ institution, the Icahn School of Medicine at Mount Sinai, receives royalty payments from Edwards Lifesciences and Medtronic for intellectual property related to development of valve repair rings; and is national co-principal investigator for Medtronic APOLLO FDA Pivotal Trial, the NeoChord ReChord FDA Pivotal Trial, the Medtronic CoreValve US Pivotal Trial, and the Abbott TRILUMINATE Pivotal Trial. Dr. Yadav is a proctor and speaker for Edwards Lifesciences; and a consultant for and holds stock in Shockwave Medical. Dr. Sievert has received honoraria, travel expenses, and consulting fees from e25,000; 4tech Cardio, Abbott, Ablative Solutions, Ancora Heart, Append Medical, Axon, Bavaria Medizin Technologie GmbH, Bioventrix, Boston Scientific, Carag, Cardiac Dimensions, Cardiac Success, Cardimed, Celonova, Corned B.V., Contego, CVRx, Dinova, Edwards Lifesciences, Endologix, Endomatic, Hemoteq, Hangzhou Nuomao Medtech, Holistick Medical, K2, Lifetech, Maquet Getinge Group, Medtronic, Makita, Occlutech, Recor, Renal Guard, Terumo, Trisol, Vascular Dynamics, Vectorious Medtech, Venus, Venock, and Vivasure Medical. Dr. Ailawadi is a consultant for Edwards Lifesciences, Abbott, Medtronic, WL Gore, Atricure, and Admedus. Dr. Sorajja is a consultant for Admedus, Abbott Structural, Boston Scientific, Evolution Medical, Half Moon Medical, Medtronic, TeleFlex, Edwards Lifesciences, Shifamed, WL Gore; and is a member of the EXPAND Steering Committee, WL Gore Pipeline Executive Committee, SUMMIT Steering Committee, TRILUMINATE Steering Committee, TRILUMINATE Eligibility Committee For Anatomy, G4 Adverse Leaflet Events Committee, Neovasc Executive Steering Committee; and is a national or global principal investigator for the TRILUMINATE Pivotal US Trial, the Tendyne MAC Pivotal Trial, and the Alt-FLOW Early Feasibility Study. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Mitral regurgitation is one of the most prevalent valvulopathies worldwide, and its surgical treatment is not feasible in all cases. The elderly and frail with several comorbidities and left ventricular dysfunction are often managed conservatively. Percutaneous treatment (repair or replacement) of the mitral valve has emerged as a potential option for those patients who are at a high risk for surgery. Mitral valve repair with the Mitraclip device proved both increased safety and mortality reduction in patients with severe mitral regurgitation. On the other hand, in the last decade, percutaneous mitral replacement opened new frontiers in the field of cardiac structural interventions. There are few mitral devices; some are in the early phase of development and some are waiting for CE mark of approval. The evolution of these devices was more complicated compared to the aortic technology due to the native mitral valve's complexity and access. This review aims to provide an overview of the current devices, their specific features, and their potential complications., Competing Interests: MS is a consultant for Abbott Vascular. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Gheorghe, Brouwer, Wang, Wunderlich, Rana, Rensing, Eefting, Timmers and Swaans.)

Aims: Long-term freedom from atrial fibrillation (AF) after catheter ablation (CA) and consequently the potential for stroke reduction remain unpredictable. Percutaneous left atrial appendage closure (LAAC) is an effective mechanical alternative to oral anticoagulation (OAC) for stroke prevention in AF patients. This study aims to evaluate long-term clinical results of combined CA and LAAC in one single procedure., Methods and Results: Patients with non-valvular AF who underwent combined CA and LAAC procedure were included in the retrospective compilation of independent prospective general LAAC registries at the individual centres. Transoesophageal echocardiography (TOE) was used to evaluate device position and LAA sealing. Between 2009 and 2015, 349 patients with AF (58% male, age 63.1 ± 8.2 years; score for stroke prediction in AF patients (CHA2DS2-VASc) 3.0; score for major bleeding in patients on anticoagulation (HAS-BLED) 3.0; 56% paroxysmal AF) were included. Indications for LAAC included previous stroke (38%), history of bleeding (22%), and physician/patient preference (29%). Periprocedural complications up to 30 days included pericardial effusion (1.5%) and one minor stroke (0.3%) but no death. After 6 weeks, TOE showed successful sealing of the LAA in 98.9%. After 35 months of follow-up, 51% of patients had AF recurrence. A total of nine ischaemic strokes were recorded, resulting in an annualized stroke rate of 0.9% compared to an expected stroke rate of 3.2% without anticoagulation and combined treatment., Conclusion: This large pooled multicentre analysis of five prospective registries shows that combining CA and LAAC is feasible, safe, and successful. Long-term follow-up shows greatly reduced stroke and bleeding rates despite recurrence of AF in more than half of the patients.

Background: Survival outcome after MitraClip treatment, compared with surgical or conservative treatment, is not well defined. We examined survival after MitraClip treatment in a large multicenter real-life setting., Methods and Results: We retrospectively formed matched high-risk surgically and conservatively treated control cohorts to compare to a high-risk MitraClip cohort. One thousand thirty-six patients were included in 4 Dutch centers, of which 568 were treated with the MitraClip. The observed survival at 5-year follow-up in our MitraClip cohort was low (39.8%) but was comparable to our conservative cohort (40.5%). Observed 5-year survival for our surgical cohort was 76.3%. However, there were significant differences between the baseline characteristics of the 3 studied cohorts, with the MitraClip cohort having the highest comorbidity burden. After adjusting for baseline differences by using Cox regression, the MitraClip and surgical cohorts showed similar survival ratios (hazard ratio, 0.92; 95% confidence interval, 0.67-1.26; P =0.609), whereas both showed a lower mortality hazard when compared with conservative treatment (hazard ratio, 0.61; 95% confidence interval, 0.49-0.77; P <0.001 and hazard ratio, 0.56; 95% confidence interval, 0.42-0.76; P <0.001, respectively)., Conclusions: This matched analysis suggests a lower mortality hazard for MitraClip intervention in a high-risk population with symptomatic mitral regurgitation when compared with conservative management alone., (© 2018 American Heart Association, Inc.)