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BACKGROUND: Despite important medical advances, infective endocarditis (IE) is still a disease with high morbidity and mortality. Its prophylaxis, diagnosis, and treatment are still a major challenge in clinical practice. METHODS: Selective literature review based on the current German and European guidelines and a PubMed search from 2004 onward. RESULTS: Essential requirements for the rapid diagnosis and specific treatment of IE are the echocardiographic demonstration of endocardial disease and the identification of the causative organism by blood culture. The modified Duke criteria have made the diagnosis more objective but are not a replacement for clinical judgement. It should be borne in mind, when the initial empirical treatment is chosen, that Staphylococcus aureus is currently the most common causative organism. If diagnostic criteria are met that suggest a methicillin-resistant S. aureus infection, then glycopeptide antibiotics are still the standard treatment. Newer agents such as daptomycin can be considered as an alternative, as suggested by recent studies and in view of the increasing frequency of impaired vancomycin susceptibility. Early surgical treatment should be considered for patients who are likely to encounter further complications along their clinical course. According to the current recommendations, antibiotics should be given for endocarditis prophylaxis only to patients about to undergo one of a small number of explicitly defined procedures, who would otherwise be at a high risk of major illness or death. The purpose of this restriction is to make prophylaxis more efficient. CONCLUSION: IE remains a potentially lethal infectious disease that can be treated effectively only by physicians from multiple disciplines working in collaboration. [ABSTRACT FROM AUTHOR]

Background: Transcatheter mitral valve repair (TMVR) using the MitraClip has become a well-established interventional therapy and is usually performed in elderly patients. The objective of this study was to assess 2-year clinical outcomes of TMVR in patients aged <65 years at three heart centres with severe mitral regurgitation (MR) and no surgical options., Methods: A retrospective study analysed data of 36 patients aged <65 years treated with TMVR . All patients were refused surgery by Heart Team decision. Baseline MR was assessed by biplane vena contracta width in two perpendicular views (mean 8.35 ± 1.87 mm). Degenerative MR was detected in 11 patients (30.6%); functional MR was detected in 25 patients (69.4%)., Results: Acute procedural success was accomplished in 88.9% of patients. No procedure-related mortality during the first 30 days was detected. Over an average of 2 years of follow-up, all-cause mortality was 19.4% and cardiovascular death was 11.1% owing to advanced heart failure. The average follow-up period was 25.8 months (median was 20 months). Statistically significant difference (p-value <0.01) was detected for N-terminal prohormone of brain natriuretic peptide (pg/ml) at baseline (mean 9,870 ± 10,819; median 7,748) compared to follow-up visits (mean 7,645 ± 11,292; median 3,263). New York Heart Association functional class improvement was achieved in 69% of patients. A second intervention (reclipping) was required in two patients to correct recurrent significant MR., Conclusion: TMVR in patients aged <65 years refused surgical repair provides satisfactory clinical outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort., Competing Interests: Disclosure: TB has received honoraria payments from Philips Medical Systems, BP has received lecture honoraria by Abbott Laboratories and Philips Medical Systems. HMHM received a scholarship grant for living and travel costs to conduct this research work in Germany from the Egyptian ministry of higher education and Minia University in Egypt. All other authors have no conflicts of interest to declare. Informed consent: All patients have given informed consent Data availability: The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethics: This study was performed in lines with the principles of the Declaration of Helsinki. The study received ethics approval from the Minia University Research Ethics Committee (Reference Number: 081064M). Authors’ contributions: Conceptualisation: AF, ME; Data Curation: HMHM, ME, AY; formal analysis: HMHM, AF, ME, AY; funding acquisition: HMHM; investigation: HMHM, AF, MAA, NMT, WS, TB; methodology: HMHM, AF, MAA, NMT, WS, TB;project administration: WS, TB; resources: BP, IJ, AY; software: BP, IJ, AY; supervision: MAA, NMT, WS, TB; validation: BP, IJ; visualisation: AF, BP, IJ; writing – original draft preparation: HMHM, AF, BP, WS, TB; writing – review and editing: HMHM, MAA, NMT, (Copyright © The Author(s), 2023. Published by Radcliffe Group Ltd.)

Background: MitraClip implantation has become the standard transcatheter mitral valve repair (TMVR) technique for severe mitral regurgitation (MR). However, approximately one third of patients have poor outcomes, with MR recurrence at follow-up. The aim of this study was to investigate whether quantitative analysis of mitral valve (MV) geometry on three-dimensional (3D) echocardiography can identify geometric parameters associated with the recurrence of severe functional MR (FMR) versus organic MR (OMR) at 6-month follow-up after TMVR using the MitraClip., Methods: Sixty-one patients with severe FMR (n = 45) or OMR (n = 16) who underwent transesophageal 3D echocardiography before and 6 months after TMVR were retrospectively analyzed. MV geometry was quantified using 3D echocardiography software. Vena contracta area (VCA) at 6-month follow-up was used to define two outcome groups: patients with good results with VCA < 0.6 cm 2  (MR < 0.6) and those with MR recurrence with VCA ≥ 0.6 cm 2  (MR ≥ 0.6)., Results: MR recurrence was found in 34% of all study patients (21 of 61). In patients with FMR, significant differences between MR < 0.6 and MR ≥ 0.6 were found at baseline for tenting index (1.13 vs 1.23, P = .004), tenting volume (2.8 vs 4.0 ml, P = .04), indexed left ventricular (LV) end-diastolic volume (68.0 vs 99.9 ml/m 2 , P = .001), and VCA (0.71 vs 1.00 cm 2 , P = .003); no significant parameters of MR recurrence were found in patients with OMR. Multivariate analysis identified indexed LV end-diastolic volume as the strongest independent determinant of MR recurrence. Receiver operating characteristic analysis identified a tenting index of 1.185 (area under the curve 0.79) and indexed LV end-diastolic volume of 88 ml/m 2 (area under the curve 0.76) to best discriminate between MR < 0.6 and MR ≥ 0.6., Conclusions: MR recurrence after TMVR in patients with FMR is associated with advanced LV dilation and MV tenting before TMVR, which provides clinical implications for a point of no return beyond which progressive LV dilation with MV geometry dilation and tethering cannot be effectively prevented by TMVR. In contrast, no significant determinants of MR recurrence and progressive MV annular dilation could be identified in patients with OMR., (Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Current recommendations for valve size selection are based on multidimensional annular measurements, yet the overlap between two different transcatheter heart valve (THV) sizes remains. We sought to evaluate whether undersizing but overfilling eliminates the gray zones of valve sizing., Methods: Data of 246 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable bioprosthesis with either conventional sizing and nominal filling (group 1 (NF-TAVR), n = 154) or undersizing but overfilling under a Less Is More (LIM)-Principle (group 2 (LIM-TAVR), n = 92) were compared. Paravalvular leakage (PVL) was graded angiographically and quantitatively using invasive hemodynamics., Results: Annulus rupture (AR) occurred only in group 1 (n = 3). Due to AR adequate evaluation of PVL was possible in 152 patients of group 1. More than mild PVL was found in 13 (8.6%) patients of group 1 and 1 (1.1%) patient of group 2 (p = 0.019). Postdilatation was performed in 31 (20.1%) patients of group 1 and 6 patients (6.5%) of group 2 (p = 0.003). For patients with borderline annulus size in group 1 (n = 35, 22.7%) valve size selection was left to the physiciańs choice resulting in selection of the larger prosthesis in 10 (28.6%). In group 2 all patients with borderline annulus (n = 36, 39.1%) received the smaller prosthesis (LIM-TAVR). The postprocedural mean transvalvular pressure gradient was significantly higher in the NF-TAVR-group (11.7 ± 4 vs. 10.1 ± 3.6 mmHg, p = 0.005)., Conclusion: LIM-TAVR eliminates the gray zones of sizing and associated PVL, can improve THV-performance, reduce incidence of annular rupture and simplify the procedure especially in borderline cases., Competing Interests: P. C. Patsalis is proctor for Edwards Lifesciences. The other authors report no conflict of interest., (© 2020 The Authors.)

Background: Underweight and obesity represent classical risk factors for adverse outcome in patients treated for cardiovascular disease., Aims: The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy., Methods and Results: From August 2010 until July 2013, 799 patients (age 75.3 ± 8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicenter German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into 4 groups: BMI <20 kg/m 2 (underweight), BMI 20.0 to <25.0 kg/m 2 (normal weight, reference group), BMI 25.0 to <30.0 kg/m 2 (overweight) and BMI ≥30 kg/m 2 (obese). Significant increased rates of procedural failure, transfusion/bleeding, sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, P < .01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine ≥1.5 mg/dL, diabetes, left ventricular ejection fraction <30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95% confidence interval (CI): 1.01-2.46, P = .044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55-0.93; P = .011)., Conclusions: Compared to other weight groups, underweight patients undergoing MitraClip implantation are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates and should therefore be carefully discussed in the heart-team., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: The transfemoral approach for transcatheter aortic valve implantation (TF-TAVI) is associated with a significant survival benefit for intermediate and high-risk patients. Due to the increased procedural risk, many operators avoid TF-TAVI in patients with aortic disease. Moreover, significant peri-interventional device interaction may occur in patients with previous endovascular aortic repair (EVAR). We evaluated the feasibility of TF-TAVI in patients with aortic disease in combination with simultaneous or sequential EVAR., Methods: Data from 15 TF-TAVI patients with concomitant aortic disease treated between 2009 and 2019 in three German heart centers representing 4410 TAVI procedures were analyzed., Results: Two patients with progressive penetrating atherosclerotic ulcers (PAUs) in the descending thoracic aorta underwent sequential and simultaneous thoracic EVAR (TEVAR), respectively. One patient with stable PAU and 4 patients with not yet relevant abdominal aortic aneurysm (AAA) underwent isolated TF-TAVI. One patient with relevant AAA underwent TF-TAVI and sequential EVAR. Seven patients with previous EVAR due to an AAA underwent TF-TAVI (5 with a bifurcated graft and 2 with a straight graft). TF-TAVI and sequential or simultaneous TEVAR were technically successful in all patients. Vascular complications occurred in 1 patient. One patient died within 30 days and 2 patients died within 12 months., Conclusion: TF-TAVI can be performed successfully in patients with aortic disease or previous endovascular aortoiliac intervention. Simultaneous and sequential (T)EVAR is feasible.

Background: MitraClip therapy is increasingly used in patients deemed inoperable to treat severe mitral regurgitation (MR), but long-tern data is scarce., Aims: The multicentre, industry-independent German Transcatheter Mitral Valve Interventions (TRAMI) registry comprises the largest prospectively enrolled cohort of patients treated by MitraClip therapy. The current analysis is focusing on long-term mortality rates, cardiac rehospitalization and reintervention., Methods and Results: Long-term follow-up (median time 1037 days) in the TRAMI registry was available for 722 patients treated at 20 German centres. Improvements in New York Heart Association (NYHA) functional class (I/II long-term: 65% vs. 1-year follow-up: 63.3%) and self-rated health-status (EuroQuol visual analogue scale [EQ VAS] long-term: 60 [50-70] vs. 1-year follow-up: 60 [50; 70]) were pertained over time. Estimated mortality rates by Kaplan-Meier method were 19.7% for 1-year, 31.9% for 2-year and 53.1% for 4-year follow-up without differences found for MR aetiology. Multivariable Cox-regression analysis identified previous aortic valve implantation (hazard ratio [HR] = 2.21; p < 0.0001), NYHA class IV (HR = 1.78; p < 0.001), prior cardiac decompensation (HR = 1.63; p < 0.001), creatinine > 1.5 mg/dl (HR = 1.63; p < 0.0001) and left ventricular ejection fraction < 30% (HR = 1.60; p < 0.001) as most predictive for long-term mortality., Conclusions: Long-term outcome in the TRAMI registry confirmed lasting clinical improvements and low intervention rates. Long-term mortality was strongly influenced by cardiac and non-cardiac co-morbidities and was found comparable for both MR aetiologies., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Besides providing spatial anatomic information on heart valves, real-time three-dimensional echocardiography (3DE) combined with color Doppler has the potential to overcome the limitations of flow quantification inherent to conventional 2D color Doppler methods. Recent studies validated the application of color Doppler 3DE (cD-3DE) for the quantification of regurgitation flow based on the vena contracta area (VCA) and the proximal isovelocity surface area (PISA) methods. Particularly the assessment of VCA by cD-3DE led to a change of paradigm by understanding of the VCA as being strongly asymmetric in the majority of patients and etiologies. This review provides a comprehensive description of the different concepts of cD-3DE-based flow quantification in the setting of different valvular heart diseases and their presentation in recent guidelines.

Aims: The use of the MitraClip system has gained widespread acceptance for the treatment of patients with mitral regurgitation (MR) who are not suitable for the conventional surgery. This study sought to investigate the early and 1-year outcome after MitraClip therapy of patients with MR and cardiac comorbidities., Methods and Results: Outcomes through 12-month follow-up of patients (n = 528) who underwent MitraClip implantation were obtained from the German transcatheter mitral valve interventions (TRAMI) registry. The majority of these patients (n = 409, 77.5 %) also suffered from coronary artery disease (CAD). Patients with a dilated cardiomyopathy (DCM, n = 65, 12.3 %) or concomitant valvular aortic disease (AV, n = 54, 10.2 %) were less frequent. Although the prevalent pathogenesis was functional MR, patients with DCM had significantly more frequent a functional MR (96.9 %) compared to patients with CAD (74.9 %) or AV (62.5 %, p < 0.001). Technical success was achieved in 97.5 % of patients. Procedural echocardiograms demonstrated in the vast majority of patients a reduction from severe MR III to mild MR I with no difference between the groups (p = 0.83). The peri-procedural complication rate was very low. At 30-day and 12-month follow-up, the majority of patients were in NYHA functional class II or lower. The rate of death, stroke, and myocardial infarction (MACCE) was comparable in the three patient groups during 12-month follow-up (DCM 26.9 %, CAD 30.3 % and AV 27.5 %, p = 0.85)., Conclusions: The MitraClip implantation is feasible and safe even in high-risk patients with MR and cardiac comorbidities.

Aims: In patients undergoing percutaneous edge-to-edge mitral valve repair for mitral valve regurgitation (MR), our aim was to evaluate acute and follow-up differences with pre-existing sinus rhythm (SR) or atrial fibrillation (AF), as well as comparisons stratified by baseline heart rate., Methods and Results: Seven hundred and sixty patients who underwent a MitraClip procedure were prospectively enrolled in the TRAnscatheter Mitral valve Interventions (TRAMI) registry, and stratified according to baseline heart rhythm and heart rate with a cut-off value of 70 beats per minute. Technical success, procedural characteristics and MR reduction were similar throughout the subgroups. Overall, in-hospital adverse event rates were low in this high-risk patient collective. At 12 months, survival was higher in SR (83.5%) than AF patients (74.9%, p<0.05), while the cumulative major adverse cardio-cerebrovascular event rate did not differ, and a sustained improvement of NYHA functional class occurred in all subgroups., Conclusions: These registry data, comprising the largest number of unselected "real-world" MitraClip patients, suggest that the intervention can be performed safely and effectively, and reduces MR in the majority of patients irrespective of baseline rhythm or heart rate. While 12-month survival was higher for patients with SR, overall MACCE and clinical improvement did not differ between the subgroups.

Aims: Myocardial injury reflected by a post-procedural increase of serum troponin I (TnI) occurs frequently during transcatheter aortic valve implantation (TAVI). It is potentially caused by intraprocedural hypotension, periprocedural coronary microembolisation and post-procedural (para)valvular leakages (PVLs). We invasively assessed coronary flow dynamics including coronary flow velocity reserve (CFVR), embolic high-intensity transient signals (HITS) as well as rapid pacing induced hypotension and post-procedural PVLs to determine their contribution to post-procedural TnI increases., Methods and Results: In 15 transfemoral TAVI patients, TnI was measured serially, and cardiac MRIs with late gadolinium enhancement (LGE) were performed pre- and post-interventionally. There were no significant correlations between coronary flow dynamics, CFVR and the area under the curve (AUC) of TnI over 72 hours. Despite the detection of HITS in all patients and during all procedural steps, there was also no correlation between the amount of HITS and the AUC of TnI. However, there were positive correlations between the duration of rapid pacing as well as the time of subsequent blood pressure recovery and the AUC of TnI. Both LGE and more than mild PVL were observed in a single case only., Conclusions: Myocardial injury after TAVI appears to be related more to hypoperfusion-induced ischaemia than to periprocedural microembolisation.

The factor time plays an important role in diagnosis and treatment of acute aortic syndromes, not only as a short interval between diagnosis and surgical therapy, but also as a delay of definitive therapy in the selected cases. Severe organ damage caused by malperfusion or other mechanisms can be overcome by a surgical delay, improving prognosis. We report a successful attempt of a controlled delayed surgical treatment in a patient with an acute aortic syndrome complicated from multiorgan failure.

Aims: To analyze risk and outcomes of complications during and after MitraClip implantation using multicenter data from the prospective German Transcatheter Mitral Valve Interventions (TRAMI) registry., Methods and Results: Data of 828 patients (mean age: 76.0 [71-81] years, 327 (40%) females) undergoing MitraClip implantation in Germany between 2010 and 2013 were analyzed. Most patients (85%) underwent elective procedures with on average implantation of 1.4 ± 0.6 clips. Emergent cardiac surgery was not required; a single patient died intraoperatively. During the in-hospital period, complications occurred in 215 (25.9%) patients, of which 106 (12.8%) were considered major. Major bleeding complications were among the most frequent major complications (7.4%), while rates of pericardial tamponade (1.9%) and clip-specific complications (embolization: 0%, partial clip detachment: 1.9%) were low. In-hospital death, stroke or myocardial infarction (MACCE) occurred in 2.2, 0.9, and 0% patients, respectively. Patients with complications appeared to be older and more critically ill pre-interventionally; in-hospital mortality was significantly higher as compared to those without procedural complications., Conclusions: MitraClip implantation appears to be a safe treatment option with low rates of MACCE and clip-specific complications. Nevertheless, MitraClip therapy is not without complications. Careful patient selection and improvements in preventing peri-procedural bleeding have the potential of reducing post-procedural complications and improving outcomes., (© 2015 Wiley Periodicals, Inc.)

Mitral regurgitation (MR) is considered the most common valve disease with a prevalence of 2-3 % of significant regurgitation (moderate to severe and severe) in the general population. Accurate assessment of the severity of regurgitation was demonstrated to be of significant importance for patient management and prognosis and consequently has been widely recognized in recent guidelines. However, evaluation of severity of valvular regurgitation can be potentially difficult with the largest challenges presenting in cases of mitral regurgitation. Real-time three-dimensional echocardiography (RT3DE) by the use of color Doppler has the potential to overcome the limitations of conventional flow quantification using 2D color Doppler methods. Recent studies validated the application of color Doppler RT3DE for the assessment of flow based on vena contracta area (VCA) and proximal isovelocity surface area (PISA). Particularly, the assessment of VCA by color Doppler RT3DE led to a change of paradigm by understanding the VCA as being strongly asymmetric in the majority of patients and etiologies. In this review, we provide a discussion of the current state of clinical evaluation, limitations, and future perspectives of the two methods and their presentation in recent literature and guidelines.

Aims: As periprocedural risk is low, MitraClip implantation is often performed in critically ill, not fully recompensated patients, who are in NYHA functional class IV at the time of the procedure, to accelerate convalescence. We herein sought to evaluate the procedural and 30-day outcome of this patient group., Methods and Results: A total of 803 patients undergoing MitraClip implantation were included in the German Mitral Valve Registry, and 30-day outcomes were prospectively assessed. Patients were separated based on NYHA functional class [(NYHA IV (n = 143), III (n = 572), and I/II (n = 88)]. No difference was noted in co-morbities and echocardiographic parameters of LV function between groups. However, parameters of severity of mitral regurgitation (MR) were higher in NYHA IV patients. High procedural success rates and low residual MR grades at discharge were observed throughout all groups. In-hospital major adverse cardiac events were similar between groups. Importantly, 30-day mortality (8.0% vs. 3.2% vs. 4.8%; P < 0.05) was significantly higher in NYHA IV patients, whereas rehospitalization did not differ between groups. At 30 days, 47.6% of NYHA IV patients were still in NYHA class III or IV compared with 32.5% and 14.8% in the other groups (P < 0.05), although NYHA functional class decreased in 69% of patients. Quality of life, which was very poor at baseline, showed an overall improvement in NYHA IV patients after 30 days, with, for example, a reduction of bed-ridden patients from 19.6% to 3.3%., Conclusion: MitraClip therapy is feasible and safe even in critically ill, not fully recompensated patients and leads to symptomatic improvement in over two-thirds of these patients; however, it is associated with an elevated 30-day mortality., (© 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.)

Objectives: This study sought to determine the feasibility, safety, and exploratory efficacy of the Embrella Embolic Deflector (EED) system (Edwards Lifesciences, Irvine, California) in patients undergoing transcatheter aortic valve replacement (TAVR)., Background: Few data exist on the value of using embolic protection devices during TAVR., Methods: This pilot study included 52 patients who underwent transfemoral TAVR. The EED system was used in 41 patients, whereas 11 patients underwent TAVR without embolic protection (control group). Cerebral diffusion-weighted magnetic resonance imaging (DW-MRI) was performed at baseline and within 7 days and 30 days after TAVR., Results: The EED system was successfully deployed at the level of the aortic arch in all patients with no complications. The deployment of the EED system was associated with high-intensity transient signals (HITS) as evaluated by transcranial Doppler (median: 48 [interquartile range: 17 to 198] HITS), and a higher total number of HITS was observed in the EED group (p < 0.001 vs. control group). DW-MRI performed within 7 days after TAVR showed the presence of new ischemic lesions in all patients in both groups, with a median number of 7 (interquartile range: 3 to 13) lesions per patient. The use of the EED system was associated with a lower lesion volume compared with the control group (p = 0.003). All new cerebral lesions had disappeared on the DW-MRI performed at 30 days after TAVR. Two strokes unrelated to the EED system occurred 2 and 29 days after TAVR., Conclusions: This study showed the feasibility and safety of using the EED system in TAVR procedures. The EED system did not prevent the occurrence of cerebral microemboli during TAVR or new transient ischemic lesions as evaluated by DW-MRI, but it was associated with a reduction in lesion volume. Further studies are warranted to determine the efficacy of using the EED system during TAVR procedures., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The risk of clinically apparent, periprocedural stroke after thoracic endovascular aortic repair (TEVAR) due to dislodgement and embolization of aortic debris from intravascular manipulation of guidewires, catheters, and large-bore delivery systems ranges between 2% and 6% and has been associated with increased postoperative mortality. The rate of clinically silent cerebral ischemia is yet unknown, but may be even higher., Methods: Nineteen patients (13 male, 6 female) who underwent TEVAR were included into this descriptive study. Periprocedural apparent and silent cerebral ischemia was assessed by daily clinical neurologic assessment and serial cerebral diffusion-weighted magnetic resonance imaging (DW-MRI) at baseline and 5 days (median, interquartile range: 3.5) after the procedure., Results: The TEVAR was successful in all patients without immediate clinically apparent neurologic deficits. Postinterventional cerebral DW-MRI detected a total of 29 new foci of restricted diffusion in 12 of 19 TEVAR patients (63%). Lesions were usually multiple (1 to 6 lesions per patient) and ranged in size between 15 mm3 and 300 mm3; 16 lesions were found in the left hemisphere, 13 lesions in the right hemisphere. Overstenting of the left subclavian artery was performed in 8 cases, but was not associated with lateralization of lesions. There were no additional apparent neurologic events during the in-hospital period., Conclusions: Thoracic endovascular aortic repair resulted in a high incidence of new foci of restricted diffusion on cerebral DW-MRI in a pattern suggestive of periprocedural embolization. Although multiple lesions per patients were found, these lesions were not associated with apparent neurologic deficits during the in-hospital period. Further developments in TEVAR should be directed toward reducing the risk of periprocedural cerebral embolization., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aim: Sclerosis distribution, topography and morphology in aortic stenosis may have an impact on the localisation of post-procedural paravalvular leakage (PVL) following transcatheter aortic valve implantation (TAVI)., Methods: Between 05/2005 and 03/2011 a total of 208 patients underwent either transapical (TA) or transvascular (TV) TAVI using the Edwards-SAPIEN(TM), or CoreValve(TM) system. Aortic cusp and annular sclerosis distribution and aortic valve sclerosis symmetry were evaluated by preoperative transesophageal echocardiography (TOE). Mild, moderate and severe PVL after TAVI (group 1, N.=117) were analysed and compared to those patients with no signs of postprocedural PVL (group 2, N.=91). Commercial available image processing and analysing software were used to evaluate all relevant calcific sections (aortic sclerosis score 0-66; symmetry score 0-5) and were matched with the localization of the PVLs., Results: A total of 117 patients (83±6 years, mean logistic EuroSCORE 20.1±12.7%) were identified with a mild-moderate PVL (TV, N.=102; TA, N.=15). Mean aortic sclerosis score was 38.7±7.6 in group 1 compared to 33.7±8.3 in group 2 (P<0.001) showing highest calcification in the non-coronary part for both groups. The mean symmetry score was 1.9±1.0 group 1 compared to 1.7±1.0 in group 2 (P=0.12). Regression analysis showed a significant relation of preoperative cusp localisation to the corresponding paravalvular leakage (P<0.001)., Conclusion: The present study shows that a aortic sclerosis score constructed by TOE enables prediction of postoperative PVL and moreover, the localisation of PVL after TAVI correlates with the corresponding preoperative amount of sclerosis for each cusp.

Objectives: The Trifecta valve (St Jude Medical, St Paul, Minn) is a new bioprosthetic heart valve designed for supra-annular aortic valve replacement. We compared the hemodynamic performance of the Trifecta against the Perimount-Magna and Magna-Ease valve prostheses (Edwards Lifesciences, Irvine, Calif) in a nonrandomized, observational, single-center study., Methods: A total of 346 consecutive patients with aortic valve disease underwent aortic valve replacement between January 2003 and November 2011, with implantation of the Trifecta (group 1, n = 121), the Perimount-Magna (group 2, n = 126), or the Magna Ease bioprosthesis (group 3, n = 99). Clinical and hemodynamic data were prospectively recorded and compared. Hemodynamic performance was evaluated by transthoracic echocardiography, including mean pressure gradient (MPG) and aortic valve area (AVA) at baseline, discharge, and 6-month follow-up. A multivariate model of covariance analysis was constructed to further compare the primary study end points of MPG and AVA at 6-month follow-up., Results: For all valve sizes, unadjusted MPGs did not differ (P = .08), but AVAs differed (P < .001) between groups at 6-month follow-up. After final adjustment by a multivariate model of covariance analysis, neither the MPGs (P = .16) nor the AVAs (P = .92) at 6 months postoperatively were influenced by the type of prosthesis used., Conclusions: The present observational study is the first to compare the new Trifecta valve with well-established supra-annular aortic valve bioprostheses from a hemodynamic perspective. Although mean pressure gradients and aortic valve areas seem to be advantageous at 6-month follow-up with the new Trifecta valve, after multivariate covariance analysis, no influence of prosthesis type on mean pressure gradient or aortic valve area could be demonstrated., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: To compare complication rates of a collagen-based vascular closure device (VCD) in patients with vs. without significant peripheral artery disease (PAD)., Methods: A total of 382 patients (268 men; mean age 64.6±10.8 years) undergoing either an endovascular procedure of the lower limb (PAD group, n=132) or a percutaneous coronary intervention (PCI group, n=250) via a common femoral artery access were enrolled in this prospective study if hemostasis was achieved using the collagen-based Angio-Seal. In the PCI group, significant PAD was excluded by measurement of the ankle-brachial index. In-hospital major complications (bleeding, large hematoma, pseudoaneurysm, vessel occlusion, dissection) were recorded., Results: Similar and low rates of major complications were observed in both arms of the study: 2 (1.5%) major complications in the PAD group and 3 (1.2%) in the PCI group (p=1.0). There was no significant difference in efficacy of the VCDs in the groups (PAD group 99.2% vs. 100% in PCI group, p=0.35)., Conclusion: Our study shows no significant differences in the rate of major complications after utilization of a collagen-based VCD for femoral artery access site closure in patients with severe lower limb PAD compared to those without; however, complications in the PAD group tended to be more severe, with the need for surgical repair.

Objectives: This study sought to evaluate whether supra-aortic angiography during preparatory balloon aortic valvuloplasty (BAV) improves valve sizing., Background: Current recommendations for valve size selection are based on annular measurements by transesophageal echocardiography and computed tomography, but paravalvular aortic regurgitation (PAR) is a frequent problem., Methods: Data of 270 consecutive patients with either conventional sizing (group 1, n = 167) or balloon aortic valvuloplasty-based sizing (group 2, n = 103) were compared. PAR was graded angiographically and quantitatively using several hemodynamic indices., Results: PAR was observed in 113 patients of group 1 and 41 patients of group 2 (67.7% vs. 39.8%, p < 0.001). More than mild PAR was found in 24 (14.4%) patients of group 1 and 8 (7.8%) patients of group 2. According to pre-interventional imaging, 40 (39%) patients had a borderline annulus size, raising uncertainty regarding valve size selection. Balloon sizing resulted in selection of the bigger prosthesis in 30 (29%) and the smaller prosthesis in the remaining patients, and only 1 of these 40 patients had more than mild PAR. As predicted by the hemodynamic indices of PAR, mortality at 30 days and 1 year was less in group 2 than in group 1 (5.8% vs. 9%, p = 0.2 and 10.6% vs. 20%, p = 0.01)., Conclusions: Preparatory balloon aortic valvuloplasty during transcatheter aortic valve implantation improves valve size selection, reduces the associated PAR, and increases survival in borderline cases., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to identify risk factors for thrombus formation on the Amplatzer Cardiac Plug (ACP) (St. Jude Medical, St. Paul, Minnesota) after left atrial appendage occlusion., Background: Left atrial appendage occlusion with the ACP aims to reduce the risk of embolic stroke and bleeding complications associated with vitamin K antagonists in patients with atrial fibrillation., Methods: We performed transesophageal echocardiography before discharge and after 3, 6, and 12 months in 34 patients with atrial fibrillation undergoing ACP implantation and receiving dual antiplatelet therapy. Clinical, echocardiographic, and hemostaseological parameters were retrospectively analyzed to identify risk factors for thrombus formation., Results: Three patients had thrombi before discharge, 3 more at the 3-month follow-up. No differences were found in left atrial volume, left atrial appendage velocity, spontaneous echo contrast, transmitral gradient, or mitral regurgitation between patients without or with thrombi. CHADS2 (Congestion, Hypertension, Age, Diabetes, and Stroke) score (2.0 ± 1.1 vs. 4.3 ± 1.0), CHA2DS2-VASc (CHADS2 plus Vascular Disease and Sex Category) score (5.2 ± 1.3 vs. 6.8 ± 0.8), and pre-interventional platelet count (215.9 ± 63.9/nl vs. 282.5 ± 84.4/nl) were higher and ejection fraction (50.6 ± 11.4% vs. 39.7 ± 10.6%) lower in those with thrombi. Factor 2, factor 5, or methylenetetrahydrofolate reductase mutations and genetic variants associated with reduced clopidogrel activity were not more frequent in patients with thrombi., Conclusions: Transesophageal echocardiography identified 17.6% of patients with thrombus formation on the ACP despite dual antiplatelet therapy. CHADS2 and CHA2DS2-VASc scores, platelet count, and ejection fraction are risk factors for such thrombus formation., (Published by Elsevier Inc.)

Aims: The influence of age on baseline demographics and outcomes of patients selected for MitraClip has not been previously investigated., Methods and Results: Baseline demographics and acute outcomes in 1,064 patients from the German TRAMI registry were stratified by age (525 patients ≥76 years and 539 patients <76 years). In elderly patients, logistic EuroSCORE was higher (25[15-40]% vs. 18[10-31]%, p<0.0001) and the proportion of women was greater (47.2% vs. 29.3%, p<0.0001). Elderly patients were more likely to have preserved left ventricular ejection fraction >50% (40.1% vs. 21.8%, p<0.0001) and degenerative mitral regurgitation (DMR, 35.3% vs. 25.6%, p<0.01). Age was the most frequent reason for non-surgical treatment in the elderly (69.4% vs. 36.1%, p<0.0001). The intrahospital MACCE (death, myocardial infarction, stroke) was low in both groups (3.5% vs. 3.4%, p=0.93) and the proportion of non-severe mitral regurgitation at discharge was similar (95.8% vs. 96.4%, p=0.73). A logistic regression model did not reveal any significant impact of age on acute efficacy and safety of MitraClip therapy. In both groups, the majority of patients were discharged home (81.8% vs. 86.2%, p=0.06)., Conclusions: Elderly and younger patients have similar benefits from MitraClip therapy. Age was the most frequent cause for denying surgery in elderly patients.

Aims: To report the frequency of unsuspected pathologies detected by presurgical and/or postsurgical intraoperative transesophageal echocardiography (IOTEE) and its impact on the extent of cardiac surgery and the number of pathologies remaining unoperated., Methods and Results: In a 2-year study period, 469 patients (male/female = 273/196; age 68.0 ± 11.9 years) with presurgical and/or postsurgical IOTEE out of 2,035 patients submitted for cardiac surgery were analyzed retrospectively. Presurgical IOTEE was performed in all patients referred to valve surgery or suspicious valve disease or valve diseases with open surgical decision. Postsurgical IOTEE was performed in all patients after valve surgery. Pathologies relevant for surgery were defined as valve disease of moderate degree or higher or structural disease like shunt lesions. In 464 patients (98.9 %), a total number of 757 IOTEEs were successfully performed including 351 presurgical and 384 postsurgical studies, 1-s presurgical IOTEE, 20-s postsurgical, and one-third postsurgical IOTEE. Surgically relevant unsuspected findings were detected in 33.0 % of presurgical IOTEE leading to alteration of surgery in 27.6 %. Relevant pathologies detected by postsurgical IOTEE were found in 7.8 % as remnant valvular dysfunction of the operated valve and in 12.3 % related to other structures. Relevant pathologies detected by postsurgical IOTEE finally remained unoperated in 21.2 % of patients with only postsurgical IOTEE versus only 10.7 % (p < 0.05) of patients with both presurgical and postsurgical IOTEE., Conclusion: We found an alarming high number of unsuspected pathologies by IOTEE causing substantial alterations of surgery. Beyond this, whether patients received presurgical IOTEE or not made a significant difference on the number of pathologies left unoperated.

Transcatheter aortic valve implantation (TAVI) is a novel treatment option for patients with severe, symptomatic aortic valve stenosis considered inoperable or at high risk for surgical aortic valve replacement. Despite rapid adoption of this technology into clinical application, however, recent randomized controlled clinical trials have raised safety concerns regarding an increased risk of neurological events with TAVI compared to both medical treatment and conventional, surgical aortic valve replacement. Moreover, neuro-imaging studies have revealed an even higher incidence of new, albeit clinically silent cerebral lesions as a surrogate for procedural embolization. In this article, we review currently available data on the incidence, timing, predictors, prognostic implications and potential mechanisms of neurological events after TAVI.

Aims: Residual paravalvular aortic regurgitation (PAR) after transcatheter aortic valve implantation (TAVI) is common. We therefore evaluated incidence, determinants and outcome of PAR after TAVI., Methods and Results: Data from 167 consecutive transcatheter TAVI patients were analysed. PAR was graded by angiography and the pressure gradient between diastolic aortic pressure and left ventricular end-diastolic pressure (∆PDAP-LVEDP) after implantation. TAVI was technically successful in all patients. Mortality was 9% and 20% at 30 days and one year, respectively. Post-procedural PAR was absent in 54 patients (32.3%). Mild PAR was found in 89 (53.3%), moderate in 21 (12.6%), and moderate-to-severe in three patients (1.8%). Cardiovascular mortality at 30 days and one year was increased in patients with moderate and moderate-to-severe PAR compared to patients with no and mild PAR (46% vs. 4% and 73% vs. 7%, respectively, p<0.001). Receiver operating characteristic curve analysis suggested ∆PDAP-LVEDP ≤18 mmHg as a novel predictor of mortality, with an area under the curve of 0.97., Conclusions: In patients undergoing TAVI, moderate and moderate-to-severe PAR was observed in 14.4% and associated with increased cardiovascular mortality. A pressure gradient ∆PDAP-LVEDP≤18 mmHg carries adverse prognosis and requires further intervention.

A relevant (at least moderate) paravalvular regurgitation (PAR) after transcatheter aortic valve implantation (TAVI) is found in up to 20% of cases and associated with increased mortality. The ratio of the diastolic over the systolic pressure time integral (DPTI:SPTI) has been proposed to reflect an estimate of myocardial oxygen supply versus demand and the propensity for myocardial ischemia. We have now evaluated the potential of this ratio to predict PAR-associated cardiovascular mortality after TAVI, retrospectively analyzing data from 167 consecutive TAVI patients. PAR was graded angiographically, and the myocardial supply-demand ratio was estimated from the planimetric integration of the diastolic and systolic pressure-time area (DPTI and SPTI), respectively. PAR was observed in 113 patients (67%) and angiographically graded as mild in 89 (78.8%), moderate in 21 (18.6%) or moderate to severe in 3 (2.7%) cases. The DPTI:SPTI ratio decreased with increasing Sellers grade of PAR (P < 0.001). A DPTI:SPTI of ≤0.7 predicted cardiovascular mortality (area under the curve = 0.96). Cardiovascular mortality at 30 days and 1 yr was increased in patients with DPTI:SPTI ≤ 0.7 over those with DPTI:SPTI > 0.7 (42 vs. 2% and 63 vs. 3%, respectively; P < 0.001). In conclusion, DPTI:SPTI provides an excellent cutoff value of ≤0.7 for the prediction of PAR-associated mortality.

Objectives: To evaluate feasibility, safety and efficacy of percutaneous arterial access site closure after transfemoral, transcatheter aortic valve implantation (TF-TAVI) using a single, commercially available six French monofilament suture-mediated vascular closure device (VCD) in "preclosure" technique., Background: Currently, TF-TAVI is evolving into a completely percutaneous procedure. However, percutaneous access site closure still remains a major technical challenge with room for improvement., Methods: 94 of 144 consecutive patients underwent completely percutaneous TF-TAVI using following technique for access site closure: After puncture of the common femoral artery using fluoroscopy and contralateral angiography for guidance, the VCD was deployed prior further predilatation of the vessel and insertion of the large-bore introducer sheath. At the end of the procedure, the preloaded sutures were tied for final hemostasis and crossover angiography was used for postprocedural evaluation of the access vessel., Results: Application of the VCD was technically successful in all cases, resulting in an efficient hemostasis with cessation of any bleeding within 10 min of final knot-tying in 83 of the 94 patients, and there was only one closure-failure with continuous bleeding despite prolonged manual compression requiring endovascular treatment. In addition, we observed four closure-related access vessel stenoses of hemodynamic relevance requiring endovascular treatment in three and surgical repair in one patient. However, interventional and surgical repair was not associated with death or irreversible end-organ damage and all patients recovered without sequelae., Conclusion: "Preclosure" of the arterial access site with a single six French suture-mediated VCD is relatively easy, safe and efficient method for access site closure after TF-TAVI which, along with ongoing profile reductions of TAVI devices, should further simplify and broaden the way toward a routine, completely percutaneous procedure., (Copyright © 2012 Wiley Periodicals, Inc.)

Real-time 3D echocardiography is one of the most important developments in the field of non-invasive cardiac imaging within the last years. To investigate whether this new technology can be considered as a standard method the current guidelines and recommendations were reviewed. In the field of left ventricular function assessment, evaluation of mitral valve pathologies and peri-interventional monitoring of percutaneous valve repair procedures 3D echocardiography plays a major role. For other clinical applications, such as right heart assessment, congenital heart disease and stress echocardiography, a high potential is seen but evidence is currently too weak for general recommendations. However, in the near future no echo laboratory will be working without 3D modalities.

Background: Real-time cardiovascular magnetic resonance (rtCMR) is considered attractive for guiding TAVI. Owing to an unlimited scan plane orientation and an unsurpassed soft-tissue contrast with simultaneous device visualization, rtCMR is presumed to allow safe device navigation and to offer optimal orientation for precise axial positioning. We sought to evaluate the preclinical feasibility of rtCMR-guided transarterial aortic valve implatation (TAVI) using the nitinol-based Medtronic CoreValve bioprosthesis., Methods: rtCMR-guided transfemoral (n = 2) and transsubclavian (n = 6) TAVI was performed in 8 swine using the original CoreValve prosthesis and a modified, CMR-compatible delivery catheter without ferromagnetic components., Results: rtCMR using TrueFISP sequences provided reliable imaging guidance during TAVI, which was successful in 6 swine. One transfemoral attempt failed due to unsuccessful aortic arch passage and one pericardial tamponade with subsequent death occurred as a result of ventricular perforation by the device tip due to an operating error, this complication being detected without delay by rtCMR. rtCMR allowed for a detailed, simultaneous visualization of the delivery system with the mounted stent-valve and the surrounding anatomy, resulting in improved visualization during navigation through the vasculature, passage of the aortic valve, and during placement and deployment of the stent-valve. Post-interventional success could be confirmed using ECG-triggered time-resolved cine-TrueFISP and flow-sensitive phase-contrast sequences. Intended valve position was confirmed by ex-vivo histology., Conclusions: Our study shows that rtCMR-guided TAVI using the commercial CoreValve prosthesis in conjunction with a modified delivery system is feasible in swine, allowing improved procedural guidance including immediate detection of complications and direct functional assessment with reduction of radiation and omission of contrast media.

Objectives: To evaluate feasibility, safety, efficacy as well as acute and short-term outcome of hemodynamically supported percutaneous coronary intervention (PCI) by a percutaneous, catheter-based left ventricular assist device (LVAD) (Impella LP 2.5, Abiomed Europe GmbH, Aachen, Germany) in a high-risk patient population with acute coronary syndrome., Background: Although hemodynamic support by intraaortic balloon pump favorably affects myocardial oxygen supply and demand, it has modest effects on cardiac output, providing passive support only. In contrast, the Impella LP 2.5 microaxial pump, which is placed within the left ventricular outflow tract and actively ejects blood into the ascending aorta, might offer additional hemodynamic support and thereby procedural safety during PCI., Methods: Thirty-eight consecutive high-risk patients (mean age, 69.7 ± 10.3 years, logistic EuroSCORE, 22.4 ± 14.9%) with unstable angina pectoris or non-ST-segment elevation myocardial infarction and severe three-vessel-disease were included in the study. Clinical and laboratory examinations were performed at baseline as well as at 6, 24 and 48 h after the procedure and 30 days after discharge., Results: Device insertion and explantation was feasible in all patients without vascular complications and continuous hemodynamic stability was obtained during PCI. PCI was uneventfully performed in all but one patient for technical reasons. One non procedure-related death occurred 7 days after the intervention, accounting for a total 30-day mortality of 2.86%. Other major cardiac or cerebrovascular events did not occur., Conclusions: LVAD support using a percutaneous microaxial flow pump is a promising and safe approach for high-risk PCI providing good short-term results., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

We sought to determine the level of agreement and the reproducibility of two-dimensional (2D) transthoracic (2D-TTE), 2D transesophageal (2D-TEE) and real-time three-dimensional (3D) transesophageal echocardiography (RT3D-TEE) for measurement of aortic annulus size in patients referred for transcatheter aortic valve implantation (TAVI). Accurate preoperative assessment of the dimensions of the aortic annulus is critical for patient selection and successful implantation in those undergoing TAVI for severe aortic stenosis (AS). Annulus size was measured using 2D-TTE, 2D-TEE and RT3D-TEE in 105 patients with severe AS referred for TAVI. Agreement between echocardiographic methods and interobserver variability was assessed using the Bland-Altman method and regression analysis, respectively. The mean aortic annuli were 21,7 ± 3 mm measured with 2D-TTE, 22,6 ± 2,8 mm with 2D-TEE and 22,3 ± 2,9 mm with RT3D-TEE. The results showed a small but significant mean difference and a strong correlation between the three measurement techniques (2D-TTE vs. 2D-TEE mean difference 0,84 ± 1,85 mm, r = 0,8, p < 0,0001; 2D-TEE vs. 3D-TEE 0,27 ± 1,14 mm, r = 0,91, p < 0,02; 2D-TTE vs. 3D-TEE 0,58 ± 2,21 mm, r = 0,72, p = 0,02); however, differences between measurements amounted up to 6,1 mm. Interobserver variability for 2D-TTE and 2D-TEE was substantially higher compared with RT3D-TEE. We found significant differences in the dimensions of the aortic annulus measured by 2D-TTE, 2D-TEE and RT3D-TEE. Thus, in patients referred for TAVI, the echocardiographic method used may have an impact on TAVI strategy.

Background: Cardiovascular magnetic resonance (CMR) is considered an attractive alternative for guiding transarterial aortic valve implantation (TAVI) featuring unlimited scan plane orientation and unsurpassed soft-tissue contrast with simultaneous device visualization. We sought to evaluate the CMR characteristics of both currently commercially available transcatheter heart valves (Edwards SAPIEN™, Medtronic CoreValve®) including their dedicated delivery devices and of a custom-built, CMR-compatible delivery device for the Medtronic CoreValve® prosthesis as an initial step towards real-time CMR-guided TAVI., Methods: The devices were systematically examined in phantom models on a 1.5-Tesla scanner using high-resolution T1-weighted 3D FLASH, real-time TrueFISP and flow-sensitive phase-contrast sequences. Images were analyzed for device visualization quality, device-related susceptibility artifacts, and radiofrequency signal shielding., Results: CMR revealed major susceptibility artifacts for the two commercial delivery devices caused by considerable metal braiding and precluding in vivo application. The stainless steel-based Edwards SAPIEN™ prosthesis was also regarded not suitable for CMR-guided TAVI due to susceptibility artifacts exceeding the valve's dimensions and hindering an exact placement. In contrast, the nitinol-based Medtronic CoreValve® prosthesis was excellently visualized with delineation even of small details and, thus, regarded suitable for CMR-guided TAVI, particularly since reengineering of its delivery device toward CMR-compatibility resulted in artifact elimination and excellent visualization during catheter movement and valve deployment on real-time TrueFISP imaging. Reliable flow measurements could be performed for both stent-valves after deployment using phase-contrast sequences., Conclusions: The present study shows that the Medtronic CoreValve® prosthesis is potentially suited for real-time CMR-guided placement in vivo after suggested design modifications of the delivery system.

History: A 64-year old male marathon runner noted during training an asymptomatic sudden increase in heart rate as recorded on his heart rate monitor. But this was not verifiable on subsequent Holter-ECG monitoring. However, treadmill exercise testing revealed unexpected signs of ischemia, which required further diagnostic tests., Investigations: Cardiac computed tomography (CT) demonstrated advanced coronary atherosclerosis, with suspected morphologically significant stenosis after contrast injection. Because of the absence of angina, a myocardial perfusion scintigraphy was done which gave no evidence of ischemia, and there was no late enhancement on magnetic resonance imaging. In view of these findings invasive coronary angiography was not performed., Treatment and Course: The patient received aggressive risk modifying therapy. He is still running regularly event-free after nine months., Conclusion: This case shows that the use of modern non-invasive cardiovascular imaging can have an impact in preventive clinical decision making., (Georg Thieme Verlag KG Stuttgart, New York.)

Percutaneous, transcatheter mitral valve repair has recently been introduced and various strategies--loosely based on surgical techniques--are currently under clinical and preclinical evaluation. Since percutaneous mitral valve repair techniques are rather specific regarding both the underlying cause of mitral regurgitation and patient anatomy, careful preinterventional imaging using various techniques is required for appropriate patient selection and essential for procedural success. While echocardiography is the dominant imaging modality for determination of mitral regurgitation severity and etiology, other imaging modalities like contrast-enhanced multidetector computed tomography, magnetic resonance imaging, and fluoroscopy/angiography may play an important role in the preinterventional evaluation process. In addition, imaging is of utmost importance for procedural guidance and the combined use of various imaging modalities, commonly fluoroscopy and echocardiography, is needed in the catheterization laboratory to ensure safety and efficacy of mitral valve repair procedures. Finally, imaging is essential for an adequate patient follow-up aiming to control stable device positioning, persistency of the geometric modifications induced, and continuous reduction of mitral regurgitation. This review highlights the role of various imaging techniques during preinterventional evaluation, procedural guidance and follow-up in the setting of percutaneous mitral valve repair with special focus on edge-to-edge leaflet repair and indirect annuloplasty via the coronary sinus as the best-studied approaches to date.

Percutaneous transcatheter aortic valve implantation (TAVI) is an evolving interventional therapy for high-risk, non-surgical patients with severe, symptomatic aortic valve stenosis (AS). As a standard procedure, 2D transesophageal echocardiography has been used for the preinterventional assessment of the native valve and measurement of the aortic annulus as well as for intraprocedural guidance. Recently, a new matrix array, transesophageal probe for real-time three-dimensional echocardiography (RT3D-TEE) has been introduced. We applied this new technique to monitor percutaneous aortic valve implantation and described our initial experiences with this method in patients undergoing TAVI. We hypothesized that RT3D-TEE provides improved evaluation of the native aortic valve and annulus dimension due to unlimited scan plane orientation. This new technology should also enable accurate guiding of percutaneous cardiac interventions by providing immediate information on prosthesis position and function in real-time. In our preliminary clinical experience real-time three-dimensional transesophageal echocardiography (RT3D TEE) was demonstrated to provide improved guiding of percutaneous aortic valve replacement by superior spatial visualisation of the cardiac structures and facilitated the detection of procedure-related complications. Due to the advantages of real-time 3D TEE monitoring, this technique might improve the outcome of patients treated with percutaneous aortic valve replacement.

Background: Real-time 3-dimensional color Doppler echocardiographic (RT3DE) imaging has recently been demonstrated to provide accurate direct measurement of vena contracta area (VCA). The quantification of mitral regurgitant (MR) flow directly at the lesion using color Doppler echocardiography, however, has been prevented because of multiple aliasing from high flow velocities. Recent studies, however, have demonstrated that flow at the vena contracta is laminar, with a narrow velocity spectrum that should allow the dealiasing of color Doppler flow velocities for the accurate measurement of MR flow. This hypothesis was tested in an in vitro flow model and initial patient application, with magnetic resonance imaging (MRI) used as a reference., Methods: In an in vitro flow model, MR jets of flow rates from 5 to 60 mL/s were produced through asymmetric orifices of 0.2 to 0.6 cm(2). From RT3DE data sets, MR flow was calculated by the automated integration of the nonaliased color Doppler velocities over the VCA, with aliasing avoided by maximum baseline shift. Aliased flow was calculated as VCA times the Nyquist velocity times the number of aliasing transitions derived from the maximum continuous-wave Doppler velocity. Total MR flow was calculated as the sum of nonaliased and aliased flow. This approach was also clinically evaluated in 23 patients for the measurement of MR stroke volume against MRI and the hemispheric and hemielliptic proximal isovelocity surface area methods., Results: In vitro RT3DE imaging of VCA was feasible in all flow stages without color Doppler aliasing. Flow rates calculated from RT3DE data sets showed excellent correlation with actual flow rates (r = 0.99), with a mean difference of -0.05 +/- 0.5 mL/s (not significant by t test). In vivo, good correlation and agreement were found between MR stroke volume by dealiasing and MRI (r = 0.91, -1.8 +/- 7.1 mL; not significant by t test), with better correlation and agreement compared with hemispheric proximal isovelocity surface area (r = 0.81, -17.4 +/- 9.4 mL, P < .05) and hemielliptic proximal isovelocity surface area (r = 0.89, -11.7 +/- 7.4 mL, P < .05)., Conclusions: Dealiasing of color Doppler flow at the vena contracta is feasible and appears promising for measuring MR severity quantitatively. This novel approach can be readily implemented in current systems to provide rapid semiautomated MR flow volume and MR fraction.

Infective endocarditis (IE) due to Gram-negative bacteria is a rare occurrence, with a relative frequency of less than 10% compared to that caused by Gram-positive bacteria. Herein is presented the fatal case of a 66-year-old man who had undergone mechanical aortic valve replacement 10 years previously, and developed aortic valve IE after sepsis with Pasteurella multocida caused by a cat bite at the left medial ankle. In addition, the patient suffered five months later from mitral and aortic valve endocarditis caused by Pseudomonas aeruginosa. Recurrent surgical therapy was mandatory. This unique case of recurrent Gram-negative IE shows that the condition must still be regarded as complex and often fatal, despite adequate medical and surgical treatment.