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Treatment of recurrent MR after initially successful MitraClip procedure can pose therapeutic challenges. We report a successful case of redo MitraClip to treat recurrent inter-clip MR due to progression of underlying degenerative valvular pathology with prolapsing posterior mitral leaflet between the two prior clips. In this vignette, we describe the novel use of quantitative coronary arteriography (QCA) to select redo MitraClip as the treatment strategy.

Transcatheter edge-to-edge repair (TEER) with MitraClip improves outcomes among select patients with moderate-to-severe and severe mitral regurgitation; however, data regarding sex-specific differences in the outcomes among patients undergoing TEER are limited.An electronic search of the PubMed, Embase, Central, and Web of Science databases for studies comparing sex differences in outcomes among patients undergoing TEER was performed. Summary estimates were primarily conducted using a random-effects model.Eleven studies with a total of 24,905 patients (45.6% women) were included. Women were older and had a lower prevalence of comorbidities, including diabetes, chronic kidney disease, and coronary artery disease. There was no difference in procedural success (odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.55-1.05) and short-term mortality (i.e., up to 30 days) between women and men (OR: 1.16, 95% CI: 0.97-1.39). Women had a higher incidence of periprocedural bleeding and stroke (OR: 1.34, 95% CI: 1.15-1.56) and (OR: 1.57, 95% CI: 1.10-2.25), respectively. At a median follow-up of 12 months, there was no difference in mortality (OR: 0.98, 95% CI: 0.89-1.09) and heart failure hospitalizations (OR: 1.07, 95% CI: 0.68-1.67). An analysis of adjusted long-term mortality showed a lower incidence of mortality among women (hazards ratio: 0.77, 95% CI: 0.67-0.88).Despite a lower prevalence of baseline comorbidities, women undergoing TEER with MitraClip had higher unadjusted rates of periprocedural stroke and bleeding as compared with men. There was no difference in unadjusted procedural success, short-term or long-term mortality. However, women had lower adjusted mortality on long-term follow-up. Future high-quality studies assessing sex differences in outcomes after TEER are needed to confirm these findings.

Cor triatriatum dexter is a rare congenital heart defect with a varied clinical presentation ranging from asymptomatic to right heart failure. Accurate diagnosis is imperative as it may affect clinical decision making. We present a multimodality imaging assessment of cor triatriatum dexter in a 70-year-old woman with severe tricuspid regurgitation.

PURPOSE OF REVIEW Despite the prevalence of tricuspid valve regurgitation disorders, isolated interventions on tricuspid valves were previously infrequent due to high mortality rates and lack of advanced clinical imaging technology. Due to advancements in cardiovascular imaging and interventional technologies tricuspid valve repairs and replacement interventions became increasingly more attainable. RECENT FINDINGS Noninvasive clinical imaging of the tricuspid valve can be challenging, providing anincomplete assessment of unique tricuspid anatomy. 3D printing technology represents an additional tool for more comprehensive preprocedural planning of tricuspid interventions and observation of tricuspid valve geometry. Patient-specific 3D printed replicas of tricuspid valve apparatus are especially useful in highly complicated cases, where physiological tricuspid replicas allow benchtop observation of individual patient's anatomy, device implantation in physiological tricuspid valves and interactions of devices with native tricuspid tissue, frequently leading to optimization or change in operational strategy. SUMMARY Comprehensive use of clinical imaging including echocardiography, computed tomography, and cardiac magnetic resonance along with 3D printed modeling is key to successful tricuspid repair and replacements. Patient-specific 3D printed models of tricuspid anatomy can facilitate preprocedural planning, educate patients and clinicians, and improve device design, leading to the overall improvement of patients' outcomes and care.

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Graphical abstract

Background: Women with polycystic ovary syndrome (PCOS) have increased risk of pregnancy-associated complications. However, there is scarcity of data on the trends, outcomes, and predictors of cardiovascular (CV) complications associated with PCOS diagnosis during delivery hospitalizations in the United States. Methods and Results: We used data from the National Inpatient Sample. ICD-9 or ICD-10 codes were used to identify delivery hospitalizations and PCOS diagnosis. A total of 71,436,308 weighted US hospitalizations for deliveries were identified from 2002 to 2019. Of the included hospitalizations, 0.3% were among women with PCOS (n=195,675). PCOS women were older (mean 30 vs 28 years, p Conclusions: Over a 17-year period, prevalence of PCOS and obesity increased among childbearing U.S. women. Women with PCOS had higher risks of preeclampsia/eclampsia, peripartum cardiomyopathy, heart failure, pulmonary edema, and venous thromboembolism. Moreover, delivery hospitalizations with PCOS diagnosis were associated with increased length and cost of hospitalization. Strategies to optimize pre-pregnancy cardiometabolic health may be particularly important to improve maternal CV outcomes.

A left atrial ridge is an anomaly of irregular fusion between the septum primum and septum secundum.1 Aberrant fusion of the septa results in thickened and fibrotic tissue along the region of the fossa ovalis that will occasionally protrude into the left atrium.2 The presence of a left atrial ridge has multiple clinical implications due to its close proximity to the fossa ovalis. The location of this uncommon incongruence may make transseptal catheter-based approaches more challenging, underscoring the importance of imaging guidance to determine the ideal transseptal puncture site.

Introduction: Middle Eastern (ME) immigrants are one of the fastest-growing groups in the US. Several studies have noted a relatively high burden of CVD in ME countries. In the US, while their risk profile has been partially described as part of immigrant studies, the burden of risk factors and ASCVD have not been studied in detail among ME immigrants. Methods: We used 2012-2018 data from the National Health Interview Survey (NHIS), a US nationally representative survey. ME origin was ascertained through self-reported region of birth. ASCVD and CVD risk factors were also self-reported. We compared these to US-born non-Hispanic white (NHW) individuals in the US, using chi-square tests and logistic regression models. Results: Among 139,778 adults included, 886 (representing 1.3 million individuals, mean age 46.8) were of ME origin, and 138,892 were US-born NHWs (representing 150 million US adults, mean age 49.3). ME participants were more likely to have higher education, lower income and be uninsured. The age-adjusted prevalence of hypertension (22.7% vs 27.8%) and obesity (22.1% vs 32%) were significantly lower in MEs vs NHWs participants, respectively. There were no significant differences between the groups in the age-adjusted prevalence of ASCVD, diabetes, hyperlipidemia, and smoking. Only physical inactivity was higher among ME individuals (Fig) . In multivariable analyses, ME participants had lower odds of hypertension (OR 0.71, 95% CI 0.61, 0.83) and obesity (OR 0.61, 95% CI 0.52, 0.72), and higher odds of physical inactivity (OR 1.30, 95% CI 1.11, 1.53), with no significant differences in the other factors or ASCVD (Fig) . Conclusions: ME immigrants in the US exhibit a more favourable cardiovascular risk profile compared to NHWs. Further studies are needed to determine whether this finding is related to lower risk, selection of a healthier ME subgroup in NHIS, or possible under-detection of cardiovascular risk factors in ME immigrants living in the US.

This study aimed to evaluate whether baseline tricuspid regurgitation (TR) impacted clinical outcomes after mitral valve transcatheter edge-to-edge repair (M-TEER) for severe secondary mitral regurgitation (MR).Baseline TR is common among patients undergoing M-TEER for secondary MR, although its impact on clinical outcomes is unclear.The Cochrane Library, PubMed/MEDLINE, and Google Scholar were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from January 1, 2011 through January 31, 2021. Randomized controlled trials and nonrandomized prospective studies that evaluated baseline TR by echocardiography before M-TEER for MR were included. The primary outcome was a composite of mortality and heart failure hospitalization (HFH) at 1-year.A total of 5 studies (n = 1395 patients) were included in the primary analysis. Concurrent moderate/severe TR was associated with a worse 1 year composite of all-cause mortality and HFH (OR: 2.13; 95% CI: 1.12-4.05; p = 0.02) after M-TEER for severe MR. In studies that reported TR grade pre- and post-M-TEER for severe MR, 32% of patients with moderate-to-severe baseline TR had a reduction in TR severity after the intervention.Baseline moderate-to-severe TR was associated with increased 1-year mortality and heart failure hospitalizations among patients undergoing M-TEER. Further randomized studies are needed to assess the interaction of TR among patients undergoing M-TEER.

Incidence of multivalvular heart disease is increasing, with aortic stenosis and mitral regurgitation being the most common. Data are limited on outcomes of patients undergoing multivalvular surgery. The purpose of this study was to evaluate contemporary trends and in-hospital outcomes for combined surgical aortic valve replacement (SAVR) and mitral valve repair (MVr) or replacement (MVR).We identified patient hospitalizations aged ≥18 years who underwent SAVR + MVr or MVR between 2004 and 2018 using the National Inpatient Sample. Data were weighted to estimate national estimates of the entire US hospitalized population. Exclusion criteria included endocarditis, history of heart transplant or left ventricular assist device, and any other concomitant valve surgery.Between January 1, 2004, and December 31, 2018, there were 68,882 weighted admissions for SAVR with concomitant mitral valve surgery. Overall, in-hospital mortality was 8.34% with significantly higher inpatient mortality in SAVR + MVR group compared with SAVR + MVr group (9.91% vs 5.57%, p 0.001). During the study period, adjusted in-hospital mortality decreased in both SAVR + MVr group (p-trend 0.004) and SAVR + MVR group (p-trend0.001). Age ≥70 years was associated with higher in-hospital mortality compared to those70 years (9.95% vs 6.70%, p 0.001).Combined aortic and mitral valve surgery is associated with a high risk of in-hospital mortality, especially in patients ≥ 70 years of age. Further research is needed to assess the role of transcatheter approaches in the treatment of multivalvular heart disease.

Tricuspid regurgitation (TR) is being increasingly recognized in patient population. We aimed to investigate the long-term mortality due to TR in the United States (US) and demographic disparities in TR-related mortality using "Multiple Cause of Death data" via the Centers for Disease Control and Prevention Wide-Ranging On-line Data for Epidemiologic Research datasets, 1999 to 2019. The results from present analysis suggest that TR related deaths in the US may have increased over the last 20 years. This trend may justify greater focus on timely diagnosis and management of TR.

Purpose of review This article aims to review recent landmark clinical trials that have resulted in a paradigm shift in the management of patients with mitral regurgitation. This article additionally highlights the instrumental role that structural heart disease (SHD) imaging plays in evaluation of mitral regurgitation and determining candidacy for transcatheter mitral valve repair (TMVr), in addition to the procedural guidance and detection of complications. Recent findings Edge-to-edge TMVr with the MitraClip device (Abbott Vascular, Santa Clara, California) was initially studied and subsequently approved by the US Food and Drug Administration (FDA) for treatment of primary mitral regurgitation in 2013. After the publication of a landmark clinical trial in 2018, the indications have been expanded and FDA has subsequently, in 2019, approved TMVr for patients with functional mitral regurgitation. This has been paralleled by advances in cardiac imaging with more emphasis on the role of SHD imagers as a part of the heart team. Summary TMVr has revolutionized the management of mitral regurgitation and relies heavily on SHD imaging to ensure optimal outcomes.

Background Transcatheter mitral valve replacement technologies have been developed to treat a wide range of mitral valve pathologies including primary and secondary mitral regurgitation, mitral stenosis, in addition to degenerative bioprosthetic valves and failed annuloplasty rings. Objective Transesophageal echocardiography, particularly with use of 3-dimensional imaging is key in successfully guiding these interventions. In this review, we highlight the key role of 3D transesophageal echocardiography in guiding TMVR, including valve-in-native valve, valve-in-prosthetic valve, valve-in-prosthetic ring, and valve-in-mitral annular calcification interventions.

Of the 100,000-plus valve surgeries performed each year in the United States, up to 6% of those develop complications from prosthetic valve dysfunction. Prosthetic valve dysfunction (PVD) can be life threatening and often challenging to diagnose. In this review, we discuss the prevalence and incidence of PVD, explore its different etiologies, and assess the role of multimodality imaging with an emphasis on cardiac multidetector computed tomography (MDCT) for evaluating patients with PVD. We also investigate the utility of MDCT in preprocedural planning for transcatheter devices and redo surgical planning and discuss management strategies for patients with PVD.

The effectiveness of cardiovascular disease (CVD) and diabetes care delivered by NPs and physician assistants (PAs), and resource use by these providers has not been studied.We performed regression analyses of patients with diabetes or CVD with a primary care visit in 130 Veterans Affairs (VA) facilities to assess the association between provider type and effectiveness or resource use.The diabetes cohort consisted of 156,034 patients assigned to NPs and 54,590 assigned to PAs. Glycemic and BP control, statin use, number of primary or specialty care visits, lipid panels, and A1C results were comparable between groups. The CVD cohort consisted of 185,694 patients assigned to NPs and 66,217 assigned to PAs. BP control; use of beta-blockers, statins, or antiplatelets; primary or specialty care visits; lipid panels; and number of stress tests ordered were comparable between groups.Effectiveness of care and resource use among patients in both groups were comparable.

Background 5% of patients undergoing coronary stenting have an indication for anticoagulation. The aim of our study was to determine the bleeding rates and complications in patients on triple oral antithrombotic therapy (TOAT) after coronary stenting. Methods We studied patients who underwent coronary stenting in our institution between 2003-2013 and were started on TOAT. Bleeding was the primary outcome. Results Totally, 999 patients were treated with TOAT with a median follow up of 127 days. All patients were treated with warfarin as an anticoagulant. 267 patients (26.7%) developed a total of 331 bleeding events. 100 patients had bleeding during the first 30 days of therapy. Major bleeding, minor bleeding, bleeding requiring medical attention, and minimal bleeding developed in 2.9%, 3.3%, 17.2%, and 3.3% of the patients respectively as their most significant bleeding event. Patients with anticoagulation initiated at time of stenting had a significantly higher bleeding rate compared to those already on chronic anticoagulation [adjusted HR (95% CI): 1.37 (1.03–1.79), P = 0.03]. The bleeding likelihood was significantly higher for patients with drug-eluted stents (DES) compared to bare-metal stents (BMS) [adjusted OR (95% CI): 1.52 (1.14 − 2.04), P

Paravalvular leaks (PVL) occur in 2–12% of patients after mitral valve replacement and in 1–5% after aortic valve replacement 1,2 and can cause heart failure and/or hemolytic anemia. Redo surgery h...

Single leaflet detachment (SLD) of the MitraClip device occurs in 5% of patients. It is a cause of recurrent mitral regurgitation (MR), usually within the first 30 days after implantation. 60-year-old male with remote coronary artery bypass surgery and severe MR status post 2 MitraClips at A2/P2

A 75-year-old man with a medical history of sick sinus syndrome and left bundle branch block presented for evaluation of chest pain. The patient had a dual-chamber permanent pacemaker. Figure 1 shows his electrocardiogram (ECG).

Transcatheter aortic valve replacement (TAVR) is a viable option for patients with severe chronic obstructive pulmonary disease (COPD) who are deemed inoperable or high risk for surgery. We sought to determine outcomes of patients with severe aortic stenosis (AS) and severe COPD referred for aortic valve replacement (AVR). One hundred thirty-one patients with severe AS and severe COPD (GOLD criteria) were evaluated at our center between 2008 and 2013 and were divided retrospectively into 4 groups: 1-medical management, 2-balloon aortic valvuloplasty, 3-surgical aortic valve replacement (SAVR), and 4-TAVR. Baseline, clinical, and echo data were recorded. Primary outcome was cardiovascular death. From the study cohort, 54 (41.2%), 29 (22.1%), 21 (16.0%), and 27 (20.6%) were included in groups 1-4, respectively; the age was 74.9 ± 8.8, 76.2 ± 8.8, 78.8 ± 7.4, and 82.8 ± 6.8 years, respectively (P0.01). There was no significant difference between the groups for hypertension, diabetes, aortic valve area or gradients, forced expiratory volume in first second, right ventricular systolic pressure, ejection fraction, and Society of Thoracic Surgeons predicted risk of mortality score. At 3 ± 1.5 years, death occurred in 87%, 97%, 47.7%, and 51.8% of patients in groups 1-4, respectively. Heart failure readmissions occurred in 43%, 42%, 9.6%, and 14.8% of patients in groups 1-4, respectively. When SAVR and TAVR groups were compared, there was no significant difference in survival (P = 0.719) or heart failure readmissions (P = 0.19). In patients with severe or very severe COPD and severe AS, replacing the severely stenotic aortic valve by either SAVR or TAVR improves survival and reduces rehospitalization compared with medical therapy or balloon aortic valvuloplasty.