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Selection of transcatheter valve size using preprocedural computed tomography (CT) is standardized and well established. However, valve sizing for surgical aortic valve replacement (SAVR) is currently performed intraoperatively by using sizers, which may result in variation among operators and risk for prosthesis-patient mismatch. This study evaluated the usefulness of CT annulus measurement for SAVR valve sizing. This study included patients who underwent SAVR using Inspiris or Magna Ease and received preoperative electrocardiogram-gated CT imaging. Starting from June 2022, study investigators applied a CT sizing algorithm using CT-derived annulus size to guide minimum SAVR label size. The final decision of valve selection was left to the operating surgeon during SAVR. The study compared the appropriateness of valve selection (comparing implanted size with CT-predicted size) and prosthesis-patient mismatch rates without aortic root enlargement between 2 cohorts: 102 cases since June 2022 (CT sizing cohort) and 180 cases from 2020 to 2021 (conventional sizing cohort). Implanted size smaller than CT predicted size and severe prosthesis-patient mismatch were significantly lower by CT sizing than by conventional sizing (12% vs 31% [ P =.001] and 0% vs 6% [ P =.039], respectively). Interoperator variability was a factor associated with implanted size smaller than CT predicted with conventional sizing, whereas it became nonsignificant with CT sizing. Applying CT sizing to SAVR led to improved valve size selection, less prosthesis-patient mismatch, and less interoperator variability. CT sizing for SAVR could also be used to predict prosthesis-patient mismatch before SAVR and identify patients who need aortic root enlargement. [Display omitted] [ABSTRACT FROM AUTHOR]

Quantification of myocardial changes in severe aortic stenosis (AS) is prognostically important. The potential for comprehensive myocardial assessment pre–transcatheter aortic valve replacement (TAVR) by computed tomography angiography (CTA) is unknown. This study sought to evaluate whether quantification of left ventricular (LV) extracellular volume—a marker of myocardial fibrosis—and global longitudinal strain—a marker of myocardial deformation—at baseline CTA associate with post-TAVR outcomes. Consecutive patients with symptomatic severe AS between January 2021 and June 2022 who underwent pre-TAVR CTA were included. Computed tomography extracellular volume (CT-ECV) was derived from septum tracing after generating the 3-dimensional CT-ECV map. Computed tomography global longitudinal strain (CT-GLS) used semi-automated feature tracking analysis. The clinical endpoint was the composite outcome of all-cause mortality and heart failure hospitalization. Among the 300 patients (80.0 ± 9.4 years of age, 45% female, median Society of Thoracic Surgeons Predicted Risk of Mortality score 2.80%), the left ventricular ejection fraction (LVEF) was 58% ± 12%, the median CT-ECV was 28.5% (IQR: 26.2%-32.1%), and the median CT-GLS was −20.1% (IQR: −23.8% to −16.3%). Over a median follow-up of 16 months (IQR: 12-22 months), 38 deaths and 70 composite outcomes occurred. Multivariable Cox proportional hazards model, accounting for clinical and echocardiographic variables, demonstrated that CT-ECV (HR: 1.09 [95% CI: 1.02-1.16]; P = 0.008) and CT-GLS (HR: 1.07 [95% CI: 1.01-1.13]; P = 0.017) associated with the composite outcome. In combination, elevated CT-ECV and CT-GLS (above median for each) showed a stronger association with the outcome (HR: 7.14 [95% CI: 2.63-19.36]; P < 0.001). Comprehensive myocardial quantification of CT-ECV and CT-GLS associated with post-TAVR outcomes in a contemporary low-risk cohort with mostly preserved LVEF. Whether these imaging biomarkers can be potentially used for the decision making including timing of AS intervention and post-TAVR follow-up will require integration into future clinical trials. [Display omitted] [ABSTRACT FROM AUTHOR]

[Display omitted] [ABSTRACT FROM AUTHOR]

Tricuspid regurgitation (TR) is a highly prevalent and heterogeneous valvular disease, independently associated with excess mortality and high morbidity in all clinical contexts. TR is profoundly undertreated by surgery and is often discovered late in patients presenting with right-sided heart failure. To address the issue of undertreatment and poor clinical outcomes without intervention, numerous structural tricuspid interventional devices have been and are in development, a challenging process due to the unique anatomic and physiological characteristics of the tricuspid valve, and warranting well-designed clinical trials. The path from routine practice TR detection to appropriate TR evaluation, to conduction of clinical trials, to enriched therapeutic possibilities for improving TR access to treatment and outcomes in routine practice is complex. Therefore, this paper summarizes the key points and methods crucial to TR detection, quantitation, categorization, risk-scoring, intervention-monitoring, and outcomes evaluation, particularly of right-sided function, and to clinical trial development and conduct, for both interventional and surgical groups. [Display omitted] • TR is profoundly undertreated by surgery and is often discovered late in patients presenting with right-sided heart failure. This review sheds light on the multimodality imaging of TR, the existing gaps in the published reports, and how to optimize outcomes of clinical trials. • TR detection, quantitation, categorization, risk-scoring, intervention-monitoring, and outcomes evaluation, particularly of right-sided function, are crucial for the appropriate management of these patients and for clinical trial development and conduct, for both interventional and surgical groups. • Protocolized care with routine standardized definition of TR causes/mechanisms and application of standardized quantitative methods to measure TR is a crucial step. Beyond the cursory assessment of cardiac remodeling and RV function, cardiac CT and MRI quantification represent crucial steps that warrant establishing rigorous sequences applicable in routine practice. [ABSTRACT FROM AUTHOR]

Pectus excavatum (PEx) can cause cardiopulmonary limitations due to cardiac compression and displacement. There is limited data on electrocardiogram (ECG) alterations before and after PEx surgical repair, and ECG findings suggesting cardiopulmonary limitations have not been reported. The aim of this study is to explore ECG manifestations of PEx before and after surgery including associations with exercise capacity. A retrospective review of PEx patients who underwent primary repair was performed. ECGs before and after surgical correction were evaluated and the associations between preoperative ECG abnormalities and cardiopulmonary function were investigated. In total, 310 patients were included (mean age 35.1 ± 11.6 years). Preoperative ECG findings included a predominant negative P wave morphology in V1, and this abnormal pattern significantly decreased from 86.9% to 57.4% (p < 0.001) postoperatively. The presence of abnormal P wave amplitude in lead II (>2.5 mm) significantly decreased from 7.1% to 1.6% postoperatively (p < 0.001). Right bundle branch block (RBBB) (9.4% versus 3.9%, p < 0.001), rsr' patterns (40.6% versus 12.9%, p < 0.001), and T wave inversion in leads V1-V3 (62.3% vs 37.7%, p < 0.001) were observed less frequently after surgery. Preoperative presence of RBBB (OR = 4.8; 95%CI 1.1–21.6) and T wave inversion in leads V1–3 (OR = 2.3; 95%CI 1.3–4.2) were associated with abnormal results in cardiopulmonary exercise testings. Electrocardiographic abnormalities in PEx are frequent and can revert to normal following surgery. Preoperative RBBB and T wave inversion in leads V1–3 suggested a reduction in exercise capacity, serving as a marker for the need for further cardiovascular evaluation of these patients. ECG manifestations of Pectus Excavatum ECG abnormalities are common in pectus excavatum patients mostly due to the anatomical displacement and rotation of the heart and can revert to normal after surgical correction. Preoperative right bundle branch block and T wave inversion could be associated with abnormal cardiopulmonary function. [Display omitted] • ECG abnormalities are frequent in Pectus Excavatum patients. • Most frequent alterations included P wave abnormalities, RBBB, rsr' patterns, and T wave inversion. • All these abnormalities were observed less frequently after surgical repair. • RBBB and T wave inversion in leads V1–3 were associated with a reduction in oxygen consumption. [ABSTRACT FROM AUTHOR]

High surgical risk may preclude mitral valve replacement in many patients. Transcatheter mitral valve replacement (TMVR) using transfemoral transseptal access is a novel technology for the treatment of mitral regurgitation (MR) in high-risk surgical patients. This analysis evaluates 30-day and 1-year outcomes of the Intrepid TMVR Early Feasibility Study in patients with ≥moderate-severe MR. The Intrepid TMVR Early Feasibility Study is a multicenter, prospective, single-arm study. Clinical events were adjudicated by a clinical events committee; endpoints were defined according to Mitral Valve Academic Research Consortium criteria. A total of 33 patients, enrolled at 9 U.S. sites between February 2020 and August 2022, were included. The median age was 80 years, 63.6% of patients were men, and mean Society of Thoracic Surgeons Predicted Risk of Mortality for mitral valve replacement was 5.3%. Thirty-one (93.9%) patients were successfully implanted. Median postprocedural hospitalization length of stay was 5 days, and 87.9% of patients were discharged to home. At 30 days, there were no deaths or strokes, 8 (24.2%) patients had major vascular complications and none required surgical intervention, there were 4 cases of venous thromboembolism all successfully treated without sequelae, and 1 patient had mitral valve reintervention for severe left ventricular outflow tract obstruction. At 1 year, the Kaplan-Meier all-cause mortality rate was 6.7%, echocardiography showed ≤mild valvular MR, there was no/trace paravalvular leak in all patients, median mitral valve mean gradient was 4.6 mm Hg (Q1-Q3: 3.9-5.3 mm Hg), and 91.7% of survivors were in NYHA functional class I/II with a median 11.4-point improvement in Kansas City Cardiomyopathy Questionnaire overall summary scores. The early benefits of the Intrepid transfemoral transseptal TMVR system were maintained up to 1 year with low mortality, low reintervention, and near complete elimination of MR, demonstrating a favorable safety profile and durable valve function. [Display omitted] [ABSTRACT FROM AUTHOR]

Brugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). Risk predictive scores were previously developed with various performances. The purpose of this study was to create a novel score—Predicting Arrhythmic evenT (PAT)—with internal and external validation. A systematic review was performed to identify risk factors for MAE. The odds ratios (ORs) of each factor were pooled across studies. The PAT scoring scheme was developed based on pooled ORs. The PAT score was internally validated with published 105 Asian patients (follow-up 8.0 ± 4.1 [SD] years) and externally validated with unpublished 164 multiracial patients (82.3% White, 14.6% Asian, 3.2% Black; mean follow-up 8.0 ± 6.9 years) with Brugada syndrome. Performances were assessed and compared with previous scores using receiver operating characteristic curve (ROC) analysis. Sixty-seven studies published between 2002 and 2022 from 26 countries (7358 patients) were included. Pooled ORs were estimated, indicating that 15 of 23 risk factors were significant. The PAT score was then developed accordingly. The PAT score had significantly better discrimination (ROC 0.9671) than the BRUGADA-RISK score (ROC 0.7210; P =.006), Shanghai Score System (ROC 0.7079; P =.003), and Sieira et al score (ROC 0.8174; P =.026) in an external validation cohort. PAT score ≥ 10 predicted the first MAE with 95.5% sensitivity and 89.1% specificity (ROC 0.9460) and the recurrent MAE (ROC 0.7061) with 15.4% sensitivity and 93.3% specificity. The PAT score was shown to be useful in predicting MAE for primary prevention in patients with Brugada syndrome. [Display omitted] [ABSTRACT FROM AUTHOR]

Mitral annular calcium (MAC) with severe mitral valvular dysfunction presents a complex problem, as valve replacement, either surgical or transcatheter, is challenging because of anatomy, technical considerations, concomitant comorbidities, and advanced age. The authors review the clinical and anatomical features of MAC that are favorable (green light), challenging (yellow light), or prohibitive (red light) for surgical or transcatheter mitral valve interventions. Under the auspices of the Heart Valve Collaboratory, an expert working group of cardiac surgeons, interventional cardiologists, and interventional imaging cardiologists was formed to develop recommendations regarding treatment options for patients with MAC as well as a proposed grading and staging system using both anatomical and clinical features. [Display omitted] • TMVR is emerging as an alternative for high-risk patients with MAC. • Surgical risk and anatomical features are important considerations in device choice. • MAC classification can improve patient selection and procedural outcomes. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) volume reshaping reduces myocardial wall stress and may induce reverse remodeling in patients with heart failure with reduced ejection fraction. The AccuCinch Transcatheter Left Ventricular Restoration system consists of a series of anchors connected by a cable implanted along the LV base that is cinched to the basal free wall radius. We evaluated the echocardiographic and clinical outcomes following transcatheter left ventricular restoration. We analyzed 51 heart failure patients with a left ventricular ejection fraction between 20% and 40%, with no more than 2+ mitral regurgitation treated with optimal medical therapy, who subsequently underwent transcatheter left ventricular restoration. Serial echocardiograms, Kansas City Cardiomyopathy Questionnaire scores, and 6-minute walk test distances were measured at baseline through 12 months. Primary analysis end point was change in end-diastolic volume at 12 months compared with baseline. Patients (n = 51) were predominantly male (86%) with a mean age of 56.3 ± 13.1 years. Fluoroscopy showed LV free wall radius decreased by a median of 9.2 mm amounting to a 29.6% decrease in the free wall arc length. At 12 months, the LV end-diastolic volume decreased by 33.6 ± 34.8 mL (P <.01), with comparable decreases in the LV end-systolic volume. These decreases were associated with significant improvements in the overall Kansas City Cardiomyopathy Questionnaire score (16.4 ± 18.7 points; P <.01) and 6-minute hall walk test distance (45.9 ± 83.9 m; P <.01). There were no periprocedural deaths; through the 1-year follow-up, 1 patient died (day 280) and 1 patient received a left ventricular assist device (day 13). In patients with heart failure with reduced ejection fraction without significant mitral regurgitation receiving optimal medical therapy, the AccuCinch System resulted in decreases of LV volume, as well as improved quality of life and exercise endurance. A randomized trial is ongoing (NCT04331769). [ABSTRACT FROM AUTHOR]

Anatomical and clinical criteria to define mitral transcatheter edge-to-edge repair (TEER) "unsuitability" have been proposed on the basis of a Heart Valve Collaboratory consensus opinion from physician experience with early-generation TEER devices but lacked an evidence-based approach. The aim of this study was to explore the spectrum of TEER suitability using echocardiographic and clinical outcomes from the EXPAND G4 real-world postapproval study. EXPAND G4 is a global, prospective, multicenter, single-arm study that enrolled 1,164 subjects with mitral regurgitation (MR) treated with the MitraClip G4 System. Three groups were defined using the Heart Valve Collaboratory TEER unsuitability criteria: 1) risk of stenosis (RoS); 2) risk of inadequate MR reduction (RoIR); and 3) subjects with baseline moderate or less MR (MMR). A TEER-suitable (TS) group was defined by the absence of these characteristics. Endpoints included independent core laboratory–assessed echocardiographic characteristics, procedural outcomes, MR reduction, NYHA functional class, Kansas City Cardiomyopathy Questionnaire score, and major adverse events through 30 days. Subjects in the RoS (n = 56), RoIR (n = 54), MMR (n = 326), and TS (n = 303) groups had high 30-day MR reduction rates (≤1+: RoS 97%, MMR 93%, and TS 91%; ≤2+: RoIR 94%). Thirty-day improvements in functional capacity (NYHA functional class I or II at 30 days vs baseline: RoS 94% vs 29%, RoIR 88% vs 30%, MMR 79% vs 26%, and TS 83% vs 33%) and quality of life (change in Kansas City Cardiomyopathy Questionnaire score: RoS +27 ± 26, RoIR +16 ± 26, MMR +19 ± 26, and TS +19 ± 24) were safely achieved in all groups, with low major adverse events (<3%) and all-cause mortality (RoS 1.8%, RoIR 0%, MMR 1.5%, and TS 1.3%). Patients previously deemed TEER unsuitable can be safely and effectively treated with the mitral TEER fourth-generation device. [Display omitted] [ABSTRACT FROM AUTHOR]

Heart failure (HF) is associated with both mortality and a significant decline in health status. Interatrial shunting is increasingly being investigated as a novel therapeutic option. The ALT FLOW Early Feasibility Study was designed to evaluate the safety of the Edwards left atrial to coronary sinus APTURE Transcatheter Shunt System in patients with symptomatic HF. A total of 18 centers enrolled patients with symptomatic HF with a pulmonary capillary wedge pressure >15 mm Hg at rest or 25 mm Hg during exercise. Between May 2018 and September 2022, 87 patients underwent attempted APTURE shunt implantation. Mean age was 71 years, and 53% were male. At baseline, mean left ventricular ejection fraction was 59% with 90% of the patients being in NYHA functional class III. Device success was achieved in 78 patients (90%), with no device occlusions or associated adverse events identified after implantation. The primary safety outcome occurred in only 2 patients (2.3%) at 30 days. At 6 months, health status improved: 67% of participants achieved NYHA functional class I to II status, with a 23-point improvement (P < 0.0001; 95% CI: 17-29 points) in the Kansas City Cardiomyopathy Questionnaire overall summary score. Also at 6 months, 20-W exercise pulmonary capillary wedge pressure was 7 mm Hg lower (P < 0.0001; 95% CI: −11 to −4 mm Hg) without change in right atrial pressure or other right heart function indices. In this single-arm experience, the APTURE Transcatheter Shunt System in patients with symptomatic HF was observed to be safe and resulted in reduction in pulmonary capillary wedge pressure and clinically meaningful improvements in HF symptoms and quality of life indices. [Display omitted] [ABSTRACT FROM AUTHOR]

Computed tomography angiography (CTA) assessment of myocardial extracellular volume fraction (CT-ECV) is feasible, although the protocols for imaging acquisition and post-processing methodology have varied. We aimed to identify a pragmatic protocol for CT-ECV assessment encompassing both imaging acquisition and post-processing methodologies to facilitate its clinical implementation. We evaluated consecutive patients with severe aortic stenosis undergoing evaluation for transcatheter aortic valve replacement (TAVR). Pre-contrast and 3-min-delayed CTA were obtained in systole using either helical prospective-ECG-triggered (high-pitch) or axial sequential-ECG-gated acquisition, adding to standard TAVR CTA protocol. Using a dedicated software for co-registration of CTA datasets, three methodologies for ECV measurement were evaluated: (1) mid-septum region of interest (Septal ECV), (2) averaged-global ECV (Global ECV) encompassing 16-AHA segments, and (3) average of septal and lateral segments (Averaged ECVsep and Averaged ECVlat). Among the 142 patients enrolled (median ​= ​81 years, 44% females), 8 were excluded due to significant imaging artifacts precluding Global ECV assessment. High-pitch scan mode was performed in 68 patients (48%). Suboptimal image quality for Global ECV assessment was associated with high-pitch scan mode (odds ratio: OR ​= ​2.26, p ​= ​0.036), along with the presence of intracardiac leads (OR ​= ​4.91, p ​= ​0.002), and BMI≥35 ​kg/m2 (OR ​= ​2.80, p ​= ​0.026). Septal ECV [median ​= ​29.4%] and Averaged ECVsep [29.0%] were similar (p ​= ​0.108), while Averaged ECVlat [27.5%] was lower than Averaged ECVsep (p ​< ​0.001), resulting in lower Global ECV [28.6%]. Myocardial CT-ECV assessment is feasible using a systolic sequential acquisition pre-contrast, and similar additional 3-min delayed scan. Septal ECV measurement provides similar values to Global ECV and is equally reproducible. Myocardial extracellular volume fraction assessment by cardiac computed tomography (CT-ECV) is feasible, however, the methodology for acquisition and post-processing has not been standardized. A practical workflow for myocardial CT-ECV assessment can be achieved using a specific imaging protocol encompassing a systolic sequential acquisition pre-contrast and similar 3-min delayed scan. This could be possible with any vendor. While Global CT-ECV maps allows for the identification of regional myocardial fibrosis and/or artifacts, a pragmatic post-processing with Septal ECV measurement provides similar values and is equally reproducible. [ABSTRACT FROM AUTHOR]

Commissural alignment has become an important topic in transcatheter aortic valve replacement (TAVR) because it may improve coronary access, facilitate future valve procedures, and possibly improve valve durability. The efficacy of commissural alignment with ACURATE neo2 has not yet been shown in a large population. The authors sought to determine the feasibility and success of attempting commissural alignment in an unselected TAVR population treated with the ACURATE neo2 prosthetic heart valve. A total of 170 consecutive patients underwent TAVR with a dedicated implantation technique to align the TAVR valve to the native valve. Using right-left overlap and 3-cusp views, valve orientation was adjusted by rotation of the unexpanded valve at the level of the aortic root. Effectiveness was assessed postprocedure as the degree of misalignment determined by analyzing fluoroscopic valve orientation to corresponding cusp orientation on preprocedural computed tomography. Safety endpoints included mortality, stroke/transient ischemic attack, and additional complications through 30 days. Of 170 patients, 167 (98.2%) could be analyzed for alignment, and all 170, for safety outcomes. Most patients (97%) had successful alignment (≤ mild misalignment), with 80% with commissural alignment, while the degrees of misalignment were 17% mild, 1.2% moderate, 1.8% severe. In this large evaluation of a commissural alignment technique, alignment was achieved in nearly all patients without safety concerns or impact to procedure duration. Commissural alignment appears effective and safe across all patients with this novel technique. [Display omitted] [ABSTRACT FROM AUTHOR]

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) may be associated with adverse hemodynamics, which might affect clinical outcomes. This study sought to evaluate the extent and predictors of transcatheter heart valve (THV) deformity in ViV TAVR and the relation to postprocedural hemodynamics. We examined 53 patients who underwent ViV TAVR in surgical heart valves with self-expanding Evolut prostheses. THV deformation was examined using cardiac computed tomography prospectively performed 30 days after ViV TAVR, and correlated with 30-day echocardiographic hemodynamic data. Near complete expansion of the functional portion of the implanted ViV prostheses (ie, >90%) was observed in 16 (30.2%) patients. Factors related to greater expansion of the functional portion and consequently larger neosinus volume were absence of polymer surgical frame, higher implantation and use of balloon aortic valvuloplasty or bioprosthetic valve fracture during the procedure (all P < 0.05). Underexpansion of the functional portion, but not the valve inflow frame, was closely associated with mean gradient and effective orifice area at 30 days on echocardiography, with and without adjustment for the sizes of the THV and surgical heart valve. Underexpansion of the functional portion of THV prostheses is common during ViV TAVR, occurs more frequently with deep implantation and the presence of a polymer surgical stent frame, and is associated with worse postprocedural hemodynamics. Procedural techniques, such as higher implantation and balloon postdilatation, may be used to help overcome problems with THV underexpansion and improve clinical outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

Secondary (functional) tricuspid regurgitation (sTR) is common in patients with mitral regurgitation (MR). Because combined valvular heart disease affects long-term survival, in comparison with isolated MR or tricuspid regurgitation, it is essential to offer patients adequate treatment. Despite considerable experience, no conclusive data are yet available on the prognostic impact of concomitant tricuspid valve surgery at the time of mitral valve surgery. Emerging transcatheter treatments offer the opportunity to treat both conditions (MR and sTR) simultaneously or in a stepwise fashion. This review provides a clinical overview on available data regarding the rationale for treatment of sTR in patients with relevant MR undergoing mitral transcatheter edge-to-edge repair, focusing on clinical and anatomical selection criteria. [Display omitted] • Concomitant MR and TR involve a high clinical and prognostic burden. • Isolated M-TEER, concomitant approach and wait-and-see strategy can be considered. • Ipc-PH, RV-PA coupling, and an atrial-predominant phenotype may suggest considering concomitant strategy. • Further research should evaluate optimal management strategy for patients with combined disease. [ABSTRACT FROM AUTHOR]

Over the past several decades, alcohol septal ablation has become an established therapy for selected patients, in whom there is clinical improvement in symptoms as well as objective functional capacity. Patient selection is essential to success, with continued emphasis on the procedure being performed by experienced operators as part of a multidisciplinary team. In many patients, the outcomes of alcohol septal ablation are comparable to the standard of surgical myectomy. The optimization of the outcomes of alcohol septal ablation is essential for the longitudinal care of patients with hypertrophic cardiomyopathy. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular implantable electronic device (CIED) infections are associated with increased mortality and morbidity.Objective: This study sought to evaluate the impact of early vs delayed transvenous lead removal (TLR) on in-hospital mortality and outcomes in patients with CIED infection.Methods: Using the nationally representative, all payer, Nationwide Readmissions Database, we evaluated patients undergoing TLR for CIED infection between January 1, 2016, and December 31, 2018. The timing of TLR was determined on the basis of hospitalization days after the initial admission for CIED infection. The impact of early (≤7 days) vs delayed (>7 days) TLR on mortality and major adverse events was studied.Results: Of the 12,999 patients who underwent TLR for CIED infection, 8834 (68%) underwent early TLR and 4165 (32%) underwent delayed TLR. Delayed TLR was associated with a significant increase in in-hospital mortality (8.3% vs 3.5%; adjusted odds ratio 1.70; 95% confidence interval 1.43-2.03; P < .001). Subgroup analysis of patients with CIED infection and systemic infection showed that delayed TLR in patients with systemic infection was associated with a higher rate of in-hospital mortality compared with early TLR (10.4% vs 7.5%; adjusted odds ratio 1.24; 95% confidence interval 1.04-1.49; P < .019). Delayed TLR was also associated with significantly higher adjusted odds of major adverse events and postprocedural length of stay.Conclusion: These data suggest that delayed TLR in patients with CIED infection is associated with increased in-hospital mortality and major adverse events, especially in patients with systemic infection. [ABSTRACT FROM AUTHOR]

Although cardiac computed tomography angiography (CCTA) assessment of right ventricular dysfunction (RVD) is feasible, the incremental prognostic value remains uncertain in patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. This study sought to determine the incremental clinical utility of RVD identification by CCTA while accounting for clinical and echocardiographic parameters. Patients who underwent multiphasic ECG-gated functional CCTA using dual-source system for routine TAVR planning were evaluated. Biphasic contrast protocol injection allowed for biventricular contrast enhancement. CCTA-based RVD was defined as right ventricular ejection fraction (RVEF) ​< ​50%. The association of CCTA-RVD with all-cause mortality and the composite outcome of death or heart failure hospitalization after TAVR was evaluated and examined for its incremental utility beyond clinical risk assessment and echocardiographic parameters. A total of 502 patients were included (median [IQR] age, 82 [77 to 87] years; 56% men) with a median follow-up of 22 [16 to 32] months. Importantly, 126 (25%) patients were identified as having RVD by CCTA that was not identified by echocardiography. CCTA-defined RVD predicted death and the composite outcome in both univariate analyses (HR for mortality, 2.15; 95% CI, 1.44–3.22; p ​< ​0.001; HR for composite outcome, 2.11; 95% CI, 1.48–3.01; p ​< ​0.001) and in multivariate models that included clinical risk factors and echocardiographic findings (HR for mortality, 1.74; 95% CI, 1.11–2.74; p ​= ​0.02; HR for composite outcome, 1.63; 95% CI, 1.09–2.44; p ​= ​0.02). Functional CCTA assessment pre-TAVR correctly identified 25% of patients with RVD that was not evident on 2D echocardiography. The presence of RVD on CCTA independently associates with clinical outcomes post-TAVR. TOC summary: This study evaluated the presence of right ventricular dysfunction (RVD) by functional cardiac computed tomography angiography (CCTA) in 502 patients undergoing routine evaluation for transcatheter aortic valve replacement. CCTA-RVD was defined as right ventricular ejection fraction <50%, and was tested for its prognostic value beyond conventional risk factors and echocardiography. In our study, 25% of patients have RVD on CT that was not present on 2D echocardiography. CT-RVD provides independent prognostic value that is incremental to conventional clinical and echocardiographic characteristics, and therefore should be considered in routine risk stratification of patients with severe AS. [ABSTRACT FROM AUTHOR]

Transcatheter tricuspid valve interventions (TTVIs) are rapidly growing as a less invasive treatment of high surgical risk patients with advanced TR. A comprehensive anatomic and functional assessment of the tricuspid valve and right-sided chambers is essential for candidate selection and procedural planning. Advanced imaging with cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) can provide accurate anatomic and functional assessment of the tricuspid valve, its apparatus, and the right-sided chambers. In this review, we provide an updated overview of the emerging role of CCT and CMR for TR patient evaluation, TTVI planning, and follow-up. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset. Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 mL/min/m2) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory–adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed. The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P < 0.05) but not for SAPIEN 3 TAVR. In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses. [Display omitted] [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve replacement (TMVR) is a new therapy for treating symptomatic mitral regurgitation (MR) and stenosis. The proposed benefit of TMVR is the predictable, complete elimination of MR, which is less certain with transcatheter repair technologies such as TEER (transcatheter edge-to-edge repair). The potential benefit of MR elimination with TMVR needs to be rigorously evaluated against its risks which include relative procedural invasiveness, need for anticoagulation, and chronic structural valve deterioration. Randomized controlled trials (RCTs) are a powerful method for evaluating the safety and effectiveness of TMVR against current standard of care transcatheter therapies, such as TEER. RCTs not only help with the assessment of benefits and risks, but also with policies for determining operator or institutional requirements, resource utilization, and reimbursement. In this paper, the authors provide recommendations and considerations for designing pivotal RCTs for first-in-class TMVR devices. [ABSTRACT FROM AUTHOR]

Evaluation of prosthesis-patient mismatch (P-PM) after transcatheter aortic valve replacement (TAVR) by transthoracic echocardiography (TTE) has provided conflicting results regarding its impact on outcomes. Whether post-TAVR computed tomography angiography (CTA) evaluation of P-PM can improve our understanding is unknown. We aimed to evaluate the inter-modality (TTE vs. CTA) agreement, inter-valve platform (balloon-expanding valve [BEV] vs. self-expandable valve [SEV]) differences in P-PM severity, and outcomes related to P-PM after TAVR. We analyzed patients with both CTA and TTE before and after TAVR. Indexed effective orifice area was calculated using two methods: TTE-derived left ventricular outflow tract (LVOT) area from measured diameter and post-TAVR CTA-measured area. Body size specific cut-offs for P-PM severity were used: for body mass index (BMI) ​< ​30 ​kg/m2, moderate ​= ​0.66–0.85 ​cm2/m2 and severe≤0.65 ​cm2/m2; for BMI ≥30 ​kg/m2, moderate ​= ​0.56–0.70 ​cm2/m2 and severe≤0.55 ​cm2/m2. A total of 447 patients were included (median age, 83 years; 54% male). The prevalence of P-PM (moderate or severe) was lower with CTA vs. TTE (3.5% vs. 19.5%, p ​< ​0.001). The prevalence of P-PM measured by TTE was more common in BEV compared to SEV (p ​= ​0.002), while CTA assessment showed no difference in P-PM incidence and severity between TAVR platforms (p ​= ​0.40). In multivariable analysis, CTA-defined but not TTE-defined P-PM was associated with mortality after TAVR (HR:3.97; 95%CI,1.55–10.2; p ​= ​0.004). Both CTA-defined and TTE-defined P-PM were associated with the composite of death and heart failure rehospitalization. Although post-TAVR CTA substantially downgraded the prevalence of P-PM compared to TTE, it identified a subset of patients with clinically relevant P-PM which associated with outcomes. [ABSTRACT FROM AUTHOR]

The aims of this study were to describe trends and hospital variation in same-day discharge following elective percutaneous coronary intervention (PCI) and to evaluate the association between trends in same-day discharge and patient outcomes. Insights on contemporary use of same-day discharge following elective PCI are limited. In a sequential cross-sectional analysis of 819,091 patients undergoing elective PCI at 1,716 hospitals in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009, to December 31, 2017, overall and hospital-level trends in same-day discharge were assessed. Among the 212,369 patients who linked to Centers for Medicare and Medicaid Services data, the association between same-day discharge and 30-day mortality and rehospitalization was assessed. A total of 114,461 patients (14.0%) were discharged the same day as PCI. The proportion of patients with same-day discharge increased from 4.5% in the third quarter of 2009 to 28.6% in the fourth quarter of 2017. From 2009 to 2017, the rate of same-day discharge increased from 4.3% to 19.5% for femoral-access PCI and from 9.9% to 39.7% for radial-access PCI. Hospital-level variation in the use of same-day discharge persisted throughout (median odds ratio adjusted for year and radial access: 4.15). Risk-adjusted 30-day mortality did not change over time, while risk-adjusted rehospitalization decreased over time and more quickly for same-day discharge (P for interaction <0.001). In the past decade, a large increase in the use of same-day discharge following elective PCI was not associated with worse 30-day mortality or rehospitalization. Hospital-level variation in same-day discharge may represent an opportunity to reduce costs without compromising patient outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

The purpose of this study was to introduce a novel clinically relevant nomenclature system for the TV and determine the relative incidence of each morphological type. With the rapid development of transcatheter tricuspid valve (TV) repair techniques, there is a growing recognition of the variability in leaflet morphology and a need for a unified nomenclature, which could aid in procedural planning and execution. Patients from 4 medical centers (2 in Europe, 2 in the United States) referred for transesophageal echocardiography (TEE) to assess native TV function, were retrospectively analyzed for leaflet morphology with the use of a novel classification scheme. Four morphological types were identified: type I, 3 leaflets; type II, 2 leaflets; type IIIA, 4 leaflets with 2 anterior; type IIIB, 4 leaflets with 2 posterior; type IIIC, 4 leaflets with 2 septal; and type IV, >4 leaflets. A total of 579 patients were analyzed: mean age 78.1 ± 8.0 years, 50.4% female, 70.9% in atrial fibrillation, and 32.2% with previous left heart surgery or transcatheter intervention. Tricuspid regurgitation was moderate or less in 9.4%, severe in 40.5%, massive in 32.3%, and torrential in 17.7%. The etiology of tricuspid regurgitation was primary in 9.4%, mixed in 10.8%, and secondary in all of the other patients (18.6% atriogenic/isolated). The incidence of type I morphology was 312 of 579 (53.9%), type II was 26 of 579 (4.5%), type IIIA was 15 of 579 (2.6%), type IIIB was 186 of 579 (32.1%), type IIIC was 22 of 579 (3.8%), and type IV was 14 of 579 (2.4%). A novel TV leaflet nomenclature classification scheme can be used to identify 4 types of TV morphologies with the use of TEE imaging. From this multinational retrospective study, the TV has 3 well defined leaflets in only ∼54% of patients and 4 functional leaflets in ∼39% of patients, with type IIIB (2 posterior leaflets) being the most common of the latter. The utility of this classification scheme deserves further study. [Display omitted] [ABSTRACT FROM AUTHOR]

Functional mitral regurgitation (FMR) is a common and complex valve disease, in which severity and risk stratification is still a conundrum. Although risk increases with FMR severity, it is modulated by subjacent left ventricular (LV) disease. The extent of LV remodeling and dysfunction is traditionally evaluated by echocardiography, but a growing body of evidence shows that myocardial fibrosis (MF) assessment by cardiac magnetic resonance (CMR) may complement risk stratification and inform treatment decisions. This review summarizes the current knowledge on the comprehensive evaluation that CMR can provide for patients with FMR, in particular for the assessment of MF and its potential impact in clinical decision-making. [Display omitted] • FMR is a common and complex valve disease, in which proper severity and risk stratification is still a conundrum. • MF assessed by CMR is a robust predictor of adverse events beyond conventional LV function and remodeling and represents an emergent marker of risk and procedural outcomes in patients with FMR. • The precise quantification of LV MF and the hemodynamic severity of FMR in 1-stop elevate CMR as a promising imaging modality to advance the understanding of this challenging disease. • Future research is needed to explore how the use of LV MF quantification can improve candidate selection for evolving transcatheter therapies. [ABSTRACT FROM AUTHOR]

Aims: Data regarding outcomes for patients with severe aortic stenosis (AS) with concomitant aortic insufficiency (AI), undergoing transcatheter aortic valve replacement (TAVR) are limited. This study aimed to analyze the prevalence of severe AS with concomitant AI among patients undergoing TAVR and outcomes of TAVR in this patient group.Methods and Results: Using data from the STS/ACC-TVT Registry, we identified patients with severe AS with or without concomitant AI who underwent TAVR between 2011 and 2016. Patients were categorized based on the severity of pre-procedural AI. Multivariable proportional hazards regression models were used to examine all-cause mortality and heart failure (HF) hospitalization at 1-year. Among 54,535 patients undergoing TAVR, 42,568 (78.1%) had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001).Conclusions: Severe AS with concomitant AI is common among patients undergoing TAVR, and is associated with lower 1 year mortality and HF hospitalization. Future studies are warranted to better understand the mechanisms underlying this benefit.Short Abstract: In this nationally representative analysis from the United States, 78.1% of patients undergoing TAVR had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001). [ABSTRACT FROM AUTHOR]

The aim of this study was to describe the anatomic and functional changes in left-sided chambers using computed tomographic angiography (CTA) from baseline to 1 month after transcatheter mitral valve replacement (TMVR) with the Tendyne prosthesis. Data on changes in left atrial and left ventricular (LV) volumes after TMVR implantation are very limited. Patients who underwent TMVR with the Tendyne prosthesis between 2015 and 2018 were analyzed. Changes in LV end-diastolic volume, ejection fraction, LV mass, left atrial volume, and global longitudinal strain were assessed at baseline and 1 month after TMVR using CTA. Specific Tendyne implant characteristics were identified and correlated with remodeling changes. A total of 36 patients (median age 74 years; interquartile range [IQR]: 69 to 78 years; 78% men; 86% with secondary mitral regurgitation) were included in this study. There were significant decreases in LV end-diastolic volume (281 ml [IQR: 210 to 317 ml] vs. 239 ml [IQR: 195 to 291 ml]; p < 0.001), LV ejection fraction (37% [IQR: 31% to 48%] vs. 30% [IQR: 23% to 40%]; p < 0.001), LV mass (126 g [IQR: 96 to 155 g] vs. 116 g [IQR: 92 to 140 g]; p < 0.001), left atrial volume (171 ml [IQR: 133 to 216 ml] vs. 159 ml [IQR: 125 to 201 ml]; p = 0.027), and global longitudinal strain (−11% [IQR: −17% to −8%] vs. −9% [IQR: −12% to −6%]; p < 0.001) from baseline to 1-month follow-up. Favorable LV end-diastolic volume reverse remodeling occurred in the majority (30 of 36 patients [83%]). Closer proximity of the Tendyne apical pad to the true apex (24 mm [IQR: 21 to 29 mm] vs. 35 mm [IQR: 26 to 40 mm]) was predictive of favorable remodeling (p = 0.037). TMVR with Tendyne results in favorable left-sided chamber remodeling in the majority of patients treated, as detected on CTA at 1 month after implantation. CTA identifies favorable post-TMVR changes, which could be related to specific characteristics of the device implantation. [ABSTRACT FROM AUTHOR]

This study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries. Evidence about incidence and outcomes of ACS after TAVR is scarce. We identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non–ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis. Out of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non–ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001). After TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the real-world impact of transcatheter mitral valve repair (TMVR) on hospitalizations and Medicare costs pre- versus post-TMVR. TMVR is effective in degenerative mitral regurgitation (MR) and appropriately selected patients with functional MR with high surgical risk. Patients undergoing TMVR in the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry from 2013 to 2018 were linked to Medicare claims data. Rates of hospitalizations, hospitalized days, and Medicare costs were compared 1-year pre-TMVR to 1-year post-TMVR. Across 246 sites, 4,970 patients with a median age of 83 years (interquartile range: 77 to 87 years) were analyzed. The TMVR indication was degenerative MR in 77.5% and functional MR in 16.7%. From pre- to post-TMVR, heart failure (HF) hospitalization rates (479 vs. 370 hospitalizations/1,000 person-years; rate ratio [RR]: 0.77) and cardiovascular hospitalizations (838 vs. 632; RR: 0.75) decreased significantly (p < 0.001 for all). Similarly, the rates of hospitalized days decreased for HF and cardiovascular causes (p < 0.05 for all). Following TMVR, the odds of having no Medicare costs for HF hospitalizations increased (69% vs. 79%; odds ratio: 1.67; p < 0.001). However, the average total Medicare costs per day alive among patients with any HF hospitalizations after TMVR increased significantly (p < 0.001). The HF hospitalization rates decreased for patients with functional MR (683 vs. 502; RR: 0.74) and those with degenerative MR (431 vs. 337; RR: 0.78) (p < 0.001). TMVR is associated with a decrease in cardiovascular and HF hospitalizations and a greater likelihood of having no HF Medicare costs in the year after TMVR, regardless of MR etiology. Further work is necessary to elucidate the reasons for increased costs among patients with HF hospitalizations post-TMVR. [ABSTRACT FROM AUTHOR]

New-onset left bundle branch block (N-LBBB) after transcatheter aortic valve replacement (TAVR) is a challenging clinical dilemma. In our single-center study, 60 out of 172 patients who underwent permanent pacemaker implantation (PPM) after TAVR had N-LBBB (34.9%). At a median follow-up duration of 357 days (IQR, 178; 560 days), two patients (3.5%) were completely pacemaker-dependent, and four others (7%) were partially dependent. Twelve patients (24%) recovered conduction in their left bundle at a median follow-up duration of 5 weeks (IQR, 4; 14 weeks). Due to the lack of clinical predictors of pacemaker dependency, active surveillance is warranted and may be an alternative to permanent pacemaker implantation. [ABSTRACT FROM AUTHOR]