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Background The current standard of care for the treatment of patients with primary mitral regurgitation (MR) is surgical mitral valve repair. Transcatheter edge‐to‐edge repair with the MitraClip device provides a less invasive treatment option for patients with both primary and secondary MR. Worldwide, >150 000 patients have been treated with the MitraClip device. However, in the United States, MitraClip is approved for use only in primary patients with MR who are at high or prohibitive risk for mitral valve surgery. The REPAIR MR (Percutaneous MitraClip Device or Surgical Mitral Valve Repair in Patients With Primary Mitral Regurgitation Who Are Candidates for Surgery) trial is designed to compare early and late outcomes associated with transcatheter edge‐to‐edge repair with the MitraClip and surgical repair of primary MR in older or moderate surgical risk patients. Methods and Results The REPAIR MR trial is a prospective, randomized, parallel‐controlled, open‐label multicenter, noninferiority trial for the treatment of severe primary MR (verified by an independent echocardiographic core laboratory). Patients with severe MR and indications for surgery because of symptoms (New York Heart Association class II–IV), or without symptoms with left ventricular ejection fraction ≤60%, pulmonary artery systolic pressure >50 mm Hg, or left ventricular end‐systolic diameter ≥40 mm are eligible for the trial provided they meet the moderate surgical risk criteria as follows: (1) ≥75 years of age, or (2) if Conclusions The REPAIR MR trial will determine the safety and effectiveness of transcatheter edge‐to‐edge repair with the MitraClip in patients with primary MR who are at moderate surgical risk and are candidates for surgical MV repair. The trial will generate contemporary comparative clinical evidence for the MitraClip device and surgical MV repair. Registration https://clinicaltrials.gov/ct2/show/NCT04198870 ; NCT04198870.

During the past 2 decades, the dynamic nature of valvular heart disease has become a recognized phenomenon. Changes in loading conditions, heart rate, and ventricular contractility that occur with exercise can alter the physiological effects of valvular disease.1,2 Disparity between resting evaluation of valve dysfunction and patient symptoms is not uncommon. Stress echocardiography (SE) has emerged as a modality able to provide new diagnostic information by identifying dynamic changes in the severity of valve stenosis on exertion responsible for symptoms and evaluate the severity of valve disease in altered flow states.3 This review seeks to review critically the existing evidence base, identify new emerging prognostic markers, evaluate their role in clinical practice, and identify future directions for research. The clinical scenarios where SE aids diagnosis and has prognostic value include the evaluation of asymptomatic severe aortic stenosis (AS), low-flow (LF), low-gradient (LG) AS, and moderate AS with symptoms (Table). View this table: Table. Clinical Use of Stress Echocardiography in Stenotic Valvular Heart Disease The prognosis of patients with symptomatic, severe AS is dismal.4 The prognosis for those who are asymptomatic is more favorable with a

Background— Cardiovascular magnetic resonance (CMR) can provide important structural information in patients undergoing transcatheter aortic valve implantation. Although CMR is considered the standard of reference for measuring ventricular volumes and mass, the relationship between CMR findings of right ventricular (RV) function and outcomes after transcatheter aortic valve implantation has not previously been reported. Methods and Results— A total of 190 patients underwent 1.5 Tesla CMR before transcatheter aortic valve implantation. Steady-state free precession sequences were used for aortic valve planimetry and to assess ventricular volumes and mass. Semiautomated image analysis was performed by 2 specialist reviewers blinded to patient treatment. Patient follow-up was obtained from the Office of National Statistics mortality database. The median age was 81.0 (interquartile range, 74.9–85.5) years; 50.0% were women. Impaired RV function (RV ejection fraction ≤50%) was present in 45 (23.7%) patients. Patients with RV dysfunction had poorer left ventricular ejection fractions (42% versus 69%), higher indexed left ventricular end-systolic volumes (96 versus 40 mL), and greater indexed left ventricular mass (101 versus 85 g/m 2 ; P P =0.035). After adjustment for significant baseline variables, both RV ejection fraction ≤50% (hazard ratio, 2.12; P =0.017) and indexed aortic valve area (hazard ratio, 4.16; P =0.025) were independently associated with survival. Conclusions— RV function, measured on preprocedural CMR, is an independent predictor of mortality after transcatheter aortic valve implantation. CMR assessment of RV function may be important in the risk stratification of patients undergoing transcatheter aortic valve implantation.

Background— Radial artery (RA) aortocoronary bypass grafts anastomosed to a branch of the circumflex coronary artery have significantly better patency rates than saphenous vein (SV) grafts at 5 years, but the physiological characteristics and mechanisms involved are not clearly defined. We compared RA and SV graft vasomotor and flow responses to endothelium-dependent and -independent stimuli 5 years after surgery in a subgroup of patients enrolled in the Radial artery versus Saphenous Vein Patency (RSVP) trial. Methods and Results— Twenty-seven patients were included in the study (RA, n=15; SV, n=12). Graft blood flow was calculated from flow velocity, measured by intracoronary Doppler, and luminal diameter, measured by quantitative coronary angiography, before and after intragraft infusions of adenosine, acetylcholine, and isosorbide dinitrate. At rest, RA luminal diameters were significantly smaller than SV luminal diameters ( P =0.029), blood flow velocity was greater in RA than SV ( P =0.008), and volume blood flows were similar. RA but not SV dilated in response to adenosine and isosorbide dinitrate (all P Conclusions— Five years after surgery, RA coronary bypass conduits grafted to a single coronary territory demonstrated preserved flow-mediated vasodilatation, whereas SV grafts did not. Our results may provide insight into the more favorable patency of RA grafts over SV grafts. Clinical Trial Registration— http://www.clinicaltrials.gov. Unique identifier: NCT00139399.

Background: High levels of B-type natriuretic peptide (BNP) have been shown to predict outcomes following transcatheter aortic valve implantation (TAVI). However, the relationship between pre-procedural BNP levels and magnetic resonance imaging (MRI) parameters of cardiac function has not previously been described in patients with severe aortic stenosis undergoing TAVI. Methods: 108 patients underwent cardiac MRI and had measurements of BNP taken prior to TAVI. MRI was performed using a 1.5T scanner; steady-state free precession sequences were used for aortic valve planimetry and to assess ventricular volumes and mass. Gadolinium enhancement was assessed after injection of 0.1 mmol/kg of gadolinium contrast agent. Semi-automated image analysis was performed by two specialist reviewers blinded to patient treatment. Results: The mean age of the population studied was 79 years (IQR 74-85); mean follow-up was 805 days (IQR 368-1025). The mean BNP level was 698 ng/l (range 14-6048); univariate linear regression showed significant relationships between BNP and left ventricular (LV) ejection fraction (p170ng/l to be the optimal cutoff for the prediction of all-cause mortality. Survival curve analysis showed a significantly increased risk of all-cause mortality in patients with BNP>170ng/l and MRI LV ejection fraction Conclusions: In patients with severe aortic stenosis undergoing TAVI, BNP levels are closely correlated with LV function, indexed LV mass, and both end-systolic and end-diastolic volumes, as measured by MRI. Patients with BNP>170ng/l and MRI LV ejection fraction

A 61-year-old woman with no risk factors for cardiovascular disease presented to her local hospital with symptoms of exertional angina. The resting ECG was unremarkable, but during exercise treadmill testing, the patient had her usual symptoms associated with >2-mm downsloping ST-segment depression in the inferolateral leads, which took 13 minutes to resolve. Urgent coronary angiography revealed a normal left main stem, left anterior descending artery, and circumflex artery (Figure 1; online-only Data Supplement Movie I), but right coronary artery cannulation proved impossible. The patient had chest pain during the procedure, and an aortogram was performed both to exclude dissection and to attempt to identify the right coronary artery (Figure 1; online-only Data Supplement Movie II). There was no dissection, but the right coronary artery was still not seen. As a result, contrast-enhanced 64-slice computed tomography coronary angiography was requested. This showed a small, anomalous right coronary artery but also revealed a well-defined low-attenuation filling defect consistent with a mass adjacent to the left coronary cusp of the aortic valve (Figure 1). To obtain better tissue characterization of this mass, cardiovascular magnetic resonance was performed. This demonstrated a mobile, noncalcified spherical structure attached to the aortic valve with intermediate signal intensity …

Our study showed that 5 years after aortocoronary bypass graft surgery, radial artery grafts had preserved flow-mediated dilatation, whereas saphenous vein (SV) grafts had not.1 In agreement with Brugaletta et al, we feel it would be ideal to know the preexisting vasomotor response of the study grafts in all patients. Unfortunately, not all the patients who were studied at 3 months agreed to participate at 5 years.1,2 Four patients participated in Doppler studies at both follow-ups (radial artery=2 and SV=2), and we believe that the numbers are …

A 36-year-old Afro-Caribbean woman presented with recurrent syncope and shortness of breath after a long-haul flight. On admission, ECG revealed sinus tachycardia at 130 bpm and mildly flattened T waves in V2 through V5 (Figure 1a). D-Dimers were elevated (663 ng/mL), and blood gases showed hypoxia. Chest x-ray was unremarkable (Figure 1b). Family history revealed that the patient’s mother had suffered a previous deep venous thrombosis. Figure 1. a, ECG showing sinus tachycardia and mildly flattened T waves in V2 through V5. b, Chest x-ray with unremarkable findings. The initial clinical presentation was consistent with pulmonary embolism, confirmed by computed tomographic scan that showed a large saddle-shaped embolus in the pulmonary trunk extending into the right main pulmonary artery (Figure 2a), the right ventricle, the right atrium, and the inferior vena cava (IVC). There was also a smaller extension into the left main pulmonary artery as well as smaller, segmental, and subsegmental thrombi. Figure 2. a, Contrast-enhanced pulmonary computed tomography on admission showing a large saddle embolus in the pulmonary trunk and right main pulmonary artery. b, Contrast-enhanced pulmonary computed tomography after the first thrombolytic treatment showing resolution of the large saddle-shaped embolus in the pulmonary trunk and right main pulmonary artery. Given the extensive radiological findings along with clinical deterioration, the patient received a thrombolytic regimen with streptokinase. A repeat scan 12 hours after initiation of thrombolytic therapy showed that the saddle-shaped embolus in the pulmonary trunk had resolved (Figure 2b), but thrombotic elements in the right heart cavities and the IVC remained. An echocardiogram confirmed the presence …

A 57-year-old man presented with shortness of breath on exertion following an inferior myocardial infarction 5 months previously. Echocardiogram at the local hospital showed a grossly dilated left ventricle (diameter 9.4 cm) with an ejection fraction of 29%. A ventriculogram confirmed the diagnosis of a large left ventricular (LV) aneurysm, and the patient was referred for surgical assessment and possible intervention. Presurgical cardiovascular magnetic resonance (CMR) for detailed delineation of the anatomy showed a large false aneurysm (Figures …