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Background: Treatment of aortic stenosis in patients with small annuli is challenging and can result in prosthesis-patient mismatch (PPM)., Aims: We aimed to compare the forward flow haemodynamics and clinical outcomes of contemporary transcatheter valves in patients with small annuli., Methods: The TAVI-SMALL 2 international retrospective registry included 1,378 patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm 2 ) treated with transfemoral self-expanding (SEV; n=1,092) and balloon-expandable valves (BEV; n=286) in 16 high-volume centres between 2011 and 2020. Analyses comparing SEV versus BEV and supra-annular (SAV; n=920) versus intra-annular valves (IAV; n=458) included inverse probability of treatment weighting (IPTW). The primary endpoints were the predischarge mean aortic gradient and incidence of severe PPM. The secondary endpoint was the incidence of more than mild paravalvular leak (PVL)., Results: The predischarge mean aortic gradient was lower after SAV versus IAV (7.8±3.9 vs 12.0±5.1; p<0.001) and SEV versus BEV implantation (8.0±4.1 vs 13.6±4.7; p<0.001). Severe PPM was more common with IAV and BEV when compared to SAV and SEV implantation, respectively, (8.8% vs 3.6%; p=0.007 and 8.7% vs 4.6%; p=0.041). At multivariable logistic regression weighted by IPTW, SAV protected from severe PPM regardless of its definition. More than mild PVL occurred more often with SEV versus BEV (11.6% vs 2.6%; p<0.001)., Conclusions: In small aortic annuli, implantation of SAV and SEV was associated with a more favourable forward haemodynamic profile than after IAV and BEV implantation, respectively. More than mild PVL was more common after SEV than BEV implantation.

Background: A risk score was recently derived from the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) Trial. However, external validation of this score is still lacking., Aims: We aimed to validate the COAPT risk score in a large multicentre population undergoing mitral transcatheter edge-to-edge repair (M-TEER) for secondary mitral regurgitation (SMR)., Methods: The Italian Society of Interventional Cardiology (GIse) Registry of Transcatheter Treatment of Mitral Valve RegurgitaTiOn (GIOTTO) population was stratified according to COAPT score quartiles. The performance of the COAPT score for 2-year all-cause death or heart failure (HF) hospitalisation was evaluated in the overall population and in patients with or without a COAPT-like profile., Results: Among the 1,659 patients included in the GIOTTO registry, 934 had SMR and complete data for a COAPT risk score calculation. The incidence of 2-year all-cause death or HF hospitalisation progressively increased through the COAPT score quartiles in the overall population (26.4% vs 44.5% vs 49.4% vs 59.7%; log-rank p<0.001) and COAPT-like patients (24.7% vs 32.4% vs 52.3% vs. 53.4%; log-rank p=0.004), but not in those with a non-COAPT-like profile. The COAPT risk score had poor discrimination and good calibration in the overall population, moderate discrimination and good calibration in COAPT-like patients and very poor discrimination and poor calibration in non-COAPT-like patients., Conclusions: The COAPT risk score has a poor performance in the prognostic stratification of real-world patients undergoing M-TEER. However, after application to patients with a COAPT-like profile, moderate discrimination and good calibration were observed.

Aims: The aim of this study was to report clinical outcomes of self-expanding transcatheter aortic valve implantation (TAVI) for failed small Mitroflow (MF) bioprostheses., Methods and Results: Between January 2013 and July 2016, 15 symptomatic patients (NYHA Class ≥III) with degenerated small MF (≤23 mm) underwent CoreValve (CV) or Evolut R (EvR) implantation due to high/prohibitive risk for surgical redo. The MF size was 19 or 21 mm (off-label in Europe) in eight patients. A "preventive" left main (LM) stenting was successfully performed in one patient. Early LM obstruction occurred in two cases requiring stenting. Late LM obstruction was observed in one subject. A significant correlation between virtual left transcatheter valve-to-coronary ostia (VTC) distance and left sinus of Valsalva (LSV) diameter was observed (R=0.652; p=0.012). However, only left VTC was significantly smaller in patients who experienced LM obstruction compared to those who did not (p=0.002). No cases of moderate/severe stenosis were observed in either on- or off-label procedures. No death or other major events occurred up to the one-year follow-up., Conclusions: CV or EvR implantation for failed small MF has favourable early and midterm outcomes if a careful risk evaluation and preventive measures for coronary obstruction are adopted. Low gradients can be achieved regardless of MF size.

Aims: Transcatheter aortic valve implantation (TAVI) is a new option for patients with severe aortic stenosis at high surgical risk. We compared the clinical outcome of patients referred for TAVI and subsequently treated with TAVI, surgical aortic valve replacement (SAVR), balloon aortic valvuloplasty (BAV), or medical management (MM)., Methods and Results: All consecutive patients (n=166, EuroSCORE 24.9 ± 13.9%) referred for TAVI to our two centres were enrolled in a prospective registry and were assigned to SAVR (n=21), TAVI with the CoreValve prosthesis (n=75), BAV (n=20), or MM (n=50) by a multi-specialty team. The primary endpoint was 6-month cardiac mortality. Patients undergoing BAV had a significantly higher EuroSCORE (33.6 ± 15.9%; p=0.01). Median follow-up time was nine months (interquartile range 4.5-12.4 months). Six-month freedom from cardiac death was 81.0 ± 8.6%, 92.0 ± 3.1%, 72.9 ± 10.5%, and 72.7 ± 6.5% for SAVR, TAVI, BAV, and MM groups, respectively. Freedom from major cardiac and cerebrovascular events was 76.2 ± 9.3%, 83.9 ± 4.3%, 72.9 ± 10.5%, and 65.6 ± 6.8% for SAVR, TAVI, BAV, and MM groups, respectively., Conclusions: With respect to medical management and BAV, TAVI was associated with lower cardiac mortality at six months. Clinical outcome after TAVI was similar to that of less sick patients undergoing SAVR.

Aims: Percutaneous coronary intervention (PCI) in the total occlusion of aged saphenous vein grafts (SVGO) is difficult because of inadequate dilatation and distal embolisation. The aim of this study is to report the early experience and clinical outcome of SVGO PCI with a multistaged procedure., Methods and Results: Between January 2003-2006, we treated 20 consecutive patients (pts) admitted with the diagnosis of non-ST segment elevation acute coronary syndromes with culprit lesion located in SVGO. All of them underwent a three stage procedure. Stage 1: recanalisation of graft with undersized balloon; Stage 2: anticoagulation therapy; Stage 3: treatment according to the angiographic result. We obtained vessel recanalisation with TIMI flow 1-2 in 14 pts (70%) by undersized balloon (mean diameter of 1,85±0,43 mm). The mean anticoagulation time was 11±7 days (range 1-20 days). At the Stage 3 all 14 SVG (100%) were patent. A focal lesion was present in 12 pts (86%) treated by stent implantation. In the other two pts (14%) the SVG had no residual lesion. The in-hospital major adverse cardiac event rate was 10%. No death, in-hospital late closure or major bleeding complication occurred. At 2-year follow-up one target vessel revascularisation and one in stent restenosis occurred., Conclusions: The treatment of SVGO with staged procedure may be used to decrease thrombus burden prior to definitive "short" stent placement and improve the acute and long-term results.