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Background: In secondary mitral regurgitation (SMR), effective regurgitant orifice area by the proximal isovelocity surface area method (EROAPISA) evaluation might cause an underestimation of regurgitant orifice area because of its ellipticity compared with vena contracta area (VCA). We aimed to reassess the SMR severity using VCA-related parameters and EROAPISA. Methods: The three-dimensional transesophageal echocardiography data of 128 patients with SMR were retrospectively analyzed; the following parameters were evaluated: EROAPISA, anteroposterior and mediolateral vena contracta widths (VCWs) of VCA (i.e., VCWAP and VCWML), VCWAverage calculated as (VCWAP + VCWML)/2, and VCAEllipse calculated as π × (VCWAP/2) × (VCWML/2). Severe SMR was defined as VCA ≥0.39 cm² . Results: The mean age of the patients was 77.0 ± 8.9 years, and 78 (60.9%) were males. Compared with EROAPISA (r = 0.801), VCWAverage (r = 0.940) and VCAEllipse (r = 0.980) were strongly correlated with VCA. On receiver-operating characteristic curve analysis, VCWAverage and VCAEllipse had C-statistics of 0.981 (95% confidence interval [CI], 0.963–1.000) and 0.985 (95% CI, 0.970–1.000), respectively; these were significantly higher than 0.910 (95% CI, 0.859–0.961) in EROAPISA (p = 0.007 and p = 0.003, respectively). The best cutoff values for severe SMR of VCWAverage and VCAEllipse were 0.78 cm and 0.42 cm², respectively. The prevalence of severe SMR significantly increased with an increase in EROAPISA (38 of 88 [43.2%] patients with EROAPISA <0.30 cm², 21 of 24 [87.5%] patients with EROAPISA = 0.30–0.40 cm², and 16 of 16 [100%] patients with EROAPISA ≥0.40 cm2 [Cochran–Armitage test; p < 0.001]). Among patients with EROAPISA <0.30 cm², SMR severity based on VCA was accurately reclassified using VCWAverage (McNemar’s test; p = 0.505) and VCAEllipse (p = 0.182). Conclusions: Among patients who had SMR with EROAPISA of <0.30 cm², suggestive of moderate or less SMR according to current guidelines, >40% had discordantly severe SMR based on VCA. VCWAverage and VCAEllipse values were useful for identifying severe SMR based on VCA in these patients. [ABSTRACT FROM AUTHOR]

Background: The MitraClip G4 system is the latest version of the transcatheter edge-to-edge repair (TEER) system for mitral regurgitation (MR). We aimed to investigate the impact of the new system on routine clinical practice and patient outcomes in the treatment of primary MR. Methods: Consecutive patients with primary MR who underwent TEER with either the MitraClip G2 or G4 between 2018 and 2021 were enrolled from a single center registry. Baseline clinical and echocardiographic characteristics as well as procedural and clinical outcomes up to 1 year were compared between groups. Technical and device success were defined in accordance with the Mitral Valve Academic Research Consortium criteria. Results: Among 71 patients with primary MR, 34 were treated with G2 and 37 were treated with G4. Patients treated with G4 had lower surgical risk (7.74 [5.04, 14.97] vs. 5.26 [3.98, 6.40]; p < 0.01) than those with G2. There were no significant differences in other baseline clinical variables between groups. On baseline echocardiography, MR volume and flail gap were significantly greater in the G4 group than in the G2 group (regurgitant volume: 63 [41-76] mL vs. 68 [62-84] mL; p = 0.04, flail gap: 4.5 [3.5-5.5] mm vs. 5.4 [4.5-7.1] mm; p = 0.04). Technical success was achieved in over 95% of both groups with no significant difference (p > 0.99). Device success was achieved in 61.8% of the G2 group, while in 70.3% of the G4 group (p = 0.47). Post-procedural MR severity was comparable (p = 0.42) and there was no significant difference in the occurrence of mitral stenosis (p = 0.61) between groups. Among patients who reached 1-year follow-up (n = 54), there was no significant difference between groups in a composite endpoint of death or heart failure rehospitalization (10.5% vs. 20.2%; HR 0.61; 95% CI 0.17-2.22; p = 0.45). Residual heart failure symptoms (NYHA =3) at 1 year were observed in 3.7% of the G2 group, while no patient in the G4 group (p > 0.99). Conclusions: The MitraClip G4 system achieved comparable device outcomes to the early-generation device (G2), despite treating more severe primary MR with a larger flail gap. [ABSTRACT FROM AUTHOR]

Aims The aim of this study was to clarify whether worsening of independence in activities of daily living (ADL) and also difficulties in ADL are triggered by hospitalization in older patients with heart failure (HF) and whether difficulties in ADL can predict readmission for HF regardless of independence in ADL in these patients. Methods and results We enrolled 241 HF patients in the present multi-institutional, prospective, observational study. The patients were divided according to age into the non-older patient group (<75 years, n = 137) and the older patient group (≥75 years, n = 104). The Katz index and the Performance Measure for Activities of Daily Living-8 (PMADL-8) were used to evaluate independence and difficulties in ADL, respectively. The endpoint of this study was rehospitalization for HF. Independence as indicated by the Katz index at discharge was significantly lower than that before admission only in the older patient group, and the value of the PMADL-8 at discharge was significantly higher than that before admission (P < 0.001). In all patients, after adjusting for the Katz index and other variables, PMADL-8 score was a significant predictor of rehospitalization for HF (hazard ratio 1.50; 95% confidence interval 1.07–2.13; P = 0.021). Conclusions Worsening of both independence and difficulties in ADL was triggered by hospitalization in older HF patients, and difficulties in ADL were relevant factors for risk of rehospitalization regardless of independence in ADL. These findings indicate the importance of preventing not only decreased independence but also increased difficulties in ADL during and after hospitalization. [ABSTRACT FROM AUTHOR]

Immune checkpoint inhibitor (ICI)-induced myocarditis is rare but fatal. Because of the rapid course of ICI-induced myocarditis, understanding of clinical course is only possible through information from case reports. We report a case of pembrolizumab-induced myocarditis in which we were able to document the course of electrocardiographic changes from onset to death. A 58-year-old woman with stage IV lung adenocarcinoma, who had completed her first cycle of pembrolizumab, carboplatin, and pemetrexed, was admitted with pericardial effusion. She underwent pericardiocentesis after admission. A second cycle of chemotherapy was administered 3 weeks after the first cycle. Twenty-two days after admission, she developed a mild sore throat and tested positive for SARSCoV-2 antigen. She was diagnosed with mild coronavirus disease 2019 (COVID-19), isolated, and treated with sotrovimab. Thirty-two days after admission, an electrocardiogram showed monomorphic ventricular tachycardia (VT). Suspecting myocarditis caused by pembrolizumab, the patient was started on daily methylprednisolone after coronary angiography and endocardial biopsy. Eight days after the start of methylprednisolone administration, she was considered to have passed the acute stage. However, four days later, R-on-T phenomenon triggered polymorphic VT and she died. The impact of viral infections such as COVID-19 on patients be treated with immune checkpoint inhibitors is still unknown and we need to be careful with systemic management after viral infections. [ABSTRACT FROM AUTHOR]