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The aim of this study was to report the outcomes of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) at 5 years.TAVR for degenerated surgical bioprostheses in patients at high risk for reoperative surgery is an important treatment option that may delay or obviate the need for surgical intervention; however, long-term outcomes of this procedure are unknown.The PARTNER (Placement of Aortic Transcatheter Valves) 2 ViV and continued access registries prospectively enrolled patients with failed surgical bioprostheses at high risk for reoperation. Five-year clinical and echocardiographic follow-up data were obtained in 95.9% of patients.In 365 (96 registry and 269 continued access) patients, the mean age was 78.9 ± 10.2 years, the mean Society of Thoracic Surgeons predicted risk of surgical mortality score was 9.1 ± 4.7%, and New York Heart Association functional class was III or IV in 90.4%. At 5 years, the Kaplan-Meier rates of all-cause mortality and any stroke were 50.6% and 10.5%, respectively. Using Valve Academic Research Consortium 3 definitions, the incidence of structural valve deterioration, related hemodynamic valve deterioration, or bioprosthetic valve failure at 5 years was 6.6%. Aortic valve re-replacement was performed in 6.3% (n = 14), the majority of which was due to stenosis (n = 6) and combined aortic insufficiency/paravalvular regurgitation (n = 3). The mean gradient, Doppler velocity index, paravalvular regurgitation, and quality of life measured by Kansas City Cardiomyopathy Questionnaire scores in survivors remained stable from 30 days postprocedure through 5 years.At the 5-year follow-up, TAVR for bioprosthetic aortic valve failure in high surgical risk patients was associated with sustained improvement in clinical and echocardiographic outcomes.

Despite unusual high rates of patient-prosthesis mismatch (PPM), excellent midterm clinical outcomes have been reported after surgical aortic valve replacement (SAVR) with the Avalus™ bioprosthetic valve (Medtronic). To elucidate this "PPM conundrum," the Avalus valve haemodynamics were assessed during exercise testing.Of the 148 patients who had undergone SAVR with the Avalus valve at our institution, 30 were randomly selected among those in whom stress test was deemed feasible and underwent a resting transthoracic echocardiography immediately followed by exercise echocardiography. Severe PPM was defined as indexed effective orifice area (iEOA)Measured EOA significantly increased from rest to peak exercise in all PPM groups (p .05) and the rates of moderate and severe measured PPM decreased from 40% and 20% to 27% and 0%, respectively. The patients with low-flow state (flow 250 ml/s) had significantly lower measured rest EOA (p = .03). On the basis of the estimated iEOA, there was no severe PPM and 19 patients had moderate PPM (63.3%), with a significantly lower opening reserve than the patients without estimated PPM (p = .04). The estimated iEOA was more reliably correlated to the measured iEOA at maximal stress than the measured iEOA at rest, especially in patients with a low-flow state.This study supports the concept of an opening reserve of the Avalus valve to explain the PPM conundrum and promotes the use of exercise Doppler-echocardiography to complete the assessment of mismatch, especially in patients with a low-flow state. Published estimated EOA seems reliable to predict the haemodynamic performance of the Avalus valve, whether the flow conditions at rest.

Background Transcatheter edge-to-edge mitral valve repair may lead to a reduction in mitral valve area (MVA) and elevated mean transmitral gradient (TMG). The objectives of this study were to assess the value of baseline MVA by different imaging methods and to explore the associations between MVA indexed to body surface area or left ventricular forward stroke volume and postprocedural TMG. Methods Preprocedural echocardiographic images from 76 consecutive patients were retrospectively reviewed. MVA planimetry from two-dimensional (2D) transthoracic echocardiography (MVATTE), 2D transesophageal echocardiography in the transgastric view (MVA2D TEE), and three-dimensional (3D) transesophageal echocardiography (MVA3D) were measured. Postprocedural TMGs were assessed at 1 to 3 months and all-cause mortality at 1 year. Results Postprocedural mean TMG > 5 mm Hg was associated with a 3.42-fold (95% confidence interval [CI], 1.08–10.87; P = .04) increased risk for 1-year all-cause mortality. Patients with postprocedural TMG > 5 mm Hg (25% [19 of 76]) had significantly smaller preprocedural MVA3D (3.9 ± 0.8 vs 5.2 ± 1.3 cm2, P 5 mm Hg were, respectively, 3.9 cm2 (area under the curve [AUC] = 0.80; 95% CI, 0.66–0.94; sensitivity 62%, specificity 87%) and 4.6 cm2 (AUC = 0.68; 95% CI, 0.54–0.82; sensitivity 53%, specificity 80%). MVA3D indexed to body surface area and to stroke volume showed overall the best associations with postprocedural mean TMG > 5 mm Hg, with optimal thresholds, respectively, of 2.5 cm2/m2 (AUC = 0.88; 95% CI, 0.77–0.98; sensitivity 92%, specificity 74%) and 95 cm2/L (AUC = 0.87; 95% CI, 0.77–0.97; sensitivity 85%, specificity 82%). Conclusions Elevated TMG following transcatheter edge-to-edge mitral valve repair was associated with increased mortality. The present results indicate that MVA3D, MVA3D indexed to body surface area, and MVA3D indexed to stroke volume may be considered potential predictors of postprocedural TMG > 5 mm Hg and could help optimize patient selection, while the use of 2D methods for valve area were poorly associated with TMG.

BACKGROUND OR PURPOSE We report our single-center experience with percutaneous left atrial appendage closure (LAAC) in patients with non-valvular atrial fibrillation (NVAF) and primary hemostasis disorders (HD). METHODS Consecutive patients with primary HD who underwent a percutaneous LAAC were included. Baseline characteristics, procedural data, and clinical outcomes were prospectively collected and compared with the overall LAAC cohort without HD. RESULTS Since 2013, among 229 LAAC, 17 patients (7%) had a primary HD: thrombocytopenia (n = 5), myelodysplastic syndrome (n = 6), von Willebrand syndrome (n = 4), type A hemophilia (n = 1), and dysfibrinogenemia (n = 1). The HD population's age ranged from 61 to 87 years, and the median CHA2DS2VASc was 5. Periprocedural plasmatic management was required in 47% of patients. The immediate LAAC implantation success rate was 100%. Patients received a direct oral anticoagulant (DOA) (n = 9), dual antiplatelet (n = 6), aspirin (n = 1), or no therapy (n = 1) during the first six postoperative weeks, followed with single antiplatelet (n = 16) or no therapy (n = 1) during lifelong. After 20 months, the technical success rate and procedural success rate were 100% and 94%. Zero device-/procedure-related complication and only one life-threatening bleeding occurred. Compared to patients without HD (n = 212), a baseline history of bleeding was less frequent (53% vs 91%, p

OBJECTIVES The objective of this in vitro study was to compare Doppler versus catheter transvalvular pressure gradients (TPG) in third generations balloon-expandable (BE) versus self-expanding (SE) transcatheter heart valves (THV). BACKGROUND TPG is a key parameter to assess and follow valve hemodynamic function following transcatheter aortic valve implantation (TAVI). It remains uncertain and debated whether, and to which extent, TPGs differ according to the type of THV, that is, BE versus SE and to the method used for TPG measurement, that is, Doppler echocardiography versus cardiac catheterization. METHODS The CoreValve EVOLUT PRO 26 mm and the SAPIEN 3 23 mm THVs were tested in a left heart simulator using a 21 mm aortic annulus under following conditions: heart rate: 70 bpm, mean aortic pressure: 100 mmHg, stroke volume: 30, 70 and 100 ml. Mean TPGs were measured by continuous-wave Doppler and by micro-tip pressure catheters positioned in the left ventricle and at 50 mm downstream to the tip of the THV leaflets. RESULTS Doppler TPGs (9.5 ± 3.9 mmHg) were on average 40.5 ± 13.9% higher (p

This study aimed to compare incidence and impact of measured prosthesis-patient mismatch (PPMTAVR studies have used measured effective orifice area indexed (EOAi) to body surface area (BSA) to define PPM, but most SAVR series have used predicted EOAi. This difference may contribute to discrepancies in incidence and outcomes of PPM between series.The study analyzed SAVR patients from the PARTNER (Placement of Aortic Transcatheter Valves) 2A trial and TAVR patients from the PARTNER 2 SAPIEN 3 Intermediate Risk registry. PPM was classified as moderate if EOAi ≤0.85 cmThe incidence of moderate and severe PPMEOAi measured by echocardiography results in a higher incidence of PPM following SAVR or TAVR than PPM based on predicted EOAi. Severe PPM

Objective The aim of this study was to assess the impact of sex on the management and outcome of patients according to aortic stenosis (AS) severity. Introduction Sex differences in the management and outcome of AS are poorly understood. Methods Doppler echocardiography data of patients with at least mild-to-moderate AS [aortic valve area (AVA) ≤1.5 cm2 and peak jet velocity (VPeak) ≥2.5 m/s or mean gradient (MG) ≥25 mmHg] were prospectively collected between 2005 and 2015 and retrospectively analysed. Patients with reduced left ventricular ejection fraction (mild were excluded. Results Among 3632 patients, 42% were women. The mean indexed AVA (0.48 ± 0.17 cm2/m2), VPeak (3.74 ± 0.88 m/s), and MG (35.1 ± 18.2 mmHg) did not differ between sexes (all P ≥ 0.18). Women were older (72.9 ± 13.0 vs. 70.1 ± 11.8 years) and had more hypertension (75% vs. 70%; P = 0.0005) and less coronary artery disease (38% vs. 55%, P < 0.0001) compared to men. After inverse-propensity weighting (IPW), female sex was associated with higher mortality (IPW-HR: 1.91 [1.14–3.22]; P = 0.01) and less referral to valve intervention (competitive model IPW-HR: 0.88 [0.82–0.96]; P = 0.007) in the whole cohort. This excess mortality in women was blunted in concordant non-severe AS initially treated conservatively (IPW-HR = 1.03 [0.63–1.68]; P = 0.88) or in concordant severe AS initially treated by valve intervention (IPW-HR = 1.25 [0.71–2.21]; P = 0.43). Interestingly, the excess mortality in women was observed in discordant low-gradient AS patients (IPW-HR = 2.17 [1.19–3.95]; P = 0.01) where women were less referred to valve intervention (IPW-Sub-HR: 0.83 [0.73–0.95]; P = 0.009). Conclusion In this large series of patients, despite similar baseline hemodynamic AS severity, women were less referred to AVR and had higher mortality. This seemed mostly to occur in the patient subset with discordant markers of AS severity (i.e. low-gradient AS) where women were less referred to AVR.

Introduction: Percutaneous left atrial appendage closure (LAAC) is an alternative to oral anticoagulants (OAC) in patients with non-valvular atrial fibrillation (AF) and contraindication to long-term OAC. Combined strategy with percutaneous LAAC at the same time of other cardiac structural or electrophysiological procedures has emerged as an alternative to a staged strategy. Aim: To describe our experience with combined LAAC procedures using Watchman™ devices. Methods: All patients with combined LAAC procedures using Watchman™ (WN) devices performed from 2016 to 2021 were included. The primary safety endpoint was a composite of periprocedural complications and adverse events during the follow-up. The primary efficacy endpoint included strokes, systemic embolisms, major bleeding and cardiovascular death. Results: From 2016, among 160 patients who underwent LAAC using WN devices, 19 underwent a combined strategy: 7 transcatheter edge-to-edge mitral valve repair (TEMVR) (37%), 6 typical atrial flutter ablation (31%), 2 leadless pacemaker (LP) implantation (10%) and 4 AF ablation (22%). The WN device was successfully implanted in 98% and 100% of cases for single and combined LAAC procedures, respectively (p = 0.63). Median follow-up was 13 months (IQR 25/75 3/24). Device-related complications occurred in 6 out of 141 patients (4%) who underwent single LAAC and in no (0/19) patient in the combined LAAC procedure (p = ns). The procedural-related complications did not differ significantly between groups (5% vs. 10%, respectively, in the single and combined group, p = 0.1). Conclusion: Combined procedure using the Watchman™ devices and one other structural or electrophysiological procedure appears safe and effective. Larger series are needed to confirm these results.

Bioprosthetic valve dysfunction (BVD) and bioprosthetic valve failure (BVF) may be caused by structural or nonstructural valve dysfunction. Both surgical and transcatheter bioprosthetic valves have limited durability because of structural valve deterioration. The main objective of this summary of experts participating in a virtual workshop was to propose standardized definitions for nonstructural and structural BVD and BVF following aortic or mitral biological valve replacement with the goal of facilitating research reporting and implementation of these terms in clinical practice. Definitions of structural BVF, based on valve reintervention or death, underestimate the true incidence of BVF. However, definitions solely based on the presence of high transprosthetic gradient at a given echocardiogram during follow-up overestimate the incidence of structural BVD and BVF. Definitions of aortic or mitral structural BVD must therefore include the confirmation by imaging of permanent structural changes to the leaflets alongside evidence of deterioration in valve hemodynamic function at echocardiography follow-up.

Background It is unknown whether transcatheter valves will have similar durability as surgical bioprosthetic valves. Definitions of structural valve deterioration (SVD), based on valve rel...

Initially, transcatheter aortic valve replacement (TAVR) was only used in patients with severe symptomatic aortic stenosis and prohibitive risk for surgical aortic valve replacement. Subsequently, TAVR was extended to patients with high and intermediate surgical risk. Recently, the results of randomized trials in low-surgical-risk patients showed superiority or noninferiority of TAVR versus surgical aortic valve replacement in this population. Procedural outcomes have been improved. Long-term durability of transcatheter heart valves remains to be confirmed. This article presents the evolution and current status of TAVR, with respect to the different types of devices and procedures as well as its outcomes.

Infective endocarditis (IE) is a complex disease with cardiac involvement and multiorgan complications. Its prognosis depends on prompt diagnosis that leads to an aggressive therapeutic management combining antibiotic therapy and early cardiac surgery when indicated. However, IE diagnosis always poses a challenge, and echocardiography remains diagnostically imperfect in cases of prosthetic valve IE or cardiac implantable electronic device infection. In recent years, other imaging modalities (computed tomography, magnetic resonance imaging, nuclear imaging) have experienced significant technical improvements, and their application to the detection of cardiac and extracardiac IE-related lesions seems to be a strategic way forward in the management of patients with suspected IE. However, the scientific evidence in the literature remains limited; current guidelines address the use of the multimodality imaging in the field of IE with caution; the incremental value of each technique and their combinations is debated; and their use varies across countries. Despite these limitations, healthcare providers and surgeons should be aware of the possibilities offered by the multimodal imaging approach when appropriate. Here, we emphasize the value of a multidisciplinary heart valve team, the endocarditis team, underlining the importance of cardiac and extracardiac imaging experts in playing a key role in informing the diagnosis and management of patients with IE. Illustrative cases, critical appraisal of contemporary data, and conceptual and practical suggestions for clinicians that may help to improve the prognosis of patients with IE are provided in this review article.

International audience; Background Left atrial appendage occlusion (LAAO) is increasingly used for stroke prevention in patients with atrial fibrillation who are considered unsuitable for a lifelong oral anticoagulant regimen. Recently, a single-centre study reported device-related thrombus formation in 16.7% of patients treated with the second-generation Amulet device (St. Jude Medical, St. Paul, MN, USA), presenting a potential major safety concern. As "real-world" data on device-related thrombus formation following LAAO with the Amulet occluder are scarce, we aimed to evaluate this outcome in a retrospective registry.Methods Clinical and tranosesophageal echocardiography data after LAAO with the Amulet in consecutive patients from three centres were collated.Results Among 38 patients (mean age 75.8 years), mean (standard deviation) CHA(2)DS(2)-VASc and HAS-BLED scores were 4.4 (1.2) and 3.4 (0.9), respectively. All patients underwent successful device placement without procedure-related adverse events. The antithrombotic regimen at discharge consisted of dual antiplatelet therapy (DAPT) in 27 patients (71.1%), single antiplatelet therapy in 10 patients (26.3%), and no antithrombotic therapy in one patient (2.6%). Device-related thrombus was observed in one patient (2.6%) despite DAFT regimen. The outcome of this patient was uncomplicated after adjustment of oral anticoagulant therapy. No patients presented with a thromboembolic event following LAAO during a mean (standard deviation) follow-up of 15 (5) months.Conclusions In this retrospective study, device-related thrombus formation with the second-generation Amulet device was rare and occurred at a rate similar to that of the previous device. Importantly, no patient experienced a device-related thromboembolic event during follow-up. Larger real-life studies are required to confirm the safety profile of this increasingly used device.

Introduction: Percutaneous left atrial appendage closure (LAAC) is an alternative to oral anticoagulant (OAC) in patients with non-valvular atrial fibrillation (AF) and contraindication to long-term OAC. Combined strategy with percutaneous LAAC at the same time of other cardiac structural or electrophysiological procedure has emerged as an alternative to staged strategy. Aim: To describe our experience of combined LAAC procedures using Watchman™ devices. Method: All patients with combined LAAC procedure using Watchman™ (WN) devices performed from 2016-2021 were included. The primary safety endpoint was a composite of periprocedural complications and adverse events during follow-up. The primary efficacy endpoint included strokes, systemic embolisms, major bleeding, and cardiovascular death. Results: Since 2016, among the 157 patients who underwent LAAC using WN devices, 16 underwent a combined strategy: 6 TEMVR (37%), 6 typical atrial flutter ablation (37%), 2 LP implantation (13%) and 2 atrial fibrillation ablation (13%). The WN device was successfully implanted in 98% and 100% for single and combined LAAC respectively (p = 0.63). Median follow-up was 13 months (IQR 25/75 3/24) in the whole cohort. Device related complications occurred in 6 out of 141 patients (4%) who underwent single LAAC and in no (0/16) patient in the combined LAAC procedure (p=ns). The procedural related complications did not differ significantly between groups (5% vs 12%, respectively in the single and combined group, p=0.1). Conclusion: Combined procedure combining LAAC using the Watchman™ devices and one other structural or electrophysiological procedure is safe and effective. Larger series are needed to confirm these results.

Introduction: Residual mitral regurgitation (rMR) and elevated transmitral gradients (TMG) are associated with worse outcomes after percutaneous mitral repair. This study aims to assess if pre-intervention MR jet width and its relation to the mitral commissural length (MCL) are able to predict post-procedure rMR and TMG. Methods: Preprocedural echocardiographic images were retrospectively reviewed in 74 patients who underwent an edge-to-edge repair (2014-2018). Maximal MR jet width and MCL were measured from a bi-commissural view. Complete follow-up echocardiographic examination was performed at 1-3 months. Left ventricle (LV) and left atrial (LA) severe dilation were defined as LV end-diastolic diameter ≥6.5 cm and LA indexed volume ≥48 ml/m 2 . Presence of rMR ≥moderate, combination of rMR and TMG >5 mmHg (rMR+TMG), and all-cause mortality within 1-year follow-up were examined. Results: Of 74 patients, 25 (34%) had rMR [17/25 moderate and 8/25 severe)] and 39 (53%) had either rMR or elevated TMG. Both MR jet width and its ratio with MCL were good predictors for the implantation of >2 clips (p Conclusion: MR jet width and its ratio with MCL are respectively associated to rMR or combined rMR+TMG after percutaneous mitral repair. MR jet width was also useful to identify patients who remained with severe LV and LA dilatation post-intervention.

Tricuspid regurgitation (TR) is a common finding in patients with chronic cardiopathy, and often a marker of an advanced disease. Being silent or with symptoms intertwined with the primitive left heart disease, TR has often been neglected, leading to the late referral of patients with advanced right-heart failure. Hence, isolated tricuspid surgery has been associated with high morbidity and mortality rates, the worse of all valve interventions, and medical management has been limited to symptomatic treatment. In this context, percutaneous therapies for severe TR have gained traction, addressing the unmet therapeutic gap for a less invasive disease-modifying management. The aim of this review is to provide an updated overview on transcatheter tricuspid valve interventions, focusing on devices' characteristics, associated evidence, and future perspectives.

IntroductionThere are significant sex differences in the prevalence and severity of cardiac calcifying processes. Women harbour more severe mitral annular calcification (MAC), while men exhibit worse aortic valve (AVC) and coronary artery (CAC) calcification. To better understand these differences, we investigated the correlates of cardiac calcification according to sex.MethodsWe conducted a cross-sectional study of 406 patients with ≥mild aortic stenosis (AS) defined by an aortic valve area ≤1.5 cm2, a peak aortic jet velocity >2.0 m/s, or a mean transvalvular gradient >15 mm Hg. Doppler-echocardiography and non-contrast multidetector CT were performed concomitantly to assess AS and cardiac calcifications.ResultsMean age was 71±11 years and 33% were women. The AS haemodynamics were not significantly different between sexes (all p>0.50), with a mean indexed aortic valve area of 0.59±0.21 cm2/m2, peak aortic jet velocity of 2.78 (2.37–3.68) m/s, and mean gradient of 17.9 (12.8–31.3) mm Hg for the whole cohort. Compared with men, women harboured lower AVC (480 (222–1191) vs 1003 (484–2329) Agatston unit, AU; pConclusionIn AS, factors associated with cardiac valvular and arterial calcification differ between sexes, suggesting an important contributory role of sex in the pathophysiology of these calcifying processes.

Background: The use of predilation during transcatheter aortic valve replacement (TAVR) is variable, and its association with outcomes remains unknown. We evaluated the impact of predilation versus no predilation (direct TAVR) in the low-risk population enrolled in the PARTNER 3 trial (Placement of Aortic Transcatheter Valves). Methods: In the PARTNER 3 trial, 495 patients with severe symptomatic aortic stenosis underwent TAVR with the SAPIEN 3 valve. The use of predilation was left to operator discretion. The primary end point was a composite of all-cause death, stroke, or rehospitalization. Secondary end points included valve hemodynamic performance and the need for postdilation. Propensity score matching was performed. Results: Predilation and direct TAVR were performed in 286 (57.8%) and 209 (42.2%) patients, respectively. Before matching, the primary end point occurrence at 30 days (3.8% versus 4.8%, P =0.604) and 1 year (8.7% versus 8.1%, P =0.831) was similar in the predilation versus direct TAVR groups. Similar results were observed after matching (202 patients in each groups). Incidence of ≥ mild paravalvular regurgitation was similar in both groups. Incidence of severe prosthesis-patient mismatch was low but higher in the predilation group versus the direct TAVR group (8.2% versus 2.6%, P =0.023). Compared with direct TAVR, the use of predilation was associated with longer procedure duration (63.2 versus 51.4 minutes, P =0.001), while the rate of postdilation did not differ between the 2 groups (24.8% versus 18.8%, P =0.150). Conclusions: Predilation and direct TAVR are safe in patients with low surgical risk and favorable aortic valve anatomy. Direct TAVR decreased the procedure duration and did not predispose to more postdilation. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02675114.

Purpose of review Bioprosthetic valves are now used for the majority of surgical aortic valve replacements and for all transcatheter aortic valve replacements. However, bioprostheses are subject to structural valve deterioration (SVD) and have, therefore limited durability. Recent findings Clinical, imaging, and circulating biomarkers may help to predict or indicate the presence of bioprosthetic valve SVD. The most important biomarkers of SVD includes: patient-related clinical biomarkers, such as diabetes and renal failure; valve-related biomarkers, such as absence of antimineralization process and severe prosthesis-patient mismatch; imaging biomarkers: the presence of valve leaflet mineralization on multidetector computed tomography or sodium fluoride uptake on positron emission tomography; and circulating biomarkers including: increased levels of HOMA index, ApoB/ApoA-I ratio, PCSK9, Lp-PLA2, phosphocalcic product. The assessment of these biomarkers may help to enhance risk stratification for SVD following AVR and may contribute to open novel pharmacotherapeutic avenues for the prevention of SVD. Summary SVD may affect all bioprostheses after aortic valve replacement, and is the main cause of bioprosthetic valve failure and reintervention during the follow-up. Comprehensive assessment of clinical, imaging, and circulating biomarkers associated with earlier SVD could help strengthen the follow-up in high-risk patients and provide novel pharmacologic therapeutic strategies.

In aortic stenosis (AS), metabolic syndrome (MetS), and diabetes mellitus (DM) are associated with more pronounced left ventricular (LV) hypertrophy and more concentric remodeling. We aimed to assess the impact of MetS and DM on LV mass, remodeling, and LV mass regression after aortic valve replacement (AVR) in patients with severe AS. We included 177 patients with severe AS and preserved LV ejection fraction (>50%). All patients underwent a complete echocardiogram before and 1 year after AVR. Forty-seven (27%) patients had MetS, 37 (21%) DM, and 93 (52%) neither MetS nor DM (No MetS-DM). Before AVR, indexed LV mass was higher in MetS and DM groups compared with No MetS-DM group (56.1 ± 14.2, 56.2 ± 18.2 vs 49.2 ± 14.1 g/m2.7, respectively; p

BACKGROUND We report our single center experience with percutaneous left atrial appendage closure (LAAC) in patients with non-valvular atrial fibrillation (NVAF) and primary hemostasis disorders (HD). In randomized percutaneous LAAC trials, this HD population is under-represented. METHODS AND RESULTS Consecutive patients with primary HD who underwent LAAC were included. Baseline procedural characteristics and clinical events during follow-up were prospectively collected. From 2013 to 2021, 205 patients underwent percutaneous LAAC and 17 (8.2%) had proven HD: thrombocytopenia (n=5), myelodysplastic syndrome (n=6), Von Willebrand syndrome (n=4), type A hemophilia (n=1) and dysfibrinogenemia (n=1). Median age was 78 YO, CHA2DS2VASc and HAS-BLED scores were 5 and 3, respectively. Periprocedural plasmatic management was required in 47% of patients. The LAAC device implantation was successful in all cases. Post-procedural antithrombotic regimen for the first six weeks consisted of reduced direct oral anticoagulant (DOA) in 8 patients, full dose DOA in 1, dual-antiplatelet in 6, aspirin in 1 and no therapy in 1. The transesophageal echocardiography, 45 days post-procedure, showed optimal device position, adequate sealing in all patients and no clots. After this initial period post-LAAC the long-term antithrombotic regimen was single-antiplatelet in 16 patients and no therapy in 1 patient. After a median follow-up of 1.0 year (25-75 IQR: 0.4-2.2), no thrombo-embolic or bleeding events occurred. CONCLUSION The percutaneous LAAC in patients with atrial fibrillation and primary hemostasis disorders appeared to be a safe and effective alternative for stroke and bleeding prevention at mid-term follow-up. These promising results warrant larger studies to confirm our experience.

Objectives: We aimed to report a single center experience with percutaneous left atrial appendage closure (LAAC) in patients with non-valvular atrial fibrillation (NVAF) and blood dyscrasia (BD). Background: Although strong data supports the LAAC, patients with coagulopathy and BD were under-represented in randomized trials. Methods: Consecutive patients with BD who underwent LAAC were included. Baseline and procedural characteristics and follow-up outcomes were prospectively collected. Results: From 2013 to 2020, 180 patients underwent LAAC and 14 (7.8%) had proven BD: thrombocytopenia (n=5), myelodysplastic syndrome (n=5), Von Willebrand syndrome (n=2), type A hemophilia (n=1) and dysfibrinogenemia (n=1). Median age was 78 YO, CHA2DS2VASc and HAS-BLED scores were respectively 4 and 3. Periprocedural plasmatic management was required in 50% of the patients. The WATCHMANTM, AMPLATZER CARDIAC PLUGTM and CARDIA ULTRASTEALTM devices were used in 12, 1 and 1 patients, respectively, and the procedure was successful in all cases. Post-procedural antithrombotic regimen for the first six weeks consisted of reduced direct anticoagulant (DOA) in 7 patients, dual-antiplatelet in 5, aspirin in 1 and no therapy in 1. Following that period, single-antiplatelet was used in 13 patients and no therapy in 1 patient. A transesophageal echocardiography 45 days post-procedure showed optimal device position and sealing in all patients. After a median follow-up of 1.4 years, no thrombo-embolic or bleeding events occurred. Conclusion: LAAC in patients with BD appeared to be a safe and effective alternative for stroke and bleeding prevention at mid-term follow-up. These promising results warrants larger studies to confirm our findings.

Introduction: Transcatheter valve-in-valve implantation (ViV) has emerged as an alternative to redo surgery (REDO) for the treatment of failed surgical aortic bioprostheses. However, there are few studies comparing clinical and hemodynamic outcomes between REDO and ViV in both the short- and long- term follow-up. Objective: The aim of this study was to compare hemodynamic and clinical outcomes between REDO and ViV. Methods: A total of 184 patients who underwent REDO or ViV at our institution between 2003 and 2017 were included in this study. Clinical and transthoracic echocardiography (TTE) data were collected for each patient. TTE was performed prior and after the reintervention and were retrospectively analyzed in an echocardiography core laboratory. An inverse propensity treatment weighting (IPTW) was used to compare outcomes between groups. Results: 104 patients underwent REDO and 80 underwent ViV. Prevalence of suboptimal valve hemodynamics (mean gradient ≥ 20 mmHg and/or ≥ moderate aortic regurgitation) following reintervention was higher in ViV group (29.8% vs. 61.3%, p Conclusions: ViV was associated with lower risk of 30-day but higher risk of long-term mortality compared to REDO.

Introduction: It has been shown that women present lower coronary artery (CAC) and aortic valve calcification (AVC) loads while heavier mitral annular calcification (MAC) than men. However, the sex-specific predictors to these cardiac calcifications remain poorly characterized. Methods: We conducted a cross-sectional study in patients with at least mild AS (indexed aortic valve area: AVAi < 1.5 cm 2 /m 2 , Peak aortic jet velocity: Vpeak > 2.0 m/s, or Mean gradient: MG >15 mmHg). Doppler-echocardiography and non-contrast multidetector compute tomography were performed within 3 months. Ascending aorta calcification (AAC), AVC, CAC and MAC scores were measured using the Agatston method. Descriptive statistical analyses (t-test, Wilcoxon, univariate and multivariate analysis) were performed. Results: We studied 406 patients (71±11 years, 33% women) with AVAi= 0.59±0.21 cm 2 /cm 2 , Vpeak= 3.1±9.8 m/s, MG= 24.7±17.8 mmHg (equivalent between men and women, all p>0.34). Women present less AVC (480[222-1191] vs 1005[485-2364]AU; p Conclusion: In AS patients, sex is a powerful and independent predictor of cardiac calcifications. Moreover, predictors of valvular calcification appear to be sex specific.

Introduction: The MitraClip procedure is a non-surgical alternative for patients with severe mitral regurgitation and high surgical risk. However, the MitraClip may lead to a reduction in the mitral valve orifice area (MVOA) and elevated transmitral mean gradients (TMG). The objectives of this study are to assess the value of baseline MVOA by different imaging methods and explore the value of MVOA indexed for left ventricular (LV) forward stroke volume (SV) to predict postprocedural TMG. Methods: Preprocedural echo images were retrospectively reviewed in 76 consecutive patients. MVOA from 2D transthoracic (MVOA TTE ), 2D transgastric (MVOA TG ) and 3D transesophageal (MVOA 3D ) echocardiography were measured and then indexed by the SV measured by Doppler in the LV outflow tract (MVOA/SV) . Postprocedural TMG was measured at one month and survival rate at one year. Results: Patients with postprocedural TMG >5 mmHg (18/76, 24%) had significantly smaller preprocedural MVOA 3D (3.9±0.9 vs 5.2±1.3 cm 2 , pTTE (4.9±1.1 vs 5.9±1.5 cm 2 , p=0.02). No significant difference was found for MVOA TG (5.5±1.4 vs 5.9±1.4 cm 2 , p=0.2). Best threshold values for MVOA 3D and MVOA TTE to predict postprocedural TMG >5 mmHg were respectively 3.9 cm 2 (AUC=0.80, IC95%: 0.67-0.94, p2 (AUC=0.69, IC95%: 0.54-0.83, p=0.02; Se 50%, Sp 84%). MVOA/SV from each echocardiographic modality were smaller in patients with postprocedural TMG >5 mmHg (3D: 80 [62-95] vs 113 [99-129] cm 2 /L; TTE: 92 [81-105] vs 130 [100-166] cm 2 /L; TG: 104 [83-123] vs 135 [104-166] cm 2 /L; p3D was overall the best predictor of postprocedural TMG >5 mmHg, with an optimal threshold of 96 cm 2 /L (AUC=0.86, IC95%: 0.76-0.97, p3D 2 and MVOA/SV 3D 2 /L tend to be at higher risk for mortality at one-year follow-up (69% vs 84%, p=0.14 and 67% vs 87%, p=0.11 respectively). Conclusion: Unlike preprocedural MVOAs assessed by 3D echocardiography, preprocedural MVOAs measured by 2D echocardiographic modalities were poor predictors of high TMG after MitraClip. Preprocedural MVOA 3D 2 and MVOA/SV 3D 2 /L were found to be the best cut-off values to predict postprocedural TMG >5 mmHg.

Background: Although aortic valve replacement is associated with a major benefit in high-gradient (HG) severe aortic stenosis (AS), the results in low-gradient (LG, mean gradient 2 ) and LG; and normal-flow (left ventricular ejection fraction ≥50% and stroke volume index ≥35 mL/m 2 ) and LG. The primary objective is to determine in the PARTNER 2 trial (The Placement of Aortic Transcatheter Valves) and registry the outcomes after aortic valve replacement of the 4 flow-gradient groups. Methods: A total of 3511 patients from the PARTNER 2 Cohort A randomized trial (n=1910) and SAPIEN 3 registry (n=1601) were included. The flow-gradient pattern was determined at baseline transthoracic echocardiography and classified as follows: (1) HG; (2) CLF-LG; (3) paradoxical low-flow-LG; and (4) normal-flow-LG. The primary end point for this analysis was the composite of (1) death; (2) rehospitalization for heart failure symptoms and valve prosthesis complication; or (3) stroke. Results: The distribution was HG, 2229 patients (63.5%); CLF-LG, 689 patients (19.6%); paradoxical low-flow-LG, 247 patients (7.0%); and normal-flow-LG, 346 patients (9.9%). The 2-year rate of primary end point was higher in CLF-LG (38.8%) versus HG: 31.8% ( P =0.002) and normal-flow-LG: 32.1% ( P =0.05) but was not statistically different from paradoxical low-flow-LG: 33.6% ( P =0.18). There was no significant difference in the 2-year rates of clinical events between transcatheter aortic valve replacement versus surgical aortic valve replacement in the whole cohort and within each flow-gradient group. Conclusions: The LG AS pattern was highly prevalent (36.5%) in the PARTNER 2 trial and registry. CLF-LG was the most common pattern of LG AS and was associated with higher rates of death, rehospitalization, or stroke at 2 years compared with the HG group. Clinical outcomes were as good in the LG AS groups with preserved left ventricular ejection fraction compared with the HG group.

Background The prognostic value of aortic valve calcification (AVC) measured by using multidetector computed tomography imaging has been well validated in native aortic stenosis, and sex-specific thresholds have been proposed. However, few data are available regarding the impact of leaflet calcification on outcomes after biological aortic valve replacement (AVR). Objectives The goal of this study was to analyze the association of quantitative bioprosthetic leaflet AVC with hemodynamic and clinical outcomes, as well as its possible interaction with sex. Methods From 2008 to 2010, a total of 204 patients were prospectively enrolled with a median of 7.0 years (interquartile range: 5.1 to 9.2 years) after biological surgical AVR. AVC measured by using the Agatston method was indexed to the cross-sectional area of aortic annulus measured by echocardiography to calculate the AVC density (AVCd). Presence of hemodynamic valve deterioration (HVD; increase in mean gradient [MG] ≥10 mm Hg and/or increase in transprosthetic regurgitation ≥1) was assessed by echocardiography in 137 patients at the 3-year follow-up. The primary clinical endpoint was mortality or aortic valve re-intervention. Results There was no significant sex-related difference in the relationship between bioprosthetic AVCd and the progression of MG. Baseline AVCd showed an independent association with HVD at 3 years. During follow-up, there were 134 (65.7%) deaths (n = 100) or valve re-interventions (n = 47). AVCd ≥58 AU/cm2 was independently associated with an increased risk of mortality or aortic valve re-intervention (adjusted hazard ratio: 2.23; 95% confidence interval: 1.44 to 3.35; p Conclusions Aortic bioprosthetic leaflet calcification is strongly and independently associated with HVD and the risk of death or aortic valve re-intervention. As opposed to native aortic stenosis, there is no sex-related differences in the relationship between AVCd and hemodynamic or clinical outcomes.

Paravalvular regurgitation is a frequent complication after transcatheter aortic valve replacement and its association with worse outcomes depends on the degree of its severity. Despite substantial improvement in transcatheter heart valve design, sizing and implantation technique, moderate or severe paravalvular regurgitation still occurs in 2% to 7% of patients and is associated with a more than 2-fold increase in mortality. This review provides a state-of-the-art approach to (i) paravalvular regurgitation prevention by optimizing patient selection, valve sizing, and positioning and (ii) the detection, quantitation and management of paravalvular regurgitation during and after valve implantation.