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Functional mitral valve regurgitation (FMR) is an independent risk factor of progressive heart failure. Besides surgical mitral valve replacement or repair (sMVR), percutaneous edge-to-edge repair using MitraClip (pMVR) has emerged as an alternative, minimally invasive therapeutic option. The aim of this work is to compare the results of sMVR and pMVR in patients with heart failure and severely reduced left-ventricular ejection fraction (LVEF ≦30%). The first study compares the clinical outcomes of sMVR and pMVR. A total of 132 patients with LVEF ≦30% submitted to sMVR (n=47) or pMVR (n=85) for FMR were identified. Using propensity score matching by age, logistic EuroSCORE, and LV end-systolic volume, pMVR showed lower perioperative mortality and rate of complications, yet increased residual MR grade as compared to sMVR. According to stratified multivariate Cox model analysis, residual MR severity was an independent risk factor for cardiac death and re-hospitalization for heart failure at 1-year follow-up. Stratified multivariable Cox regression analysis at 3 years identified pMVR as risk factor for cardiac death and re-hospitalization for heart failure. Also, an elevated grade of residual mitral regurgitation acted as a risk factor for cardiac death. In the second study, the impact of pre-interventional severity of functional tricuspid regurgitation (FTR) on early outcome after pMVR for FMR in patients with LVEF ≦30% was investigated. From January 2013 to December 2017, 80 patients with LVEF ≦30% and FMR underwent pMVR. The 3-year actuarial survival was 58%. Cox regression analysis of 1-year survival demonstrated a negative impact of FTR severity, preoperative New York Heart Association class and peripheral artery disease. Kaplan-Meier analysis showed that 1 year-cardiac death was higher in the moderate-to-severe FTR group compared to none-to-mild (p=0.048). In this study, 77% of moderate-to-severe FTR pre-MitraClip could not be significantly reduced. Post-MitraClip, moderate-to-severe FTR grade was related to lower survival. In conclusion, in patients with FMR and LVEF ≤30%, MitraClip therapy resulted in lower perioperative complications and mortality than sMVR. However, surgically treated patients who survived the perioperative stage had less residual mitral regurgitation and experienced lower rates of re-hospitalization for heart failure at 1 year and lower cardiac mortality at 1 and 3 years of follow-up than patients undergoing pMVR. In patients with LVEF ≦30% treated with MitraClip for FMR, post-procedural moderate-to-severe FTR was an independent predictor of cardiac death within 1 year. To improve survival, additional therapy to residual FTR should be considered in early phase after MitraClip therapy., Die funktionelle Mitralklappeninsuffizienz (FMR) stellt einen unabhängigen Risikofaktor für die Zunahme einer Herzinsuffizienz dar. Neben operativem Mitralklappenersatz oder -rekonstruktion (sMVR) steht die perkutane „Edge-to-Edge“-Rekonstruktion mit MitraClip (pMVR) als minimalinvasive Technik als Therapieoption zur Verfügung. Das Ziel dieser Arbeit ist es, die Ergebnisse von sMVR und pMVR bei Patienten mit Herzinsuffizienz und hochgradig reduzierter linksventrikulärer Ejektionsfraktion (LVEF ≤30%) zu vergleichen. In der ersten Studie werden die klinischen Verläufe von sMVR und pMVR verglichen. 132 Patienten mit LVEF ≤30% und stattgehabter sMVR (n=47) oder pMVR (n=85) bei FMR wurden identifiziert. Nach Propensity-Score-Matching bezüglich Alter, logistischem EuroSCORE und linksventrikulärem endsystolischem Volumen zeigte pMVR eine geringere perioperative Mortalitäts- und Komplikationsrate, aber auch eine höhere Rest-Mitralklappeninsuffizienz als die sMVR. Gemäß stratifizierter multivariater Cox-Modell-Analyse war die Schwere der Restinsuffizienz ein unabhängiger Risikofaktor für Herztod und erneuten Krankenhausaufenthalt wegen Herzinsuffizienz im Verlauf von 1 Jahr. Stratifizierte multivariate Cox-Regressionsanalyse nach 3 Jahren identifizierte pMVR als Risikofaktor für kardialen Tod und erneuten Krankenhausaufenthalt wegen Herzinsuffizienz. Außerdem stellte eine erhöhte Rest-Mitralklappeninsuffizienz einen Risikofaktor für Herztod dar. In der zweiten Studie wurde die Auswirkung der präoperativen Schwere einer co-existenten funktionellen Trikuspidalklappeninsuffizienz (FTR) auf das frühe Ergebnis nach pMVR mit FMR bei LVEF ≤30% untersucht. Von Januar 2013 bis Dezember 2017 unterzogen sich 80 Patienten mit LVEF ≤30% und FMR einer pMVR. Das Überleben bis 3 Jahre betrug 58%. Cox-Regressionsanalyse zur 1-Jahres-Überlebensrate zeigte eine Auswirkung der Schwere der FTR, der präoperativen Klasse nach der New York Heart Association und der peripheren Arterienerkrankung. Eine Kaplan-Meier-Analyse ergab, dass die Herztod-Rate innerhalb 1 Jahr in der Gruppe mit mittelschwerer bis schwerer FTR höher war als in der ohne oder mit milder FTR. Nach dieser Studie konnten 77% der Fälle mittelschwerer bis schwerer FTR vor dem MitraClip-Eingriff nicht signifikant reduziert werden. Ein mittelschwerer bis schwerer Grad der FTR nach dem MitraClip-Verfahren war mit einer geringeren Überlebensrate assoziiert. Insgesamt führte die MitraClip-Therapie bei Patienten mit FMR und LVEF ≤30% zu geringeren perioperativen Komplikationen und einer geringeren Mortalität als sMVR. Operativ behandelte Patienten, die das perioperative Stadium überlebten, hatten jedoch eine geringere Restinsuffizienz und weniger erneute Krankenhausaufenthalte wegen Herzinsuffizienz bis 1 Jahr sowie eine geringere Herzmortalität bis 3 Jahre als Patienten, die eine pMVR erhielten. Bei Patienten mit LVEF ≤30%, die gegen FMR mit MitraClip behandelt wurden, war eine postoperative mittelschwere bis schwere FTR ein unabhängiger Prädiktor für Herztod innerhalb von 1 Jahr. Zur Verbesserung des Überlebens sollte in der Frühphase nach der MitraClip-Therapie eine zusätzliche Therapie der Rest-FTR erwogen werden.

\(\bf Background\) Redictors of repetitive left-ventricular assist device (LVAD)-thrombosis have not been studied yet. \(\bf Methods\) We identified predictors of recurrent LVAD thrombosis in HeartWare (HVAD) patients in a long-term study from 2010 until 2020. We included all patients with two or more thrombolysis treatments for repetitive HVAD thrombosis and effectiveness of thrombolytic therapy was defined as freedom from stroke, death, another HVAD thrombosis, or surgical device exchange within 30 days after the event. Study endpoints also include all-cause mortality and heart transplantation. \(\bf Results\) A total of 534 HVAD implantations have been screened, and 73 patients (13.7%) developed first HVAD thrombosis after a median of 10 months (IQR; 6–21 months). 46 of these patients had effective thrombolysis in 71.7% (\(\it n\) = 33/46). After a median of 14 months (IQR 4–32 months) follow-up, 17 patients (51.5%) had developed a second HVAD thrombosis and all were treated with t-PA therapy again, resulting in effectiveness in 76.5% (\(\it n\) = 13/17). The four patients with ineffective t-PA therapy underwent subsequent surgical HVAD exchange. Multiple Cox regression model analysis revealed time interval between HVAD implantation and first thrombosis as an independent risk factor of recurrent thrombosis (HR, 0.93, 95% CI 0.87–0.99, \(\it p\) = 0.031). Kaplan–Meier analysis at 3 year follow-up showed no significant difference in overall survival for recurrent vs non-recurrent thrombosis groups (log-rank test, \(\it p\) = 0.959). \(\bf Conclusion\) Recurrent HVAD thrombosis mostly appears within 12 months after first thrombosis. Systemic t-PA therapy for recurrent pump thrombosis seems safe, achieving comparable effectiveness rates to initial t-PA therapy. Survival does not differ between patients with or without recurrent HVAD thrombosis.

We report the first successful case, to our knowledge, of CoreValve Evolut R (Medtronic, Minneapolis, MN) implantation into a failed HAART 300 aortic annuloplasty device (BioStable Science & Engineering, TX). An 81-year-old man presented with severe symptomatic aortic regurgitation secondary to failure of the 21 mm HAART 300 device, which had been implanted 45 days previously. Transthoracic echocardiography (TTE) revealed grade 3 aortic regurgitation with central jet, without aortic valve stenosis. Because of the high risk for redo surgery, the heart team proceeded with femoral transcatheter aortic valve implantation. The 26 mm CoreValve Evolut R was deployed into the 21 mm HAART 300 device without difficulty or complications. There were no intraoperative or postoperative complications. The patient was discharged after 5 days. TTE showed a mean aortic valve gradient of 18 mmHg, with minimal paravalvular leak. Our experience suggests that CoreValve Evolut R implantation may be an attractive option in patients with failed HAART 300 aortic annuloplasty.

Objectives Although percutaneous edge-to-edge mitral valve repair with the MitraClip system is becoming widely adopted in clinical practice, surgical experience on how to correct failed MitraClip therapy is limited. We aimed to analyse the surgical and pathological outcomes after surgical revision of the failed MitraClip therapy. Methods Between January 2011 and January 2018, 25 patients (age 73 ± 9 years; men 48%; New York Heart Association class 3.4 ± 0.49) were admitted for severe mitral regurgitation at a median of 54 days (range 1-1496 days) after MitraClip edge-to-edge repair. Perioperative variables were analysed for their association with surgical outcomes. Results All patients underwent explantation of the MitraClip system and subsequent mitral valve replacement. Perioperative mortality was as high as 28%, mainly due to pre-existing cardiogenic or septic shock. The Kaplan-Meier analysis revealed a 53% overall 1-year survival. Among preoperative variables, the logistic European System for Cardiac Operative Risk Evaluation score, left ventricular ejection fraction and liver dysfunction had a significant influence on in-hospital survival. Intraoperatively, the predominant pathology included mitral valve leaflet damage due to tear, degeneration or infection. Although leaflet tears or MitraClip detachment mainly occurred within the first 6 months after MitraClip therapy, leaflet infections and degeneration mainly occurred later during follow-up. Conclusions The surgical revision of failed MitraClip therapy is feasible but has high perioperative mortality, especially among patients with cardiogenic shock, septic shock or liver failure. Mitral regurgitation after the MitraClip therapy is mainly caused by mitral valve leaflet damage due to tear, degeneration or infection, all related to the MitraClip itself.

Device dislocation associated with left atrial appendage closure with a Watchman device is rare. Few cases of surgical treatment have been reported. Therefore, surgical options and the effects of the surgery on subsequent operations are unknown. This device was implanted in 2 patients in another hospital because of frequent brain and intestinal bleeding related to coagulation therapy for atrial fibrillation. However, routine echocardiography revealed dislocation from the left atrial appendage orifice in the early and late postoperative periods. Emergency surgical removal of the devices was performed. Perioperative device management and treatment strategies are discussed briefly.