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Background: There is conflicting evidence regarding the effect of residual transmitral mean pressure gradient (TMPG) after mitral transcatheter edge-to-edge repair (M-TEER). Different TMPG cutoffs have been employed in prior studies with varying results. Objectives: The purpose of this study was to examine the association between residual TMPG and M-TEER outcomes. Methods: Consecutive patients undergoing M-TEER at our institution between 2014 and 2022 were included and divided based on quartiles of predischarge TMPG. Outcomes were assessed using Kaplan-Meier analysis and Cox proportional hazard models. We performed subgroup analyses according to mitral regurgitation (MR) mechanism. The primary outcome was all-cause mortality or heart failure hospitalization. Results: We included 283 patients (age 76.7 ± 10.8 years, 42.8% women, 78.4% Caucasian, and baseline TMPG 2.4 ± 1.3 mm Hg). Higher baseline TMPG was a predictor of increased TMPG after M-TEER (coefficient 0.60 [95% CI: 0.40-0.70]; P

A 59-year-old male patient with history of rheumatic heart disease with 3 previous surgical aortic valve replacements with the last one being homograft followed by transcatheter aortic valve implantation in failed homograft presented with severe aortic regurgitation and cardiogenic shock requiring urgent TAV-in-TAV-in homograft. (Level of Difficulty: Advanced.)

Transesophageal echocardiography is the main imaging modality for localizing and quantifying prosthetic aortic regurgitation. We describe a case of bioprosthetic aortic paravalvular leak (PVL) where transesophageal echocardiography was inadequate; aortic root angiography and computed tomography fusion were critical in diagnosing and guiding closure. Multimodality imaging can be pivotal in localizing PVL and guiding transcatheter PVL closure. (Level of Difficulty: Intermediate.)