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OBJECTIVE Tricuspid regurgitation (TR) in heart transplant patients is associated with poor outcome. The increased risk for surgical and post-operative complications might be reduced in these vulnerable patients by transcatheter therapies. METHODS All patients with prior heart transplantation (HTX) undergoing transcatheter edge-to-edge repair in tricuspid position (T-TEER) were prospectively enrolled in an institutional registry. RESULTS Seven transplanted patients (5/7 female) at a mean age of 53 [48; 64] and median TRI-SCORE of 14 [7; 22] underwent T-TEER to treat symptomatic TR ≥ IV in an elective (n = 6) and urgent (n = 1) setting, respectively. Median time from HTX to T-TEER was 13 years. A total of 2 (n = 4) and 3 (n = 3) clips were implanted with a technical success in 6/7 (one single device detachment). TR reduction was effective and durable within a median echocardiographic follow-up time of 10 months (TR baseline vs last follow-up: p = 0.03). Further, a significant right ventricular remodelling (right ventricular end-diastolic diameter: 50 mm to 36 mm, p = 0.02), decrease in the inferior vena cava diameter (24 mm to 18 mm, p = 0.04) and in the gamma-glutamyl-transferase (255 U/l to 159 U/l, p = 0.04) was found. Four of 7 patients were free of cardiovascular death (n = 1, 267 days after T-TEER), cardiac redo surgery (n = 1), heart failure hospitalization (n = 2) and had no further clinical signs of right heart failure. CONCLUSIONS T-TEER after HTX demonstrates to be feasible and effective regarding TR reduction in a short-term follow-up. The initial results may pave the way of a novel approach in TR management in HTX patients.

ZusammenfassungDie interventionelle Therapie der Mitralklappe stellt im Gegensatz zur Aortenklappenintervention eine größere Herausforderung dar. Die Therapie mittels Mitra-Clip zur Rekonstruktion der Mitralklappe wurde erstmals im Jahr 2003 durchgeführt und ist seit dem Jahr 2008 in Europa zugelassen. Die erste Implantation der einzig zugelassenen interventionellen Mitralklappe erfolgte im Jahr 2014, die Zulassung in Europa erfolge im Jahr 2020. Es befinden sich zahlreiche andere Klappensysteme in klinischer Prüfung und werden das Portfolio wahrscheinlich erweitern. In diesem Artikel werden die Indikation für diese neue Therapieform, die technische Umsetzung sowie die spezifischen Herausforderungen für die perioperative Betreuung besprochen.

Heterotopic caval valve implantation may be a reasonable option for alleviating symptoms in select high-risk patients with recurrent tricuspid regurgitation after failed interventional tricuspid valve repair. However, altered right atrial hemodynamic status should be considered in procedural planning to avoid potential right-left shunting in cases of septal defects. (Level of Difficulty: Advanced.)

Transcatheter therapy of the mitral valve is more challenging compared to the aortic valve. Interventional therapy with the Mitra-Clip system, mimicking the surgical edge-to-edge repair, was first introduced in 2003 and received the CE mark in 2008. The first implantation of the Tendyne system, which is currently the only commercially available system for mitral valve replacement, was performed in 2014, and routine clinical use was approved in 2020. Several new valve platforms are in clinical development and will expand the treatment portfolio. This article will discuss the clinical indications, technical challenges and specific requirements for perioperative management.Die interventionelle Therapie der Mitralklappe stellt im Gegensatz zur Aortenklappenintervention eine größere Herausforderung dar. Die Therapie mittels Mitra-Clip zur Rekonstruktion der Mitralklappe wurde erstmals im Jahr 2003 durchgeführt und ist seit dem Jahr 2008 in Europa zugelassen. Die erste Implantation der einzig zugelassenen interventionellen Mitralklappe erfolgte im Jahr 2014, die Zulassung in Europa erfolge im Jahr 2020. Es befinden sich zahlreiche andere Klappensysteme in klinischer Prüfung und werden das Portfolio wahrscheinlich erweitern. In diesem Artikel werden die Indikation für diese neue Therapieform, die technische Umsetzung sowie die spezifischen Herausforderungen für die perioperative Betreuung besprochen.

Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.

Background Atorvastatin and ticagrelor have been shown to prevent against tissue injury in animals. It is unclear if these beneficial effects are also detectable in humans. We studied the effect of high-dose atorvastatin combined with ticagrelor loading on endothelial dysfunction in a model of forearm vascular ischemia-reperfusion (IR) injury. Methods 32 healthy subjects (n=16 per group) were enrolled in this randomized, placebo-controlled, double-blinded trial. Forearm blood flow (FBF) measurements in response to increasing intra-arterial doses of the vasodilator acetylcholine (ACh; endothelium-dependent agonist) and glyceryltrinitrate (GTN; endothelium-independent) were performed before and after a cuff-induced 20min forearm ischemia, respectively. FBF reactivity was assessed prior to any pharmacological intervention and after 14days intake of 80mg atorvastatin once daily or placebo, followed by an oral loading dose of 180mg ticagrelor. In addition, lipoprotein parameters and platelet aggregation were evaluated. Results Ticagrelor loading mitigated ischemia-induced endothelial dysfunction and in combination with repeated atorvastatin dosing the response to ACh during reperfusion was completely normalized (FBF ACh AUC ratio post- vs. pre-ischemia: 0.81 [ticagrelor] vs. 1.04 [atorvastatin+ticagrelor]; P=0.001). As expected, GTN-induced vasodilation was not affected by IR injury. Atorvastatin significantly reduced total and low density lipoprotein cholesterol concentrations, while high density lipoprotein cholesterol and triglyceride levels remained unchanged. Conclusion Chronic atorvastatin treatment combined with ticagrelor loading prevents against endothelial dysfunction after acute forearm ischemia. Ticagrelor alone mitigated the impaired endothelium-dependent FBF response as compared to no pharmacological intervention. Clinical trial registration URL: https://clinicaltrials.gov. Unique identifier: NCT02910778.

Background: Younger patients with severe symptomatic aortic stenosis are a particularly challenging collective with regard to the choice of intervention. High-risk patients younger than 75 years of age are often eligible for both the transcatheter aortic valve replacement (TAVR) and the isolated surgical aortic valve replacement (iSAVR). Data on the outcomes of both interventions in this set of patients are scarce. Methods: One hundred and forty-four propensity score-matched patients aged 75 years or less who underwent TAVR or iSAVR at the Hietzing Heart Center in Vienna, Austria, were included in the study. The mean age was 68.9 years (TAVR 68.7 vs. SAVR 67.6 years, p = 0.190) and the average EuroSCORE II was 5.4% (TAVR 4.3 [3.2%] vs. iSAVR 6.4 (4.3%), p = 0.194). Results: Postprocedural adverse event data showed higher rates of newly acquired atrial fibrillation (6.9% vs. 19.4%, p = 0.049), prolonged ventilation (2.8% vs. 25.0%, p &lt, 0.001) and multi-organ failure (0% vs. 6.9%) in the surgical cohort. The in-hospital and 30-day mortality was significantly higher for iSAVR (1.4% vs. 13.9%, p = 0.012, 12.5% vs. 2.8%, p = 0.009, respectively). The long-term survival (median follow-up 5.0 years (2.2–14.1 years)) of patients treated with the surgical approach was superior to that of patients undergoing TAVR (p &lt, 0.001). Conclusion: Although the survival analysis revealed a higher in-hospital and 30-day survival rate for high-risk patients aged ≤75 years who underwent TAVR, iSAVR was associated with a significantly higher long-term survival rate.