BACKGROUND:Transcatheter tricuspid valve intervention (TTVI) has expanded therapeutic options for tricuspid regurgitation (TR); however, a substantial proportion of patients remain ineligible because of anatomical and clinical constraints. We sought to characterize patients screened out from TTVI and evaluate their clinical outcomes. METHODS:In this single-centre retrospective cohort study (January 2021 to May 2025), we included consecutive patients with symptomatic severe TR referred for TTVI evaluation who were deemed ineligible by a multidisciplinary heart team. Patients were identified through institutional logs and clinical trial screening databases. Baseline clinical, echocardiographic, and hemodynamic data were collected. Outcomes included 1-year all-cause mortality, heart failure hospitalization (HFH), and their composite. RESULTS:Among 205 patients evaluated, 83 (40.5%) were deemed ineligible. The mean age was 72.2 years, with a high burden of comorbidities. Severe or torrential TR was present in 84.4% of patients. The most frequent reasons for exclusion were unfavourable anatomy, including significant tricuspid annular dilation (69.5%) and a coaptation gap ≥ 7-10 mm (59.8%). Patients who died within 1 year had higher right-sided filling pressures on invasive hemodynamic assessment. At 1 year, all-cause mortality was 20.5%, HFH occurred in 31.3%, and the composite end point in 51.8%. Kaplan-Meier estimates showed survival of 77.5% and freedom from HFH of 58.3% at 12 months. CONCLUSIONS:Patients deemed ineligible for TTVI represent a high-risk cohort with substantial morbidity and mortality at 1 year. These findings underscore the importance of earlier referral, optimized screening strategies, and continued device innovation to expand treatment eligibility.

Tricuspid regurgitation in orthotopic heart transplantation recipients is a common complication that has been associated with poor outcomes. Surgical intervention carries a high risk in this population given prior sternotomy, immunosuppression, and comorbidities. We report a case series of 4 orthotopic heart transplantation recipients with severe symptomatic tricuspid regurgitation who were treated successfully with tricuspid transcatheter edge-to-edge repair. All patients demonstrated clinical and echocardiographic improvement postprocedure, with no procedural complications or rehospitalizations at short-term follow-up.

BACKGROUND:Quantitative assessment of right ventricular (RV) function by transthoracic echocardiogram (TTE) commonly relies on tricuspid annular plane systolic excursion (TAPSE) and lateral tricuspid annulus peak systolic velocity (S'). However, full cardiac cycle data may provide additional information beyond these two systolic measures. OBJECTIVE:We sought to (1) automate the estimation of systolic parameters (TAPSE and S') from tissue spectral Doppler imaging (Tissue Doppler Imaging [TDI]) and (2) integrate these tabular systolic parameters and the full-cycle functional signal to estimate RV systolic function. METHODS:We identified 387 patients who underwent both TTE and cardiac magnetic resonance imaging (CMR) within 24 h. We developed and validated an automated algorithm to extract TAPSE and S' from raw TDI. We trained two classifier models for RV dysfunction (RVEF < 45%): (1) Tabular model (RVDTABULAR) using algorithmic measurement of TAPSE/S' and age/sex, and (2) Integrated model (RVDINTEGRATED), an attention-based neural network model using the entire digitized TDI waveforms in addition to tabular data. RESULTS:In the TTE-CMR paired dataset, the proposed algorithm accurately estimated S' (mean error: -0.05 cm/s) and TAPSE (mean error: -0.97 mm). Tabular model RVDTABULAR achieved an AUROC of 0.71 and an AUPRC of 0.48 for predicting RVEF <45%, while the integrated model RVDINTEGRATED achieved significantly better performance (AUROC: 0.768; AUPRC: 0.56). In the external validation cohort with pulmonary hypertension (PH), the integrated model's prediction was significantly associated with event-free survival (p = 0.036). CONCLUSIONS:We developed a fully automated pipeline that integrates digitized TDI waveforms with both parametric and non-parametric features to classify RVEF <45%. This approach can effectively risk-stratify patients with PH.

BACKGROUND:Traditional heart transplant registries often lack the granularity required for deep phenotyping and rely on labor-intensive manual abstraction. We describe the methodology and validation of a next-generation, automated, multi-source registry designed to address these limitations. METHODS:Utilizing a High-Performance Computing environment, we integrated structured data from Epic data warehouses (Clarity and Caboodle), external molecular diagnostics, and verified UNOS survival records. A custom deterministic rule-based Natural Language Processing (NLP) engine was developed to extract echocardiographic measures, rejection grades, and vasculopathy scores from over 21,000 unstructured clinical reports. RESULTS:The Houston Methodist J.C. Walter Jr. Transplant Center Precision Registry and Platform-Heart (TCPR-Heart) captures 1687 heart transplants (1636 patients) spanning the years 1984-2025. The TCPR-Heart comprises 1054 transplants with active clinical follow-up: 555 transplants were extracted and abstracted from our modern electronic health record (EHR) in the decade since deployment, providing access to data throughout the patient's course of heart transplant; 427 were legacy active transplants (transplanted pre-2016 with continued follow-up), and 72 were external transplants (transplanted elsewhere but followed at Methodist). Additionally, the registry houses a historic cohort of 633 transplants (last follow-up < June 2016) with limited variables. Automated deep phenotyping successfully generated longitudinal data trends across clinical domains, including immunosuppression strategies, rejection, immunologic HLA data, renal function, metabolic profiles, vasculopathy, graft function, hospitalization burden and survival information. CONCLUSION:This automated framework unifies clinical, administrative, and molecular data streams. By leveraging an automated, regularly updated registry, we established a scalable, high-fidelity data source as a foundation for further innovations and novel applications based on an expertly curated and validated data source.

Introduction:Despite the HeartMate 3 (HM3) improved hemocompatibility, adverse neurological events (ANE) remain a major concern, and limited data exists on the combined effect of inflow and outflow cannula positioning on ANE risk. Methods:This single-center study included 103 HM3 recipients who underwent contrast-enhanced cardiac CT between 2016 and 2024. We measured inflow angle, inflow depth, distance to the anterior wall, and outflow angle. Optimal cutoffs were identified using ROC analysis, with associations with ANE evaluated by Kaplan-Meier and Cox regression. Results:Among the 103 patients, 25 (24%) experienced ANE over a median follow-up of 3.1 years. The ANE group had significantly shallower inflow depth (13.0 vs. 16.7 mm; p = 0.011) and a shorter distance to the anterior wall (13.0 vs. 16.7 mm; p = 0.006), along with a non-significant trend toward a larger outflow angle (56.3° vs. 51.7°; p = 0.175) and a more inferior inflow angle (-3.3°; p = 0.294). In multivariable Cox regression, inflow angle ≤ -4.1° (HR 4.34; 95% CI: 1.42-13.23), inflow depth ≤ 14.5 mm (HR 5.03; 95% CI: 1.76-14.37), and outflow angle > 42.7° (HR 5.52; 95% CI: 1.19-25.72) were independently associated with ANE. A greater number of cannula-related anatomical risk factors was significantly associated with worse 5-year ANE-free survival (p = 0.0004). Conclusions:Shallower inflow depth, inflow angle closer to inferior wall, and larger outflow angle, are significantly associated with ANE in HM3 patients. Optimizing cannula orientation during implantation may help mitigate stroke risk in this population.

Introduction An implantable pulmonary artery pressure (PAP) sensor is approved to reduce heart failure hospitalizations (HFH) in symptomatic patients. Key trials have excluded those with advanced chronic kidney disease (CKD), or eGFR <25 mL/min per 1.73 m². Real-world use of ambulatory hemodynamic monitoring in advanced CKD has not been well-described. Methods Hemodynamic Frontiers in Heart Failure (HF2) is an academic consortium of 14 US centers that developed a registry to collect data on patients following implantation with a PAP sensor, including demographics, hemodynamics, and clinical events (ED visits, HFH, or death). We analyzed patients with at least 12 months of hemodynamic monitoring data, comparing events in patients with normal kidney function (eGFR ≥60), mild to moderate CKD (eGFR 30-59), and advanced CKD (eGFR <30). Baseline demographic and implant hemodynamic data were compared using One-Way ANOVA test (IBS SPSS Statistics Version 29.0). In time-to-event analysis, patients who had no events were censored at their 12 month follow up as their last seen date. Those with an event > 12 months from the implant date were censored. The Registry has IRB approval from individual sites and is supported by CTSA Award UL1TR002366. Results Of 236 total patients, 70 (29.7%) had advanced and 112 (47.5%) had mild to moderate CKD (Table 1A). Those with CKD were more likely to be older, diabetic, and with higher baseline right atrial and pulmonary artery mean pressures. Patients with CKD had more frequent hospitalizations and those with advanced CKD had more frequent death and progression to LVAD/transplant or ESRD/dialysis (Table 1B). Of those with advanced CKD, only 2 (1.5%) progressed to ESRD. Conclusion Longitudinal real-world data from the HF2 Registry demonstrates use of PAP sensors in patients with a broad range of kidney function. Although ambulatory hemodynamic monitoring has been shown to reduce HFH, the same may not be true for those with advanced CKD. More research is needed in this high-risk population.

Right ventricular failure (RVF) is a common complication following left ventricular assist device (LVAD) implantation and increases patient morbidity and mortality. Due to the complex and limited understanding of RVF pathophysiology, efforts to prognosticate RVF after LVAD have been challenging. To fill the gaps, current efforts have been focused on identifying molecular drivers and physiological mechanisms of right ventricular dysfunction in this population. Recent work suggests that pro-inflammatory and oxidative stress pathways contribute to the development and progression of RVF post-LVAD, and elevation of inflammatory indices have been correlated with poor prognosis. Current prediction models are limited and performed only modestly in validation studies and do not include immunologic and molecular parameters, which could enhance pre-operative risk stratification towards reducing post-operative burden of RVF post-LVAD. In this review, we identified and summarized clinically relevant molecular and inflammatory markers of RVF and RVF following LVAD placement. Correlating these markers with current haemodynamic and echocardiographic parameters provides an avenue to reduce RVF after LVAD.

Background Women have been underrepresented in heart failure (HF) trials, including key trials for implantable pulmonary artery pressure (PAP) sensors. Sex-specific analysis of the use of ambulatory hemodynamic monitoring devices are lacking. Methods Hemodynamic Frontiers in Heart Failure (HF2) is an academic consortium of 14 US centers that has developed a registry to collect data on patients following PAP sensor implantation. We analyzed patients with at least 12 months of hemodynamic monitoring data and compared patients based on reported sex. Clinical events including ED visits, HF hospitalizations, and death have been captured. Baseline demographic and implant hemodynamic data were compared using independent samples t-test (IBM SPSS Statistics Version 29.0). The registry has IRB approval from individual sites and is supported by CTSA Award UL1TR002366. Results Of 238 patients, 100 (42%) were female. Women were more likely to have lower creatinine, higher BMI and ejection fraction (Table 1). They were less likely to have ischemic etiology or baseline SGLT2 inhibitor use. There were no significant differences in baseline hemodynamics. Female patients had fewer total events than their male counterparts (1.49 vs 1.91 events/person-year) and fewer HF hospitalizations (Figure 1). The majority of ED visits were non-cardiac and the majority of hospitalizations were not HF-related. There were 5 deaths total: 3 HF-related in males, 1 HF-related in a female and 1 non-cardiac in a female. Four patients progressed to LVAD, 3 of which were males. Three patients progressed to ESRD, all males. Conclusion The HF2 Registry is a real-world, multi-center registry of an approved PAP sensor. As compared to key trials leading to initial and expanded indications for the devices, this registry houses a higher proportion of female patients. Although there were no differences in baseline hemodynamics, there were substantial sex-based variations in other demographics and in outcomes. More research is needed to understand potential sex-specific effects and to encourage higher female representation in HF device trials and utilization.

BACKGROUND:The clinical significance of elevated baseline natriuretic peptide level and prior heart failure hospitalization (HFH) within the prior year in mitral transcatheter edge-to-edge repair outcomes is unclear. This analysis examined the impact of BNP (B-type natriuretic peptide) or NT-proBNP (N-terminal pro-B-type natriuretic peptide) and prior HFH on outcomes in patients with severe secondary mitral regurgitation. METHODS:The COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) was a randomized controlled trial of subjects assigned to mitral valve transcatheter edge-to-edge repair with the MitraClip device versus guideline-directed medical therapy alone. COAPT patients were grouped by BNP/NT-proBNP levels and prior HFH within 1 year: (1) Mild heart failure (HF): no prior HFH with BNP/NT-proBNP<median; (2) Moderate HF: prior HFH with BNP/NT-proBNP<median or no prior HFH with BNP/NT-proBNP≥median; and (3) Severe HF: prior HFH and BNP/NT-proBNP≥median. The primary measures were 2-year rates of death or HFH. RESULTS:Of 572 patients, mild, moderate, and severe HF were present in 125 (21.9%), 288 (50.3%), and 159 (27.8%) patients, respectively. With guideline-directed medical therapy alone, the 2-year rates of death or HFH in mild, moderate, and severe HF were 56.4%, 60.5%, and 84.1%, respectively (Ptrend=0.001). These rates were 48.7% and 73.4% among patients with moderate HF and a prior HFH only versus elevated BNP/NT-proBNP≥median only (P=0.003). Mitral transcatheter edge-to-edge repair reduced death/HFH compared with guideline-directed medical therapy alone regardless of HF severity (Pinteraction=0.50). CONCLUSIONS:In patients with HF with severe secondary mitral regurgitation enrolled in the COAPT trial, 2-year rates of death/HFH were increased with an elevated baseline BNP/NT-proBNP≥median, and more so if HFH within 1 year prior had occurred. Treatment with mitral transcatheter edge-to-edge repair reduced all-cause mortality and HFH consistently in mild, moderate, and severe HF. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Background:In 2018, changes in the United Network for Organ Sharing (UNOS) allocation system led to a shift in practices, making durable left ventricular assist devices less desirable as a bridge to transplantation compared to temporary mechanical circulatory support. This study compares the composite outcome of waitlist mortality and delisting incidence at 1 year between these two support types. Methods:All actively listed adult patients on mechanical circulatory support listed for heart transplantation under the current UNOS system from October 2018 to October 2021 were included, excluding those with right ventricular devices, biventricular devices, total artificial hearts, and extracorporeal membrane oxygenators. The primary outcome was the composite of waitlist mortality and delisting due to clinical deterioration at 1 year. Survival analysis was conducted using Kaplan-Meier curves and multivariable Cox regression. Results:A total of 4,569 patients were included, with 1,877 on temporary mechanical circulatory support and 2,692 on left ventricular assist devices. Propensity-score matching was performed on 660 patients divided into two groups. The event rate was lower in the left ventricular assist device group compared to the temporary mechanical circulatory support group (15.9% vs 35.2%, p < 0.001). Temporary mechanical circulatory support had a significantly higher multivariable hazard ratio (HR) for outcome events (HR 3.37, p < 0.001). The HeartMate 3 (HM3) had the best outcomes compared to all other device types. Conclusion:In this propensity-score-matched analysis, durable mechanical circulatory support had better outcomes than temporary mechanical circulatory support. HM3 had the lowest risk of composite outcomes.

This study compared structural and functional alterations using cardiac MRI (CMR) in heart transplant recipients with and without acute cellular rejection (ACR) and analyzed their association with clinical outcomes. ACR patients showed reduced left ventricular global longitudinal strain (LV GLS) (10% vs 12%; P = 0.03), reduced right ventricular global longitudinal strain (16% vs 18%; P = 0.04), increased left ventricular (LV) mass (72 vs 61 g/m²; P = 0.003), and decreased right ventricular stroke volume (70 vs 79 mL; P = 0.05). Univariate analysis revealed that LV ejection fraction (EF) (HR 0.90, P < 0.001), RV ejection fraction (HR 0.91, P = 0.004), LV stroke volume (SV) (HR 0.96, P = 0.01), RV SV (HR 0.96, P = 0.003), and LV scar size (HR 1.13, P = 0.002) were significantly associated with cardiovascular hospitalization or mortality. After adjusting for relevant covariates, indexed RV SV (HR 0.90, P = 0.015) and LV scar size (HR 1.17, P = 0.026) remained significant predictors of the clinical outcome. CMR can identify sequelae of ACR, potentially influencing clinical decisions.