Atrial fibrillation (AF) is a prevalent cardiac arrhythmia treated increasingly with catheter ablation, yet recurrence rates remain high. Genetic factors contribute to both AF susceptibility and response to therapy. This review summarises evidence on how common AF-associated variants, polygenic risk scores and rare monogenic variants influence ablation outcomes. Common single-nucleotide polymorphisms at loci such as 4q25 near PITX2 and 16q22 within ZFHX3 predispose to AF, but their individual effects on ablation success are modest. Polygenic risk scores aggregate small effects across many variants and have been linked to atrial conduction abnormalities and higher post-ablation recurrence, although they are not yet used routinely in clinical practice. In early-onset or familial AF, pathogenic variants in cardiomyopathy genes (e.g., TTN) may create an atrial cardiomyopathy yet do not necessarily preclude successful ablation, whereas LMNA mutations are associated with extensive fibrosis and poor outcomes. Genetic variation affects atrial electrical and structural remodeling, ectopic trigger distribution, fibrosis and autonomic tone, all of which influence ablation efficacy. Current guidelines do not recommend routine genetic testing for most patients; however, genotyping may inform risk stratification and follow-up in selected populations. Future work should integrate polygenic scores with clinical risk factors and explore genotype-guided procedural strategies and adjunctive therapies. We additionally address the relationship between genetic susceptibility and thromboembolic risk, the interplay between obesity, its genetic determinants, and AF perpetuation, and how ablation modality (radiofrequency, cryoballoon, and pulsed-field ablation) may interact with genetically determined substrate. A proposed clinical algorithm integrates genetic evaluation into the ablation pathway.

Background:Thalassemia and sickle cell disease are now increasingly present as lifelong chronic conditions in high-income countries, with growing numbers of patients reaching their 50s and 60s. This demographic shift transforms hemoglobinopathies from childhood-threatening disorders into chronic, multisystem conditions with cumulative morbidity. However, data specifically focused on later-life hemoglobinopathy populations remain limited, fragmented, and often extrapolated from younger cohorts, leaving hematologists and internists relatively unprepared for the functional decline, vulnerability, and geriatric syndromes that can characterize later life in these populations. Content:This expert opinion narrative review synthesizes available evidence on the intersection of disease-driven pathology (anemia, hemolysis, vasculopathy), long-term treatment burden (transfusion-related iron overload, chelation toxicities), and aging biology (declining physiologic reserve, sarcopenia, cognitive vulnerability) in adults beyond midlife. Given the historical survival patterns in hemoglobinopathies and the inconsistent definition of "older adult" across studies, particularly in sickle cell disease, we use a pragmatic age threshold of >=50 years for the main gerontological framing, while incorporating evidence from cohorts beginning at 40-49 years when that is how the literature defines older hemoglobinopathy populations. We distinguish disease-specific priorities: thalassemia faces myocardial and hepatic iron deposition and endocrine failure, while sickle cell disease confronts cerebrovascular disease, chronic pain, and cardiopulmonary complications. Critically, care targets in later life must extend beyond survival and organ-specific metrics to functional endpoints, disability prevention, cognitive health, and quality of life. A conceptual mapping links mechanisms of hemoglobinopathy to established gerontology constructs, including inflammaging, cellular senescence, and vascular aging, while acknowledging that direct mechanistic evidence in older hemoglobinopathy cohorts remains incomplete. Conclusions:Three adjustments are necessary in adults beyond midlife: monitoring should prioritize early detection of treatable complications and emerging functional impairment rather than only documenting cumulative organ damage; therapeutic decisions should weigh treatment benefit, treatment burden, comorbidity burden, and goals of care rather than defaulting to pediatric-era protocols; and care systems should embed shared decision-making, palliative principles, and multidisciplinary coordination within primary care networks, with specialist hemoglobinopathy centers functioning as disease-specific hubs rather than stand-alone primary care providers.

Background: Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases, with a rising global incidence. The 2025 European Society of Cardiology (ESC) guidelines introduced updated pathophysiological and morphological concepts for secondary MR, distinguishing ventricular and atrial mechanisms. Concurrent advances in cardiovascular imaging and therapeutic technologies have transformed the diagnostic and management landscape of MR. Methods: This review summarizes current evidence on the diagnosis and treatment of MR, with a focus on the updated ESC classification, multimodality cardiovascular imaging, minimally invasive surgical techniques, and contemporary transcatheter repair strategies. Recent literature was evaluated to highlight advances in anatomical assessment and individualized therapeutic approaches. Results: Multimodality imaging provides comprehensive evaluation of mitral valve anatomy, ventricular remodeling, and disease mechanisms, enabling accurate patient selection and procedural planning. Surgical management has evolved from conventional repair or replacement to minimally invasive approaches, including video-assisted right thoracotomy and robotic-assisted surgery, which have demonstrated favorable perioperative and clinical outcomes. In parallel, transcatheter interventions have expanded the therapeutic armamentarium for patients at high surgical risk or with complex anatomy. These include direct and indirect annuloplasty, transcatheter edge-to-edge repair, and emerging catheter-based repair technologies targeting specific structural abnormalities of the mitral valve apparatus. Conclusions: Contemporary management of MR requires an integrated understanding of disease pathophysiology, advanced imaging, and patient-specific anatomical characteristics. The combination of minimally invasive surgical techniques and rapidly evolving transcatheter interventions has broadened treatment options and supports a tailored, multidisciplinary approach to improve clinical outcomes and expand access to effective therapy for patients with severe MR.

Mitral regurgitation (MR) is a prevalent and prognostically relevant valvular disease, especially in patients with heart failure, in whom MR contributes to adverse remodeling, increased symptom burden, and higher mortality. Surgical repair or replacement remains the standard of care for suitable candidates, but many patients are excluded because of advanced age, comorbidities, or high surgical risk. Transcatheter methods have emerged as transformative alternatives, including mitral transcatheter edge-to-edge repair (MTEER) with devices such as MitraClip and PASCAL, annuloplasty-based devices such as Carillon and Cardioband, and transcatheter mitral valve replacement (TMVR) with devices such as Tendyne, Intrepid, and others under development. Data from randomized trials and registries have established that MTEER lowers hospital readmission rates and improves mortality in carefully selected secondary MR subjects, and that device upgrades improve procedural success and anatomical versatility. Annuloplasty provides targeted repair for functional MR with annular dilation, whereas TMVR offers an alternative for anatomically complex cases or those ineligible for MTEER, albeit with distinct procedural risks. Management of severe mitral annular calcification remains difficult and demands meticulous pre-procedural planning and customized device strategies. Careful patient selection based on MR etiology, proportionality, ventricular function, and anatomical suitability is essential for optimizing outcomes in this rapidly evolving field.

Coronary microvascular dysfunction (CMD) is increasingly recognized as a significant cardiovascular condition, particularly among women, yet its diagnosis and management during pregnancy remain poorly understood. CMD may arise de novo in the context of hypertensive disorders of pregnancy or represent an exacerbation of pre-existing endothelial dysfunction. This article views current evidence surrounding CMD in pregnancy, outlines the limitations of current diagnostic and treatment approaches, and highlights critical research gaps that must be addressed to improve outcomes in this vulnerable population.

BACKGROUND:Delayed diagnosis of haemoglobinopathy in adulthood is a recognised but incompletely characterised clinical problem, particularly in populations with high carrier prevalence. Adults with thalassaemia syndromes and haemoglobin variants are frequently misclassified as having iron deficiency or other common causes of microcytic anaemia, leading to prolonged diagnostic uncertainty, inappropriate iron supplementation and deferred access to genetic counselling and disease-specific management. The present exploratory study aimed to characterise diagnostic trajectories and candidate clinical cues associated with delayed recognition in a small single-centre cohort. METHODS:This was a retrospective, descriptive, single-centre pilot study of 19 adults who received a confirmed haemoglobinopathy diagnosis after a prolonged diagnostic delay, defined as a documented interval of ≥ 12 months between the first recorded abnormal haematological finding or symptom onset and the final confirmed diagnosis. We extracted clinical presentation, laboratory parameters, diagnostic pathway and retrospectively identified candidate clinical cues. Data are reported descriptively. As a secondary, hypothesis-generating exercise, we describe the components and cohort-level distribution of a preliminary clinical suspicion framework-the Haemoglobinopathy Suspicion Score (HSS) derived from the recurrent features observed in this dataset. No external comparator group was available; all analyses are descriptive and exploratory only. RESULTS:Median age at diagnosis was 39.0 years (IQR 31.0-53.5); five patients (26.3%) were diagnosed at age ≥ 54 years. The cohort was predominantly of Greek origin (18/19, 94.7%) with combined α/β phenotypes predominating (12/19, 63.2%). Recurring descriptive features within this small cohort included a combined microcytosis-hemolysis laboratory profile: median MCV was 63.6 fL (IQR 61.8-67.6), ferritin 201 ng/mL (IQR 89.6-283.9) and total bilirubin 1.8 mg/dL (IQR 1.1-2.3). Persistence of microcytic anaemia despite documented iron supplementation was retrospectively identified in 12/19 patients (63.2%; exact 95% CI 38.4%-83.7%). Iron deficiency anaemia was the initial misdiagnosis in 6/19 patients (31.6%). Patients consulted a median of 2.0 specialties (IQR 1.0-2.5) before a correct diagnosis was established. Applying HSS components retrospectively, a score of ≥ 3 was present in 18/19 patients (94.7%); this observation is descriptive only and cannot be interpreted as diagnostic performance in the absence of a comparator population. CONCLUSIONS:This exploratory single-Centre pilot study identifies recurring descriptive features associated with diagnostic delay in a small cohort of adults with haemoglobinopathy. The proposed HSS is a preliminary, hypothesis-generating clinical suspicion framework and has not been validated for clinical use. Larger, prospective, multicentric studies with appropriate comparator populations are required to derive and formally validate any bedside suspicion tool for this setting.

Background Single-leaflet device attachment (SLDA) is an uncommon but clinically significant complication of transcatheter edge-to-edge repair (TEER), associated with recurrent mitral regurgitation (MR). Case Summary A 73-year-old man with heart failure and severe MR presented with progressive dyspnea despite optimal medical therapy. Imaging demonstrated complex degenerative mitral valve anatomy. TEER with a PASCAL P10 device achieved initial MR reduction and hemodynamic improvement. Early follow-up revealed SLDA with posterior leaflet detachment and recurrent severe MR. A bailout TEER with implantation of a second PASCAL Ace device restored leaflet coaptation and stabilized the initial device. Discussion This case highlights the importance of early imaging surveillance and suggests that device orientation may influence leaflet insertion in complex anatomy. Conventional clocking strategies, such as 11-5 orientation, may not ensure optimal leaflet engagement in all patients. Take-Home Messages Device orientation should be individualized in complex mitral anatomy. Early SLDA can be effectively managed with imaging-guided bailout TEER.

BACKGROUND:Atrial fibrillation (AF) is linked to significant morbidity and mortality, with ischaemic stroke being a leading cause of death. Identifying modifiable risk and protective factors may help reduce stroke incidence in patients with AF. METHODS:This umbrella review evaluated meta-analyses of observational studies and randomised controlled trials (RCTs) to assess the association of protective and risk factors with stroke and transient ischaemic attack (TIA) in patients with AF. Observational associations were graded with the Ioannidis framework. Associations from RCTs and non-randomised baseline factors in meta-analyses of RCTs were assessed with GRADE (Grading of Recommendations Assessment, Development and Evaluation). Composite risk scores were summarised separately as risk-stratification tools. RESULTS:35 studies were included, comprising 23 meta-analyses of observational studies, reporting on 45 associations and 22 meta-analyses of RCTs on 24 associations based on data from over 7 276 000 participants. Among observational studies, only high levels of N-terminal pro-brain Natriuretic Peptide (NT-proBNP) provided convincing evidence of stroke risk. Previous stroke/TIA and age (65-74 years) were also associated with stroke, supported by a highly suggestive level of evidence. Among meta-analyses of non-randomised factors, female sex, kidney failure, non-paroxysmal AF and type 2 diabetes mellitus were risk factors with moderate to high evidence. However, other well-established risk factors, such as hypertension and vascular disease, were associated with stroke; however, they were supported with a weak level of evidence. CONCLUSIONS:Despite stroke being the most severe complication of AF, this umbrella review reveals that few risk factors are supported by high-level evidence. Our findings confirm that elevated NT-proBNP, age and prior stroke are credible stroke risk factors in patients with AF. However, risk factors with weaker evidence, such as hypertension and vascular disease, require further investigation to clarify their actual impact. PROSPERO registration number CRD42023471263.

Abstract Introduction Diastolic dysfunction emerges as the earliest cardiac abnormality in individuals with hemoglobinopathies including sickle cell disease (SCD) and β-thalassemia major (β-ΤΜ). In symptomatic patients with hemoglobinopathies, Heart Failure with preserved Ejection Fraction (HFpEF) stands out as the predominant cardiac phenotype. Left Atrial Stiffness Index (LASI) has been established as a prognostic indicator in HFpEF patients. Purpose To investigate potential LASI differences between SCD and β-ΤΜ patients. Methods In this cross-sectional study, thirty-four SCD patients (mean age 46.6 ± 15.6 years, 44.2% males), sixty, age- and sex-matched, patients with β -ΤΜ, and twenty-nine, age- and sex-matched, controls were enrolled. Various echocardiographic parameters, including left ventricular ejection fraction (LVEF), early mitral inflow velocity to basal septal early diastolic velocity ratio (E/e’), left atrial volume index (LAVI), tricuspid valve regurgitation velocity (TVR), and left atrial deformation at reservoir phase (LASr), were calculated. LASI was derived as the [E/e’]/[LASr] ratio. Patients with LVEF <50% were systematically excluded. Diastolic dysfunction was established based on 2016 ASE/EACVI Guidelines and Standards. Results LASI was greater in β-ΤΜ patients compared to both SCD patients (0.30 ± 0.22 vs 0.22 ± 0.11, p = 0.006) and controls (0.30 ± 0.22 vs 0.18 ± 0.06, p = 0.002). No statistically significant difference was observed between SCD patients and controls. Among SCD patients, those with diastolic dysfunction (n = 12) demonstrated elevated LASI (0.31 ± 0.10 vs 0.16 ± 0.04, p = 0.001) and reduced LASr (24.50 ± 3.20 vs 51.50 ± 11.20, p = 0.001) compared to those without diastolic dysfunction. Moreover, SCD patients with diastolic dysfunction had a higher LASI value (0.31 ± 0.10 vs 0.16 ± 0.06, p = 0.001) compared to controls. Conclusions There is significant difference in terms of left atrial stiffness between β-ΤΜ and SCD. A possible explanation could be the regular blood transfusions in β-ΤΜ patient group that could contribute to the increased left atrial stiffness in these patients.

Abstract Background Percutaneous left atrial appendage occlusion (LAAO) is typically performed under the guidance of transesophageal echocardiography (TEE) and fluoroscopy. Intracardiac echocardiography (ICE) appears to be a potential alternative to guide implantation. Purpose We sought to perform a meta-analysis comparing ICE vs TEE for the guidance of percutaneous LAAO. Methods A comprehensive literature search was performed using MEDLINE, Scopus and Web of Science electronic databases from their inception to November 2023 regarding published abstracts and manuscripts. Studies reporting clinical outcomes comparing ICE vs TEE for percutaneous LAAO were included. Primary efficacy and safety outcomes included technical success and the occurrence of any reported procedure-related and device-related complication. Secondary outcomes included procedural characteristics such as procedural time, fluoroscopy time and the volume of contrast agent used. Results A total of 18 studies with 124,230 patients fulfilled the criteria. Outcomes assessed including procedure time between ICE vs TEE (risk ratio [RR], 1.01; 95% CI, 1.00-1.01), fluoroscopy time (MD: 1.45 minutes, 95% CI -1.32 to 4.22, p=0.30) and contrast medium volume (SMD: 0.02, 95% CI -0.23 to 0.26, p=0.89) were found to be similar between both groups. Technical success with higher odds was found with the use of ICE (OR: 1.36, 95% CI 1.14 to 1.63, p=0.006) and fewer devices employed in cases of ICE guidance (SMD: -0.22, 95% CI -0.43 to -0.01, p=0.04, I2=62%). There was also no significant difference in procedure- or device-related adverse events between both groups. Interestingly, patients undergoing LAAO under ICE guidance had higher risk for pericardial effusion/tamponade and iatrogenic residual shunts compared to those in the TEE group (11 studies, RR: 1.66, 95% CI 1.13 to 2.43, p=0.014) and (4 studies, RR: 1.53, 95% CI 1.12 to 2.09, p=0.02, I2=1%), respectively. More vascular complications were noted in cases of ICE (RR: 1.56, 95% CI 1.06 to 2.32, p=0.03). Conclusions Although TEE is the gold standard for perioperative guidance of LAAO, imaging with ICE is an effective alternative to TEE in LAAO procedures. However, further studies are needed to clarify safety of this new perioperative imaging technique.

Pulmonary embolism (PE) represents the third leading cause of cardiovascular death, despite the implementation of European Society of Cardiology guidelines, the establishment of PE response teams and advances in diagnosis and treatment modalities. Unfavorable prognosis may be attributed to the increasing incidence of the disease and pitfalls in risk stratification using the established risk stratification tools that fail to recognize patients with intermediate-high risk PE at normotensive shock in order to prevent further deterioration. In this light, research has been focused to identify novel risk stratification tools, based on the hemodynamic impact of PE on right ventricular function. Furthermore, a growing body of evidence has demonstrated that novel interventional treatments for PE, including catheter directed thrombolysis, mechanical thrombectomy and computer-assisted aspiration, are promising solutions in terms of efficacy and safety, when targeted at specific populations of the intermediate-high- and high-risk spectrum. Various therapeutic protocols have been suggested worldwide, regarding the indications and proper timing for interventional strategies. A ST-elevation myocardial infarction-like timing approach has been suggested in high-risk PE with contraindications for fibrinolysis, while optimal timing of the procedure in intermediate-high risk patients is still a matter of debate; however, early interventions, within 24-48 hours of presentation, are associated with more favorable outcomes.

Pulmonary embolism (PE) ranks as the third leading cause of cardiovascular-related deaths in Western nations. Patients classified as high-risk (HR)-those exhibiting hemodynamic instability-require immediate interventions to restore blood flow. While intermediate-HR (IHR) individuals remain hemodynamically stable, they face a significant chance of clinical decline and thus need close and continuous observation. Effective risk assessment, mortality prediction, and therapeutic decision-making in these patients rely on a combination of clinical evaluation and imaging studies. Catheter-directed therapy (CDT) has emerged as a promising option, offering the ability to alleviate clot burden and reduce strain on the right ventricle, all while posing a lower risk of major bleeding compared to systemic thrombolysis. The growing adoption of CDT reflects its increasing relevance in PE treatment, especially when managed by specialized PE response teams that ensure individualized, multidisciplinary care. As clinical practices evolve, further studies and robust clinical trials are necessary to clearly define CDT's role in lowering the risks of complications and death among IHR PE patients. This article explores the current understanding and future direction of managing PE, focusing in the role of catheter-based interventions.

Background: Chronic liver disease (CLD) and cirrhosis contribute to approximately 2 million deaths annually, with primary causes including alcohol-related liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and chronic hepatitis B and C infections. Among these, MASLD has emerged as a significant global health concern, closely linked to metabolic disorders and a leading cause of liver failure and transplantation. Objective: This review aims to highlight the interplay between cirrhosis and cardiac dysfunction, emphasizing the pathophysiology, diagnostic criteria, and management of cirrhotic cardiomyopathy (CCM). Methods: A comprehensive literature review was conducted to evaluate the hemodynamic and structural cardiac alterations in cirrhosis. Results: Cirrhosis leads to portal hypertension and systemic inflammation, contributing to CCM, which manifests as subclinical cardiac dysfunction, impaired contractility, and electrophysiological abnormalities. Structural changes, such as increased left ventricular mass, myocardial fibrosis, and ion channel dysfunction, further impair cardiac function. Vasodilation in the splanchnic circulation reduces peripheral resistance, triggering compensatory tachycardia, while the activation of the renin–angiotensin–aldosterone system (RAAS) promotes fluid retention and increases cardiac preload. Chronic inflammation and endotoxemia exacerbate myocardial dysfunction. The 2005 World Congress of Gastroenterology (WCG) and the 2019 Cirrhotic Cardiomyopathy Consortium (CCC) criteria provide updated diagnostic frameworks that incorporate global longitudinal strain (GLS) and tissue Doppler imaging (TDI). Prolonged QT intervals and arrhythmias are frequently observed. Managing heart failure in cirrhotic patients remains complex due to intolerance to afterload-reducing agents, and beta-blockers require careful use due to potential systemic hypotension. The interaction between CCM and major interventions, such as transjugular intrahepatic portosystemic shunt (TIPS) and orthotopic liver transplantation (OLT), highlights the critical need for thorough preoperative cardiac evaluation and vigilant postoperative monitoring. Conclusions: CCM is a frequently underdiagnosed yet significant complication of cirrhosis, impacting prognosis, particularly post-liver transplantation. Early identification using echocardiography and thorough evaluations of arrhythmia risk in cirrhotic patients are critical for optimizing management strategies. Future research should focus on targeted therapeutic approaches to mitigate the cardiac burden in cirrhotic patients and improve clinical outcomes.

BACKGROUND Cardiovascular diseases and cancer are leading causes of morbidity and mortality. Patients with malignancies are at increased risk for cardiovascular complications including acute coronary syndromes, chemotherapy or radiation therapy related complications and cardiac metastasis. CASE SUMMARY We present a case of a 47-year-old female with metastatic cancer on immunotherapy presented with anterior ST elevation myocardial infarction followed by emergent percutaneous coronary intervention in the left anterior descending artery. Echocardiography after 72 hours showed thickening of inferior wall and cardiac magnetic resonance depicted inflammation and necrosis attributable to either cardiac metastasis or immunotherapy induced myocarditis. Biopsy was not performed because of treatment with antiplatelet drugs and a definite diagnosis was achieved after probationary administration of high-dose intravenous methylprednisolone that led to recovery. CONCLUSION In patients with malignancy, chemotherapy-induced cardiovascular complications and cardiac metastasis are common concerns and may coexist with common acute cardiovascular diseases including acute coronary syndromes. In such cases clinical suspicion aided by multimodality imaging is crucial for the diagnosis. A multidisciplinary team approach is required for prompt initiation of the appropriate treatment.

BACKGROUND:Acute pulmonary embolism (PE) with medical treatment results in high 30-day mortality rates, even when the patients present as hemodynamically stable. Catheter-directed treatment emerges as a viable first-line therapeutic approach for such patients (intermediate-high risk PE). CASE SUMMARY:The authors describe the successful treatment of a patient with angiographically massive but clinically only intermediate-high PE, using percutaneous transcatheter mechanical thrombectomy, resulting in removal of an embolus of a rather unusually long length. The patient's clinical condition rapidly improved with excellent follow-up CONCLUSIONS: Interventional treatment of acute PE is emerging as an efficacious and safe strategy.

Abstract Background/Introduction There are two types of mitral regurgitation (MR); primary, which is characterized by abnormalities of the mitral valve apparatus and secondary or functional, caused by left atrioventricular remodeling. The implementation of 3D transesophageal echocardiography (3D-TEE) has resulted in the precise depiction of the anatomical characteristics of mitral valve apparatus that prompts appropriate treatment. Purpose The aim of this study is to describe the anatomical characteristics of the mitral valve among patients with moderate or severe primary MR by using 3D-TEE. Methods From 2017 to 2023, 333 3D-TEE examinations have been performed in our center to evaluate MR cases. Specifically, 181 cases were classified as primary MR (52 moderate and 129 severe), in which visualization of the mitral apparatus had been performed via 3D-TEE. The recorded 3D data were retrospectively analyzed with specialized software and the pathophysiology of MR was described in each case. Results The median patient age was 63.9 years (SD±13.5), while 58% of patients were men. The left atrium was moderately or severely enlarged in 79% of the cases and the left ventricular ejection fraction was >60% in 61.5% of the patients. Mitral valve prolapse (MVP) with or without flail was found in 109 (61.9%) patients. Furthermore, it was noticed that MVP had been occurred at the anterior leaflet in 45.5% of the cases, at the posterior leaflet in 25% and at both leaflets in 29.5% of the cases. Moreover, in 65.5% of the cases, one or two mitral valve scallops had been affected. In the MR cases where the predominant pathophysiology was flail valve, the posterior mitral leaflet had been involved in 94.8% of the cases with one or two scallops been affected (83.9%). Among patients with both flail valve and MVP, the former was found at the posterior leaflet, while the latter at the anterior leaflet (in 63.9% of the cases). Mitral valve cleft in the absence of another mitral valve pathology was found in 7 patients (4%), while in 8 patients (4.4%) MVP was present and in 4 cases (2.2%) a combination of MVP and flail was found. The mitral cleft was depicted on P1P2 (38.1%) and P2P3 (23.8%) scallops respectively. Bileaflet cleft was found only in 4.8% of the cases. Moreover, calcified mitral lesions as primary cause of MR were found in 37 patients (21%), while rheumatic mitral valve pathology was found in 13 patients (7.4%). Among the rest causes of MR, infective endocarditis was found in 7 patients (4%) and systolic anterior motion of mitral valve in the context of hypertrophic cardiomyopathy in 3 patients (1.7%). Conclusions The description of mitral valve anatomy with the use of 3D-TEE provides useful information regarding morphological features that are used as favorable criteria for mitral valve repair procedures. It is suggested that cardiologists should get familiarized with 3D-TEE aiming at optimal clinical decisions to achieve maximum benefit for the patient.

Transcatheter aortic valve implantation (TAVI) has become an established treatment for severe aortic stenosis. However, the need for unplanned conversion to cardiac surgery (CS) during TAVI remains an infrequent but critical event. It is unclear whether this risk is higher in patients undergoing urgent procedures. We conducted a systematic review and meta-analysis to compare the incidence of unplanned conversion to CS between patients undergoing urgent versus elective TAVI. A systematic search of PubMed, SCOPUS, and Cochrane databases was performed to identify eligible studies. The primary outcome was the rate of unplanned conversion to CS. Secondary outcomes included mortality, device success, vascular complications, device embolization, acute kidney injury (AKI), stroke, permanent pacemaker implantation (PPI), moderate-or-severe paravalvular regurgitation (PVL), need for second valve implantation, bleeding, and duration of hospitalization. Seven studies comprising 71,909 patients were analyzed; 5108 underwent urgent TAVI and 66,801 underwent elective TAVI. No significant difference in conversion to CS was observed between the groups (RR: 0.89; 95% CI: 0.65-1.22). Device success rates were similar (RR: 0.99; 95% CI: 0.97-1.00). Urgent TAVI was associated with prolonged hospitalization (mean difference: 7.75 days; 95% CI: 4.06-11.45) and increased AKI risk (RR: 2.20; 95% CI: 1.53-3.16). Vascular complications, device embolization, stroke, PPI, PVL, second valve implantation, and major bleeding rates were comparable between the groups. Urgent TAVI is not associated with an increased risk of unplanned conversion to surgery. The observed higher AKI rates and longer hospital stay suggest that patient-related factors beyond procedural urgency may contribute to adverse outcomes.