Severe mitral regurgitation (MR) is one of the most common valvular heart diseases and is frequently associated with advanced left ventricular (LV) systolic dysfunction. Transcatheter edge-to-edge repair (TEER) offers effective symptom relief but may induce abrupt hemodynamic changes leading to afterload mismatch and acute LV failure. Levosimendan may help mitigate this complication by improving contractility, yet evidence supporting its use in this setting is scarce. Therefore, the aim of this study was to systematically evaluate the evidence on the effects of Levosimendan in patients with severe MR and LV dysfunction undergoing TEER. We performed a comprehensive search of PubMed, Embase, Scopus, and Google Scholar. Primary outcomes were postprocedural LV ejection fraction (LVEF) and systolic pulmonary artery pressure (sPAP). Secondary outcomes included procedural success, procedure duration, and in-hospital complications. Five studies comprising 315 patients (n = 141 Levosimendan, n = 174 controls) met the inclusion criteria. Pooled analysis showed no significant difference in postprocedural LVEF between Levosimendan-treated patients and controls (mean difference 0.45%, 95% CI [−1.46–2.35] p = 0.65) and no significant change from baseline. Similarly, postprocedural sPAP did not differ significantly. Procedural success was higher with Levosimendan, and procedure duration was shorter. These hypothesis-generating findings highlight the need for larger, prospective randomized trials to clarify the role of Levosimendan in this setting.

Photon‑counting detector CT (PCD‑CT) enables ultra‑high resolution (UHR, 0.2 mm) and may improve visualization of coronary stents compared with standard‑resolution (SR, 0.4 mm). In this ex- vivo study, we utilized a phantom heart model to simulate physiological attenuation and imitated the most common coronary bifurcation stenting techniques by creating multiple stent layers and stent- crush situations (single layer, crushed, two‑ and three‑layer). We compared UHR and SR PCD‑CT using Bv72 and Bv56 kernels. Objective endpoints were in‑stent lumen visibility, signal-to-noise ratio, and percentage change in stent attenuation; subjective image quality was rated on a 5‑point Likert scale (1 = excellent to 5 = non‑diagnostic). Depending on distribution, two‑sided t‑tests (mean ± SD) or Mann–Whitney U tests (median[IQR]) were applied, p‑values were Bonferroni‑corrected for multiple comparisons. In the pooled Crush cohort, UHR Bv72 improved in‑stent lumen visibility when compared with both, SR Bv72 (single-layer: 68.08 ± 4.30% vs. 79.03 ± 3.79%; crushed: 63.62 ± 4.97% vs. 74.73 ± 2.51%) and SR Bv56 (single-layer: 63.63 ± 4.47% vs. 79.03 ± 3.79%; crushed: 62.18 ± 3.55% vs. 74.73 ± 2.51%), all p < 0.01. The effect was even more pronounced in small stents (single‑layer 65.45 ± 1.91% (SR) vs. 77.11 ± 2.55% (UHR) and crushed 60.67 ± 2.67% vs. 74.00 ± 2.67%), both p < 0.01. Regarding subjective image quality, UHR was associated with better sharpness and less blooming, e.g., UHR Bv72 vs. SR Bv56 (multilayer: sharpness 1[0] vs. 2[0], blooming 1[0] vs. 2[0]; crush: sharpness 1[0] vs. 2[0], blooming 1[0] vs. 2[1]; all p ≤ 0.01) and UHR Bv72 vs. SR Bv72 (multilayer: sharpness 1[0] vs. 1[1], blooming 1[0] vs. 1[1]; crush: sharpness 1[0] vs. 1[1]; all p ≤ 0.05). These findings indicate that UHR PCD‑CT with Bv72 might enable assessment of complex stents in a phantom setting; even though clinical studies are warranted.

Background Cardiogenic shock (CS) induced by severe aortic stenosis (AS) is a life-threatening condition with high mortality. Despite advancements in emergency interventions, the optimal treatment approach remains uncertain.Aim This study aimed to systematically review and analyse the existing evidence on outcomes of emergency transcatheter aortic valve implantation (eTAVI) and emergency balloon aortic valvuloplasty (eBAV) in CS patients.Methods A systematic literature review and meta-analysis was performed. The primary endpoint was mortality at 30 days. Secondary endpoints were in-hospital mortality, 1-year mortality, bleeding, major vascular complications, myocardial infarction, stroke, incidence of pacemaker implantation, acute kidney injury and aortic regurgitation.Results Seventeen studies were included, totalling 2811 patients. The analysis revealed a 30-day mortality pooled estimated rate for eTAVI of 19% (CI 0.17 - 0.20) and for eBAV 39% (CI 0.32 - 0.46). In-hospital mortality pooled estimated rates were 11% for eTAVI (CI 0.06 - 0.18) and for eBAV 40% (CI 0.28 - 0.54). One-year mortality pooled estimated rates for eTAVI were 29% (CI 0.20 - 0.40) and for eBAV 67% (CI 0.58 - 0.74). Pooled estimated rates of any bleeding were 12% for eTAVI (CI 0.06 - 0.20) and 15% for eBAV (CI 0.10 - 0.21). The rate of major vascular complications for eTAVI was 8% (CI 0.07 - 0.10) and 3% for eBAV (CI 0.0 - 0.23).Conclusions This meta-analysis indicates that mortality in CS due to AS remains high despite emergency interventional treatment. These findings offer critical insights for clinical decision-making optimising patient care in this critically ill population.

The aim of our study was to evaluate two different virtual non-contrast (VNC) algorithms applied to photon counting detector (PCD)-CT data in terms of noise, effectiveness of contrast media subtraction and aortic valve calcium (AVC) scoring compared to reference true non-contrast (TNC)-based results. Consecutive patients underwent TAVR planning examination comprising a TNC scan, followed by a CTA of the heart. VNC series were reconstructed using a conventional (VNCconv) and a calcium-preserving (VNCpc) algorithm. Noise was analyzed by means of the standard deviation of CT-values within the left ventricle. To assess the effectiveness of contrast media removal, heart volumes were segmented and the proportion of their histograms > 130HU was taken. AVC was measured by Agatston and volume score. 41 patients were included. Comparable noise levels to TNC were achieved with all VNC reconstructions. Contrast media was effectively virtually removed (proportions > 130HU from 81% to < 1%). Median calcium scores derived from VNCconv underestimated TNC-based scores (up to 74%). Results with smallest absolute difference to TNC were obtained with VNCpc reconstructions (0.4 mm, Br36, QIR 4), but with persistent significant underestimation (median 29%). Both VNC algorithms showed near-perfect (r²>0.9) correlation with TNC. Thin-slice VNC reconstructions provide equivalent noise levels to standard thick-slice TNC series and effective virtual removal of iodinated contrast. AVC scoring was feasible on both VNC series, showing near-perfect correlation, but with significant underestimation. VNCpc with 0.4 mm slices and Br36 kernel at QIR 4 gave the most comparable results and, with further advances, could be a promising replacement for additional TNC.

Background: In this study, we investigated various acute myocardial infarction (AMI) symptoms and their associations with short-term (28 day) and long-term mortality. Methods: The analysis was based on 5900 patients, aged 25 to 84 years, with fi rst-time AMI recorded by the population-based Myocardial Infarction Registry Augsburg between 2010 and 2017. Median followup time was 3.8 years (interquartile range: 1.1-6.3). As part of a faceto-face interview, the presence (yes/no) of 11 most common AMI symptoms at the acute event was assessed. Using multivariableadjusted logistic regression and Cox regression models, the association between various symptoms and all-cause mortality was investigated. P values of the regression models were false discovery rate adjusted. Results: Pain in various body parts (chest pain, left and right shoulder/ arm/hand, between shoulder blades), sweating, nausea/vomiting, dizziness and fear of death/feeling of annihilation were signi fi cantly associated with a decreased 28-day mortality after AMI. The pain symptoms and sweating were also signi fi cantly associated with a decreased long-term mortality. Shortness of breath was signi fi cantly associated with a higher long-term mortality. Conclusions: The absence of several symptoms, including typical chest discomfort (chest pain or retrosternal pressure/tightness), is associated with unfavourable outcomes after AMI. This fi nding has implications for patient management and public health measures designed to encourage appropriate and prompt medical consultation of patients with atypical AMI symptoms.

Graphical abstract Unique 40-year survival after heart transplantation with normal graft function and spontaneous operational tolerance.

Background: For patients with acute myocardial infarction (AMI), direct coronary angiography (CA) is recommended, while for non-AMI patients, the diagnostic work-up depends on clinical criteria. This analysis provides initial prospective German data for the degree of guideline-adherence (GL) in the use of CA on non-AMI patients presenting at the emergency department (ED) with suspected acute coronary syndrome (ACS) according to the 2015 ESC-ACS-GL. Furthermore the implications of the application of the 2020 ESC-ACS-GL recommendations were evaluated.Methods: Patient symptoms were identified using a standardized questionnaire; medical history and diagnostic work-up were acquired from health records. In accordance with the 2015 ESC-ACS-GL, CA was considered GL-adherent if intermediate risk criteria (IRC) were present or non-invasive, image-guided testing (NIGT) was pathological.Results: Between January 2019 and August 2021, 229 patients were recruited across seven centers. Patients presented with chest pain, dyspnea, and other symptoms in 66.7%, 16.2% and 17.1%, respectively, were in mean 66.3 +/- 10.5 years old, and 36.3% were female. In accordance with the 2015 ESC-ACS-GL, the use of CA was GL-adherent for 64.0% of the patients. GL-adherent compared to non-adherent use of CA resulted in revascularization more often (44.5% vs. 17.1%, p < 0.001). Applying the 2020 ESC-ACS-GL, 20.4% of CA would remain GL-adherent.Conclusions: In the majority of cases, the use of CA was adherent to the 2015 ESC-ACS-GL. With regard to the 2020 and 2023 ESC-ACS-GL, efforts to expand the utilization of NIGT are crucial, especially as GL-adherent use of CA is more likely to result in revascularization.

ObjectiveVentricular secondary mitral regurgitation (SMR) (Carpentier type IIIb) results from left ventricular (LV) remodelling, displacement of papillary muscles and tethering of mitral leaflets. The most appropriate treatment approach remains controversial. We aimed to assess the safety and efficacy of standardised relocation of both papillary muscles (subannular repair) at 1-year follow-up (FU).MethodsREFORM-MR (Reform-Mitral Regurgitation) is a prospective, multicentre registry that enrolled consecutive patients with ventricular SMR (Carpentier type IIIb) undergoing standardised subannular mitral valve (MV) repair in combination with annuloplasty at five sites in Germany. Here, we report survival, freedom from recurrence of MR >2+, freedom from major adverse cardiac and cerebrovascular events (MACCEs), including cardiovascular death, myocardial infarction, stroke, MV reintervention and echocardiographic parameters of residual leaflet tethering at 1-year FU.ResultsA total of 94 patients (69.1% male) with a mean age of 65.1±9.7 years met the inclusion criteria. Advanced LV dysfunction (mean left ventricular ejection fraction 36.4±10.5%) and severe LV dilatation (mean left ventricular end-diastolic diameter 61.0±9.3 mm) resulted in severe mitral leaflet tethering (mean tenting height 10.6±3.0 mm) and an elevated mean EURO Score II of 4.8±4.6 prior to surgery. Subannular repair was successfully performed in all patients, without operative mortality or complications. One-year survival was 95.5%. At 12 months, a durable reduction of mitral leaflet tethering resulted in a low rate (4.2%) of recurrent MR >2+. In addition to a significant improvement in New York Heart Association (NYHA) class (22.4% patients in NYHA III/IV vs 64.5% patients at baseline, p<0.001), freedom from MACCE was observed in 91.1% of patients.ConclusionsOur study demonstrates the safety and feasibility of standardised subannular repair to treat ventricular SMR (Carpentier type IIIb) in a multicentre setting. By addressing mitral leaflet tethering, papillary muscle relocation results in very satisfactory 1-year outcomes and has the potential to durably restore MV geometry; nevertheless, long-term FU is mandatory.Trial registration numberNCT03470155.

BACKGROUND:Shock index (SI) and modified shock index (mSI) are useful instruments for early risk stratification in acute myocardial infarction (AMI) patients. They are strong predictors for short-term mortality. Nevertheless, the association between SI or mSI and long-term mortality in AMI patients has not yet been sufficiently examined. MATERIAL AND METHODS:For this study, a total of 10,174 patients with AMI was included. All cases were prospectively recorded by the population-based Augsburg Myocardial Infarction Registry from 2000 until 2017. Endpoint was all-cause mortality with a median observational time of 6.5 years [IQR: 3.5-7.4]. Using ROC analysis and calculating Youden-Index, the sample was dichotomized into a low and a high SI and mSI group, respectively. Moreover, multivariable adjusted COX regression models were calculated. All analyses were performed for the total sample as well as for STEMI and NSTEMI cases separately. RESULTS:Optimal cut-off values were 0.580 for SI and 0.852 for mSI (total sample). AUC values were 0.6382 (95% CI: 0.6223-0.6549) for SI and 0.6552 (95% CI: 0.6397-0.6713) for mSI. Fully adjusted COX regression models revealed significantly higher long-term mortality for patients with high SI and high mSI compared to patients with low indices (high SI HR: 1.42 [1.32-1.52], high mSI HR: 1.46 [1.36-1.57]). Furthermore, the predictive ability was slightly better for mSI compared to SI and more reliable in NSTEMI cases compared to STEMI cases (for SI and mSI). CONCLUSION:High SI and mSI are useful tools for early risk stratification including long-term outcome especially in NSTEMI cases, which can help physicians to make decision on therapy. NSTEMI patients with high SI and mSI might especially benefit from immediate invasive therapy.Key messagesShock index and modified shock index are predictors of long-term mortality after acute myocardial infarction.Both indices predict long-term mortality not only for STEMI cases, but even more so for NSTEMI cases.

Introduction: The prognostic value of aortic valve calcification prior to transcatheter aortic valve replacement (TAVR) is well established. Its reliable quantification requires a non-contrast computed tomography (CT) of the heart (‘true non contrast’, TNC) which in this cohort is not regularly performed at all centers. Photon Counting Detector CT (PCD-CT) permits the routine derivation of ‘virtual non-contrast’ (VNC) and ‘virtual non-iodine’ (VNI) series from CT Angiography (CTA) acquisitions due to its intrinsic spectral sensitivity. These might render separate non-contrast acquisitions unnecessary. Hypothesis: We hypothetized that quantification of aortic valve calcification of VNC/ VNI series derived from CTA scans is feasable and correlates with calcium scores of TNC series. Methods: 45 consecutive patients underwent pre TAVR CT on a novel PCD-CT (NAEOTOM Alpha, Siemens Healthineers, Erlangen, Germany) comprising a non-contrast CT of the heart, followed by a CTA of the heart, aorta, and iliac arteries. VNC series were derived from CTA acquisitions and two readers independently quantified aortic valve calcium scores (Agaston score) and calcium volumes on VNC-, VNI- and TNC-series. Results: A total of 41 patients (41.46% female) were included in the study. In comparison with aortic valve calcium scores and volume scores derived from TNC series (i.e., 2800[2075-3681] vs. 2206[1645-2894] mm3), those derived from VNC (i.e., 752[390-1357] vs. 653.3[319.5-1052.3] mm3) and VNI (i.e., 1986[1270-3278] vs. 1515[971-2480] mm3) series were consistently lower but correlation was excellent for both, i.e., calcium and volume score, respectively (r’s: 0.96 and 0.96 for VNC; r’s: 0.92 and 0.91 for VNI, p< 0.05). Conclusions: Our initial patient experience with TAVR planning CT on a novel PCD-CT showed signficant correlation of aortic valve calcium scores and volumes derived from VNC and VNI series, as compared with those derived from TNC series, thus rendering non-contrast acquisitions for TAVR planning redundant.

Abstract Background Transcatheter mitral valve-in-valve (TMVIV) or valve-in-ring (TMVIR) replacement offer an alternative therapy for high risk patients. We aimed to highlight the operative and postoperative results of TMVIV and TMVIR procedures. Results We included all patients underwent TMVIV and TMVIR procedures between 2017 and 2020 at two heart centers in Germany. We included a total of 36 high risk patients in our study where 12 received TMVIV and 24 received TMVIR. All patients underwent TMVIV or TMVIR with Edwards Sapien XT or S3 transcatheter valves (Edwards Lifesciences). The mean age was 79 (75–83 years old). The median (IQR) preoperative STS score was 9 (7–13)% and EuroSCORE II was 14.5% (12–16). The majority of our patients were operated via transapical approach (n = 26) and the minority via transseptal approach (n = 10). Out of our records, none of our patients required reopening for bleeding or any other surgical complications. None of our patients required reintervention during the 6 months follow-up period. One mortality was recorded on fifth postoperative day due to low cardiac output syndrome (obviously because of LVOT obstruction by the anterior mitral leaflet). The average blood loss was 200 ml in the first 24 h in patients underwent transapical approach. Average operative time was 93 min and all patients were immediately extubated after the procedure in the operating room (even the patient with echocardiographically documented LVOT obstruction who died on the fifth postoperative day). Length of Intensive Care Unit stay was 2 ± 1.2 days and length of hospital stay was 4.1 ± 1.2 days. In the follow up period, echocardiograms showed normal prosthetic valve function with low transvalvular gradients, no LVOT obstruction in TMVIR cases and no evidence of valve migration or thrombosis (except in one patient). Concerning 6 months readmission, it was recorded in 2 patients due to right sided heart failure symptoms due to preexisting high degree of tricuspid valve regurge which did not disappear or even decrease after the operation and the other patient due to gastrointestinal bleeding. Conclusions TMVIV and TMVIR offer an efficient, safe and less invasive alternative in high surgical risk patients.

BackgroundIn this study we investigated the prevalence of undiagnosed impaired glucose tolerance and type-2-diabetes (T2D) among patients with acute myocardial infarction (AMI) and prospectively analyzed whether these patients have a higher long-term mortality.MethodsThe analysis was based on 2,317 AMI patients aged 25–84 years from the population-based Myocardial Infarction Registry Augsburg, recruited between 2009 and 2014 and followed-up until 2019 (median follow-up time 6.5 years [IQR: 4.9–8.1]). AMI patients with a diagnosis of diabetes were divided into a high (>7.0%) and a low HbA1c group (≤7.0%) according to HbA1c values at admission. The remaining patients (without known diabetes) were grouped into normal (<5.7%), elevated (5.7–6.4%), and high (≥6.5%) HbA1c groups. In a multivariable-adjusted COX regression analysis, the association between HbA1c groups and long-term mortality was investigated. Linear regression models were used to identify AMI patients with elevated HbA1c values by means of personal characteristics.ResultsAt admission, 29.5% of all patients reported a diagnosis of diabetes. Of all patients without known diabetes, 5.4% had HbA1c values of ≥ 6.5 and 37.9% had HbA1c values between 5.7 and 6.4%. The fully adjusted Cox regression model showed a non-significant trend toward higher long-term mortality for AMI patients with increased HbA1c values (HbA1c 5.7–6.4% HR: 1.05 [0.79–1.38], HbA1c > 6.5% HR: 1.34 [0.77–2.31]). A linear regression model including the variables admission serum glucose, BMI, age, sex and type of infarction (STEMI, NSTEMI) showed only poor prediction of HbA1c values (R2: 11.08%).ConclusionA fairly high number of AMI patients without known diabetes have elevated HbA1c values. Though we could not prove a higher risk of premature mortality in these patients, early detection and adequate therapy might lead to reduced diabetes-associated complications and improve long-term outcomes.

The aim of this study was to compare characteristics of incident acute myocardial infarction (AMI) and first and second time reinfarctions in terms of sociodemographic characteristics, comorbidities, symptoms, treatment, clinical characteristics, medication and outcome. A further aim was to identify predictors for an increased risk of hospitalized reinfarction. Between 2000 and 2017, a total of 13,276 AMI cases were recorded by a population-based registry in the area of Augsburg, Germany, and were included in this study (11,871 incident events, 1217 cases of first-time reinfarction and 202 cases of second-time reinfarction). Median follow-up time was 5.3 years. For differences in baseline characteristics, Chi-square tests and analysis of variance (ANOVA) were calculated. To determine factors that are associated with an increased risk of hospitalized reinfarction COX regression models were fitted. Myocardial reinfarctions differ from incident events in some major characteristics such as the frequency of comorbidities, laboratory values, ECG presentation and therapy, but not regarding 28-day mortality. Moreover, typical comorbidities and risk factors (diabetes, hypertension, hyperlipidemia, smoking, impaired renal function) are associated with an increased risk of hospitalized reinfarction. Conversely, STEMI ECG, being married, German nationality and bypass surgery are predictors for a lower risk of hospitalized reinfarction. Incident AMI and reinfarction are distinctly different in many characteristics, which physicians should have in mind when treating patients with prior AMI. Typical comorbidities are risk factors for hospitalized reinfarction. This underlines the importance of comprehensive treatment of these comorbidities including education of patients and encouragement towards lifestyle adjustments.

The introduction and development of artificial intelligence (AI) goes alongside with the technological progress observed during the past decades. This latter made feasible the use of artificial neural networks, that aim to overcome some of the main limits of natural intelligence, seeking to obtain objectivity and repeatability of qualitative and quantitative assessment. On this purpose, deep learning (DL) convolutional nets have been a major breakthrough, allowing the application of computational algorithms as a tool used to integrate and reproduce large amount of data and information by AI.

OBJECTIVES:Subannular repair techniques in addition to undersized ring annuloplasty have been developed to address high mitral regurgitation (MR) recurrence rates after mitral valve repair in type IIIb MR. We compared the results of annuloplasty with simultaneous standardized subannular repair versus isolated annuloplasty, focusing on the periprocedural outcomes of minimally invasive procedures.METHODS:A consecutive series of 108 patients with type IIIb functional MR with severe signs of bileaflet tethering underwent an annuloplasty + subannular repair (group A; n = 60) versus isolated annuloplasty (group B; n = 48). The primary end point of this prospective, parallel cohort study was death or recurrent MR >2, 1 year postoperatively. The secondary end points were survival and clinical outcomes, with special regard for the minimally invasively treated subgroups.RESULTS:Duration of surgery, cardiopulmonary bypass time and aortic cross-clamp time were comparable between both study groups. Procedural outcomes as well as echocardiographic outcome parameters were similar and independent of access (fully endoscopic versus full sternotomy). At the 12-month follow-up, death or MR >2 occurred in 3.3% (2/60) of patients in group A vs in 20.8% (10/48) of patients in group B (P = 0.037). The overall mortality rate during the follow-up period was 1.7% (1/60) in group A vs 12.5% (6/48) in group B (P = 0.041).CONCLUSIONS:Standardized realignment of papillary muscles is feasible and reproducible via a minimally invasive approach, resulting in excellent periprocedural outcomes, and has a clear potential to significantly decrease MR recurrence and improve 1-year outcomes compared to isolated annuloplasty.

Background. The major drawback of isolated annuloplasty in secondary mitral regurgitation (MR) is the reoccurrence of MR. We prospectively compared the results of isolated annuloplasty vs annuloplasty with simultaneous standardized subannular repair. Methods. The study comprised 101 patients with secondary type IIIb MR. Of these, 51 underwent annuloplasty plus standardized subannular repair with realignment of both papillary muscles (subannular repair) and 50 underwent isolated annuloplasty. The primary study end point was the reoccurrence of MR >2 at the 1-year follow-up. Secondary end points were survival, freedom from major adverse cardiac events, and residual leaflet tethering. Results. Baseline characteristics were comparable in both groups. There was no significant difference in inhospital mortality (P =.3). Although postrepair MR was comparable between the subannular repair and isolated annuloplasty subgroups, the residual leaflet tethering (tenting area, 127.6 +/- 35.8 mm(2) vs 166.3 +/- 47.3 mm(2), P =.02; posterior mitral leaflet angle, 19.2 +/- 4.7 degrees vs 24.8 +/- 5.2 degrees, P =.001; anterior mitral leaflet angle, 25.4 +/- 5.8 degrees vs 34.1 +/- 4.0 degrees, P =.001; and tenting height, 5.9 +/- 1.4 mm vs 9.2 +/- 2.2 mm, P =.001) were significantly increased in the isolated annuloplasty group (P <.001). At the 1-year follow-up, we found a significant difference between the groups in the freedom from MR >2 of 98% (50 of 51) for subannular repair vs 86.7% (39 of 45) for isolated annuloplasty (P =.045) and mortality of 0% (0 of 51) for subannular repair vs 10% (5 of 50) for isolated annuloplasty (P =.025). Conclusions. In secondary MR with reduced leaflet motion, the combination of annuloplasty and standardized subannular repair is associated with a significantly reduced MR reoccurrence, decreased residual leaflet tenting, and significantly improved 1-year outcome compared with annuloplasty alone. (C) 2019 by The Society of Thoracic Surgeons

Systolic heart failure is frequently accompanied by a relevant functional mitral valve regurgitation (FMR) which develops as a direct sequela of the ongoing left ventricular remodelling. The severity of mitral regurgitation is further aggravated by progressive left ventricular enlargement causing leaflet tethering and reduced systolic leaflet movement. The prognosis of such patients is obviously limited by an underlying left ventricular disease, and the correction of secondary FMR has been previously suggested as predominantly 'cosmetic' surgery in the setting of ongoing cardiomyopathy. Inferior results of an isolated annuloplasty in type IIIb FMR supported the philosophy of malignant course of progressive cardiomyopathy and resulted in increasingly restricted indications for mitral valve surgery for FMR in the guidelines. The lack of a standardized pathophysiological approach to correct type IIIb FMR led to the development of valve replacement strategy and edge-to-edge catheter-based mitral valve procedures, which became the most frequent procedures in the FMR setting in Europe. Modern mitral valve surgery combines the advantages of 3-dimensional endoscopic minimally invasive surgical approach with standardized subannular repair to address the pathophysiological background of type IIIb FMR. The perioperative results have been significantly improved, and there is a growing evidence of improved long-term stability of subannular repair procedures as compared to isolated annuloplasty. This review article aims to present the current state-of-the-art of the modern mitral valve surgery in FMR and provides suggestions for future trials analysing the potential advantages in these patients.

Here we will describe the first case of a novel JenaValve design (JenaValve Technology, Irvine, CA, USA) using the transfemoral approach in a 78-year-old female patient with pure aortic regurgitation. The implantation was successfully performed with good haemodynamics and good clinical outcome at six-month follow- up. The technology is especially appealing in non-calcified anatomies due to the clipping mechanism which was previously utilised in the transapical design.

We present a case of transcatheter valve-in-valve replacement performed because of structural valve deterioration of a subcoronary implanted stentless aortic bioprosthesis. A 23-mm self-expandable transcatheter heart valve (THV) with supraannular seating was chosen. The procedure was performed with the patient under conscious sedation. After anchoring and partial valve deployment, the patient experienced an acute onset of angina. The angiogram showed left main coronary artery obstruction. Prompt resheathing and retrieval of the THV was performed, and the procedure was aborted. Subsequently, an open-heart redo operation was performed by the use of a sutureless aortic bioprosthesis, with satisfactory hemodynamic and clinical results.