Tricuspid valve infective endocarditis (TVIE) is increasing, largely driven by rising injection drug use and the expanding use of cardiac implantable electronic devices (CIEDs). Percutaneous mechanical aspiration (PMA) has emerged as a viable catheter-based therapy to achieve source control through vegetation debulking in patients with a suboptimal response to antimicrobial therapy or those deemed at high risk for surgery. An expanding literature has demonstrated favorable feasibility and promising outcomes, and recent societal guidelines recognized PMA as a therapeutic option for carefully selected cases. Optimal results rely on multidisciplinary evaluation, rigorous patient selection, appropriate device choice, and meticulous procedural technique. This review summarizes the growing evidence base, outlines patient selection and technical considerations, and highlights future directions for PMA in the management of TVIE.

Percutaneous mechanical aspiration has emerged as a novel, catheter-based strategy for the management of right-sided infective endocarditis, particularly in patients with a suboptimal response to antimicrobials or in those considered high risk for surgery. Initially developed for thrombus extraction, percutaneous mechanical aspiration has been increasingly used to achieve source control by debulking large vegetations. Despite growing clinical adoption and support from societal statements and guidelines, there have been no randomized controlled trials evaluating its safety or efficacy in right-sided infective endocarditis. Current evidence is derived from retrospective case series, registries, and administrative data sets, all limited by heterogeneity in patient populations, procedural techniques, and outcome definitions. Nevertheless, recent data from multicenter registries demonstrate promising procedural success and feasibility in select patients. In response to expanding use and persistent knowledge gaps, this American Heart Association Science Advisory aimed to (1) define the rationale and evolving indications for percutaneous mechanical aspiration in right-sided infective endocarditis, (2) summarize the available clinical evidence and technical considerations, (3) provide expert consensus on patient selection and procedural planning, and (4) identify priorities for future prospective investigation.

Background:The accurate evaluation of right ventricular function and its response to correction of tricuspid valve pathology are challenging. This retrospective study evaluated the predictive value of right ventricular-pulmonary arterial (RV-PA) coupling in patients undergoing isolated or combined tricuspid and mitral valve surgery. Methods:Patients at Massachusetts General Hospital who underwent isolated tricuspid or combined tricuspid and mitral valve surgery between January 2013 and June 2024 with available preoperative transthoracic echocardiography images were included. The RV-PA coupling ratio was calculated by dividing the tricuspid annular plane systolic excursion (TAPSE) by PA systolic pressure. The optimal cut-off value for this ratio was determined using the maximal log-rank test. The primary outcome was mid-term survival, while secondary outcomes included in-hospital mortality, intensive care unit (ICU) stay duration, hospital stay, and prolonged postoperative inotrope use. Results:A total of 264 patients were followed for a median of 23 months (interquartile range, 7.0-48.0 months). The optimal RV-PA coupling ratio linked to mortality was 0.339 mm/mmHg. Patients with an RV-PA coupling ratio of ≤0.339 mm/mmHg had significantly higher all-cause mortality (25.5% vs. 10.0%; P<0.002), longer median ICU stay (4.0 vs. 3.0 days; P<0.001), longer median hospital stay (11.5 vs. 9.0 days; P=0.002), increased need for inotropic support (45.7% vs. 21.8%; P<0.001), and higher in-hospital mortality (10.6% vs. 2.9%). In multivariable Cox regression analysis, an RV-PA coupling ratio >0.339 mm/mmHg was linked to a reduced risk of all-cause mortality (hazard ratio 0.09, P=0.003). TAPSE and RV free-wall strain showed no association with mortality. Conclusions:Echocardiography-derived RV-PA coupling is a robust, independent predictor of adverse outcomes in patients undergoing tricuspid valve surgery, particularly in those undergoing combined procedures. It captures a critical dimension of RV physiology not fully appreciated by standard measures and may serve as a powerful tool in surgical risk stratification and patient selection.

Background Secondary tricuspid regurgitation (TR) often develops or persists following left-sided valve surgery. However, its impact on outcomes and the optimal timing of intervention is unclear. This study examined the association between isolated postoperative secondary TR and outcomes in patients with a history of mitral or aortic valve surgery.Methods This observational single-centre cohort study included patients with left-sided valve surgery and less than moderate preoperative TR who underwent follow-up echocardiography between 2002 and 2024. The presence of isolated postoperative secondary TR was evaluated in relation to clinical outcomes. The primary endpoint was a composite of all-cause death and heart failure hospitalisations (HFH).Results The cohort consisted of 2487 patients with a mean age of 68 years and a median follow-up time of 3 years. All-cause mortality and HFH increased with the grade of postoperative TR (p<0.001). Postoperative TR was associated with the composite endpoint independent of cardiovascular risk factors and baseline comorbidities (adjusted HR 1.29; 95% CI 1.18 to 1.41; p<0.001). The association between postoperative TR and the primary endpoint remained significant after adjustment for right ventricular (RV) remodelling and moderate mitral regurgitation (adjusted HR 1.40; 95% CI 1.28 to 1.53; p<0.001). An increase in TR by at least two grades from the preoperative assessment was observed in 12.5% of patients and was associated with the composite endpoint (p<0.001). Age, sex, myocardial infarction, coronary artery bypass grafting, atrial fibrillation and RV remodelling were factors associated with TR progression (p<0.01).Conclusions In patients following left-sided valve surgery, isolated postoperative secondary TR is independently associated with mortality and HFH independent of RV size, function and baseline comorbidities. An increase in TR severity by at least two grades from the preoperative assessment is associated with adverse outcomes.

Background:Atrial fibrillation (AF) is linked to adverse left atrial (LA) remodeling, including fibrosis and mechanical dysfunction. LA strain is an imaging marker of atrial function that may improve risk stratification for AF, but its predictive and prognostic value in the primary care population remains unclear. Objective:This study aimed to evaluate whether LA strain is associated with new-onset AF and adverse clinical outcomes after AF diagnosis. Methods:We performed a 2-part study within a longitudinal primary care cohort (2001-2019). In a nested case-control analysis, 216 patients with new-onset AF were compared with 216 age- and sex-matched controls. LA strain parameters, including peak atrial longitudinal strain (PALS), peak atrial contractile strain, and LA conduit strain (LACS), were measured using speckle-tracking echocardiography before AF onset. In 127 patients with new-onset AF, Cox models examined associations between LA strain and all-cause mortality, stroke, myocardial infarction, and heart failure hospitalization. Results:Lower PALS and LACS were independently associated with more than 3-fold higher odds of AF (both P < .001). Addition of strain measures to the LA volume index improved discrimination (area under the curve 0.66-0.73 for PALS; 0.72 for LACS). Over 4.6 years of follow-up, lower PALS remained independently associated with all-cause mortality (HR 2.70; P = .02) and the composite outcome (HR 2.31; P = .02). Conclusion:In a primary care cohort, impaired LA strain was independently associated with new-onset AF and adverse outcomes after AF diagnosis, supporting its role in AF risk stratification.

BACKGROUND:The TRISCEND II (EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device) trial demonstrated clinical benefits for transcatheter tricuspid valve replacement (TTVR) with the EVOQUE System over medical therapy for the primary safety and effectiveness endpoint to 1 year. OBJECTIVES:The authors report echocardiographic outcomes at 1 year for the randomized cohort and evaluate hemodynamic and structural changes. METHODS:The multicenter, prospective TRISCEND II trial enrolled 400 patients with severe, symptomatic tricuspid regurgitation (TR) and randomized them in a 2:1 ratio to TTVR (n = 267) or medical therapy (control) (n = 133). The secondary echocardiographic endpoint was reduction in TR severity from baseline to discharge. Echocardiograms were evaluated by an independent echocardiographic core laboratory. RESULTS:All patients had severe TR at baseline; at discharge, 95.5% of patients who underwent TTVR had mild TR. On paired analysis from baseline to 1 year, 95.3% of patients who underwent TTVR and 2.3% of control patients achieved mild TR. Between baseline and 1 year, the mean inferior vena cava diameter decreased significantly more for patients who underwent TTVR (normal breathing P < 0.001; forced inhalation P = 0.038). Patients who underwent TTVR experienced greater improvements in diastolic right ventricular (RV) size (P < 0.05) and larger decreases in RV systolic function (P < 0.001), consistent with reduced preload from TR reduction. RV stroke volume and cardiac output increased significantly in patients who underwent TTVR (P < 0.001) but not in control patients. CONCLUSIONS:One-year echocardiographic outcomes from the TRISCEND II trial demonstrated that near elimination of TR following TTVR is associated with reduced venous congestion, RV reverse remodeling, and significant improvements in forward stroke volume and cardiac output. (EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device [TRISCEND II Pivotal Trial]; NCT04482062).

Disorders of the pulmonic valve (PV) receive considerably less attention than other forms of valvular heart disease. Due to the dramatically improved survival of children with congenital heart disease over the last 5 decades, there has been a steady increase in the prevalence of adults with congenital heart disease, which necessitates that clinicians become familiar with the anatomy and the evaluation of right ventricular outflow tract and PV anomalies. A multimodality imaging approach using echocardiography, cardiac computed tomography, and magnetic resonance imaging is essential for a comprehensive evaluation of the anatomy and function of the right ventricular outflow tract, PV, and supravalvular region. As clinical presentation is often insidious with nonspecific symptoms, yet morbidity and mortality associated with severe untreated PV disease are significant, a high index of suspicion coupled with appropriate use of imaging techniques is critical in facilitating timely diagnosis and treatment. In this review, we aim to present a comprehensive approach to the diagnosis of PV disease and associated right ventricular outflow tract or supravalvular pulmonary stenosis, including optimal use of multimodality imaging to facilitate timely diagnosis, optimize therapeutic strategies, enhance postprocedural surveillance, and ultimately improve patient outcomes.

Background:Intravenous drug use (IVDU) significantly increases the risk of infective endocarditis (IE). This study evaluates the 2023 Duke-International Society of Cardiovascular Infectious Diseases (ISCVID) criteria for diagnosing IE in patients with a history of IVDU. Methods:This multicenter retrospective study evaluates these criteria in a cohort of 205 patients with intravenous drug use (IVDU) history, comparing outcomes with the 2000 modified Duke criteria. At 2 academic centers, patient records were reviewed for clinical, microbiologic, and imaging data to assess diagnostic classifications. Results:The 2023 Duke-ISCVID criteria reclassified 11 patients (5.3%), primarily due to updates in microbiological criteria, including the inclusion of various streptococcal species and Staphylococcus epidermidis in patients with cardiovascular implantable electronic devices (CIEDs). Notably, an unexpected prevalence of Streptococcus pyogenes as a causative agent was identified in 6 of 20 cases at 1 site. Conclusions:The 2023 Duke-ISCVID criteria reclassified 5% of IE cases in patients with IVDU due to expanded microbiological definitions. The unexpected prevalence of S. pyogenes highlights the need to consider atypical pathogens in high-risk groups.

Background: Paradoxical low-flow, low-gradient (PLFLG) severe aortic stenosis (AS) is a high-risk phenotype characterized by low transvalvular gradients despite preserved left ventricular ejection fraction (LVEF). While stroke volume index is conventionally used to define flow state, transvalvular flow rate (Q)—a measure incorporating both volume and ejection duration— offers a more physiologic assessment of forward flow. Given known sex-based differences in flow dynamics, we aimed to evaluate whether sex-specific Q thresholds are associated with adverse outcomes in PLFLG severe AS. Methods: We included 1,189 patients with adjudicated PLFLG severe AS (aortic valve area <1.0 cm2, mean gradient <40 mmHg, LVEF ≥50%, and Q ≤210 mL/sec) from an institutional echocardiographic database. Sex-specific Q thresholds were derived using the maximally selected rank statistic (≤150 mL/sec in males, ≤180 mL/sec in females). The primary outcome was a composite of all-cause mortality and aortic valve replacement (SAVR/TAVR). Results: In both sexes, lower Q was associated with a smaller aortic valve area, lower stroke volume index and reduced transvalvular gradients. Patients with low Q had significantly lower event-free survival, particularly among females, for both all-cause mortality and the composite outcome (log-rank p<0.001)(Figure). In a multivariable analysis, low Q independently predicted adverse composite outcome in both males (HR 1.54, 95% CI: 1.10–2.16) and females (HR 1.39, 95% CI: 1.16–1.65). Conclusion: Sex-specific transvalvular flow rate thresholds are independently associated with adverse outcomes in paradoxical low-flow low-gradient severe aortic stenosis. These findings support the clinical utility of sex-specific Q, particularly in women, for refining risk stratification and guiding timely intervention.

Background: Chronic inflammation is a key driver of cardiovascular disease progression and may impact transcatheter aortic valve replacement (TAVR) outcomes. Higher periaortic adipose tissue (PAAT) attenuation reflects aortic wall inflammation and can be measured on routine preprocedural CT. Yet, its prognostic value in TAVR patients remains unclear. Aim: To explore whether PAAT attenuation predicts long-term mortality in TAVR patients beyond traditional risk factors. Methods: We retrospectively analyzed preprocedural CT scans from consecutive TAVR patients treated at a single tertiary center between 2013 and 2023. The aorta was automatically segmented using a deep learning-based segmentation tool (TotalSegmentator) from the sinotubular junction to the distal infrarenal segment. PAAT attenuation was defined as the mean attenuation (Hounsfield units, HU) of all voxels within a 10mm radial cylinder around the aortic wall and an attenuation range of -190 to -30 HU. PAAT attenuation was associated with 5-year all-cause mortality using Cox regression models, adjusting for technical parameters (tube voltage, signal-to-noise ratio, BSA-indexed PAAT volume) and clinical covariates (age, sex, BMI, and Society of Thoracic Surgeons [STS] risk score). Incremental predictive value of PAAT attenuation was evaluated using Harrell’s C-statistic, and a high-attenuation threshold was derived by Euclidean distance within a receiver operating characteristic framework. Results: The study included 1,003 patients (51.5 % male, mean age 80±8y, BMI 28.6±6.0 kg/m 2 , median STS score 4.3 [2.5–7.0]%), followed for a median 22 (14–37) months; 5-year mortality rate was 23.6% (n=237). Mean PAAT attenuation was -77.3±7.3 HU. Non-survivors had higher mean PAAT attenuation than survivors (-75.9 vs -77.8 HU, P<0.001), Figure 1 . Those with high PAAT attenuation (>-77 HU) were slightly older, and more often female (both P≤0.05). PAAT attenuation independently predicted mortality (aHR [per 10 HU] 1.71, 95%-CI: 1.29–2.26; P<0.001) after adjustment. Adding PAAT attenuation to the clinical model (age, sex, BMI, STS score) improved discrimination for 5-year death (Harrell’s C from 0.69 to 0.70; P<0.001). Conclusions: High periaortic fat attenuation on preprocedural CT independently predicts long-term mortality in patients undergoing TAVR. Quantifying PAAT inflammation may offer additional prognostic value beyond established clinical risk factors and refine preprocedural risk stratification.

Therapeutic Area Preventive Cardiology Best Practices – clinic operations, team approaches, outcomes research Background Aortic valve replacement (AVR) is a guideline driven therapy for severe aortic stenosis (SAS), yet a substantial proportion of patients do not receive AVR and consequently suffer adverse outcomes and reduced survival. We evaluated the impact of electronic physician notifications (EPN) on provider rates of AVR within 1 year of index transthoracic echocardiogram (TTE). Methods In a pragmatic, cluster randomized clinical trial conducted within a multicenter academic health system, we randomly assigned 285 providers caring for patients with potential SAS (aortic valve area ≤ 1.0 cm2) on TTE to EPN or usual care. Providers receiving EPN were sent email and electronic medical record notifications highlighting the detection of SAS and tailored clinical guideline recommendations. Provider assignment remained durable for their subsequent patients found to have SAS on TTE. Provider rates of AVR reflect the proportion of their patients with severe AS that underwent AVR within 1 year of the index TTE. Results A total of 144 providers were randomized to EPN and 141 to usual care, resulting in 496 and 443 patients in each group, respectively. Providers consisted of procedural valve specialists (4%), cardiologists (48%), primary care physicians (33%), and other specialists (15%). Rates of AVR within 1-year were 11.0% ([1.3, 19.2]; p=0.02) higher with EPN. Provider AVR treatment rates were highly variable, and mean rates were 41% with EPN and 30% with usual care (p=0.02). Provider AVR rates were numerically higher with EPN across provider specialties. The proportion of providers with no patient undergoing AVR for SAS was 56.7% with usual care and 43.1% with EPN (p=0.03; Figure). Provider AVR rates in women were higher among EPN providers (42.3 vs. 16.0%; p<0.001), and EPN diminished gender disparity in provider AVR rates. Patients treated by providers with higher rates of AVR treatment had improved survival in both study arms. Conclusions Electronic provider notification improved provider utilization of AVR for SAS across specialties and mitigated gender disparity in AVR utilization. EPN therefore serves as a simple, scalable tool to improve the quality of care for SAS.

Background: Patients with paradoxical low flow low gradient severe aortic stenosis (LFLGAS) exhibit low transvalvular flow rates due to reduced stroke volumes, while maintaining preserved left ventricular ejection fraction (LVEF). The presence of mitral regurgitation (MR) adds complexity to this already challenging diagnosis, by further lowering flow rate. However, the impact of aortic valve intervention in this patient population remains uncertain. Methods: A total of 1178 patients were included from an institutional echo database with adjudicated aortic valve area (AVA <1.0 cm2), transaortic gradients (mean gradient< 40 mmHg) and low flow rate (Q ≤210 ml/sec), to confirm the diagnosis of LFLGAS and preserved LVEF (>50%). Subgroups were formed based on the presence of severe MR and subsequent surgical and transcatheter aortic valve intervention (SAVR/TAVR). Patients who underwent mitral valve intervention were censored. All-cause mortality was assessed as the primary outcome. Results: Patients with severe MR had significantly lower flow rates compared to patients w/o severe MR (166.5 ± 26.3 vs 174.7 ± 25, p=0.006). During a median follow up of 1.3 years, 745 deaths (62.2%) were identified, with a cumulative incidence significantly lower in the intervention groups (Figure). After multivariate propensity adjustment for age, sex, aortic valve area and comorbidities, aortic valve intervention showed a significant reduction in mortality risk in both intervention groups, which was more pronounced in the severe MR group compared to patients w/o severe MR (AdjHR 0.334, p=0.015 vs 0.436, p<0.001, p for interaction =0.24). Conclusions: In paradoxical low-flow low-gradient severe aortic stenosis, aortic valve intervention results in a survival benefit, especially among patients with concomitant severe MR. Our findings highlight the importance of recognizing severe MR as a flow-diverting lesion that can impact outcomes in LFLGAS.

BACKGROUND:Catheter-based percutaneous mechanical aspiration (PMA) is an emerging acute intervention for debulking infective vegetations in right-sided infective endocarditis (RSIE); however, its outcomes and safety remain undefined. OBJECTIVES:The authors sought to assess early clinical outcomes and safety of PMA in patients with RSIE. METHODS:The CLEAR-IE (Cardiac Lesion Extraction and Aspiration Registry for Infective Endocarditis) is a large multicenter retrospective registry of consecutive patients with RSIE who have undergone PMA. Procedural success was defined as a ≥70% reduction in site-reported vegetation size or a residual size ≤1 cm on intraprocedural echocardiography, which included transesophageal echocardiography (TEE), intracardiac echocardiography (ICE), and transthoracic echocardiography (TTE), selected at the operator's discretion to guide the intervention. The primary endpoint was a composite of in-hospital mortality, new pulmonary embolism (PE), or emergency surgery. Secondary endpoints included each component of the primary endpoint and in-hospital worsening tricuspid regurgitation (TR). RESULTS:Between January 2014 and January 2024, 256 patients from 19 institutions were included. Median age was 43 years; 43% were women, and 51% had history of injection drug use. Acute PE (50.8%) and shock (27%) were frequent at presentation. Tricuspid valve involvement was present in 70%, with a median site-reported vegetation size of 2.4 cm (Q1-Q3: 0.6-9 cm). Severe TR was noted in 31.3% at baseline. Staphylococcus aureus was the predominant pathogen (73.8%). Procedural success was achieved in 89.4%, with a median residual vegetation size of 0.7 cm (Q1-Q3: 0.2-1.1 cm). Overall, 86.9% completed the procedure free from procedure-related complications. The primary endpoint occurred in 18% (mortality: 9.8%; new PE: 8.3%; emergency surgery: 3.1%). Among those without baseline severe TR, worsening TR occurred in 16.9%. On univariate analysis, shock (OR: 2.27; 95% CI: 1.15-4.43; P = 0.03) and hypoxia (OR: 3.62; 95% CI: 1.83-7.17; P < 0.001) were significantly associated with the primary endpoint, whereas worsening TR was not. On multivariate analysis, hypoxia (OR: 2.76; 95% CI: 1.34-5.73; P = 0.006) remained significantly associated with the primary outcome. CONCLUSIONS:PMA of RSIE is feasible with high procedural success. Adverse events were acceptable and largely driven by underlying RSIE. Randomized trials are warranted to confirm the clinical impact and safety of PMA in RSIE.