Background:Structural heart disease interventions, including transcatheter aortic valve implantation (TAVI), transcatheter edge-to-edge repair (TEER), patent foramen ovale (PFO) closure, and left atrial appendage closure (LAAC), have transformed the management of valvular and congenital heart disease. However, antithrombotic therapy following these procedures remains a major challenge, as clinicians must balance the prevention of thromboembolic events with the risk of bleeding. Evidence from randomized trials and registries has provided guidance, yet optimal strategies are still evolving. Methods:This review synthesizes current evidence regarding antithrombotic therapy in structural heart disease. We examined published randomized controlled trials, observational studies, and guideline recommendations from mainly 2015 to 2025. The focus was on post-procedural antithrombotic regimens, including single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), and oral anticoagulation, as well as their impact on clinical outcomes such as stroke, systemic embolism, device-related thrombosis, and major bleeding. Results:In TAVI, early studies favored DAPT to reduce thromboembolic complications, but subsequent trials demonstrated increased bleeding without significant benefit compared to SAPT. Current guidelines increasingly recommend SAPT in patients without concomitant indications for anticoagulation. In TEER, antithrombotic therapy is less standardized; anticoagulation is generally continued in patients with atrial fibrillation, while antiplatelet therapy is used in sinus rhythm. For PFO closure, short-term DAPT (3-6 months) followed by SAPT is widely adopted to prevent device-related thrombosis, with long-term therapy tailored to stroke risk. In LAAC, anticoagulation combined with antiplatelet therapy is typically prescribed for 45 days to 3 months until device endothelialization occurs, after which SAPT is sufficient. Across all interventions, bleeding risk remains a critical determinant of therapy duration and intensity, particularly in older and comorbid populations. Conclusion:Antithrombotic therapy in structural heart disease requires individualized decision-making that integrates procedural type, patient comorbidities, and bleeding risk. Recent evidence supports a trend toward simplified regimens, with SAPT increasingly favored over DAPT in TAVI and tailored strategies in TEER, PFO closure, and LAAC. Despite advances, significant heterogeneity persists, underscoring the need for further randomized trials to refine optimal regimens. Clinicians must remain vigilant in balancing thromboembolic protection with bleeding avoidance, as antithrombotic therapy continues to play a pivotal role in the success of structural heart interventions.

BACKGROUND:Inferior sinus venosus (SV) atrial septal defect (ASD) is a rare interatrial communication, found near the inferior vena cava (IVC)-right atrial (RA) junction, that may be overlooked on transesophageal echocardiography (TEE). CASE SUMMARY:A 52-year-old woman with childhood secundum ASD closure presented with progressive right heart enlargement. Transthoracic echocardiography showed marked right-sided dilation without a detectable shunt. TEE confirmed an intact fossa ovalis patch but did not adequately visualize the IVC-RA junction. Electrocardiogram-gated cardiac computed tomography (CT) revealed an inferior SVASD with anomalous drainage of 2 right lower pulmonary veins into the RA. Intracardiac echocardiography (ICE) identified a low interatrial communication and Doppler evidence of anomalous pulmonary venous inflow. Surgical baffle repair redirected pulmonary venous return to the left atrium without complications. DISCUSSION:CT and ICE provided complementary anatomic and functional information when TEE was inconclusive. TAKE-HOME MESSAGES:TEE may not detect inferior SVASDs. CT and ICE serve as critical complementary modalities.

A residual false lumen after type A aortic dissection repair may rarely serve as an embolic route to the cerebral circulation. A woman in her 60s underwent ascending aortic replacement for Stanford type A aortic dissection, leaving a residual patent dissection involving the supra-aortic branches and the descending aorta. Despite receiving anticoagulant and antiplatelet therapies, the patient developed recurrent multifocal cerebral infarctions. Transesophageal echocardiography (TEE) demonstrated an entry tear in the descending aorta communicating from the true lumen to the false lumen. Flow became markedly stagnant toward the proximal false lumen, with thrombus-like echogenic material. Four-dimensional computed tomography (4DCT) confirmed delayed retrograde flow ascending within the false lumen toward the arch. Total arch replacement was performed to eliminate the suspected embolic route. Intraoperative findings confirmed thrombotic material within the false lumen. No recurrent cerebral infarctions were observed postoperatively.

Objective To describe a physiology-guided approach to evaluating and closing a clinically significant iatrogenic atrial septal defect after transseptal structural heart intervention. Key Steps The approach included echocardiographic identification of right-to-left shunting, invasive assessment of interatrial pressure gradients and pulmonary vascular load, inhaled nitric oxide as rescue therapy and an adjunctive physiologic maneuver, 3-dimensional assessment of defect morphology, and urgent transcatheter closure. Potential Pitfalls Inhaled nitric oxide should not be used as a stand-alone determinant of closure. Closure decisions should integrate shunt direction, interatrial pressure gradient, oxygenation, right-sided loading conditions, and whether the defect may serve as left atrial decompression. Take-Home Message Postprocedural iatrogenic atrial septal defect closure should be individualized according to physiology rather than anatomy alone.

INTRODUCTION:Whether the mortality impact of ischemic stroke and major bleeding differs across left ventricular ejection fraction (LVEF) categories in patients hospitalized for acute heart failure (AHF) with atrial fibrillation (AF) remains uncertain. METHODS:We retrospectively analyzed 716 patients hospitalized for AHF with prevalent AF (mean age: 79 ± 11 years; 49% female). During up to 3 years of follow-up (median: 1.4 years), 53 patients developed stroke and 89 developed major bleeding. Time-dependent Cox models were used to evaluate associations between poststroke and post-major bleeding states and all-cause and cardiovascular mortality, stratified by LVEF category: heart failure with reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction. RESULTS:There were 160 deaths, including 106 cardiovascular deaths. As first qualifying events, 34 were stroke-first, and 74 were bleeding-first, with the remaining patients experiencing death-first or being censored. In time-dependent Cox models, post-major bleeding status was associated with higher all-cause mortality, whereas the poststroke association was imprecise (hazard ratio [HR] 2.00, 95% confidence interval [CI] 1.22-3.28 vs. HR 1.35 [95% CI 0.67-2.70]). For cardiovascular death, neither exposure reached conventional statistical significance (HR 1.97 [95% CI 0.93-4.17] after stroke and 1.69 [0.88-3.26] after bleeding). LVEF-stratified estimates were imprecise, and interaction tests did not support definitive effect modification. CONCLUSION:In patients hospitalized for AHF with prevalent AF, transition into a post-major bleeding state was associated with higher subsequent all-cause mortality, whereas the poststroke association was imprecise. LVEF-stratified findings were exploratory because interaction tests were not significant and event counts were limited. Bleeding-risk mitigation should accompany continued stroke prevention, not replace it.

PURPOSE:To examine associations of left atrial reservoir strain, diameter, and volume index with first rehospitalization and recurrent readmission burden in acute heart failure with atrial fibrillation. METHODS:Among 716 enrolled patients, 691 with an available measurement formed the left atrial diameter analysis cohort; left atrial volume index (LAVI) and reservoir strain (LArs) were evaluated in a 320-patient single-center subgroup. Same-day rehospitalization and death were classified as death-first. Fine-Gray and negative-binomial models examined first rehospitalization and recurrent readmission burden. RESULTS:Of 691 patients, 189 had rehospitalization-first, 118 death-first, and 384 were censored. In the 320-patient subgroup, lower LArs was associated with first rehospitalization (adjusted subdistribution hazard ratio [sHR] 0.920 per 1 percentage-point increase, 95% confidence interval [CI] 0.870-0.973) and with a higher recurrent readmission rate (incidence rate ratio 0.877, p < 0.001); the first-event association persisted after additional echocardiographic adjustment including left atrial diameter (sHR 0.928, 95% CI 0.876-0.984). Left atrial diameter was associated with rehospitalization-first (sHR 1.025/mm, 95% CI 1.011-1.039) but not death-first, whereas LAVI was associated with neither, including per standard deviation. With exploratory cutoffs, only combined abnormality was associated with first rehospitalization (sHR 2.12, 95% CI 1.16-3.85). Left atrial indices did not significantly improve discrimination. CONCLUSION:Lower LArs was associated with first heart failure rehospitalization and recurrent readmission burden, and remained associated after additional echocardiographic adjustment including left atrial diameter. Left atrial diameter was associated with first rehospitalization but LAVI was not; a general left atrial structural mechanism is not established. Incremental predictive value was limited; cohort-derived cutoffs require external validation.

BACKGROUND:Selecting the optimal WATCHMAN FLX (a second-generation left atrial appendage [LAA] closure device) size for a borderline-sized LAA, for which 2 device sizes are acceptable, remains challenging. OBJECTIVES:The aim of this study was to evaluate how device size affects procedural and clinical outcomes in borderline-sized LAAs undergoing LAA closure. METHODS:From the Japanese multicenter TERMINATOR (Transcatheter Modification of Left Atrial Appendage by Obliteration with Device in Patients With NVAF) registry, 1,190 patients who underwent LAA closure with the second-generation device between May 2021 and September 2023 were reviewed. Of these, 757 with borderline-sized LAAs were included and categorized into large (n = 390) and small (n = 367) device groups. The median follow-up duration was 274 days (Q1-Q3: 100-368 days). Outcomes included peridevice leak (PDL), all-cause mortality, ischemic cerebrovascular accident or systemic embolism, major bleeding, and device-related thrombus. RESULTS:PDL occurred less frequently in the large device group compared with the small device group (1.54% [6 of 390] vs 4.90% [18/367]; P = 0.015). Ischemic cerebrovascular accident or systemic embolism was lower in the large device group (8.4% [95% CI: 1.8%-34.1%] vs 10.5% [95% CI: 3.6%-28.4%]; P = 0.036). No significant difference was observed in all-cause mortality (15.2% [95% CI: 6.0%-35.7%] vs 12.3% [95% CI: 4.6%-30.6%]; P = 0.288), major bleeding (4.5% [95% CI: 2.6%-7.7%] vs 15.7% [95% CI: 4.3%-48.7%]; P = 0.570), or device-related thrombus (8.6% [95% CI: 3.2%-22.2%] vs 3.2% [95% CI: 1.6%-6.4%]; P = 0.603). CONCLUSIONS:In borderline-sized LAAs, the larger device was associated with fewer PDLs and ischemic events without increased procedural risk.

BACKGROUND:Although warfarin plus aspirin as an antithrombotic regimen after percutaneous left atrial appendage closure (LAAC) has been proposed in initial randomized trials, other regimens are often used in real-world settings because of differences in patient characteristics and the widespread use of direct oral anticoagulant agents (DOACs). However, variations in antithrombotic regimens after LAAC and their impact on major adverse events remain unclear in Asian patients, who have a higher risk for bleeding and a lower risk for ischemic events than non-Asian patients. OBJECTIVES:The aim of this study was to investigate variations in antithrombotic regimens after LAAC and the impact of these regimens on major adverse events. METHODS:A total of 1,449 patients who underwent LAAC between August 2019 and May 2023 were analyzed in a multicenter, observational, real-world registry from Japan. The outcomes were the antithrombotic regimens at discharge and major adverse events at 6 months according to these regimens. Covariate adjustment using propensity scores was performed to compare the impact of antithrombotic regimens on major adverse events. RESULTS:Median follow-up duration was 184 days (Q1-Q3: 174-195 days). The 5 most common antithrombotic regimens at discharge were DOAC only (32.4% [469 of 1,449]), DOAC and aspirin (30.3% [439 of 1,449]), warfarin and aspirin (13.7% [199 of 1,449]), DOAC and P2Y12 inhibitor (10.4% [151 of 1,449]), and warfarin only (6.2% [90 of 1,449]). Differences in the antithrombotic regimens were not significantly associated with major adverse events after covariate adjustment. CONCLUSIONS:In a real-world registry from Japan, the initial antithrombotic regimen after LAAC was not commonly used, and differences in antithrombotic regimens did not significantly affect short-term clinical outcomes. (Transcatheter Modification of Left Atrial Appendage by Obliteration With Device in Patients With NVAF [TERMINATOR]; UMIN000044934.

Background: Bone scintigraphy using technetium-99m hydroxymethylene diphosphonate (99mTc-HMDP) is extensively employed to detect bone metastases. However, incidental myocardial uptake may indicate wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM), a frequently overlooked diagnosis with important clinical implications. Case Presentation: Two elderly female patients with a history of breast cancer were subjected to 99mTc-HMDP bone scintigraphy as part of a routine evaluation for possible bone metastases. Both cases demonstrated incidental myocardial uptake (Perugini Grade 2 and Grade 3, respectively), raising suspicion for ATTRwt-CM, which was subsequently confirmed by endomyocardial biopsy. Review of the Literature: We reviewed published studies reporting cardiac uptake on bone scintigraphy, summarizing the frequency, patient demographics, and tracer types, and emphasizing the clinical relevance of this finding in cancer patients. Conclusions: In oncology patients, bone scintigraphy performed during routine metastatic screening may facilitate early detection of ATTRwt-CM, enabling timely diagnosis and treatment initiation, potentially improving clinical outcomes.

While transcatheter paravalvular leak (PVL) closure offers a viable alternative to reoperation in high-risk patients, data from Japan remain limited. To address this, we retrospectively analyzed 28 consecutive patients who underwent percutaneous PVL closure at a single center in Japan between 2014 and 2022 (mitral, n = 23, aortic, n = 5; median follow-up, 2.0 years). We herein discuss real-time transesophageal echocardiography (TEE) with three-dimensional imaging, guided defect characterization, device sizing, and intra-procedural assessment. The study’s primary clinical endpoint was all-cause mortality, and its primary procedural endpoint was technical success, defined as a residual PVL < moderate on intra-procedural TEE in the absence of emergency surgery or death. The secondary clinical endpoint was a composite of all-cause death, heart failure hospitalization, or reintervention. Technical success was achieved in 71

BACKGROUND:Clinical responses after transcatheter atrial septal defect (ASD) closure are heterogeneous, and predictors of suboptimal response remain poorly defined. AIMS:We aimed to determine whether pre-closure invasive hemodynamic parameters might predict clinical response after ASD closure. METHODS:We retrospectively screened 223 consecutive patients undergoing percutaneous secundum ASD closure. After exclusion of 19 patients aged < 18 years, 204 adult patients were included. Clinical response was categorized as improved (n = 66), unchanged (n = 109), or suboptimal (n = 29; defined as persistent or newly apparent dyspnea and/or new initiation of diuretic therapy). Invasive hemodynamic parameters, including pulmonary capillary wedge pressure (PCWP), mean pulmonary artery pressure (mPAP), and pulmonary vascular resistance (PVR), were assessed before closure. RESULTS:Patients with suboptimal clinical response accounted for 14.2% of the adult cohort and had higher baseline mPAP and PCWP than those with improved or unchanged response. Although PVR differed across groups, it was not independently associated with suboptimal response in the multivariable analysis. In the multivariable model, age (OR, 1.05 per year; 95% CI, 1.00-1.09; p = 0.032) and mPAP (OR, 1.10 per mmHg; 95% CI, 1.01-1.20; p = 0.025) were independently associated with suboptimal clinical response, whereas PCWP showed a borderline association. ROC analysis demonstrated moderate discriminative ability of mPAP (AUC, 0.794; 95% CI, 0.698-0.889; p < 0.001). CONCLUSIONS:Baseline invasive hemodynamic burden, particularly mPAP, was associated with suboptimal clinical response and may help identify patients at elevated risk after percutaneous ASD closure.

Background Balloon pulmonary angioplasty (BPA) is an established treatment for chronic thromboembolic pulmonary hypertension (CTEPH). However, some totally occlusive lesions remain uncrossable with conventional antegrade BPA because the proximal entry of the occlusion cannot be identified angiographically.Aims To evaluate the outcomes of transcollateral retrograde BPA for lesions that are not amenable to antegrade recanalization.Methods We retrospectively investigated the procedural outcomes of 30 lesions in 19 patients treated with transcollateral retrograde BPA at our institution between April 2016 and December 2025. All lesions were either uncrossable with a guidewire despite antegrade attempts or had an indistinct proximal end of the occlusion, precluding identification of a safe antegrade entry point despite angiographic and intravascular imaging assessment. Procedural success was defined as successful balloon dilation restoring antegrade flow. Procedure-related complications were defined as hemoptysis, respiratory deterioration requiring positive-pressure ventilation, or procedure-related death.Results Procedural success was achieved in 15 of 30 lesions (50%). When divided into three sequential groups of 10 lesions each, success rates were 50%, 30%, and 70%, respectively. Mild hemoptysis occurred in 3 cases (10%), whereas severe complications or death did not occur. Causes of procedural failure included inability to cross the collateral channel (12 cases) and failure to penetrate the occlusion (3 cases). Difficult collateral channels were characterized by severe tortuosity, small vessel diameter, and capillary-like connections.Conclusions Transcollateral retrograde BPA may enable recanalization of otherwise untreatable occlusive pulmonary artery lesions with an acceptable safety profile.