OBJECTIVES:Current guidelines recommend patent foramen ovale (PFO) closure in patients with cryptogenic stroke, while atrial septal defect (ASD) closure is indicated for a shunt with right atrial/right ventricular (RV) enlargement. Major procedural complication rates from PFO/ASD closure are low. However, there is a theoretical risk of thrombus formation early after implantation, prior to endothelialization of the device, that may be prevented by dual antiplatelet therapy (DAPT). There is little data on the optimal timing and duration of DAPT post-device placement; thus, this study aimed to evaluate the safety of shortened DAPT after PFO/ASD closure with respect to device thrombosis and clinical stroke. METHODS:One hundred ninety-four patients 18 years or older who underwent transcatheter PFO/ASD closure from 2010 to 2021 were included in the study. The primary outcome was the rate of device thrombosis at 1 year. The secondary outcome was stroke and peripheral embolization at 1 year. RESULTS:Closures were primarily performed for cryptogenic stroke (41.9%) and ASD closure for RV enlargement (26.9%). The average length of DAPT was 2.91 ± 2.6 months. At 1 year, there were no cases of device thrombosis or embolization. CONCLUSIONS:This study suggests that 3 months or less of DAPT may be safe in patients after percutaneous PFO/ASD closure.

BACKGROUND:Coronary microvascular dysfunction (CMD) and vasospastic angina (VSA) are common, yet underdiagnosed. Existing studies of invasive CMD/VSA assessment have specified patient selection and procedural technique, with little known about testing use in real-world practice. OBJECTIVES:The purpose of the study was to observe procedural and therapeutic decision-making for patients undergoing invasive CMD/VSA assessment. METHODS:FlowLab was a multicenter, prospective study of patients with possible CMD in whom the treating physician used the CoroFlow bolus thermodilution system to measure coronary flow reserve and index of microcirculatory resistance (IMR). As the purpose was to observe how testing is performed in current practice, procedural technique, including whether to perform vasospasm testing, was at operator discretion. Procedural data were collected in real-time. RESULTS:A total of 253 procedures were performed at 14 U.S. sites. The most common presenting symptoms were chest pain (222/253; 88%) and dyspnea (93/253; 37%). The median CoroFlow duration was 10 (IQR: 7-14) minutes and provocative vasospasm testing was performed in 50% (124/246). Forty-three percent (110/253) of patients had abnormal coronary flow reserve (<2.5) and 28% (72/253) had abnormal IMR (≥25). CMD/VSA was identified in 53% (135/253) of patients, with a final diagnosis of CMD in 59% (19/32) of these and VSA in 28% (9/32). Anginal therapy addition was more common in those with elevated IMR (61% [44/72] vs 29% [53/181]; P < 0.0001). CONCLUSIONS:In a prospective assessment of invasive testing for CMD/VSA, we observed varied procedural and technical approaches. Testing was rapid, and a final diagnosis of CMD or VSA was common with immediate implications for patient management. Further integration of CMD/VSA evaluation may help address current gaps in diagnosis and treatment.

Background: Invasive hemodynamics are the gold standard for diagnosis of heart failure with preserved ejection fraction (HFpEF). A novel, FDA-approved artificial intelligence (AI) technology that uses a single, 4-chamber transthoracic echocardiogram (TTE) image to screen patients for HFpEF shows promise as a non-invasive tool to assist in diagnosis. Development of right ventricular (RV) dysfunction is a sign of a more advanced HFpEF. Advanced RV hemodynamic parameters, beyond pulmonary arterial pressures (PAP), have not been well studied in HFpEF. We sought to correlate advanced RV hemodynamic parameters in patients screened for HFpEF with this AI screening tool. Method: We retrospectively evaluated two cohorts of patients with suspected HFpEF that underwent TTE and RHC at our institution. The most recent TTE for each patient was screened using the AI-based analysis tool and was reported as either “suggestive” or “non-suggestive” of HFpEF – labeled as “positive” or “negative,” respectively. Mean PAP, pulmonary vascular resistance (PVR), pulmonary artery pulsatility index (PAPI), RV cardiac power output (RV-CPO), RV myocardial performance score (RV-MPS), and right atrial pressure to pulmonary capillary wedge pressure ratio (RA:PCWP) were calculated using invasive hemodynamic parameters at rest, and exercise when available. RV-CPO was calculated as [(mean PAP-RAP) x cardiac output] /451, and RV-MPS was calculated as (RV-CPO x PAP)x1.5. Median values were calculated. AI positive and negative groups were compared using Student’s t-test. Results: A total of 47 patients (82% women, 79% Black, average EF 62%) were included, with 23 undergoing subsequent exercise RHC. There were 18 (38%) that screened positive for HFpEF, and 29 (62%) screened negative by TTE AI software. Positive patients had a significantly higher mean PAP (median 31 vs 23 mmHg, p=0.01), PVR (2.1 vs 1.3 WU, p=0.02), and RV-CPO (0.26 vs. 0.17, p=0.04) than patients who were screened negative. There were no significant differences in PAPI, RV-MPS, and RA:PCWP at rest. There were no significant differences in mean PAP, PVR, PAPI RV-CPO, RV-MPS, or RA:PCWP with exercise. Conclusion: Patients screened positive for HFpEF by a novel AI TTE software had significantly higher PAP and RV-CPO at rest, but no differences in PAPI, RV-MPS, or RA:PCWP ratio. This tool may help identify more advanced HFpEF.

Background: Right heart catheterization (RHC) is the gold standard for diagnosing heart failure with preserved ejection fraction (HFpEF). An FDA-approved artificial intelligence (AI) technology uses a four-chamber transthoracic echocardiogram (TTE) image to screen patients for HFpEF. Methods: We compared invasive hemodynamic data between patients screened for HFpEF by this TTE AI algorithm. We retrospectively collected data from two cohorts of patients with an ejection fraction (EF) ≥ 50% undergoing RHC for the evaluation of HFpEF. The most recent TTE was screened using the AI tool and reported as either suggestive or non-suggestive for HFpEF – labeled as “positive” or “negative,” respectively. Invasive hemodynamic parameters at rest and during exercise were collected. Positive and negative groups were compared using Student’s t-test and Mann-Whitney U test. Results: A total of 47 patients (82% women, 79% Black, average EF 62%) had a previous RHC, with 23 undergoing subsequent exercise RHC. There were 18 patients (38%) with a positive AI result and 29 (62%) negative. Positive patients had significantly higher rates of atrial fibrillation (38% vs 11%, p=.03), NT-proBNP levels (median 451 vs 117 ug/mL, p=.001), and H2FPEF (median 6 vs 4, p<.001) and HFA-PEFF scores (median 5 vs 2, p=.005). Of 18 positive patients, 16 (89%) had a resting pulmonary capillary wedge pressure (PCWP) > 15 mmHg, consistent with HFpEF, compared to only 14 of 28 (50%) negative patients. With exercise 6 of 7 (86%) positive patients had PCWP ≥ 25 mmHg, consistent with HFpEF, compared to 11 of 20 (55%) negative patients. At rest, positive patients had significantly higher PCWP, mean pulmonary arterial pressure (mPAP), and pulmonary vascular resistance (PVR). After exercise, there were no significant differences in PCWP or mPAP between the two groups, but thermodilution cardiac output was significantly lower in the positive patients. Conclusion: Patients identified as HFpEF positive by a validated TTE-guided AI tool were more likely to have HFpEF confirmed invasively, indicating its potential for risk stratification. However, the negative predictive value for HFpEF confirmed by invasive hemodynamics was low in this population.

BACKGROUND:Cardiogenic shock (CS) is complicated by high mortality rates. Targeted temperature control (TTC) has been proposed as an adjunct therapy in CS. This study aims to examine the safety of TTC in patients presenting with CS. METHODS AND RESULTS:In this open-label, randomized controlled pilot trial, 20 patients with hemodynamic criteria for CS were assigned to standard of care plus TTC vs standard of care alone. The primary outcome was a composite safety outcome, including well-described complications of TTC. Secondary outcomes included mortality at 90 days, invasive hemodynamic and echocardiographic parameters, electrocardiographic measurements, and inotrope dosing. There were no significant differences in the composite analysis of prespecified safety outcomes (3 events in the TTC group vs 0 events in the control group; P = 0.24). Patients randomized to TTC demonstrated a statistically significant increase in cardiac index and cardiac power index compared to the control group at 48-96 hours after randomization (3.6 [3.1, 3.9] L/min/m2 vs 2.6 [2.5, 3.15] L/min/m2; P = 0.029 and 0.61 [0.55, 0.7] W/m2 vs 0.53 [0.435, 0.565] W/m2; P = 0.029, respectively). CONCLUSION:TTC may be a safe adjunct therapy for patients presenting with CS and may yield improvement in specific hemodynamic parameters.

A 56-year-old female diagnosed with hypertrophic obstructive cardiomyopathy and myocardial bridge (MB) of the left anterior descending (LAD) coronary artery underwent septal myectomy with resolution of her left ventricular outflow tract gradient. She had ongoing refractory symptoms of exertional angina and fatigue for over a decade and finally presented to our clinic to be re-evaluated for treatment. Provocative angiographic testing confirmed significant ischemia secondary to LAD MB. She underwent robotic totally endoscopic off pump unroofing of the LAD MB with complete relief of her symptoms and return to full activity. We conclude that patients undergoing septal myectomy for hypertrophic obstructive cardiomyopathy should be evaluated for MB and undergo unroofing of the bridge at the time of surgery. Learning objective A myocardial bridge (MB) is a condition in which a coronary artery, most often the left anterior descending, takes an intramuscular route and is covered by the myocardium leading to compression and potential ischemia. This case report adds to the growing body of evidence supporting the significance of considering MB in the overall management of hypertrophic obstructive cardiomyopathy, and the symptomatic relief that a patient can obtain from an unroofing procedure.

OBJECTIVE:Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing. METHODS:There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ). RESULTS:The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery. CONCLUSIONS:In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.

ImportanceGreater splanchnic nerve ablation may improve hemodynamics in patients with heart failure and preserved ejection fraction (HFpEF). ObjectiveTo explore the feasibility and safety of endovascular right-sided splanchnic nerve ablation for volume management (SAVM). Design, Setting, and ParticipantsThis was a phase 2, double-blind, 1:1, sham-controlled, multicenter, randomized clinical trial conducted at 14 centers in the US and 1 center in the Republic of Georgia. Patients with HFpEF, left ventricular ejection fraction of 40% or greater, and invasively measured peak exercise pulmonary capillary wedge pressure (PCWP) of 25 mm Hg or greater were included. Study data were analyzed from May 2023 to June 2024. InterventionSAVM vs sham control procedure. Main Outcomes and MeasuresThe primary efficacy end point was a reduction in legs-up and exercise PCWP at 1 month. The primary safety end point was serious device- or procedure-related adverse events at 1 month. Secondary efficacy end points included HF hospitalizations, changes in exercise function and health status through 12 months, and baseline to 1-month change in resting, legs-up, and 20-W exercise PCWP. ResultsA total of 90 patients (median [range] age, 71 [47-90] years; 58 female [64.4%]) were randomized at 15 centers (44 SAVM vs 46 sham). There were no differences in adverse events between groups. The primary efficacy end point did not differ between SAVM or sham (mean between-group difference in PCWP, -0.03 mm Hg; 95% CI, -2.5 to 2.5 mm Hg; P = .95). There were also no differences in the secondary efficacy end points. There was no difference in the primary safety end point between the treatment (6.8% [3 of 44]) and sham (2.2% [1 of 46]) groups (difference, 4.6%; 95% CI, -6.1% to 15.4%; P = .36). There was no difference in the incidence of orthostatic hypotension between the treatment (11.4% [5 of 44]) and sham (6.5% [3 of 46]) groups (difference, 4.9%; 95% CI, -9.2% to 18.8%; P = .48). Conclusions and RelevanceResults show that SAVM was safe and technically feasible, but it did not reduce exercise PCWP at 1 month or improve clinical outcomes at 12 months in a broad population of patients with HFpEF. Trial RegistrationClinicalTrials.gov Identifier: NCT04592445

Coronary microvascular dysfunction (CMD) can cause myocardial ischemia in patients presenting with angina without obstructive coronary artery disease (ANOCA). Evaluating for CMD by using the thermodilution technique offers a widely accessible means of assessing microvascular resistance. Through this technique, 2 validated indices, namely coronary flow reserve and the index of microcirculatory resistance, can be computed, facilitating investigation of the coronary microcirculation. The index of microcirculatory resistance specifically estimates minimum achievable microvascular resistance within the coronary microcirculation. We aim to review the bolus thermodilution method, outlining the fundamental steps for conducting measurements and introducing an algorithmic approach (CATH CMD) to systematically evaluate the coronary microcirculation. Embracing a standardized approach, exemplified by the CATH CMD algorithm, will facilitate adoption of this technique and streamline the diagnosis of CMD.

Background Myocardial bridges (MB) are prevalent but not universally associated with angina. The mechanisms linking MB and angina are poorly defined. The objective of this study was to determine the prevalence of epicardial spasm, microvascular spasm, and/or endothelium-independent coronary microvascular dysfunction (CMD) in patients with MB which might explain symptoms. Methods Patients with known MB and chest pain at the University of Chicago Medical Center between 2020-2023 were included. All patients underwent dobutamine testing with measurement of resting full-cycle ratio to determine hemodynamic significance (resting full-cycle ratio ≤0.76). Endothelium-independent CMD was defined as coronary flow reserve <2.0 or index of microvascular resistance ≥25 on adenosine testing. Microvascular spasm was defined as chest pain and electrocardiogram changes with nonischemic fractional flow reserve with acetylcholine. Epicardial spasm was defined as dynamic stenosis of >90% of the epicardial vessel or ischemic fractional flow reserve (≤0.8) with acetylcholine. Results A total of 30 patients (mean age, 47 ± 10 years; 60% female) with MB were studied. Endothelium-independent CMD, microvascular spasm, and epicardial spasm occurred commonly in 60%, 29%, and 37% of patients respectively, with 77% having at least one abnormality. The MB was hemodynamically significant in 47% of patients, and the prevalence of these coexisting conditions was not affected by hemodynamic significance. Conclusions Epicardial spasm, microvascular spasm, and endothelium-independent CMD are prevalent in patients presenting with known MB and chest pain irrespective of the hemodynamic significance of the bridge. Invasive coronary function testing may play an important role in uncovering alternative explanations for angina in patients with known MB.

BACKGROUND:Ischemia with no obstructive coronary arteries is frequently caused by coronary microvascular dysfunction (CMD). Consensus diagnostic criteria for CMD include baseline angiographic slow flow by corrected TIMI (Thrombolysis In Myocardial Infarction) frame count (cTFC), but correlations between slow flow and CMD measured by invasive coronary function testing (CFT) are uncertain. OBJECTIVES:The aim of this study was to investigate relationships between cTFC and invasive CFT for CMD. METHODS:Adults with ischemia with no obstructive coronary arteries underwent invasive CFT with thermodilution-derived baseline coronary blood flow, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR). CMD was defined as abnormal CFR (<2.5) and/or abnormal IMR (≥25). cTFC was measured from baseline angiography; slow flow was defined as cTFC >25. Correlations between cTFC and baseline coronary flow and between CFR and IMR and associations between slow flow and invasive measures of CMD were evaluated, adjusted for covariates. All patients provided consent. RESULTS:Among 508 adults, 49% had coronary slow flow. Patients with slow flow were more likely to have abnormal IMR (36% vs 26%; P = 0.019) but less likely to have abnormal CFR (28% vs 42%; P = 0.001), with no difference in CMD (46% vs 51%). cTFC was weakly correlated with baseline coronary blood flow (r = -0.35; 95% CI: -0.42 to -0.27), CFR (r = 0.20; 95% CI: 0.12 to 0.28), and IMR (r = 0.16; 95% CI: 0.07-0.24). In multivariable models, slow flow was associated with lower odds of abnormal CFR (adjusted OR: 0.53; 95% CI: 0.35 to 0.80). CONCLUSIONS:Coronary slow flow was weakly associated with results of invasive CFT and should not be used as a surrogate for the invasive diagnosis of CMD.

Background:Guidelines on the management of acute pulmonary embolism (PE) recommend consideration of endovascular therapies (EVT) for patients at intermediate-high risk. However, long-term data on the outcomes of patients after EVT as compared to medical therapy is lacking. This study aimed to compare outcomes of patients receiving EVT as compared to medical therapy alone at 3 to 6 months. Methods:In this single-center, retrospective cohort study, 190 patients with PE underwent evaluation for presence of right ventricular (RV) dysfunction by transthoracic echocardiogram, residual perfusion defects on ventilation-perfusion scanning, and functional capacity by 6-minute walk distance (6MWD) at 3 to 6 month follow-up. Results:Fifty-eight (31%) patients received EVT for the management of their acute PE. At follow-up (median 120 [97-170] days), 71% of patients who received EVT had normalization of RV function compared with only 34% of patients who received medical therapy alone (P < .001). Patients who received EVT had a significantly greater increase in their estimated glomerular filtration rate (P = .001), decrease in N-terminal proB-type natriuretic peptide (P = .003), and decrease in hemoglobin values (P = .018). Patients with intermediate-high to high risk PE who received EVT had significantly greater distance achieved on their 6MWD as compared to those who received medical therapy alone (P = .025). Conclusions:Patients with acute PE who received EVT plus medical therapy were more likely to achieve normalization of RV dysfunction at 3 to 6 month follow-up compared to patients who received medical therapy alone. These data suggest that EVT is an effective therapy option for acute PE in intermediate-high and high risk patients with potential durable long-term benefits.

Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.

OBJECTIVE:The standard management of concomitant aortic valve (AV) and coronary artery disease has been coronary artery bypass and AV replacement (AVR). With the advent of minimally invasive options, many isolated lesions have been successfully managed using a sternal-sparing approach. In our institution, patients with isolated AV disease are offered minimally invasive surgical or transcatheter AVR, and those with isolated coronary artery disease are routinely managed with robotic totally endoscopic coronary artery bypass or percutaneous coronary intervention. Various combinations of these techniques can be used when a sternal-sparing posture is desired because of patient risk or preference. The aim of this study was to review the outcomes in patients with combined AV and coronary disease who were managed using sternal-sparing approaches.METHODS:We reviewed the records of 10 patients in our minimally invasive surgical database who presented with concomitant AV and coronary artery disease and underwent combined sternal-sparing management of these 2 lesions using various combinations of minimally invasive approaches.RESULTS:Four patients had totally endoscopic coronary artery bypass and minimally invasive AVR at the same time, 2 patients underwent transcatheter AVR followed by totally endoscopic coronary artery bypass, and 4 patients underwent minimally invasive AVR with percutaneous coronary intervention. There was no 30-day mortality. The duration of postoperative surgical hospital stay was 3.1 ± 0.9 days.CONCLUSIONS:Sternal-sparing approaches in combined AV and coronary artery disease are feasible with patient-specific treatment selection of minimally invasive techniques.

Predictors of Residual Severe Tricuspid Regurgitation After Transcatheter Mitral Valve RepairJournal of the Society for Cardiovascular Angiography & Interventions100612PreviewSevere tricuspid regurgitation (TR) may persist after a mitral transcatheter edge-to-edge repair (M-TEER) and is associated with worsened clinical outcomes and survival. It is unclear which patients with concomitant mitral regurgitation (MR) and TR will have TR reduction after M-TEER. The aim of this study was to identify the predictors of residual TR after transcatheter edge-to-edge repair (TEER). Full-Text PDF Open Access Tricuspid regurgitation (TR) has been associated with worse outcomes with increasing severity. Community-based echocardiographic studies of asymptomatic patients demonstrated the prevalence of at least moderate TR or greater can range from 3% to 8%, with 1-year–adjusted mortality rates for moderate TR at 29.5% and severe TR at 45.6%.1d'Arcy J.L. Coffey S. Loudon M.A. et al.Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE Population Cohort Study.Eur Heart J. 2016; 37: 3515-3522Crossref PubMed Scopus (300) Google Scholar,2Chorin E. Rozenbaum Z. Topilsky Y. et al.Tricuspid regurgitation and long-term clinical outcomes.Eur Heart J Cardiovasc Imaging. 2020; 21: 157-165PubMed Google Scholar The 2020 ACC/AHA guidelines define a staging system for TR with 3 principal stages: progressive TR (stage B), asymptomatic severe TR (stage C), and symptomatic severe TR (stage D).3Otto C.M. Nishimura R.A. Bonow R.O. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines.Circulation. 2020; 143: e72-e227PubMed Google Scholar It is a class I recommendation that concomitant tricuspid valve surgery be performed in patients with stage C or D TR undergoing left-sided valvular surgery. Progressive stage B TR by definition is clinically asymptomatic with no hemodynamic consequences. A study examining patients with stage B TR who underwent isolated left-sided valvular surgery showed that those with a tricuspid annular diastolic diameter of >40.0 mm (or >21.0 mm/m2) who did not undergo concomitant tricuspid annuloplasty had worse New York Heart Association functional class and worsening TR by more than 2 grades in 5-10 years of follow-up.4Dreyfus G.D. Corbi P.J. Chan K.M. Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?.Ann Thorac Surg. 2005; 79: 127-132Abstract Full Text Full Text PDF PubMed Scopus (672) Google Scholar This supported a class 2a recommendation for patients with stage B TR to undergo concomitant tricuspid valve surgery at the time of left-sided valve surgery. For patients who are not suitable conventional surgical candidates for concomitant mitral and tricuspid valve repair/replacement, transcatheter therapies may be considered. Currently, no commercially available FDA-approved transcatheter therapy exists for TR in the United States. Therefore, these patients are often evaluated for isolated mitral transcatheter edge-to-edge repair (m-TEER) with the goal of improving TR by reducing pulmonary arterial (PA) pressures due to severe mitral regurgitation (MR). Unlike the strength of recommendations guiding surgical intervention, rigorous evidence on the transcatheter management of coexisting MR and TR is lacking. Approximately 60% of patients undergoing m-TEER also have moderate or greater TR with significantly decreased 1-year survival in patients with residual severe TR compared with those with lesser degrees of TR after m-TEER.5Geyer M. Keller K. Bachmann K. et al.Concomitant tricuspid regurgitation severity and its secondary reduction determine long-term prognosis after transcatheter mitral valve edge-to-edge repair.Clin Res Cardiol. 2021; 110: 676-688Crossref PubMed Scopus (16) Google Scholar This is consistent with subgroup analyses from the Transcatheter Mitral Valve Interventions (TRAMI) and Getting Reduction of Mitral Insufficiency by Percutaneous Clip Implantation (GRASP) registries that showed worse 12-month outcomes of mortality, rehospitalization for heart failure, and major adverse cardiovascular and cerebrovascular events.6Ohno Y. Attizzani G.F. Capodanno D. et al.Association of tricuspid regurgitation with clinical and echocardiographic outcomes after percutaneous mitral valve repair with the MitraClip System: 30-day and 12-month follow-up from the GRASP Registry.Eur Heart J Cardiovasc Imag. 2014; 15: 1246-1255Crossref PubMed Scopus (111) Google Scholar,7Kalbacher D. Schäfer U. von Bardeleben R.S. et al.Impact of tricuspid valve regurgitation in surgical high-risk patients undergoing MitraClip implantation: results from the TRAMI registry.EuroIntervention. 2017; 12: e1809-e1816Crossref PubMed Scopus (52) Google Scholar Basman et al8Basman C Kodra A Pirelli L et al.Predictors of residual tricuspid regurgitation after transcatheter mitral valve repair.J Soc Cardiovasc Angiogr Interv. 2023; 2100612Google Scholar present prospectively collected registry data analyzed retrospectively in a single-hospital system comprising 4 high volume m-TEER centers. Their goal was to identify predictors of severe TR at the 1-month follow-up transthoracic echocardiography (TTE) after m-TEER. TR improvement was defined as a reduction in TR grade by at least 1+ resulting in moderate (2+) or less TR. Approximately half of the patients who underwent successful MR reduction also experienced significant TR reduction. Multivariate analyses showed MR reduction of ≥3+ as the only predictor of significant TR reduction. Univariate predictors of severe residual TR were right atrial area and unsuccessful m-TEER. Other factors such as atrial arrhythmia, previous cardiac implantable electronic device, mechanism of MR, tricuspid annular dilation, right ventricular (RV) function, PA systolic pressure, and left ventricular (LV) dimensions did not reach statistical significance. The authors should be commended on their report of the largest analysis to date on significant predictors of severe TR after m-TEER. However, several limitations should be noted. First, methodologic challenges and the small sample size in a single-system limit the study’s potential larger scale effect. The number of operators and their experience is not known, which may affect procedural success and outcomes. In addition, all baseline covariates were TTE-based parameters although all patients underwent transesophageal echocardiography (TEE) guidance for m-TEER. Baseline TEE mitral and tricuspid valve parameters were a potential valuable missed repository of important analyzable predictors. For example, baseline tricuspid coaptation gap, although not directly studied in this context, has been shown to affect tricuspid-TEER procedural strategy and success.9Donal E. Sitges M. Panis V. et al.Impact of coaptation gap location on procedural strategy and outcomes following tricuspid transcatheter edge-to-edge repair: insights from the TriClip bRIGHT study.Eur Heart J. 2022; 43: 2127PubMed Google Scholar Because >90% of the TR pathology in the study Basman et al was functional, baseline coaptation gap and its correlation with ultimate TR reduction could be very relevant. In addition, other pertinent baseline TEE covariates could have been examined such as quantification of TR by proximal isovelocity surface area and tricuspid annular measurements. For degenerative MR, qualitative and quantitative characterization of the MR pathology on TEE such as myxomatous disease and flail width/gap are important to understand the severity of degenerative MR in this cohort and contextualize the observed outcomes. Even though 45% of the cohort had functional MR, the degree of LV systolic dysfunction was not quantified. Rather, LV dysfunction was analyzed as a binary variable that does not accurately capture the effect of varying degrees of baseline cardiomyopathy on MR reduction after m-TEER and consequent TR outcomes. Procedural information is also not available such as average number of clips per case, type of clip(s), and end-procedural/short-term follow-up mitral mean gradient. Iatrogenic mitral stenosis from m-TEER could significantly increase resultant TR. Regarding the span of the study, only 30-day follow-up was analyzed when 12-month outcomes would have had more significance. Pre-procedure and post-procedure brain natriuretic peptide levels and TTE inferior vena cava assessment could also be an important gauge of volume status that could affect follow-up TR assessment. Finally, quantifying TR based on the ACC/AHA staging system instead of the routinely cited 5-grade system may have more relevance in future guideline derivation. The authors’ primary conclusion of significant MR reduction as a predictor of significant TR reduction is intuitive but not necessarily additive. Physiologically, it can be explained by the effective reduction of left atrial pressure leading to consequent reduction in mean PA pressure and TR reduction. The authors acknowledge the inability to account for the presence of intrinsic PA hypertension. Although PA systolic pressure was not found to be a significant risk factor for severe residual TR, TTE-derived pulmonary vascular resistance could have been explored as an important covariate. The authors also report that right atrial area was a predictor of severe residual TR in univariate analyses, but not RV dysfunction. RV dysfunction, similar to the LV, was also treated categorically (moderate or severe). Quantification of RV ejection fraction, RV area, and tricuspid annular dilation assessed by pre- and post-cardiac magnetic resonance imaging may help refine our understanding on the role of right atrioventricular remodeling on TR reduction. Strain analyses could have also strengthened the study findings. One study demonstrated improvement in RV free-wall global longitudinal strain at 12 months after m-TEER, but not LV strain.10Peters A.P. Leya M. Baldridge A. et al.Temporal trends in left and right heart remodeling following transcatheter edge-to-edge mitral repair for degenerative mitral regurgitation.Struct Heart. 2021; 5: 634-636Abstract Full Text Full Text PDF Scopus (0) Google Scholar This may suggest that the RV may be more able to reverse remodel in response to improvements in PA pressure. Longitudinal changes in RV strain may play an important role in predicting residual TR after m-TEER. The recently published 5-year COAPT trial data and the ongoing REPAIR-MR and PRIMARY trials may expand m-TEER to larger patient populations.11Stone GW, Abraham W, Lindenfeld J, et al. Five-year follow-up after transcatheter repair of secondary mitral regurgitation. N Engl J Med. Published online March 5, 2023. https://doi.org/10.1056/NEJMoa2300213Google Scholar If m-TEER in the future reaches a comparable ubiquity with transcatheter aortic valve replacement, studies similar to the one reported by Basman et al are warranted to identify salient predictors of significant TR reduction in patients with severe MR treated with m-TEER. The generalizability of this study is confined by the sample size and single-system experience. Limited clinical and TTE-based covariates and the absence of longer-term follow-up cap the study’s ability to be practice-changing. Despite these limitations, Basman et al provide essential insight into predicting severe TR after m-TEER. Future studies in larger cohorts using hemodynamic parameters and multimodality imaging will help elucidate in which patients residual TR after m-TEER is a bystander responsive to reduction in PA pressure or an accomplice to severe MR that will continue to portend a poor prognosis even after successful m-TEER. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Myocardial bridge (MB) detection rates vary across methods and most studies that have assessed MB include symptomatic patients. Intravascular ultrasound (IVUS) is a sensitive tool for MB detection and donor hearts may serve as a surrogate measure of asymptomatic patients. We used IVUS and coronary angiography to measure MB prevalence in heart transplant patients during routine follow-up invasive coronary assessments. This was a retrospective, single-center study of heart transplant patients who received follow-up cor-onary assessments at the University of Chicago Heart and Vascular Center between December 2014 and December 2021. A single experienced interventional cardiologist assessed incidental findings of MB in IVUS and coronary angiography. Detection rates were compared with meta-analysis-reported prevalence. Of 129 patients, IVUS-detected MB in 87 patients (67.4%), whereas coronary angiography detected 41 (31.8%). All MB found by coronary angiography were detected by IVUS. Some level of cardiac allograft vasculopathy was found in 92 patients (71.3%). Our IVUS-detected MB prevalence was greater than meta-analysis-reported pooled prevalence across all methods: autopsy, com-puted tomography angiography, and coronary angiography (67.4% [95% confidence interval [CI] 59.4 to 75.5] vs 42% [95% CI 30 to 55]; 22% [95% CI 18 to 25]; 6% [95% CI 5 to 8], p & LE;0.005). The difference between our observed IVUS-detected MB prevalence and meta-analysis autopsy reported MB prevalence was 1.25 (95% CI 1.11 to 1.40). In con-clusion, the high prevalence of MB recorded in donor hearts emphasizes the need to fur-ther investigate the causes of chest pain in patients who are found to have MB.Published by Elsevier Inc. (Am J Cardiol 2023;205:176-181)