Background and Objectives: Mitral valve transcatheter edge-to-edge repair (TEER) is a widely adopted therapeutic approach for managing significant mitral regurgitation (MR) in high-risk surgical candidates. While procedural safety and efficacy have been demonstrated, the impact of institutional expertise on outcomes remains unclear. We aimed at evaluating whether the institutional monthly volume of TEER influences short- and long-term clinical results. Materials and Methods: This analysis from the multicenter, prospective GIOTTO trial study evaluated the impact of institutional monthly volume on outcomes of TEER to remedy significant mitral regurgitation. Centers were stratified into tertiles based on monthly volumes (≤2.0 cases/month, 2.1–3.5 cases/month, >3.5 cases/month), and key clinical, echocardiographic, and procedural outcomes were analyzed. Statistical analysis was based on standard bivariate tests as well as unadjusted and multivariable adjusted Cox models. Results: A total of 2213 patients were included, stratified into tertiles based on institutional procedural volume: 645 (29.1%) patients in the first tertile, 947 (42.8%) patients in the second tertile, and 621 (28.1%) patients in the third tertile. Several baseline differences were found, with some features disfavoring less busy centers (e.g., functional class and surgical risk, both p < 0.05), and others suggesting a worse risk profile in those treated in busier institutions (e.g., frailty and history of prior mitral valve intervention, both p < 0.05). Procedural success rates were higher in busier centers (p < 0.001), and hospital stay was also shorter there (p < 0.001). Long-term follow-up (median 14 months) suggested worse outcomes in patients treated in less busy centers at unadjusted analysis (e.g., p = 0.018 for death, p = 0.015 for cardiac death, p = 0.014 for death or hospitalization for heart failure, p < 0.001 for cardiac death or hospitalization for heart failure), even if these associations proved no longer significant after multivariable adjustment, except for cardiac death or hospitalization for heart failure, which appeared significantly less common in the busiest centers (p < 0.05). Similar trends were observed when focusing on tertiles of overall center volume and when comparing for each center the first 50 cases with the following ones. Conclusions: High institutional monthly volume of TEER mitral valve repair appears to correlate with an improved procedural success rate and shorter hospitalizations. Similarly favorable results were found for long-term rates of cardiac death or hospitalization for heart failure. These findings inform on the importance of operator experience and center expertise in achieving state-of-the-art results with TEER, while confirming the usefulness of the proctoring approach when naïve centers begin a TEER program.

Mitral regurgitation (MR) is a common valvular disorder often seen in a severely dilated left ventricle (LV) and reduced LV function. In chronic heart failure (HF), severe functional MR increases preload, wall tension, LV workload, and worsening prognosis. The MitraClip device offers a percutaneous treatment option in HF, although its safety and efficacy in advanced and acute HF remain a gray zone. We present a successful case of the emergent MitraClip intervention in a patient with advanced HF and review the relevant literature.

OBJECTIVES:The smoke-like effect (SE), the spontaneous echocardiographic contrast in the left atrium at transesophageal echocardiography, has been anecdotally reported after transcatheter edge-to-edge repair (TEER) for mitral regurgitation (MR), but uncertainty persists on its impact. Thus, the authors aimed at appraising the incidence, correlates, and outcomes of SE after TEER Methods. The authors conducted a retrospective multicenter observational study that included all patients in whom successful TEER with MitraClip (Abbott) had been completed. Smoke-like effect was defined as the presence of swirling spontaneous echocardiographic contrast in the left atrium. Baseline clinical characteristics, echocardiographic features, and procedural details were collected. Outcomes included death, reintervention, and rehospitalization for heart failure (HF). RESULTS:A total of 2228 patients were included, with 143 (6.4%) exhibiting SE. Several baseline differences disfavored these individuals, including age, functional class, surgical risk, and significant tricuspid regurgitation (all P less than .05). Procedurally, SE was associated with implantation of multiple MitraClips and longer procedures, but lower rates of significant residual MR (all P less than .05). Hospital outcomes were similarly favorable and the same held true for subsequent follow-up (average 19 months, all P greater than .05). The only exception was the risk of rehospitalization for HF, which appeared marginally significant disfavoring the SE group at unadjusted analysis (hazard ratio [HR] = 1.68 [95% CI, 1.04-2.70], P = .033). This association was, however, no longer significant when baseline differences were taken into account (HR = 1.52 [95% CI, 0.94-2.48], P = .091). CONCLUSIONS:SE after TEER is not uncommon, and is typically associated with a significantly worse clinical profile, particularly prior atrial fibrillation. Irrespectively, SE is not associated with adverse outcomes in the short- or long-term. Accordingly, it should not be considered per se as an indication for more aggressive medical management, with antithrombotic regimens being instead informed by other more established indications.

Percutaneous coronary interventions (PCI) in patients with prior coronary artery bypass grafting (CABG) could present significant challenges, especially when the navigation of arterial conduits is necessary. The selective cannulation of internal mammary artery (IMA) is the first step of these high-risk procedures, in which technical complexities and ischemic complications are frequently faced. Acknowledging the lack of pre-shaped guiding catheter alternatives, IMA cannulation is time and contrast–consuming and potentially dangerous, as both catheter probing and wiring attempts may threaten vessel integrity.To address this unmet need we developed a novel, easy-to-use technique to achieve selective internal mammary artery (IMA) graft cannulation. Our method proposes to first engage the arterial graft by means of any diagnostic catheter, whose shape can be chosen according to the specific features of the graft. Afterwards, a 0.014-inch workhorse guidewire is advanced to the distal segment of the graft. A 5- or 6-French IM guiding catheter is finally tracked over the wire rail into the ostium to reach stable engagement, ensuring procedural success. This approach is applicable irrespective of access route (ipsilateral or contralateral, transradial or transfemoral), and ultimately reduces procedural complexities and ischemic risks associated with traditional practice. This method also promotes the adoption of smaller guide catheters, thus reducing the ischemic triggers during selective cannulation. Furthermore, it offers versatility in catheter selection and guidewire support, enhancing personalization to diverse patient anatomies and clinical scenarios.By streamlining procedures and improving success rates, our technique represents a significant advancement in PCI via IMA grafts, promising safer and more efficient interventions for CABG patients.

Background Transcatheter mitral edge-to-edge repair (TEER) with transcatheter devices has become a mainstay in the minimally invasive treatment of patients with severe mitral regurgitation at increased surgical risk. Despite its apparently favorable risk profile, there is uncertainty on the risk and features of cerebrovascular accidents (CVA) early and long after TMVR. We aimed at appraising incidence and predictors of CVA in patients undergoing TEER. Methods We explicitly queried the dataset of an ongoing multicenter prospective observational study dedicated to TEER with MitraClip (Abbott Vascular, Santa Clara, CA, USA). Incidence of CVA after TEER was formally appraised, and we explored also potential predictors of such event. Descriptive, bivariate and diagnostic accuracy analyses were performed. Results Out of 2238 patients undergoing TEER, CVA occurred in 33 (1.47% [95% confidence interval 1.02% to 2.06%]), including 6 (0.27% [0.10% to 0.58%]) inhospital strokes and 27 events after discharge (0.99% [0.66% to 1.44%]) over a median follow-up of of 14 months. Most CVA were major ischemic strokes, during the inhospital phase as well as subsequently. Overall, CVA were more common in patients with atrial fibrillation (p=0.018), renal dysfunction (p=0.032), higher EuroSCORE II (p=0.033), and, as expected, higher CHA2DS2-VASc score (p=0.033), despite the limited prognostic accuracy of such score. Notably, the occurrence of CVA did not confer a significantly increased risk of long-term death (p=0.136) or cardiac death (p=0.397). Conclusions The incidence of CVA in patients undergoing TEER is low, with most events occurring after discharge, and being associated with pre-existing risk features. These findings, while reassuring on the safety of TEER, call for proactive antithrombotic therapy whenever CVA risk is increased before, as well as after such intervention.

Background Minimally invasive mitral valve repair has a favorable risk–benefit profile in patients with significant de novo mitral regurgitation. Its role in patients with prior mitral valve repair is uncertain. We aimed to appraise the outcome of patients undergoing transcatheter edge‐to‐edge repair (TEER) with prior transcatheter or surgical mitral valve repair (SMVR). Methods and Results We queried the Italian multicenter registry on TEER with MitraClip, distinguishing naïve patients from those with prior TEER or (SMVR). Inhospital and long‐term clinical/echocardiographic outcomes were appraised. The primary outcome was the occurrence of death or rehospitalization for heart failure. A total of 2238 patients were included, with 2169 (96.9%) who were naïve to any mitral intervention, 29 (1.3%) with prior TEER, and 40 (1.8%) with prior SMVR. Several significant differences were found in baseline clinical and imaging features. Respectively, device success was obtained in 2120 (97.7%), 28 (96.6%), and 38 (95.0%, P =0.261) patients; procedural success in 2080 (95.9%), 25 (86.2%), and 38 (95.0%; P =0.047); and inhospital death in 61 (2.8%), 1 (3.5%), and no ( P =0.558) patients. Clinical follow‐up after a mean of 14 months showed similar rates of death, cardiac death, rehospitalization, rehospitalization for heart failure, and their composite (all P >0.05). Propensity score–adjusted analysis confirmed unadjusted analysis, with lower procedural success for the prior TEER group (odds ratio, 0.28 [95% CI, 0.09–0.81]; P =0.019) but similar odds ratios and hazard ratios for all other outcomes in the naïve, TEER, and SMVR groups (all P >0.05). Conclusions In carefully selected patients, TEER can be performed using the MitraClip device even after prior TEER or SMVR.

BACKGROUND:Tethering is a common condition of the mitral valve apparatus in the presence of significant regurgitation. Its impact on outcomes of transcatheter edge-to-edge repair (TEER) remains poorly characterized. METHODS:We appraised the prevalence, features, procedural details, and outcomes of patients with or without mitral valve tethering in a prospective multicenter observational study. The primary endpoint was the risk of cardiac death or rehospitalization for heart failure at mid-term follow-up. RESULTS:We included 2238 patients, 1467 (65.5 %) without tethering and 771 (34.5 %) with tethering (487 [21.8 %] with symmetric and 284 [12.7 %] with asymmetric tethering). Several differences in baseline features were evident among groups, yet procedural results were similar. After a median of 14 months, rates of cardiac death or rehospitalization for heart failure was significantly higher at unadjusted analysis in patients with tethering (191 [24.8 %] vs. 272 [18.5 %] in those without tethering, p = 0.001), but weres similar between tethering subtypes (p = 0.666). At adjusted analysis, the presence of any tethering was no longer a significant predictor of cardiac death or rehospitalization for heart failure, and the same results were obtained focusing on tethering subtypes (all p > 0.05). CONCLUSIONS:Tethering is common among patients with an indication to TEER, and is associated with adverse baseline and procedural features. In spite of this, device and procedural success rates are not significantly impacted by the presence of tethering that does not even have a negative prognostic effect at follow-up. Accordingly, tethering should not be considered a contraindication to TEER in suitable patients.

Objectives: Transcatheter edge-to-edge repair (TEER) has become an established minimally invasive treatment for significant mitral regurgitation. Ongoing refinements and the availability of different clipping devices have expanded the indications for and effectiveness of TEER, but comprehensive comparative data on this issue are lacking. In this study, we compared NT, NTr, and XTr MitraClip devices (Abbot) for TEER. Methods: Details on patient, imaging, and procedural details, as well as short- and long-term outcomes, were sought from a national prospective clinical registry on TEER with MitraClip. The primary outcome of interest was discharge after procedural success without major clinical complications. Results: A total of 2236 patients were included, 1228 (54.9%) in whom NT implantation only was attempted, 233 (10.4%) in whom NTr but not XTr implantation was attempted, and 775 (34.7%) in whom XTr implantation was attempted. Clinical and imaging features differed substantially across the groups, reflecting expanding indications with NTr and XTr devices. In-hospital outcomes were largely similar among the 3 groups, including death. Long-term unadjusted estimates of effect showed significant differences in several outcomes, including death, rehospitalization, and their composite, which demonstrated that NT was associated with more unfavorable outcomes compared with the other devices (all P less than .05). However, most differences depended on baseline features, as adjusted analysis showed no significant differences for early as well as long-term outcomes, including long-term death, rehospitalization, and their composite (all P greater than .05). Conclusions: New-generation MitraClip devices are associated with favorable procedural and clinical outcomes, despite being used in patients with more adverse features, when compared with patients treated with previous devices.

Coronary artery calcifications (CAC) affect more than 90% of men and more than 67% of women older than 70; the spread is mainly due to the high occurrence of major cardiovascular risk factors. The presence of CAC can be detected by several noninvasive and invasive methods like computed tomography (CT), coronary angiography (CA), Intravascular Ultrasound (IVUS), and Optical Coherence Tomography (OCT), with each system providing different information that can be used in the treatment strategy of CAC. Several devices can modify calcium during PCI: high-pressure non-compliant balloons, cutting/scoring balloons, atheroablative technologies, and intravascular Lithotripsy (IVL). Each technique has advantages and disadvantages that every interventional cardiologist should know to perform an optimal PCI and to achieve the best result and clinical outcome. This is a narrative review that aims to illustrate the contemporary management of CAC, focusing on the available techniques to assess calcifications and their novel advancements and explaining the existing tools to treat CAC with a focus on their significant challenges and pitfalls.

Background: In hospitalized patients, the SARS-CoV2 infection induces a thromboinflammatory state characterized by endothelial cell dysfunction, platelet activation, and hypercoagulability, leading to an increased risk of thrombosis. In ACS patients with concomitant SARS-CoV2 infection, a higher in-hospital mortality rate is reported; however, no information on the impact of this infection on the thromboinflammatory profile of patients presenting with ACS is currently available. Similarly, no role of hemostatic biomarkers in predicting in-hospital or long-term mortality risk has been established in this population. Aim: In a prospective cohort of ACS patients, we aimed to 1) characterize the contribution of concomitant SARS-CoV2 infection to the thromboinflammatory status by measuring a panel of hemostatic and inflammatory biomarkers; and 2) assess the role of these biomarkers in predicting in-hospital and/or two-year mortality. Methods: Consecutive patients admitted to interventional cardiology for ACS (i.e., ST-elevation myocardial infarction [STEMI], non-STEMI [NSTEMI], or unstable angina [UA]) during the first wave of the pandemic in Bergamo, Italy, from March to May 2020, were enrolled and followed-up for 2 years. Coronary angiography and percutaneous coronary intervention (PCI) data were collected. At admission, patients underwent complete blood cell count and an extensive coagulation profiling, including biomarkers of endothelial-cell activation (von Willebrand factor [vWF] antigen and activity, and ADAMTS13); hypercoagulation (prothrombin fragment 1+2 [F1+2], and D-dimer); and fibrinolytic proteins (tissue plasminogen activator [t-PA], and inhibitor [PAI-1]). In addition, the inflammatory biomarkers fibrinogen, factor VIII (FVIII), neutrophil extracellular traps (NETs), and C reactive protein (CRP) were tested. The occurrence of in-hospital and two-year mortality was prospectively recorded. Results: A total of 99 (76M/23F, median age 67 years) ACS patients (56 STEMI, 34 NSTEMI, 9 UA) were analyzed. Based on nasal swabs, 24 positive and 75 negative SARS-CoV-2 patients were identified. At admission, all patients showed significantly (p<0.05) higher levels of thromboinflammatory biomarkers compared to normal range values. Furthermore, ACS SARS-CoV-2-positive patients displayed significantly (p< 0.05) higher levels of fibrinogen, FVIII, D-dimer, vWF, t-PA, PAI-1, CRP, and NETs, together with significantly (p<0.05) lower levels of lymphocytes, hemoglobin, platelets, and ADAMTS-13 as compared to negative patients. The STEMI SARS-CoV2-positive group exhibited the highest values of the biomarkers. When performed, PCI ended more frequently with partial coronary reperfusion (TIMI grade flow <3) in SARS-CoV2-positive compared to negative patients (p= 0.004). The cumulative incidence of in-hospital mortality was 10%. The univariable analysis identified SARS-CoV-2 positivity as the strongest independent risk factor for mortality (HR 5.9 [95%CI 1.2-31.1]). Regarding the other clinical and laboratory parameters, the multivariable analysis identified dyspnea at presentation, vWF antigen, and leukocytes as independent risk factors for in-hospital mortality. These variables were used to develop a continuous score. Based on this score, the cumulative incidence of mortality was 0 % in the low-risk group, 19% in the intermediate-risk group (95% CI 6.1- 48.2%), and 71% in the high-risk group (95% CI 28.2-113.2%). After a 2-year observation, the mortality rate was 8%. Age was the sole independent risk factor for a 2-year mortality, with a HR of 1.2 (95% CI 1.04-1.3), regardless of the initial SARS-CoV2 status. Conclusions: For the first time, our study demonstrates that SARS-CoV2 infection worsens the thromboinflammatory state of ACS patients. This harmful effect might explain the observed heightened mortality rate among ACS patients concomitantly infected with SARS-CoV-2, which in our study was six times higher than in non-infected ACS patients. Additionally, the proposed scoring system, based on thromboinflammatory biomarkers, has proven effective in identifying ACS patients with elevated risks of in-hospital mortality. The potential role of this scoring system in identifying high-risk patients may possibly extend beyond our study to other highly inflammatory settings.

BACKGROUND:The clinical impact of coronary artery disease (CAD) on the prognosis of patients undergoing MitraClip implantation is still unclear.METHODS:One thousand nine hundred fifty-three patients undergoing MitraClip implantation included in the multicenter GIOTTO Registry were stratified according to CAD. Endpoints were all-cause death, cardiac death, and re-hospitalization for heart failure at follow-up (median 15.8 months).RESULTS:Although younger, CAD patients were more symptomatic, had worse cardiovascular risk profile, higher burden of comorbidities, more frequently affected by functional MR, with higher left ventricle (LV) diameters and lower ejection fraction (EF). At follow-up, CAD patients showed higher rates of all-cause death (25.4% vs. 19.6%; P=0.002), cardiovascular death (14.0% vs. 10.1%; P=0.007) and re-hospitalization for heart failure (13.9% vs. 10.2%; P=0.011). Dividing the population according to mitral regurgitation (MR) etiology (functional vs. non-functional MR), no differences were observed between CAD and no-CAD patients. At multivariate logistic regression, NYHA III/IV class, prior heart failure hospitalization, severe chronic kidney disease, atrial fibrillation, LV end-diastolic diameter and LVEF<30% but not CAD resulted independent predictors of all-cause death. The same finding was confirmed even after propensity score adjustment.CONCLUSIONS:CAD did not show a relevant impact on mid-term prognosis per se, but seemed to identify a more complex and diseased cohort of patients with worse clinical and functional status.

BACKGROUND:Uncovered struts are a determinant of stent failure. The impact of plaque composition and procedural factors on the occurrence, evolution, and outcomes of uncovered struts in a high-risk setting has not been investigated.OBJECTIVE:To investigate the determinants and long-term clinical impact of largely uncovered struts (LUS) in thin-struts drug-eluting stents (DES) implanted in complex lesions by intracoronary optical coherence tomography (OCT).METHODS:Ninety patients with multivessel disease undergoing staged complete revascularization were randomly assigned to bioabsorbable or durable polymer DES. OCT were serially performed during the index procedure, at 3- and 18-month follow-up, and analyzed by an independent core lab. Struts were defined uncovered by OCT if no tissue was visible above the struts. LUS were defined as ≥30% of uncovered struts at 3-month follow-up. Clinical outcomes were the occurrence of target vessel failure (TVF) and major adverse cardiac and cerebrovascular events (MACCE) at 5-year follow-up.RESULTS:LUS occurred in 31 patients (34.4%) regardless of stent platform. At 5 years, no differences were observed in the rate of TVF (12.7% vs. 13.4%; p = 0.91) and MACCE (23.9% vs. 24.9%; p = 0.88) between the two groups. At multivariate logistic regression, plaque rupture, mean lumen diameter, proximal reference vessel area, and maximum stent deployment pressure were independent predictors of LUS.CONCLUSIONS:LUS are a frequent finding in complex coronary lesions treated with thin-struts DES, especially in the presence of plaque rupture. However, in this study, no significant safety signal related to LUS emerged in long-term follow-up.

HomeCirculation: Heart FailureVol. 15, No. 5Diastolic Ventricular Interaction in a Heart Transplant Patient With Severe Tricuspid Regurgitation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBDiastolic Ventricular Interaction in a Heart Transplant Patient With Severe Tricuspid Regurgitation Attilio Iacovoni, MD, FESC, Nicolina Conti, MD, Ottavio Zucchetti, MD, Luigi Fiocca, MD and Michele Senni, MD, FESC Attilio IacovoniAttilio Iacovoni https://orcid.org/0000-0003-0347-6672 Cardiovascular Department, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy. , Nicolina ContiNicolina Conti Correspondence to: Nicolina Conti, MD, Cardiovascular Department, ASST Papa Giovanni XXIII, Piazza Organizzazione Mondiale Sanità,1, 24100 Bergamo BG, Italy. Email E-mail Address: [email protected] https://orcid.org/0000-0001-7141-8453 Cardiovascular Department, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy. , Ottavio ZucchettiOttavio Zucchetti https://orcid.org/0000-0003-0564-7578 Cardiovascular Department, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy. , Luigi FioccaLuigi Fiocca https://orcid.org/0000-0003-1114-2250 Cardiovascular Department, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy. and Michele SenniMichele Senni Cardiovascular Department, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy. Originally published22 Feb 2022https://doi.org/10.1161/CIRCHEARTFAILURE.121.009368Circulation: Heart Failure. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 22, 2022: Ahead of Print A 59-year-old man who underwent orthotopic heart transplant in 2018 developed asymptomatic severe tricuspid regurgitation after endomyocardial biopsy. Three years later, a routine hemodynamic evaluation was performed.Right heart catheterization showed a slight increase in right atrial pressure (8 mm Hg) with ventricularized pressure tracings, congruent with severe tricuspid regurgitation (Figure 1A). Pulmonary artery mean pressure, capillary wedge pressure, and pulmonary vascular resistance were normal, with preserved cardiac output. Left and right ventricular pressures were recorded simultaneously. A deep inspiration revealed an increase in right and left diastolic ventricular pressures with a discordant change in systolic pressures as right ventricular systolic pressure increased and left ventricular systolic pressure decreased, consistent with enhanced ventricular interdependence (Figure 1B). The respiratory variation in pulmonary capillary wedge and in diastolic left ventricular pressure was similar.Download figureDownload PowerPointFigure 1. Severe tricuspid regurgitation enhances diastolic ventricular interaction despite an opened pericardium in a heart transplanted patient. A, Right atrial (RA) pressure waveform showing signs of severe tricuspid regurgitation (prominent V wave and deep Y wave or ventricularized RA pressure tracings). B, Simultaneous recording of left ventricular (LV) and right ventricular (RV) pressure during inspiration (arrow 1) and expiration (arrow 2). During inspiration, there is a discordant change of the systolic peak of the LV and RV as RV systolic pressure increases, while LV systolic pressure decreases. Diastolic pressures increase in both ventricles. HR indicates heart rate.Ventricular interdependence refers to the forces transmitted between the ventricles through the septum, the common muscle fibers, and the pericardium1 and is important in right ventricular pressure or volume overload states such as pulmonary hypertension, right ventricular infarct, massive pulmonary embolism, and congenital heart defects.2 Changes in volume in one ventricle affect the compliance of the other, shifting the pressure-volume loop upward and to the left (diastolic ventricular interaction [DVI]).3 It is recognized that pericardial diseases enhance DVI,4 but preclinical studies revealed DVI even without pericardium.5This case highlights that right ventricular volume overload can enhance DVI independently from an intact pericardium. In contrast with constrictive pericarditis, the opposite variation in right and left ventricular systolic pressures was not associated with a decrease in diastolic pressure gradient from the pulmonary veins to the left ventricle. To verify that DVI in our patient is amplified by right ventricular volume overload, a control study was performed in another heart transplant patient without tricuspid regurgitation, showing concordant decrease in systolic biventricular pressure during inspiration (Figure 2).Download figureDownload PowerPointFigure 2. Normal pressure tracings in a heart transplanted patient without tricuspid regurgitation. A, Right atrial (RA) pressure waveform showing a normal tracing. B, Simultaneous recording of left ventricular (LV) and right ventricular (RV) pressure during inspiration (arrow 1) and expiration (arrow 2). During inspiration, there is a consistent decrease in biventricular systolic and diastolic pressures. HR indicates heart rate.Article InformationSources of FundingNone.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page 531.Correspondence to: Nicolina Conti, MD, Cardiovascular Department, ASST Papa Giovanni XXIII, Piazza Organizzazione Mondiale Sanità,1, 24100 Bergamo BG, Italy. Email nicolina.[email protected]comReferences1. Santamore WP, Dell'Italia LJ. Ventricular interdependence: significant left ventricular contributions to right ventricular systolic function.Prog Cardiovasc Dis. 1998; 40:289–308. doi: 10.1016/s0033-0620(98)80049-2CrossrefMedlineGoogle Scholar2. Clyne CA, Alpert JS, Benotti JR. Interdependence of the left and right ventricles in health and disease.Am Heart J. 1989; 117:1366–1373. doi: 10.1016/0002-8703(89)90418-3CrossrefMedlineGoogle Scholar3. Janicki JS, Weber KT. The pericardium and ventricular interaction, distensibility, and function.Am J Physiol. 1980; 238:H494–H503. doi: 10.1152/ajpheart.1980.238.4.H494MedlineGoogle Scholar4. Borlaug BA, Reddy YNV. The role of the pericardium in heart failure: implications for pathophysiology and treatment.JACC Heart Fail. 2019; 7:574–585. doi: 10.1016/j.jchf.2019.03.021CrossrefMedlineGoogle Scholar5. Naeije R, Badagliacca R. The overloaded right heart and ventricular interdependence.Cardiovasc Res. 2017; 113:1474–1485. doi: 10.1093/cvr/cvx160CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2022Vol 15, Issue 5 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.121.009368PMID: 35189707 Originally publishedFebruary 22, 2022 Keywordshumansventricular functioncardiac outputtricuspid valve insufficiencybiopsyPDF download Advertisement SubjectsTransplantationValvular Heart Disease

BackgroundDual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist is the cornerstone of therapy in patients with acute coronary syndrome (ACS). Adherence to medical therapy is an important issue, as premature DAPT discontinuation increases the risk of new ischemic events. The aim of the present observational prospective multicenter study was to evaluate in the real-world incidence and discontinuation patterns of ticagrelor during the first 12 months after ACS.MethodsWe analyzed 431 ACS patients, discharged with ticagrelor, by 7 Italian centers. The primary end-point was the incidence of cessation of ticagrelor up to 12 months from the index event.ResultsDefinitive ticagrelor cessations occurred in 52 patients (12.1%), of which 35 were discontinuations (clinically driven) and 17 disruptions (due to acute events). Temporary cessation occurred in 14 cases (3.3%). Age ≥ 80 years and anticoagulant therapy were independent predictors of premature discontinuation. Bleeding occurred in 74 patients, of which 25 suffered a BARC ≥ 2 bleeding event. Bleeding were more frequent in female sex (27.0% vs 17.2%, p-value 0.049) and in patients with a history of bleeding (8.1% vs 2.9%, p-value 0.035).ConclusionsOur study found that the adherence to DAPT with ticagrelor after an ACS is still an important issue, premature discontinuation occurred mainly in fragile patients, like elderly, who suffered a previous bleeding or underwent previous percutaneous coronary intervention.

BACKGROUND Coronavirus Disease-2019 (COVID-19) may impair outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The extent of this phenomenon and its mechanisms are unclear.Methods and Results:This study prospectively included 50 consecutive STEMI patients admitted to our center for primary percutaneous coronary intervention (PCI) at the peak of the Italian COVID-19 outbreak. At admission, a COVID-19 test was positive in 24 patients (48%), negative in 26 (52%). The primary endpoint was in-hospital all-cause mortality. Upon admission, COVID-19 subjects had lower PO2/FiO2 (169 [100-425] vs. 390 [302-477], P<0.01), more need for oxygen support (62.5% vs. 26.9%, P=0.02) and a higher rate of myocardial dysfunction (ejection fraction <30% in 45.8% vs. 19.2%, P=0.04). All patients underwent emergency angiography. In 12.5% of COVID-19 patients, no culprit lesions were detected, thus PCI was performed in 87.5% and 100% of COVID-19 positive and negative patients, respectively (P=0.10). Despite a higher rate of obstinate thrombosis in the COVID-19 group (47.6% vs. 11.5%, P<0.01), the PCI result was similar (TIMI 2-3 in 90.5% vs. 100%, P=0.19). In-hospital mortality was 41.7% and 3.8% in COVID-19 positive and negative patients, respectively (P<0.01). Respiratory failure was the leading cause of death (80%) in the COVID-19 group, frequently associated with severe myocardial dysfunction. CONCLUSIONS In-hospital mortality of COVID-19 patients with STEMI remains high despite successful PCI, mainly due to coexisting severe respiratory failure. This may be a critical factor in patient management and treatment selection.

BACKGROUND Transcatheter mitral valve repair (TMVR) with the MitraClip device is an established treatment for mitral regurgitation (MR). More than one MitraClip may be implanted if a single one does not reduce MR adequately. We aimed at appraising the outlook of patients undergoing implantation of one, two or multiple MitraClips for TMVR. METHODS Exploiting the ongoing prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) Study dataset, we compared patients, procedural details and outcomes distinguishing those receiving one, two or multiple MitraClips. The primary endpoint was the composite of 1-year cardiac death or rehospitalization for heart failure. Additional endpoints included all cause death, surgical mitral repair, and functional class. Multivariable adjusted Cox proportional hazard analysis was used for confirmatory purposes. RESULTS As many as 1824 patients were included: 718 (39.4%) treated with a single MitraClip, and 940 (51.5%) receiving two MitraClips, and 166 (9.1%) receiving three or more. Significant differences were found for baseline features, including age, female gender, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, prior myocardial infarction, atrial fibrillation, permanent pacemaker, cardiac resynchronization therapy, implantable cardioverter defibrillator, and prior mitral valve repair (all p<0.05). Several imaging features were also different, including left ventricular dimensions, MR severity and proportionality, mitral valve area, flail leaflet, and pulmonary vein flow (all p<0.05). Among procedural features, significant differences were found for anesthesia type, MitraClip type, fluoroscopy, device, and operating room times, postprocedural mitral gradient, residual MR, smoke-like effect, device success partial detachment and surgical conversion (all p<0.05). In-hospital death occurred more frequently in patients receiving multiple MitraClips, and the same applied severe residual MR (all p<0.05). Mid-term follow-up (15±13 months) showed significant difference in the risk of death, cardiac death, rehospitalization for heart failure, and their composites, mainly, but not solely, associated with multiple MitraClips (all p<0.05). Adjusted analysis confirmed the significantly increased risk of composite adverse events when comparing the multiple vs single MitraClip groups (p=0.014 for death and rehospitalization, p=0.013 for cardiac death or rehospitalization). CONCLUSIONS Implantation of one or two MitraClips is associated with favorable clinical outcomes. Conversely, bail-out implantation of three or more MitraClips may portend a worse long-term prognosis.

Abstract Background Hospitalised COVID-19 pneumonia patients are characterised by the occurrence of a hypercoagulable state associated to a high risk of thromboembolic events. The main laboratory findings of this coagulopathy include D-dimer increase, mild thrombocytopenia, prolonged PT, and increase endothelial activation biomarkers (vWF, thrombomodulin). No data are available about coagulation profile in patients presenting with an acute coronary syndrome (ACS) combined with SARS-CoV-2 infection. Purpose In this prospective study, we aimed to evaluate the contribute of concomitant SARS-CoV-2 infection to the haemostatic system derangement (i.e., from endothelial cell activation to fibrinolytic phase) observed in patients presenting with ACS. Further, the role of haemostatic biomarkers (HB) for in-hospital mortality risk prediction was also explored. Methods Consecutive patients admitted to our hospital for ACS at peak intensity of local pandemia were enrolled into this study. At admission, all patients underwent routine blood examinations with blood count, serum biochemical tests and an extensive coagulation profiling. Data from coronary angiography and percutaneous coronary intervention (PCI), when performed, were collected. In-hospital major adverse cardio and cerebrovascular events –MACCEs- (total and cardiovascular death, stroke, systemic or pulmonary embolism, re-MI and bleedings) are reported. Results A total of 99 (76M/23F) consecutive patients with a median age of 66.7 (±12.1) were enrolled. According to nasal swab, 24 patients were SARS-CoV-2 positive and 75 negative. The two groups, similar in age, sex and cardiovascular risk factors, significantly differed in presenting symptoms (p<.001) and radiological signs of pneumonia (p<.0001). At admission, there were no differences in routine laboratory values between groups. Differently, analysis of the HB showed significantly higher values of D-dimer, vWF antigen, vWF activity and vWF; RiCof, t-PA and PAI-1 and lower levels of ADAMTS-13 in the positive group. Furthermore, among ACS patients, both STEMI and NSTEMI subjects, positive for SARS-CoV-2, had significantly higher plasma values of all the HB compared to the respective negative counterparts, with SARS-CoV-2 positive STEMI subjects displaying the highest values. When performed, PCI finished more frequently with a final TIMI flow <3 (p=.004) in positive patients. The in-hospital rate of MACCEs was 24% (24/99 patients) with a higher (p<.0001) prevalence in SARS-Co-V2 positive group. Cardiovascular mortality accounted for the majority of deaths (8/10; p=.019). At multivariable analysis, we identified dyspnoea at presentation, vWF antigen and leukocyte values as independent risk factors for in-hospital death. Conclusions In patients presenting with ACS combined with SARS-Cov-2 infection an additional HB asset derangement with stronger endothelial cell activation occurs which negatively impact the outcome, regardless of the invasive treatment. Funding Acknowledgement Type of funding sources: None.

Background We aimed at appraising features and outcomes of patients undergoing MitraClip treatment according to their age. Methods We queried the prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) multicenter registry dataset including 19 Italian centers performing MitraClip implantation, distinguishing patients <80 vs ≥80 years of age. Results In total, 1853 patients were included, 751 (40.5%) octogenarians and 1102 (59.5%) non-octogenarians. Several baseline and procedural features were significantly different, including gender, regurgitation etiology, and functional class (all p < 0.05). In-hospital outcomes were similarly satisfactory, with death occurring in 18 (2.4%) and 32 (2.9%, p = 0.561), respectively, and improvement in mitral regurgitation in 732 (97.4%) and 1078 (97.8%, p = 0.746), respectively. After a mean follow-up of 15 months, death occurred in 152 (20.2%) and 264 (24.0%), and cardiac death in 85 (11.3%) and 138 (12.5%), respectively (both p > 0.05). Rehospitalization for heart failure and the composite of cardiac death or rehospitalization for heart failure were significantly less common in octogenarians: 63 (8.4%) vs 156 (14.2%, p < 0.001), and 125 (16.6%) vs 242 (22.0%, p = 0.005), respectively. Multivariable analysis showed that these differences were largely due to confounding features, as after adjustment for baseline, clinical and imaging characteristics no significant difference was found for the above clinical endpoints. Conclusions Transcatheter mitral valve repair with the MitraClip in carefully selected octogenarians appears feasible and safe, and is associated with favorable clinical outcomes at mid-term follow-up.