Valvular heart disease (VHD) affects millions worldwide and remains a major cause of morbidity and mortality, placing a substantial and growing burden on healthcare systems. Over the past two decades, transcatheter therapies have emerged to meet this challenge, transforming the management of aortic, mitral, and tricuspid valve disease. Initially developed for inoperable or high-risk surgical patients, procedures such as transcatheter aortic valve implantation (TAVI) and mitral transcatheter edge-to-edge repair (M-TEER) are now routinely offered across a broader risk spectrum. More recently, tricuspid therapies, including tricuspid transcatheter edge-to-edge repair (T-TEER) and transcatheter valve replacement (TTVR), have emerged to address a significant unmet clinical need. With transcatheter interventions becoming more widely available, clinicians across general and acute medical specialities are increasingly likely to encounter patients before and after these procedures. Familiarity with these therapies will support better decision-making and coordinated care. This review summarises the evolution of transcatheter valve therapy, its role alongside surgery, and the evidence supporting its use. Surgery remains the gold standard for younger or low-risk patients, particularly where long-term durability is essential. Transcatheter therapies now offer safe and effective treatment for older patients, including those with frailty or significant comorbidity, supported by landmark trials, which have demonstrated favourable clinical outcomes in carefully selected populations and underpinned guideline endorsement across risk categories. The importance of the multidisciplinary Heart Team is emphasised, ensuring treatment decisions reflect individual anatomy, comorbidity burden, life expectancy, and procedural risk. As device technology, imaging, and procedural expertise continue to advance, the integration of surgical and transcatheter approaches will support more individualised care and broaden access to definitive treatment for patients across the clinical spectrum.

OBJECTIVE:Mitral valve repair (MVr) is the standard treatment for degenerative mitral regurgitation (MR). However, MR may recur, and reoperation is associated with increased mortality and technical complexity. Microinvasive MVr using the NeoChord technique in redo setting is performed off-pump, offering clear advantages, particularly in high-risk patients. METHODS:This retrospective, multicenter, international registry included 92 patients treated with the NeoChord technique between 2014 and 2025 for recurrent MR after previous MVr across 32 centers. The primary composite end point was freedom from recurrence of severe MR, need for reintervention due to technical failure, and 30-day or cardiovascular mortality. RESULTS:Neochord repair was successful in 91 patients (98.9%); one was converted to open surgery. Mean age was 64.6 ± 11.6; 22 patients (23.9%) were female. Mean left ventricle ejection fraction was 57.4 ± 8.1%; European System for Cardiac Operative Risk Evaluation was 4.3 ± 3.2%. A median of 3 chords was implanted. Mean procedural time was 139 ± 65 minutes. At discharge, MR was mild or less in 93.5%. One patient (1.1%) died on day 8. One life-threatening bleeding and one acute myocardial infarction were reported. Median hospital length-of-stay was 5 days; 47.8% of patients were extubated in the operating room. The primary end point was achieved in 81.3 ± 6.6% of patients at 5 years (Kaplan-Meier analysis). Seven patients (8.6%) underwent re-reintervention; 3 remained with severe MR. In the multivariate analysis, older age was associated with an increased risk (hazard ratio, 1.160; 95% CI, 1.021-1.317), whereas greater hemoglobin levels were protective (hazard ratio, 0.423; 95% CI, 0.233-0.768). CONCLUSIONS:Microinvasive NeoChord repair provides excellent procedural and 5-year outcomes with very low mortality, supporting its role as a valuable option for reoperative mitral valve surgery.

IntroductionThe aim of this study was to report clinical and hemodynamic results from a real-world registry of aortic valve replacement (AVR) with the Perceval sutureless bioprosthesis, comparing mini-sternotomy (MS) versus mini-thoracotomy (MT) approach.MethodsThis prospective international registry enrolled 1,652 patients across 55 institutions between 2011 and 2021. Patients undergoing isolated AVR by minimally invasive cardiac surgery approaches were analyzed. Preoperative covariates were adjusted using 1:1 propensity score matching, reaching a final cohort of 261 patients for each approach.ResultsIsolated AVR via minimally invasive approaches was performed in 710 patients—406 in MS and 304 in MT. After matching, the baseline characteristics were similar between the two groups, except for the preoperative NYHA class distribution. MT was associated with shorter intensive care unit and hospital stays (p = <0.001 and p = 0.050, respectively), but with higher cross-clamp and cardiopulmonary bypass times compared to MS (<0.001). Within 30 days, one cardiovascular death occurred in the MS group, while 4 (1.5%) reinterventions were reported in the MT group. Pacemaker implantation was required in 5 (1.9%) patients in the MS group and 14 (5.4%) patients in the MT group, with no statistically significant difference. In the matched cohort, survival probability for late events showed no difference between surgical approaches. Mean pressure gradients remained stable during follow-up, with no difference between the groups.DiscussionOur propensity-matched analysis demonstrates that the use of Perceval in minimally invasive approaches is associated with low perioperative complication rates. Sutureless implanted in MT has lower intensive care and in-hospital stay without significant differences in long-term clinical and echocardiographic outcomes.

OBJECTIVES:Sutureless aortic valve prostheses reduce surgical times and facilitate minimally invasive approaches, improving patient outcomes. However, it remains unclear whether these devices provide specific benefits to female patients, in whom sex-related differences in valve surgery outcomes remain a matter of debate. METHODS:Up to September 2024, 535 subjects (261 women) received Perceval Plus at 35 investigational sites from Mitral, Aortic aNd Tricuspid Post-maRket Study in a reAl-world Setting observational prospective registry. Moreover, meta-regression was performed to assess whether sex modifies outcomes. RESULTS:Men have a larger body size (body surface area: male 2.0 ± 0.2 vs female 1.8 ± 0.2, P < .001), resulting in a larger prosthesis size (size S: male 2.9% vs female 34.9%). Surgery was still significantly faster in women (cross-clamp time: male 63.7 ± 29.4 min vs female 56.8 ± 29.4 min, P = .002), partly because approximately 10% of procedures in male patients were combined, increasing duration. Early outcomes were comparable between sexes (hospital deaths: male 3 [1.1%] vs female 5 [1.9%], P = .49). At follow-up, no significant differences were observed (follow-up deaths: male 9 [3.3%] vs female 5 [1.9%], P = .42). Meta-regression showed no effect of female sex prevalence. CONCLUSIONS:Our registry and meta-regression analysis did not reveal significant differences in outcomes between men and women. Preoperative characteristics, however, differ between sexes and may influence outcomes and prosthesis choice. Long-term conclusions are limited by the current follow-up duration and will be further explored as data collection progresses. CLINICAL REGISTRATION NUMBER:NCT05002543, ClinicalTrials.gov (https://clinicaltrials.gov/study/NCT05002543).

OBJECTIVE:Perceval sutureless valve (Corcym, Saluggia, Italy) has been in clinical use for more than 15 years. The aim of this study is to report clinical and hemodynamic performance from a real-world registry in patients who underwent aortic valve replacement (AVR) with a Perceval, comparing outcomes of minimally invasive (MICS) versus full sternotomy (FS) settings. METHODS:This prospective international registry enrolled 1,652 patients implanted with a sutureless aortic valve in 55 institutions from 2011 to 2021. Patients with isolated AVR were analyzed by MICS and FS approaches. Preoperative covariates were adjusted with propensity score matching 2:1, reaching a final cohort of 857 isolated AVR patients with 558 patients in MICS and 299 in FS groups. RESULTS:Successful first implantation was 98.0% for both approaches (P > 0.999). As expected, surgical timings were significantly longer in MICS versus FS (P = 0.004 and P < 0.001), but intensive care unit and hospital lengths of stay were significantly lower in the MICS cohort, resulting in about 0.5 days and 1.5 days less spent in the intensive care unit and hospital, respectively. The surgical approach did not show any effect on early or late survival, disabling stroke, leaks greater than 2, pacemaker rate, or hemodynamics. CONCLUSIONS:Our propensity-matched analysis demonstrates the noninferiority of MICS with regard to hard endpoints and better outcomes for secondary endpoints such as reduced length of intensive care and in-hospital stay.

Aims:Aortic stenosis (AS) is a condition marked by high morbidity and mortality in severe, symptomatic cases without intervention via transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). Racial and ethnic disparities in access to these treatments have been documented, particularly in North America, where socioeconomic factors such as health insurance confound analyses. This study evaluates disparities in AS management across racial and ethnic groups, accounting for socioeconomic deprivation, using an artificial intelligence (AI) framework. Methods and results:We conducted a retrospective cohort study using a natural language processing pipeline to analyse both structured and unstructured data from > 1 million patients at a London hospital. Key variables included age, sex, self-reported race and ethnicity, AS severity, and socioeconomic status. The primary outcomes were rates of valvular intervention and all-cause mortality. Among 6967 patients with AS, Black patients were younger, more symptomatic, and more comorbid than White patients. Black patients with objective evidence of AS on echocardiography were less likely to receive a clinical diagnosis than White patients. In severe AS, TAVI and SAVR procedures were performed at lower rates among Black patients than among White patients, with a longer time to SAVR. In multivariate analysis of severe AS, controlling for socioeconomic status, Black patients experienced higher mortality (hazard ratio = 1.42, 95% confidence interval = 1.05-1.92, P = 0.02). Conclusion:An AI framework characterizes racial and ethnic disparities in AS management, which persist in a universal healthcare system, highlighting targets for future healthcare interventions.

The treatment of aortic valve disease in small annuli remains a debated topic in terms of prosthetic choice - biological or mechanical - and risk of patient prosthesis mismatch. The clinical data of the 241 patients who received a small size sutureless prosthesis from the Sorin Universal REgistry on Aortic Valve Replacement (SURE-AVR) (NCT02679404) were analysed at 30 days and at follow-up. The mean age was 75.5 ± 7.8 years (89.2

Abstract Introduction Aortic stenosis (AS) is the most common valvular heart disease in developed countries. Severe AS is defined as a mean pressure gradient (MG) ≥ 40 mmHg, a maximum aortic jet velocity≥4 m/s and an aortic valve area (AVA)≤1 cm2. However, classification of AS severity may be challenging due to discordant results on echocardiography. The normal-flow low-gradient severe AS (NFLG-AS) is defined as AVA≤1 cm2, MG<40 mmHg, left ventricular ejection fraction ≥ 50%, and stroke volume index (SVi) ≥ 35 ml/m2, whereas in the presence of MG > 40mmHg the condition is described as normal-flow high-gradient AS (NFHG-AS). Purpose The purpose of this study was to seek differences in the dynamic changes of the aortic valve tract throughout the cardiac cycle between the two clinical entities: NFHG-AS (Group 1) and NFLG-AS (Group 2). Methods In total, 130 patients with normal flow severe AS who underwent TAVI and had 3D transoesophageal echocardiographic data sets were screened. 38 patients with NFHG-severe AS and 40 patients with NFLG-severe AS with matching clinical characteristics and aortic valve area were identified. A custom-made semi-automated application developed by SQ was used. The application allows tracking of the aortic valve tract surface throughout the cardiac cycle in 3D transoesophageal echocardiograms and provides measurements of the geometrical planes at 4 levels: left ventricular outflow tract (LVOT), aortic annulus (AoA), sinuses of Valsalva (SoV) and sinotubular junction (STJ). Results The echocardiographic characteristics and the dynamic changes of the aortic valve tract between the two groups are shown in Tables 1 and 2. Both groups had comparable echocardiographic characteristic apart from the mean aortic valve pressure gradient as expected. With regards to the aortic valve tract geometrical dynamic changes, the relative LVOT and AoA area changes were bigger in Group 1 (36.8±15.9% vs 29.1±11.9%; p=0.017 and 21.0±8.39% vs 17.1±6.6%; p=0.028). The SoV and STJ relative changes were similar between the two groups. The same applies to aortic stiffness parameters, namely compliance and distensibility of the ascending aorta, systemic arterial compliance, and valvulo-arterial impedance. Conclusion The LVOT and aortic annulus area demonstrate more prominent dynamic changes in patients with normal-flow high-gradient severe AS compared to individuals with normal-flow low-gradient severe AS. While the SoV and the STJ geometry does not change significantly through the cardiac cycle, a more elastic outflow tract allows larger expansion in systole and higher pressure gradients across the aortic valve, whereas a stiffer outflow tract and annulus result in lower pressure gradients, despite the presence of severe aortic stenosis (AVA<1.0cm2). These differences in dynamic LVOT and aortic annulus changes may explain the discrepancy between aortic valve area and pressure gradients in patients with normal-flow low-gradient AS.

OBJECTIVES:Memo 4D is a semi-rigid ring with an exclusive saddle shape and progressive increased anteroposterior diameter. This preliminary analysis reports 30-day clinical and haemodynamic outcomes of the MANTRA Memo 4D sub-study. METHODS:MANTRA is an 'umbrella' prospective, multicentre, worldwide post-market study to collect real-life safety and performance data on the Corcym devices. Clinical and echocardiographic outcomes were gathered preoperatively, at discharge and each follow-up. KCCQ-12 questionnaires were collected preoperatively and at 30 days. Echocardiographic studies were performed per a predefined protocol and assessed by an independent core laboratory. RESULTS:In total, 166 patients (52, 31.3% female, mean age 60.7 ± 11.4 years) underwent mitral valve repair with Memo 4D in 17 international institutions between July 2021 and June 2023 (enrolment is still ongoing). Primary was the most common aetiology (157, 94.6%), of which 33 cases of Barlow's disease (19.9%); secondary mitral regurgitation was present in six cases (3.6%). Thirty-day mortality was 0.6% (1). One stroke event (0.6%), one acute kidney failure (0.6%), one myocardial infarction (0.6%) and two reoperations within 30 days were reported. Surgery marked improvement in the patient's NYHA class associated with a significant increase in KCCQ-12 summary score, from 69.1 (SD = 23.7) preoperatively to 83.9 (SD = 15.7) at 30 days. End-diastolic left ventricular diameters decreased from 55.19 (SD = 7.10) preoperatively to 52.70 (SD = 3.76) mm at 30 days, and left atrial volume decreased from 125.79 (SD = 46.33) preoperatively to 91.51 (SD = 37.20) ml at 30 days. Mitral regurgitation significantly reduced after the operation and up to 30-day follow-up. CONCLUSIONS:Mitral valve repair with Memo 4D is associated with good clinical and haemodynamic outcomes in the early period.MANTRA ClinicalTrials.gov number NCT05002543.

IMPORTANCE This study uses artificial intelligence (AI) technologies to augment quality measurement and improvement in the setting of aortic stenosis (AS). We characterise racial and ethnic disparities in the diagnosis, management, and outcome of AS within a universal healthcare system. OBJECTIVE To use natural language processing (NLP) AI methods applied to the electronic health records (EHR) to identify racial and ethnic disparities in AS while correcting for the effects of socioeconomic deprivation. DESIGN Retrospective cohort study. SETTING King’s College Hospital NHS Foundation Trust, a multi-site tertiary care hospital in London, UK PARTICIPANTS Adult patients with a diagnosis of AS between 2010-2020. MAIN OUTCOMES AND MEASURES Key outcomes were all-cause mortality, frequency of AS intervention (TAVI or surgical aortic valve replacement [AVR]) and the time from diagnosis of severe AS to intervention. All analyses were adjusted for age, sex and socioeconomic deprivation. RESULTS 5859 patients with AS were identified, with self-reported race and ethnicity labels as 4.5% Asian, 7.5% Black, and 88.0% White. For those with severe AS, TAVI was performed in 19.6% of Asian patients, 17.6% of Black patients and 24.9% of White patients; AVR was performed in 39.2% of Asian patients, 27.9% of Black patients and 32.8% of White patients. The mean time from severe AS diagnosis to TAVI was 0.69 years for Asian patients, 1.03 years for Black patients and 0.62 years for White patients (P=n.s.). The mean time to AVR was longer for Black patients (1.35 years) compared to Asian (0.49 years) and White patients (0.41 years, P<0.001). Survival in the overall cohort did not associate with ethnicity. However, in patients with severe AS, Black ethnicity was independently associated with increased mortality (hazard ratio=1.42, 95% CI=1.05-1.92, P=0.02). CONCLUSIONS AND RELEVANCE In patients with severe AS, Black patients experience lower rates of TAVI, longer time from diagnosis to AVR and higher rates of mortality, despite correction for socioeconomic deprivation. These data exhibit how AI technologies may be leveraged to shed light on health inequities, here showing that racial and ethnic disparities in AS persist in a universal healthcare system, and should stimulate strategies to address inequity. Question Do racial and ethnic disparities in the diagnosis, management, and outcome of aortic stenosis (AS) exist within a universal healthcare system? Finding In this retrospective cohort study using natural language processing enabled analysis of electronic healthcare record data of 5859 patients with aortic stenosis, we identified that in severe AS, Black patients experience lower rates of transcatheter aortic valve implantation (TAVI), longer times from diagnosis to surgical aortic valve replacement (AVR) and higher rates of mortality. Meaning Natural language processing may be used to identify health inequities. Here, we find racial and ethnic disparities in AS exist even in a universal healthcare setting. ### Competing Interest Statement AMS serves as an advisor to Forcefield Therapeutics and CYTE - Global Network for Clinical Research. ### Funding Statement This work was supported by grants from the British Heart Foundation (CH/1999001/11735, RG/20/3/34823 and RE/18/2/34213 to AMS; CC/22/250022 to RJDB, AMS, JT and KOG) and King's College Hospital Charity (D3003/122022/Shah/1188 to AMS). This work was funded by the British Heart Foundation Adrian Beecroft Cardiovascular Catalyst award CC/22/250022. With thanks to King's College Hospital Charity for charitable Grant that has made this research possible. Dr O'Gallagher is funded by the British Heart Foundation Centre of Research Excellence, King's College London and by a Medical Research Council Clinician Scientist Fellowship (MR/Y001311/1). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This project operated under London South-East Research Ethics Committee approval (18/LO/2048) granted to the King's Electronic Records Research Interface (KERRI). This study complies with the Declaration of Helsinki. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The datasets analysed during the current study are not publicly available due to hospital information governance regulations but are available from the corresponding author on reasonable request. * AS : Aortic Stenosis AVR : Surgical aortic valve replacement IMD : Index of multiple deprivations LVEF : Left ventricular ejection fraction NLP : Natural language processing TAVI : Transcatheter aortic valve implantation

OBJECTIVES: Perceval sutureless valve has been in clinical use for >15 years. The aim of this study is to report the real-word clinical and haemodynamic performance from the SURE-aortic valve replacement international prospective registry in patients who underwent aortic valve replacement with Perceval valve. METHODS: From 2011 to 2021, patients from 55 institutions received a Perceval valve. Postoperative, follow-up, and echocardiographic outcomes were analysed. RESULTS: A total of 1652 patients were included; mean age was 75.3 +/- 7.0 years (53.9% female); mean EuroSCORE II was 4.1 +/- 6.3. Minimally invasive approach was performed in 45.3% of patients; concomitant procedures were done in 35.9% of cases. Within 30 days, 0.3 and 0.7% valve-related reinterventions were reported. Transient ischaemic attack, disabling and non-disabling strokes were limited (0.4%, 0.4% and 0.7%, respectively). Pacemaker implant was required in 5.7% of patients. Intra-prosthetic regurgitation >= 2 was present in 0.2% of cases, while paravalvular leak >= 2 in only 0.1%. At a maximum follow-up of 8 years, 1.9% of cardiovascular deaths and 0.8% of valve-related reintervention occurred. Among the 10 cases of structural valve deterioration (mean 5.6 +/- 1.4 years after implant; range: 2.6-7.3 years), 9 were treated with a transcatheter vale-in-valve implantation and 1 with explant. Mean pressure gradient decreased from 45.8 +/- 16.5 mmHg preoperatively to 13.3 +/- 5.2 mmHg at discharge and remained stable during follow-up. CONCLUSIONS: This experience represents the largest prospective real-world cohort of patients treated with Perceval showing that Perceval is a safe and effective alternative to conventional surgical aortic valve replacement, providing favourable clinical and haemodynamic results also at mid-term follow-up.

Mitral interventions remain technically challenging owing to the anatomical complexity and heterogeneity of mitral pathologies. As such, multi-disciplinary pre-procedural planning assisted by advanced cardiac imaging is pivotal to successful outcomes. Modern imaging techniques offer accurate 3D renderings of cardiac anatomy; however, users are required to derive a spatial understanding of complex mitral pathologies from a 2D projection thus generating an ‘imaging gap’ which limits procedural planning. Physical mitral modelling using 3D printing has the potential to bridge this gap and is increasingly being employed in conjunction with other transformative technologies to assess feasibility of intervention, direct prosthesis choice and avoid complications. Such platforms have also shown value in training and patient education. Despite important limitations, the pace of innovation and synergistic integration with other technologies is likely to ensure that 3D printing assumes a central role in the journey towards delivering personalised care for patients undergoing mitral valve interventions.

Background: Ethnic disparities exist in the diagnosis and management of aortic stenosis (AS), including decreased rates of transcatheter aortic valve implantation (TAVI) in Black patients. We sought to identify if disparities persist in the setting of universal healthcare and whether they are affected by social deprivation. Methods: A validated natural language processing pipeline was applied to the electronic health records of >1M patients at King’s College Hospital (UK) to identify 6214 patients with AS (4.5% Asian, 7.6% Black, 87.9% White self-reported ethnicity). All analyses are adjusted for age and social deprivation. Results: Black and Asian patients had more comorbidities (P<0.05), while Black patients had more cardiac symptoms compared to White patients (P<0.05). Mean time from first report of breathlessness to AS diagnosis was 2.61 years for Asian patients, 2.93 years for Black patients, and 2.09 years for White patients (P<0.05). For those with severe AS, TAVI was performed in 14.3% of Asian patients, 14.3% of Black patients, and 20.2% of White patients. The mean time from severe AS diagnosis to TAVI was 0.41 years for Asian patients, 0.88 years for Black patients, and 0.52 years for White patients (P= NS). Surgical aortic valve replacement (AVR) was performed in 12.5% of Asian patients, 15.5% of Black patients, and 15.4% of White patients. The mean time to AVR was longer for Black patients (1.07 years) compared to Asian (0.19 years) and White patients (0.35 years, P<0.05). The mortality benefit of TAVI or AVR interventions was similar between race and ethnicity groups in a Cox multivariate analysis. Conclusions: Ethnicity-based differences exist in the presentation, diagnosis and management of AS, despite correction for social deprivation. Further, Black patients with severe AS are less likely to receive TAVI intervention, and wait significantly longer for AVR, despite similar efficacy. These data should stimulate strategies to address inequity.

Objective To describe the long-term outcomes of mitral valve repair (MVr) versus mitral valve replacement (MVR) in patients with native valve infective endocarditis (IE) at a centre with high-repair rates. Methods We conducted a retrospective single-centre cohort study. From 2005 to 2021, 183 patients with active or healed native valve IE were included. The primary outcome was long-term mortality. Patient status was last confirmed 31 March 2021. Secondary outcomes were post-operative MR, MV reoperation, length of post-operative intensive care stay and total hospital stay. Results 85 patients (46.4%) underwent MVr and 98 (53.6%) underwent MVR. Follow-up was 98.9% complete. Mean follow-up time was 5.3 years with 17% of patients reaching a follow-up time of over 10 years. There were 47 deaths (25.7%) within the follow-up period. MVR patients were more likely to have higher logistic EuroSCORE, active IE and were less likely to have elective surgery. In multivariate Cox proportional hazards analysis, there was no significant difference in long-term mortality between MVr and MVR groups (hazard ratio 1.09, 95% confidence interval [0.59–2.00]). In Kaplan–Meier analysis, MVR patients had a higher all-cause mortality although there was no significant difference at the endpoint. Propensity score matching analysis showed a significantly higher mortality in the replacement group instead ( p = 0.002), Subgroup analysis revealed there remained no significant difference in mortality even in patients with active IE ( P -interaction = 0.859) or non-elective surgery ( P -interaction = 0.122). MV reoperation (odds ratio 1.00 [0.24–4.12]), post-operative intensive care stay ( p = 0.9650) and total hospital stay ( p = 0.9144) were comparable. Conclusions Our data demonstrates repair was at least non-inferior to replacement in IE, supporting more aggressive use of repair. There is no reason the general principle of why repair is superior to replacement should not hold in IE, with enough operator expertise. Other experienced units should be encouraged to increase repair rates as feasible in line with current guidelines.

Introduction: In mitral valve replacement (MVR), sudden increase in afterload and disruption of the annular-chordal-papillary-left-ventricular wall causes LV dysfunction in the early postoperative period. Preservation of the posterior mitral leaflet apparatus (MVR-P) has a favourable outcome on LV function. However, there is paucity of data on the impact of complete preservation of the sub-valvular apparatus (MVR-C). Objective: We investigated the impact of MVR-P and MVR-C on baseline and 3-months postoperative LV ejection fraction (EF) and global longitudinal strain (GLS). Methods: We retrospectively analysed a cohort of 29 MVR-P and 19 MVR-C patients with complete echo data at our unit, who were operated between 2012-2017. Between-group changes in LVEF and GLS were compared using independent sample T-test. Results: Median age was 59 years (IQR 50-69 years). Baseline LVEF was 58% (51 - 60%). Baseline GLS was -18.4 (-21.2 - -15.5). There were no significant differences between all baseline demographics including age (p=0.45), underlying MV pathology (p=0.1), baseline LVEF (p=0.48) and GLS (p=0.15). There was significantly less worsening of GLS in MVR-C group as compared to the MVR-P group (p=0.023), indicating better preservation of LV function. There was also a lower decrease in LVEF in the MVR-C as compared to the MVR-P group, although the difference was not statistically significant (p=0.23). Conclusion: MVR with complete preservation of the sub-valvular apparatus shows a favourable impact on the longitudinal function of the heart at 3 months. Further studies with larger patient numbers are indicated to investigate the long-term results of this surgical approach.

The anatomical and functional complexities of mitral valve pathologies render clinical decision-making and intervention challenging particularly in emergent settings such as acute papillary muscle (PM) rupture. Although rare since the advent of percutaneous coronary intervention, PM rupture carries a dismal prognosis, with a recent multicentre study published in this journal revealing an in-hospital mortality of 24.9% in those undergoing surgical intervention [1]. Given the rarity of PM rupture, the literature comprises of small retrospective studies producing a paucity of evidence to comprehensively guide patient selection, timing of intervention and the use of bridging strategies Moreover, the limited evidence base precludes a comprehensive understanding of the anatomical, haemodynamic and physiological mechanisms underpinning outcomes in such patients. In this context, Marin-Cuartas et al. [2] have developed the an ex vivo platform comprising of porcine valves mounted within a left heart simulator to model the haemodynamic effects of acute PM rupture simulated by incrementally cutting chordae to a given PM head. Ex vivo mitral models are fundamental to mitral research and this diligently designed study provides an apt reminder of the strengths of this modelling modality in enhancing our understanding of mitral disease processes and spawning research hypotheses especially in areas where the evidence base is limited such as PM rupture. This commendable hypothesis generating work suggests the presence of sub-phenotypic groups within those with PM rupture, the characterization of which could allow for more precise and efficacious interventional strategies and sets the stage for further study in this challenging research area. Given the acuity and rarity of PM rupture, such information would be difficult to derive from clinical studies. Despite the robust study design, the limitations of ex vivo mitral modelling are also apparent. Indeed, porcine models are not patient specific and do not fully emulate the complex biomechanics and anatomical variations of human mitral tissue nor would they simulate the various aetiologies of PM rupture and the concomitant sequalae such as left ventricular dysfunction and arrhythmia. Validation of such models is difficult, thereby limiting their translational value to only experimental use. Largescale use of animal tissue within ex vivo simulators may also be costly and carry ethical implications. The advent and rapid evolution of disruptive technologies in medicine—namely three-dimensional (3D) printing, computational modelling, machine learning and extended realities—and advances in cardiac imaging have the scope to revolutionize mitral modelling. Moreover, they bear the translational potential to facilitate ‘personalized’ cardiac care and improve clinical outcomes by offering patient-specific procedure planning, surgical simulation training and procedural augmentation. Such technologies are also capable of being integrated with ex vivo platforms, therefore enhancing their effectiveness. Indeed, it is unlikely that ex vivo platforms will be rendered obsolete with the advent of these novel technologies. By integrating volumetric cardiac imaging, material technologies and software engineering, 3D printing transforms digital objects into 3D replicas through multi-layered material deposition over a digitally defined geometry. Advances in cardiac imaging—notably in cardiac CT and 3D transoesophageal echo (TOE)—enable rendering of highly accurate 3D images of cardiac structures. Progress in software engineering, particularly with the integration of machine learning (ML), now enables highly accurate and rapid delineation of anatomical boundaries in a process known as segmentation [3]. Meanwhile, polyjet printers could enable the fusion of multiple printing materials to better emulate the structural complexities of human valves. Therefore, having begun from simply 3D printing mitral valve replicas for anatomical observation of pathology, it is now feasible to create costeffective patient-specific deformable mitral valve replicas, which can be modelled within a left heart simulator using TOE, thereby enabling haemodynamic and imaging characterization of mitral pathologies as demonstrated by Ginty et al. [4]. Such platforms carry the potential for incorporation into patient-specific procedure planning, the evaluation of novel mitral technologies and simulation training. The domain agnostic nature of ML enables identification of complex associations within big data with the efficacy of such models increasing with volume of inputted data. The quantitative nature of structural heart imaging naturally lends itself to ML and such methods have found a myriad of applications in mitral modelling particularly in automating and enhancing mitral segmentation to rapidly produce accurate 3D mitral replicas in the EX P ER IM EN TA L

HomeJournal of the American Heart AssociationVol. 11, No. 7Reshaping the Evidence for Surgical Correction of Pectus Excavatum Using Cardiopulmonary Exercise Testing Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessEditorialPDF/EPUBReshaping the Evidence for Surgical Correction of Pectus Excavatum Using Cardiopulmonary Exercise Testing Ashok Kar, MB BChir, Max Baghai, MBBS, PhD and Ian Hunt, MBBS Ashok KarAshok Kar https://orcid.org/0000-0001-9680-2224 , Department of Thoracic Surgery, , St Georges Hospital NHS Foundation Trust, , London, , United Kingdom, , Max BaghaiMax Baghai , Department of Cardiothoracic Surgery, , King's College Hospital NHS Foundation Trust, , London, , United Kingdom, and Ian HuntIan Hunt * Correspondence to: Ian Hunt, MBBS, Department of Thoracic Surgery, St Georges' Hospital NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom. Email: E-mail Address: [email protected] https://orcid.org/0000-0002-6893-1384 , Department of Thoracic Surgery, , St Georges Hospital NHS Foundation Trust, , London, , United Kingdom, Originally published4 Apr 2022https://doi.org/10.1161/JAHA.122.025273Journal of the American Heart Association. 2022;11:e025273This article is a commentary on the followingCardiopulmonary Outcomes After the Nuss Procedure in Pectus ExcavatumOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 4, 2022: Ahead of Print Pectus excavatum is the most encountered chest wall deformity1 yet there is ongoing debate as to the physiological and cardiopulmonary impact of this disease and significantly if surgical repair may offer benefit to patients.2 In the United Kingdom, the controversy around the physiological and psychological impact of pectus deformities led the National Health Service to decommission (not for routine) pectus surgery treatment.3 This judgment has had far‐reaching and significant effects and led to questions being asked in the Houses of Parliament as well as formal review of the policy (decision pending).There have been 275 papers published in the past 10 years on "functional" changes before and after corrective pectus surgery. Many of those papers are small cohort and retrospective case series4, 5, 6 and are, as reflected by National Health Service's decision in the United Kingdom, heterogenous in nature and quality of evidence presented.In this issue of the Journal of the American Heart Association (JAHA), new work by Jaroszewski et al.7 investigates using cardiopulmonary exercise testing (CPET), the cardio‐respiratory effects of minimally invasive "Nuss" surgical repair (MIRPE).A prior study by the same group using transesophageal echocardiography following pectus repair demonstrated immediate and significant improvements in anatomic and functional cardiac parameters (including right and left ventricular dimensions, stroke volume, and speckle tracking strain).8 Indeed, the authors previously published a detailed review paper summarizing the available literature on cardiopulmonary outcomes along with quality of life and patient satisfaction after pectus excavatum repair.9Among surgeons it is clearly recognized that although subjective improvement in exercise tolerance is often reported by patients following MIRPE,10 few studies have robustly investigated this potentially functional benefit, especially in such a large cohort of patients, taking into consideration physiological parameters as opposed to anatomic assessment.11The authors in the current issue share the findings performed from a retrospective study among patients operated between 2011 and 2020 and identified 392 undergoing CPET before MIRPE of whom 68% had abnormal peak oxygen consumption. Of these, 130 patients also underwent CPET immediately before bar removal at a mean time interval of 3.4 years post repair with a significant demonstrable improvement in outcomes including peak VO2, oxygen consumption at anaerobic threshold, and maximal ventilation. In a small subgroup of 39 patients with available pre‐ and postrepair transesophageal echocardiography studies of the right heart, improvement in stroke volume was also demonstrated. Notably, there was also an improvement in patients with normal baseline cardiopulmonary function and without severe anatomical defects. No significant association was found in a univariate analysis between the improvement in VO2 max and anatomical variables such as Haller Index, sternal tilt, or cardiac compression index.When trying to generalize the findings, it is important to note that all operations were performed by a single, high‐volume surgeon experienced in repair of adult pectus excavatum. A 2‐bar technique was used in 69% of patients and 3‐bar in 31% with an average age of 30 years old. The average age is interesting in that it certainty reflects the "adult" nature of the practice presented as most published studies12, 13 on MIRPE are in a younger age group. The retrospective nature of this study also meant that 78 patients (78/262, 29.78%) during the study period declined postoperative CPET evaluation (before bar removal) for personal reasons, particularly during the COVID‐19 surge, when they did not want to prolong hospital admission. Moreover, at the end of the current study period, of the 262 patients without a postoperative CPET, the bar removal procedure had not yet been performed for 184 cases (184/262, 70.22%).Despite most patients being symptomatic before surgery, the authors in the study were unable to perform a formal, objective survey of changes to patient symptoms before bar removal, which could have supported further the reported improvement in CPET outcomes. We therefore look forward to the authors sharing their mid‐ and long‐term outcomes related to symptoms in patients with upcoming CPET testing as well as those who have had bars removed and are willing to have repeat CPET testing at 6 months to 1 year post bar removal. And particularly because following bar removal, 10% to 15% of patients with pectus excavatum can have recurrence, it would be interesting to therefore evaluate the physiological impact based on CPET in this group.Overall, the authors should be congratulated for conducting this study in such a large number of patients. Following the take‐up of MIRPE by the surgical community, early work investigated changes to lung function (spirometry), oxygen pulse, and incremental exercise testing but in small patient cohorts.14 Further assessment of cardiac function based on echocardiography15 or imaging16 (cardiovascular magnetic resonance) have also been reported in patients undergoing corrective pectus surgery, but again the number of patients is small, whereas there are other reported studies that have shown improvement in cardiopulmonary response.17Pectus excavatum is too often viewed as a cosmetic disorder with a known associated psychological impact18, 19, 20 but no definitive physiological measures that are reproducibly found to show that surgery can be of benefit.As the authors of the study point out, this can affect the ability of patients to obtain insurance coverage to undergo surgical correction. In publicly funded health care systems such as the UK National Health Service, a cited lack of evidence that MIRPE can improve cardiopulmonary outcomes has resulted in the withdrawal of this treatment for patients. This timely and very interesting study provides support for the surgical correction of pectus excavatum and future studies are sought by clinicians involved in the care of this patient population.DisclosuresNone.Footnotes* Correspondence to: Ian Hunt, MBBS, Department of Thoracic Surgery, St Georges' Hospital NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom. Email: ian.[email protected]nhs.ukFor Disclosures, see page 2.See Article by Jaroszewski et al.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.References1 Biavati M, Kozlitina J, Alder AC, Foglia R, McColl RW, Peshock RM, Kelly RE, Garcia CK. Prevalence of pectus excavatum in an adult population‐based cohort estimated from radiographic indices of chest wall shape. PLoS One. 2020; 15:e0232575. doi: 10.1371/journal.pone.0232575CrossrefMedlineGoogle Scholar2 Maagaard M, Heiberg J. Improved cardiac function and exercise capacity following correction of pectus excavatum: a review of current literature. Ann Cardiothorac Surg. 2016; 5:485. doi: 10.21037/acs.2016.09.03CrossrefMedlineGoogle Scholar3 NHS England . Clinical commissioning policy: surgery for pectus deformity. NHS England Specialised Services Clinical Reference Group for Radiotherapy and Specialised Cancer Surgery: NHS England; 2019.Google Scholar4 Pawlak K, Gąsiorowski Ł, Gabryel P, Gałęcki B, Zieliński P, Dyszkiewicz W. Early and late results of the Nuss procedure in surgical treatment of pectus excavatum in different age groups. 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J Am Heart Assoc. 2022; 10:e022149. doi: 10.1161/JAHA.121.022149Google Scholar8 Chao C, Jaroszewski DE, Kumar PN, Ewais MM, Appleton CP, Mookadam F, Gotway MB, Naqvi TZ. Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients—an intraoperative transesophageal echocardiographic study. Am J Surg. 2015; 210:1118. doi: 10.1016/j.amjsurg.2015.07.006CrossrefMedlineGoogle Scholar9 Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. Patient Relat Outcome Meas. 2018; 9:65–90. doi: 10.2147/PROM.S117771CrossrefMedlineGoogle Scholar10 Nuss D, Kelly RE. Indications and technique of Nuss procedure for pectus excavatum. Thorac Surg Clin. 2010; 20:583. doi: 10.1016/j.thorsurg.2010.07.002CrossrefMedlineGoogle Scholar11 Rodriguez‐Granillo GA, Raggio IM, Deviggiano A, Bellia‐Munzon G, Capunay C, Nazar M, Martinez JL, Carrascosa P, Martinez‐Ferro M. Impact of pectus excavatum on cardiac morphology and function according to the site of maximum compression: effect of physical exertion and respiratory cycle. Eur Heart J Cardiovasc Imaging. 2020; 21:77. doi: 10.1093/ehjci/jez061CrossrefMedlineGoogle Scholar12 Kelly RE, Goretsky MJ, Obermeyer R, Kuhn MA, Redlinger R, Haney TS, Moskowitz A, Nuss D. Twenty‐one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg. 2010; 252:1072. doi: 10.1097/SLA.0b013e3181effdceCrossrefMedlineGoogle Scholar13 Brungardt JG, Chizek PW, Schropp KP. Adult pectus excavatum repair: national outcomes of the Nuss and Ravitch procedures. J Thorac Dis. 2021; 13:1396. doi: 10.21037/jtd‐20‐2422CrossrefMedlineGoogle Scholar14 Haller JA, Loughlin GM. Cardiorespiratory function is significantly improved following corrective surgery for severe pectus excavatum. Proposed treatment guidelines. 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Eur J Cardiothorac Surg. 2011; 40:e77. doi: 10.1016/j.ejcts.2011.03.045MedlineGoogle Scholar18 Zuidema WP, Oosterhuis JWA, Zijp GW, van der Heide SM, van der Steeg AFW, van Heurn LWE. Early consequences of pectus excavatum surgery on self‐esteem and general quality of life. World J Surg. 2018; 42:2502. doi: 10.1007/s00268‐018‐4526‐9CrossrefMedlineGoogle Scholar19 Luo L, Xu B, Wang X, Tan B, Zhao J. Intervention of the Nuss procedure on the mental health of pectus excavatum patients. Ann Thorac Cardiovasc Surg. 2017; 23:175. doi: 10.5761/atcs.oa.17‐00014CrossrefMedlineGoogle Scholar20 Eisingger RS, Islam S. Caring for people with untreated pectus excavatum: an international online survey. Chest. 2020; 157:590. doi: 10.1016/j.chest.2019.10.034CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesCardiopulmonary Outcomes After the Nuss Procedure in Pectus ExcavatumDawn E. Jaroszewski, et al. Journal of the American Heart Association. 2022;11 April 5, 2022Vol 11, Issue 7Article InformationMetrics Copyright © 2022 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.122.025273PMID: 35377161 Originally publishedApril 4, 2022 KeywordsCPETpectus surgeryEditorialsMIRPEpectus excavatumcardiopulmonary outcomesPDF download SubjectsCardiovascular SurgeryExercise TestingQuality and OutcomesTreatment

Culture-negative infective endocarditis (IE) accounts for 7–31% of all cases. Metagenomics has contributed to improving the aetiological diagnosis of IE patients undergoing valve surgery. We assessed the impact of 16S ribosomal DNA gene polymerase chain reaction (16S rDNA PCR) in the aetiological diagnosis of culture-negative IE. Between January 2016 and January 2020, clinical data from culture-negative IE patients were reviewed retrospectively. Identification of bacteria was performed using 16S rDNA PCR in heart valve specimens. 36 out of 313 patients (12%) with culture-negative IE had their valve tissue specimens submitted for 16S rDNA PCR. 16S rDNA PCR detected and identified bacterial nucleic acid in heart valve tissue significantly more frequently compared to valve culture alone 25(70%) vs 5(12%); p < 0.05. Mean age was 57 years (SD 18) and 80% were male. Native and aortic valve were involved in 76% and 52% of cases, respectively. Streptococcus spp. (n 15) were the most commonly detected organisms, followed by bacteria of the HACEK group (Haemophilus parainfluenzae 2, Aggregatibacter actinomycetemcomitans 1), nutritionally variant streptococci (Abiotrophia defectiva 2), and one each of Staphylococcus aureus, Corynebacterium pseudodiphtheriticum, Helcococcus kunzii, Neisseria gonorrhoeae, Tropheryma whipplei. 16S rDNA PCR may be a useful diagnostic tool for the identification of the causative organism in culture-negative IE. Efforts towards a shorter turnaround time for results should be consider and further studies assessing the clinical impact of this technique in culture-negative IE are needed.