Development of functional tricuspid regurgitation (TR) because of chronic mitral disease and subsequent heart failure is common. However, the effect of TR on clinical outcomes after transcatheter mitral valve replacement (TMVR) remains unclear. We aimed to evaluate the impact of baseline TR on outcomes after TMVR. This was a single-center, retrospective analysis of patients who received valve-in-valve or valve-in-ring TMVR between 2012 and 2022. Patients were categorized into none/mild TR and moderate/severe TR based on baseline echocardiography. The primary outcome was 3 years all-cause death and the secondary outcomes were in-hospital events. Of the 135 patients who underwent TMVR, 64 (47%) exhibited none/mild TR at baseline, whereas 71 (53%) demonstrated moderate/severe TR. There were no significant differences in in-hospital events between the groups. At 3 years, the moderate/severe TR group exhibited a significantly increased risk of all-cause death (adjusted hazard ratio 3.37, 95% confidence interval 1.35 to 8.41, p = 0.009). When patients with baseline moderate/severe TR were stratified by echocardiography at 30 days into improved (36%) and nonimproved (64%) TR groups, although limited by small sample size, there was no significant difference in 3-year all-cause mortality (p = 0.48). In conclusion, this study investigating the impact of baseline TR on clinical outcomes revealed that moderate/severe TR is prevalent in those who underwent TMVR and is an independent predictor of 3-year all-cause mortality. Earlier mitral valve intervention before the development of significant TR may play a pivotal role in improving outcomes after TMVR. (c) 2024 Elsevier Inc. All rights reserved. (Am J Cardiol 2024;220:84 -91)

BACKGROUND:Transcatheter closure of transcatheter heart valve (THV)-related paravalvular leak (PVL) is associated with a high failure rate with available devices due to the complex interaction of THV and aortic/mitral annulus. OBJECTIVES:This study reports on novel transcatheter techniques to treat PVL after THV. METHODS:The authors describe consecutive patients who underwent PVL closure after transcatheter aortic valve replacement (TAVR) or transcatheter mitral valve replacement (TMVR). A covered self-expanding stent (Viabahn) was deployed in the defect to create a seal between the THV and annulus. A vascular plug (Amplatzer Vascular Plug 2 [AVP2] or AVP4) was then deployed inside the covered stent to obliterate PVL. RESULTS:Eight patients with THV-related PVL were treated using this method (aortic [3 SAPIEN, 1 Evolut], mitral [2 SAPIEN-in-MAC (mitral annular calcification), 2 M3 TMVR). Various combinations of stents and plugs were used (5 mm × 2.5 cm Viabahn + 6 mm AVP4 [n = 2], 8 mm × 2.5 cm Viabahn + 10 mm AVP2 [n = 5], and 10 mm × 5.0 cm Viabahn + 12 mm AVP2 [n = 1]). All had technical success with immediate elimination of target PVL, without in-hospital complications. None had signs of postprocedure hemolysis. All patients were discharged alive (median 3.5 days [Q1-Q3: 1.0-4.8 days]). No residual PVL was seen at discharge, except for 1 patient with mild regurgitation due to another untreated PVL location. One patient died before 30 days due to complication of valve-in-MAC TMVR. In remaining patients, none had recurrence of PVL at 30 days. Symptoms decreased to NYHA functional class I/II in 6 patients. NYHA functional class III symptoms remained in 1 patient with mitral regurgitation awaiting subsequent valve replacement procedure. CONCLUSIONS:The technique of sequential deployment of a covered stent and vascular plug may effectively treat THV-related PVL.

Key points Technical advancements in devices and the development of techniques to optimize valve implantation have been the cornerstone of improvement in outcomes of TAVR. While device success and the rate of paravalvular leak have decreased over time, the rate of permanent pacemaker implantation following self‐expanding valve systems remains high. Reduction in the rate of permanent pacemaker implantation compared to surgical aortic valve replacement remains a high priority.

BACKGROUND:Transcatheter pulmonary valve replacement (TPVR) in patients with a congenital or acquired abnormality resulting in enlarged right ventricular outflow tract (RVOT) is challenging and may preclude treatment with dedicated devices. We describe a technique using a physician-modified endograft to facilitate TPVR.METHODS:Six patients underwent physician-modified endograft-facilitated TPVR for severe symptomatic pulmonary insufficiency with enlarged RVOT. The fenestration was created in a commercially available endograft before implantation, which was then deployed from the dominant branch pulmonary artery into the RVOT, with the fenestration aligned with the ostium of the nondominant pulmonary artery. A covered stent was placed through the fenestration into the nondominant branch pulmonary artery, and a transcatheter heart valve was deployed within the endograft at the level of the original pulmonary valve.RESULTS:Four patients had tetralogy of Fallot, 1 had pulmonary atresia, and 1 had rheumatic valve disease. The RVOT/main pulmonary artery was severely enlarged (diameter, 44.2 [43.5-50.6] mm). All patients had reduced right ventricular (RV) function and dilated RVs (RV end-diastolic volume, 314 [235-316] mL). Successful endograft, covered stent, and transcatheter heart valve deployment were achieved in all cases without stent/valve embolization, vascular complications, or bleeding complications. At 30 days, 1 patient had mild pulmonary insufficiency, while others had none. The RV size measured by echocardiography was significantly reduced after TPVR (RV area, 34.4 [baseline] versus 29.0 [pre-discharge] versus 25.3 [30 days] cm2; P=0.03). During median follow-up of 221.5 (range, 29-652) days, there were no deaths or need for pulmonary valve reintervention. One patient developed severe tricuspid regurgitation due to entrapment of the anterior tricuspid leaflet by the endograft. The patient underwent successful tricuspid replacement and resection of the offending endograft with preservation of the pulmonary valve prosthesis.CONCLUSIONS:Simple fenestration of an off-the-shelf endograft and associated covered stent placement through the fenestration allows TPVR for patients with dysfunctional native or patch-repaired pulmonary valves and RVOT enlargement.

Key Points Baseline transmitral gradient can predict reduction in left atrial pressure and residual transmitral gradient after transcatheter edge‐to‐edge repair (TEER). Understanding the possible multiple causes of elevated transmitral gradient before and after TEER may be important for selecting patients. Further research is necessary to elucidate the complex interaction of mitral regurgitation, the mitral annulus, left atrial, and ventricular function and their response to TEER.

A cardiogenic shock patient with a history of a surgical mitral valve replacement presented to the hospital with critical mitral stenosis with thickening of prosthetic valve leaflets and thrombus in left atrial appendage. We considered TMVR inside of the degenerated bioprosthetic valve. However, there were two concerns during TMVR based on multimodality imaging assessment: 1) LVOT obstruction due to the surgical bioprosthetic leaflet, 2) stroke due to left atrial appendage thrombus. We performed TMVR with LAMPOON (laceration of the anterior leaflet of the surgical valve to prevent left ventricular outflow tract obstruction) for the bioprosthesis using cerebral protection. While the LAMPOON procedure has developed to prevent LVOT obstruction by the native anterior mitral leaflet during transcatheter mitral valve-in-ring or valve-in-mitral annular calcification, this is the first case that illustrates its use for mitral valve-in-valve replacement.

Key Points Prosthetic valve endocarditis is a rare but important complication of transcatheter aortic valve replacement. Treatment of prosthetic valve endocarditis in patients who are status‐post transcatheter aortic valve replacement is difficult due to antibiotic resistance, and outcomes indicate a mortality >10%. In the absence of clinical trials of effective prophylactic antibiotics at the time of transcatheter aortic valve replacement, a careful search for infection both pre‐ and post‐transcatheter aortic valve replacement is critical to prevent infection and treat infection early.

BACKGROUND: Postinfarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction. Surgical repair still has poor outcomes. This report describes clinical outcomes after a novel hybrid transcatheter/surgical repair in patients with apical VSD. METHODS: Seven patients with postmyocardial infarction apical VSD underwent hybrid transcatheter repair via subxiphoid surgical access. A transcatheter occluder (Amplatzer Septal Occluder) with a trailing premounted suture was deployed through the right ventricular wall and through the ventricular septum into the left ventricular apex. The trailing suture was used to connect an anchor external to the right ventricular wall. Tension on the suture then collapses the right ventricular free wall against the septum and left ventricular occluder, thereby obliterating the VSD. Outcomes were compared with 9 patients who underwent surgical repair using either patch or primary suture closure. RESULTS: All patients had significant left-to-right shunt (Qp:Qs 2.5:1; interquartile range [IQR, 2.1–2.6] hybrid repair versus 2.0:1 [IQR, 2.0–2.5] surgical repair), and elevated right ventricular systolic pressure (62 [IQR, 46–71] versus 49 [IQR, 43–54] mm Hg, respectively). All had severely depressed stroke volume index (22 versus 21 mL/m 2 ) with ≈45% in each group requiring mechanical support preprocedurally. The procedure was done 15 (IQR, 10–50) versus 24 (IQR, 10–134) days postmyocardial infarction, respectively. Both groups of patients underwent repair with technical success and without intraprocedural death. One patient in the hybrid group and 4 in the surgical group developed multiorgan failure. The hybrid group had a higher survival at discharge (86% versus 56%) and at 30 days (71% versus 56%), but similar at 1 year (57% versus 56%). During follow-up, 1 patient in each group required reintervention for residual VSD (hybrid: 9 months versus surgical: 5 days). CONCLUSIONS: Early intervention with a hybrid transcatheter/surgical repair may be a viable alternative to traditional surgery for postinfarction apical VSD.

Key Points No randomized trials have been done for TAVR in bicuspid aortic valve (BAV) and probably will never be done. TAVR for BAV has a similar risk profile to tricuspid aortic valve patients except for a higher risk of permanent pacemaker implantation at 30 and 180 days after the index procedure. Further real‐world data are needed to refine patient selection, procedural technique, and lifetime planning of intervention.

Key Points Particularly in a higher risk population, transcatheter aortic valve in valve replacement is a suitable alternative to repeat surgical valve replacement—with possibly better short term outcomes. Challenges remain: Valve‐in‐valve TAVR may require a second valve placement and has more residual valve leak than surgery. Long‐term clinical outcomes comparing transcatheter and surgical replacements for degraded stentless aortic valves are still needed.

Key Points Two different methods for measurement of membranous septum length have weak correlation and poor agreement. Both approaches have significant interobserver variability in membranous septum length measurements. Membranous septum length alone or in combination with implantation depth appears to provide no incremental value in predicting new pacemaker implantation after TAVR over implantation depth alone.

Key Points Approximately one‐third of patients with functional mitral regurgitation (FMR) have atrial FMR (A‐FMR) and need to be identified. Transcatheter edge to edge repair (TEER) may benefit patients with A‐FMR. Many unknowns remain concerning A‐FMR and TEER which require further investigation.

Key Points Particularly in an elderly population, carotid artery stenting may be a suitable alternative to carotid endarterectomy with an experienced operator and careful patient selection Large randomized clinical trials comparing carotid artery stenting and carotid endarterectomy are still pending Recent update of guidelines from the European Stroke Organization is helpful for deciding which patients are best suited for carotid intervention

Dr. Kern is a consultant or speaker for Abbott Inc., Boston Scientific, Philips Inc., Acist Medical Inc., and Opsens Inc.

Key Points The CoreValve Evolut PRO/PRO + adapt to left ventricular outflow tract (LVOT) calcification by eccentric deformation at the level of the inflow while preserving circularity at the waist, leaflet tips, and outflow. The CoreValve Evolut PRO/PRO + maintain their favorable hemodynamics and sealing in the short term despite the presence of LVOT calcification. The effect of eccentric inflow deformation in the long term and geometric comparison of self‐expanding valves and balloon‐expandable valves require further investigation.

Mild paravalvular leak after TAVR is associated with increased 5-year mortality. Current noninvasive and invasive prediction models for mortality may only hold for short term outcomes. Other imaging modalities aside from transthoracic echocardiography should be strongly considered when assessing paravalvular leak, regardless of severity.

Mitral valve disease is the most common valvular disease in the United States and its prevalence increases with age: patients younger than 45 years; patients older than 75 years. Approximately half of patients with severe symptomatic recurrent mitral regurgitation are denied surgical options due to their high surgical risk. The recent evolution of transcatheter mitral valve replacement (TMVR) (i.e., transcatheter mitral valve-in-valve replacement and transcatheter mitral valve-in-ring replacement) has allowed a transcatheter option for those patient. Some solutions are available for complications after TMVR. To secure the landing zone and establish good coaxiality, an additional suture is used to help bend the delivery system more acutely (Preparation Of U-stitch to correct Lateral deflection for Endovascular mitral replacement in short landing Zone [POULEZ]). The LAMPOON (intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction) procedure is a transcatheter technique which is done at the time of TMVR.

OBJECTIVES The aim of this study was to test the hypothesis that narrowing the landing zone using commercially available endografts would enable transcatheter pulmonary valve replacement (TPVR) using commercially available transcatheter heart valves. BACKGROUND TPVR is challenging in an outsized native or patch-repaired right ventricular outflow tract (RVOT). Downsizing the RVOT for TPVR is currently possible only using investigational devices. In patients ineligible because of excessive RVOT size, TPVR landing zones were created using commercially available endografts. METHODS Consecutive patients with native or patch-repaired RVOTs and high or prohibitive surgical risk were reviewed, and this report describes the authors' experience with endograft-facilitated TPVR (EF-TPVR) offered to patients ineligible for investigational or commercial devices. All EF-TPVR patients were surgery ineligible, with symptomatic, severe pulmonary insufficiency, enlarged RVOTs, and severe right ventricular (RV) enlargement (>150 ml/m(2)). TPVR and surgical pulmonary valve replacement (SPVR) were compared in patients with less severe RV enlargement. RESULTS Fourteen patients had large RVOTs unsuitable for conventional TPVR; 6 patients (1 surgery ineligible) received investigational devices, and 8 otherwise ineligible patients underwent compassionate EF-TPVR (n = 5 with tetralogy of Fallot). Three strategies were applied on the basis of progressively larger RVOT size: single-barrel, in situ fenestrated, and double-barrel endografts as required to anchor 1 (single-barrel and fenestrated) or 2 (double-barrel) transcatheter heart valves. All were technically successful, without procedure-related, 30-day, or in-hospital deaths. Two late complications (stent obstruction and embolization) were treated percutaneously. One patient died of ventricular tachycardia 36 days after EF-TPVR. Compared with 48 SPVRs, RV enlargement was greater, but 30-day and 1-year mortality and readmission were no different. The mean transvalvular pressure gradient was lower after EF-TPVR (3.8 +/- 0.8 mm Hg vs. 10.7 +/- 4.1 mm Hg; p < 0.001; 30 days). More than mild pulmonary insufficiency was equivalent in both (EF-TPVR 0.0% [n = 0 of 8] vs. SPVR 4.3% [n = 1 of 43]; p = 1.00; 30 days). CONCLUSIONS EF-TPVR may be an alternative for patients with pulmonic insufficiency and enlarged RVOTs ineligible for other therapies. (C) 2020 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved.

There is a paucity of data regarding the optimum timing of percutaneous coronary intervention (PCI) in relation to transcatheter aortic valve replacement (TAVR). We compared the major adverse cardiovascular and cerebrovascular events (MACCE) rates among patients who underwent PCI before TAVR with