Data on left atrial appendage closure (LAAC) in valvular patients remain limited. This study aimed to evaluate procedural safety and outcomes of LAAC in patients with and without prior mitral valve interventions (PMVI). Patients who underwent transcatheter LAAC between 2016 and 2023 across high-volume centers in Europe and North America were included. Patients were stratified according to the presence or absence of PMVI (surgical or transcatheter). The primary endpoint was a composite of all-cause mortality and ischemic events (ischemic stroke or systemic embolism) at 2 years. Among 1,213 consecutive patients, 142 had PMVI. Patients with PMVI had higher rates of chronic heart failure, permanent AF, and lower left ventricular ejection fraction. Disc-lobe devices and combined procedures were more frequently used in the PMVI group. Procedural success was very high in both groups (99.3

BACKGROUND:Bioprosthetic tricuspid valve replacement is increasingly performed, but long-term durability data are limited. The Edwards Mitris Resilia valve, designed for the mitral position, has been used off-label in the tricuspid position, with scarce evidence of outcomes. CASE SUMMARY:We report 2 patients who developed early (<2-year) structural valve degeneration of the Mitris Resilia bioprosthesis in the tricuspid position. Both presented with symptomatic severe intraprosthetic tricuspid regurgitation. Given the prohibitive surgical risk of redo sternotomy, we opted for valve-in-valve (ViV) transcatheter tricuspid valve replacement (TTVR) using the Edwards Sapien 3 Ultra Resilia transcatheter heart valve. Both procedures were successful, with no residual regurgitation or paravalvular leak. DISCUSSION:To our knowledge, this is the first reported series of early Mitris Resilia structural valve degeneration in the tricuspid position. The cases highlight potential concerns about the durability of bioprostheses in the tricuspid position, especially in congenital heart disease or redo settings. Valve-in-valve tricuspid valve replacement with balloon-expandable transcatheter valves proved to be feasible, safe, and effective, preventing high-risk surgical reoperation. Early intervention is crucial to avoid irreversible right ventricular dysfunction.

Background The management of postinfarction ventricular septal defect (VSD) is contentious, especially when complicated by cardiogenic shock and concomitant severe aortic stenosis, with no clear guidelines. Case Summary A 73-year-old woman presented with cardiogenic shock due to a large postinfarction VSD (Qp:Qs = 5) and unsuspected severe aortic stenosis. A percutaneous strategy was attempted, but the patient died from a residual shunt and multiorgan failure. Discussion Three management strategies were initially considered: Viewpoint 1 advocated for immediate combined surgery (VSD repair, aortic valve replacement, coronary artery bypass grafting), arguing for a definitive, single-stage correction given the patient's profile. Viewpoint 2 proposed venoarterial extracorporeal membrane oxygenation as a bridge to delayed surgery, prioritizing stabilization and tissue healing to reduce the high risk of operating on acute, friable myocardium. Viewpoint 3 deemed surgery and extracorporeal membrane oxygenation prohibitively risky, favoring a staged transcatheter approach (balloon valvuloplasty followed by VSD closure) to circumvent the morbidity of open surgery. Take-Home Messages Postinfarction VSD management requires urgent, multidisciplinary consensus. All strategies carry significant risks, and percutaneous solutions are limited by tissue friability in the acute phase.

Paravalvular leak (PVL) is a well-known complication of valve replacement, occurring in up to 10% of aortic and 17% of mitral prosthetic valves. Although many leaks are small and clinically insignificant, ≈1% to 5% of cases are associated with clinically relevant complications, such as heart failure symptoms and hemolytic anemia. Surgical reoperation is currently considered the first-line option; however, it encompasses high mortality and morbidity risks. In the past years, transcatheter PVL closure has proven to be highly effective when performed in experienced centers. Transcatheter PVL closure requires advanced imaging modalities, specialized materials, and techniques, reflecting the high complexity of the procedure. We review the complex nature of PVL, including its diagnostic workup and the available transcatheter treatment strategies, with a special focus on the treatment of mitral and aortic PVL using plugging devices.

BACKGROUND:An 80-year-old man presented with progressive dyspnea due to severe isolated regurgitation of a 29-mm ATS 3f stentless (model 1000) aortic bioprosthesis. Because of his advanced age and multiple severe comorbidities, the Heart Team opted for a valve-in-valve transcatheter aortic valve replacement (TAVR). CASE SUMMARY:Based on preprocedural computed tomography planning, a valve-in-valve TAVR procedure was successfully performed via transfemoral access using a 27-mm JenaValve Trilogy System. DISCUSSION:Although the use of dedicated TAVR devices for the treatment of native aortic regurgitation has been well-described, to our knowledge, there are no existing reports on their use to address regurgitation caused by the structural valve deterioration of a stentless bioprosthesis. TAKE-HOME MESSAGE:Consider a dedicated transcatheter valve to treat pure regurgitation in a failing stentless bioprosthesis.

Background Catheter kinking during coronary angiography is a common complication, particularly in patients with tortuous vascular anatomy. Traditional retrieval methods may be unsuccessful in such scenarios. Case Summary We report a case of a 73-year-old man presenting with cardiogenic shock secondary to severe mitral regurgitation due to posteromedian papillary muscle rupture. During coronary angiography, the guide catheter kinked in the common femoral artery. Conventional untwisting and snaring techniques failed. A novel approach utilizing a Raptor grasping device facilitated successful catheter retrieval by steering the catheter into a snaring device. Discussion This case highlights the potential efficacy of the Raptor grasping device for catheter kinking in challenging vascular anatomy.

BACKGROUND AND AIMS:Adults with repaired tetralogy of Fallot (TOF) face long-term risks of ventricular tachycardia (VT) and sudden cardiac death (SCD). There is no consensus on arrhythmia management during surgical pulmonary valve replacement (PVR). This study assessed whether pre-operative electrophysiological (EP) testing with targeted intraoperative cryoablation of identified anatomical isthmuses during PVR is associated with a reduction in post-operative VT inducibility and long-term risk of clinical VT/SCD. METHODS:In this prospective multicentre cohort study, consecutive adults with TOF undergoing surgical PVR (2005-22) underwent standardized pre-operative EP studies. Surgical ablation strategy (EP-guided vs empiric) was at the discretion of the treating team. Post-operative EP studies assessed residual inducibility; clinical VT/SCD were evaluated during follow-up. RESULTS:Among 204 patients (age 35.5 ± 13.1 years, 43.1% female), 91 (45.1%) had inducible VT. Among those undergoing surgical ablation, post-operative VT was non-inducible in 74.1% with EP-guided vs 15.0% with empiric ablation [adjusted odds ratio 20.4, 95% confidence interval (CI) 4.5-91.8, P < .0001]. Persistent post-operative inducibility was associated with increased hazard of VT/SCD compared to patients without inducible VT pre-operatively [adjusted hazard ratio (HR) 5.3, 95% CI 1.8-16.0, P = .003], over a median 10.2-year follow-up. Compared to patients without inducible VT pre-operatively, empiric ablation was associated with a significantly higher hazard of VT/SCD (HR 5.2, 95% CI 1.6-16.5, P = .005), whereas EP-guided ablation was not (HR 2.8, 95% CI 0.8-10.3, P = .228). CONCLUSIONS:In adults with repaired TOF undergoing PVR, inducible VT is common. An EP-guided surgical strategy is associated with greater post-operative non-inducibility and improved long-term arrhythmic outcomes compared with empiric ablation.

BACKGROUND:Percutaneous left atrial appendage occlusion (LAAO) is an alternative stroke prevention strategy in atrial fibrillation patients deemed unsuitable to tolerate long-term oral anticoagulation. Although current LAAO devices have been shown to provide stroke protection, they have been associated with peridevice leak and pericardial effusion. The VERITAS study evaluates the safety and effectiveness of Abbott's next-generation dual-seal LAAO device. OBJECTIVES:The purpose of this study was to assess the VERITAS primary endpoints and key clinical outcomes through 45 days. METHODS:In this prospective, global, multicenter, single-arm study, atrial fibrillation patients with CHA2DS2-VASc ≥2 for men and ≥3 for women underwent LAAO with the next-generation dual-sealing device (Amulet 360). The primary safety endpoint included key adverse events through 7 days postprocedure or hospital discharge, whichever was later. The primary effectiveness endpoint was LAAO (leak ≤5 mm) by 45-day transesophageal echocardiography, assessed by an independent core laboratory. RESULTS:Across 34 global sites, 400 patients (age 73.8 ± 7.4 years, 62% men, CHA2DS2-VASc 4.1 ± 1.4, and HAS-BLED 3.1 ± 1.0) were enrolled and underwent an implant attempt. LAAO implant success was 99.8% (399 of 400). The incidence for the primary safety endpoint was 0.0% (0 of 400). All (100%) patients assessed with echocardiography met the primary effectiveness endpoint. At 45 days, complete LAAO (0 mm leak) was observed in 93.9% of patients. Two (0.5%) patients required percutaneous draining for pericardial effusions and device-related thrombus was observed in 2.4% of patients. CONCLUSIONS:The VERITAS study demonstrates high implant success of the next-generation dual-seal LAAO device, and a favorable short-term safety and sealing profile. (Abbott Medical-VERITAS Study; NCT06707688).

BACKGROUND:The optimal antithrombotic treatment after transcatheter left atrial appendage closure (LAAC) remains to be determined. The objective of this trial was to compare anticoagulation and antiplatelet therapy for preventing device-related thrombosis (DRT) after LAAC. METHODS:This was a prospective multicenter international randomized trial comparing 2 different antithrombotic strategies for preventing DRT after LAAC in patients with nonvalvular atrial fibrillation. Patients were randomized (1:1) to receive direct oral anticoagulants (DOACs) or dual antiplatelet therapy (DAPT; aspirin+clopidogrel) for 60 days. Patients underwent transesophageal echocardiography at 60 days, and the images were analyzed in a central echocardiography laboratory by experienced echocardiographers blinded to the allocated treatment. The primary outcome was DRT as determined by transesophageal echocardiography 60 days after LAAC in patients receiving the allocated treatment at the time of transesophageal echocardiography (per-protocol analysis). The safety outcome included all-cause mortality, stroke, bleeding, or site-reported DRT within 60 days after LAAC in all randomized patients (intention-to-treat analysis). RESULTS:A total of 510 patients (mean age 77±9 years, 35% women) were included between October 2018 and May 2025, and 253 and 257 patients were randomized to the DOAC and DAPT groups, respectively. Of these, 399 patients underwent transesophageal echocardiography and were receiving the allocated treatment at 60 days after LAAC. The primary outcome occurred in 3 patients (1.5%) in the DOAC group compared with 8 patients (4.1%) in the DAPT group (difference, -2.7% [95% CI, -6.0% to 0.6%]; P=0.110). The safety outcome occurred in 52 patients (22.5%) in the DOAC group compared with 82 patients (34.9%) in the DAPT group (difference, -12.4% [95% CI, -20.6% to -4.2%]; P=0.003), and differences were mainly driven by a lower rate of bleeding events in the DOAC group (44 patients [17.4%] versus 64 patients [24.9%]; difference, -7.5% [95% CI, -14.6% to -0.4%]; P=0.038). CONCLUSIONS:The use of DOACs after LAAC failed to reduce DRT compared with DAPT, but it was associated with an improved safety profile. The results of this study should be interpreted with caution because of statistical power issues related to the narrower-than-expected between-group differences and will need confirmation in future larger studies. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03568890.

Introduction and objectives: The optimal antithrombotic therapy (AT) after left atrial appendage closure (LAAC) is debated. We assessed the impact of intensive vs nonintensive AT on the incidence of device-related thrombus (DRT) based on whether the device implantation was classified as optimal or suboptimal. Methods: This study included patients who underwent successful LAAC in 9 centers. Patients were classified according to the quality of device implantation: optimal (proximal implant without >= 3 mm peridevice leak) or suboptimal (distal implant and/or >= 3 mm peridevice leak). Postimplant AT was classified as either intensive (dual antiplatelet therapy, anticoagulants, or a combination of both) or nonintensive (no AT or a single antiplatelet therapy). The primary endpoint was the incidence of DRT between the 6th and 12th weeks postprocedure. Results: A total of 1225 patients underwent LAAC, with 757 (61.8%) achieving optimal device implantation and 468 (38.2%) classified as suboptimal. After a median follow-up of 20 months, the incidence of DRT in the optimal implant group was 2.6% with intensive AT and 3.7% with nonintensive AT (P = .38). In the suboptimal implant group, the incidence of DRT increased to 11.2% with intensive AT and 15.5% with nonintensive AT (P = .19). On multivariate analysis, suboptimal implantation (HR, 4.51; 95%CI, 2.70-7.54, P < .001) but not intensive AT (HR, 0,66; 95%CI, 0.40-1.07, P = .09) emerged as an independent predictor of DRT. Conclusions: The incidence of DRT after LAAC was higher in patients with suboptimal device implantation. In patients with optimal implantation, the incidence of DRT was low and similar between nonintensive and intensive AT strategies. Large, randomized trials are warranted to confirm these results. (c) 2024 Sociedad Espa & ntilde;ola de Cardiolog & iacute;a. Published by Elsevier Espa & ntilde;a, S.L.U. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background: The Fontan procedure is the palliative intervention of choice for patients with single ventricle physiology. Pulmonary vascular disease (PVD) is a major contributor to Fontan circulatory failure. Our study utilized optical coherence tomography (OCT) imagery in pulmonary arteries to better characterize PVD in Fontan patients. Methods: In a prospective pilot study, OCT images were acquired during cardiac catheterization in a distal left pulmonary artery (PA) branch (A10). The PA intima-media ratio and wall-vessel ratio (i.e., difference between the external elastic membrane area and the luminal area divided by the external elastic membrane area) were measured off-line. Results: A total of 9 Fontan patients (5 women), median age of 23.0 (21.0,38.0) years, were included. All patients exhibited an intima-to-media ratio above 1.0. The ratio exceeded 2.8 in patients with high pulmonary vascular resistance. No difference is observed between patients for the wall-vessel ratio. No relation between time of completion of Fontan and intima-media ratio is identified. Conclusion: OCT shows promise in evaluating PVD in patients with Fontan palliation. PA remodeling is characterized by intimal hyperplasia with medial regression. Further studies are required to determine the role of OCT in guiding treatment decisions and assessing therapeutic responses.

Introducción y objetivos: El tratamiento antitrombótico (TA) óptimo tras el cierre de la orejuela izquierda (COI) es objeto de debate. Se evaluó el impacto de los TA intensivo y no intensivo en la incidencia de trombosis relacionada con el dispositivo (TD) según el implante fuera óptimo o subóptimo.Métodos: El estudio incluyó a pacientes que se sometieron a un COI exitoso en 9 centros. Se clasificó a los pacientes según el implante del dispositivo fuera óptimo (implante proximal sin fuga peridispositivo ≥ 3 mm) o subóptimo (implante distal y/o fuga ≥ 3 mm) y el TA, intensivo (doble antiagregación plaquetaria, anticoagulación o una combinación de ambas) o no intensivo (sin TA o antiagregación plaquetaria simple) tras el implante. El objetivo primario fue la incidencia de TD entre las semanas 6 y 12 tras el procedimiento.Resultados: Un total de 1.225 pacientes se sometieron a COI. Se lograron implantes óptimo y subóptimo del dispositivo en 757 (61,8%) y 468 (38,2%) de ellos. Tras un seguimiento de 20 meses, los pacientes con implante óptimo y TA intensivo o no intensivo presentaron una incidencia de TD del 2,6 y el 3,7% (p = 0,38). En aquellos con un implante subóptimo, la incidencia de TD aumentó al 11,2% con TA intensivo y el 15,5% con TA no intensivo (p = 0,19). En el análisis multivariable, el implante subóptimo (HR = 4,51; IC95%, 2,70-7,54; p < 0,001), pero no el TA intensivo (HR = 0,66; IC95%, 0,40-1,07; p = 0,09), se identificó como un predictor independiente de TD.Conclusiones: La incidencia de TD tras el COI fue mayor en pacientes con implante subóptimo del dispositivo. En el grupo de implante óptimo, la incidencia de TD fue baja y similar entre TA no intensivo y TA intensivo. Se requieren ensayos clínicos grandes y aleatorizados para confirmar estos resultados.

In congenital heart diseases (CHD) of moderate to great complexity involving the right ventricle (RV), the morphologic RV can be exposed to significant stressors across the lifespan either in a biventricular circulation in a sub-pulmonary or sub-aortic position, or as part of a univentricular circulation. These include pressure and/or volume overload, hypoxia, ischemia, and periprocedural surgical stress leading to remodeling, maladaptation, dilation hypertrophy and dysfunction. This review examines the macroscopic remodeling of the RV in various forms of CHD and explores remodeling trajectories, along with the effects of surgeries and residual lesion repair, in tetralogy of Fallot, Ebstein anomaly, congenitally corrected transposition of the great arteries, transposition of the great arteries with atrial switch surgery, and single ventricle palliated by Fontan. Additionally, the role of metabolism, genetic markers and imaging criteria of RV remodeling are explored. Finally, the optimal timing for addressing residual lesions in CHD through surgery or percutaneous interventions is discussed, along with advanced heart failure management strategies and medical therapy aimed at preventing further RV dilation and/or systolic deterioration or promoting reverse remodeling.

Background Mental health disorders are prevalent comorbidities in adults with congenital heart diseases (CHD). This study aimed to provide a biopsychosocial portrait of overall health in adults with CHD and compare by sex and age to a general population. Methods A cross-sectional study of 264 adults with CHD at the Montreal Heart Institute collected clinical data and self-reported lifestyle, sociodemographic, and psychological measures (the Hospital Anxiety and Depression Scale and the Worry and Anxiety Questionnaire). Descriptive and comparative statistics were used to compare with local population or stratified by age and sex. Results Anxiety scores were higher in females and younger adults with CHD, whereas depression scores show no significant differences. Although mean anxiety and depression scores in adults with CHD were similar to a Québec primary care population, subgroup comparisons show differences such as higher anxiety scores in younger adults with CHD. Fewer adults with CHD were sedentary or very active in comparison with controls, with more engaged in moderate activities. Moreover, they reported lower caffeine, alcohol, and cannabis consumption than the general population. Rates of smoking use or nonprescription medications were similar in both populations. Conclusions This study highlights key trends in the psychological and behavioral profiles of adults with CHD, including higher anxiety among young adults and differences in physical activity and alcohol consumption compared with the general population. These findings underline the importance of a holistic approach to management of this population.