BACKGROUND: The healthcare sector is a major contributor to climate change, mainly due to greenhouse gas emissions from electricity generation. Radiology imaging devices account for considerable energy consumption, but there is limited knowledge of the energy consumption of cardiac catheterisation units and of specific cardiac interventions. OBJECTIVES: To quantify energy consumption in kilowatt-hours (kWh) during diagnostic and therapeutic cardiac procedures and to identify potential areas for saving energy. METHODS: Current transformers measured true power in three cardiac catheterisation units in May and June 2024. The data were matched to system operational modes ‘off’, ‘idle’ and ‘intervention’. Clinical software provided information about the intervention type, operators and dose-area product. RESULTS: The total energy consumption was 6647.62 kWh, 76.5% of which was used for non-productive modes (62.8% ‘idle’ and 13.7% ‘off’). Interventions accounted for 23.5% of energy consumption and 9.1% of total time. The median (IQR) energy consumption of 564 performed interventions was 2.20 (2.02) kWh. Coronary interventions with ≥4 stents (4.86 [1.48] kWh) and mitral valve edge-to-edge repair (4.37 [2.59] kWh) used the most, while diagnostic coronary angiograms (0.91 [0.74] kWh) used the least energy from first to last scanning action. Energy consumption correlated significantly with intervention time (r = 0.98, p <0.001) and dose-area product (r = 0.62, p <0.001). CONCLUSION: Non-productive operational modes accounted for more than ¾ of overall energy consumption. Reducing ‘idle’ energy consumption appears to have the largest energy-saving potential.

Background: Mitral transcatheter edge-to-edge repair (M-TEER) is an established option for high-risk primary mitral regurgitation (PMR) patients, but data on the impact of anatomical complexity on prognosis are scarce and conflicting. Objectives: The aims of this study were to characterize patients with severe PMR undergoing M-TEER, assess mid-term prognosis after M-TEER, and identify prognostic factors based on PMR mechanism. Methods: Data from symptomatic PMR patients with severe PMR treated with M-TEER between July 2013 and October 2023 at two Swiss centers were collected retrospectively until 2017 and prospectively thereafter. Patients were categorized by lesion type: A2-P2 prolapse/flail vs. non-A2-P2 prolapse/flail. A subset was classified by mitral valve (MV) anatomical complexity (defined by the presence of ≥1 of the following: ≥moderate calcifications, Barlow’s disease, multiple prolapses, or commissural prolapses). Cox regression identified predictors of 1-year all-cause mortality. Results: Among 315 patients (mean age 82.2 ± 6.3 years, 46.3% female, European System for Cardiac Operative Risk Evaluation II 5.1% ± 4.1%) followed for a median (interquartile range [IQR]) of 13 months (5-33), technical success was 93.0%. Compared with the non-A2-P2 prolapse/flail group (n = 186), the A2-P2 prolapse/flail group (n = 129) had better echocardiographic outcomes at discharge (residual mitral regurgitation [MR] ≤ 1+: 70.5 vs. 60.4%; p = 0.031) and superior symptomatic improvement at 1 year (New York Heart Association class ≤ II: 91.4 vs. 74.5%; p = 0.017) but similar 1-year all-cause mortality (15.1 vs. 18.8%; p = 0.492). Among patients classified by MV anatomical complexity (n = 143), patients with complex MV anatomy (n = 68) had a higher mortality at a median (IQR) follow-up of 22 months (9-36) compared to those with noncomplex MV anatomy (n = 75) (51.5 vs. 34.7%; p = 0.042). Multivariate analysis identified complex MV anatomy and severe renal failure as predictors of 1-year all-cause mortality. Conclusions: MV anatomical characteristics have a significant influence on symptomatic improvement and all-cause mortality at 1 year and should be carefully considered during the selection of PMR patients for M-TEER.

The number of patients undergoing transcatheter aortic valve implantation (TAVI) is rising. While TAVI improves survival, symptoms, and quality of life, ESC guidelines highlight the lack of validated tools to predict futile outcomes. Around 20

BACKGROUND:Three-dimensional transesophageal echocardiography (3D TEE) is the primary imaging guidance tool for mitral transcatheter edge-to-edge repair (M-TEER). EARLY REPORTS SUMMARY:DeviceGuide technology is a novel investigational software program using artificial intelligence to automatically track the M-TEER device within the 3D TEE volume and reformat images to guide implantation. DISCUSSION:DeviceGuide can automatically generate multiplanar-reconstructed images that: 1) maintain target location on 3D-rendered views while imaging device location/orientation, 2) automatically generate two-dimensional orthogonal target views with real-time indicators of device position and trajectory, and 3) continuously generate a consistent two-dimensional image of the device and surrounding tissue. NOVELTY:Automatic 3D TEE multiplanar reconstruction reformatting reduces the need for manually reformatting while continuously informing proceduralists about device trajectory, position, and orientation. TAKE-HOME MESSAGE:DeviceGuide artificial intelligence-enhanced imaging software has the potential for improving the safety, efficiency, and efficacy of M-TEER implantation for both routine and anatomically complex cases irrespective of operator experience.

Background Currently, no clear impact of sex on short‐ and long‐term survival following transcatheter edge‐to‐edge mitral valve repair (TEER) is evident, although no data are available on postprocedural life expectancy. Our aim was to assess sex‐specific differences in outcomes of patients with mitral regurgitation (MR) treated by TEER. Methods and Results Short‐term and 5‐year outcomes in men and women undergoing TEER between 2011 and 2018 who were included in the large, multicenter, real‐world MitraSwiss registry were analyzed. Outcomes were compared stratified by sex and according to MR cause (primary versus secondary). The impact of TEER on postprocedural life expectancy was estimated by relative survival analysis. Among 1142 patients aged 60 to 89 years, 39.8% were women. They were older, with fewer cardiovascular risk factors and lower functional capacity compared with men. Thirty‐day mortality was higher in men than in women (3.3% versus 1.1%; odds ratio, 3.16 [95% CI, 1.16–10.7]; P =0.020). Five‐year survival was comparable in both sexes (adjusted hazard ratio for 5‐year mortality in men, 1.14 [95% CI, 0.90–1.44], P =0.275). Both men and women with either primary or secondary MR showed similar clinical efficacy over time. TEER provided high relative survival estimates among all groups, and fully restored predicted life expectancy in women with primary MR (5‐year relative survival estimate, 97.4% [95% CI, 85.5–107.0]). Conclusions TEER is not associated with increased short‐term mortality in women, whereas 5‐year outcomes are comparable between sexes. Moreover, TEER completely restored normal life expectancy in women with primary MR. A residual excess mortality persists in secondary MR, independently of sex.

Background: Little is known about gender-dependent outcomes after aortic valve replacement (AVR) through right anterior thoracotomy (RAST). The aim of our study was to analyze the mid-term outcomes of our cohort. Methods: This study is a retrospective analysis of 338 patients (2013–2022). Subgroup analysis included a gender-dependent comparison of age groups ≤60 and >60 years. Results: Women were older (69.27 ± 7.98 vs. 64.15 ± 11.47, p < 0.001) with higher Euroscore II (1.25 ± 0.73 vs. 0.94 ± 0.45, p < 0.001). Bypass and cross-clamp time were shorter (109.36 ± 30.8 vs. 117.65 ± 33.1 minutes, p = 0.01; 68.26 ± 21.5 vs. 74.36 ± 23.3 minutes, p = 0.01), while ICU, hospital stay and atrial fibrillation were higher (2.48 ± 8.2 vs. 1.35 ± 1.4 days, p = 0.005; 11 ± 7.8 vs. 9.48 ± 2.3 days, p = 0.002; 6.7% vs. 4.4%, p = 0.024). Mortality was 0.9%, while stroke was 0.6%. Age subgroup analysis showed that women were older (p = 0.025) with longer ICU and hospital stays (p < 0.001, p = 0.007). On mid-term follow-up (4.52 ± 2.67 years) of 315 patients (94.3%), there was no significant difference in survival, MACCE and re-intervention comparing gender and age groups. Conclusions: Despite older age, higher Euroscore II, longer ICU and hospital stay in women, mortality, MACCE and reoperation were low and comparable in gender and age groups. We believe that our patient-tailored heart team decision making combined with RAST translates into gender-tailored medicine, which equalizes the widely reported negative outcomes of female patients after cardiac surgery.

AIMS OF THE STUDY: The 2021 European Society of Cardiology Guidelines on valvular heart disease recommend transcatheter aortic valve implantation (TAVI) for patients with symptomatic severe aortic stenosis at low surgical risk and age ≥75 years who are suitable for a transfemoral approach (recommendation class IA) based on two large randomised controlled trials (PARTNER 3 and Evolut Low Risk) comparing transcatheter aortic valve implantation with surgical aortic valve replacement (SAVR). Whether such an approach is cost-effective in Switzerland remains unclear. The aim of this cost-utility analysis was to compare transcatheter aortic valve implantation with SAPIEN 3 versus surgical aortic valve replacement in symptomatic severe aortic stenosis patients at low risk of surgical mortality from the perspective of Swiss compulsory health insurance using data from the PARTNER 3 trial (reflecting specifically the safety and efficacy of the SAPIEN 3 TAVI device). METHODS: A previously published two-stage Markov-based model that captured clinical outcomes from the PARTNER 3 trial was adapted from the perspective of the Swiss compulsory health insurance system, using local or geographically close general population mortality and utility data, unit costs and medical resource use from publicly available sources and based on expert opinion. The model had a lifetime horizon with a 3% yearly discounting factor. The cost–utility analysis estimated changes in both direct healthcare costs and health-related quality-adjusted life years for transcatheter aortic valve implantation compared with surgical aortic valve replacement in patients with symptomatic severe aortic stenosis at low risk of surgical mortality. RESULTS: Overall, transcatheter aortic valve implantation with SAPIEN 3 resulted in lifetime costs per patient of CHF 79,534 and quality-adjusted life years per patient of 9.64, compared with surgical aortic valve replacement lifetime costs and quality-adjusted life years per patient of CHF 76,891 and 8.96, respectively. Compared with surgical aortic valve replacement, transcatheter aortic valve implantation was estimated to offer an incremental improvement of +0.68 quality-adjusted life years per patient at an increased cost of +CHF 2643 per patient over a lifetime horizon. The incremental cost-effectiveness ratio was CHF 3866 per quality-adjusted life year gained and remained below CHF 50,000 per quality-adjusted life year gained across several sensitivity analyses. CONCLUSIONS: This analysis suggests that transcatheter aortic valve implantation using the SAPIEN 3 device is likely to be a highly cost-effective alternative for symptomatic severe aortic stenosis patients at a low risk of surgical mortality, treated in the contemporary Swiss setting. These findings may help to inform a holistic approach when making policy decisions for the management of this patient group.

Background: There is increasing evidence that female gender is an independent risk factor for cardiac surgery. Minimally invasive mitral surgery (MIV) has proven to have excellent long-term results, but little is known about gender-dependent outcomes. The aim of our study was to analyze our heart team's decision-based MIV-specialized cohort. Methods: In-hospital and follow-up data were retrospectively collected. The cohort was divided into gender groups and propensity-matched groups. Results: Between 22 July 2013 and 31 December 2022, 302 consecutive patients underwent MIV. Before matching, the total cohort showed that women were older, had a higher EuroSCORE II, were more symptomatic, and had more complex valve pathology and tricuspid regurgitation resulting in more valve replacements and tricuspid repairs. Intensive and hospital stays were longer. In-hospital deaths (n = 3, all women) were comparable, with more atrial fibrillation in women. The median follow-up time was 3.44 (0.008–8.9) years. The ejection fraction, NYHA, and recurrent regurgitation were low and comparable and atrial fibrillation more frequent in women. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.9 and p = 0.2). Propensity matching compared 101 well-balanced pairs; women still had fewer resections and more atrial fibrillation. During the follow-up, women had a better ejection fraction. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.3 and p = 0.3). Conclusions: Despite women being older and sicker, with more complex valve pathology and subsequent replacement, early and mid-term mortality and the need for reoperation were low and comparable before and after propensity matching, which might be the result of the MIV setting combined with our patient-tailored decision-making. We believe that a multidisciplinary heart team approach is crucial to optimize patient outcomes in MIV, and it might also reduce the widely reported increased surgical risk in female patients. Further studies are needed to prove our findings.

IntroductionIn our high-tech medical world of rapidly increasing and improving new transcatheter valve technologies, many cardiac surgeons have come to ask themselves if they will be able to perform heart surgery in ten years.Therefore, some have begun to learn how to perform transcatheter interventions although it is far from their vocation, belief, and passion.However, they did what every other living creature does when their evolving environment threatens them: they adapt to it to avoid extinction.However, is this radical step really necessary in the case of cardiac surgery?At the beginning of the 21 st century, there were already comparable concerns: percutaneous angioplasty became

Objectives: To compare the efficacy and clinical outcomes of transcatheter edge -to-edge mitral valve repair (TMVr) and surgical mitral valve repair (SMVr) among patients with secondary mitral regurgitation (SMR).Methods: Consecutive patients with SMR treated using either TMVr (n = 199) or SMVr (n = 222) at 2 centers were included and retrospectively analyzed. To account for differences in patient demographic characteristics, 1:1 propensity score match-ing was performed. The primary endpoint was all-cause death within 2 years after the procedure.Results: The study population consisted of 202 matched patients. At 2 years, all -cause mortality was 24.3% for TMVr and 23.0% for SMVr (hazard ratio, 0.97; 95% confidence interval, 0.55-1.71; P = .909). Severe heart failure symptoms at 2 years were less prevalent after SMVr (New York Heart Association functional class III or IV: 13.5% vs 29.5%; P = .032) than after TMVr. A higher proportion of the SMVr patients had SMR reduction to none or mild at discharge (90.8% vs 72.0%; P < .001) and 2 years (86.5% vs 59.6%; P < .001). Among patients who achieved none or mild MR at discharge, 7 patients (10.1%) in the SMVr group and 15 (34.9%) in the TMVr group had progression to moderate or greater MR at 2 years (P = .003). Left ventricular ejection fraction (LVEF) significantly improved (+10.1% +/- 11.1%; P <.001) after SMVr (LVEF at 2 years: 45.7% +/- 12.8%), whereas it remained unchanged (-1.3% +/- 8.9%; P = .260) after TMVr (LVEF at 2 years: 34.0% +/- 13.2%).Conclusions: In this propensity score-matched analysis, there was no significant difference in 2-year survival between TMVr and SMVr, despite greater and more du-rable SMR reduction, as well as LVEF improvement in the surgical group. (J Thorac Cardiovasc Surg 2023;165:2037-46)

OBJECTIVE:Transcatheter aortic valve implantation (TAVI) is an off-label procedure for selected patients at high surgical risk with native non- or mildly calcified aortic regurgitation (AR). Traditionally, self-expanding transcatheter heart valves (THV) have been favored over balloon-expandable THV's probably due to assumed better device fixation. We report a series of patients with native severe AR successfully treated with a balloon-expandable THV. METHODS:Between 2019 and 2022, 8 consecutive patients (5 male, 82 (interquartile range 80-85) years old, STS PROM 4.0 % (interquartile range 2.9-6.0), EuroSCORE II 5.5% (IQR 4.1-7.0) with non- or mildly calcified pure AR were treated with a balloon-expandable THV. All procedures were performed after heart team discussion and standardized diagnostic workup. Clinical endpoints were collected prospectively and included device success, procedural complications (according to VARC-2 definitions) and 1-month survival. RESULTS:Device success was 100% with no device embolization or migration. Two preprocedural nonfatal complications were reported (one access site complication that required stent implantation and one pericardial tamponade). Two patients required permanent pacemaker implantation for complete AV block. At discharge and at 30-day follow-up all patients were alive and no patient showed more than minimal AR. CONCLUSION:This series documents that treatment of native non- or mildly calcified AR with balloon-expandable THV is feasible, safe and offers favorable short-term clinical outcomes. Hence, TAVI with balloon-expandable THVs may offer a valuable treatment option in patients with native AR at high surgical risk.

Aims: Microvascular obstruction (MVO) following ST-elevation myocardial infarction (STEMI) is associated with greater infarct size, adverse left-ventricular (LV) remodeling and reduced ejection fraction. We hypothesized that patients with MVO may constitute a subgroup of patients that would benefit from intracoronary stem cell delivery with bone marrow mononuclear cells (BMCs) given previous findings that BMCs tended to improve LV function only in patients with significant LV dysfunction. Methods and Results: We analyzed the cardiac MRIs of 356 patients (303 M, 53 F) with anterior STEMIs who received autologous BMCs as part of 3 clinical trials that included the Cardiovascular Cell Therapy Research Network (CCTRN) TIME trial and its pilot (n=157), the multi-center French BONAMI trial (n=91) and the SWISS-AMI trial (n=108). All patients received 100 - 150 million intracoronary autologous BMCs or placebo / control 3 - 7 days following primary PCI and stenting. LV function, volumes, infarct size and MVO were assessed prior to infusion of BMCs and 1 year later. Patients with MVO (n=210) had reduced LVEF and much greater infarct size and LV volumes compared to patients without MVO (n=146) (all p < 0.01) (TABLE). At 12 months, patients with MVO who received BMCs had significantly greater recovery of LVEF compared to those patients with MVO who received placebo (absolute difference = 2.7 %; p < 0.05). Similarly, the changes in left-ventricular end-diastolic (LVEDV) and end-systolic volumes (LVESV) were consistent with significantly less adverse remodeling in patients with MVO who received BMCs compared to placebo ( % change; LVEDV = -9.7%; p < 0.05 and LVESVI = -14.7 %; p = 0.006). In contrast, patients without MVO experienced no benefit of BMC administration compared to placebo. Conclusion: The presence of MVO on cardiac MRI following STEMI identifies a subgroup of patients who may benefit from intracoronary stem cell delivery of BMCs.

BACKGROUND Survival data after mitral transcatheter edge-to-edge repair (TEER) are scarce, and its impact on predicted life expectancy is unknown.OBJECTIVES The aim of this study was to estimate the impact of TEER on postprocedural life expectancy among patients enrolled in the MitraSwiss registry through a relative survival (RS) analysis.METHODS Consecutive TEER patients 60 to 89 years of age enrolled between 2011 and 2018 (N = 1140) were evaluated. RS was defined as the ratio between post-TEER survival and expected survival in an age-, sex-and calendar period-matched group derived from the Swiss national 2011 to 2019 mortality tables. The primary aim was to assess 5-year survival and RS after TEER. The secondary aim was to assess RS according to the etiology of mitral regurgitation, age class and sustained procedural success over time.RESULTS Overall, 5-year survival after TEER was 59.3% (95% CI: 54.9%-63.4%), whereas RS reached 80.5% (95% CI: 74.6%-86.0%). RS was 91.1% (95% CI: 82.5%-98.6%) in primary mitral regurgitation (PMR) and 71.5% (95% CI: 63.0%-79.3%) in secondary mitral regurgitation (SMR). Patients 80 to 89 years of age (n = 579) showed high 5-year RS (93.0%; 95% CI: 83.3%-101.9%). In this group, restoration of predicted life expectancy was achieved in PMR with a 5-year RS of 100% (95% CI: 87.9%-110.7%), whereas sustained procedural success increased the RS rate to 90.6% (95% CI: 71.3%-107.3%) in SMR.CONCLUSIONS Mitral TEER in patients 80 to 89 years of age is able to restore predicted life expectancy in PMR, whereas in SMR with sustained procedural success, high RS estimates were observed. Our analysis suggests that successful, sustained mitral regurgitation reduction is key to survival improvement, particularly in patients 80 to 89 years of age.

A 76-year-old female patient who had undergone quadruple coronary bypass surgery and aortic valve replacement 10 years earlier was referred to our clinic for severe symptomatic mitral valve stenosis secondary to extensive mitral annular calcification (MAC). Due to the high surgical risk, the excessive MAC and no possibility of an interventional approach for anatomical reasons the Heart Team opted for a hybrid approach (sternotomy with surgical transatrial mitral Valve-In-MAC procedure using a balloon-expandable Edwards SAPIEN-3 29 mm prosthesis). The intervention was successful and the patient was discharged 13 days after surgery. Despite an uneventful recovery, a transthoracic echocardiography 30 days later (Panel A) showed a left ventricular (LV) discontinuity with a paraventricular cavity suggestive of a pseudoaneurysm (astir). Computed tomography (Panel B) and angiography (Panel C) confirmed the diagnosis of a ‘bilobular’ covered perforation connecting with the LV through a narrow neck (white arrow)....

BACKGROUND AND AIMS: The soluble form of suppression of tumourigenicity 2 (sST2), a recently introduced biomarker, is a strong and NTproBNP-independent predictor of outcome in heart failure patients. This study sought to evaluate the added clinical value of sST2 in addition to NTproBNP in a heterogeneous cardiac outpatient population. METHODS: A total of 297 all-comer patients visiting the outpatient clinic of Heart Clinic Zurich, Switzerland, from January to December 2018 were included. Patients were divided into four groups depending on their sST2 and NTproBNP levels: group 1 (n = 91, 30.6% of all patients) with normal levels of both biomarkers, group 2 (n = 41, 13.8%) with isolated elevation of sST2 but normal NTproBNP, group 3 (n = 97, 32.7%) with elevated NTproBNP but normal sST2 levels, and group 4 (n = 68, 22.9%) with elevation of both biomarkers. Differences between groups, Spearman’s correlations and linear and multiple regression analysis for sST2 were calculated. RESULTS: The median age was 74 ± 19 years and 41.8% were women. NTproBNP levels continuously increased across the groups (medians in pg/ml: group 1 123.0, group 2 152.0, group 3 990.0 and group 4 2610.0), whereas sST2 levels did not (medians in ng/ml: 28.7, 58.9, 28.4 and 63.7 for groups 1 to 4, respectively). In patients with normal NTproBNP (groups 1 and 2), elevation of sST2 (group 2) was associated with significantly higher rates of coronary artery disease, peripheral vascular disease and renal dysfunction. In patients with elevated NTproBNP (groups 3 and 4), the additional elevation of sST2 (group 4) was associated with clinical signs of heart failure, higher EuroScore II and worse left ventricular ejection fraction (LVEF group 3 58.0% vs group 4 53.3%, p = 0.022). Correlation of sST2 was overall weak and weaker than of NTproBNP with most clinical variables. Soluble ST2 significantly correlated with EuroScore II (R = 0.280), kidney function (R = −0.259), C-reactive protein (R = 0.248), right ventricular function (R = 0.213) and left atrial volume (R = 0.199), all p ≤0.001. In multiple regression analysis, left atrial volume was the strongest independent predictor of sST2 elevation (p = 0.002). CONCLUSION: In this all-comer cardiology population, the added clinical value of sST2 measurements in addition to NTproBNP was small. In patients with elevated NTproBNP, the simultaneous elevation of sST2 was associated with clinical signs of heart failure. Soluble ST2 measurements could thus be beneficial in patients with uncertain signs of heart failure and confounding factors for NTproBNP elevation. Surprisingly, this study found elevated sST2 levels in a substantial number of a patients with normal NTproBNP levels, pointing to an additional pathway of sST2 elevation independent of heart failure.

Two heart transplant patients aged 80 and 83 years with recurrent heart failure due to severe tricuspid regurgitation are reported. In view of their high perioperative risk, both patients underwent percutaneous transcatheter edge-to-edge tricuspid valve repair, and both experienced excellent technical success, with favorable 2-year clinical outcome. (Level of Difficulty: Advanced.)

Transcatheter edge-to-edge repair (TEER) for the treatment of isolated tricuspid regurgitation (TR) is emerging as an alternative to surgery. These patients commonly have right ventricular (RV) leads which must be evaluated on a patient-specific basis to determine the feasibility of TEER.

AIMS:The Swiss national registry on percutaneous mitral valve interventions (MitraSwiss) was established in 2011 to monitor safety/efficacy of percutaneous mitral valve repair (PMVR) with the MitraClip device. The aim of this analysis was to report the outcome after PMVR in a real-world, all-comers population and its predictors after inclusion of more than 1,200 patients, stratifying the results according to mitral regurgitation (MR) aetiology. Here we report the in-hospital, short and midterm outcomes of all patients prospectively enrolled. METHODS AND RESULTS:Since 2011, MitraSwiss has enrolled 1,212 patients with moderate and severe MR of functional (FMR) or degenerative (DMR) aetiology treated with PMVR in 10 centres. Pre-specified endpoints included clinical, echocardiographic and functional parameters with follow-up planned up to five years. Outcomes are compared according to MR aetiology. Acute procedural success was achieved in 91.5% of cases, with no differences between FMR and DMR and sustained good midterm results. NYHA class and pulmonary pressure improved significantly in both cohorts. Cumulative probability of death at five years was 54% (95% CI: 45-63) in FMR and 45% (95% CI: 37-54) in DMR (HR 1.15, p=0.009). Age, anaemia, impaired renal function and reduced left ventricular ejection fraction resulted in being independent predictors of death at five years. CONCLUSIONS:In a large contemporary cohort of non-surgical patients with severe MR, the safety and effectiveness of PMVR have been confirmed. At midterm follow-up, mortality and MACE were lower in DMR patients, though MR aetiology was not directly and independently associated with outcome.

Transcatheter aortic valve replacement (TAVR) has become the preferred procedure for aortic valve replacement.1 Preprocedural multidetector computed tomographic (MDCT) imaging for aortic root analysis and prosthetic valve sizing is considered standard of care.2 However, the use of iodinated contrast agent during MDCT angiography bears a significant nephrotoxicity risk in patients with chronic severe kidney failure. Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is considered a valuable alternative for aortic root sizing in this population.