Background: Transcatheter edge-to-edge repair (TEER) has become an established therapeutic option for patients with severe secondary mitral regurgitation (SMR). While randomized trials and registry data have reported outcomes up to 5 years, longer follow-up data remain scarce. Case Summary: We report the case of a 48-year-old male patient who was admitted to our hospital with cardiogenic shock, first diagnosis of dilated cardiomyopathy and severe ventricular SMR in August 2016. With the use of mechanical circulatory support, the patient underwent urgent M-TEER with implantation of one MitraClip device, reducing MR from severe to mild-to-moderate. At 9-year follow-up in 2025 and consequent optimization of guideline directed medical therapy, the patient remains clinically stable, with sustained MR reduction and good device function. Discussion: This case highlights the durability of M-TEER even in a critically ill patient initially presenting with cardiogenic shock and multiorgan failure. To our knowledge, this represents one of the longest follow-up observations after M-TEER, supporting its role as a durable treatment strategy in high-risk patients. Conclusions: M-TEER can achieve durable long-term MR reduction and symptomatic benefit.

BACKGROUND:The effect of transcatheter tricuspid-valve repair on clinical outcomes, including death and hospitalization for heart failure, in patients with severe tricuspid regurgitation remains uncertain. METHODS:We randomly assigned patients with symptomatic severe tricuspid regurgitation and an increased risk of future heart-failure events in a 2:1 ratio to tricuspid-valve repair plus medical therapy (tricuspid-repair group) or medical therapy alone (medical-therapy group). The first primary end point was a hierarchical composite of death from any cause, hospitalization for heart failure, and quality-of-life improvement at 1 year, assessed by win ratio. If the between-group difference was significant, a second primary end point would be tested: a composite of death from any cause or hospitalization for heart failure through 3 years. RESULTS:A total of 360 patients underwent randomization (237 patients were assigned to the tricuspid-repair group and 123 to the medical-therapy group). The mean (±SD) age of the patients was 80.3±6.4 years, and 56.4% were women. The win ratio for the first primary end point was 2.42 (95% confidence interval [CI], 1.76 to 3.33; P<0.001), favoring tricuspid-valve repair. The Kaplan-Meier estimate for freedom from death from any cause or hospitalization for heart failure (second primary end point) through 3 years was 52.4% (95% CI, 43.2 to 63.6) in the tricuspid-repair group and 21.0% (95% CI, 12.7 to 34.6) in the medical-therapy group (hazard ratio for death from any cause or hospitalization for heart failure, 0.40; 95% CI, 0.29 to 0.55; P<0.001). Major adverse events within 30 days occurred in 14 patients (5.9%) in the tricuspid-repair group. CONCLUSIONS:Among patients with symptomatic severe tricuspid regurgitation, transcatheter tricuspid-valve repair plus medical therapy was superior to medical therapy alone with respect to a hierarchical composite of death from any cause, hospitalization for heart failure, and quality-of-life improvement at 1 year and was also associated with a lower risk of a composite of death from any cause or hospitalization for heart failure through 3 years. (Funded by the German Center for Cardiovascular Research and others; TRIC-I-HF ClinicalTrials.gov number, NCT04634266.).

AIMS:In tricuspid regurgitation (TR), conventional parameters of right ventricular (RV) function have limited prognostic utility. Our aim was to evaluate the prognostic value of RV pressure-strain-volume (PSV) analysis-derived work parameters in patients undergoing transcatheter tricuspid valve intervention (TTVI). METHODS:This multicenter retrospective observational study included 166 patients, of whom 140 (84.3%) underwent transcatheter tricuspid valve repair (TTVr) and 26 (15.7%) underwent transcatheter tricuspid valve replacement. A dedicated artificial intelligence-based software was used to reconstruct the RV pressure curve based on the peak RV systolic pressure and to fuse this curve with three-dimensional (3D) RV longitudinal strain and volumetric data to construct PSV loops and calculate corresponding RV work parameters. The outcomes of interest were TR progression after TTVr and the composite of heart failure (HF) hospitalization and all-cause death within 12 months after TTVI. RESULTS:Higher values of PSV-derived global wasted work (PSV-GWW) were associated with an increased risk of TR progression after TTVr (adjusted odds ratio per 100-unit increase = 1.108 [95% CI, 1.012-1.218], P = .028), whereas no significant associations were observed for other RV functional parameters. In the entire study cohort, both PSV-GWW (adjusted hazard ratio per 100-unit increase = 1.038 [95% CI, 1.002-1.075], P = .036) and 3D RV global longitudinal strain (adjusted hazard ratio per 1-unit decrease = 1.121 [95% CI, 1.029-1.221], P = .009) were independently associated with the composite endpoint. CONCLUSIONS:Pressure-strain-volume-GWW and 3D RV global longitudinal strain were independently associated with HF hospitalization and all-cause death within 12 months after TTVI. Pressure-strain-volume-GWW identified patients at increased risk of TR progression after TTVr.

ObjectivesWe aimed to synthesize existing evidence on predictive machine learning (ML) models for valvular heart disease (VHD) and examine how these models have been applied across clinical tasks, data modalities and validation settings.BackgroundML is gaining traction for improving cardiovascular care, particularly in the management of VHDs. However, empirical evidence on how ML models handle the multimodal complexity of valvular pathologies remain sparse.MethodsWe conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines searching PubMed, Web of Science, and Embase from 2014 to 2025. We included articles that developed ML for clinical prediction in VHD patients. (PROSPERO: CRD42025644167).ResultsWe identified 195 studies that met the inclusion criteria. Seventy-five studies (38.5%) developed single-lesion models for aortic stenosis. Retrospective datasets were used in 86% of the included studies and 79% relied on internal validation. Sixteen studies (8.2%) developed multimodal models, integrating different types of ML input data. The multimodal models demonstrated a 6.3 percentage point increase in average performance across tasks compared to their unimodal counterparts within the same cohort.ConclusionAcross the literature, unimodal ML models for VHDs demonstrate promising performance for disease detection, patient stratification, and risk prediction, but multimodal approaches are emerging with potential advantages for procedural planning and outcome forecasting. Translation to clinical practice will require large, multicenter datasets to validate and standardize data-driven VHD management.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD42025644167.

AIMS:Mitral valve edge-to-edge repair (M-TEER) is increasingly being used for the treatment of severe mitral regurgitation; however, outcomes in inoperable patients with very complex or even unfavourable mitral valve (MV) disease as 'ultima ratio' are unknown. The study aimed to evaluate patient outcomes according to mitral valve anatomical complexity, as suggested in a recent review article. METHODS AND RESULTS:In this single-centre, retrospective analysis, consecutive patients who underwent M-TEER were categorized as 'Non-Complex' (NC), 'Complex' (C), 'Very Complex' (VC), and 'Ultimately Complex' (UC). Study endpoints were MR reduction, symptomatic improvement as expressed by changes in New York Heart Association (NYHA) functional class and two-year survival. The study included 789 consecutive patients at a mean age of 74.9 ± 11.1 years (42.7% female; 49% with secondary and 51% with primary or mixed MV disease). 203 patients (25.7%), 409 patients (51.8%), 138 patients (17.5%), and 39 patients (4.9%) were classified as NC, C, VC, UC, respectively. Improvement to NYHA functional class ≤ II and 2-year survival rates were comparable across anatomical complexity groups (NYHA ≤ II: 68.4%, 61.8%, 63.5%, and 75.0%, P = 0.454; survival: 64.6%, 71.2%, 68.0%, and 71.0%; P = 0.454; for NC, C, VC, and UC, respectively). MR reduction was observed in all categories and it was comparable in secondary MV disease, while increasing MV complexity was associated with an increasing prevalence of residual MR ≥3 + in primary MR (7.9%, 8.3%, 10.9%, and 23.0% for NC, C, VC, and UC, respectively; P = 0.002). CONCLUSION:This study provides the first large-scale validation of a recently proposed mitral valve complexity framework. Anatomical complexity showed an etiology-specific impact, with no relevant effect on MR reduction or clinical outcomes in SMR, but increasing residual MR in primary disease. Given an acceptable rate of MR reduction, M-TEER can even be considered in selected patients with unfavourable MV anatomy as 'ultima ratio'.

Background Transcatheter tricuspid valve (TV) interventions are an effective treatment option for patients with severe symptomatic tricuspid regurgitation (TR). TV transcatheter edge-to-edge repair (T-TEER) and transcatheter TV annuloplasty (TTVA) represent distinct repair strategies; however, comparative data remain limited. Objectives The objective of the study was to compare procedural and clinical outcomes after T-TEER and TTVA in patients with severe secondary TR. Methods Consecutive T-TEER or TTVA-treated patients (2017-2024) were included. A 1:1 propensity-score matching was performed. Endpoints included residual TR ≤ 1+/≤2+, a ≥2-grade reduction, procedural complications, symptomatic improvement, reinterventions, and the composite of all-cause mortality or first heart failure hospitalization within 1 year. Results Among 1,122 patients (882 T-TEER; 240 TTVA), 111 well-balanced matched pairs were identified. At discharge, T-TEER achieved higher rates of residual TR ≤ 1+ (50.0% vs 34.2%) and ≤2+ (87.7% vs 67.6%; all P < 0.05) compared with TTVA, whereas a ≥2-grade reduction was comparable. Procedural complications were less frequent with T-TEER (any complication: 4.5% vs 27.0% for T-TEER vs TTVA; P < 0.001). Symptomatic improvement and reintervention rates within 1 year were similar between groups. Freedom from the composite endpoint of all-cause mortality or first heart failure hospitalization at 1-year was 75.0% (95% CI: 66.8-84.1) after T-TEER and 79.8% (95% CI: 72.4-87.9) after TTVA (P = 0.408). Conclusions In patients with severe secondary TR and sufficient clinical and anatomical overlap for matched comparison, T-TEER showed a more favorable safety profile and more effective, durable TR reduction, whereas early clinical outcomes at 1 year were comparable after adjustment for baseline differences, highlighting the need for longer-term evaluation.

Background: Right ventricular (RV) heart failure as assessed by RV to pulmonary artery coupling (RVPAc) is a prognostic marker in transcatheter tricuspid valve repair (T-TEER). However, quantification of RVPAc components by 2-dimensional (2D) echocardiography in patients with severe tricuspid regurgitation (TR) has significant limitations, and the traditional RVPAc parameter neglects the degree of volume overload/dilatation of the RV, which is another key clinical indicator for right ventricular dysfunction (RVD). Therefore, we aimed to assess RVD by a novel RVPAc parameter, including the 3 important drivers of RVD, for an improved prediction of 1-year mortality after T-TEER. Methods: We analyzed 262 patients undergoing T-TEER with complete 3D RV echocardiography and 1-year follow-up. Results: Increased 3D-RV end diastolic volume (3D-RVEDV: hazard ratio [HR], 1.85; 1.10-3.12; P = 0.020) and impaired RV free-wall longitudinal strain (RVFWLS: HR, 1.73, 1.02-2.92; P = 0.042) predicted 1-year mortality. A novel RVPAc parameter (RVFWLS/[3D-RVEDV & lowast;sPAP(invasive)]) including all 3 important drivers for RVD was developed, associating RVPA-uncoupling with a tripled risk for 1-year mortality (HR, 3.19, 1.7-6.0; P < 0.001). The novel RVPAc parameter significantly outperformed the traditional noninvasive RVPAc parameter in 1-year mortality prediction (C-index: 0.68 vs 0.57 for novel vs traditional noninvasive RVPAc; P = 0.027). Conclusions: The novel RVPAc parameter, integrating RV function, volume stress, and pressure stress is a powerful metric for RV failure and a superior predictor for survival post-T-TEER. Clinical trial registration: Data is based on the EveryValve Registry (ethical code number: 19-840). No further clinical Trial registration.

Right ventricular reverse remodelling (RVRR) is linked to improved survival in patients with severe tricuspid regurgitation (TR) and right-sided heart failure who underwent interventional treatment. However, the role of residual TR on RVRR remains unclear. In this analysis the impact of residual TR on RVRR after interventional TR treatment, which was validated by two independent cohorts at four sites using echocardiography or cardiac magnetic resonance (CMR) imaging, was investigated. Overall, 253 patients who were treated for severe TR and right-sided heart failure using different treatment modalities (tricuspid transcatheter edge-to-edge repair [T-TEER], transcatheter tricuspid valve annuloplasty, orthotopic transcatheter TV replacement [TTVR], heterotopic TTVR) were included. Three-dimensional echocardiographic and CMR-based assessment of RVRR and clinical evaluation of decongestion or exercise capacity were performed at baseline and 30 days after the procedure. Mortality was analysed at 1 year after transcatheter tricuspid valve intervention (TTVI). In patients with residual TR ≤1+ pronounced reduction of right ventricular end-diastolic and end-systolic volumes was observed. In patients with residual TR ≥2+ the effect of RVRR gradually decreased with higher residual TR reinforcing the relevance of optimal procedural results for RVRR. These findings were validated in two independent cohorts. In contrast to RVRR, residual TR ≤1+ and 2+ were associated with similar 1-year survival. RVRR was only observed after T-TEER or orthotopic TTVR, but not after heterotopic TTVR as expected. However, all three treatment modalities were accompanied by significant decongestion and functional improvement at 30-day follow-up. In patients with severe TR and right-sided heart failure undergoing TTVI, superior procedural results were associated with more pronounced RVRR.

Treatment options for mitral regurgitation (MR) have markedly evolved over the past few decades, with mitral valve transcatheter edge-to-edge repair (M-TEER) expanding the clinical armamentarium of guideline-directed medical therapy and surgical techniques. However, the variety of mitral valve anatomies, the presence of heart failure (HF), and consideration of the individual patient risk require a multidisciplinary Heart Team approach to identify the optimal treatment for MR for each patient. Despite the growing field of transcatheter mitral interventions and the longstanding availability of surgical mitral valve repair and replacement, evidence from randomized clinical trials comparing intervention with surgery remains scarce. In the meantime, the increasing safety and experience of surgical and interventional procedures have shifted the perspective on mitral valve disease in terms of when and how to treat it. Therefore, the multidisciplinary Heart Team discussion has become of paramount importance in the evaluation and treatment decisions for patients with mitral valve disease.

BACKGROUND Patients with severe tricuspid regurgitation (TR) typically present with heterogeneity in the extent of cardiac dysfunction and extra-cardiac comorbidities, which play a decisive role for survival after transcatheter tricuspid valve intervention (TTVI). OBJECTIVES This aim of this study was to create a survival tree-based model to determine the cardiac and extra-cardiac features associated with 2-year survival after TTVI. METHODS The study included 918 patients (derivation set, n = 631; validation set, n = 287) undergoing TTVI for severe TR. Supervised machine learning-derived survival tree-based modelling was applied to preprocedural clinical, laboratory, echocardiographic, and hemodynamic data. RESULTS Following univariate regression analysis to pre-select candidate variables for 2-year mortality prediction, a survival tree-based model was constructed using 4 key parameters. Three distinct cluster-related risk categories were identified, which differed significantly in survival after TTVI. Patients from the low-risk category (n = 261) were defined by mean pulmonary artery pressure <= 28 mm Hg and N-terminal pro-B-type natriuretic peptide <= 2,728 pg/mL, and they exhibited a 2-year survival rate of 85.5%. Patients from the high-risk category (n = 190) were defined by mean pulmonary artery pressure >28 mm Hg, right atrial area >32.5 cm(2), and estimated glomerular filtration rate <= 51 mL/min, and they showed a significantly worse 2-year survival of only 52.6% (HR for 2-year mortality: 4.3, P < 0.001). Net re-classification improvement analysis demonstrated that this model was comparable to the TRI-Score and outperformed the EuroScore II in identifying high-risk patients. The prognostic value of risk phenotypes was confirmed by external validation. CONCLUSIONS This simple survival tree-based model effectively stratifies patients with severe TR into distinct risk categories, demonstrating significant differences in 2-year survival after TTVI. (c) 2025 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

AIMS:Data on the prognostic value of left- and right-atrial strain after transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) are limited. Aim of this study was to evaluate outcomes of patients undergoing TAVR stratified by left- and right-atrial strain. METHODS AND RESULTS:Using data from a high-volume academic centre, left- and right-atrial reservoir strain (LASr and RASr) was obtained in patients who underwent TAVR for severe AS from 2018 until 2021. Patients were stratified into groups with normal atrial function (LASr and RASr normal), uni-atrial strain impairment (LASr or RASr impaired), and bi-atrial strain impairment (LASr and RASr impaired). Endpoints were 3 year survival, symptomatic improvement as assessed by New York Heart Association functional class (NYHA class) as well as technical and device success defined by the Valve Academic Research Consortium composite endpoints. The study included 1888 patients at a mean age of 81.0 ± 7.8 years (44.3% women). Mean LASr and RASr were 16.5 ± 9.4% and 21.6 ± 12.4%, respectively. Optimized cut-offs for mortality prediction were 15.5% for LASr and 15.0% for RASr. LASr and RASr were normal in 751 patients (39.8%). Impairment of either right-atrium (RA) or left-atrium (LA) strain was observed in 633 patients (33.5%) and 504 patients (26.7%) presented with reduced LA and RA strain. While impairment of either LASr or RASr was associated with a 1.7-fold increased risk of 3 year all-cause mortality after adjustment for multiple confounders (95% confidence interval [CI] 1.2-2.5, P = 0.005), bi-atrial strain impairment exhibited an even higher 3 year mortality risk (Hazard ratio 2.5, 95% CI 1.7-3.6, P < 0.001). CONCLUSION:Pre-procedural assessment of atrial strain is associated with increased 3 year mortality and might facilitate outcome prediction and patient selection in patients undergoing TAVR for severe AS.

AIMS:Current guidelines provide no recommendations for the management of patients with dual atrioventricular valve regurgitation (DAVR) undergoing transcatheter aortic valve replacement (TAVR), and existing data on its clinical impact remain absent. Therefore, we aimed to provide detailed insights into the impact of DAVR on outcomes after TAVR, with the potential to refine clinical risk stratification tools and influence future management guidelines. METHODS AND RESULTS:We retrospectively analysed 3491 consecutive patients who underwent TAVR between 2013 and 2021. DAVR was defined as the presence of both mitral regurgitation (MR) and tricuspid regurgitation (TR) ≥ 2+. Patients were divided into four groups based on echocardiography before TAVR: no/mild atrioventricular (AV) regurgitation, isolated MR ≥ 2+, isolated TR ≥ 2+, and DAVR. DAVR was present in 269 patients (7.7%) and was associated with significantly reduced 3-year survival (47.3%) compared with isolated MR (64.3%), isolated TR (54.4%), and no/mild AV regurgitation (73.0%, P < 0.001). Multivariate analysis identified DAVR as an independent predictor of 3-year mortality [hazard ratio (HR): 1.36, 95% confidence interval (CI), 1.1-1.8, P = 0.021]. A leading TR ≥ 3+ in DAVR patients was associated with a particularly poor prognosis (3-year survival: 27%). While an MR improvement following TAVR was linked to better survival (HR: 0.45, 95% CI, 0.30-0.69, P < 0.001), a TR improvement had no significant impact on survival (HR: 0.69, 95% CI: 0.45-1.05, P = 0.086). Notably, 54% of DAVR patients continued to experience significant exertional dyspnoea at follow-up (NYHA ≥ II). CONCLUSION:These findings underscore the importance of recognizing DAVR as a high-risk condition in TAVR patients, highlighting the need for refined risk stratification tools and potential adjunctive therapeutic strategies to improve outcomes.