Background: The potential benefit of using larger or smaller transcatheter heart valves (THV) in patients with borderline aortic annulus measurement (BAM) remains uncertain. The objective of this study was to evaluate the clinical outcomes associated with the selection of larger or smaller THV in the context of BAM. Methods: This was a multicenter observational study including patients who underwent transcatheter aortic valve replacement with the SAPIEN 3 or SAPIEN 3 Ultra-valve systems (Edwards Lifesciences, Irvine, CA) from April 2014 to June 2021. BAM was defined according to the manufacturer sizing chart and included the following annulus areas: 314 to 346, 400 to 430, 500 to 546 mm ² . A 1:1 propensity score matching was used to compare outcomes of patients with larger or smaller THV. Results: From a total of 2467 patients, BAM was identified in 852 patients (34.5%). A larger and smaller THV was selected in 338 (39.7%) and 514 patients (60.3%) patients, respectively. The choice of a larger THV was associated (before and after propensity matching) with a higher risk of new-onset left bundle branch block (HR, 2.25 [95% CI, 1.39–3.65; P =0.001) and permanent pacemaker implantation (HR, 1.86 [95% CI, 1.11–3.09]; P =0.016) without any impact on gradients or the risk of moderate or severe paravalvular regurgitation at discharge (HR, 0.78 [95% CI, 0.41–1.45]; P =0.427). The risk of periprocedural complications such as aortic rupture and tamponade was low (<1%) and similar between groups. Conclusions: In patient with BAM, selecting a larger SAPIEN 3/Ultra THV increased the risk of conduction disturbances without any benefit on valve hemodynamics and clinical outcomes.

Acute ischaemic mitral regurgitation (IMR) is an increasingly rare and challenging complication following acute myocardial infarction. Despite recent technical advances in both surgical and percutaneous interventions, a poor prognosis is often associated with this challenging patient cohort. In this review, we revisit the diagnosis and typical echocardiographic features, and evaluate current surgical and percutaneous treatment options for patients with acute IMR.

BACKGROUND: The Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) has recently introduced a consensus document that outlines risk factors to identify high bleeding risk in patients undergoing transcatheter aortic valve replacement. The objective of the present study was to evaluate the prevalence and predictive value of the VARC-HBR definition in a contemporary, large-scale transcatheter aortic valve replacement population. METHODS: Multicenter study including 10 449 patients undergoing transcatheter aortic valve replacement. Based on consensus, 21 clinical and laboratory criteria were identified and classified as major or minor. Patients were stratified as at low, moderate, high, and very high bleeding risk according to the VARC-HBR definition. The primary end point was the rate of Bleeding Academic Research Consortium type 3 or 5 bleeding at 1 year, defined as the composite of periprocedural (within 30 days) or late (after 30 days) bleeding. RESULTS: Patients with at least 1 VARC-HBR criterion (n=9267, 88.7%) had a higher risk of Bleeding Academic Research Consortium 3 or 5 bleeding, proportional to the severity of risk assessment (10.8%, 16.1%, and 24.6% for moderate, high, and very-high-risk groups, respectively). However, a comparable rate of bleeding events was observed in the low-risk and moderate-risk groups. The area under receiver operating characteristic curve was 0.58. Patients with VARC-HBR criteria also exhibited a gradual increase in 1-year all-cause mortality, with an up to 2-fold increased mortality risk for high and very-high-risk groups (hazard ratio, 1.33 [95% CI, 1.04–1.70] and 1.97 [95% CI, 1.53–2.53], respectively). CONCLUSIONS: The VARC-HBR consensus offered a pragmatic approach to guide bleeding risk stratification in transcatheter aortic valve replacement. The results of the present study would support the predictive validity of the new definition and promote its application in clinical practice to minimize bleeding risk and improve patient outcomes.

Background: Significant tricuspid regurgitation (TR) is associated with increased morbidity and mortality. The development of transcatheter valve repair therapies has opened a wide range of opportunities for treatment of patients with high surgical risk. Real‐world data might improve patient selection and outcome. The authors sought to investigate acute and short‐term cardiovascular outcomes of tricuspid transcatheter edge‐to‐edge repair (T‐TEER) with dedicated devices in a real‐world setting. Methods and Results: This is a retrospective, single‐arm, multicenter registry conducted at 15 sites in Spain. The primary end point was a composite of all‐cause death, rehospitalization for heart failure, and tricuspid valve re‐intervention. Patients included (n=283) were older (76±9 years, 70% female), and showed significant comorbidities. Massive or torrential TR was present in 55% of subjects, with secondary cause being the main mechanism of regurgitation in ≈80% of individuals. Intraprocedural success was achieved in 79% of patients. At 1‐year follow‐up, significant improvements in TR grade (≥3+, 100% to 25%, P <0.001) and New York Heart Association functional class (I/II, 33%–86%, P <0.001) were observed. Lead‐induced cause and single leaflet device attachment emerged as independent predictors of at least severe predischarge residual TR. In‐hospital mortality occurred in 4 (1.4%) patients, whereas the Kaplan–Meier estimated 1‐year primary end point occurrence rate was 21%. Intraprocedural success (hazard ratio, 0.353 [95% CI, 0.156–0.798]; P =0.012), was found to be an independent predictor of primary end point. Conclusions: In a real‐world contemporary setting, tricuspid transcatheter edge‐to‐edge repair with dedicated devices emerged as effective therapeutic option for patients with severe TR.

BACKGROUND: Cardiac structural complications (CSCs) have been recently established by the Valve Academic Research Consortium 3 consensus as a combined end point including multiple life-threatening periprocedural events following transcatheter aortic valve replacement. The objective was to assess the incidence, timing, management, and clinical impact of CSCs in the contemporary transcatheter aortic valve replacement era. METHODS: Multicenter study including consecutive patients undergoing transcatheter aortic valve replacement in 18 European and Canadian centers from 2014 to 2024. According to the Valve Academic Research Consortium 3 criteria, CSCs included cardiac structure perforation, injury or compromise, new pericardial effusion, and coronary obstruction. Data was collected in a dedicated database, and patients were followed at 30 days, 1 year, and yearly thereafter. RESULTS: Among a total of 10 541 patients, CSCs occurred in 221 (2.1%), with 126 (1.2%) patients exhibiting >1 CSC: 146 (1.4%) cardiac structure compromise events (annular rupture: 41.1%, left ventricular perforation: 26.0%; right ventricular perforation: 24.0%, other injuries: 8.9%), 150 (1.4%) new pericardial effusions, and 59 (0.6%) coronary obstructions. Up to 75.6% of CSCs occurred intraprocedurally, and 61 (27.6%) patients had conversion to open heart surgery. The incidence of CSCs remained similar throughout the study period (from 1.3% to 3.2%, median annual rate of 2.3%). Thirty-day mortality was 35.3% (52.5% among patients requiring conversion to surgery), with annular rupture associated with the highest (41.0%) mortality rate. CONCLUSIONS: About 2% of contemporary transcatheter aortic valve replacement recipients presented CSCs, which did not decrease over time, required conversion to surgery in more than one-fourth of cases, and were associated with very high periprocedural mortality rates. Further research is needed regarding potential preventive strategies and optimal surgical bailout management.

BACKGROUND: Data on the long-term incidence and clinical impact of bioprosthetic valve failure (BVF) after transcatheter aortic valve replacement remain limited. This study aimed to assess the incidence, predictors, and clinical impact of BVF following transcatheter aortic valve replacement. METHODS: We analyzed data from an international, multicenter registry including consecutive patients undergoing transcatheter aortic valve replacement at 13 centers. The primary outcome was BVF according to Valve Academic Research Consortium-3 criteria. The cumulative incidence of BVF was estimated using a competing-risk approach. The association between BVF and clinical outcomes was assessed using competing-risk models with BVF as a time-dependent covariate. RESULTS: Among 7501 patients, BVF occurred in 380 (5.1%) patients over a median follow-up of 4 (interquartile range, 2–5) years. The cumulative incidence of BVF increased over time, reaching 1.4% at 1 year, 4.6% at 5 years, and 8.3% at 10 years. Independent predictors of BVF included younger age, smoking, balloon-expandable valve, prosthesis size <26 mm, valve-in-valve procedure, mean gradient at discharge ≥15 mm Hg, moderate or severe aortic regurgitation at discharge, and early hemodynamic valve deterioration. BVF was independently associated with an increased risk of all-cause mortality (adjusted hazard ratio, 1.72 [95% CI, 1.47–2.01]; P <0.001), cardiovascular mortality (adjusted hazard ratio, 3.23 [95% CI, 2.73–3.82]; P <0.001), stroke (adjusted hazard ratio, 2.08 [95% CI, 1.08–4.23]; P =0.043), and heart failure hospitalization (adjusted hazard ratio, 1.43 [95% CI, 1.03–1.98]; P =0.032). Consistent findings were observed in different sensitivity analyses. CONCLUSIONS: BVF is a clinically relevant event associated with adverse long-term outcomes. These findings support the implementation of tailored surveillance and preventive strategies to mitigate BVF-related risk.