Aims: Patients with diastolic dysfunction (DD) experience worse outcomes after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value and clinical utility of left atrial reservoir strain (LARS) in patients undergoing TAVR for aortic stenosis (AS). Methods and results: All consecutive patients undergoing TAVR between January 2018 and December 2018 were included if discharge echocardiography and follow-up were available. LARS was derived from 2D-speckle-tracking. Patients were grouped into three tertiles according to LARS. DD was analysed using the ASE/EACVI-algorithm. The primary outcome was a composite of all-cause death and readmission for worsening heart failure 12 months after TAVR. Overall, 606 patients were available [age 80 years, interquartile range (IQR) 77–84], including 53% women. Median LARS was 13.0% (IQR 8.4–18.3). Patients were classified by LARS tertiles [mildly impaired 21.4% (IQR 18.3–24.5), moderately impaired 13.0% (IQR 11.3–14.6), severely impaired 7.1% (IQR 5.4–8.4), P < 0.0001]. The primary outcome occurred more often in patients with impaired LARS (mildly impaired 7.4%, moderately impaired 13.4%, and severely impaired 25.7%, P < 0.0001). On adjusted multivariable Cox regression analysis, LARS tertiles [hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.44–0.86, P = 0.005] and higher degree of tricuspid regurgitation (HR 1.82, 95% CI 1.23–2.98, P = 0.003) were the only significant predictors of the primary endpoint. Importantly, DD was unavailable in 56% of patients, but LARS assessment allowed for reliable prognostication regarding the primary endpoint in subgroups without DD assessment (HR 0.64, 95% CI 0.47–0.87, P = 0.003). Conclusion: Impaired LARS is independently associated with worse outcomes in patients undergoing TAVR. LARS allows for risk stratification at discharge even in patients where DD cannot be assessed by conventional echocardiographic means.

Over the past two decades, percutaneous left atrial appendage occlusion (LAAO) has proven to be a viable alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF), in particular in those patients who are at increased risk for stroke and bleeding complications. This systematic review provides a comprehensive evaluation of anatomical features, patient selection, procedural planning and execution, complications, medical treatment following the procedure, and contemporary outcome data.

Background: Fatal thrombo-embolic events like cerebral stroke or myocardial infarction are rare complications of prosthetic heart valve leaflet thrombosis. Nevertheless, prevention and management of leaflet thrombosis is gaining increased attention, particularly with the widespread adoption of transcatheter heart valves. Case summary: We herein present the case of a 79-year-old man who had undergone a transcatheter aortic valve implantation procedure. Seven months later, he presented with a non-ST-segment elevation myocardial infarction. Coronary angiography did not reveal obstructive lesions. A dedicated cardiac computed tomography scan showed thrombosis of both right- and non-coronary leaflets of the prosthetic aortic valve, while prosthetic valve function was normal on echocardiography. Transmural myocardial infarction lesions in the midventricular and apical inferior wall were detected by cardiac magnetic resonance imaging. Discussion: Subclinical leaflet thrombosis of prosthetic aortic valves is a common finding. In this case report, we show that myocardial infarction presumably due to leaflet thrombosis was the first symptom in an otherwise asymptomatic patient. This finding raises the question of the validity in distinguishing between subclinical and clinical leaflet thrombosis based on prosthetic valve function.

Background: Limited data is available on long‐term outcomes and valve durability measures of transcatheter aortic valve implantation (TAVI). Aims: This study sought to assess clinical and echocardiographic outcomes of high‐risk patients during the early experience of TAVI with a follow‐up period extending beyond 10 years. Methods: Patients were included who had undergone TAVI at the Heart Center Leipzig between 2006 and 2012. Valve durability measures including moderate and severe structural valve deterioration (SVD) were defined according to the updated standardized definitions of the Valve Academic Research Consortium 3 (VARC‐3). Results: A total of 1825 patients were included. The 12‐year mortality rate was 92.8%. At 12 years post‐TAVI, the cumulative incidence of SVD was 9.8% in the total population. Complete echocardiographic follow‐up at ≥ 9 years was available for 56 patients. The median follow‐up of this subgroup was 10.0 years. Moderate SVD was observed in three patients of the echocardiographic follow‐up cohort (5.4%) and severe SVD in two patients (3.6%). Self‐expanding (SE) transcatheter heart valves (THV) had a significantly lower rate of any SVD (2.8% vs 20.0%, p = 0.030) than balloon‐expandable (BE) THV. Conclusion: Long‐term mortality rates in high‐risk patients treated with TAVI more than 10 years ago are substantial, which limits assessment of valve durability measures. In a subgroup of survivors beyond 9 years, the cumulative incidence of SVD was low.

Coronary obstruction (CO) during transcatheter aortic valve replacement (TAVR) is rare but potentially fatal. Computed tomography (CT)-based risk assessment algorithms aim to identify high-risk patients, but their utility remains underexplored. The aim of this study was to examine the clinical utility of a CT-derived algorithm for predicting CO during TAVR and identify predictors of CO despite coronary protection (CP). In this prospective study, 164 patients at risk for CO during TAVR were enrolled. Preprocedural CT was used to classify risk using a published algorithm. A novel volumetric parameter, valve-to-coronary volume (VTCV), was calculated in high-risk cases using sinus width and valve-to-coronary (VTC) distance. The decision to use CP was left to the heart team. Clinical endpoints followed Valve Academic Research Consortium 3 definitions. According to the CT-based algorithm, 58.5% of patients (96 of 164) were at low risk, 24.4% (40 of 164) at intermediate risk, and 17.1% (28 of 164) at high risk. CP was performed in 12.8% of low-risk patients (16 of 125), 52.8% of intermediate-risk patients (28 of 53), and 93.9% of high-risk patients (31 of 33). All CO events (n = 7) occurred in the high-risk group. VTC distance and VTCV were significantly lower in patients with CO (P = 0.006 and P = 0.005, respectively). VTCV independently predicted CO (area under the curve, 0.841; 95% CI: 0.702-0.979; P < 0.001), outperforming VTC distance alone. The predictive value of VTCV was validated in an external cohort including 11 European centers. A CT-based algorithm stratifies patients into 3 CO risk categories, though the decision for CP in clinical practice seems to incorporate additional clinical and procedural variables. Although CP reduces CO risk, its efficacy is limited in patients with very small VTCV, which can be predicted preprocedurally via CT. (Leipzig TAVR Registry; NCT05015452).

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is an established therapy for failed bioprosthetic valves but carries risks for coronary obstruction and subclinical leaflet thrombosis, characterized by hypoattenuated leaflet thickening (HALT) on multidetector computed tomography. Intentional leaflet modification techniques, such as BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction), have been developed to prevent coronary obstruction, but their impact on leaflet thrombosis remains unclear. The aim of this study was to evaluate the association of intentional leaflet modification with the incidence of HALT in patients undergoing ViV TAVR. In a retrospective analysis of 141 patients undergoing ViV TAVR with postprocedural multidetector computed tomography, 61 patients received leaflet modification, and 80 underwent standard ViV TAVR without leaflet modification. Baseline characteristics, post-TAVR computed tomographic findings including HALT, and other procedural outcomes were compared. A sensitivity analysis stratified outcome by transcatheter heart valve type. Predictors of HALT were assessed using multivariable logistic regression with clinically relevant covariates. Leaflet modification was more frequently performed in female patients (62.3% vs 45%; P = 0.04) and those with small (≤21 mm) prosthetic valves (50% vs 22.5%; P < 0.001). Patients undergoing leaflet modification had significantly lower postprocedural mean transvalvular gradients (13 ± 6 mm Hg vs 18 ± 9 mm Hg; P < 0.001) and a reduced incidence of HALT (19.7% vs 40%; P < 0.01) compared with those without leaflet modification. These findings persisted after the analysis was restricted to self-expanding transcatheter heart valves. HALT involving multiple leaflets was numerically less common with leaflet modification (33.3% vs 65.6%; P = 0.054), and thrombosis predominantly affected nonlacerated cusps (66.6% vs 33.3%). No cases of HALT were observed in patients undergoing dual-leaflet modification. Reduced leaflet motion was identified in one-third of patients with HALT, with no significant difference between groups. In patients undergoing ViV TAVR, intentional leaflet modification is associated with a significantly reduced incidence of HALT, suggesting a protective association with subclinical leaflet thrombosis. These results support a potentially hemodynamic benefit of leaflet modification beyond coronary obstruction prevention.