Objectives To investigate prevalence of iatrogenic atrial septal defects (iASDs) after mitral valve (MV) transcatheter edge-to-edge repair (TEER) with the MitraClip in the long-term follow-up. Background MV TEER requires transseptal puncture using a large 22 F sheath. Prevalence, impact and haemodynamic effects of these iASDs remain unknown in the long-term follow-up. Methods This prospective study enrolled patients who had undergone first-time TEER at our university hospital between January 2017 and June 2018 for a clinical long-term follow-up study. Prevalence of iASD was investigated 12 months post-TEER using transoesophageal echocardiography (TEE). Study protocol further consisted of transthoracic echocardiography (TTE) and exercise testing. Incidence of all-cause death was compared 12 months post-TEE follow-up. This study was approved by local ethics committee. Results 48 patients participated in clinical follow-up examinations. Median time between TEER and clinical follow-up examination (TEE, TTE, exercise testing) was 19.5 (IQR: 7.0) months after TEER. Persistent iASD was found in 41.7% of patients. TEER was found to be equally effective in reducing MR and clinical symptoms in both groups at baseline as well as follow-up. Procedural fluoroscopy and device times were significantly longer in the iASD group. MR reduction and functional status (New York Heart Association Class, 6 Minute Walking Test distance) were similar in both groups. Nevertheless, a significant decrease in systolic pulmonary artery pressure (sPAP) and significantly smaller atrial diameters were observed in patients with iASD at follow-up. Conclusion Prevalence of iASDs after TEER in long-term follow-up was about 41%. Although a significant reduction of sPAP and better left atrial reverse remodelling were accomplished in patients with iASD, clinical impact appears low. Manipulation at the atrial septum might play a key role in creating persisting iASD.

Bleeding in the context of cardiac catheterization is frequent and negatively impacts on short- and long-term patient outcome. We evaluated the clinical impact of in-hospital bleeding events after transcatheter mitral valve repair (TMVr) in the long-term follow- up. 586 consecutive patients treated with first-time TMVr were enrolled in this registry. In-hospital MVARC (Mitral Valve Academic Research Council) bleedings were assessed and patients were grouped according to the incidence of a bleeding event. Multivariate logistic regression was used to identify significant independent predictors of MVARC bleeding. This study received approval by local ethics committee. 78 patients (13.3%) suffered from an MVARC bleeding event (Access site-related bleedings: 46.2%; GI tract bleeding: 35.9%; Other bleedings: 17.9%). Among these bleeding subgroups, neither relevant differences in baseline characteristics nor in severity of bleeding events were observed. Despite not being an independent predictor for overall death in the multivariate Cox regression analysis, MVARC bleeding was associated with prolonged hospital stay. The ORBIT bleeding score was the best match to predictors of any MVARC bleeding found in our cohort (c-score overall cohort: 0.68; c-score GI bleeding cohort: 0.72). MVARC bleedings after TMVr are frequent findings but were only in half of the cases related to the access site. The ORBIT score could be useful for identification of patients at high risk for non-access site bleeding and especially GI bleeding.

Background: Recent developments in transcatheter mitral valve repair (M-TEER) have expanded the indication for the procedure beyond conventional criteria to include patients with anatomically complex degenerative mitral regurgitation (DMR), but long-term outcomes are not well known. Aims: To investigate outcomes by specific anatomical criteria in patients with severe DMR and complex valve anatomy enrolled in the prospective MitraUlm registry. Methods: Clinical and echocardiographic 3-year outcomes of 304 patients with DMR and complex mitral valve anatomy, defined according to the CLASP IID registry criteria, were investigated. Outcomes were analysed separately for specific anatomical complexities. Results: 33.5% of patients had ≥ independent significant jets, 12% multisegmental prolapse, 12.3% mitral valve orifice area < 4 cm², 10.9% commissural lesions with wide/multiple jets, and 10.1% large flail. Mitral regurgitation (MR) reduction ≤ 2 was achieved in 93.8% of patients at discharge and in 85.9% at 3-year follow-up. Patients with multisegmental prolapse and commissural lesions with multiple/wide jets had the lowest MR reduction at discharge. Compared to patients treated with MitraClip Generation 1–3, patients treated with MitraClip Generation 4 had significantly better post-procedural MR reduction (MR ≤ 1 in 74.3% vs 50.7%, P < 0.001) and higher 3-year survival rates (80.2% vs 61.6%, Log Rank P = 0.002). Postprocedural MR reduction to MR ≤ 1 was the strongest independent predictor of 3-year survival, whereas the presence of at least two anatomical complexities and elevated post-procedural left atrial pressure predicted 3-year all-cause mortality. Conclusions: In patients with anatomically complex DMR, advances in procedural techniques for M-TEER have allowed successful treatment with sustained MR reduction and improved long-term survival. Graphical

Summary: CT-based opportunistic screening using artificial intelligence finds a high prevalence (43%) of osteoporosis in CT scans obtained for planning of transcatheter aortic valve replacement. Thus, opportunistic screening may be a cost-effective way to assess osteoporosis in high-risk populations. Background: Osteoporosis is an underdiagnosed condition associated with fractures and frailty, but may be detected in routine computed tomography (CT) scans. Methods: Volumetric bone mineral density (vBMD) was measured in clinical routine thoraco-abdominal CT scans of 207 patients for planning of transcatheter aortic valve replacement (TAVR) using an artificial intelligence (AI)-based algorithm. Results: 43% of patients had osteoporosis (vBMD < 80 mg/cm ³ L1-L3) and were elderly (83.0 {interquartile range [IQR]: 78.0–85.5} vs. 79.0 {IQR: 71.8–84.0} years, p < 0.001), more often female (55.1 vs. 28.8%, p < 0.001), and had a higher Society of Thoracic Surgeon’s score for mortality (3.0 {IQR:1.8–4.6} vs. 2.1 {IQR: 1.4–3.2}%, p < 0.001). In addition to lumbar vBMD (58.2 ± 14.7 vs. 106 ± 21.4 mg/cm ³ , p < 0.001), thoracic vBMD (79.5 ± 17.9 vs. 127.4 ± 26.0 mg/cm ³ , p < 0.001) was also significantly reduced in these patients and showed high diagnostic accuracy for osteoporosis assessment (area under curve: 0.96, p < 0.001). Osteoporotic patients were significantly more often at risk for falls (40.4 vs. 22.9%, p = 0.007) and required help in activities of daily life (ADL) more frequently (48.3 vs. 33.1%, p = 0.026), while direct-to-home discharges were fewer (88.8 vs. 96.6%, p = 0.026). In-hospital bleeding complications (3.4 vs. 5.1%), stroke (1.1 vs. 2.5%), and death (1.1 vs. 0.8%) were equally low, while in-hospital device success was equally high (94.4 vs. 94.9%, p > 0.05 for all comparisons). However, one-year probability of survival was significantly lower (84.0 vs. 98.2%, log-rank p < 0.01). Conclusion: Applying an AI-based algorithm to TAVR planning CT scans can reveal a high rate of 43% patients having osteoporosis. Osteoporosis may represent a marker related to frailty and worsened outcome in TAVR patients. Graphical

Background: Transcatheter tricuspid edge-to-edge repair (T-TEER) is widely used to treat atrial (AFTR) and ventricular (VFTR) functional tricuspid regurgitation (FTR). Methods: The outcome of 136 patients treated with T-TEER for severe AFTR or VFTR was analyzed using a composite endpoint of all-cause death and rehospitalization for decompensated heart failure. AFTR was defined as TR in the context of left ventricular ejection fraction ≥50%, right ventricular fractional area change (RVFAC) ≥ 35% and sPAP ≤ 50 mmHg. Results: Patients with VFTR (N = 109) and AFTR (N = 27, 19.9%) were both elderly (82.0 {IQR: 74.5–84.5} vs. 82.0 {IQR: 75.0–84.0} years, p = 0.98) and had similar interventional risk according to the EuroScore II (6.1 {4.0–9.8} vs. 4.7 {3.6–9.6} %, p = 0.3). Atrial fibrillation was equally frequent in both groups (89.9 vs. 88.9%, p = 0.88). AFTR patients were significantly more often female (56.0 vs. 77.8%, p = 0.04) and had lower NT-proBNP (3600.0 {1706.0–6302.0} vs. 1988.0 {1034.8–3723.3} pg/mL, p < 0.01). While RVFAC (29.5 ± 8.6 vs. 42.1 ± 4.3%, p < 0.01) and LVEF (48.5 ± 12.3 vs. 58.6 ± 8.0%, p < 0.01) were expectedly lower in patients with VFTR, right atrial dilation (RA volume: 126.7 ± 56.5 vs. 127.6 ± 74.2 mL, p = 0.99) was similar. Successful T-TEER with TR reduction ≥ 2 degrees (96.3 vs. 92.6%, p = 0.34) was observed in both groups, and residual TR ≤ II was equally frequent (94.5 vs. 96.3%, p = 1.0). The incidence of the 1-year composite endpoint was significantly higher (34.3 vs. 12.0%) in patients with VFTR (log-rank p = 0.02). AFTR was inversely associated with the composite endpoint (HR: 0.21, 95% CI: 0.06–0.7, p < 0.01) in multivariate Cox regression. Conclusions: Despite equally effective TR reduction through T-TEER, a better outcome was observed in patients with AFTR.

Background: Diabetes mellitus worsens outcomes in patients suffering from heart disease undergoing cardiac procedures. Objectives: To investigate the impact of diabetes in patients undergoing mitral transcatheter edge-to-edge repair (M-TEER). Methods: 1118 patients treated with M-TEER for functional (FMR) and degenerative (DMR) mitral regurgitation (MR) between 2010 and 2021 were analyzed using the combined endpoint of death/rehospitalization for heart failure (HFH). Results: Among diabetics (N = 306; 27.4%), comorbidities such as coronary artery disease (75.2% vs. 62.7%; p < 0.001) and progressed (stage III/IV) chronic kidney disease (79.5% vs. 72.6%; p = 0.018) were more frequent. The rate of FMR was higher in diabetics (71.9% vs. 64.5%; p < 0.001). The combined endpoint occurred more frequently in diabetics (40.2% vs. 35.6%; log-rank = 0.035). While no difference was observed in FMR patients (36.8% vs. 37.6%; log-rank p = 0.710), rates of the combined endpoint differed significantly between diabetics and non-diabetics in DMR patients (48.8% vs. 31.9%; log-rank p = 0.001) only. However, diabetes did neither predict the combined endpoint in the overall (OR: 0.97; 95% CI 0.65–1.45; p = 0.890) nor in the DMR cohort (OR: 0.73; 95% CI 0.35–1.51; p = 0.389). Among diabetics treated with M-TEER, troponin (OR: 2.32; 95% CI 1.3–3.7; p = 0.002) and estimated glomerular filtration rate (OR: 0.52; 95% CI 0.3–0.88; p = 0.018) independently predicted the combined endpoint. Conclusions: Diabetes is associated with adverse outcomes after M-TEER, particularly in DMR patients. However, diabetes does not predict the combined endpoint. In diabetics undergoing M-TEER, biochemical markers associated with organ function and damage independently predict the combined endpoint of death and rehospitalization.