Mitral regurgitation (MR) is a common valvular disease associated with poor prognosis. Percutaneous mitral valve repair (PMVR) combined with guideline-directed medical therapy has shown prognostic benefits, yet a substantial proportion of patients experience major adverse cardiovascular events (MACE), including death and heart failure hospitalization, within the first year. Identifying short-term nonresponders remains a clinical priority. This study evaluated the prognostic value of advanced right ventricular (RV) function parameters in predicting MACE following PMVR using the MitraClip system. A total of 60 consecutive patients with symptomatic severe MR undergoing PMVR were analyzed. Echocardiographic assessments were performed at baseline, postprocedure before discharge, and at 6-month follow-up. Parameters included tricuspid annular plane systolic excursion (TAPSE) normalized to pulmonary artery systolic pressure (TAPSE/PASP), right ventricular end-diastolic area (TAPSE/RVAD), and end-systolic area (TAPSE/RVAS), along with RV myocardial work indices. During the first year, 35% of patients experienced MACE. At baseline, those who developed MACE had significantly higher creatinine, troponin T, NT-proBNP levels, larger right heart dimensions, and lower TAPSE (all p <0.05), while other clinical, imaging, and procedural characteristics were similar. In multivariate analysis, TAPSE/PASP, TAPSE/RVAS, and TAPSE/RVAD were independent predictors of MACE (all p <0.05), with AUC values ranging from 0.80 to 0.85, indicating strong predictive capacity. Throughout follow-up, these indices remained significantly lower in patients with MACE, while RV myocardial work parameters had lower predictive accuracy (AUC<0.60). In conclusion, a comprehensive RV assessment, particularly TAPSE-based indices, can help identify patients at higher risk of adverse outcomes after PMVR, whereas RV myocardial work indices appear less reliable.

Atrial secondary mitral valve regurgitation (ASMR) is a distinct anatomical subset of secondary mitral regurgitation (SMR). Evidence of the effect of transcatheter edge-to-edge repair (TEER) on left atrial (LA) anatomy and function, especially reverse remodelling (LARR), is still sparse.

We retrospectively evaluated all consecutive patients treated with TEER for mitral regurgitation (MR) in our centre between January 2013 and October 2023. Of the 597 patients with SMR, 103 patients (17.3%) met the inclusion criteria for ASMR. All patients in the ASMR group (mean age 79.4 ± 6.8 years, 71% female) were symptomatic (89% NYHA ≥ III) and had a mean logistic EuroScore of 22.5 ± 12.4%. TEER was successfully performed in all patients, and invasive LA mean pressures decreased intraprocedurally from 17.8 ± 5.7 to 13.1 ± 4.8 mmHg (P < 0.001). At hospital discharge, 94% of patients had mild residual or non/trace MR. At 1YFUP, the prevalence of residual moderate MR was 7% and 1% had severe MR. A significant reduction in LA volume compared with baseline, both at end-systole (151.4 ± 64 vs. 113 ± 64 mL, P < 0.001) and at end-diastole (119.8 ± 56 vs. 91.2 ± 56.9 mL, P < 0.001) could be observed. Seventy per cent of patients had a sustained decrease in NYHA class ≤ II. LARR, defined as LAESV decrease ≥15% at 1YFUP, was documented in 59% of patients. These patients were more likely to have lower post-interventional mitral valve mean pressure gradients (2.2 ± 0.8 mmHg vs. 2.8 ± 1.1 mmHg, P = 0.02) and lower BNP at discharge and at 1 month follow-up [319 (197.8 to 526) vs. 560 (279.3 to 929), P = 0.07, and 287.5 (191.3 to 386.3) vs. 506.5 (223.3 to 935.5), P = 0.06, respectively]. A multivariate logistic regression analysis identified pre-procedural MPG (P = 0.06, OR 0.92, CI 95% 0.85-1.00) and BNP at discharge (P = 0.11, OR 0.99, CI 95% 0.99-1.00) as independent predictors for the occurrence of LARR at 1 year.

Transcatheter mitral valve repair by edge-to-edge therapy represents a safe and effective therapeutic option in symptomatic patients with atrial secondary mitral regurgitation and might have the potential to induce left atrial reverse remodelling.

Prevalence of mitral regurgitation (MR) and comorbidity burden rise with age. Mitral valve transcatheter edge-to-edge repair (M-TEER) is increasingly performed in elderly patients, but only limited data are available for this specific subgroup. In this study, outcomes of octogenarians and nonagenarians undergoing M-TEER were analysed using a large real-world dataset.

This retrospective study included consecutive patients undergoing M-TEER at the Ulm University Heart Center between January 2010 and December 2021. The cohort was divided into an elderly group and a younger group based on the cohorts' median age. Group differences regarding 1 and 3 year mortality and heart failure hospitalization rates were assessed using Kaplan-Meier survival analysis and Cox proportional hazard models.

A total of 1118 patients [median age 79 (inter-quartile range 74-83) years; 42% female] were included and divided into 513 elderly (≥80 years) and 605 younger (<80 years) patients. Primary MR was more frequent in the elderly group (56% vs. 27%, P < 0.001). Pre-procedural and post-procedural MR grades were comparable between groups (pre-procedural MR grade 4: 69% in the elderly group vs. 71% in the younger group, P = 0.67; post-procedural MR grade 1: 60% in the elderly group vs. 58% in the younger group, P = 0.77) as well as in-hospital mortality rates (0.2% vs. 0.3%, P = 0.66). Three-year heart failure hospitalization rates did not differ significantly between both groups (30.7% in the older age cohort vs. 36.0% in the younger cohort, P = 0.191). While 1 year all-cause mortality rates were comparable (18% vs. 16.4%, P = 0.577), 3 year all-cause mortality was significantly higher in the elderly [43.1% vs. 33.0%; hazard ratio (HR) 1.29 (95% confidence interval 1.02-1.65), P = 0.035]. Pre-procedural N-terminal pro-brain natriuretic peptide (NT-proBNP) ≥3402 pg/mL [HR 2.29 (95% CI 1.34-3.90), P = 0.002], pre-interventional MR grade [HR 1.79 (95% CI 1.01-3.17), P = 0.045] and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II [HR 1.06 (95% CI 1.03-1.08), P < 0.001] were identified as independent predictors of 3 year mortality in the elderly.

M-TEER displays a safe and effective treatment option for elderly patients with symptomatic MR, offering symptom relief and comparable 1 year outcomes to younger patients. Elderly patients with elevated EuroSCORE II and advanced heart failure might benefit from additional care to further reduce 3 year mortality.

Accurate quantification of mitral valve regurgitation (MVR) is crucial for patient management. While different MVR quantification methods based on cardiac magnetic resonance imaging (CMR) exist, their reproducibility and reliability remain uncertain. This study aims to evaluate the reproducibility of different CMR 2D-phase contrast (PC) and 4D-flow MVR quantification methods. The inter-reader and intra-reader reproducibility were assessed using intraclass correlation coefficients (ICC). Seven methods were evaluated: 2D-PC standard (LVSV minus aortic flow), 2D-PC mitral-aortic (mitral inflow minus aortic flow), 2D-PC direct (quantifying mitral backflow), 4D-flow standard, 4D-flow mitral-aortic, 4D-flow direct, and volumetric method (LVSV minus RVSV) in 32 patients (74.8 ± 9.8 years, 28% females) with secondary MVR, analyzed independently by two experienced readers. A total of 26 patients were included in the analysis for 2D-PC and 15 for 4D-flow methods. Among all techniques, 2D-PC standard was the most reliable method with both good inter-reader (ICC = 0.85, p < 0.001) and intra-reader agreement (ICC = 0.87, p < 0.001). The 4D-flow standard (ICC = 0.97, p < 0.001) and the volumetric method (ICC = 0.81, p < 0.001) showed excellent and good intra-reader agreements, respectively, but only moderate inter-reader reproducibility (ICC = 0.52, p = 0.027 and ICC = 0.71, p < 0.001). In patients with secondary MVR, 2D-PC standard method demonstrated the highest reproducibility, while 4D-flow methods showed excellent intra-reader reliability but more variable inter-reader agreement. Standardized post-processing protocols and training would likely enhance the clinical application of these techniques. Future studies should investigate these methods in larger, diverse cohorts and correlate findings with clinical outcomes.

Mitral regurgitation and tricuspid regurgitation are the most common valvular heart diseases in patients with heart failure and have independent prognostic value. Transcatheter interventions are now available for the treatment of valvular heart disease, and their efficacy and safety have been tested in randomized controlled trials. However, evidence is still limited and sometimes inconclusive because several aspects of these trials limit their interpretation or consistency. These include heterogeneity in the pathogenesis and clinical characteristics of patients, the dynamic nature of secondary atrioventricular valve disease severity, the role of heart failure medications and devices, dependency on procedural results and operators' skills, smaller number of patients enrolled and the power to detect differences in trials, and limitations to use patients' reported outcomes with unblinded study protocols. These specific aspects of trials in patients with atrioventricular valve disease are reviewed in this article with a focus on possible solutions to generate further evidence for the efficacy and safety for transcatheter treatments of atrioventricular valve disease in patients with heart failure.

The impact of the COAPT results on clinical practice has not yet been investigated in large real-world cohort study. The aim of the study is to evaluate the potential impact of the COAPT trial by analyzing the temporal trends of baseline characteristics and outcome of secondary mitral regurgitation (SMR) patients undergoing MitraClip (MC) included in the GIOTTO registry.

The study population was divided into 2 groups, considering the enrolment before or after the COAPT publication. Temporal trend analyses were performed to evaluate the changes in baseline patients' characteristics and clinical outcome over time, and whether the COAPT publication influenced these changes. The outcome measure was the composite of hospitalization for heart failure (HF) and all-cause death at 1 year.

The analysis included 1184 consecutive SMR patients treated with MC at 19 Italian centres between January 2016 and March 2020, 809 (68.3%) in the pre-COAPT group and 375 (31.7%) in the post-COAPT group. Temporal trend analyses showed a decreasing trend for New York Heart Association (NYHA) class (P = .003), hemoglobin (P = .014), and a significant upward trend for left ventricular ejection fraction (P < .001) and peripheral arterial disease (PAD, P = .046). The publication of the COAPT trial impacted only on NYHA trend. Nonsignificant differences in the composite outcome were observed between groups (P = .086).

The selection process of SMR patients undergoing MC changed over time, with a significant impact of the COAPT publication mainly on the trend of NYHA class. At 1-year, patients in the post-COAPT group showed a nonsignificant reduction in the incidence of hospitalization for HF and all-cause death.

While transcatheter edge-to-edge repair (TEER) with MitraClip is increasingly used, data on the risk stratification for assessing early mortality after this procedure are scarce.

This study aimed to assess early mortality and analyze the risk factors of early mortality among patients who underwent TEER.

Using the all-payer, nationally representative Nationwide Readmissions Database, our study included patients aged 18 years or older who had TEER between January 2017 and November 2020. We categorized the cohort into two groups depending on the occurrence of early mortality (death within 30 days after the procedure). Based on the ICD-10, we identified the trend of early mortality after TEER and further analyzed the risk factors associated with early mortality.

A total of 15,931 patients who had TEER were included; 292 (1.8 %) with early mortality and 15,639 (98.2 %) without. There was a decreasing trend in early mortality from 2.8 % in the first quarter of 2017 to 1.2 % in the fourth quarter of 2020, but it was not statistically significant (p = 0.18). In multivariable analysis, the independent risk factors for early mortality were chronic kidney disease not requiring dialysis (adjusted odds ratio [aOR]: 1.57; 95 % confidence interval [CI]: 1.11-2.22, p = 0.01), end-stage renal disease (aOR: 2.34; CI: 1.44-3.79, p < 0.01), chronic liver disease (aOR: 4.90; CI: 3.29-7.29, p < 0.01), coagulation disorder (aOR: 3.42; CI: 2.35-5.03, p < 0.01), systolic heart failure (aOR: 2.81; CI: 1.34-5.90, p < 0.01), diastolic heart failure (aOR: 2.69; CI: 1.24-5.84, p = 0.01) and unspecified heart failure (aOR: 3.23; CI: 1.49-7.01, p < 0.01). Among those who died during 30-day readmission following TEER, the most common cardiac cause and non-cardiac-cause of readmission were heart failure (18.2 %) and infection (26.6 %), respectively.

The early mortality following TEER was low at 1.8 %. The independent risk factors associated with early mortality were chronic kidney disease (including end-stage renal disease), chronic liver disease, coagulation disorder, and heart failure (both systolic and diastolic).

Valvular heart disease (VHD) is rapidly increasing in prevalence worldwide, affecting millions and significantly impacting global health care systems. Despite notable advancements in understanding VHD progression, perioperative management, imaging techniques, and transcatheter therapies over the past 2 decades, the condition has not received the attention it deserves from the public and policymakers. Many patients with VHD in low- and middle-income countries continue to experience low detection, intervention, and follow-up rates. Systematic care for elderly patients and those with severe comorbidities, as well as postoperative patients, remains insufficient, leading to higher mortality and morbidity rates. This review focuses on the deficiencies in VHD treatment within the Chinese health care system and discusses the modern management program, known as the whole-life cycle management system, that has been implemented to enhance the survival prognosis of VHD patients.

Mitra-clip is an established therapy for high-risk surgical candidates who are refractory to optimal medical treatment. Reports have shown that right ventricular dysfunction (RVD) has been associated with increased morbidity and mortality in heart failure (HF) patients. Our goal of this systematic review/meta-analysis is to assess the prognosis of baseline RV function markers including TAPSE (tricuspid annular plane systolic excursion) and TAPSE:PASP (pulmonary artery systolic pressure) ratio after Mitra-clip. MEDLINE and EMBASE were searched from inception to December 20th, 2023, for studies discussing the prognostic outcome of pre-existing RVD in Mitra-clip patients. Definition of RV dysfunction was reported as an abnormal TAPSE (< 15-16 mm) or RV-PA (right ventricle-pulmonary artery) uncoupling expressed as abnormal TAPSE:PASP ratio (< 0.30-0.37 mm/mmHg). We included all original research studies (excluding reviews, meta-analysis, commentaries/editorials, and animal studies) that assessed the prognostic utility of TAPSE and TAPSE:PASP ratio in patients with MR undergoing Mitra-clip. Reviewers independently screened the studies and extracted the pertinent data. Odds ratios (OR) were calculated using a random-effects model. Twelve reports enrolling 3526 patients were included. Mean age ranged from 70 to 81 years and 61.1% patients were male. Primary, secondary, and mixed MR were reported in 36.9%, 61.4%, and 1.8% respectively. Mean LVEF ranged from 27% to 57.1% and 93.7% of patients had MR grade ≥ 3 + (at least moderate to severe MR). Patients with RVD had a reduction in the overall survival (OS) after Mitra-clip at 6 months (81.8% vs 90.5%, OR = 0.45 [0.35-0.58]; P < 0.001), 1-year (71.1% vs 85.7%, OR = 0.40 [0.33-0.48]; P < 0.001), and 2-year (60.3% vs 76.8%, OR = 0.37 [0.31-0.45]; P < 0.001) compared to normal RV group. Likewise, HF re-admission free survival was minimized among RVD patients at 6 months (76.8% vs 88.1%, OR = 0.47 [0.34-0.65]; P < 0.001), 1-year (64.5% vs 81.3%, OR = 0.44 [0.35-0.55]; P < 0.001), and 2-year (58.2% vs 78.9%, OR = 0.41 [0.30-0.56]; P < 0.001) compared to normal RV group. Decreased TAPSE: PASP was associated with lower OS at 6-month (OR = 0.46 [0.31-0.68]; P < 0.001), 1-year (OR = 0.37 [0.29-0.47]; P < 0.001), and 2-year (OR = 0.35 [0.25-0.47]; P < 0.001) and reduced HF re-admission free survival at 6-month ((OR = 0.44 [0.31-0.62]; P < 0.001), 1-year (OR = 0.41[0.31-0.54]; P < 0.001), and 2-year (OR = 0.41 [0.31-0.58]; P < 0.001) after Mitra-clip. Furthermore, decreased TAPSE negatively impacted the OS and HF re-admission at 6-month (OR = 0.40 [0.21-0.77]; P = 0.006), and 1-year (OR = 0.50 [0.31-0.80]; P = 0.004) and increased HF re-admission rate at 6-month (OR = 0.27 [0.13-0.56]; P = 0.0005), and 1-year (OR = 0.30 [0.15-0.58]; P = 0.0004). Pre-existing RVD as expressed by TAPSE < 15-16 mm or TAPSE:PASP ratio < 0.30-0.37 mmHg reduced the OS and HF readmission free survival after Mitra-clip.

Combined M- and T- TEER typically involves two separate systems, complicating logistics and increasing procedural risks. This study aims to evaluate the safety and efficacy of combined mitral (M-TEER) and tricuspid (T-TEER) transcatheter edge-to-edge repair using a single TriClip® steerable guide catheter (SGC).

Patients with moderate-to-severe (3+) or severe (4+) degenerative (DMR) or functional (FMR) mitral regurgitation and massive/torrential or severe functional tricuspid regurgitation (TR), classified as New York Heart Association (NYHA) class III or IV, who underwent combined M- and T- TEER with the same TriClip SGC between January 2022 and December 2024, were included. The primary objectives included procedural outcomes, MR and TR severity reduction, and NYHA class improvement.

Among 42 patients (64 % female; median age: 77 years [IQR: 9]), the implantation success rate was 100 %, with mean device and procedure times of 39.2 ± 6.9 and 71.2 ± 9.6 min, respectively. There were no in-hospital or 30-day major adverse events (MAEs), except for 2 patients (4.8 %) with tricuspid single leaflet device attachment (SLDA), and 1 patient (2.4 %) who underwent atrial septal defect (ASD) closure. Over a median follow-up period of 0.91 years, 3 (7.1 %) patients were hospitalized for heart failure, with zero mortality. At 1-year follow-up, all patients achieved NYHA class ≤II, along with MR ≤2+ and 34 (81 %) patients had only trivial/mild TR.

Combined M-TEER and T-TEER using the same TriClip SGC demonstrated favorable safety and efficacy, along with significant functional and echocardiographic improvements.

Transcatheter edge-to-edge repair (TEER) has been shown to be an effective treatment option for patients experiencing cardiogenic shock (CS) with concomitant high-grade mitral valve regurgitation. However, haemodynamic changes following M-TEER have not been thoroughly investigated. Afterload mismatch, leading to the deterioration of haemodynamics subsequent to mitral regurgitation correction, could potentially occur and adversely impact prognosis. Our objective was to analyse the effect of TEER on haemodynamic and echocardiographic parameters in patients with CS.

We conducted a retrospective study of patients undergoing TEER for mitral valve regurgitation in the setting of CS. Haemodynamic and echocardiographic parameters before and after TEER were systematically analysed. A total of 25 patients underwent TEER in the context of CS. All patients were successfully treated with at least of one grade reduction in mitral regurgitation. The median left atrial mean pressure decreased from 23 mmHg (IQR 17-30) to 16 mmHg (IQR 11-20, P < 0.01), and the V-wave decreased from 36 mmHg (IQR 27-44) to 21 mmHg (IQR 14-25, P < 0.01) following the procedure. The stroke volume index and cardiac index increased from 25 mL/m2 (IQR 18-29) to 34 mL/m2 (IQR 25-44, P < 0.01) and from 1.90 L/min/m2 (IQR 1.41-2.30) to 2.50 L/min/m2 (IQR 1.99-2.86, P < 0.01), respectively. We did not observe any worsening of the ejection fraction after the procedure. Ten patients (40%) died during their hospital stay.

Our study demonstrates that TEER leads to favourable haemodynamic changes in patients with CS. We observed a significant reduction in left atrial pressure, V-wave, and an elevation in cardiac index. Importantly, we did not observe any deterioration in left ventricular function following the procedure. This supports the concept of haemodynamic stabilization with TEER in patients with CS and high-grade mitral regurgitation.

Functional mitral regurgitation (FMR) is associated with adverse outcomes in patients with heart failure, and current guideline-directed medical therapy (GDMT) offers limited efficacy in managing FMR. This study aims to evaluate the therapeutic impact of the sodium-glucose cotransporter 2 inhibitor (SGLT2i) dapagliflozin in patients with moderate or severe FMR.

In this randomized controlled trial, 104 patients with moderate or severe FMR were assigned in a 1:1 ratio to receive either dapagliflozin 10 mg once daily or no additional treatment alongside current GDMT for FMR, with a follow-up period of 3 months. The primary endpoint was the change in effective regurgitant orifice area (EROA) of mitral regurgitation (MR). Secondary endpoints included changes in regurgitant volume (RV), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular mass (LVM), left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF), E/e' ratio, and left atrial volume index (LAVI). The incidence of hospitalization for heart failure or cardiovascular death was also compared between the groups. As a result, dapagliflozin significantly reduced the EROA of FMR (-0.074 ± 0.099 vs. -0.030 ± 0.058 cm2 for dapagliflozin vs. control, P = 0.008). It also significantly decreased RV (-9.08 ± 15.27 vs. -2.98 ± 9.28 mL, P = 0.017), E/e' ratio (-5.88 ± 7.41 vs. -1.98 ± 7.63, P = 0.011), and LAVI (-2.50 ± 4.75 vs. -0.43 ± 3.14 mL/m2, P = 0.011) while improving LVEF (6.57 ± 10.10 vs. 1.92 ± 9.57%, P = 0.017). No significant differences were observed in changes in LVEDV, LVESV, LVM, and LVMI between groups (P > 0.05). Hospitalization for heart failure occurred in 9.6% of the dapagliflozin group and 15.3% of the control group (hazard ratio, 0.60; 95% CI, 0.20-1.83; P = 0.368). Cardiovascular death occurred in 1.9% of the dapagliflozin group compared to 3.8% of the control group (hazard ratio, 0.49; 95% CI, 0.04-5.41; P = 0.561) during the 3-month follow-up.

Dapagliflozin demonstrates the potential to further reduce the degree of MR and enhance myocardial remodelling in patients with FMR when used in addition to current GDMT. These findings suggest the importance of SGLT2i in heart failure patients with FMR as an additive positive effect on echocardiographic parameter and possibly outcome.

Transcatheter structural heart procedures have become standard therapy for elderly patients with high surgical risk. Over time, these procedures have significantly increased worldwide, accompanied by a concomitant reduction of major complications, including those requiring emergent cardiac surgery (ECS). This marked decline in ECS is due to technological advancements, improved patient selection and procedural techniques, and increased institutional and operators expertize. Moreover, most major structural complications after transcatheter structural heart procedures are now managed percutaneously, with only a small proportion requiring ECS. It is important to note that outcomes for patients requiring ECS remain unfavorable, even in the optimal setting. Currently, ECS after percutaneous structural interventions is very rare, less than 0.5%, as reported in multicenter available studies. However, fragmented data exist in the literature on the need of ECS. Indeed, low incidence, different definitions, and lack of recent reports make it difficult to have a precise and up-to-date overview of bailout surgery for treatment of procedural complications. This is the first comprehensive analysis focusing on ECS following the major frequent percutaneous structural procedures, that is, transcatheter aortic valve replacement, mitral valve repair/replacement, and left atrial appendage occlusion. More in general, a collaborative approach among Heart Team members, along with thorough procedural planning guided by advanced imaging techniques, is essential for ensuring high-quality interventions thus minimizing the risk of adverse events.

Transcatheter mitral leaflet repair is a non-surgical technique used to treat severe mitral regurgitation. The technique has matured significantly since its commercial introduction, and with device iteration and increasing operator experience, it is now an important treatment option for patients at higher risk for conventional mitral valve surgery. Randomised clinical trials have established the safety and efficacy of the technique in the treatment of primary and secondary mitral regurgitation, and its use was approved by the National Institute for Health and Care Excellence in 2019. This position statement summarises the clinical evidence and indications for the procedure and provides expert consensus on best practice in terms of patient selection, the procedure and post-procedure care. Standards are also described with respect to team composition, minimum case volume and collection of procedural and outcome data.

Ischemic heart disease (IHD) is the leading global cause of death, affecting millions and leading to significant morbidity and mortality. Ischemic cardiomyopathy (ICM), a manifestation of IHD, results in severe left ventricular dysfunction due to coronary artery disease and poses a significant challenge due to the complex pathophysiology, variable clinical presentation, and overall poor prognosis. Recent advances in medical therapy, device interventions, and revascularization techniques offer newfound hope in improving ICM patient outcomes. This article reviews the state-of-the-art management approaches for ICM, emphasizing the importance of personalized treatment plans that integrate the various contemporary therapies to address the multiple mechanisms of disease development and progression. A meticulously tailored treatment approach for each individual patient offers the hope of prolonged survival through the synergy of therapies designed to address the different and complex mechanisms that contribute to their disease process.

This review describes and evaluates the representation of women in cardiovascular randomized controlled trials (RCT), it reports significant under-representation of women in clinical trials both as participants and researchers and discusses the ethical implications of under-representation. The under-representation of women as participants in cardiovascular RCTs is evident in trials investigating cardiovascular drugs, acute coronary syndrome, heart failure and interventional procedures and devices. Under-representation of women is also evident in the authorship of cardiovascular clinical trials and in trial leadership roles, and under-representation of women as trial investigators is independently associated with under- recruitment of women as trial participants. A notable lack of RCTs investigating conditions that disproportionately affect women is also evident, this triad of underrepresentation for women as participants, and investigators, and the lack of RCTs into conditions predominantly experienced by women, all contribute to the gender gap in cardiovascular outcomes. Better representation of women in clinical trials, in trial leadership and authorship is a key factor to address to equity, distributive justice and improve outcomes for women with cardiovascular disease.

The management of valvular heart disease has undergone a remarkable transformation over the past two decades, which was driven by the advent of catheter-based treatment methods. Whereas medical therapy was the only available treatment option for many older patients deemed unsuitable for conventional surgery until the early 2000s, a wide range of interventional therapies is now available. Transcatheter aortic valve replacement and mitral valve transcatheter edge-to-edge repair evidently provide prognostic advantages over medical therapy for inoperable patients with severe aortic stenosis and secondary mitral regurgitation, and they have been demonstrated to be non-inferior to conventional surgery in certain operable patient groups. Although catheter-based therapies of aortic and tricuspid regurgitation have not yet been proven to provide prognostic benefits, these approaches enable substantial and sustainable improvements in symptoms as well as quality of life while demonstrating a favorable safety profile. Given the multitude of available options for the treatment of valvular heart diseases, determining the appropriate indication and selecting the optimal therapeutic approach often pose significant challenges. This review article highlights the latest advancements in valvular heart disease management and explores the patient-centered application of available therapies within the framework of an approach toward precision medicine.

Background: Pulmonary hypertension (PH) is associated with the outcomes of mitral valve transcatheter edge-to-edge repair (M-TEER) in patients with severe mitral regurgitation (MR). However, the prognosis of baseline PH on MR patients after M-TEER has been controversial. This meta-analysis aimed to determine the prognostic value of PH with early and late outcomes after M-TEER with MitraClip. Methods: We systematically searched PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science for studies. The results of the meta-analysis are summarized as the hazard ratio (HR), odds ratios (ORs) or mean difference (MD) and 95% confidence interval (CI). Results: A total of 20 publications were included in the systematic review, of which six were observational cohort studies including 5684 patients. The pooled incidence estimate of all-cause mortality was more common in severe PH than in patients who were non-PH. On pooled multivariate analysis, baseline PH was associated with late (≥1-year) all-cause mortality (HR = 1.61, 95% CI [1.23-2.11]) and the combined outcome of late HF rehospitalization and all-cause mortality (HR = 1.33, 95% CI [1.15-1.53]) after M-TEER. The level of SPAP significantly decreased after MitraClip in MR patients with PH (MD = -12.33 mmHg, 95% CI [-14.08--10.58]). Conclusions: Baseline PH had a worse prognosis of early (≥30-day) cardiac mortality, late all-cause mortality as well as the composite outcome of HF rehospitalization and all-cause mortality after M-TEER compared to non-PH patients. Future studies are needed to prove these findings.

Background/Objectives: Transcatheter edge-to-edge mitral valve repair (M-TEER) has emerged as an efficacious treatment modality among patients at high perioperative risk. Given the steady increase in procedures and the limited capacity for intensive care, there is a need to identify patients at high risk for postinterventional intensive care. Methods: All patients who underwent M-TEER between 2014 and 2023 were investigated. The intensive care unit (ICU) stay ended when patients met all the following criteria: no further need for catecholamine support, no oxygen requirement > 6 L O2/min, no indication for renal replacement therapy, and no delirium or relevant bleeding. Uni- and multivariable logistic regression analyses were used to identify independent predictors of the need for ICU treatment. Results: In total, 33% of patients (62/183) had an indication for ICU treatment after M-TEER. Patients with an indication for ICU treatment had significantly lower survival rates three years after M-TEER (37.4% [23/62] vs. 61.6% [75/121], p < 0.001) than patients without an ICU indication. A EuroSCORE II of >10% (OR 2.6, 95% CI 1.3-5.4, p = 0.006), a MitraScore of >3 (OR 2.5, 95% CI 1.2-5.2, p = 0.02), and a hospital stay of >5 days before M-TEER (OR 3.2, 95% CI 1.6-6.4, p < 0.001) were independently associated with the need for ICU treatment. Conclusions: One-third of the patients were indicated for ICU treatment, which was associated with a high mortality rate. On the basis of these predictors of required ICU care, tailored treatment strategies can be developed to improve treatment outcomes.

Valvular heart disease (VHD) is the third leading cause of cardiovascular morbidity, with its incidence and public health impact projected to increase significantly. This study adopts a novel perspective, focusing on elderly individuals residing in rural areas, highlighting the unique dynamics of small-town settings.

This multicenter, observational study was conducted from May 2022 to September 2023, under the coordination of the AOU Careggi Echo Core-Lab, which managed the entire screening program. In 10 small Italian villages, each municipality facilitated the enrollment of asymptomatic individuals aged ≥ 65 years, with no prior VHD history, through voluntary participation. Participants were grouped into three age categories (65-69, 70-74, and ≥ 75 years) and underwent a thorough evaluation, including a Quality of Life (QoL) questionnaire and comprehensive echocardiographic assessment focusing on VHD detection and grading.

Among 1,113 participants, the prevalence and severity of VHD showed a significant increase with age (p < 0.0001). Remarkably, 94% of individuals aged ≥ 75 years had at least one valvular defect, with 22.5% presenting moderate or severe valvulopathy, including a prevalence of 4.8% for moderate or severe aortic valve stenosis and 7.5% for mitral regurgitation. Right-sided valvulopathies followed a similar trend, affecting 71.9% of elderly participants. QoL evaluations revealed a generally positive perceived health status, with a mean score of 77 ± 16.

Our registry highlights that the prevalence of VHD in asymptomatic individuals over 65 years living in small Italian communities is substantial, increases with age, and is predominantly degenerative in etiology. Notably, most individuals with undiagnosed VHD perceived themselves as healthy.

Advanced heart failure (AHF) represents the terminal stage of heart failure (HF), characterized by persistent symptoms and functional limitations despite optimal guideline-directed medical therapy (GDMT). This review explores the clinical definition, pathophysiology, and therapeutic approaches for AHF. Characterized by severe symptoms, New York Heart Association (NYHA) class III-IV, significant cardiac dysfunction, and frequent hospitalizations, AHF presents substantial challenges in prognosis and management. Pathophysiological mechanisms include neurohormonal activation, ventricular remodeling, and systemic inflammation, leading to reduced cardiac output and organ dysfunction. Therapeutic strategies for AHF involve a multidisciplinary approach, including pharmacological treatments, device-based interventions like ventricular assisted devices, and advanced options such as heart transplantation. Despite progress, AHF management faces limitations, including disparities in access to care and the need for personalized approaches. Novel therapies, artificial intelligence, and remote monitoring technologies offer future opportunities to improve outcomes. Palliative care, which focuses on symptom relief and quality of life, remains crucial for patients ineligible for invasive interventions. Early identification and timely intervention are pivotal for enhancing survival and functional outcomes in this vulnerable population. This review underscores the necessity of integrating innovative technologies, personalized medicine, and robust palliative strategies into AHF management to address its high morbidity and mortality.

Although the prognostic implications of severe mitral regurgitation (MR) are well recognised, they are less clear in moderate MR. We therefore explored the prognostic impact of both moderate and severe MR within the large National Echocardiography Database Australia cohort.

Echocardiography reports from 608 570 individuals were examined using natural language processing to identify MR severity and leaflet pathology. Atrial (aFMR) or ventricular (vFMR) functional MR was assessed in those without reported leaflet pathology. Using individual data linkage over median 1541 (IQR 820 to 2629) days, we examined the association between MR severity and all-cause (153 612/25.2% events) and cardiovascular-related mortality (47 840/7.9% events).

There were 319 808 men and 288 762 women aged 62.1±18.5 years, of whom 456 989 (75.1%), 102 950 (16.9%), 38 504 (6.3%) and 10 127 (1.7%) individuals had no/trivial, mild, moderate and severe MR, respectively, reported on their last echo. Compared with those with no/trivial MR (26.5% had leaflet pathology, 19.2% died), leaflet pathology (51.8% and 78.9%, respectively) and actual 5-year all-cause mortality (54.6% and 67.5%, respectively) increased with MR severity. On an adjusted basis (age, sex and leaflet pathology), long-term mortality was 1.67-fold (95% CI 1.65 to 1.70) and 2.36-fold (95% CI 2.30 to 2.42) higher in moderate and severe MR cases (p<0.001) compared with no/trivial MR. The prognostic pattern for moderate and severe MR persisted for cardiovascular-related mortality and within prespecified subgroups (leaflet pathology, vFMR or aFMR, and age<65 years).

Within a large real-world clinical cohort, we confirm that conservatively managed severe MR is associated with a poor prognosis. We further reveal that moderate MR is associated with increased mortality, irrespective of underlying aetiology.

Australian New Zealand Clinical Trials Registry (ACTRN12617001387314).

The Cardiovascular Outcomes Assessment for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) risk score predicts the risk of death or hospitalization for heart failure within 2 years after transcatheter edge-to-edge repair (TEER) of mitral regurgitation (MR) using the MitraClip device. We performed an international validation of the score in patients who underwent TEER in Italian and Polish cardiology centers. Patients with severe functional MR who underwent TEER with MitraClip between March 2012 and July 2023 were included. Patients were categorized as COAPT-eligible or -noneligible based on the COAPT trial criteria. Clinical data were collected from medical records and the COAPT risk score was calculated for each patient. The primary end point was a composite of all-cause mortality and hospitalization for heart failure at the 2-year follow-up. Of 344 patients, 218 were COAPT-eligible (63%) and 126 were COAPT-noneligible (37%). A higher COAPT score correlated to increased risk of primary end point in the overall population (p <0.001) and COAPT-eligible (p = 0.020) and COAPT-noneligible groups (p = 0.042). The COAPT score had a poor predictive value for the primary end point in every group (area under the curve [AUC] ≤0.61 for all). It performed better in lower-risk patients (<4 points) than higher-risk patients (≥4 points) (AUC 0.658 vs AUC 0.523). The COAPT score was independently associated with an increased risk of primary end point in patients with <4 points (adjusted hazard ratio 1.338, 95% confidence interval 1.031 to 1.737, p = 0.028) but not those with higher score values. In conclusion, the COAPT risk score has a poor performance in COAPT-eligible and -noneligible patients with severe functional MR. The score performance depends on the patient baseline risk, with better accuracy in lower-risk patients.

Moderate-to-severe mitral regurgitation (MR) and tricuspid regurgitation (TR) are common in patients hospitalized with heart failure (HF) and have been associated with poor quality of life and increased mortality. The impact of these valve lesions on in-hospital decongestion and postdischarge outcomes is less clear. This study analyzed 617 patients hospitalized for acute HF in the Diuretic Optimization Strategies in Acute Heart Failure (DOSE-AHF), Renal Optimization Strategies Evaluation in Acute Heart Failure (ROSE-AHF), and Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARESS-HF) trials. We assessed biomarkers, physical examination findings, and symptom scores in 288 patients without moderate-to-severe regurgitation, 221 patients with moderate-to-severe MR, and 242 patients with moderate-to-severe TR to evaluate decongestion efficacy and outcomes. For patients with moderate-to-severe MR, there was no difference in weight loss, net fluid loss, or change in creatinine compared with those without moderate-to-severe regurgitation (all p >0.05 at 72 hours). For patients with moderate-to-severe TR, there was more weight loss (-4.77 vs -2.83 pounds at 24 hours, p = 0.029; -9.32 vs -6.99 pounds at 72 hours, p = 0.007), net fluid loss (-4,988 vs -4,581 ml, p = 0.008), and improvement in creatinine (-0.09 mg/100 ml vs +0.06 mg/100 ml at 72 hours, p = 0.002) than those without moderate-to-severe regurgitation. In those with and without moderate-to-severe regurgitation, there was no difference in the change in patient-reported dyspnea or global well-being (all p >0.05 at 72 or 96 hours). For postdischarge outcomes, compared with patients without moderate-to-severe regurgitation, moderate-to-severe MR was associated with a nonsignificant trend toward increased death, rehospitalization, or unscheduled clinic or emergency department visit 60 days after hospital discharge (48.4% vs 38.2% of patients, p = 0.098). This association was not clearly apparent in patients with moderate-to-severe TR (43.8% vs 38.2%, p = 0.407). In conclusion, patients with moderate-to-severe MR experienced similar in-hospital decongestion compared with those without significant regurgitation but had a trend toward worse postdischarge outcomes. Patients with moderate-to-severe TR experienced significantly more decongestion but this was not associated with incremental improvement in dyspnea, global well-being, or clinical outcomes.

With the expansion of indications for mitral transcatheter edge-to-edge repair into nondegenerative etiologies, it is unknown whether changes in technical success and clinical outcomes have occurred.

The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/TVT) registry was analyzed from 2013 to 2023. Patients in shock were excluded. Patients were grouped by the mechanism of mitral regurgitation (MR) and divided into time periods.

Overall, 68 028 patients were included. The application of mitral transcatheter edge-to-edge repair has evolved over the past decade to include more nondegenerative etiologies-increasing from 19% to 43%. The biggest growth was observed in functional MR (atrial and ventricular). Excluding acute ischemic MR, the odds of technical success were significantly higher for all mechanisms compared with degenerative MR (DMR). Over time more procedures were performed using only 1 implanted device (64.7% during 2022-2023 versus 54.6% during 2013-2017), without negatively impacting technical success. In multivariable analyses, the risk of 1-year heart failure readmission for ventricular functional MR was not higher than for DMR (P=0.10642), while patients with chronic ischemic MR and atrial MR had a 19% higher risk of 1-year heart failure readmission compared with DMR (P=0.00493) even if they had a successful procedure. However, the risk of 1-year mortality was not higher in nondegenerative etiologies compared with DMR. There was no statistically significant interaction between MR mechanism and time in outcomes analyses, indicating that the effect of MR mechanism on the technical and 1-year clinical outcomes did not vary significantly over time.

The application of mitral transcatheter edge-to-edge repair for nondegenerative etiologies increased considerably. While the odds of technical success were higher for all etiologies except acute ischemic MR, a similar 1-year mortality risk was observed in nondegenerative etiologies compared with DMR in real-world settings. These data support the use of mitral transcatheter edge-to-edge repair in degenerative and nondegenerative etiologies.

Transcatheter edge-to-edge repair (TEER) is currently indicated in symptomatic patients with severe functional mitral regurgitation (MR) who are not eligible for surgery and who have a high likelihood of responding to treatment. This recommendation is based on two randomized trials suggesting that the benefits of TEER may be limited to patients with severe MR, defined by an effective regurgitant orifice area (EROA) ≥0.40 cm2, and a non-excessively remodelled left ventricle. The randomized RESHAPE-HF2 study recently showed that compared to medical therapy alone, treatment with TEER by MitraClip in patients with symptomatic heart failure and less severe functional MR, with lower EROA (mean 0.23 cm2), is associated with a significant reduction in hospitalizations for heart failure, and an improvement in symptoms and quality of life, without a clear benefit on mortality. However, within the cohort of patients with less severe MR enrolled in the RESHAPE-HF2 study, the benefits of MitraClip compared to medical therapy alone seem more significant in selected patients with characteristics associated with a higher risk of heart failure exacerbation, suggesting the importance of careful selection of patients with symptomatic heart failure and MR who could benefit from TEER.

Mitral regurgitation (MR) is the most common valvular disease in industrialized countries, with a significant impact on patient quality of life and survival, especially in an increasingly elderly and comorbid population. Repair surgery is considered the treatment of choice for primary MR, offering excellent long-term outcomes. However, the MitraClip system, a less invasive percutaneous option based on the edge-to-edge principle, has proved to be a valid alternative for patients at high surgical risk, showing initial benefits in terms of fewer post-operative complications. Surgery remains superior in terms of durability and prevention of residual regurgitation, but the MitraClip system offers advantages in selected patients, with improvements in quality of life and reductions in hospitalizations for heart failure. A multidisciplinary approach and careful patient selection are essential to optimize outcomes.

To assess in-hospital outcomes in patients undergoing urgent versus non-urgent transcatheter mitral edge-to-edge repair (TEER).

We used the NIS database 2016-2019 to include admissions who underwent TEER. Inverse probability of treatment weighting (IPTW) was used to compare urgent versus non-urgent groups.

A total of 29 730 weighted admissions were included, of whom 21.6% were urgent admissions. Urgent admissions had a higher risk of in-hospital mortality (risk ratio [RR] 3.67, 95% confidence interval [CI] 2.39-5.62), cardiogenic shock (RR 4.95, 95% CI 3.73-6.57), intra-aortic balloon pump (RR 3.97, 95% CI 2.53-6.23), percutaneous ventricular assist device (RR 17.24, 95% CI 6.37-46.66), mechanical ventilation (RR 3.79, 95% CI 2.80-5.11), acute stroke (RR 2.56, 95% CI 1.32-4.97), in-hospital cardiac arrest (RR 2.25, 95% CI 1.08-4.69), major bleeding (RR 5.18, 95% CI 2.97-9.06), increased length of stay (6 vs. 2 days, p < 0.001), and higher total costs ($229 160 vs. $164 653, p < 0.01) compared to non-urgent admissions. There was no difference between both groups for renal replacement therapy and pericardial complication.

Our results suggest that urgent TEER implantation was associated with an increased risk of in-hospital death and other short-term complications.

Objectives: Randomized evidence on the role of heart failure guideline-directed medical therapy for patients with functional mitral regurgitation (FMR) is lacking. The present meta-analysis sought to investigate the prognostic impact of different pharmacotherapy categories recommended in heart failure on subjects with FMR. Methods: A systematic literature review was conducted to identify studies reporting the association of renin angiotensin system inhibitors (RASi), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) with outcomes in FMR. A random-effects meta-analysis was conducted to quantify the unadjusted and adjusted hazard ratios [(a)HRs] for all-cause death and the composite outcome in each medical category. Results: Twelve studies with 6,715 FMR patients were included. The use of RASi and BB was associated with a significantly lower risk of all-cause mortality (HR 0.52 [0.39-0.68]; p < 0.00001, I2 = 62% and HR 0.62 [0.49-0.77]; p < 0.0001, I2 = 44%, respectively) and the composite outcome (HR 0.54 [0.44-0.67]; p < 0.00001, I2 = 33% and HR 0.62 [0.52-0.75], p < 0.00001, I2 = 35%, respectively) in unadjusted models. Both RASi (aHR 0.73 [0.56-0.95], p = 0.02, I2 = 52%) and BB (aHR 0.60 [0.41-0.88], p = 0.009, I2 = 55%) retained their association with the composite outcome in pooled adjusted models. The prognostic benefit of using RASi or BB was retained in subgroup analyses including only (1) patients with moderate or severe FMR and (2) patients with reduced or mildly reduced left ventricular ejection fraction. MRA did not demonstrate a significant association with improved outcomes. Conclusions: RASi and BB administration appear to have a favorable prognostic impact on patients with FMR, regardless of the severity of regurgitation.

Mitral regurgitation (MR) is a prevalent valvular heart disease with significant morbidity, particularly in aging populations. Management strategies for MR have evolved from traditional open-heart surgery to innovative transcatheter approaches, addressing the limitations of surgical repair in high-risk patients. Transcatheter edge-to-edge repair, exemplified by devices such as MitraClip and PASCAL, has shown efficacy in reducing MR severity, improving functional capacity, and decreasing heart failure hospitalizations in selected patients. Advances in annuloplasty and chordal repair offer minimally invasive options with promising early outcomes. Transcatheter mitral valve replacement represents the frontier of MR treatment, addressing anatomical complexities unsuitable for repair, though complications such as left ventricular outflow tract obstruction persist. Emerging data from clinical trials underscore the importance of patient selection and a multidisciplinary heart team approach. In this review, each modality is discussed concerning its indications, procedural techniques, outcomes, and associated challenges. It highlights the transformative potential of transcatheter mitral valve interventions while emphasizing the need for ongoing innovation and research to optimize outcomes and expand therapeutic options for patients with severe MR.

The increasing prevalence of heart failure (HF) has led to advancements in therapeutic strategies, including the development of new pharmacological treatments and the expansion of guideline recommendations across the spectrum of left ventricular ejection fractions. Despite these advancements, the full benefits of guideline-directed medical therapy (GDMT) are often limited by various barriers that result in incomplete implementation or suboptimal responses. For patients who cannot tolerate or only partially respond to GDMT, therapeutic options remain limited. This gap is particularly significant for those with contraindications to heart replacement therapies (HRT), such as left ventricular assist device (LVAD) or heart transplant. In light of these potential limitations, this review article proposes categorizing HF patients into four distinct phenoprofiles based on their tolerance to GDMT and candidacy for HRT. Considering these HF phenoprofiles may guide treatment decisions regarding the selection and use of novel device-based HF therapies. Furthermore, we summarize data on commercially available and emerging device-based HF therapies, evaluating their clinical utility, mechanisms of action, and selection criteria based on current evidence. Finally, we describe clinical cases across various proposed HF phenoprofiles to illustrate how these HF profiles can guide the use of novel device-based therapies to achieve clinical stability, improve GDMT tolerance, or serve as a bridge to, or be used in tandem with HRT in select patients.

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.