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AbstractObjectivesThe aim of this study was to determine the safety of eliminating the pre‐discharge transthoracic echocardiogram (TTE) on 30‐day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).BackgroundTTE is utilized before, during, and after TAVR. Post‐procedural, pre‐discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR.MethodsPatients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre‐discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post‐TAVR.ResultsA total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre‐discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre‐discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre‐discharge TTE group and none in the group without pre‐discharge TTE at 30‐day follow‐up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre‐discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71).ConclusionsElimination of the pre‐discharge TTE is safe and associated with comparable 30‐day outcomes to routine pre‐discharge TTE. These findings have implication for TAVR practice cost‐efficiency and health care utilization.

AbstractBackgroundThe predictors and clinical significance of increased Doppler‐derived mean diastolic gradient (MG) following transcatheter edge‐to‐edge mitral valve repair (MVTEER) remain controversial.ObjectiveWe sought to examine baseline correlates of Doppler‐derived increased MG post‐MVTEER and its impact on intermediate‐term outcomes.MethodsPatients undergoing MVTEER were analyzed retrospectively. Post‐MVTEER increased MG was defined as >5 mmHg or aborted clip implantation due to increased MG intraprocedurally. Baseline MG and 3D‐guided mitral valve area (MVA) by planimetry were retrospectively available in 233 and 109 patients.Results243 patients were included; 62 (26%) had MG > 5 mmHg post‐MVTEER or aborted clip insertion, including 7 (11%) that had aborted clip implantation. Mortality occurred in 63 (26%) during a median follow up of 516 days (IQR 211, 1021). Increased post‐MVTEER MG occurred more frequently in females (44% vs. 16%, p < 0.001), those with baseline MVA <4.0 cm2 (71% vs. 16%), baseline MG ≥4 mmHg (61% vs. 20%), or multiple clips implanted (33% vs. 21%, p = 0.04). Increased post‐MVTEER MG was associated with increased subsequent mortality compared to those with normal gradient (HR 1.91 95% CI 1.15–3.18 p = 0.016) as was aborted clip insertion compared to all others (HR 5.23 95% CI 2.06–13.28 p < 0.001).ConclusionsSmaller baseline MVA and increased baseline MG are associated with increased MG post‐MVTEER and patients with a Doppler‐derived post‐MVTEER MG >5 mmHg suffered excess subsequent mortality. In high risk patients considered for MVTEER, identification of those at risk of iatrogenic mitral stenosis with MVTEER is important as they may be optimally treated with alternate surgical or transcatheter therapies.

Introduction: Excised aortic valve weight (AVW) correlates with severity of AS. There is some debate about the true severity of AS in low gradient AS (LGAS) compared to high gradient AS (HGAS). We sought to compare patient characteristics and operatively excised AVW in patients with LGAS vs HGAS vs moderate AS. Methods: 916 patients with EF ≥50% undergoing surgical aortic valve replacement for AS between 2010-2012 were included. Clinical and echocardiographic characteristics of LGAS patients (AVA≤1cm 2 , MnG<40mmHg; N=68) were compared to HGAS patients (AVA≤1cm 2 , MnG≥40mmHg; N=745) and operatively excised AVW were compared to moderate AS (AVA>1cm 2 , MnG<40mmHg; N=102). Results: Compared to HGAS, LGAS patients were older (mean age 77 ± 10 vs 73 ± 10 years; p=0.001), often female (56% vs 38%; p=0.006), but without differences in diabetes (26% vs 29%; p=0.78), hyperlipidemia (85% vs 86%, p=0.86), coronary artery disease (49% vs 44%; p=0.53), or hypertension (81% vs 76%; p=0.38). LGAS patients predominantly had trileaflet aortic valves (91% vs 71%; p<0.001), smaller LVOT diameter (2.16 ± 0.15 vs 2.25 ± 0.20 cm; p=0.002), lower stroke volume index (42.1 ± 7.3 vs 49.0 ± 8.8 cc/m 2 ; p<0.001), lower systemic compliance (0.77 ± 0.30 vs 0.93 ± 0.33 ; p<0.001), but no difference in valvulo-arterial impedance (3.96 ± 0.76 vs. 3.84 ± 0.80, p=0.24) compared to HGAS. Excised AVW were lower in patients with LGAS vs HGAS (1.77 ± 0.76 vs 2.69 ± 1.26 g, p<0.001), but not different from moderate AS (1.77 ± 0.76 vs 2.04 ± 0.94 g; p=0.1). This relationship held true when AVW was indexed to body surface area. Three-year mortality post-valve replacement was significantly higher in LGAS compared to HGAS (22% vs 11%, p=0.02). Conclusions: LGAS occurs mostly in older female patients with trileaflet aortic valves. Excised AVW in LGAS is similar to moderate AS but lower than HGAS. However, systemic compliance is higher in LGAS vs HGAS contributing to increased afterload. Poorer outcomes after surgery in LGAS patients may be attributed to noncompliant vasculature which is not corrected with valve replacement and evaluation of patients with LGAS should include assessment of peripheral resistance.

Introduction: Presence of subclinical left ventricle (LV) dysfunction may influence outcomes after percutaneous mitral balloon valvotomy (PMBV), but cannot be detected by conventional echocardiography. Hypothesis: Preprocedure LV global longitudinal strain (GLS) by speckle tracking TTE detects subclinical LV dysfunction and predicts long-term outcome after successful PMVB. Methods: Consecutive patients undergoing PMBV between 2003-2011 who had comprehensive baseline TTE were included. Patients with suboptimal immediate results (repeat PMBV or mitral surgery within first 6 months) and those with suboptimal TTE strain were excluded. LV strain was analyzed with commercial software (Syngo VVI), and GLS averaged from 18 segments. The primary end point was all-cause mortality. Secondary end point was the composite of death and mitral valve reintervention. Results: Of 110 patients screened, 29 (26%) had unsuitable strain imaging, and 8 (7%) had poor immediate results, leaving 73 in the final cohort. Median follow-up was 3.7 years (interquartile range 1.3-7.2). There were 10 deaths (14%) and 25 late mitral valve interventions (34%). Univariate predictors of death were GLS, age, EF, stroke volume, pulmonary artery pressure, mitral valve area and coronary artery disease. In a multivariate Cox model, GLS was the strongest predictor of death after adjustment for age [HR=1.40 (1.09-1.84), P=0.008]. For the composite endpoint, GLS, mitral valve gradient, and invasively mean left atrial pressure were univariate predictors of death or reintervention. At multivariate analysis, GLS was the sole predictor of events [HR=1.17 (1.01-1.34), P=0.03]. Event-free survival is shown in figure. Intra and inter observer intra-class correlation for strain analysis was 0.87 (0.66-0.96) and 0.84 (0.53-0.95), respectively. Conclusions: GLS is a powerful predictor of long-term outcome after PMVB and appears to have an incremental prognostic value over traditional parameters.

Introduction: In asymptomatic patients with severe aortic stenosis (SAS), left ventricular (LV) ejection fraction (EF) <50% is generally considered to be the threshold for referral for aortic valve replacement (AVR). Hypothesis: We investigated the importance of LVEF on long-term outcome after AVR in symptomatic and asymptomatic SAS patients and studied whether LVEF < 50% is the optimal threshold for referral for AVR. Methods and Results: We retrospectively identified 2017 patients with SAS (aortic valve area (AVA)<1cm2, mean aortic valve gradient ≥40 mm Hg, or indexed AVA <0.6 cm2/m2) who underwent surgical AVR from January 1995 to June 2009 at our institution. Patients were divided into 4 groups depending on preoperative LVEF (<50% in 300 (15%) patients, 50-59% in 331 (17%), 60-69% in 908 (45%), and ≥70% in 478 (24%)). The primary end-point was all-cause mortality. During follow-up of 5.3±4.4 years, 1056 (52%) died. Five-year mortality rate increased with decreasing LVEF (41% (n=106), LVEF<50%); 35% (n=98), LVEF 50-59%; 26% (n=192), LVEF 60-69%; 22% (n=90), LVEF≥70%, p<0.0001). Compared to patients with LVEF≥60%, patients with LVEF 50-59% had increased mortality (HR 1.58, p<0.001), with a similar risk increase in both symptomatic (HR=1.56, p<0.001) and asymptomatic patients (HR 1.58, p=0.006, Figure). In a Cox regression analysis corrected for standard risk factors, LV mass index, AVA, and stroke volume index, LVEF was predictive of all-cause mortality (HR=0.89 per 10%, p<0.001). When this multivariable analysis was repeated in the subset of 1333 patients with no history of coronary artery disease, LVEF was still associated with all-cause mortality (HR=0.90 per 10%, p=0.009). Conclusion: In patients with SAS undergoing AVR, patients with LVEF 50-59% have also increased mortality compared to patients with LVEF>60%, suggesting that a different LVEF threshold should be used when referring for AVR.

Tricuspid regurgitation (TR) adversely impacts both quality of life and long-term survival, which generates interest in therapeutic approaches to mitigate these effects. Historically, therapeutic options for TR were limited to surgical approaches, which are often complicated by significant morbidity and mortality in elderly patients with multiple comorbidities. This gap in therapeutic options led to the rapid evolution of transcatheter tricuspid valve intervention (TTVI), with a wide variety of approaches pursued and early results suggesting that TTVI improves clinical outcomes. Numerous strategies, including edge-to-edge repair, annular reduction, spacers, caval valve implantation, and transcatheter tricuspid valve replacement form the basis of TTVI today. In this review, the authors discuss the current state of each approach.

Introduction: Ischemic stroke (IS) causes substantial morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI) with a 5 yr incidence ~ 3%. We sought the test the accuracy of Machine learning (ML) algorithms in predicting IS in patients undergoing PCI. Methods: Mayo Clinic CathPCI registry data were retrospectively analyzed from Jan 2003 - June 2018 including 21,872 patients who underwent PCI. The cohort was randomly divided into a training sample (75%, n=16404) and a unique test sample (25%, n=5468) prior to model generation. The risk prediction model was generated utilizing a random forest algorithm (RF model) on 188 unique variables to predict the risk of IS at 6-month, 1, 2, and 5-year post PCI. Conventional risk factors for stroke were used for logistic regression. The receiver operating characteristic (ROC) curve and area under the curve for the RF and logistic regression models were compared for the test cohort. Results: The mean age was 66.9 ± 12.4 years, and 71% were male. Patient demographics and outcomes are shown in Table 1 . The ROC area under the curve for the RF model was superior compared to the logistic regression model in predicting IS at 6 months, 1,2 and 5 yrs for the test cohort ( Figure 1 .) Conclusions: The RF model accurately predicts short and long term risk of IS and outperforms logistic regression analysis in patients undergoing PCI.

AbstractObjective/BackgroundSmall balloon expandable valves have higher echocardiographic transvalvular gradients and rates of prosthesis‐patient mismatch (PPM) compared to larger valves. However, the impact of these echocardiographic findings on clinical outcomes is unknown. We sought to determine the clinical outcomes of 20 mm SAPIEN 3 (S3 BEV) compared to larger S3 BEV in relation to echocardiographic hemodynamics.MethodsUsing the STS/ACC transcatheter valve registry, we performed a propensity‐matched comparison of patients undergoing treatment of native aortic valve stenosis using transfemoral, balloon‐expandable implantation of 20 mm and ≥ 23 mm S3 BEVs. Baseline and procedure characteristics, echocardiographic variables and survival were analyzed. Multivariable logistic regression was used to identify predictors of 1‐year mortality.ResultsAfter propensity matching of the 20 mm and ≥ 23 mm SAPIEN 3 valves, 3,931 pairs with comparable baseline characteristics were identified. Small valves were associated with significantly higher echocardiographic gradients at discharge (15.7 ± 7.1 mmHg vs. 11.7 ± 5.5 mmHg, p < 0.0001) and severe PPM rates (21.5% vs. 9.7%, p < 0.0001). There was no significant difference in 1‐year all‐cause mortality (20 mm: 13.0% vs. ≥23 mm: 12.7%, p = 0.72) or other major adverse event rates and outcomes between the two cohorts. Based on a multivariable analysis, elevated discharge mean gradient (>20 mmHg), severe PPM and the use of 20 mm versus ≥23 mm were not independent predictors of 1‐year mortality.ConclusionSAPIEN 3 20 mm valves were associated with higher echocardiographic gradients, and severe PPM rates compared to larger valves but these factors were not associated with significant differences in 1‐year all‐cause mortality or rehospitalization.

Abstract Background Bioprosthetic tricuspid valve stenosis (TS) is an uncommon and frequently under-diagnosed condition. Although the resulting right heart failure symptoms are well-known, the associated thrombogenic potential is under-recognized. Case summary A 44-year-old woman with bioprosthetic tricuspid valve (TV) replacement in 2001 was referred for urgent consultation due to acute worsening of dyspnoea and severe swelling and pain in her left arm and neck. She was diagnosed with atrial fibrillation 6 months before the presentation and was found to have right atrial (RA) thrombus with pulmonary embolism and extensive retrograde venous extension 1 month prior. Review of studies done at her local institution revealed 10 mmHg mean gradient (MG) across the bioprosthetic TV that was only reported as mild–moderate TS. Echocardiography done at our instruction confirmed suspicion of severe TS with calcified immobile leaflets. Computed tomography showed persistent RA thrombus and therefore surgical replacement of the TV was undertaken. Subsequently, patient’s dyspnoea rapidly improved. Discussion Progressive dyspnoea and symptoms of right heart failure in a patient with a history of bioprosthetic TV replacement should be investigated for prosthetic valve dysfunction. Due to its rarity, TS diagnosis can be overlooked on routine echocardiography. In our patient, despite a measured MG of 10 mmHg, the presence of critical TS was not initially recognized. As TS is associated with increased thrombogenic potential and given the rare occurrence of in situ RA thrombosis, physicians must have a high index of suspicion for TS in the appropriate clinical context.