Alon Shechter

Background: Residual moderate or greater mitral regurgitation (MR) after transcatheter edge‐to‐edge repair is strongly associated with adverse clinical outcomes. However, the prognostic impact of implanting additional clips in patients with significant residual MR after the first clip remains uncertain. We evaluated the clinical and echocardiographic outcomes of multiple‐clip implantation for significant residual MR following placement of the initial clip. Methods: We retrospectively evaluated 826 patients with moderate or greater residual MR on intraprocedural transesophageal echocardiography after placement of the first clip during transcatheter edge‐to‐edge repair at the Cedars‐Sinai Medical Center from 2014 to 2023. Patients were categorized into single‐clip (n=113) and multiple‐clip (n=713) groups. The primary end point was the composite of all‐cause mortality and heart failure hospitalization at 1 year. Results: Procedural technical success and complication rates were comparable between groups. The multiple‐clip group demonstrated greater MR reduction and higher transmitral pressure gradients at discharge, 30 days, and 1 year. At 1 year, the composite end point occurred less frequently in the multiple‐clip group than in the single‐clip group (16.8% versus 29.2%; P =0.002), along with greater and more sustained improvement in New York Heart Association functional class. In subgroup analyses, multiple‐clip implantation consistently reduced major adverse cardiovascular events in patients with moderate as well as moderate–severe/severe residual MR. Conclusions: In patients with significant residual MR after implanting the first clip, multiple‐clip implantation improved MR reduction and 1‐year outcomes without increasing complications. Even in moderate residual MR, additional clips were associated with more favorable clinical outcomes.

Valvular heart disease remains a major challenge in contemporary cardiology, owing in part to the complex interplay among loading conditions, filling pressures, cardiac remodeling, and ventricular function, which contributes to substantial variability in clinical presentation and disease progression. Further, the assessment and management of multivalvular disorders is substantially less well defined than those of isolated valvular lesions, potentially leading to mistreatment. Our current Research Topic aims to address these challenges by bringing together contemporary work spanning novel diagnostic technologies, perioperative risk stratification, and advanced echocardiographic phenotyping. The four manuscripts published within this collection illustrate innovative directions in the evolving field of valvular heart disease, while highlighting areas in which additional research is needed.The first article, by Li and colleagues, deals with intraoperative hemodynamic assessment during valve replacement surgery. In a retrospective matched cohort of 162 patients, the investigators compared transesophageal echocardiography (TEE) combined with FloTrac monitoring with TEE accompanied by conventional invasive arterial pressure monitoring.Significant differences between monitoring strategies were observed in several hemodynamic variables, including cardiac output, cardiac index, stroke volume variation, and their temporal behavior during surgery. However, despite the greater hemodynamic detail provided by TEE plus FloTrac, postoperative complication rates, including cognitive decline, did not differ significantly between groups, suggesting that a intraprocedural physiological measurement does not necessarily translate into improved clinical outcomes. Once again, further prospective studies are needed to investigate the prognostic impact of monitoring protocols during valvular The second paper, by Close and colleagues, reports on the detection of isolated aortic stenosis using auscultation recordings obtained with unmodified mobile phones and analyzed by computational nonlinear dynamics. In this single-center pilot study of 248 participants, the bestperforming model for aortic stenosis achieved an area under the curve of 0.872 and a sensitivity of 92.3%. Interestingly, recordings obtained by study personnel and by participants themselves appeared to be equally informative, suggesting feasibility of patient-generated recordings. The implications of this work extend beyond aortic stenosis itself, as access to definitive diagnostic tests requiring appropriately trained personnel is limited in general, and the need for low-cost screening tools is as high as ever. While thought-provoking, the study's findings require external prospective validation across broader populations as well as evaluation of whether such screening improves referral, diagnosis, treatment, and outcomes.The third article, by Gharehdaghi and colleagues, focuses on risk stratification in isolated tricuspid regurgitation (TR). In this multicenter retrospective study of of 104 patients with at least moderate TR, the TRI-SCORE independently forecasted the risk for all-cause mortality and/or heart failure hospitalizations following both conservative and invasive (i.e., surgery or transcatheter edge-to-edge repair) management. Moreover, one-year mortality increased progressively across low-, intermediate-, and high-risk categories, from 7% to 13% and 33%, respectively. These findings are particularly relevant, as proper risk stratification is essential for successful treatment and the avoidance of a futile one. Yet, the absence of a significant survival difference between treatment groups in this observational cohort highlights the limitations of non-randomized comparisons.Last but not least, Liao and colleagues explore advanced echocardiographic markers in medically managed secondary mitral regurgitation. Among 399 patients followed for a median of

Background Aortic stenosis (AS) is a progressive valvular disease with a growing clinical burden in ageing populations. We aimed to characterize the contemporary presentation and progression of AS and to evaluate the association between disease severity, clinical outcomes, and aortic valve intervention.Methods We conducted a retrospective cohort study using an echocardiographic registry at large tertiary medical center. AS severity was classified according to the ESC guidelines. Clinical characteristics, disease progression, aortic valve interventions, and all-cause mortality were assessed using multivariable Cox regression and propensity score matching.ResultsAmong 66,530 individuals undergoing 502,752 echocardiograms, AS was present in 7% at baseline. Over a median follow-up of eight years, AS deterioration occurred in 56.8% of patients with mild AS and 42.8% with moderate AS. Aortic valve intervention occurred in 79.9% of patients with severe AS, of whom 52.4% underwent transcatheter aortic valve implantation. All-cause mortality increased stepwise with AS severity, reaching 26.8 events per 100 person-years in severe AS. In multivariable analysis, any stage of AS was independently associated with increased mortality (mild: HR 1.26, 95% CI 1.19–1.34; moderate: HR 1.35, 95% CI 1.25–1.45; severe: HR 1.56, 95% CI 1.45–1.68; all p<0.001). In the matched cohort, mild AS was associated with an 18% increased risk of all-cause mortality compared with controls (HR 1.18, 95% CI 1.10–1.25).ConclusionsAS is a progressive disease with a substantial clinical burden, even at mild stages. Disease severity at presentation and comorbidities are strong predictors of mortality, underscoring the importance of vigilant monitoring and timely intervention.

Little is known regarding in-hospital transthoracic echocardiography (TTE) utilization and its prognostic implications among stable patients with acute myocardial infarction (AMI). We aimed to explore patient and disease characteristics, treatment strategies, and mid-term outcome following uncomplicated AMI according to TTE use during the hospitalization phase. A single-center, retrospective analysis was conducted that included consecutive adult individuals admitted for AMI who did not develop cardiogenic shock and who survived the index hospitalization. Stratified by in-hospital TTE administration status, the cohort was evaluated for all-cause mortality at 1-year post-discharge. Overall, 15,971 subjects (mean age 66 ± 14 years, 69.8% males, 46.1% with ST-elevation myocardial infarction) were analyzed, of whom 12,610 (79.0%) underwent TTE. TTE use correlated with younger age, fewer comorbidities, greater odds of invasive revascularization and intensive coronary care unit management, and lengthier hospital stay. Ultimately, it was associated with a lower rate, cumulative incidence, and—independent of accompanying prognostic markers—risk of all-cause mortality (n = 1032/12,619, 8.2% vs. n = 804/3361, 23.9%, p < 0.001; Log-Rank p < 0.001; adjusted hazard ratio 0.75, 95% confidence interval 0.67–0.83, p < 0.001). Similar results were observed within a 6270-patient, 1-1 propensity score-matched sub-cohort. To conclude, in our experience, in-hospital TTE administered for stable AMI patients was associated with improved mid-term survival. Further research is needed to re-evaluate the present-day recommendation’s Level of Evidence C for its routine use.

Background and Objectives: Acute myocardial infarction (AMI) increases the risk of developing type 2 diabetes mellitus (T2DM), yet the long-term prognostic significance of new-onset T2DM after AMI remains unclear. We aimed to evaluate long-term mortality among AMI survivors who developed T2DM during follow-up compared with those who remained non-diabetic and those with pre-existing T2DM. Materials and Methods: We conducted a retrospective cohort study of consecutive AMI patients hospitalized between 2002 and 2017 at a large tertiary medical center. Patients were categorized into three groups: (1) new-onset T2DM after AMI (NOT2DM), 1–15 years post-discharge; (2) no diabetes (No DM), with no evidence of T2DM during the same period; (3) pre-existing T2DM (T2DM), diagnosed prior to or during the index AMI. Age- and sex-matching was performed. Primary outcome: all-cause mortality with up-to 10 years of follow-up. Results: A total of 4207 patients were included (1202 NOT2DM; 2404 No DM; 601 T2DM). Over a median follow-up of 2729 days, 1492 patients (35.5%) died. Mortality was highest in the NOT2DM group (44.9%) compared with No DM (31.2%) and T2DM (33.4%) (p < 0.001). After adjustment, NOT2DM remained strongly associated with increased mortality versus No DM (AdjHR 1.408; 95% CI 1.256–1.578) and T2DM (AdjHR 1.272; 95% CI 1.074–1.508) (p < 0.001 for each). The mortality impact was most pronounced in patients < 65 years. Conclusions: Development of T2DM after AMI identifies a high-risk subgroup with significantly worse long-term survival, especially among the young patients. These findings underscore the need for systematic metabolic surveillance and early preventive strategies in AMI survivors.

Aims: Chronic kidney disease (CKD) is associated with adverse cardiovascular outcomes, yet few contemporary studies stratify outcomes by specific CKD stages in the era of modern percutaneous coronary intervention (PCI) techniques and new-generation drug-eluting stents (DESs). We aim to assess the relationship between CKD and post-PCI outcomes in an updated, stage-specific, and long-term cohort. Methods: We retrospectively analyzed 11,489 patients who underwent PCI between 2010 and 2020. Kidney function was classified as preserved (eGFR ≥ 60 mL/min/1.73 m²), stage III CKD (eGFR 30–59), or stage IV/V CKD (eGFR < 30) using the CKD-EPI equation. The primary endpoint was a composite of all-cause mortality, non-fatal myocardial infarction (MI), and target vessel revascularization (TVR) at 1 year; secondary endpoints included individual components and outcomes through 5 years. Associations were evaluated using multivariable Cox regression. Results: Stage III and stage IV/V CKD were present in 18% and 5.6% of patients, respectively. At 1 year, both stage III (HR 2.13, p < 0.01) and stage IV/V CKD (HR 4.91, p < 0.01) were associated with higher risk of the composite endpoint. Mortality rose sharply with CKD severity (33% in stage IV/V vs. 4% in preserved renal function), and MI risk was significantly higher in stage IV/V CKD. These associations persisted after 5 years. Unadjusted TVR risk was higher in stage IV/V CKD but lost significance after adjustment. Conclusions: CKD, particularly in advanced stages, is independently associated with increased mortality and MI after PCI, with effects persisting in the long term. While advanced CKD showed higher unadjusted TVR risk, this was not independent after adjustment. These findings support individualized treatment strategies and extended follow-up in PCI patients with CKD.

Background: Preprocedural contrast-enhanced computed tomography (CT) is essential for planning Transcatheter Aortic Valve Implantation (TAVI), but concerns remain regarding contrast-induced (CI) acute kidney injury, especially in patients with chronic kidney disease. This study aimed to evaluate the incidence of CI-acute kidney injury following contrast-enhanced CT performed before TAVI. Methods: CI-acute kidney injury was defined according to the Kidney Disease—Improving Global Outcomes (KDIGO) guidelines. Nonionic, low-osmolality iodinated contrast material was used for all CT studies. The primary outcome was the incidence of CI-acute kidney injury post-CT. Secondary outcomes included the need for renal replacement therapy and the 30-day post-CT mortality rate. Results: Our study included 359 patients. The median age was 81, and 44% were males. Chronic kidney disease was present in 59.3% of patients, and the overall incidence of CI-acute kidney injury occurred in 24 patients (7%), without a significant difference between patients with and without baseline chronic kidney disease (4.8% vs. 8%, respectively; p = 0.331). Three consecutive creatinine tests within a median of 5.8 days showed that acute kidney injury occurred in only six patients (1.7%). No patients required new dialysis initiation within 30 days. Multivariable analysis did not identify baseline chronic kidney disease or IV contrast volume as independent predictors of CI-acute kidney injury. Conclusions: CI-acute kidney injury following pre-TAVI CT is low, even among patients with chronic kidney disease. Most cases were transient and did not require dialysis. Routine avoidance of CT due to chronic kidney disease may not be warranted.