Tobias Zeus

Background: Calcific aortic stenosis (AS) is one of the most common and prognostically relevant valvular heart diseases, with a growing global burden driven by population ageing. Prediction of disease progression from moderate to severe AS, which would be instrumental for earlier diagnosis and treatment, remains challenging. At the same time, moderate AS is increasingly recognized as a heterogeneous condition associated with clinically relevant risk, particularly in patients with cardiac damage, heart failure, or rapid disease progression. Conventional echocardiographic parameters incompletely capture the biological heterogeneity underlying AS progression. The MODAS study was established to investigate biomarkers and mechanisms of AS progression and outcome using longitudinal multimodal phenotyping. Methods: The MODAS Study is a prospective, multicenter, longitudinal observational cohort study enrolling adults with moderate calcific tricuspid AS at three tertiary heart valve centers in Germany. Participants undergo standardized baseline assessment including clinical phenotyping, laboratory testing, electrocardiography, transthoracic echocardiography, cardiac computed tomography and cardiac magnetic resonance imaging. Biospecimens are collected for biomarker, immunologic, proteomic, and genetic analyses, including genome-wide association studies and assessment of clonal haematopoiesis. Participants are followed annually for up to 5 years with repeat clinical assessment, laboratory testing, and echocardiography. The primary endpoint is time to progression to severe AS according to 2025 ESC/EACTS guideline criteria or aortic valve replacement for severe AS, adjudicated by the local multidisciplinary Heart Team. Secondary endpoints include all-cause mortality and additional clinical outcome trajectories. Multimodal data integration will be used to develop and validate prediction models for disease progression and outcome. Discussion: The MODAS Study will provide a harmonized, deeply phenotyped longitudinal dataset to improve risk stratification in moderate AS and to identify imaging, inflammatory, and genetic markers associated with rapid progression and adverse outcomes. The study is designed to support future personalized surveillance strategies, improved selection for earlier intervention, and mechanistic understanding of calcific AS progression. Trial registration: ClinicalTrials.gov NCT05851209 . Registered on 9 May 2023.

BACKGROUND: Accurate preprocedural planning is crucial for a successful transcatheter aortic valve implantation to ensure patient safety and valve longevity. Through 3-dimensional visualization, virtual reality (VR) offers the potential to enhance this process. The study investigated whether the inclusion of VR in preprocedural planning can improve the procedural preparation, impact intraprocedural parameters, and improve short-term patient outcomes. METHODS: This randomized, prospective, controlled study included 140 patients who underwent transcatheter aortic valve implantation at the University Hospital Duesseldorf between April and August 2024. In the control group, preprocedural planning was based on multislice computed tomography data using 3mensio software, while in the intervention group, it was supplemented with VR software. In addition, interventionalists assessed both tools via a structured questionnaire. RESULTS: The evaluation did not reveal any relevant differences in patient characteristics. VR was superior to 3mensio software with respect to the 3-dimensional understanding ( P P <0.05). There was no significant difference in the length of hospital stay or postprocedural transthoracic echocardiography data evaluations. CONCLUSIONS: The data show that VR visualization can optimize preparation for the procedure by improving the 3-dimensional understanding of the aortic valve and adjacent structures. The detailed visualization of the access routes can lead to a reduction in periprocedural complications.

Background: Transcatheter tricuspid valve replacement (TTVR) with the EVOQUE system has expanded therapeutic options for severe tricuspid regurgitation (TR), but a prohibitively dilated tricuspid annulus may exceed the device-sizing matrix and preclude implantation. No transcatheter strategy has been described to mechanically pre-condition such an annulus. Case summary: A 71-year-old woman with heart failure with reduced ejection fraction (left ventricular ejection fraction 38%, suspected premature-ventricular-complex–induced cardiomyopathy), permanent atrial fibrillation, and class III obesity presented with torrential atrial functional TR refractory to fully optimized guideline-directed medical therapy. Screening cardiac computed tomography (CT) classified the native annulus as ‘outside parameters’ for the 56 mm EVOQUE (Edwards Lifesciences); the Heart Team also deemed standalone tricuspid edge-to-edge repair (T-TEER) inadequate owing to the massively dilated annulus. We performed the TriArtic procedure—a single TriClip XTW (Abbott) deployed in the septo-anterior position as a transcatheter annuloplasty step. Repeat CT after 27 days demonstrated an ∼11% reduction in tricuspid annular area and conversion of projected-derived-diameter oversizing from −2.9% to +3.3% (within parameters). Transfemoral EVOQUE 56 mm was implanted 48 days after the TriClip; postprocedural imaging confirmed no residual regurgitation and a mean transtricuspid gradient of 1 mm Hg, with rapid recovery of cardiorenal function. Discussion: Transcatheter tricuspid annuloplasty by a strategically placed commissural TEER device may convert a prohibitively dilated annulus into one within EVOQUE-implantable parameters. In carefully selected patients ineligible for either standalone strategy, sequential transcatheter annuloplasty followed by valve replacement—the TriArtic procedure—may offer a feasible pathway, conceptually analogous to the mitral ARCTIC technique. This single case demonstrates feasibility only and does not establish general applicability.

(1) Background: Transesophageal echocardiography (TEE) is the gold standard for diagnosing patent foramen ovale (PFO) in cryptogenic ischemic stroke. However, false-positive diagnoses remain clinically relevant, exposing patients to unnecessary invasive procedures. (2) Methods: We retrospectively analyzed 346 patients with cryptogenic ischemic stroke who underwent TEE for PFO from 2012–2021. PFO was confirmed in 326 patients (94.2%), whereas 20 patients (5.8%, 95% CI 3.6–8.9%) were adjudicated as false positives during subsequent cardiac catheterization (intracardiac echocardiography, angiography, and inability to cross the interatrial septum). Univariable and multivariable logistic regression identified predictors of diagnostic accuracy. (3) Results: False-positive cases were associated with less frequent use of the mid-esophageal bicaval view (50% vs. 87%, p < 0.001) and absence of early bubble transit. Multivariable analysis confirmed the mid-esophageal bicaval view as an independent predictor of accurate diagnosis (OR 5.23, 95% CI 2.11–12.9, p < 0.001). (4) Conclusion: False-positive PFO diagnoses occur in ~6% of patients referred for closure. Three quality criteria—mid-esophageal aortic valve short axis, bicaval view, and bubble test with x-plane analysis—may improve diagnostic reliability. These hypothesis-generating findings require prospective validation and alignment with ASE/ESC guidelines to reduce unnecessary invasive procedures.

Background: Transesophageal echocardiography (TEE) is regarded as the gold standard for diagnosing patent foramen ovale (PFO). However, the occurrence of false positive PFO diagnoses is common in clinical practice, which may lead to unnecessary percutaneous interventions, as PFO occluders can only be placed when PFO presence is unequivocally confirmed. Various medical societies recommend a systematic protocol for the thorough assessment of the interatrial septum. Purpose: This study aimed to evaluate the incidence of false positive PFO diagnoses and analyze the underlying causes of misdiagnosis by comparing imaging data. Methods: In this retrospective observational study, we included 346 patients who were diagnosed with PFO following a cryptogenic ischemic stroke from January 2012 to December 2021. We first assessed the incidence of false positive PFO diagnoses. Subsequently, we compared stored imaging sequences from the screening TEE examinations with recommended diagnostic protocols outlined in European and American guidelines, identifying sources of diagnostic error. Results: The patient cohorts were divided into two groups: Group A consisted of 20 patients (5.8%) with PFO misdiagnoses, while Group B included 326 patients (94.2%) with accurate PFO occlusions. Our review of guideline compliance revealed that imaging planes in the mid-esophagus were used significantly more frequently than modified transgastric probe positions in the upper esophagus (71-96% vs. 1-2%). Three-dimensional imaging of the interatrial septum (IAS) was rarely utilized (0-3%), and the stepwise enlargement of the transducer angle in 15° increments was only partially documented. Comparisons between the two subgroups indicated reduced utilization of the bicaval viewing plane in the middle esophagus for the false positive group (Group A: 50% vs. Group B: 87%, pConclusion: The incidence of false-positive PFO diagnoses before procedures was found to be 5.8% over the past decade. To mitigate such misdiagnoses, we identified three critical quality criteria that should be incorporated into all TEE examinations: 1) 2D imaging in the short axis view at the aortic valve level (30-75°), 2) 2D-imaging in the bicaval axis view (90-120°), and 3) a bubble test performed in conjunction with these views utilizing x-plane mode.

Background: An accurate device sizing for percutaneous left atrial appendage closure (LAAC) can be challenging. Intraprocedural automated LAA evaluation by transoesophageal echocardiography (TEE) based on an artificial intelligence-assisted 3D model may facilitate sizing and prediction of C-arm angulation for device implantation in a one-stop-shop procedure. This study aimed to evaluate the feasibility and accuracy of automated echocardiographic LAA sizing based on a patient-specific 3D heart model prototype in real-time. Methods: A prospective monocentric study was conducted in 66 patients who underwent LAAC with the Amulet device. All major LAA morphologies were represented. Preprocedural multidetector computed tomography (MSCT) measurements and intraprocedural TEE and angiography measurements of the ostium, landing zone, and C-arm angulation were compared with the 3D heart model measurements. Results: The procedure achieved a 100% success rate. The measurements for the maximum diameter of the ostium in the 3D heart model were not significantly different from those obtained via angiography, TEE, and MSCT. Specifically, the maximum diameter of the landing zone did not differ significantly compared to TEE and angiographic measurements (20.90 ± 3.42 mm vs. 20.96 ± 4.81 mm, p = 0.563; compared to 21.20 ± 3.90 mm, p = 0.291). However, these measurements were significantly smaller than the average MSCT measurements (18.30 ± 2.68 mm vs. 21.03 ± 4.34 mm, p < 0.001). Additionally, the predicted implantation angles showed no significant differences between the 3D heart model and MSCT. Conclusions: The intraprocedural application of this prototype is both safe and feasible. The measurements obtained from the 3D heart model were consistent with those from TEE and angiography, although discrepancies were noted when compared to MSCT measurements. Notably, the predicted implantation angles demonstrated strong agreement with MSCT, further supporting the prototype’s efficacy in clinical settings.

Background: Congenital heart disease (CHD) affects approximately 9 per 1000 live births worldwide, with increasing prevalence due to improved survival. Today, over 90% of individuals with CHD reach adulthood, resulting in a growing population of adults with congenital heart disease (ACHD). Despite its clinical relevance, iron deficiency (ID) and anemia have been insufficiently studied in this group. Objectives: To evaluate the prevalence and clinical impact of iron deficiency and anemia in ACHD, particularly their relationship with exercise capacity. Methods: We retrospectively analyzed 310 ACHD patients at University Hospital Düsseldorf between January 2017 and January 2019. Iron status was assessed using serum ferritin, transferrin saturation (TSAT), and hemoglobin levels. Exercise capacity was measured by cardiopulmonary exercise testing (VO₂ max). Prevalence and clinical associations were compared with those reported in heart failure populations, using ESC guideline criteria. Analyses were adjusted for age, sex, and defect complexity. Results: Iron deficiency (ID) was present in 183 patients (59.0%). Anemia was observed in 13 patients (4.2%), with 6 (46.2%) classified as microcytic and 5 (38.5%) as normocytic. Reduced exercise capacity, defined as VO₂ max p < 0.001). ID was associated with a trend toward lower VO₂ max (21.3 vs. 23.5 mL/min/kg, p = 0.068), while anemia correlated with significantly reduced performance (19.8 ± 4.1 vs. 22.9 ± 6.3 mL/min/kg, p = 0.041). Conclusions: Iron deficiency is highly prevalent, and anemia—though less common—was consistently associated with reduced functional capacity in ACHD. These findings highlight the need for targeted screening and management strategies in this growing patient population.

Background: Multiple valvular heart disease correlates with poor outcomes following transcatheter aortic valve replacement. Previous studies have focused on mitral regurgitation (MR) or tricuspid regurgitation (TR) individually, without comparing their long‐term effects. The impact of staged transcatheter edge‐to‐edge repair (TEER) remains unclear. We aimed to assess the prevalence and effects of severe multiple valvular heart disease (sMVHD) and evaluate the impact of staged TEER on outcomes. Methods: Patients were recruited from 4 transcatheter aortic valve replacement centers. The primary cohort included 2823 patients to evaluate the prevalence of sMVHD. All patients were screened for additional valvular interventions; those undergoing TEER for severe MR (n=147) or TR (n=59) were included. Results: Concomitant sMVHD was observed in 369 patients, with 208 having severe MR and 161 having severe TR. The 1‐year mortality rate was higher in patients with sMVHD compared with the overall cohort (9.0 versus 5.2 per 100 person‐years; P P P P P P <0.01). Conclusions: Persistent sMVHD was associated with an increased mortality rate following transcatheter aortic valve replacement, with severe TR posing a higher risk than severe MR. Staged TEER was associated with improved outcomes and warrants consideration in sMVHD.