Background: Atriogenic tethering (AT) is a characteristic feature of the mitral valve in atrial functional mitral regurgitation (AFMR). However, the factors associated with AT are not well known.

Methods and Results: This was a post hoc analysis of REVEAL-AFMR, a retrospective observational study involving patients with moderate or greater AFMR. A stepwise binary logistic regression model was used to identify factors associated with AT. The primary endpoint was a composite of cardiovascular death, heart failure hospitalization, and mitral valve intervention. Of 1,007 patients, 245 (24%) had AT and 762 (76%) did not. Of 15 clinical variables related to AT in AFMR, greater left ventricular end-systolic dimension and left atrial diameter were independently associated with AT. The 3-year rate of freedom from the primary outcome was significantly lower in the group with than without AT (63.2% vs. 71.2%; P=0.002). The risk of the primary outcome was significantly higher in the group with than without AT (adjusted hazard ratio 1.34; 95% confidence interval 1.04–1.74; P=0.026), although the results were inconsistent in the sensitivity analysis using propensity score overlap weighting.

Conclusions: AT was identified in 24% of patients with moderate or greater AFMR. Greater left ventricular end-systolic and left atrial anteroposterior dimensions were factors associated with AT. Among patients with AFMR, those with AT showed a poor prognosis.

Background: Changes in mitral valve (MV) morphology during MV transcatheter edge-to-edge repair (MV-TEER) are associated with short-term reduction of mitral regurgitation (MR). However, whether these changes are associated with prognosis remains unclear. Using 3-dimensional transesophageal echocardiography, this study evaluated the impact of MV morphological parameters on the mid-term prognosis of patients with functional MR (FMR).

Methods and Results: We analyzed 99 patients with FMR who were treated with MV-TEER. The primary endpoint was a composite of all-cause mortality and hospitalization due to heart failure. Patients were divided into 2 groups based on the post-procedural sphericity index of the mitral valve (SI-MV), which is the ratio of the vertical to horizontal MV diameter. Using receiver operating characteristic curve (ROC) analysis for the primary endpoint, the SI-MV cut-off value was determined to be 0.86. The incidence of the primary endpoint was significantly (log-rank P=0.013) higher among patients with a post-procedural SI-MV >0.86 (circular MV morphology) than among those with post-procedural SI-MV ≤0.86 (elliptical MV morphology). Post-procedural SI-MV >0.86 was an independent determinant of the primary endpoint in multivariate analysis (hazard ratio 2.35; 95% confidence interval 1.25–4.42; P=0.0077).

Conclusions: A larger post-procedural SI-MV is associated with increased mid-term adverse clinical events after MV-TEER in patients with FMR.

Background: Increasing use of mitral valve repair has shifted operations to older patients, potentially increasing the post-repair thromboembolic risk. However, the incidence, timing, and determinants of ischemic stroke/transient ischemic attack (TIA) after mitral repair in patients without preoperative atrial fibrillation (AF) remain undetermined.

Methods and Results: We retrospectively analyzed 636 patients (mean age, 58±13 years) with degenerative mitral regurgitation and sinus rhythm who underwent mitral valve repair. The primary endpoint was stroke/TIA. Over a mean follow-up of 7.4±5.5 years (4,681 patient-years), 28 (4.4%) developed stroke/TIA. Incidence peaked in the first postoperative year (1.4%/year), declined thereafter, and rose again at 10–15 years (0.67%/year). New-onset AF occurred in 54 patients (8.4%), based on 3,119 ECGs (mean, 4.9±5.8 per patient). Early events (≤1 year) rather than late events (>1 year) occurred in older patients (early vs. late events: 72±8.8 vs. 62±13 years, P=0.052). Later events were associated with larger left atrial size (48±6.7 vs. 41±7.6 mm, P=0.016) and a higher prevalence of new-onset AF (58% vs. 11%, P=0.039). Age ≥70 years (adjusted hazard ratio (HR), 4.4; P<0.001), new-onset AF (adjusted HR, 4.0; P<0.001) and NYHA class (adjusted HR: 2.0, P=0.02) were identified by Fine–Gray regression as independent determinants of stroke/TIA.

Conclusions: After mitral repair, ischemic stroke/TIA occurred in 4.4% of patients without preoperative AF, associated with advanced age, new-onset AF, and higher NYHA functional class. This supports close rhythm surveillance and heart failure management.

Background: The prognostic impact of ischemic mitral regurgitation (IMR) in recurrent myocardial infarction (MI) remains poorly defined. This study evaluated dynamic changes in IMR during recurrent MI and determined prognostic implications.

Methods and Results: We retrospectively reviewed 4,091 patients who underwent primary percutaneous coronary intervention for acute MI between May 2008 and July 2022. Of these patients, 88 experienced a second MI and underwent transthoracic echocardiography at 3 time points: before recurrent MI, at onset, and at discharge. IMR severity was assessed using mean vena contracta width. Logistic regression was used to determine predictors of persistent IMR, and Cox analysis was used to evaluate 5-year adverse outcomes (a composite of all-cause death, heart failure hospitalization, and third MI). IMR worsened at the onset of recurrent MI and remained elevated at discharge (P<0.001). Older age, lower left ventricular ejection fraction (LVEF), and greater IMR severity at onset independently predicted persistent IMR. In multivariable Cox analysis, residual IMR (per 1-mm increase: hazard ratio [HR] 1.22; 95% confidence interval [CI] 1.08–1.38) and reduced LVEF (per 1% decrease: HR 0.95; 95% CI 0.92–0.98) were independently associated with a higher risk of 5-year adverse events.

Conclusions: IMR changes dynamically during recurrent MI and often persists despite acute treatment. Residual IMR and reduced LVEF predicted long-term adverse outcomes, highlighting the importance of residual IMR assessment for risk stratification.

Background: Aortic valve regurgitation (AR) impairs cardiac function, but the underlying mechanisms remain unclear. Vector flow mapping (VFM) enables evaluation of blood flow patterns and energy loss in the left ventricle (LV). This study investigated the effect of AR on LV blood flow patterns, energy loss, and heart failure progression using VFM.

Methods and Results: Forty patients with severe AR undergoing aortic valve replacement (AVR) between January 2016 and March 2018 were included. Echocardiogram-based VFM in apical long-axis and 4-chamber views was performed before and after AVR, with results compared to a control group without valvular diseases (n=21). Preoperative LV energy loss due to an AR jet was significantly higher in patients with AR (median 8.7 J; interquartile range [IQR] 5.7–13.3 J) than in controls (1.7 J; IQR 0.7–2.6 J; P<0.001), and was positively correlated with preoperative serum B-type natriuretic peptide (BNP) concentrations (P=0.029). LV energy loss was not associated with LV systolic function or regurgitant volume, but was significantly affected by AR jet direction. Postoperatively, after AVR, LV energy loss (median 2.0 J; IQR 1.5–2.7 J) decreased to the same level as in the control group.

Conclusions: The regurgitant jet in severe AR increases LV energy loss, which is positively correlated with serum BNP concentrations, indicating that the AR jet contributes to the progression of heart failure through LV energy loss.

Background: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in hemodialysis patients; however, contemporary outcomes and risk stratifications remain unreported.

Methods and Results: Using data from a multicenter database, this study included 2,888 patients who underwent TAVI between 2021 and 2024: 336 (11.6%) on hemodialysis and 2,552 (88.4%) not. The primary outcome was all-cause death after TAVI; the median follow-up was 527 days. Hemodialysis patients were younger, predominantly male, and had more comorbidities with higher surgical risk. Hemodialysis and non-hemodialysis patients had similar 30-day mortality (2.9% vs. 1.5%, respectively) and major procedural complications. Hemodialysis patients had 2- to 3-fold higher rates of all-cause death (14.4% vs. 6.5% at 1-year; 21.5% vs. 11.0% at 2 years), cardiovascular death, and the composite of all-cause death and heart failure hospitalization. After adjusting for confounders, hemodialysis had no significant effect on all-cause death and the composite endpoint. Body mass index, Clinical Frailty Scale, and albumin levels were associated with all-cause death in hemodialysis patients, allowing risk stratification into low-, intermediate-, and high-risk groups.

Conclusions: In this study, hemodialysis patients were younger and had more comorbidities, but 30-day mortality and complications were similar to the non-hemodialysis group. Although hemodialysis patients had higher all-cause mortality, the worse outcomes in this group were attributed to comorbidities rather than the hemodialysis itself.

Background: The benefits of adding aspirin to warfarin and warfarin treatment intensity for Japanese patients with mechanical valve replacement (MeVR) are unclear.

Methods and Results: This multicenter non-randomized observational study recruited 158 Japanese patients who underwent MeVR in 11 university hospitals in Kyushu and Okinawa; 74 patients were allocated to the warfarin (W) group and 84 were allocated to the warfarin plus aspirin (W+A) group. Patients were followed for a mean (±SD) of 5.0±1.9 years. The primary and secondary endpoints were mainly atherosclerotic/thrombotic and bleeding events, respectively. There was no difference in the incidence of the primary endpoint between the W and W+A groups (14% vs. 22%, respectively; P=0.13). Univariate analysis revealed a higher incidence of the secondary endpoint in the W+A than W group (35% vs. 22%; P=0.032), but the difference was not significant in multivariate analysis. For the entire cohort, the postoperative mean international normalized ratio of prothrombin time (PT-INR) was relatively low (2.1±0.3). There were no differences in the incidence of events between PT-INR <2.0 and 2.0–3.0 (primary endpoint: 21% vs. 16%, respectively [P=0.41]; secondary endpoints: 33% vs. 26%, respectively [P=0.19]).

Conclusions: Adding aspirin to warfarin treatment was not superior to warfarin alone, and relatively weak warfarin treatment (PT-INR <2.0) was not necessarily associated with an increased number of events (vs. PT-INR 2.0–3.0) in Japanese patients who underwent MeVR.

Background: Preoperative risk assessment is very important to ensure surgical safety and predict postoperative complications. However, no large-scale studies have evaluated the risk of perioperative cardiovascular events in Japan. This study evaluated perioperative cardiovascular events using real-world data. In addition, the applicability of machine learning to risk stratification was examined to develop a predictive model for perioperative cardiovascular events.

Methods and Results: This was an observational cohort study using the Japan Medical Data Center database, which includes claim and health examination data in Japan, between January 2005 and April 2021. In all, 133,634 gastrointestinal surgeries were included in the analysis. The primary outcome was 30-day risk of major adverse cardiovascular events (MACE). The 30-day MACE incidence rate following surgery was 3.8%. Machine learning was used to perform a binary classification task to predict MACE occurrence within 30 days after surgery. A clustering algorithm was developed based on the Shapley additive explanation values obtained from training data, and generalizability was evaluated using test data. Of the variables, age, history of ischemic heart disease or heart failure, history of stroke, diabetes, hypertension, atrial fibrillation, cases of malignancy, and pancreatic biliary surgery were identified as factors associated with MACE occurrence.

Conclusions: A machine learning model built from basic clinical information, comorbidities, and surgical information demonstrated the capacity to stratify MACE risk in patients undergoing gastrointestinal surgery.

Background: Harmony^TMtranscatheter pulmonary valve implantation (TPVI) was developed to treat pulmonary regurgitation (PR) in patients with an enlarged native right ventricular outflow tract. Favorable outcomes have been reported in cohorts from the USA, but data from other regions are limited.

Methods and Results: This prospective single-center study included 55 Japanese adults who underwent Harmony^TMTPVI between March 2023 and September 2024. Echocardiography and cardiac magnetic resonance imaging were performed at baseline and at 3 months. The median age was 45 years (interquartile range [IQR]: 29–54 years) and the median body mass index (BMI) was 20 kg/m²(IQR: 18–24). Procedural success was achieved in all patients. The PR fraction improved from 46% to 2.3% (P<0.01). Right ventricular end-diastolic and end-systolic volume indices decreased from 156 to 108 mL/m²and from 84 to 69 mL/m², respectively (P<0.01). Stroke volume increased from 59 to 64 mL, and cardiac index from 2.4 to 2.6 L/min/m²(P<0.05). During a median follow-up of 17 months, all patients remained free from reintervention.

Conclusions: In Japanese patients characterized by older age and lower BMI, Harmony^TMTPVI achieved high procedural success and rapid right ventricular reverse remodeling, indicating it is a safe and effective treatment option.

Background: In repaired tetralogy of Fallot (TOF) and related diseases, reoperation for pulmonary regurgitation (PR) may be delayed unless marked right ventricular (RV) enlargement is present.

Methods and Results: 32 patients with significant PR post-repair underwent catheterization and 4D flow MRI for reoperation evaluation. The Non-severe RV Dilation group (n=20) did not meet the surgical volume criteria, whereas the Severe RV Dilation group (n=12) did. The Non-severe RV Dilation group had higher biventricular filling pressures. The RV-Energy loss index in both groups was high.

Conclusions: Diastolic dysfunction could serve as a therapeutic target in PR patients with heterogeneous etiologies.

Background: The effect of residual pulmonary hypertension (PH) on clinical outcomes in patients with secondary mitral regurgitation (MR) after transcatheter edge-to-edge repair (TEER) remains unexplored.

Methods and Results: We analyzed 62 patients with secondary MR who underwent TEER. In 32 (51.6%) patients with residual PH after TEER, adverse clinical events were observed more frequently compared with those without residual PH. Multivariate analysis confirmed residual PH as an independent predictor of all-cause death or hospitalization for heart failure.

Conclusions: In patients with secondary MR, residual PH after TEER is an independent predictor of adverse clinical outcomes.