Objective: Some patients with severe aortic stenosis (AS) have cardiac amyloidosis. However, its prevalence and clinical implications, particularly in Japanese patients receiving transcatheter aortic valve replacement (TAVR), remain unknown.

Methods: Patients who received ^99mTc-pyrophosphate (^99mTc-PYP) scintigraphy tests before TAVR were prospectively included. No patients had any unique symptoms or signs associated with cardiac amyloidosis. Clinical data were compared between those with scintigraphy positive and those without.

Results: Among the 102 patients (median age 85 years, 30% men), 5 patients (5%) showed positive deposits in the ^99mTc-PYP scintigraphy tests. There were no statistically significant differences in the baseline and post-TAVR clinical parameters including the severity of AS between the two groups. Following TAVR, plasma B-type natriuretic peptide and cardiac hypertrophy remained unchanged in the scintigraphy-positive group, whereas they improved in the scintigraphy-negative group. Post-TAVR heart failure readmission rate was higher in the scintigraphy-positive group (0.182 versus 0.058 events per year, p = 0.064).

Conclusion: The existence of suspected cardiac amyloidosis might be associated with inadequate cardiac unloading and persistent cardiac hypertrophy following TAVR in the Japanese cohort.

Objective: Little is known regarding the impact of right ventricular (RV) function on clinical outcomes following MitraClip therapy. The aim of this study was to investigate the prognostic impact of RV dysfunction and its cut-off value following MitraClip therapy.

Methods: Consecutive 77 patients (median 79 years, 33% female) who underwent MitraClip therapy were enrolled. Clinical endpoint was defined as cardiovascular (CV) events, including CV death and rehospitalization for heart failure (HF).

Results: Twenty-two (29%) patients had primary mitral regurgitation (MR). During follow-up, 5 patients died due to CV events and 8 were hospitalized for HF. On univariate Cox regression analysis, CV events were associated with estimated glomerular filtration rate (hazard ratio [HR]: 0.960, 95% confidence interval [CI]: 0.926–0.995, p = 0.027), tricuspid annular plane systolic excursion (TAPSE; HR: 0.874, 95% CI: 0.789–0.968, p = 0.010), and significant residual MR (HR: 11.652, 95% CI: 3.257–41.691, p <0.001). On multivariate Cox regression analysis, TAPSE (HR: 0.788, 95% CI: 0.788–0.987, p = 0.029) and significant residual MR (HR: 9.373, 95% CI: 2.581–34.033, p = 0.001) were independently associated with CV events. TAPSE <11 mm was the best cut-off criteria for predicting CV events.

Conclusion: RV function was independently associated with clinical outcomes following MitraClip therapy. TAPSE is a simple parameter for predicting CV events in patients with MR who are undergoing MitraClip therapy.

Objective: Chronic kidney disease (CKD) increases the risk of cardiorenal (CR) events such as progression leading to regular hemodialysis, rehospitalization for heart failure (re-HF), and death from cardiac or renal cause (CR death). This study aimed to assess the rates of late adverse CR events among patients with CKD following transcatheter aortic valve replacement (TAVR).

Methods: Data of 2588 patients who underwent TAVR were extracted from the Japanese multicenter registry. The rates of progression leading to regular hemodialysis, re-HF in 1 year, predictive value of re-HF within 1 year, and mortality were assessed according to each CKD category divided into stages 1+2, 3a, 3b, 4, and 5. The advanced CKD was defined as CKD stage ≥3b.

Results: The incidences of hemodialysis after TAVR (n = 20) were increased across the CKD stages (0%, 0.13%, 0.58%, 2.17%, and 20.9%, respectively, p <0.001) and rates of re-HF within 1 year (n = 162) were significantly increased across the CKD stages (3.3%, 5.2%, 8.2%, 10.9%, and 17.0%, respectively, p <0.001). The Cox regression multivariable analysis revealed that the advanced CKD was the independent factor for predicting re-HF within 1 year after TAVR (all p <0.05). The Cox regression multivariable analysis demonstrated that the advanced CKD significantly increased the risk of all-cause death and CR death after TAVR (all p <0.05). The landmark analysis beyond 1 year after TAVR showed similar mortality rates between the patients with non-advanced CKD with re-HF within 1 year and those with advanced CKD without re-HF within 1 year (p = 0.74).

Conclusion: The re-HF and subsequent mortality increase in 1 year as the late CR events after TAVR were significantly increased across the CKD stages. Careful preventative management of re-HF is necessary after TAVR in patients with CKD, especially in the advanced CKD patients.

Objective: The optimal risk assessment of coronary obstruction (CO) during balloon-expandable transcatheter aortic valve replacement (TAVR) has not been established in patients with severe aortic stenosis of native aortic valve. We aimed to retrospectively determine the anatomical features of native aortic valve associated with CO during balloon-expandable TAVR.

Methods: Between June 2010 and December 2019, 279 consecutive patients with symptomatic severe aortic stenosis of native aortic valve were treated with a SAPIEN XT or SAPIEN 3 valve. Coronary angiography was performed in patients with suspected CO on aortograms or transesophageal echocardiograms. Subsequently, intravascular ultrasound was performed to confirm the presence of CO. In patients whom preprocedural contrast-enhanced computed tomography (CT) measurements were obtained, we compared the anatomical parameters between those with and without CO.

Results: Four patients (1.4%) had significant stenosis at the left coronary artery (LCA) ostium and underwent stent deployment, and 7 patients (2.5%) had mild stenosis at the LCA ostium and underwent conservative treatment. Preprocedural contrast-enhanced CT measurements were obtained in 234 patients (83.9%), showing that the incidence of CO was not significantly different between patients with both left coronary height <12 mm and left sinuses of Valsalva diameter <30 mm and the remaining patients (4.4% [2/45 patients] vs. 4.8% [9/189 patients], P >0.99), but was significantly higher in patients with both the left leaflet length to coronary distance ratio (LCR) >1 and the left projected virtual transcatheter valve to coronary ostium distance (p-VTC) <4 mm than in the remaining patients (31.8% [7/22 patients] vs. 1.9% [4/212 patients], P <0.001).

Conclusion: The left LCR >1 and the left p-VTC <4 mm may be associated with CO during balloon-expandable TAVR.

Objective: We report a case of cardiogenic shock, which was apparent soon after transcatheter aortic valve replacement (TAVR) and was refractory to medical therapy.

Case Presentations: An 86-year-old woman with symptomatic severe aortic stenosis was admitted to our hospital for TAVR. Transthoracic echocardiography showed a severely calcified aortic valve with the peak flow velocity of 4.6 m/s and the mean pressure gradient of 46 mmHg. Late peaking of left ventricular (LV) outflow tract acceleration with a V_max of 2.4 m/s at rest was observed. Coronary angiography revealed no significant coronary artery stenosis. A 23-mm SAPIEN 3 valve was successfully implanted with mild perivalvular leakage (PVL). The patient’s hemodynamic profile was stable as long as systolic blood pressure (BP) was maintained at >140 mmHg. However, when systolic BP was maintained at <110 mmHg, sudden hemodynamic collapse with a significant pressure gradient between the LV and aorta (Ao) was observed. Echocardiography revealed that the prosthetic valve functioned properly with mild PVL. Significant left ventricular outflow tract (LVOT) obstruction with systolic anterior movement and severe mitral regurgitation (with a maximum pressure gradient of 61 mmHg between the LV and Ao) was revealed. Given these findings, we considered that LVOT obstruction after removing the LV pressure overload with TAVR mainly contributed to hemodynamic collapse. We immediately started cibenzoline and a betablocker, and titrated this over 3 days. However, her hemodynamic status remained dependent on the afterload of catecholamines. Therefore, we decided to perform alcohol septal ablation (ASA). Isopropyl alcohol was infused into the two septal branches, and subsequent angiography revealed occlusion of the vessel. After ASA was performed, her hemodynamics improved, and the peak pressure gradient at the LVOT level demonstrated almost complete resolution (3 mmHg) on echocardiography. Catecholamines were successfully weaned off, and she was discharged without any complications.

Conclusion: Recognizing the physiological changes that can occur following TAVR is critical. Urgent ASA should be considered as an alternative treatment strategy for these patients.

Objective: Trans-subclavian (TS)-transcatheter aortic valve replacement (TAVR) is a well-established alternative to transfemoral TAVR. In TS-TAVR, the axillary artery is commonly accessed through an infraclavicular incision. However, it is not rare that the axillary artery is too narrow or tortuous to access. The subclavian artery, which can be accessed through a supraclavicular incision, has a larger diameter and a lower tortuosity than the axillary artery. We report two cases of supraclavicular TS-TAVR and discuss the advantages and disadvantages of this approach.

Case Presentations: Both patients had symptomatic severe aortic stenosis and underwent supraclavicular TS-TAVR due to tortuous axillary arterial access. In case 1, we successfully performed TAVR using a self-expandable valve through the right subclavian artery. The patient’s postoperative course was unremarkable. The patient was discharged on postoperative day 6. In case 2, we performed TAVR using a self-expandable valve through the left subclavian artery. We encountered a vascular injury of the access route, which was unmanageable by surgical repair. We treated the injury site using endovascular repair with a stent graft. Postoperatively, the patient presented with muscle weakness in the left upper limb, which was suspected to be due to the intraoperative compression of the brachial plexus for hemostasis. The patient was discharged on postoperative day 16 and was fully recovered at the 3-month postoperative follow-up.

Conclusion: Supraclavicular TS-TAVR offers several advantages. If the surgeon is careful of the vessel and nerve injury, otherwise this can be one of the beneficial alternative approaches in cases where femoral and axillary arteries are not feasible.

Objective: Acute mitral regurgitation (MR) secondary to papillary muscle rupture (PMR) is a lethal complication of acute coronary syndrome. Although surgery is considered the first-line therapy for this condition, some of these patients have no choice but to quit with prohibitively high surgical risk. Transcatheter mitral valve edge-to-edge repair (TEER) using the MitraClip system (Abbott Vascular, Santa Clara, CA, USA) is an established treatment option and viable alternative for patients with high-risk or prohibitive-risk open heart surgery.

Case Presentation: We present a case of successful TEER for a patient with severe MR due to PMR after acute myocardial infarction using the MitraClip. The patient, who had post-gastrectomy peritonitis, was in a critical condition. After a few days, he developed acute heart failure with cardiogenic shock. Emergency angiography revealed severe left main-trunk stenosis. A percutaneous coronary intervention was performed for the culprit lesion under a ventilator and an intra-aortic balloon pump support. Echocardiography revealed massive MR with a partial tear in the posteromedial papillary muscle and a large regurgitant jet directed to the posterior wall with severely reduced left ventricular function. We performed TEER using three clips, which resulted in mild residual MR. Subsequently, the patient was hemodynamically stabilized.

Conclusion: TEER with the MitraClip system is a viable treatment option for cardiogenic shock due to PMR.

Objective: Cerebral infarction is a serious complication of transcatheter aortic valve replacement (TAVR). We report a case of a symptomatic severe aortic stenosis (AS) patient with thrombi in the left ventricle and atrial appendage who successfully underwent TAVR using the SENTINEL Cerebral Protection System (CPS) (Boston Scientific, Marlborough, MA, USA).

Case Presentation: We performed TAVR with the SENTINEL CPS in a patient with severe AS, who presented with a high risk of cerebral infarction due to thrombi in the left ventricle and atrial appendage. The perioperative and postoperative courses were uneventful and was without cerebral infarction or other complications.

Conclusion: Employment of the SENTINEL CPS during TAVR may be useful in reducing the risk of stroke in patients with a high risk of perioperative stroke, such as a left intracardiac thrombus.

Objective: We present a case of successful transcatheter aortic valve implantation (TAVI) via cusp-overlap technique performed with fluoroscopy and transesophageal echocardiography (TEE) guidance without any contrast agent in a patient with severe aortic stenosis (AS) and chronic kidney disease.

Case Presentation: An 83-year-old female with severe AS was admitted to our hospital undergoing TAVI. Contrastenhanced CT was not performed due to her severe renal dysfunction. Therefore, we planned a non-contrast transfemoral TAVI. Under general anesthesia, we performed a 3D measurement of TEE before the TAVI procedure for choosing an appropriate transcatheter heart valve (THV) size. Using two pigtail catheters as landmarks, we adjusted the perpendicular view and the cusp-overlap view. After pre-dilation, a THV was deployed and implanted using the cusp-overlap view and the left anterior oblique view without using any contrast agent, and TEE demonstrated that the THV was implanted at an optimal implantation depth. She was transferred to another hospital for rehabilitation on postoperative day 6 without any complications including any conduction delay.

Conclusion: We first described a successful non-contrast TAVI with the cusp-overlap technique, which could be performed using two pigtail catheters as a landmark without a contrast agent. An appropriately sized THV was selected and deployed at an optimal position guided by TEE. We believe that this technique is feasible, and the permanent pacemaker implantation rate could be decreased in patients with severe AS and severe chronic kidney disease.

Objective: The objective of this report was to be able to understand how to use the MitraClip G4 XT/XTW device effectively without complications particularly for non-central pathologies.

Case Presentation: A 76-year-old woman was hospitalized for decompensated heart failure. Transthoracic echocardiography revealed severe mitral regurgitation (MR) due to a large P3 prolapse. She was at a high risk for open-heart surgery, and our heart team decided to perform transcatheter edge-to-edge repair (TEER). Under transesophageal echocardiographic guidance, the MitraClip XTW system was placed perpendicularly above the prolapsed leaflet. Given the limited space below the lesion in the left ventricle (LV), the device was entrapped in the deep LV twice, resulting in worsening MR and a transient drop in blood pressure to 30 mmHg. Finally, the clip arm was opened to 120°, with the device being advanced only halfway, allowing for the anterior and posterior parts of the clip arms to slide under the mitral valves without deep advancement into the LV. It was then easily positioned on both leaflets. Finally, the XTW device was fully closed with adequate leaflet insertion in both arms. The degree of MR significantly decreased from severe to trace levels. The patient was then discharged.

Conclusion: The “minimal advancement technique” is particularly safe and effective in patients who require TEER with a long MitraClip G4 system for non-central pathologies, as it allows the clip arms of the MitraClip device to slide under the mitral valve leaflets without advancing deep into the LV.