Objective: Only a few reports have detailed the early- to mid-term outcomes of transcatheter aortic valve replacement (TAVR), especially in patients with small body size. This study aimed to evaluate the early- and mid-term outcomes of redo-TAVR in Japanese patients.

Methods: This was a retrospective, non-randomized, single-center study. In all 16 consecutive cases (15 patients) who underwent redo-TAVR (excluding redo-TAVR because of intraoperative bailout) were enrolled in this study.

Results: The mean age was 82.1 ± 7.1 years, and 31.3% were men (mean body surface area was 1.45 ± 0.18 m² and median STS score was 12.5%). Fifteen of the failed transcatheter aortic valves (TAVs) were balloon-expandable (bTAV), and one was a self-expanding TAV (sTAV). For a period of postoperative 30 days, all-cause mortality, all stroke, and moderate or greater patient-prosthesis mismatch were observed in 0%, 6.3%, and 25.0%, respectively. During the follow-up period (mean duration, 1154 days), freedom from cardiovascular mortality rates at postoperative 1 year and 3 years were 81.3% and 81.3%, respectively; freedom from all stroke rates at postoperative 1 year and 3 years were 93.8% and 73.1%, respectively; and freedom from structural valve deterioration rates at postoperative 1 year and 3 years were 92.9% and 92.9%, respectively.

Conclusions: Whether using the same or different types of TAV, the mid-term outcomes of redo-TAVR for bTAV and sTAV in the Japanese patients were favorable.

Objective: To investigate reverse cardiac remodeling in self-expandable valve (SEV) and balloon-expandable valve (BEV) in patients with low-flow, low-gradient aortic stenosis (LFLGAS) who performed transcatheter aortic valve replacement (TAVR).

Methods: Patients with classical low-flow, low-gradient aortic stenosis (CLFLGAS) and paradoxical low-flow, low-gradient aortic stenosis (PLFLGAS) after TAVR from the Optimized transCathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation registry were analyzed. The baseline characteristics, transthoracic echocardiographic data, and outcomes were examined in the SEV and BEV groups for each low gradient type. Echocardiography was performed at baseline and 1 year after TAVR. In this study, reverse cardiac remodeling was defined as both of increase in left ventricular ejection fraction (LVEF) ≥10% and reduction in left ventricular mass index (LVMi) ≥10% at 1 year.

Results: Among 163 patients with LFLGAS, 95 patients had CLFLGAS and 68 patients had PLFLGAS. LVEF in patients with CLFLGAS significantly improved 1 year after TAVR in both the SEV and BEV groups (SEV group, baseline: 36.6% [interquartile range {IQR} 28.6%–46.3%] vs. 1 year: 56.0% [IQR 42.0%–67.1%], p = 0.006; BEV group, baseline: 36.0% [IQR 30.5%–44.1%] vs. 1 year: 57.4% [IQR 41.0%–63.5%], p <0.001). LVEF in patients with PLFLGAS did not improve 1 year after TAVR in both valves. LVMi in patients with CLFLGAS significantly decreased 1 year after TAVR in both valves. (SEV group, baseline: 146.4 g/m² [IQR 110.7 g/m²–180.2 g/m²] vs. 1 year: 56.0 g/m² [IQR 42.0 g/m²–67.1 g/m²], p = 0.028; BEV group, baseline: 132.5 g/m² [IQR 120.3 g/m²–161.3 g/m²] vs. 1 year: 122.6 g/m² (standard deviation ± 34.7 g/m²), p = 0.004). LVMi in patients with PLFLGAS did not improve 1 year after TAVR in both valves. The rates of reverse cardiac remodeling in patients with CLFLGAS were significantly higher than those in patients with PLFLGAS (47.8% vs. 9.1%, p <0.001). There was no significant difference in reverse cardiac remodeling rates between SEV and BEV in patients with CLFLGAS and PLFLGAS. (CLFLGAS, 54.5% vs. 45.7%, p = 0.609; PLFLGAS, 28.6% vs. 5.4%, p = 0.113).

Conclusions: Reverse cardiac remodeling was more observed after TAVR among patients with CLFLGAS than those with PLFLGAS. The valve type did not affect the rates of reverse cardiac remodeling after TAVR in each LFLG type.

Objective: Transcatheter edge-to-edge repair (TEER) using MitraClip (Abbott, Abbott Park, IL, USA) is a less invasive treatment for patients with mitral regurgitation (MR) than mitral valve surgery. Treatment strategies for degenerative MR tend to be individually influenced by the anatomical characteristics of the lesion and patient background, and the middle- to long-term clinical outcomes of TEER with MitraClips, including the fourth-generation (G4) system, are unclear. This study aimed to evaluate the middle-term clinical outcomes of TEER for degenerative MR based on actual clinical practice.

Methods: Patients who underwent TEER for degenerative MR at our institution, including those who could be followed up for up to 3 years, were enrolled. The primary endpoints were all-cause mortality and hospitalization for heart failure after TEER for degenerative MR with the MitraClip second-generation (G2) and G4 systems.

Results: The subjects were 26 consecutive patients undergoing TEER for degenerative MR between June 2019 and December 2022 at our institution. Sixteen patients underwent TEER with the MitraClip G2 system (61.5%), and ten patients underwent TEER with the G4 system (38.5%). Twenty-five patients (96.2%) achieved acute procedural success defined as an MR severity grade of 2+ or less at the time of discharge. All patients underwent the procedure without major complications, and mortality at 30 days was 0%. At 3 years, the percentages of patients with freedom from all-cause mortality and hospitalization for heart failure were 82.1% and 83.7%, respectively.

Conclusion: Excellent procedural outcomes and acceptable freedom from all-cause mortality and hospitalization for heart failure at 3 years were observed in 26 consecutive cases of TEER for degenerative MR at our institution. Our results show that TEER is a feasible and effective treatment for high-risk patients undergoing mitral valve surgery for degenerative MR.

The treatment of functional mitral regurgitation (FMR) has evolved dramatically in recent years and remains dynamic. Generally, the treatment of FMR involves a combination of medication optimization and surgical or transcatheter interventions. The use of transcatheter edge-to-edge repair has been increasing for FMR. This less invasive approach allows for transcatheter mitral valve repair, avoiding open heart surgery. On the other hand, surgical mitral valve repair techniques, such as annuloplasty, still play a crucial role in managing FMR. Simultaneous surgical ablation for atrial fibrillation or left atrial appendage closure can be performed. Surgical interventions also encompass concomitant operations, including addressing commonly coexisting secondary tricuspid valve pathology or performing coronary artery bypass grafting, which is relevant, especially in the case of ischemic mitral regurgitation. The management of FMR involves a multidisciplinary heart team consisting of cardiologists, cardiac surgeons, and other specialists. This collaborative approach aims to tailor treatment strategies to individual patients, considering survival and the quality of life.

Severe tricuspid regurgitation (TR) is now widely thought of as a significant contributor to cardiac morbidity and mortality. Neither medical therapy nor conventional surgery is efficacious for most patients. In contrast, with the rapid development of transcatheter tricuspid valve therapies, TR can now be corrected without incurring the risks of conventional surgery, and it is showing promise to improve quality of life and mortality. In this review, we discuss transcatheter tricuspid valve interventions (TTVIs), the current status of clinical trials in the United States, TTVI devices we have used, and our experience.

Objective: The wire route in the left ventricle (LV) is a key factor for successful transcatheter aortic valve implantation (TAVI). The transapical (TA) approach is the only antegrade approach in which valve crossing is usually easy. In this case, we failed to cross the wire after the transcatheter heart valve (THV) became lodged. However, we bailed out and implanted successfully by confirming the wire route with a dummy valve cross technique.

Case Presentation: A woman in her late 70s presented with symptomatic severe aortic valve stenosis and shaggy descending aorta. As she was frail after bilateral arthroplasty, our heart team decided to perform TA-TAVI under general anesthesia. After apical puncture, the guidewire was passed through the aortic valve under fluoroscopy. Transesophageal echocardiography (TEE) showed the wire running along the septal wall, and the THV was advanced into the LV. However, the THV became lodged below the aortic valve. We reviewed the TEE findings and concluded the wire and delivery system had passed through the chordae tendineae. Therefore, we removed the whole system from the LV and reattempted wire crossing. To confirm the correct wire route, we advanced an aortic valvuloplasty balloon as a dummy valve before inserting the actual THV. The THV passed smoothly through the aortic valve and was implanted successfully. The postoperative course was uneventful, with no bleeding.

Conclusion: In TA-TAVI, the wire route in the LV around the apex is poorly visualized. A dummy valve cross technique might be useful to confirm the wire route.

Objective: Mitral valve transcatheter edge-to-edge repair (TEER) is an effective therapeutic alternative to mitral valve surgery for high-risk surgical patients with mitral regurgitation (MR). The TEER route necessitates the use of the femoral vein approach. We present a case report of a patient with atrial functional MR (AFMR) and an indwelled inferior vena cava filter (IVCF) who underwent TEER using the MitraClip system (Abbott Vascular, Santa Clara, CA, USA).

Case Presentation: A 78-year-old male with an IVCF experienced frequent hospitalization for heart failure (HF) due to severe AFMR despite receiving maximally tolerated doses of guideline-directed medical therapy. Treatment for AFMR was necessary to prevent HF-related hospitalization. Considering the patient’s high surgical risk and frailty, a minimally invasive approach was favored. However, the presence of the indwelled IVCF obstructed the use of the femoral vein for the MitraClip approach. Computed tomography revealed that all IVCF struts had penetrated the inferior vena cava (IVC) wall. Our heart team determined that endovascular venoplasty or stenting to establish the MitraClip approach route posed a high risk of IVC rupture. Consequently, we initially performed surgical IVCF removal, followed by TEER using the MitraClip system via conventional femoral vein access after one month. Following the intervention therapies, the patient has remained free from HF-related rehospitalization for 2 years.

Conclusion: Surgical IVCF removal emerges as a viable treatment option for establishing the MitraClip system access route.

Objective: Though high prosthesis implantation mitigates the risk of conduction disturbance after transcatheter aortic valve implantation (TAVI) using the self-expandable valve, we have to be aware of the increasing risk of delayed coronary obstruction particularly in patients with small anatomy.

Case Presentation: A 76-year-old female was admitted to the emergent room complaining chest pain at rest. Prior to this admission, she underwent TAVI with a self-expandable valve using the cusp overlap technique. Based on the finding of ST-segment elevation at inferior leads, we emergently performed coronary angiography and found severe stenosis at the ostium of right coronary artery. After percutaneous coronary intervention (PCI), intravascular ultrasound (IVUS) images detected thrombus within the stent located in the native sinus, which could not find during preprocedural IVUS. After the PCI, we added warfarin to single antiplatelet therapy as antithrombotic therapy to suppress the thrombus within the native sinus of Valsalva (SOV). After a year of this emergent PCI, she had no symptoms and no rehospitalization.

Conclusion: We experienced a case of delayed coronary obstruction due to a thrombus of the native SOV after TAVI using a self-expandable valve, confirmed by multi-imaging modalities.

Objective: We report a case of left ventricular perforation during transfemoral transcatheter aortic valve implantation (TAVI) caused by significant tortuosity of the access route that affected the guidewire.

Case Presentation: An 89-year-old woman with severe aortic stenosis was admitted to our hospital for TAVI. Computed tomography revealed an extremely tortuous descending thoracic aorta characterized by an acute bend without calcification. Our heart team decided to perform transfemoral TAVI because it is minimally invasive. A standard 14-French e-sheath (Edwards Lifesciences, Irvine, CA, USA) was inserted, and a Safari2 (Boston Scientific, Marlborough, MA, USA) guidewire was advanced into the left ventricle. Subsequently, a Lunderquist wire (Cook Medical, Bloomington, IN, USA) was introduced as a buddy wire to facilitate delivery of a Sapien3 23-mm (Edwards Lifesciences) transcatheter heart valve (THV). However, significant tortuosity of the thoracic aorta remained. During manipulation of the delivery system for THV depth adjustment, the tortuosity of the thoracic aorta unexpectedly straightened, causing the Safari2 guidewire to penetrate deeply into the left ventricular apex. After the deployment of the THV, the patient’s blood pressure decreased due to cardiac tamponade. An open chest hemostatic procedure successfully identified and repaired the bleeding point at the left ventricular apex, allowing for patient recovery.

Conclusion: Severe tortuosity of the access route can affect guidewire manipulation and increase the risk of left ventricular perforation. This emphasizes the critical importance of precise anatomical evaluation and careful approach selection in cases of TAVI with significant tortuosity of the access route.

Objective: The repeatability of transcatheter aortic valve implantation (TAVI) is an important issue for younger patients or patients with early structural valve deterioration (SVD) concerns.

Case Presentation: A 74-year-old female patient on hemodialysis (HD) visited our hospital for symptomatic severe aortic stenosis and difficulty of HD. She was at a high risk for open-heart surgery, and our heart team decided to perform TAVI. Pre-procedural electrocardiogram showed a complete right bundle branch block, and multidetector computed tomography (MDCT) revealed a low height of coronary artery and sinotubular junction and short membrane septum. Because she was on dialysis, we were concerned about early SVD, and implanting a 23-mm SAPIEN 3 Ultra RESILIA, which was suitable for her aortic annulus, would be a high risk for sinus sequestration in the future redo TAVI. Furthermore, she was at high risk for complete atrioventricular block, and implanting a transcatheter aortic valve (TAV) at a low position was not acceptable. So, we decided to select a 20-mm SAPIEN 3 Ultra RESILIA implanting overfilling with 2 ml. TAVI was performed with no complication, and post-procedural echocardiography revealed the TAV function was acceptable, and MDCT after TAVI showed suitable anatomy for redo TAVI.

Conclusion: We experienced a successful TAVI case with an out-of-range smaller SAPIEN 3 Ultra RESIRIA. An out-of-range smaller balloon-expandable valve might be a good choice if TAVI is required to be redone in the future.