Heart Team Decision Research Articles

C36 NON–CYCLIC INTERMITTENT PROSTHETIC MITRAL VALVE DYSFUNCTION: A CASE REPORT OF A DIFFICULT DIAGNOSIS CONFIRMED WITH MULTIMODALITY IMAGING

Abstract A 59–year–old man,obese,with history of hypertension, 3 years ago underwent mitral valve (MV) replacement with a mechanical prothesis(Sorin Bicarbon 31) and preservation of the native subvalvular apparatus for severe mitral regurgitation due to anterior leaflet flail. Pre–discharge transthoracic echocardiography (TTE) showed normal prothesis function (mean pressure gradient (PG) 3,2mmHg), no valvular leaks and a normal ejection fraction (EF). Lately, the patient was admitted twice to emergency department for signs of heart failure, solved with increasing dose of oral diuretics. In both cases a TTE showed a normal EF, a trans–prosthetic mean PG of 6,5mmHg and no valvular impairment/leaks. Since the suboptimal TTE acoustic windows, a transesophageal echocardiography (TEE) was recommended. TEE showed a normal motion of both MV discs and no pannus/thrombus or leaks with the use of a 2–beat acquisition protocol. However, with longer observation a pattern of non–cyclic intermittent valve dysfunction was noted: whereas some cardiac cycles showed normal discs’ motion, other cycles demonstrated an emi–disc opening delay or blockage during diastole with significant prolongation of transmitral pressure half–time and higher transvalvular gradient, suggestive of flow impairment. A cine fluoroscopy and a CT assessment were also performed, showing the visible intermittent pattern of valve dysfunction without radiological signs of thrombosis or pannus. At this point, the interference of the MV apparatus with the emidisc was considered the most probable mechanism of dysfunction. A Heart Team decision toward reintervention was taken since the risk of a sudden worsening of the mechanical valve function, with potentially lethal consequences, was considered high. The surgeon at visual inspection confirmed the interference of the subvalvular apparatus with the posterior emidisc motion. The chronic shear stress generated on the mitral remnant likely developed a progressive fibrotic response that determined the thickening of the tissue and the periodical entrapment of the disc. MV prothesis was replaced with resection of the subvalvular apparatus. At dismissal,TTE evaluation showed normal valvular function confirmed at 6 months follow–up. Intermittent prosthetic MV dysfunction is a rare but potentially serious complication of MV replacement with subvalvular apparatus preservation. TEE, cine–fluoroscopy and CT may be useful as complementary tools to detect this rare complication.

Systematic coronary physiology improves level of agreement in diagnostic coronary angiography

ObjectiveThe training of interventional cardiologists (ICs), non-interventional cardiologists (NICs) and cardiac surgeons (CSs) differs, and this may be reflected in their interpretation of invasive coronary angiography (ICA) and management plan....

Combined CT Coronary Artery Assessment and TAVI Planning.

Computed tomography angiography (CTA) of the aorta and the iliofemoral arteries is crucial for preprocedural planning of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS), because it provides details on a variety of aspects required for heart team decision-making. In addition to providing relevant diagnostic information on the degree of aortic valve calcification, CTA allows for a customized choice of the transcatheter heart valve system and the TAVI access route. Furthermore, current guidelines recommend the exclusion of relevant coronary artery disease (CAD) prior to TAVI. The feasibility of coronary artery assessment with CTA in patients scheduled for TAVI has been established previously, and accumulating data support its value. In addition, fractional flow reserve determined from CTA (CT-FFR) and machine learning-based CT-FFR were recently shown to improve its diagnostic yield for this purpose. However, the utilization of CTA for coronary artery evaluation remains limited in this specific population of patients due to the relatively high risk of CAD coexistence with severe AS. Therefore, the current diagnostic work-up prior to TAVI routinely includes invasive catheter coronary angiography at most centers. In this article, the authors address technological prerequisites and CT protocol considerations, discuss pitfalls, review the current literature regarding combined CTA coronary artery assessment and preprocedural TAVI evaluation, and provide an overview of unanswered questions and future research goals within the field.

Transcatheter Mitral Valve Repair via MitraClip in Patients Aged

Transcatheter mitral valve repair (TMVR) using the MitraClip has become a well-established interventional therapy and is usually performed in elderly patients. The objective of this study was to assess 2-year clinical outcomes of TMVR in patients aged <65 years at three heart centres with severe mitral regurgitation (MR) and no surgical options. A retrospective study analysed data of 36 patients aged <65 years treated with TMVR . All patients were refused surgery by Heart Team decision. Baseline MR was assessed by biplane vena contracta width in two perpendicular views (mean 8.35 ± 1.87 mm). Degenerative MR was detected in 11 patients (30.6%); functional MR was detected in 25 patients (69.4%). Acute procedural success was accomplished in 88.9% of patients. No procedure-related mortality during the first 30 days was detected. Over an average of 2 years of follow-up, all-cause mortality was 19.4% and cardiovascular death was 11.1% owing to advanced heart failure. The average follow-up period was 25.8 months (median was 20 months). Statistically significant difference (p-value <0.01) was detected for N-terminal prohormone of brain natriuretic peptide (pg/ml) at baseline (mean 9,870 ± 10,819; median 7,748) compared to follow-up visits (mean 7,645 ± 11,292; median 3,263). New York Heart Association functional class improvement was achieved in 69% of patients. A second intervention (reclipping) was required in two patients to correct recurrent significant MR. TMVR in patients aged <65 years refused surgical repair provides satisfactory clinical outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort.

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

The evolution of technical prerequisites and local boundary conditions for optimization of mitral valve interventions-Emphasis on skills development and institutional risk performance.

This viewpoint report describes how the evolution of transcatheter mitral valve intervention (TMVI) is influenced by lessons learned from three evolutionary tracks: (1) the development of treatment from mitral valve surgery (MVS) to transcutaneous procedures; (2) the evolution of biomedical engineering for research and development resulting in predictable and safe clinical use; (3) the adaptation to local conditions, impact of transcatheter aortic valve replacement (TAVR) experience and creation of infrastructure for skills development and risk management. Thanks to developments in computer science and biostatistics, an increasing number of reports regarding clinical safety and effectiveness is generated. A full toolbox of techniques, devices and support technology is now available, especially in surgery. There is no doubt that the injury associated with a minimally invasive access reduces perioperative risks, but it may affect the effectiveness of the treatment due to incomplete correction. Based on literature, solutions and performance standards are formulated with an emphasis in technology and positive outcome. Despite references to Heart Team decision making, boundary conditions such as hospital infrastructure, caseload, skills training and perioperative risk management remain underexposed. The role of Biomedical Engineering is exclusively defined by the Research and Development (R&D) cycle including the impact of human factor engineering (HFE). Feasibility studies generate estimations of strengths and safety limitations. Usability testing reveals user friendliness and safety margins of clinical use. Apart from a certification requirement, this information should have an impact on the definition of necessary skills levels and consequent required training. Physicians Preference Testing (PPT) and use of a biosimulator are recommended. The example of the interaction between two Amsterdam heart centers describes the evolution of a professional ecosystem that can facilitate innovation. Adaptation to local conditions in terms of infrastructure, referrals and reimbursement, appears essential for the evolution of a complete mitral valve disease management program. Efficacy of institutional risk management performance (IRMP) and sufficient team skills should be embedded in an appropriate infrastructure that enables scale and offers complete and safe solutions for mitral valve disease. The longstanding evolution of mitral valve therapies is the result of working devices embedded in an ecosystem focused on developing skills and effective risk management actions.

Surgical extraction of cardiac implantable electronic device leads based on a heart team approach

BackgroundAs cardiac implantable electronic devices, such as pacemakers, cardioverter defibrillators, and cardiac resynchronization therapies, have become more popular, device extraction has become more frequent. At our institution, individual treatment strategies are discussed at a heart team meeting. Transvenous lead extraction (TVLE) is a first-line treatment; however, surgical lead extraction (SLE) is sometimes selected as a primary choice to provide optimal treatment and maintain the medical safety policy. This study aimed to investigate the validity of this heart team decision-making. MethodsFrom 2013 to 2021, 384 consecutive patients underwent lead extraction at our institution. ResultsSLE was proposed as the primary intervention for 21 patients who had high risk of bleeding, difficult TVLE conditions, large vegetations, and other concomitant cardiac diseases. Of the 363 TVLE patients, 10 patients required surgical intervention; 5 had TVLE difficulty followed by SLE and 5 had excessive bleeding. SLE was performed in 26 patients, 19 of whom required valve surgery, and 8 required plication of the great veins. In 4 of the 17 hybrid procedures with SLE and TVLE, excessive bleeding occurred due to laceration of the superior vena cava and innominate vein. Operative mortality was not observed in SLE patients but was observed in 1 of the 4 TVLE patients who required emergent open-chest hemostasis. ConclusionsThe heart team discussion was essential to provide optimal treatment and maintain medical safety policies for each patient. SLE should be selected for patients with high risk of TVLE or other cardiac complications such as tricuspid valve incompetence.

Short- and long-term impact of nutrition in a large cohort of patients undergoing transcatheter aortic valve implantation: prognostic value of GNRI

Abstract Background Nutritional status, as measured by Geriatric Nutritional Risk Index (GNRI), an easy-to-use tool combining both clinical and laboratory parameters, was shown to predict short-term survival in patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) by our group and others, and this has been extensively confirmed later on. However, data on the long-term impact of nutritional indexes on TAVI outcomes are still lacking. Purpose We aimed at confirming our previous short-term findings in a large population and to investigate the prognostic impact of GNRI in the long-term. Methods All consecutive patients who underwent TAVI between Oct. 2015 and Dec. 2021 at our centre were selected. Baseline nutritional parameters were consistently recorded. An up-to-6-year prospective follow-up was performed. Patients with missing albumin values or with no follow-up available were excluded. Taking into account the old age of patients usually being treated with TAVI, the geriatric version of NRI (GNRI for age&amp;gt;65) was used, and the very few patients younger than 65 years were excluded. GNRI was calculated as described by Bouillanne et al using the following formula: Geriatric (G) NRI = (1.489)×Albumin (g/L) + [(41.7×(present weight/ideal weight)]. The primary endpoint was long-term all-cause mortality. Patients were divided into: GNRI&amp;gt;98 (no risk of malnutrition) and ≤98 (risk of malnutrition). Kaplan-Meier curves were plotted and impact on prognosis was calculated using Cox regression analyses. Results A total of 1084 patients, median (IQR) age 82.2 (78.5–85.5) years, 44.4% female, were included. Median (IQR) BMI was 26.6 (24.2–30.0) kg/m2, corresponding to a slightly overweight population. Median (IQR) GNRI at baseline was 113.7 (106–120.2). 8.6% of patients showed risk of malnutrition (GNRI ≤98). Kaplan-Meier curves showed a significant impact on long-term mortality in patients with risk of malnutrition compared to those with no malnutrition risk, with curves starting to diverge in the first weeks after the procedure. The effect of nutritional status measured by GNRI increased with time. A significant association was shown in univariate analyses (HR 2.3 [95% CI 1.7–3.1], p&amp;lt;0.001) and also in multivariate analyses after adjusting for potential confounding factors (including age, sex and Euroscore II, among others) (HR 1.7 [95% CI 1.2–2.5], p&amp;lt;0.002). According to area under curve for ROC curves, GNRI showed a better predictive value than the widely used BMI. Conclusion This study confirmed the negative impact of the malnutrition risk status, as measured by GNRI, on short-term mortality after TAVI, and showed an even more pronounced effect in the long-term. GNRI could be easily recorded on admission, before TAVI procedure, and considered for heart team decisions. Further studies may be warranted to identify potential mechanisms for nutritional effects and to investigate the potential use of nutrition-improving measures in selected patients. Funding Acknowledgement Type of funding sources: None.

How to deal with nonsevere stenoses in coronary artery bypass grafting - a critical perspective on competitive flow and surgical precision.

For invasive treatment of coronary artery disease (CAD), we assess anatomical complexity, analyse surgical risk and make heart-team decisions for percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). With PCI, treating flow-relevant lesions is recommended, and reintervention easily treats disease progression. For CABG, some stenoses may only be borderline or nonsevere despite a clear surgical indication. As reoperations are not easy, the question on how to address these lesions has been around from the start, but has never satisfactorily been answered. With a new mechanistic perspective, we had suggested that infarct-prevention by surgical collateralization is the main prognostic mechanism of CABG in chronic coronary syndrome. Importantly, the majority of infarctions arise from nonsevere coronary lesions. Thus, surgical collateralization may be a valid treatment option for nonsevere lesions, but graft patency moves more into focus here, because graft patency directly correlates with the severity of coronary stenoses. In addition, CABG may even accelerate native disease progression. We here review the evidence for and against grafting nonsevere CAD lesions, suggesting that patency of grafts (to moderate lesions) may be improved by increasing surgical precision. In addition, we must improve our ability to predict future myocardial infarctions.

Cardiac magnetic resonance imaging versus computed tomography to guide transcatheter aortic valve replacement: study protocol for a randomized trial (TAVR-CMR)

BackgroundThe standard procedure for the planning of transcatheter aortic valve replacement (TAVR) is the combination of echocardiography, coronary angiography, and cardiovascular computed tomography (TAVR-CT) for the exact determination of the aortic valve dimensions, valve size, and implantation route. However, up to 80% of the patients undergoing TAVR suffer from chronic renal insufficiency. Alternatives to reduce the need for iodinated contrast agents are desirable. Cardiac magnetic resonance (CMR) imaging recently has emerged as such an alternative. Therefore, we aim to investigate, for the first time, the non-inferiority of TAVR-CMR to TAVR-CT regarding efficacy and safety end-points.MethodsThis is a prospective, randomized, open-label trial. It is planned to include 250 patients with symptomatic severe aortic stenosis scheduled for TAVR based on a local heart-team decision. Patients will be randomized in a 1:1 fashion to receive a predefined TAVR-CMR protocol or to receive a standard TAVR-CT protocol within 2 weeks after inclusion. Follow-up will be performed at hospital discharge after TAVR and after 1 and 2 years. The primary efficacy outcome is device implantation success at discharge. The secondary endpoints are a combined safety endpoint and a combined clinical efficacy endpoint at baseline and at 1 and 2 years, as well as a comparison of imaging procedure related variables. Endpoint definitions are based on the updated 2012 VARC-2 consensus document.DiscussionTAVR-CMR might be an alternative to TAVR-CT for planning a TAVR procedure. If proven to be effective and safe, a broader application of TAVR-CMR might reduce the incidence of acute kidney injury after TAVR and thus improve outcomes.Trial registrationThe trial is registered at ClinicalTrials.gov (NCT03831087). The results will be disseminated at scientific meetings and publication in peer-reviewed journals.

The Impact of a Dedicated Chronic Total Occlusion PCI Program on Heart Team Decision Making.

Guidelines endorse a heart team (HT) approach to standardize the decision-making process for patients with complex coronary artery disease (CAD). With percutaneous treatment options for complex CAD increasing, we hypothesized that practice had changed over the past decade-and that more individuals, previously deemed too high risk for intervention, would now be referred for either surgical or percutaneous revascularization. This observational study was conducted at St Thomas' Hospital (London, United Kingdom). All patients discussed at HT meetings were recorded and treatment recommendations audited. A subset of historic cases was selected for blinded, repeat discussion. From April 2018 to 2019, a total of 52 HT meetings discussing 375 cases were held. Patients tended to be male, with a majority demonstrating multivessel CAD in the context of preserved left ventricular function. SYNTAX scores were balanced across the tertiles. Thirty-five percent of patients had at least 1 chronic total occlusion (mean J-CTO, 3 [interquartile range, 2-3]), affecting the right coronary artery in 60%. Fifteen historic patients with isolated CTOs were re-presented an average of 8 years later; only 3 patients received the same outcome, with 80% now receiving a recommendation for revascularization over medical therapy. A dedicated program supporting complex coronary intervention is associated with a change in treatment recommendations issued by the local HT. In line with international guidelines, this might indicate that any complex or multivessel CAD should be discussed at HT meetings with, ideally, the presence of CTO operators.

Long-Term Outcomes of Conservative Versus Invasive Approach of Coronary Aneurysm.

Up to date, the management of coronary artery aneurysm (CAA) is not well defined and depends on local heart team decision. Data reported in literature are scarce and controversial. We aim to compare the long-term outcomes of different therapeutic strategies of CAA (medical vs percutaneous coronary intervention (PCI) vs coronary artery bypass graft(CABG)). A retrospective cohort study was conducted on 100 consecutive patients who underwent coronary angiography at Toulouse University Hospital, Toulouse France and fulfilled the diagnostic criteria of CAA. Coronary angiograms were reviewed, and all necessary data were collected. CAA was defined by a coronary dilation exceedingly at least 50% of reference coronary diameter. We identified 100 patients with CAA with a mean age of 67.9 12 years. The left anterior descending coronary artery was most affected (36%). CAA is associated with significant coronary artery disease in 78% of cases. The incidence of major adverse cardiovascular and cerebrovascular events (MACCE) was 13% during a median follow-up period of 46.2 24 months. A 53% of patients underwent PCI or CABG. The rate of MACCE was lower in CABG group (9.1%) compared to PCI (14.3%) and medical (12.8%) groups, but without reaching statistically significant level. Longitudinal aneurysm diameter was positively linked to MACCE [OR = 1.109, 95% CI (1.014-1.214), p = 0.024]. No benefits have been attributed to anticoagulant regimen over antiplatelet therapy. In our retrospective observational study, there seems to be no significant differences in MACCE-free survival between all groups (Medical vs PCI vs CABG). Larger longitudinal aneurysm diameter was identified as a predictor of poor prognosis during follow-up.

An Individualized Approach of Multidisciplinary Heart Team for Myocardial Revascularization and Valvular Heart Disease-State of Art.

The multidisciplinary Heart Team (HT) remains the standard of care for highly-burdened patients with coronary artery disease (CAD) and valvular heart disease (VHD) and is widely adopted in the medical community and supported by European and American guidelines. An approach of highly-experienced specialists, taking into account numerous clinical factors, risk assessment, long-term prognosis and patients preferences seems to be the most rational option for individuals with. Some studies suggest that HT management may positively impact adherence to current recommendations and encourage the incorporation of patient preferences through the use of shared-decision making. Evidence from randomized-controlled trials are scarce and we still have to satisfy with observational studies. Furthermore, we still do not know how HT should cooperate, what goals are desired and most importantly, how HT decisions affect long-term outcomes and patient’s satisfaction. This review aimed to comprehensively discuss the available evidence establishing the role of HT for providing optimal care for patients with CAD and VHD. We believe that the need for research to recognize the HT definition and range of its functioning is an important issue for further exploration. Improved techniques of interventional cardiology, minimally-invasive surgeries and new drugs determine future perspectives of HT conceptualization, but also add new issues to the complexity of HT cooperation. Regardless of which direction HT has evolved, its concept should be continued and refined to improve healthcare standards.

Three-dimensional QCA-based vessel fractional flow reserve (vFFR) in Heart Team decision-making: a multicentre, retrospective, cohort study

ObjectivesTo evaluate the feasibility of three-vessel three-dimensional (3D) quantitative coronary angiography (QCA)-based fractional flow reserve (FFR) computation in patients discussed within the Heart Team in whom the treatment decision was...

Comparison of SYNTAX and Gensini Scores in the Decision of Surgery or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease.

Introduction: Many scoring systems have been developed to determine the extent of coronary artery disease (CAD) in patients with multi-vessel disease. The most widely used of these are Synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) and Gensini scoring. Gensini scoring system can successfully show coronary plaque burden. In our study, we aimed to test the predictive power of SYNTAX and Gensini scores for surgical or percutaneous intervention decisions made by the cardiac team in patients with three-vessel disease.Methods: A total of 476 patients without ST-elevation myocardial infarction with the three-vessel disease were included in the study. SYNTAX and Gensini scores of the patients were calculated from their coronary angiographies. Receiver operating characteristic curve (ROC-curve) analysis was performed using both scores.Results: Both the SYNTAX score and Gensini score were able to predict heart team decisions (AUC: 0.759, 0.680; p<0.001). Diabetes and smoking were more common in patients who were decided to have surgery (p<0.001).Conclusion: In the light of our study results, the decisions to be made with the SYNTAX score will be closer to the decisions of the heart team than the Gensini score.

Transcatheter Closure of a Ragged Post-Myocardial Infarction Ventricular Septal Defect Using an Off-Label ASD Occluder

Post-myocardial infarction ventricular septal defect has become a rare event following ST Elevation Myocardial Infarction (STEMI) but is still a life-threatening complication with high mortality. Transcatheter closure of post-myocardial infarction ventricular septal defects has emerged as an alternative therapeutic approach but often requires individual strategies due to complex morphology. We report a case of a 62-year-old man who was admitted to our hospital after STEMI of the inferior wall with pulmonary congestion due to a post-myocardial infarction VSD for interdisciplinary evaluation and therapy. The patient was characterized by estimated high perioperative risk and underwent interventional closure of the VSD according to heart team decision. Because of ragged nature of the VSD closure with a conventional Occlutech™ VSD occluder was not possible. Therefore, we decided to close the defect using an off-lable device for ASD closure which was successfully implanted without relevant residual shunt.

Heart team approach for comprehensive management of aortic coarctation in the adult.

Aortic coarctation in the adult is usually associated with chronic systemic hypertension, which leads to the sequelae of congestive heart failure, vascular dysfunction and decreased lifespan. Open and endovascular treatment modalities both provide excellent procedural outcomes with minimal mortality and morbidity, but a structured algorithm for workup and periprocedural decision making is not well established. We outline our heart team decision making approach along with our institution's experience treating this condition. We retrospectively reviewed twenty-four consecutive adult patients treated for aortic coarctation since 2010 at a single center. Outcomes of interest included mortality, treatment approach, device used and post-procedure hypertension status. We describe our protocol for work-up and intervention decision making. We explain our rationale for recommending treatment and the approach, open or endovascular, using existing literature and our experience. Procedural success rate was 100%, and there were no 30-day, one-year or five-year mortalities, whether the approach was open or endovascular. At last contact, 32% of patients were normotensive and no longer taking blood pressure medications. Several patients presented with complex problems as a result of commonly described complications of prior open or endovascular repair, and we describe our approach to the management of these difficult cases. Even at a high-volume heart and vascular hospital, aortic coarctation is an uncommon presentation in adult patients. Our experience suggests that excellent outcomes are obtained by discussing each patient among a multidisciplinary heart team and developing a work-up and treatment protocol to guide selection of interventional modality.

Heart Team for Optimal Management of Patients with Severe Aortic Stenosis-Long-Term Outcomes and Quality of Life from Tertiary Cardiovascular Care Center.

Background: This retrospective study was proposed to investigate outcomes of patients with severe aortic stenosis (AS) after implementation of various treatment strategies following dedicated Heart Team (HT) decisions. Methods: Primary and secondary endpoints and quality of life during a median follow-up of 866 days of patients with severe AS qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and transcather aortic valve replacement (TAVR) or OMT and surgical aortic valve replacement (SAVR) were evaluated. As the primary endpoint composite of all-cause mortality, non-fatal disabling strokes and non-fatal rehospitalizations for AS were considered, while other clinical outcomes were determined as secondary endpoints. Results: From 2016 to 2019, 176 HT meetings were held, and a total of 482 participants with severe AS and completely implemented HT decisions (OMT, TAVR and SAVR for 79, 318 and 85, respectively) were included in the final analysis. SAVR and TAVR were found to be superior to OMT for primary and all secondary endpoints (p < 0.05). Comparing interventional strategies only, TAVR was associated with reduced risk of acute kidney injury, new onset of atrial fibrillation and major bleeding, while the superiority of SAVR for major vascular complications and need for permanent pacemaker implantation was observed (p < 0.05). The quality of life assessed at the end of follow-up was significantly better for patients who underwent TAVR or SAVR than in OMT-group (p < 0.05). Conclusions: We demonstrated that after careful implementation of HT decisions interventional strategies compared to OMT only provide superior outcomes and quality of life for patients with AS.

Transcatheter mitral valve repair (TMVR) using MitraClip in patients younger than 65 years: a multicenter analysis of 2-years outcomes

Abstract Background TMVR using MitraClip became a well-established interventional therapy for severe MR. However, TMVR has been almost only applied to old aged patients rejected from surgical therapy. Objective To present 2-years outcomes of 36 patients younger than 65 years with no surgical options treated by TMVR. Methods A retrospective clinical and TEE study was conducted to evaluate 36 patients younger than 65 years treated by TMVR in 3 heart centers. Results Mean age of the 36 study patients was 56.3±6.6 years, male gender was 72.2%. High operative risk was estimated by STS score (mean = 8.73±2.97) and EuroSCORE (mean = 24.71±12.79). All patients were refused for surgery by heart team decision, therefore admitted to TMVR. Baseline severity of MR was assessed by 3D-TEE based biplane vena contracta width (mean = 8.35±1.87 mm). Baseline transmitral mean pressure gradient was 1.81±0.78 mmHg. 21 patients showed mitral annular dilatation as the main cause of MR, 8 patients had leaflet prolapse, 4 patients exhibited papillary muscle displacement leading to leaflet tethering and 3 patients showed mitral leaflet thickening and/or retraction due to fibrosis. Procedural success was achieved in all patients with 1/2/3 clips implanted in 52.8%/44.4%/2.8% of cases with a mean of 1.5 clip per case. Two grades or more reduction in severity of MR (MR grade ≤ II/IV) was accomplished in 88.9% of patients. Mean postprocedural MPG was 3.78±1.96 mmHg. Average follow-up (FU) period was 25,8 months and the median was 20 months (25th–75th percentile: 12–36 months). During 2-years FU, statistically significant difference (p value &amp;lt;0.002) was detected for NT-proBNP levels compared to baseline (mean = 9870±10819, median = 7748, 25th–75th percentile: 2702–14237 pg/ml) and at follow up visits (mean = 7645±11292, median = 3263, 25th-75th percentile: 883–8078 pg/ml). Furthermore, persistent symptomatic improvement during FU, defined as NYHA functional class improvement by 2 or more Grades, was achieved in 69% of patient in parallel with efficient reduction of MR in 34 patients so that a second intervention by reclipping was required in 2 patients to correct recurrent significant MR. Only two patients experienced procedure-related complications by large puncture site hematoma. No procedure-related mortality during the first 30 days was detected. However, mortality was recorded in 2 patients during the first month and was attributed to severe advanced heart failure in one case and septicemia after exclusion of infective endocarditis in another case. Over 2 years FU, other 5 patients passed away, 3 cases owing to advanced heart failure, one case due to multi-organ failure and one because of tumor disease. Conclusion TMVR in patients younger than 65 years refused from surgical repair provides satisfactory clinical and echocardiography outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hassan M.H. Mohammed received a scholarship grant from the Egyptian ministry of higher education and Minia University, Egypt.

Coronary revascularization: Interventional therapy or coronary bypass surgery

Coronary artery disease remains the leading cause of death and is responsible for myocardial infarction, heart failure and angina. Therapy combines optimal control of cardiovascular risk factors with coronary revascularization performed by interventional therapy or bypass surgery. While interventional therapy is preferred for single or two vessel disease, interdisciplinary heart team decision should be reached for complex lesion, three vessel or left main disease. Both revascularization strategies perform similar for low level complexity three vessel or left main disease while coronary bypass surgery proved superior for more complex coronary artery disease. Heart team decision should be based on vascular anatomy and expected revascularization success under consideration of operative risk and patient preference.