Objective Whether patients with severe aortic stenosis (AS) and significant functional mitral regurgitation (MR) should undergo isolated aortic (aortic valve replacement [AVR]) or double aortic‐mitral valve procedure (DVP) remains controversial. We sought to determine outcomes of such patients undergoing surgical (surgical aortic valve replacement [SAVR]) and transcatheter AVR (TAVR) or DVP, identify echocardiographic parameters predictive of significant residual MR after isolated AVR, and determine its impact on long‐term survival. Methods Data prospectively collected from 736 consecutive patients with severe AS and significant MR undergoing AVR or DVP were retrospectively analyzed. Exclusion of organic MR, other valve diseases and concomitant CABG yielded a final population of 74 patients with significant functional MR (32 TAVR, 23 SAVR, 19 DVP). Demographics, postoperative complications and age‐adjusted survival were compared. Echocardiographic predictors of significant residual MR and its impact on survival were analyzed for patients undergoing isolated AVR. Results In the isolated AVR group, MR improvement occurred in 60% of patients and was associated with a significant increase in survival compared to persistence of significant MR (p = .03). Patients with improved MR had significantly greater preoperative left ventricular dilatation (LVEDD: 49 vs. 43 mm, p = .001; LVESD: 35 vs. 29 mm, p = .03; LVEDV: 101 vs. 71 ml, p = .0003; LVESV: 57 vs. 33 ml, p = .002). There was no significant difference in perioperative mortality (5.3 vs. 4.4 vs. 9.4%, p = .85) or age‐adjusted long‐term survival between isolated AVR and DVP groups (76.3 vs. 84.2% survival at 2‐year follow‐up, p = .26), or between SAVR, TAVR and DVP groups (78.2 vs. 75.0 vs. 84.2% survival at 2‐year follow‐up, p = .13). Conclusions After isolated AVR, MR improvement occurs in 60% of patients. It is predicted by greater ventricular dimensions and associated with significantly better long‐term survival. Whether a staged approach with transcatheter correction of MR should be considered in patients with significant residual MR following AVR remains undetermined.

Background Fulminant viral myocarditis (FVM) is a rare cause of cardiogenic shock associated with high morbidity and mortality rates. An inappropriately activated immune system results in severe myocardial inflammation. Acute immunosuppressive therapy for FVM therefore gained in popularity and was described in numerous retrospective studies. Methods We conducted an extensive review of the literature and compared it with our single-centre retrospective review of all cases of FVM from 2009-2019 to evaluate the possible effect of acute immunosuppression with intravenous immunoglobulins and/or high dose corticosteroids in patients with FVM. Results We report on 17 patients with a mean age of 46 ± 15 years with a mean left ventricular ejection fraction (LVEF) of 15 ± 9% at admission. Fourteen (82%) of our patients had acute LVEF recovery to ≥ 45% after a mean time from immunosuppression of 74 ± 49 hours (3.1 days). Extracorporeal membrane oxygenation (ECMO) was required in 35% (6/17) of our patients for an average support of 126 ± 37 hours. Overall mortality was 12% (2/17). No patient needed a long-term left ventricular assist device or heart transplant. All surviving patients achieved complete long-term LVEF recovery. Conclusions Our cohort of 17 severely ill patients received acute immunosuppressive therapy and showed a rapid LVEF recovery, short duration of ECMO support, and low mortality rate. Our suggested scheme of investigation and treatment is presented. These results bring more cases of successfully treated FVM with immunosuppression and ECMO to the literature, which might stimulate further prospective trials or a registry.

ObjectiveCurrent guidelines support the use of transcatheter mitral valve interventions to treat some selected high-risk patients with significant mitral valvulopathy. As with any other interventional cardiac procedure, concerns have been raised about cerebrovascular event. The aim of this systematic review and meta-analysis was to determine the incidence of cerebrovascular events following (1) transcatheter mitral valve edge-to-edge repair with mitral valve clip and (2) transcatheter mitral valve replacement (TMVR).MethodsWe conducted a systematic review of studies reporting the cerebrovascular adverse events after transcatheter mitral valve edge-to-edge repair and TMVR procedures. The primary endpoint was the incidence of cerebrovascular events as defined by the Mitral Valve Academic Research Consortium. An event that occurred within 30 days or during index hospitalisation was defined as periprocedural; otherwise it was defined as non-periprocedural. This study was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Aggregated study-level data were pooled using a random effect model. The quality of each study was appraised with the Hawker checklist, a method of systematically reviewing research from different paradigms.ResultsSixty studies totalling 28 155 patients undergoing edge-to-edge repair with mitral valve clip were included in the analysis. Periprocedural stroke and non-periprocedural stroke rates were 0.9% (95% CI 0.6 to 1.1) and 2.4% (95% CI 1.6 to 3.2), respectively. For TMVR procedures, 26 studies including 1910 patients were analysed. The estimated periprocedural stroke incidence was 1% (95% CI 0.5 to 1.8) compared with 7% (95% CI 0.8 to 18.5) for non-periprocedural stroke.ConclusionsTranscatheter mitral valve interventions are associated with low rates of cerebrovascular events. The exact mechanisms of these complications are still poorly understood given the relative paucity of good quality data.Trial registration numberCRD42019117257.

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BACKGROUND: At least 40% of adults have 1 lifetime faint and 20% of adults faint recurrently. Despite its alarm, the incidence of associated injuries is unknown. Purpose: To determine the incidence, severity, and predictors of injuries due to syncope in patients (pts) in 3 syncope clinical trials. METHODS AND RESULTS: POST studies are multicenter randomized syncope treatment trials. POST 2 and 4 studied fludrocortisone and midodrine for vasovagal syncope, and POST 3 studied management strategies for bifascicular block and syncope. Injuries were recorded during the year after enrollment. Injury was categorized as minor (bruising, scrapes), moderate (lacerations), and severe (fracture, burns, joint pain). Results: 183/459 pts had 1 faint, for a total of 645 faints. The median ages were 34 y with a median 3 faints in the prior yr. 59/ 194 pts (30%) had at least 1 injury related to syncope, and 103/698 faints (15%) resulted in injury. Of 459 pts, 48 (10%), 7 (2%), and 4 (1%) had minor, moderate and severe injuries, respectively. Of 59 injured pts, 81%, 12%, and 7% had minor, moderate and severe injuries, respectively. Of 103 injuries, 83 (81%), 16 (16%), and 4 (4%) were minor, moderate, and severe, respectively. The sex of the pt did not predict injury-free survival (male vs female, 71.2% vs 67.7% p¼0.43), nor did age above and below median age (old vs young, 70.8% vs 67% p¼0.92). None of age, sex and prior year syncope frequency predicted injury severity (age, minor vs rest p¼0.48; sex, minor vs rest, p¼0.54; frequency, minor vs rest p¼0.52). Patients with 3 or more syncope in prior year were more likely to get injured in the follow up period, cumulative incidence 35% vs 26%, p¼0.02 Wilcoxon. Presence of prodromes did not prevent injuries. In POST 3 and 4, injuries occurred in 16/67 pts (24%) with a history of prodromes in prior year and 14/ 30 pts (47%) without a history of prodromes in prior year, p¼0.12 Logrank (Figure 1). Also, In POST 3 and 4, injuries occurred in 13/31 pts (42%) without prodromes and 17/66 pts (26%) with prodromes, p¼0.31, Logrank (Figure 2). CONCLUSION: Injuries are frequent in syncope patients, occurring in 15% of faints. Most injuries are bruises, and musculoskeletal injuries are uncommon. Patients with frequent syncope are more likely to be injured, while age, sex and presence of prodromes did not predict injury.