Degenerative mitral stenosis (MS) secondary to extensive mitral annular calcification (MAC) represents a growing clinical challenge in an aging population. These patients are often elderly, frail, and harbor a significant burden of comorbidities, rendering conventional mitral valve surgery prohibitively high-risk. While transcatheter mitral valve replacement (TMVR) has emerged as a potential alternative, the current evidence is only derived from single-arm observational registries. Therefore, the transition toward randomized controlled trials to define optimal patient selection and long-term prosthetic durability is necessary. This review examines the current landscape of TMVR for degenerative MS, focusing on the role of multimodal pre-procedural planning, procedural technique, and prevention of the principal complications. The integration of echocardiography and multi-slice computed tomography (MSCT) is essential for evaluating anatomical feasibility, particularly in predicting neo left ventricle outflow tract (neo-LVOT) obstruction, the primary determinant of procedural mortality. However, it is limited due to the absence of standardized protocol. We are showing the outcomes of off-label balloon-expandable aortic prostheses and dedicated TMVR system, which are the only two devices which data in patients with MS are available. Despite high technical success rates in specialized centers, complications, including paravalvular leak, valve thrombosis, and device migration, remain more prevalent than in aortic interventions. We present some tips and tricks to prevent and manage adverse events. TMVR represents a transformative frontier for inoperable patients with severe MAC. However, its routine clinical adoption requires further refinement of dedicated technologies and standardized imaging protocols to improve safety and bridge the gap between palliative medical therapy and definitive intervention.

Mitral annular calcification (MAC) is a complex structural abnormality often associated with severe mitral stenosis, regurgitation, or both. Mitral valve surgery carries greater risk especially in elderly patients with MAC, making transcatheter mitral valve replacement (TMVR) an emerging alternative. We report the case of an 84-year-old woman with a history of surgical bioprosthetic aortic valve replacement and recurrent hospitalizations due to severe MAC-related mitral valve disease. She was deemed inoperable by the heart team. Detailed multimodal imaging, including multidetector computed tomography (MDCT), revealed extensive MAC with acceptable neo-left ventricular outflow tract (neo-LVOT) dimensions and an acute aorto-mitral angle. Thus, TMVR was successfully performed via a transseptal approach using a 30.5 mm balloonexpandable Myval transcatheter heart valve (THV). Post-procedural imaging confirmed optimal valve position, no paravalvular leak, and no LVOT obstruction. The patient was discharged in stable condition. This is the first reported case from Türkiye of TMVR in MAC using the Myval THV, contributing to the growing worldwide experience. This report also emphasizes the role of advanced imaging in guiding patient selection and procedural planning and illustrates the feasibility of the Myval THV for valve-in-MAC in challenging mitral anatomy.

Many proposed FE models to predict the vertebral risk of fracture consider single vertebrae only, neglecting the role of the intervertebral discs in load transmission and distribution across vertebrae. Inclusion of the intervertebral discs in multi-vertebrae models would allow more physiological boundary conditions. However, while CT allows material properties to be assigned to the vertebrae, no information about the discs is provided. Hence, the aim of this study was to build multi-level FE models uniquely based on CT data and validate them by comparing the predicted displacements and strains against the experimental measurements. One spine segment (T10-L1) was harvested from a human spine and tested in flexion-compression in the elastic regime. During the test, displacements and strains on the anterior surface were measured with digital image correlation. The FE model was built starting from the CT scan of that same spine segment. HU-based isotropic linear elastic properties were assigned to the vertebral bone. Five different combinations of hyperelastic material properties from the literature were assigned to the discs, modeling the nucleus pulposus and the anulus fibrosus separately. The boundary conditions replicated the flexion-compression test performed experimentally. Predicted displacements and strains on the vertebrae surfaces were compared against the measured displacements and strains. The model excellently predicted the displacement field (R2 = 0.92/0.99). On the other hand, different constitutive laws for the discs resulted in different principal strain distributions, which substantially differed from the experimental one, showing average relative errors higher than 34%. In conclusion, a different modeling approach should be adopted for the discs in CT-based multi-level FE models to achieve acceptable accuracy.

PurposeRight ventricular impairment (RVI) can be alleviated by the initiation of veno-venous extracorporeal membrane oxygenation (V-V ECMO), which enhances gas exchange and allows for less invasive mechanical ventilation. However, the progression of RVI during V-V ECMO remains unclear. This study assesses echocardiographic changes in RVI over a five-day period in twenty acute respiratory distress syndrome (ARDS) patients with V-V ECMO support.Material and MethodsOver a five-day period of V-V ECMO support, we examined echocardiographic markers of RVI, including right and left ventricular end-diastolic area ratio (RVEDA/LVEDA), tricuspid annular plane systolic excursion (TAPSE), tricuspid valve lateral anulus peak systolic velocity (S'), right ventricular fractional area change (FAC), and right ventricular myocardial performance index. Secondary objectives included changes in mechanical power transmitted to the respiratory system, hemodynamics and gas-exchange.ResultsRVEDA/LVEDA ratio remained elevated (0.8 [0.7-0.8] vs 0.7 [0.7-0.9]; p = .986), TAPSE decreased (2.0[1.6-2.5] cm vs 1.7 [1.4-2.2] cm; p = .024) while no changes were observed in S' (16 [13-21] cm/s vs 15 [12-18] cm/s; p = .136) and FAC (38 [27-47] % vs 36 [29-43] %; p = .627). The right ventricular myocardial performance index improved (0.74 [0.45-1.00] vs 0.51 [0.42-0.80]; p = .004). Lung mechanical power was significantly reduced due to a decrease in lung elastic and resistive components.ConclusionsDespite preserved longitudinal function and improved global performance, RVI persisted in severe ARDS patients on V-V ECMO, as indicated by the RVEDA/LVEDA ratio. These findings suggest that mechanisms beyond hypoxemia, hypercapnia and the invasiveness of mechanical ventilation contribute to RVI in these patients.Trial registrationThis trial was registered with the German Clinical Trials Register (DRKS00028584) on March 28, 2022. https://drks.de/search/en/trial/DRKS00028584.

Introduction: Three-dimensional speckle-tracking echocardiography (3DSTE) can be used to accurately measure the dimensions of the left ventricle (LV) and aortic valve anulus (AVA) at the same time. The present study aimed to conduct an extensive 3DSTE-based investigation of simultaneously assessed end-diastolic and end-systolic LV volumes and AVA dimensions in healthy adults with LVs and AVAs of different sizes. Methods: One hundred and seven healthy adults (mean age 35.4 ± 12.2 years, 67 males) were voluntarily enrolled in the present study. Results: With increasing end-diastolic AVA area, tendentious increase in both end-diastolic and end-systolic LV volumes could be detected, resulting in preserved LV-EF. With increasing end-systolic AVA area, similar findings were present. Comparing the smaller than mean and the larger than mean end-systolic AVA area subgroups, the end-systolic LV volume proved to be significantly increased in the latter group. With the increase in end-diastolic LV volume, the AVA dimensions remained preserved. With the increase in end-systolic LV volume, only the highest end-systolic LV volume was associated with larger end-systolic AVA area and perimeter; the other parameters remained preserved. In certain circumstances, end-systolic AVA area and perimeter proved to be significantly increased compared to their end-diastolic counterpart. Conclusions: With the increase in end-diastolic and end-systolic AVA areas, a tendentious increase in both LV volumes could be detected in healthy adults. Larger end-diastolic LV volume was not associated with dilated AVA dimensions, while larger end-systolic LV volume was associated with dilated end-systolic AVA area and perimeter.

Objective: The totally endoscopic approach is on the rise to become the new standard in mitral valve surgery. The aim of this study was to develop a morphometric measurement tool for educational purposes to predict operability with low conversion and high repair rates. Methods: From January 2020 to March 2023, 64 patients underwent totally endoscopic mitral valve repair (TE-MVR). Of these, 15 patients were deemed to be unsuitable for TE-MVR due to narrow space and/or anticipated complex repair techniques and underwent repair through sternotomy (MVR-open). Angio-CT scanning was performed for preoperative planning and measurements of the following: the distance between the sternum and the spine (DSS), the distance between the skin incision and the anterior anulus of the mitral valve (DNM) and the intercostal space at the level of the skin incision (ICS). Results: The repair rate for all patients was 98.7%. In the TE-MVR group, the conversion rate to sternotomy was 3.1%. The 30-day survival was 100%. The DSS was 130.4 ± 18.8 mm and 108.1 ± 17.3 mm, and the DSM 70.7 ± 12.1 mm and 58.5 ± 13.6 mm in the TE-MVR and MVR-open, respectively (p < 0.001). Twenty-one TE-MVR patients were found to be technically demanding due to friction and less freedom to move the instruments. The composite morphometric parameter DSS plus 4xICS minus DNM was 53.3, 39.8 and 25.6 for TE-TMReasy, TE-TMRdemanding and MVR-open, respectively (p < 0.05 and p < 0.01). Conclusions: Surgical skills and a long history of expertise are mandatory to achieve excellent results with a low conversion and high repair rate. The composite morphometric parameter may be an easy tool for educational demands to predict the ease and feasibility of TE-MVR.

Background: Paravalvular leak (PVL) was initially recognized as one of the most common complications after transcatheter aortic valve implantation (TAVI) and has been linked to adverse clinical outcomes, including mortality. This study aims to assess the long-term clinical effects of PVL in patients undergoing TAVI with the latest generation of transcatheter aortic valves, as part of the national observational prospective multicenter study OBSERVANT II. Methods: OBSERVANT II included all consecutive patients with severe aortic stenosis who underwent TAVI across 28 Italian centers from December 2016 to September 2018. A total of 2125 patients were included in this analysis and stratified according to the presence of moderate-to-severe PVL (significant PVL, n = 155) versus no/trace-to-mild PVL (no significant PVL, n = 1970). The primary endpoint was 5-year major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, stroke, myocardial infarction, and coronary revascularization. Five-year all cause death and re-hospitalization for heart failure (HF) were the secondary endpoints. Results: In our cohort, the incidence of moderate-to-severe PVL was 7%. Age, aortic anulus perimeter, and self-expandable valves were determinants of PVL. The risk of MACCE, all-cause death, and re-hospitalization for HF at the 5-year follow-up were not different between the study groups [HR = 1.07 (95% CI: 0.85-1.34) p = 0.571; HR = 1.10 (95% CI: 0.87-1.39) p = 0.435; HR = 1.20 (95% CI: 0.88-1.62) p = 0.245, respectively]. Conclusions: In this analysis of the OBSERVANT II study, moderate/severe PVL was not associated with a higher incidence of MACCE and re-hospitalization for heart failure at the 5-year follow-up.

Intervertebral disc (IVD) degeneration is suspected to affect the distribution of stress and strain near the vertebral endplates and in the underlying bone. This scenario is worsened by the presence of metastatic lesions on the vertebrae (primarily thoracic vertebrae (60-80 %)) which increase the risk of fracture. As such, this study aimed to evaluate the effect of IVD degeneration on the internal volumetric strains and failure modes of human metastatic vertebral bodies. Five human thoracic spinal segments including one vertebra with lytic metastases and one radiologically healthy vertebra (control) were in situ tested in pure compression within a μCT scanner (isotropic voxel size = 39μm). Each specimen was tested in the elastic regime before and after inducing mock IVD degeneration (enzymatic degeneration with collagenase); and at failure after IVD degeneration. The volumetric strain field was measured using a global Digital Volume Correlation approach (BoneDVC). After IVD degeneration, larger maximum (+187 %, P = 0.002, 95 % CI= [-4447, -1209]) and minimum (+174 %, P = 0.002, 95% CI= [1679, 4258]) principal strains were observed in both metastatic and control vertebrae, with peak differences in correspondence of the IVD anulus fibrosus. IVD degeneration caused a transversal fracture pattern in the vertebrae with failure location onset in the middle portion of the vertebral body and in the cortical shell. In conclusion, IVD degeneration was found to be a key factor in determining the failure mode, suggesting the clinical relevance of including IVD level of degeneration to assess patients' risk of spinal instability. STATEMENT OF SIGNIFICANCE: Vertebrae can be affected by pathologies, like bone metastases, while intervertebral discs tend to degenerate during life. Generally, these structures and pathologies are studied separately. In this study, we explored the effects of artificial intervertebral disc degeneration on the mineralised tissues of the vertebrae with metastases. We observed that the induced intervertebral disc degeneration changes the mechanical behaviour of the vertebral trabecular bone. We believe that the findings of this study may influence the scientific community to develop new clinical tools for the prediction of the risk of fracture in vertebrae with spinal metastases, including the degeneration of the intervertebral discs as a parameter.