Deutsches Herzzentrum Berlin

Although several treatment options are available for patients with severe mitral regurgitation (MR), a significant proportion of patients remain ineligible for any mitral valve (MV) intervention. We aimed to analyse the phenotypic characteristics of surgical high-risk patients ineligible for MV interventions using an unsupervised phenotypic clustering approach.

Between 2014 and 2022, the CHOICE-MI registry included 984 patients with MR undergoing screening for transcatheter MV replacement at 33 international sites. For this study, only patients with screening failure receiving medical therapy alone were included. Patients receiving transcatheter or surgical treatment were excluded. A cluster analysis using K-means was performed on baseline clinical, demographic, and imaging variables to identify different patient phenotypes. Among 284 patients with MR (77.4 ± 8.82 years, 56.0% female, EuroSCORE II: 6.6 ± 5.8%) considered ineligible for any MV intervention, two clinically distinct phenogroups (PGs) were identified using unsupervised hierarchical clustering of principal components: PG1, elderly women with primary MR, preserved left ventricular function, and annular calcification; and PG2, patients with secondary MR, advanced heart failure, and high prevalence of comorbidities. One-year all-cause mortality did not differ between the PGs (PG1: 21.4%, PG2: 23.4%, P = 0.89). Predictors of mortality were albumin, renal function, and extracardiac arteriopathy for PG1 and albumin, coronary artery disease, and prior myocardial infarction for PG2.

This study identified two major subgroups among patients ineligible for mitral interventions showing profound differences in clinical and anatomical profiles. Identifying these factors may drive technological evolution to address the unmet clinical need for therapeutic options in MR patients.

NCT04688190 (CHOICE-MI Registry)

Atrial fibrillation (AF) is the most common persistent arrhythmia and demonstrates a notable recurrence rate after ablation. Previous studies have suggested that surrogate markers of insulin resistance could predict postablation AF recurrence. This systematic review and meta-analysis aimed to assess studies examining the relationship between surrogate insulin resistance markers and the recurrence of AF after ablation. We searched PubMed, Web of Science, Embase, and Scopus for observational studies published from inception to August 2024. We incorporated studies that assessed the relationship between surrogate insulin resistance markers and the occurrence of postablation AF in patients with either paroxysmal or persistent AF. The random-effects model was used for meta-analysis. The Newcastle-Ottawa scale was used to evaluate risk of bias, and the leave-one-out method was applied for sensitivity analysis (PROSPERO: CRD42024584526). Nine studies involving 7729 participants met the inclusion criteria. Significant associations with AF recurrence were observed for the triglyceride-glucose index (hazard ratio [HR] 1.29; 95% confidence interval [CI] 1.15-1.44; I² = 44%), homeostatic model assessment of insulin resistance (HR 1.27; 95% CI 1.14-1.42; I² = 0%), and metabolic score for insulin resistance (HR 1.04; 95% CI 1.03-1.05; I² = 0%). However, the triglyceride-to-high-density lipoprotein ratio did not demonstrate a statistically significant association with AF recurrence (HR 1.09; 95% CI 0.96-1.24; I² = 86%). Surrogate markers of insulin resistance can be valuable predictors for assessing the risk of AF recurrence in patients who have undergone catheter ablation, potentially aiding in preventive strategies. Nevertheless, further prospective studies are required to validate our findings.

Epicardial access during electrophysiology procedures offers valuable insights and therapeutic options for managing ventricular arrhythmias (VAs). The current clinical consensus statement on epicardial VA ablation aims to provide clinicians with a comprehensive understanding of this complex clinical scenario. It offers structured advice and a systematic approach to patient management. Specific sections are devoted to anatomical considerations, criteria for epicardial access and mapping evaluation, methods of epicardial access, management of complications, training, and institutional requirements for epicardial VA ablation. This consensus is a joint effort of collaborating cardiac electrophysiology societies, including the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, the Latin American Heart Rhythm Society, and the Canadian Heart Rhythm Society.