Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment.

Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.

Tricuspid valve disease and cardiac implantable electronic devices.

The role of cardiac implantable electronic device (CIED)-related tricuspid regurgitation (TR) is increasingly recognized as an independent clinical entity. Hence, interventional TR treatment options continuously evolve, surgical risk assessment and peri-operative care improve the management of CIED-related TR, and the role of lead extraction is of high interest. Furthermore, novel surgical and interventional tricuspid valve treatment options are increasingly applied to patients suffering from TR associated with or related to CIEDs. This multidisciplinary review article developed with electrophysiologists, interventional cardiologists, imaging specialists, and cardiac surgeons aims to give an overview of the mechanisms of disease, diagnostics, and proposes treatment algorithms of patients suffering from TR associated with CIED lead(s) or leadless pacemakers.

How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement.

PURPOSE OF REVIEW: In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications. RECENT FINDINGS: Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.

Why Follow-up Examinations After Left Atrial Appendage Closure Are Important: Detection of Complications During Follow-up and How to Deal with Them.

PURPOSE OF REVIEW: Device-related thrombus (DRT) formation and incomplete left atrial appendage closure (LAAC) are the two major complications that can occur after LAAC and can potentially limit the success of such a procedure. This review discusses the incidence, clinical and/or prognostic significance, detection methods, treatment options, and potential strategies to prevent these complications. RECENT FINDINGS: It has recently been proven that the presence of a DRT represents an independent predictor for ischemic stroke after LAAC. Continued need for anticoagulation due to incomplete LAAC is clinically relevant to the patient. The appearances of a DRT or an incompletely closed LAA after a LAAC procedure are not rare complications. Due to the clinical and/or prognostic significance of these complications, it is important to detect them in a timely manner during follow-up by using the appropriate diagnostic imaging techniques. Since a DRT is associated with an increased risk of stroke, the therapy should be aggressive. In the case of incomplete LAA closure, an additional closure device may be used to complete occlusion and avoid lifelong anticoagulation therapy.

Degenerative Mitral Regurgitation: Assessment, Physical Examination, and Imaging.

PURPOSE OF REVIEW: In this review, we provide a comprehensive approach to assess degenerative mitral regurgitation. RECENT FINDINGS: In the evaluation of MR, it is important to differentiate between primary (degenerative/organic) MR in which an intrinsic mitral valve lesion(s) is responsible for the occurrence of MR and secondary (functional) MR where the mitral valve is structurally normal, but alterations of the left ventricular geometry cause deterioration of the MV apparatus. Advanced imaging modalities, foremost two-dimensional and three-dimensional echocardiography, are essential for this determination. In the evaluation of degenerative MR, the exact mechanism, the extent of the disease, associated valve lesions, the grade of mitral regurgitation severity, and hemodynamic consequences require careful assessment in order to provide patients with appropriate monitoring and treatment.

Rheumatic Mitral Valve Stenosis: Diagnosis and Treatment Options.

PURPOSE OF REVIEW: This review provides an update on rheumatic mitral stenosis. Acute rheumatic fever (RF), the sequela of group A ß-hemolytic streptococcal infection, is the major etiology for mitral stenosis (MS). RECENT FINDINGS: While the incidence of acute RF in the Western world had substantially declined over the past five decades, this trend is reversing due to immigration from non-industrialized countries where rheumatic heart disease (RHD) is higher. Pre-procedural evaluation for treatment of MS using a multimodality approach with 2D and 3D transthoracic and transesophageal echo, stress echo, cardiac CT scanning, and cardiac MRI as well as hemodynamic assessment by cardiac catheterization is discussed. The current methods of percutaneous mitral balloon commissurotomy (PMBC) and surgery are also discussed. New data on long-term follow-up after PMBC is also presented. For severe rheumatic MS, medical therapy is ineffective and definitive therapy entails PMBC in patients with suitable morphological mitral valve (MV) characteristics, or surgery. As procedural outcomes depend heavily on appropriate case selection, definitive imaging and interpretation are crucial. It is also important to understand the indications as well as morphological MV characteristics to identify the appropriate treatment with PMBC or surgery.

Aortic Regurgitation.

PURPOSE OF REVIEW: Aortic regurgitation (AR) is a common form of valvular disease which is characterized by reflux of blood from the aorta into the left ventricle (LV) during diastole. AR results from various etiologies, affecting the aortic valve cusps or the aortic root. The clinical presentation of patients with AR depends on the severity of the regurgitation and differs whether AR develops acutely or if it progresses over a prolonged period, allowing the cardiac chambers to adapt. Echocardiography is the primary method to determine the etiology of AR and to define its severity. We review the current data regarding the diagnosis and treatment of AR. RECENT FINDINGS: No single parameter is sufficient to determine AR severity; thus, an integrative, multi-parametric approach is required. Echocardiography is key for imaging the aortic valve morphology and flow as well as aortic root and ascending aorta. Determining LV ejection fraction and dimensions is essential for patient management and optimizing timing for intervention. Three-dimensional (3D) echocardiography is useful in the evaluation of AR etiology and severity. The use of Trasncatheter aortic valve replacement (TAVR) has emerged as an alternative to surgery in patients at high operative risk. The diagnosis and management of AR requires a comprehensive approach and routine clinical and echocardiographic follow-up. Surgical or percutaneous therapy is indicated when symptoms develop and in those who have LV dysfunction or LV dilation.

Transcatheter patch closure of an atrial septal defect of sinus venosus type using the immediate release patch.

Following promising preclinical studies, we report our first clinical experience with transcatheter closure of an atrial septal defect of sinus venosus type in a 65-year-old patient using the Immediate Release Patch.

Lack of "obesity paradox" in patients presenting with ST-segment elevation myocardial infarction including cardiogenic shock: a multicenter German network registry analysis.

BACKGROUND: Studies have associated obesity with better outcomes in comparison to non-obese patients after elective and emergency coronary revascularization. However, these findings might have been influenced by patient selection. Therefore we thought to look into the obesity paradox in a consecutive network STEMI population. METHODS: The database of two German myocardial infarction network registries were combined and data from a total of 890 consecutive patients admitted and treated for acute STEMI including cardiogenic shock and cardiopulmonary resuscitation according to standardized protocols were analyzed. Patients were categorized in normal weight (≤24.9 kg/m(2)), overweight (25-30 kg/m(2)) and obese (>30 kg/m(2)) according to BMI. RESULTS: Baseline clinical parameters revealed a higher comorbidity index for overweight and obese patients; 1-year follow-up comparison between varying groups revealed similar rates of all-cause death (9.1 % vs. 8.3 % vs. 6.2 %; p = 0.50), major adverse cardiac and cerebrovascular [MACCE (15.1 % vs. 13.4 % vs. 10.2 %; p = 0.53)] and target vessel revascularization in survivors [TVR (7.0 % vs. 5.0 % vs. 4.0 %; p = 0.47)] with normal weight when compared to overweight or obese patients. These results persisted after risk-adjustment for heterogeneous baseline characteristics of groups. An analysis of patients suffering from cardiogenic shock showed no impact of BMI on clinical endpoints. CONCLUSION: Our data from two network systems in Germany revealed no evidence of an "obesity paradox"in an all-comer STEMI population including patients with cardiogenic shock.

Transcatheter valve-in-ring implantation after a failed surgical mitral repair using a transseptal approach and a veno-arterial loop for valve placement.

A failure of a mitral valve repair, which includes the implantation of a mitral annuloplasty ring in the majority of cases, is associated with relevant mortality. Surgery is considered as the standard treatment for these patients. For patients who have an unacceptable high peri-surgical risk a transcatheter valve-in-ring (TVIR) procedure might be an option. Isolated case reports and small case series report on the feasibility of a TVIR implantation in mitral position. We present a case where a 29-mm Edwards Sapien valve was placed in a 32-mm Carpentier Edwards ring. To our knowledge no valve has been implanted so far in this ring size and this is the first case where a veno-arterial loop was used as guide rail for valve implantation and helped considerably to position the valve properly.

Initial clinical experience with the Coherex FlatStent™ and FlatStent™ EF PFO closure system for in-tunnel PFO closure: results of the Coherex-EU study.

OBJECTIVE: The Coherex-EU Study evaluated the safety and efficacy of PFO closure utilizing novel in-tunnel PFO closure devices. BACKGROUND: Transcatheter closure of patent foramen ovale (PFO) followed the development of transcatheter closure devices designed to patch atrial septal defects (ASDs). The Coherex FlatStent™ and FlatStent™ EF devices were designed specifically to treat PFO anatomy. METHODS: A total of 95 patients with a clinical indication for PFO closure were enrolled in a prospective, multicenter first in man study at six clinical sites. Thirty-six patients received the first-generation FlatStent study device, and 57 patients received the second-generation FlatStent EF study device, which was modified based on clinical experience during the first 38 cases. Two patients enrolled to receive the first generation did not receive a device. RESULTS: At 6 months post-procedure, 45% (17/38) of the intention-to-treat (ITT) cohort receiving the first-generation FlatStent device had complete closure, 26% (10/38) had a trivial residual shunt, and 29% (11/38) had a moderate to large residual shunt. In the ITT cohort receiving the second-generation FlatStent EF device, 76% (43/57) had complete closure, 12% (7/57) had a trivial shunt, and 12% had a moderate to large shunt. Five major adverse events occurred, all without sequelae. CONCLUSION: This initial study of the Coherex FlatStent/FlatStent EF PFO Closure System demonstrated the potential for in-tunnel PFO closure. The in-tunnel Coherex FlatStent EF may offer an alternative to septal repair devices for PFO closure in appropriately selected patients; however, further investigation will be necessary to establish the best use of this device.

Predictors for prolonged hospital stay after transcatheter mitral valve repair with the MitraClip.

OBJECTIVE: The aim is to find predictors for a prolonged LOHS after MitraClip implantation. BACKGROUND: Due to its less invasive nature, average length of hospital stay (LOHS) after the MitraClip procedure is shorter compared to mitral valve surgery. However, some patients have a prolonged LOHS. METHODS: Records of consecutive patients who underwent MitraClip procedure were reviewed. A total of 41 consecutive patients with MitraClip implantation (76 ± 9 years, 59% men) were included. Median hospital stay was 7 days. Hospitalization lasting longer than 7 days was considered prolonged. RESULTS: Procedural success was achieved in 88% of the cases. In-hospital death occurred in 4 of 41 patients (10%). Patients with a prolonged hospital stay (46%) had a higher EuroSCORE I (22.7% [IQR 10.3-28.3] vs. 6.7% [IQR 3.5-18.3], P = 0.017), a higher STS mortality score (6.1%[(IQR 3.7-7.5] vs. 2.6% [IQR 1.4-4.8]; P = 0.043) and a higher STS long-length-of-stay score (18.9% [IQR 11.3-22.5] vs. 9.6% [IQR 6.2-16.1]; P = 0.039) as well as a lower estimated glomerular filtration rate (eGFR) (41 ml/min/1.73 m(2) [IQR 19-52] vs. 56 ml/min/1.73 m(2) [IQR 49-62]; P = 0.008) than those whose did not. In the multivariate model, lower eGFR was identified as predictor for a prolonged hospitalization. CONCLUSION: Lower pre-procedure eGFR is independently associated with a longer hospitalization.

Change in mitral annular size and geometry after MitraClip® implantation in patients with functional and degenerative mitral regurgitation.

BACKGROUND: MitraClip® therapy is an alternative to conventional surgery. The aim was to characterize the mitral annular geometry pre- and postrepair with the MitraClip® taking into account the regurgitation mechanism. METHODS: We retrospectively collected pre- and postprocedural transesophageal echocardiography data in 46 patients. Patients were categorized as having isolated degenerative (DMR, n = 18), isolated functional (FMR, n = 9) or a combination of both functional and degenerative mitral regurgitation (MMR, n = 19). RESULTS: A significant reduction in septolateral (SL) diameters in all patients occurred. Noteworthy, in those with DMR, there was no significant change in intercommissural (IC) diameters whereas in those with FMR and MMR, it increased significantly in systole (FMR: +2.8 ± 3.4 mm, P = 0.03, MMR: +2.1 ± 2.6 mm, P = 0.002). In DMR, a significant reduction in mitral annular areas post-procedure was observed (-1.8 ± 2.3 cm(2), P = 0.001 in diast., -0.8 ± 1.0 cm(2), P = 0.004 in syst.). In patients with FMR and MMR, though the SL diameter decreased, this occurred at the expense of an increase in IC diameter causing a change in annular shape but leaving the annular area unchanged. Nevertheless, a comparable reduction in regurgitant severity (DMR: P = <0.001; FMR: P = 0.003; MMR: P = <0.001) and improvement in functional class occurred regardless of regurgitant mechanism. CONCLUSIONS: Though changes in mitral annular geometry after MitraClip® repair differ depending on regurgitant mechanism, this does not appear to have an impact on residual regurgitation or clinical status in the short-term.

Long-term results of a randomized trial comparing three different devices for percutaneous closure of a patent foramen ovale.

AIMS: Percutaneous patent foramen ovale (PFO) closure for secondary stroke prevention is discussed controversially. Long-term data comparing different closure devices are limited. The objective is the prospective comparison of procedural complications and long-term results after PFO closure in patients with cryptogenic stroke randomized to three different closure devices. METHODS AND RESULTS: Between January 2001 and December 2004, 660 patients with cryptogenic stroke were randomized to three different closure devices (Amplatzer, CardioSEAL-STARflex, and Helex occluder, 220 patients per group). The primary endpoint was defined as recurrent cerebral ischaemia [stroke, transient ischaemic attacks (TIA), or Amaurosis fugax], death from neurological cause, or any other paradoxical embolism within 5 years after the index procedure. Device implantation was technically successful in all interventions (n = 660; 100%). The procedure was complicated by pericardial tamponade requiring surgery in one patient (Amplatzer group) and device embolization in three patients (all Helex group). Thrombus formation on the device was detected in 12 cases (11 CardioSEALSTARflex, 1 Helex, 0 Amplatzer; P < 0.0001), of which 2 required surgery. Complete closure after single device implantation was more common with the Amplatzer and with the CardioSEAL-STARflex than with the Helex occluder: Amplatzer vs. Helex vs. CardioSEAL-STARflex: n = 217 (98.6%) vs. n = 202 (91.8%) vs. n = 213 (96.8%; P = 0.0012). Within 5 years of follow-up, the primary endpoint occurred in 25 patients (3.8%; 10 TIAs, 12 strokes and 3 cases of cerebral death). Compared with the CardioSEAL-STARflex (6%; 6 TIAs, 6 strokes, 1 cerebral death) and Helex groups (4%; 4 TIAs, 4 stroke, 1 cerebral death), significantly fewer events (P = 0.04) occurred in the Amplatzer group (1.4%; 2 strokes, 1 cerebral death). CONCLUSION: Although procedural complications and long-term neurological event rates are low regardless of the device used, the recurrent neurological event rate was significantly lower after Amplatzer than after CardioSEAL-STARflex or Helex implantation. This has important implications regarding the interpretation of trials comparing PFO closure with medical management.

A novel approach to treat residual peridevice leakage after left-atrial appendage closure.

Left atrial appendage (LAA) device closure has emerged as an alternative treatment to conventional anticoagaluation therapy for the prevention of thromboembolic events in patients with atrial fibrillation. In 8-10% of patients with interventional LAA obliteration, relevant residual flow into the LAA persists due to incomplete seal. We present two cases in whom for the first time two different devices were placed to complete occlusion after residual leak with a first device.

Recurrent events after percutaneous closure of patent foramen ovale.

OBJECTIVES: To determine the incidence of symptomatic recurrent embolic events after patent foramen ovale (PFO) closure and potential causes for these events. BACKGROUND: It is well-known that cerebral or other embolic events may occur after PFO closure. METHODS: This is a retrospective analysis of consecutive patients who underwent PFO closure for secondary prevention of embolic events at a single institution. RESULTS: 1,930 patients (mean age of 50 ± 13.3 years) underwent transcatheter PFO closure. Complete closure occurred in 92%. The annual recurrence rate of embolic events before PFO closure was 22.4% (785 events in 3,497 patient-years). During follow-up (mean 39 months), 63 recurrent events were documented: 25 strokes, 36 transient ischemic attacks (TIAs), and 2 peripheral embolic events. The overall annual recurrence rate after the procedure was 1% per year (63 events in 6,211 patient-years). The majority of events occurred in patients without residual shunts (54/63). There was no significant association between the presence of a residual shunt and recurrent events [hazard ratio (HR) 1.7; 95% confidence interval (CI) 0.8-3.6, P = 0.16]. The most common cause for recurrent events was atherosclerosis. Nine out of 63 events were considered likely or possible paradoxical embolism due to residual shunt [stroke (2), TIA (5), and peripheral embolism (2)]. After PFO closure, the annual rate of events potentially related to paradoxical embolism was 0.14% (9 events in 6,211 patient-years). CONCLUSION: The incidence of symptomatic embolic events after PFO closure is low. Most recurrent events are related to coexistent conditions associated with thromboembolic risk rather than residual shunts.

Safety and performance of the Spider™ patent foramen ovale occluder.

OBJECTIVES: The aim of this clinical trial was to assess safety, efficacy, and technical handling of a novel ceramic-coated double-disc patent foramen ovale (PFO) occluder. BACKGROUND: Though percutaneous PFO closure is performed with increasing frequency worldwide, certain risks such as thrombus formation and incomplete endothelialization remain. The Spider™ PFO occluder was designed to minimize these risks. METHODS: The Spider™ PFO occluder is a self-expandable double-disc device with a ceramic coated nitinol wire mesh and an integrated expanded polytetrafluoroethylene (ePTFE) membrane on the right atrial side and ceramic coated nitinol anchors and ePTFE patch on the left atrial side. Study patient assessments were conducted at baseline, periprocedure, and discharge and at 1-, 6- and 12-month follow-up. RESULTS: Fifty-one patients (mean age 52 ± 14 years; 63% male) were enrolled in the prospective, multicenter clinical trial. Implantation was successful in all patients. Mean procedural time was 30.0 ± 8.6 min. No periprocedural or in-hospital complications occurred. Four patients (8%) had paroxysmal atrial fibrillation (AF) at 1-month follow-up. Otherwise, no procedure or device related adverse events occurred. Importantly, there were no recurrent embolic events. At 1-month follow-up 63% (32/51) of patients had no residual shunt with contrast transesophageal echocardiography during Valsalva maneuver. Of all patients who underwent 6-month echo follow-up to date, 78% (39/50) had no residual shunt during Valsalva maneuver. CONCLUSION: Initial results with the novel Spider™ PFO occluder show that the device is safe and easy to use for percutaneous closure of PFO. The overall complication rate was low. The rate of AF needs further investigation.

Transcatheter closure of multiple interatrial communications.

OBJECTIVES: We sought to examine acute and midterm results of closure of multiple interatrial communications with staged device deployment and to review the relevant literature. BACKGROUND: Information about percutaneous methods of closure for multiple defects is limited. METHODS: We treated 148 patients with multiple defects. Of these, 88 had a relevant left to right shunt ("LRS"), 52 had a presumed paradoxical embolism ("PPE"), five had both (LRS and PPE), and one patient, respectively, had migraine, decompression sickness, and a right to left shunt. After implantation of the first device, closure of additional septal defects was attempted only if indicated clinically. RESULTS: Ninety-four patients received a single device and 53 more than one. In four patients, surgical defect closure followed. At the end of follow-up (FU; mean 4.5 ± 3.4 years), complete closure of all defects occurred in 67.6% (62.1% for LRS, 76.5% for PPE). Clinical success (small or trivial residual shunt) was achieved in 86.9% (83.9% for LRS, 90.2% for PPE). Complications included pericardial effusions in 2.7%, recurrent thromboembolic events in 4.8%, and new onset of atrial fibrillation in 10.1%. In a significant number of patients with multiple defects, after single device implantation, the likelihood of complete closure increased with FU time (26% complete closure at 1 month vs. 78% at 24 months). CONCLUSION: Percutaneous closure of multiple interatrial communications is feasible and safe. Importantly, many residual defects close without further intervention at FU. Therefore, staged device delivery is an alternative to simultaneous device implantation, possibly requiring fewer and smaller second devices.

Impact of aortic valve calcification on the outcome of transcatheter aortic valve implantation: results from the prospective multicenter German TAVI registry.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is an emerging technology in patients with severe aortic stenosis. BACKGROUND: Whether the degree of aortic valve calcification impacts the outcome after TAVI has not been thoroughly evaluated. METHODS: We analyzed data from the prospective multicenter German TAVI registry, including 1,365 patients as of July 2010. Patients were divided into three groups, based on the degree of aortic valve calcification: mild (n = 67), moderate (n = 392), and severe (n = 906) valve calcification, determined by visual estimation by the operator. RESULTS: Mean age was 81.7 ± 6.2 years; mean logistic EUROscore was 20.6 ± 13.7%. Patients with severe aortic valve calcification had a higher mean and peak-to-peak gradient before the intervention (P < 0.0001). Technical success was achieved in 97%, similar in each group. The Medtronic CoreValve was implanted in 80.8%, the Sapien Edwards prosthesis in the remaining cases. The duration of the procedure and fluoroscopy was higher in the group with severe calcification (P < 0.01 for procedure and P < 0.05 for fluoroscopy). During the periprocedural period there were no differences among the groups regarding in-hospital death, cerebrovascular events, myocardial infarction, thromboembolic events, aortic dissection, or severe vascular complications. Furthermore, there was no significant difference in postprocedural aortic mean gradient (7.0 mm Hg vs. 5.6 mm Hg vs. 6.3 mm Hg; P = 0.07), in residual aortic regurgitation (74% vs. 72% vs. 68%; P = 0.3) or postprocedure pacemaker implantation (38% vs. 30.4% vs. 34.2%; P = 0.35). During 30-day follow up there was no difference in regard to the number of death, strokes, and myocardial infarctions. CONCLUSIONS: Our results of a real-world registry suggest that the extent of aortic valve calcification does not influence the success or procedural outcome significantly.

Multimodality imaging for patient selection, procedural guidance, and follow-up of transcatheter interventions for structural heart disease: a consensus document of the EACVI Task Force on Interventional Cardiovascular Imaging: part 1: access routes, transcatheter aortic valve implantation, and transcatheter mitral valve interventions.

Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation.