Tricuspid valve disease (TVD) has long been underrecognized compared with left-sided valvular disorders, yet it represents a major determinant of cardiovascular morbidity and mortality. Tricuspid regurgitation (TR), the predominant manifestation of TVD, is being recognized with increasing frequency as populations age and the burden of left-sided heart disease rises. While mild TR is often physiological, moderate and severe TR are associated with adverse outcomes, independent of left ventricular function or pulmonary pressures. Secondary TR, driven by right atrial or right ventricular remodeling, constitutes the majority of cases, whereas primary TR due to intrinsic valvular pathology is less frequent. Cardiac implantable electronic device (CIED)-related TR represents a distinct and increasingly prevalent mechanism that often requires dedicated management considerations. Historically, management of TVD has often been delayed until the onset of advanced right heart failure or end-organ dysfunction, resulting in poor outcomes. Contemporary evidence emphasizes the importance of early recognition, precise etiologic characterization, and timely intervention within a multidisciplinary framework. Surgical repair, particularly annuloplasty, remains the reference standard in suitable candidates, offering durable results when performed before irreversible right ventricular remodeling develops. Transcatheter tricuspid valve interventions have expanded therapeutic options for high-risk or inoperable patients, demonstrating symptomatic and hemodynamic improvement in early studies. Optimal management of TVD follows a lifetime approach, integrating multimodality imaging, risk stratification, and individualized treatment strategies. General physicians and cardiologists play a key role in early detection, while coordinated collaboration among imaging specialists, electrophysiologists, heart failure experts, interventional cardiologists, cardiac surgeons, and anesthesiologists is essential for comprehensive care. Ultimately, a patient-centered lifetime management strategy initiated early and adapted to disease progression offers the best opportunity to preserve right heart function, improve survival, and maintain quality of life in patients with TVD.

BackgroundIn Korea, rheumatic mitral valve (MV) disease remains relatively prevalent compared with Western countries. Given this demographic profile, we aimed to evaluate long-term rhythm and clinical outcomes of surgical ablation of atrial fibrillation (AF) during MV surgery in patients with degenerative versus rheumatic MV disease, using the data from the nation’s highest-volume center.MethodsWe retrospectively analyzed consecutive patients with AF who underwent MV surgery with concomitant surgical ablation between 2001 and 2020 at a high-volume center in Korea. Patients were categorized by MV etiology (rheumatic vs. degenerative). The primary outcome was AF recurrence after a 3-month blanking period. Secondary outcomes included all-cause mortality, stroke, and permanent pacemaker (PPM) implantation. The probability of AF recurrence was estimated using logistic regression with generalized estimating equations, and competing risk models were used to assess stroke and PPM implantation.ResultsAmong 1,872 patients (mean age 58.7±11.5 years; 56.9% women), 1,157 (61.8%) had rheumatic MV disease, and 715 (38.2%) had degenerative disease. Compared with patients with degenerative disease, those with rheumatic disease were younger, more often female, had more persistent AF, larger left atrial dimensions, and a higher likelihood of undergoing MV replacement. The adjusted probability of AF recurrence at 3, 5, and 10 years was 23.6%, 28.6%, and 40.1%, respectively, and did not significantly differ between rheumatic and degenerative groups (10-year: 39.8% vs. 40.6%; P=0.746). Rheumatic etiology was not associated with an increased risk of death (P=0.518), stroke (P=0.520), or PPM implantation (P=0.052).ConclusionsIn a contemporary Korean cohort, surgical ablation during MV surgery provided sustained rhythm control and favorable clinical outcomes in patients with both degenerative and rheumatic disease. Given the continued burden of rheumatic heart disease in Korea, these findings support the routine application of surgical ablation during MV surgery, regardless of underlying etiology.

Mitral annular calcification (MAC) remains a challenging pathology in the context of mitral valve disease. It is associated with known cardiovascular risk factors, as well as a variety of chronic inflammatory, infective, or connective tissue diseases. Surgically, patients are at specific operative risk for atrioventricular dehiscence or rupture and/or injury to the circumflex artery. To mitigate these risks, a broad portfolio of surgical options exists to safely anchor annular sutures. This can be performed after the calcium bar has been removed and the posterior annulus reconstructed with a patch, or even when the calcium bar is left in place. Knowledge of these techniques will help surgeons manage MAC and implant a properly sized valve. Even in the presence of severe MAC with additional involvement of the mitral valve leaflets, transatrial transcatheter heart valve (THV) implantation may be a viable option. An individualized decision-making process to determine the applicable technique should be used for patients with MAC, leading to adequate treatment for this high-risk patient group.

BackgroundMitral annular calcification (MAC) poses technical and clinical challenges in patients undergoing mitral valve intervention. Patients with severe MAC were excluded from major previous randomized controlled trials evaluating mitral therapies. Consequently, outcomes following mitral transcatheter edge-to-edge repair (M-TEER) in this population remain controversial.MethodsMEDLINE and EMBASE were searched through June 2025 to identify studies reporting outcomes after M-TEER in patients with MAC. This systematic review assessed the difference in MAC grading and M-TEER eligibility across studies. The definition of procedural success was documented to highlight inconsistencies. The primary endpoint was all-cause mortality during follow-up. Secondary endpoints included procedural success, heart failure rehospitalization, mitral valve reintervention, residual mitral regurgitation (MR), and mean mitral gradient.ResultsSix studies met inclusion criteria, including 2,808 patients undergoing M-TEER, of whom 363 (12.9%) had moderate-to-severe MAC. Most studies defined procedural success as MR reduction to grade ≤2, though only one incorporated a mean transmitral gradient <5 mmHg. MR reduction to ≤2 rates were comparable between patients with none-mild MAC and moderate-severe MAC. However, device success (MR reduction ≤2 and mean gradient <5 mmHg) was significantly lower in MAC patients (56.1% versus 81.3%). Post-procedural mitral valve gradient >5 mmHg occurred in 18.5–48.3% of MAC cases. Two studies reported increased all-cause mortality in patients with moderate-severe MAC during follow-up, with a mean follow-up of 20.4 months. Residual MR and reintervention rates were generally similar between groups, though mitral valve gradients tended to be higher in MAC patients.ConclusionsM-TEER is feasible in well-selected patients with moderate-to-severe MAC; however, elevated post-procedural gradients remain a concern and may impact long-term outcomes. The absence of standardized eligibility criteria for M-TEER and consistent MAC quantification limits optimal patient selection. Comparative studies with surgical repair/replacement and transcatheter mitral valve replacement are critically needed to define optimal therapy.

Transcatheter mitral valve intervention (TMVI) has emerged as a potential alternative to surgery for patients with mitral annular calcification (MAC)-associated mitral valve disease, a population often deemed high-risk due to clinical and anatomic complexities. However, MAC also presents significant challenges to TMVI itself. In transcatheter edge-to-edge repair (TEER), procedural success may be limited by fibrotic and short leaflets, reduced mitral valve area, and subvalvular calcium protrusion. Transcatheter mitral valve replacement (TMVR) poses further anatomical hurdles, including a small, eccentric, or non-conforming annuli; insufficient MAC to ensure anchoring; narrow aortomitral angle; septal hypertrophy; elongated anterior mitral leaflet predisposing to left ventricular outflow tract (LVOT) obstruction; and heterogeneous MAC morphology leading to paravalvular leak or suboptimal fixation. Mechanical injury to adjacent structures such as the circumflex artery and atrioventricular groove is also a concern. Balloon-expandable valves, used off-label for TMVR, may be delivered via transapical, transfemoral, transseptal, or hybrid transatrial approaches. While early data show high mortality for valve-in-MAC (ViMAC) procedures, a shift toward transfemoral transseptal access has improved outcomes. The hybrid transatrial approach offers advantages including resection of the anterior leaflet, septal myectomy, and reinforcement of the valve skirt with Teflon felt. Among dedicated self-expanding TMVR systems, only Tendyne has both CE mark and US Food and Drug Administration (FDA) approval and is delivered transapically. New transfemoral transseptal systems—such as Intrepid, AltaValve, and Cephea—are under active investigation. Techniques like LAMPOON (Laceration of the Anterior Mitral leaflet to Prevent Outflow ObstructioN) and BATMAN (Balloon-Assisted Translocation of the Mitral Anterior Leaflet) have been developed to mitigate the risk of fatal LVOT obstruction. Despite progress, mid-term mortality after ViMAC TMVR remains high. Continued innovations in technique, device design, and patient selection are critical to establishing TMVI as a viable treatment for MAC-associated mitral valve disease.

BackgroundThe frozen elephant trunk (FET) provides single-stage repair of complex, concomitant aortic arch and descending aortic disease, integrating both conventional and endovascular approaches. While multiple meta-analyses affirm short-term safety, long-term outcomes remain largely unknown, especially regarding overall survival and freedom from re-intervention. This current systematic review and meta-analysis aims to summarize the short- and long-term outcomes following the use of FET in aortic pathology.MethodsStudies with at least two years of follow-up data on FETs were identified in five electronic databases, which were searched from inception of records until July 2025. The primary outcome of interest was mortality, with short-term data presented as either 30-day or in-hospital mortality, and long-term data as aggregated Kaplan-Meier curves. Subgroup analysis was also compared by etiology. Secondary outcomes included relevant morbidity outcomes.ResultsFollowing independent screening, 28 studies were included for analysis, with 11,292 patients and a mean follow-up period of 40.4 months. Actuarial overall survival at 1, 5 and 10 years was 86.2%, 78.8% and 67.9%, respectively. Long-term survival for acute dissection for these points was marginally higher, at 86.2%, 82.4%, and 75.2%, respectively. Overall freedom from distal reintervention at 1, 5, and 10 years was 93.9%, 87.4% and 81.5%, respectively. Comparatively, pooled short-term mortality was marginally higher in the aortic dissection cohort than the overall cohort at 7.7% [95% confidence interval (CI): 6–11%] and 7% (95% CI: 5–9%), respectively. The breakdown for these was 254/3,379 and 742/9,428 patients, respectively. For the overall cohort, postoperative spinal cord injury (SCI), postoperative cerebrovascular accident (CVA), and acute renal failure (ARF) requiring dialysis were 4%, 8% and 11%, respectively. Pooled mean intensive care unit (ICU) length of stay was 7 days. A high level of heterogeneity was present, likely due to the mixed etiologies included.ConclusionsOur long-term data expands on previous literature while affirming similar favorable long-term survival for the FET procedure. The consistent pattern of improved late-survival in acute dissections supports the hypothesis that early false-lumen exclusion and acute remodeling result in clear long-term benefits. The need for re-intervention has remained consistent with the published literature, further highlighting the importance of patient selection.

BackgroundThe frozen elephant trunk (FET) technique has revolutionized the surgical management of aortic dissection. However, distal stent-graft-induced new entry (dSINE) and reinterventions remain major challenges. This study presents the long-term results of a dissection-specific (DS) “Soft Elephant Trunk” (SET) (MedEng, Penza, Russia) hybrid prosthesis and its impact on distal remodeling compared to conventional hybrid prosthesis.MethodsA retrospective review of hybrid aortic repairs from 2014 to 2024 identified 241 patients with aortic dissection. Patients were categorized into two cohorts: DS SET prosthesis (n=170) and conventional prosthesis (non-DS, n=71). Propensity score matching was performed. Primary endpoints included the incidence of dSINE and aortic reinterventions. Secondary endpoints evaluated perioperative complications and long-term survival. Cox regression analysis identified independent predictors of dSINE.ResultsSurvival rates, freedom from reoperation, and the incidence of dSINE did not differ between the groups. However, cumulative incidence of new events—including distal aortic reoperations and dSINE—was significantly lower in the DS group versus non-DS both before matching (12.9% vs. 29.6%, P<0.001) and after matching (15.5% vs. 29.6%, P=0.04). Long-term endoleak rates (>5 years) were significantly higher in the non-DS group (31.4% vs. 7.1%, P=0.009). According to multivariable Cox regression analysis, the key predictors for dSINE included connective tissue disease [hazard ratio (HR) =3.22, 95% confidence interval (CI): 1.09–9.52, P=0.034], Stanford type B aortic dissection (HR =4.3, 95% CI: 7–14.61, P=0.019), and chronic phase of dissection (HR =7.8, 95% CI: 0.72–84.21, P=0.09). The highest dSINE risk was observed in non-DS patients with chronic dissection (P=0.009), Type B dissection (P=0.012), CTD (P=0.005), and aortic dilation >45 mm (P=0.004).ConclusionsIn comparison to conventional hybrid grafts, the SET graft exhibits a protective trend against dSINE, particularly in high-risk cases. This strategy may reduce distal complications and the need for secondary interventions, thereby improving long-term patient outcomes.