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Background: The prevalence of left atrial thrombi in patients scheduled for electrical cardioversion (ECV) of atrial fibrillation (AF) remains unknown in contemporary real-life practice., Methods and Results: Patients scheduled for ECV underwent transesophageal echocardiography (TEE) regardless of AF duration and type of anticoagulant. Of 277 consecutive patients (65% men, mean age 71 ± 10 years, CHA 2 DS 2 -VASc 3.1 ± 1.4), 92 were on direct oral anticoagulants (DOACs) and 99 on antivitamin K (AVK) oral agents for at least 3 weeks before and 4 after ECV. Eighty-five patients with paroxysmal AF on low-molecular-weight heparin were also considered. Real time three-dimensional TEE detected left atrial appendage (LAA) thrombus in 7% of patients, without significant difference among three groups (P = .334). Anticoagulation was ineffective in eight patients on AVK oral agents, two of them had thrombus. Eight patients assumed incorrectly DOACs, four of them had thrombus. Among the 175 patients on effective anticoagulation, five showed thrombus, three on AVK oral agents, and two on DOACs (P = .716). Effective anticoagulation was associated with reduced risk of thrombosis (OR: 0.16, 95%CI: 0.06-0.45, P = .001). In patients with correct anticoagulation, predictors of thrombus were CHA 2 DS 2 VASc (for each point of increment OR: 1.97, 95%CI: 1.08-3.61, P = .029), low left ventricular ejection fraction (OR: 0.92, 95%CI: 0.86-0.99, P = .026), and degree of spontaneous echo-contrast (for each point increase OR: 10, 95%CI: 2-39, P < .0001)., Conclusion: Patients with AF, on effective anticoagulation, had a prevalence of thrombus not negligible regardless of type of anticoagulant. TEE is prudent before ECV and mandatory if unsuccessful anticoagulation is proved or suspected., (© 2021 Wiley Periodicals LLC.)

Purpose: To assess the prognostic utility of quantitative 2D-echocardiography, including strain, in patients with COVID-19 disease., Methods: COVID-19-infected patients admitted to the San Paolo University Hospital of Milan that underwent a clinically indicated echocardiographic examination were included in the study. To limit contamination, all measurements were performed offline. Quantitative measurements were obtained by an operator blinded to the clinical data., Results: Among the 49 patients, nonsurvivors (33%) had worse respiratory parameters, index of multiorgan failure, and worse markers of lung involvement. Right ventricular (RV) dysfunction (as assessed by conventional and 2-dimensional speckle tracking) was a common finding and a powerful independent predictor of mortality. At the ROC curve analyses, RV free wall longitudinal strain (LS) showed an AUC 0.77 ± 0.08 in predicting death, P = .008, and global RV LS (RV-GLS) showed an AUC 0.79 ± 0.04, P = .004. This association remained significant after correction for age (OR = 1.16, 95%CI 1.01-1.34, P = .029 for RV free wall LS and OR = 1.20, 95%CI 1.01-1.42, P = .033 for RV-GLS), for oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen (OR = 1.28, 95%CI 1.04-1.57, P = .021 for RV free wall-LS and OR = 1.30, 95%CI 1.04-1.62, P = .020 for RV-GLS) and for the severity of pulmonary involvement measured by a computed tomography lung score (OR = 1.27, 95%CI 1.02-1.19, P = .034 for RV free wall LS and OR = 1.30, 95%CI 1.04-1.63, P = .022 for RV-GLS)., Conclusions: In patients hospitalized with COVID-19, offline quantitative 2D-echocardiographic assessment of cardiac function is feasible. Parameters of RV function are frequently abnormal and have an independent prognostic value over markers of lung involvement., (© 2020 Wiley Periodicals LLC.)

Background: Guideline recommendations for aortic valve replacement (AVR) in asymptomatic patients with chronic aortic regurgitation (AR) have historically focused on linear dimensions without normalization for the body surface area (BSA). Values for grading the severity of end-diastolic volume dilatation by 2D echocardiography remain to be established., Methods and Results: We retrospectively analyzed 543 consecutive asymptomatic patients with pure chronic moderate/severe AR (mean age 66 ± 17 years, 37.7% males). Applying the ASE/EACVI guidelines, BSA-indexed LV end-diastolic volume (LVEDVi) and indexed LV end-diastolic diameter (LVEDDi) were assessed. Then, we identified 192 patients with at least mild LV end-diastolic dilatation by volumetric or linear measurements. The outcome endpoint was the combination of cardiac death, hospitalization for acute heart failure or AVR during a median follow-up of 4.5 ± 3.6 years. Multivariable Cox regression analyses including age, LV ejection fraction (EF) and AR severity showed an independent prognostic value of the LVEDDi and LVEDVi (P < .001 and P < .01, respectively). Congruent severe LVEDDi and LVEDVi dilatation was associated with a higher event rate compared to discordant severe LV end-diastolic dilatation or nonsevere LV dilatation (P = .001) even after landmark analysis (P = .02). In patients with EF > 50%, only the LVEDVi showed and independent prognostic value (P < .001)., Conclusions: In a cohort of asymptomatic patients with AR, the presence of severe LV volume and diameter dilatation on the basis of the cutoff values proposed by current recommendations and normalized for BSA may be instrumental in the identification of patients at increased risk of clinical progression regardless of EF., (© 2020 Wiley Periodicals LLC.)

Despite advancement in therapy and management, left ventricular thrombus (LVT) after anterior myocardial infarction (MI) is sporadically encountered and remains associated with a very high risk of major cardiovascular events and mortality. Cardiac magnetic resonance (CMR) is considered the gold standard technique for LVT detection, but it is a time-consuming and expensive test not available in all centers, especially when repeated examinations are necessary. Transthoracic echocardiography represents a useful tool to screen for LVT and to identify predictors of high risk of developing LVT. The advances in ultrasound technology and the use of contrast agents may potentially help clinicians to identify LVT and the use of sequential echocardiography for each patient with acute MI complicated by LVT may provide an opportunity to quantify regression and its correlation with outcomes to tailor the management of these patients. Hence, this narrative review focuses on the added value of echocardiographic-guided LVT management in patients with recent anterior MI to reduce mortality and morbidity excess related to LVT based on current evidence., (© 2020 Wiley Periodicals LLC.)

Background: Stress testing in patients with low pretest probability (PTP) of coronary artery disease (CAD) has become an increasing practice, potentially leading to underestimation of its true clinical value. Our aim was to describe the current use of most employed imaging functional tests and their prognostic value., Methods and Results: We selected patients with low PTP of CAD (CAD consortium clinical score < 15%) who underwent exercise or dipyridamole stress echocardiography or single photon emission computed tomography for suspected angina. Main exclusions were age < 45, known CAD, and abnormal rest wall motion. Of the 2279 subjects undergoing stress test, 883 (39%) had low PTP, and 91 (10.3%) had a positive test for ischemia. After a median follow-up of 5.8 years, 36 patients had events (21 died, 14 had nonfatal myocardial infarction). The percentage of events in the abnormal and normal stress test groups were similar (5 [5.5%] vs 31 [3.9%], P = ns), as the annualized event rate (0.87% vs 0.62%, P = ns). Age was the only variable associated with outcome in the regression analysis (hazard ratio 1.072, 95% CI 1.034-1.113, P < 0.001). An abnormal result was not associated with worse outcome in each of the subgroups of functional tests., Conclusions: In our geographical area, a considerable proportion of patients undergoing imaging functional tests for stable chest pain have a low estimated PTP of CAD. Of these, 1 in 10 resulted positive for inducible ischemia. However, none of the most common imaging functional tests, single photon emission computed tomography (SPECT), and stress echocardiography offer prognostic information in these patients., (© 2019 Wiley Periodicals, Inc.)

Background: To assess prevalence and clinical implications of left ventricular (LV) remodeling considering: LV volume, mass and relative wall thickness at the time of aortic valve stenosis diagnosis., Methods and Results: We retrospectively analyzed 343 patients (age 79.2 ± 9.5 years, 48.1% males) with functional aortic valve area (AVA) ≤ 1.5 cm 2 . LV geometric patterns and clinical outcomes (combined death, cardiac hospitalization, aortic valve replacement [AVR]) were evaluated. According to the new LV remodeling classification, 4.9% had normal geometry, 7.5% concentric remodeling, 39.3% concentric hypertrophy (LVH), 22.4% mixed LVH, 12.5% dilated LVH, 3.2% eccentric LVH and 4.3% eccentric remodeling, 5.5% had not classifiable LVH. Indexed stroke volume (SVi) was higher in patients with concentric LVH (40.3 ± 11.9 mL/m 2 ) and mixed LVH (41.6 ± 13.4 mL/m 2 ) and lower in patients with eccentric LVH (24.9 ± 7.7 mL/m 2 ), concentric (36.6 ± 12.7 mL/m 2 ) and eccentric remodeling (34.9 ± 9.5 mL/m 2 ), P = 0.003. During a median follow-up of 2.2 years, 260 (75.8%) had the combined end point. A significant association between the combined end point and LV dilation (P = 0.010) or LV remodeling patterns (P = 0.0001) was found. After multivariable adjustment for AVR, concentric remodeling (HR 3.12, IC 95% 1.14-8.55; P = 0.02) and dilated LVH (HR 3.48, IC 95% 1.31-9.27; P = 0.01) were strongly associated with death or cardiac hospitalizations., Conclusions: In patients with AVA ≤ 1.5 cm 2 , when the new LV remodeling classification system is applied, only a minority had normal geometry and less than half had "classic" concentric LVH or remodeling. LV volume dilatation is frequent and associated with adverse outcome. Concentric remodeling, eccentric remodeling, dilated LVH had the worst noninvasive hemodynamic profile and prognosis., (© 2019 Wiley Periodicals, Inc.)

Background: Left ventricular (LV) remodeling due to aortic regurgitation (AR) often leads to maladaptive responses. We assessed the prevalence and clinical implications of LV remodeling considering LV volume, mass, and relative wall thickness at the time of AR diagnosis., Methods and Results: Between 2008 and 2017, 370 consecutive patients (mean age 67.3 ± 16.1 years, 56.5% males), with moderate or severe AR, were retrospectively analyzed. LV geometric patterns and clinical outcomes (cardiovascular death, hospitalization for heart failure, or aortic valve replacement) were evaluated. LV dilatation (LV end-diastolic volume >75 mL/m 2 ) was present in 228 patients (61.6%). Applying the new LV remodeling classification system, 40 (10.8%) patients had normal geometry, 14 (3.8%) concentric remodeling, 43 (11.6%) concentric hypertrophy (LVH), 45 (12.2%) indeterminate LVH, 38 (10.3%) mixed LVH, 93 (25.1%) dilated LVH, 54 (14.6%) eccentric LVH, and 43 (11.6%) eccentric remodeling. During a median follow-up of 3.48 years (25th-75th percentile 0.91-5.57), 97 (26.2%) had the combined endpoint. LV dilation (P < 0.001), LVH (P < 0.001), and LV remodeling patterns were significantly associated with the combined endpoint. After multivariable adjustment for age, EF, aortic stenosis, CAD history, and moderate mitral regurgitation, dilated LVH (HR 7.61, IC 95% 1.82-31.80; P = 0.005) and eccentric LVH (HR 7.91, IC 95% 1.82-34.38; P = 0.006) were associated with adverse outcome compared to eccentric remodeling, that showed the best event-free survival rate., Conclusions: In a contemporary cohort of patients with AR, applying the new LV remodeling classification system, only a minority had normal geometry. Dilated LVH and eccentric LVH showed distinct outcome penalty after adjustment for confounders., (© 2018 Wiley Periodicals, Inc.)

Background: After acute myocardial infarction (MI) the severity of diastolic dysfunction by echocardiography represents an independent prognostic marker. However, the mechanisms whereby diastolic dysfunction portends an increased risk after MI are not fully understood. We investigated the relationship between echocardiographic diastolic dysfunction severity and infarct size quantitatively measured by contrast-enhanced magnetic resonance (ce-MR)., Methods: Cross-sectional prospective study. We quantified "healed" infarct size by ce-MR measuring the percentage of delayed enhancement with respect to left ventricular mass and diastolic function by Doppler echocardiography. Both exams were scheduled at least 1 month after a first acute ST segment elevation MI (STEMI) successfully treated with primary angioplasty and stenting. To increase the specificity, individual echocardiographic parameters were integrated to grade global diastolic function in 4 grades: normal diastolic function, impaired relaxation with normal, or near-normal filling pressures; impaired relaxation with moderate elevation of filling pressures, and impaired relaxation with marked elevation of filling pressures, "restrictive filling.", Results: We prospectively enrolled 52 patients (mean age 62 +/- 13 years, 77% men). ce-MR and echocardiography were performed 48 +/- 15 days after the MI. There was a significant but modest correlation between diastolic function grade and infarct size (r = 0.423, P = 0.002), which was independent of global and regional systolic function and persisted after further adjustment for age, sex, body surface area, left ventricular mass, end-diastolic volumes, and sphericity index (all P < 0.05). Among single echocardiographic variables, infarct size correlated best with tissue Doppler velocities Em (r =-0.307, P = 0.03), Am (r =-0.39, P = 0.005), and flow propagation velocity (r =-0.34, P = 0.015)., Conclusions: In healed STEMI successfully treated with primary angioplasty and stenting, diastolic function grade was independently albeit weakly correlated with infarct size. Therefore, the increased risk of diastolic dysfunction after MI is not fully explained by infarct size.