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Aims We sought to propose a novel risk stratification system for severe tricuspid regurgitation (TR) using 3D-anatomical regurgitant orifice area (3D-AROA) and the slope of tricuspid annular plane systolic excursion vs. systolic pulmonary artery pressure (TAPSE/SPAP) and to validate its prognostic significance. Methods and results Sixty-four patients with severe functional TR (52% torrential) underwent 3D echocardiography and exercise–stress echocardiography. As an estimate of regurgitation severity, 3D-AROA was measured with the customized software package. As an index of right ventricular (RV) contractile reserve, the TAPSE/SPAP slope was calculated by plotting the relationship between TAPSE and SPAP during exercise test. Haemodynamic parameters were obtained by right heart catheterization (RHC). Based on receiver operating characteristics curves, optimal cut-off values of 3D-AROA and TAPSE/SPAP slope to identify all-cause mortality were 161 mm2 and 0.046 mm/mmHg, respectively. During a median follow-up of 559 days, 20 patients (31%) died. After correcting for potential confounders, 3DAROA≥ 161 mm2 (HR 4.37; 95% CI 1.34–14.07; P = 0.015) and TAPSE/SPAP slope≤0.046 mm/mmHg (HR 4.76; 95% CI 1.46–15.53; P = 0.009) were echocardiographic parameters independently associated with all-cause mortality. The cumulative survival rate was lower in patients with 3D-AROA≥161 mm2 and TAPSE/SPAP slope≤0.046 mm/mmHg compared with their counterparts (both P <0.05). RHC confirmed higher right atrial pressure (P <0.001) and lower cardiac index (P = 0.004) in patients with both 3D-AROA≥161 mm2 and TAPSE/SPAP slope ≤0.046 mm/mmHg. Conclusion Large AROA and reduced RV contractile reserve during exercise are independently associated with poor prognosis. The new grading scheme of severe TR was validated by haemodynamics and may improve risk stratification. [ABSTRACT FROM AUTHOR]

Aims This study aimed to evaluate the prevalence and distribution of pulmonary venous systolic flow reversal (PVSFR) in patients with severe mitral regurgitation (MR), and to examine the relationship between PVSFR profile and cardiac parameters. Methods and results A total of 125 patients with severe MR who had transoesophageal echocardiography (TOE) performed were reviewed. Of these, 121 (96.8%) patients showed all four pulmonary venous (PV) flows by TOE. They were categorized into three groups by the MR aetiology: degenerative MR (DMR) (n  = 72), ventricular functional MR (V-FMR) (n  = 20), and atrial functional MR (A-FMR) (n  = 16). Eighteen (16.7%) patients had PVSFR in all four PVs. Twenty-nine (26.9%) had PVSFR in three PVs, 23 (21.3%) in two PVs, and 23 (21.3%) in one PV. PVSFR appeared at right PVs more frequently compared with left PVs. A high number of PVSFR was significantly correlated with higher pulmonary capillary wedge pressure (PCWP) and 3D vena contracta area (3D-VCA). With regard to MR aetiology, the number of PVSFRs was correlated with high 3D-VCA in patients with DMR and A-FMR, while it was correlated with high PCWP in patients with V-FMR. Laminar-type PVSFR appeared more frequently in FMR compared with DMR, and it had a relationship with higher PCWP and lower right ventricular fractional area change (RVFAC). Conclusion All four PV were detected in 96.8%, and 16.8% patients had PVSFR in all four PVs. PCWP and 3D-VCA were correlated with the number of PVSFRs in severe MR patients. Laminar-type PVSFR was related to higher PCWP and lower RVFAC. [ABSTRACT FROM AUTHOR]

Aims  We sought to investigate tricuspid valve (TV) geometry and right heart remodelling in atrial functional tricuspid regurgitation (AF-TR) as compared with ventricular functional TR with sinus rhythm (VF-TR). Methods and results  Transoesophageal 3D echocardiography datasets of the TV and right ventricle were acquired in 51 symptomatic patients with severe TR (AF-TR, n  = 23; VF-TR, n  = 28). Three-dimensional right ventricular (RV) endocardial surfaces were reconstructed throughout the cardiac cycle and then postprocessed using semiautomated integration and segmentation software to calculate position of papillary muscle (PM) tips. Compared with VF-TR, AF-TR had more dilated and posteriorly displaced annulus and less leaflet tethering angles with more prominent right atrium and smaller RV end-systolic volume. On the XY (annular) plane, the centre of annulus was getting closer towards the anterior and posterior PM tips and was going away from the medial PM tip caused by prominent annular dilatation in AF-TR. On the Z -axis, the position of each PM tip in AF-TR was not so much displaced apically as that in VF-TR. Multiple linear regression analyses revealed that right atrial volume and right atrial/RV end-systolic volume ratio were determinants of annular area and orientation in AF-TR, respectively (both P  <   0.001). Additionally, the posteromedial-directed component of posterior PM tip position and the apically directed component of the position of all three PM tips were independently associated with TV tethering angles of each leaflet in AF-TR (all P  <   0.02). Conclusion  Right heart remodelling and its association with 3D TV geometry differ entirely between AF-TR and VF-TR, which may offer distinctive therapeutic implication. [ABSTRACT FROM AUTHOR]

Background: Estimation of left ventricular filling pressure (LVFP) is the essential part of the echocardiographic workup for exercise intolerance. The ratio of the mitral early filling velocity to the left ventricular global longitudinal strain (E/LVGLS) has emerged as a novel index of LVFP. This study aimed to investigate the relationship between E/LVGLS and exercise capacity. Methods and results: We retrospectively reviewed 90 patients with exertional dyspnea who underwent echocardiography and cardiopulmonary exercise test. Patients were classified into three groups according to their percent‐predicted maximal oxygen consumption (ppVo2) (G ≧ 75, ppVo2 > 75%, n = 20; G 50‐75, ppVo2 75‐50%, n = 57; G < 50, ppVo2 < 50%, n = 13). Measurements were (a) the relationship between ppVo2 and E/LVGLS and (b) the efficiency of integrated diastolic assessment using E/LVGLS, left ventricular volume, mitral annular early diastolic velocity (E′), and tricuspid regurgitation to identify the patient with impaired exercise capacity. Univariate linear regression analysis demonstrated that E/LVGLS had significant correlation with ppVo2 (ρ = 0.52, P < 0.001). The area under the ROC of E/LVGLS for ppVo2 < 50% was 0.86 (95%CI 0.75‐0.97). The DeLong test showed that E/LVGLS was efficient to detect ppVo2 < 50% than E/E′ (P = 0.007). When used in the integrated assessment of LVFP as the alternative for E/E′, E/LVGLS improved risk classification for impaired exercise capacity. Conclusion: E/LVGLS may be a more efficient index than E/E′ to identify exercise impairment as a single index and as a part of the integrated diastolic assessment. [ABSTRACT FROM AUTHOR]

Background: Persistent AF makes left side heart expansion especially left atrium, but the effect on the right side heart is unknown. The influence to right cardiac morphology with recovering from persistent AF by catheter ablation is almost uncertain even though some guidelines suggest characterize the category of tricuspid regurgitation (TR) due to persistent AF. Objectives: The aim of this study is to seek whether the recover from persistent atrial fibrillation (AF) would provide the contraction in volume of right heart and TR. Methods and Results: A total of 101 patients (60.4 ± 9.3 years, 83 male) with persistent AF continued more than one year were performed first catheter ablation in our institution for 5 years. Of those, 71 patients kept sinus rhythm (SR) at 3 month and one year after ablation (SR Group), 15 patients had AF rhythm at both times of follow up (Recurrence Group). Before catheter procedure, only left atrial (LA) size (LA volume index; 46.8 ± 11.9 vs. 59.3 ± 12.8 ml/m2, p<0.01) had significant difference in echocardiac parameters between two groups. In follow up, right atrium (RA) area (19.5 ± 4.5 vs. 15.5 ± 3.5 cm2, p<0.01), tricuspid annular diameter (28.7 ± 4.0 vs. 27.2 ± 3.8 mm, p<0.01) and TR area [1.4 (IQR 0.7 - 2.6) vs. 0.6 (IQR 0.2 - 1.2) cm2, p<0.01] decreased three month after catheter ablation and these were maintained at one-year follow up in SR Group. No parameters changed in Recurrence Group. Conclusions: In patients with persistent AF, restoration to SR makes RA area and tricuspid annular diameter decrease. Persistent AF can be the reason of right side heart enlargement and it is reversible change. [ABSTRACT FROM AUTHOR]

Abstract: Background: Pathologically, the lesions responsible for acute coronary syndrome (ACS) are ruptures of vulnerable plaques (and occasionally fibrous-cap erosions or calcified nodules) with a superimposed thrombosis. We aimed to clarify the clinical presentations related to the morphologies of coronary lesions of ACS using intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Methods and results: Seventy-five culprit lesions of ACS patients were clearly assessed with IVUS and OCT. Patients were classified into two groups based on the presence or absence of a rupture of a culprit plaque as identified by OCT. Clinical characteristics and lesion morphologies were compared between the two groups. Waist circumference was significantly greater (p<0.02) and prevalence of the metabolic syndrome (MS) higher (p=0.0011) in the rupture group. The prevalence of prodromal angina was higher in patients without plaque ruptures (p<0.0001). Using multivariate analysis, the MS and prodromal angina were independent predictors of rupture of a culprit coronary plaque (odds ratio (OR): 27.30, p<0.003 and OR: 0.04, p=0.0004, respectively). Among the components of the MS, the prevalence of abdominal obesity was a significant independent predictor of rupture of a culprit plaque (OR: 4.24, p<0.02). Conclusions: There are two presentations related to the coronary lesion morphologies of ACS: we should understand these aspects of ACS. [Copyright &y& Elsevier]

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Aims: We sought to propose a novel risk stratification system for severe tricuspid regurgitation (TR) using 3D-anatomical regurgitant orifice area (3D-AROA) and the slope of tricuspid annular plane systolic excursion vs. systolic pulmonary artery pressure (TAPSE/SPAP) and to validate its prognostic significance., Methods and Results: Sixty-four patients with severe functional TR (52% torrential) underwent 3D echocardiography and exercise-stress echocardiography. As an estimate of regurgitation severity, 3D-AROA was measured with the customized software package. As an index of right ventricular (RV) contractile reserve, the TAPSE/SPAP slope was calculated by plotting the relationship between TAPSE and SPAP during exercise test. Haemodynamic parameters were obtained by right heart catheterization (RHC). Based on receiver operating characteristics curves, optimal cut-off values of 3D-AROA and TAPSE/SPAP slope to identify all-cause mortality were 161 mm2 and 0.046 mm/mmHg, respectively. During a median follow-up of 559 days, 20 patients (31%) died. After correcting for potential confounders, 3DAROA≥ 161 mm2 (HR 4.37; 95% CI 1.34-14.07; P = 0.015) and TAPSE/SPAP slope≤0.046 mm/mmHg (HR 4.76; 95% CI 1.46-15.53; P = 0.009) were echocardiographic parameters independently associated with all-cause mortality. The cumulative survival rate was lower in patients with 3D-AROA≥161 mm2 and TAPSE/SPAP slope≤0.046 mm/mmHg compared with their counterparts (both P<0.05). RHC confirmed higher right atrial pressure (P<0.001) and lower cardiac index (P = 0.004) in patients with both 3D-AROA≥161 mm2 and TAPSE/SPAP slope ≤0.046 mm/mmHg., Conclusion: Large AROA and reduced RV contractile reserve during exercise are independently associated with poor prognosis. The new grading scheme of severe TR was validated by haemodynamics and may improve risk stratification., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Aims: This study aimed to evaluate the prevalence and distribution of pulmonary venous systolic flow reversal (PVSFR) in patients with severe mitral regurgitation (MR), and to examine the relationship between PVSFR profile and cardiac parameters., Methods and Results: A total of 125 patients with severe MR who had transoesophageal echocardiography (TOE) performed were reviewed. Of these, 121 (96.8%) patients showed all four pulmonary venous (PV) flows by TOE. They were categorized into three groups by the MR aetiology: degenerative MR (DMR) (n = 72), ventricular functional MR (V-FMR) (n = 20), and atrial functional MR (A-FMR) (n = 16). Eighteen (16.7%) patients had PVSFR in all four PVs. Twenty-nine (26.9%) had PVSFR in three PVs, 23 (21.3%) in two PVs, and 23 (21.3%) in one PV. PVSFR appeared at right PVs more frequently compared with left PVs. A high number of PVSFR was significantly correlated with higher pulmonary capillary wedge pressure (PCWP) and 3D vena contracta area (3D-VCA). With regard to MR aetiology, the number of PVSFRs was correlated with high 3D-VCA in patients with DMR and A-FMR, while it was correlated with high PCWP in patients with V-FMR. Laminar-type PVSFR appeared more frequently in FMR compared with DMR, and it had a relationship with higher PCWP and lower right ventricular fractional area change (RVFAC)., Conclusion: All four PV were detected in 96.8%, and 16.8% patients had PVSFR in all four PVs. PCWP and 3D-VCA were correlated with the number of PVSFRs in severe MR patients. Laminar-type PVSFR was related to higher PCWP and lower RVFAC., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: We sought to investigate tricuspid valve (TV) geometry and right heart remodelling in atrial functional tricuspid regurgitation (AF-TR) as compared with ventricular functional TR with sinus rhythm (VF-TR)., Methods and Results: Transoesophageal 3D echocardiography datasets of the TV and right ventricle were acquired in 51 symptomatic patients with severe TR (AF-TR, n = 23; VF-TR, n = 28). Three-dimensional right ventricular (RV) endocardial surfaces were reconstructed throughout the cardiac cycle and then postprocessed using semiautomated integration and segmentation software to calculate position of papillary muscle (PM) tips. Compared with VF-TR, AF-TR had more dilated and posteriorly displaced annulus and less leaflet tethering angles with more prominent right atrium and smaller RV end-systolic volume. On the XY (annular) plane, the centre of annulus was getting closer towards the anterior and posterior PM tips and was going away from the medial PM tip caused by prominent annular dilatation in AF-TR. On the Z-axis, the position of each PM tip in AF-TR was not so much displaced apically as that in VF-TR. Multiple linear regression analyses revealed that right atrial volume and right atrial/RV end-systolic volume ratio were determinants of annular area and orientation in AF-TR, respectively (both P < 0.001). Additionally, the posteromedial-directed component of posterior PM tip position and the apically directed component of the position of all three PM tips were independently associated with TV tethering angles of each leaflet in AF-TR (all P < 0.02)., Conclusion: Right heart remodelling and its association with 3D TV geometry differ entirely between AF-TR and VF-TR, which may offer distinctive therapeutic implication., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: Both the H 2 FPEF-score and nomogram-score, which consist of simple clinical parameters, can assist in diagnosing "early" heart failure with preserved ejection fraction (HFpEF) and only exertional dyspnea, but their these usefulness in Japanese remains unclear. We sought to investigate the correlation between these scores and exercise response, including the peak oxygen uptake (V̇O 2 ), the pulmonary artery systolic pressure (PASP), the ratio of early diastolic transmitral flow velocity to early diastolic mitral annular velocity (E/e') and stroke volume (SV) using exercise stress echocardiography (ESE) combined with cardiopulmonary exercise testing (CPET).Methods and Results:In this single-center, retrospective cross-sectional study the H 2 FPEF-score and nomogram-score were calculated in a total of 139 patients who underwent ESE combined with CPET. The scores correlated with peak V̇O 2 (r=-0.48, r=-0.44), PASP (r=0.23, r=0.29) and SV (r=-0.32, r=-0.19) at peak exercise. The nomogram-score correlated with E/e' (r=0.24). The prevalence of exercise intolerance (percent predicted peak V̇O 2 <75% and <50%) increased as the H 2 FPEF-score increased and reached 88.9% and 22.2% among the patients with high H 2 FPEF-score (6-9 points)., Conclusions: The H 2 FPEF-score may be useful as the initial step to diagnosing 'early' HFpEF. The nomogram-score may be more useful in Japanese because of its more universal association with exercise response than the H 2 FPEF-score.

Objective: Very late stent thrombosis (VLST) remains an unresolved problem, and recent reports have indicated that VLST onset can occur in patients treated with both drug-eluting stents (DES) and bare metal stents (BMS). We evaluated the causes of VLST using optical coherence tomography (OCT)., Methods: OCT was performed in 22 patients (12 DES-treated patients, 10 BMS-treated patients). Because two instances of VLST occurred simultaneously in one case in the DES group, the DES group comprised 13 lesions, while the BMS group comprised 10 lesions. All struts were counted in each frame, and the proportion of uncovered or malapposed struts was calculated based on the overall number of struts in the stent., Results: The interval from stent implantation to VLST onset was significantly longer in the BMS group. The proportion of uncovered struts and the ratio of malapposed struts were significantly higher in the DES group than in the BMS group. The OCT analysis demonstrated intimal hyperplasia or intimal disruption in all patients in the BMS group. However, in the DES group, severe hyperplasia and/or neoatherosclerosis was observed in only eight lesions (61.5%), while uncovered and malapposed struts were involved in the other lesions., Conclusion: In most BMS-treated lesions, it appeared that VLST was caused by the occurrence of neoatherosclerosis after stent implantation. The causes of VLST in DES-treated lesions are more various and complicated than those observed for BMS-treated lesions.