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This editorial refers to ‘Biventricular mechanical pattern of the athlete’s heart: comprehensive characterization using 3D echocardiography’, by A. Fábián et al., https:// doi.org/10.1093/eurjpc/zwac026.

We report the case of an abscess complication of infective endocarditis detected by electrocardiogram (ECG). A 51-year-old man was admitted to the Emergency Department for fever (39 C°) and asthenia from few days. About 2 months earlier he had undergone cardiac surgery for aortic valve replacement with biological valve for severe aortic stenosis. Vital signs included low blood pressure and high respiratory rate; he was also pyretic. On cardiac auscultation he had a systolic murmur on aortic focus. He underwent blood gas analysis, which showed an increase in serum lactate, ECG, which detected a I grade atrioventricular block, and blood sampling, which showed severe increases in white blood cells, C-reactive protein and procalcitonin. Chest x-ray was normal. An echocardiogram was therefore performed: thickened and hyperechogenic cusps of the aortic biological prosthesis were detected; masses, with character of mobility at the level of the left coronary cusp (maximum size of 1.4×1cm) were also described; there was also a slight increase in transprosthetic gradients and mild valve insufficiency. The first diagnostic hypothesis was therefore that of infective endocarditis (IE), further supported by a recent odontogenic procedure for dental abscesses to which the patient would have undergone a few weeks after heart surgery (possible IE according to the Duke modified criteria). Blood cultures were performed on three samples and empirical antibiotic therapy was initiated until Streptococcus mitis was isolated (definite IE according to the Duke modified criteria) and thus Ceftriaxone was started. During hospitalization in the cardiology ward the patient presented dysarthria and left hemiplegia. A cerebral angio-computed tomography and neurological consultation were conducted and an ischemic stroke of thromboembolic origin from biological valve endocarditis was diagnosed. However, in view of the extensive ischemic hypodensity, acute reperfusion treatment was not indicated. The patient therefore underwent cardiac surgery consultancy but, due to his severe comorbidities and expired clinical conditions, there was no indication for cardiac surgery. After few days, during daily ECG recording, left main coronary artery (LMCA) stenosis-like ECG modifications were detected, with ST elevation in lead aVR in addition to marked ST depression in leads V3 through V6 and in peripherals leads (Fig.). A troponin sample was immediately taken, which would have been increased. He immediately underwent new echocardiogram which revealed a new periprosthetic abscess across left coronary cusp. Given the course of LMCA through the abscess, we believe that the acute coronary syndrome that has occurred to the patient may be due either to a compression of the LMCA by the periprosthetic abscess or to embolization of abscess material in the le LMCA. It was not possible to perform coronary angiography neither to perform cardiac surgery as the patient died a few hours later due to septic shock.

A 65-year-old man was admitted to the emergency department for abdominal pain begun 4 days before. Past medical history consisted of ischemic stroke and diabetes mellitus. Of note, he was not taking any medication. Vital signs: blood pressure 90/50 mmHg, heart rate 50/minute, respiratory rate 18/minute, body temperature 36.5°C; saturation oxygen level 93%. High-sensitivity cardiac troponin was mildly elevated (121 pg/mL). Electrocardiogram showed sinus bradycardia, Q waves with ST elevation in antero-lateral leads consistent with subacute STEMI. Transthoracic echocardiogram (TTE) revealed aneurysmatic expansion of apical left ventricular (LV) walls (ejection fraction 30%) with a large apical thrombus (35×15 mm). Coronary angiography showed complete occlusion of proximal left anterior descending artery and a critical stenosis of right coronary artery; percutaneous coronary intervention with stent implantation on right coronary artery was performed. He received triple antithrombotic therapy with aspirin, clopidogrel, intravenous heparin first and then oral anticoagulation with warfarin. During coronary care unit stay, the patient was asymptomatic and hemodynamically stable. However, a control TTE (day 6) in cardiology ward revealed the presence of pseudoaneurysm with an oval out-pouching (23 × 13 mm) from the apical aspect of LV septum, communicating with the LV chamber through a passage measuring 1.6 cm. Partially organized pericardial effusion was evident around right ventricular free wall (Figure 1). Thus, the patient was immediately transferred to the cardiac surgery department for urgent surgical repair. The LV anterior wall rupture with pseudoaneurysm was then treated with endoaneurysmectomy of the LV with dacron patch and freewall reconstruction with prolene sutures and teflon felt stripes. The patient was finally discharged 3 weeks after surgery with betablockers, ace- inhibitors, diuretics, statins and dual antiplatelet therapy with aspirin and clopidogrel. At one month follow-up visit, the patient was hemodynamically stable with acceptable functional capacity. Figure 1Modified five chamber view (a, b) and three chamber view (c, d) showing apical LV pseudoaneurysm (arrows) with moderate pericardial effusion (arrowhead); color Doppler through the passage (arrow) in 3 chamber view (d). LV, left ventricular.

Background: Takotsubo syndrome is an increasingly recognised cardiac condition that clinically mimics an acute coronary syndrome, but data regarding its prognosis remain controversial. It is currently unknown whether acute coronary syndrome risk scores could effectively be applied to Takotsubo syndrome patients. This study aims to assess whether the Global Registry of Acute Coronary Events (GRACE) score can predict clinical outcome in Takotsubo syndrome and to compare the prognosis with matched acute coronary syndrome patients. Methods: A total of 561 Takotsubo syndrome patients was included in this prospective registry. According to the GRACE score, the population was divided into quartiles. The primary endpoint was all-cause mortality and the secondary endpoints were cardiocerebrovascular events (a composite of all-cause mortality, cardiovascular death, recurrence of Takotsubo syndrome and stroke). Results: The median GRACE risk score was 139±27. Takotsubo syndrome patients with a higher GRACE risk score mostly have a higher rate of physical triggers and lower left ventricular ejection fraction on admission. During long-term follow-up, all-cause mortality rates were 5%, 11%, 12% and 22%, respectively, in the first, second, third and fourth quartile (P Conclusion: In Takotsubo syndrome, the GRACE risk score allows us to predict all-cause mortality and cardiocerebrovascular events at long-term follow-up.

Background This study aims to evaluate the prevalence and clinical significance of the right ventricular pulmonary arterial (RV–PA) uncoupling in patients with cardiac amyloidosis (CA). Methods The study population consisted in 92 consecutive patients with CA (age 71.1±12.2 years, 71% males; 47% with immunoglobulin light chain (AL), 53% with transthyretin [ATTR]). All patients underwent a comprehensive evaluation. A pre–specified tricuspid annulus plane systolic excursion on pulmonary arterial systolic pressure (TAPSE/PASP) value Results Thirty–two patients (35%) showed RV–PA uncoupling at baseline evaluation (15/44 [34%] AL and 17/48 [35%] ATTR). Patients with RV–PA uncoupling in both AL and ATTR showed worse NYHA functional class, lower systemic blood pressure, and more pronounced left and right ventricular systolic dysfunction than those with RV–PA coupling. During a median follow–up of 8 months (IQR 4–13), 26 patients (28%) experienced cardiovascular death. Patients with RV–PA uncoupling showed lower survival at 12 months follow–up than those with RV–PA coupling (42.7% [95%CI 21.7–63.7%] vs. 87.3% [95%CI 78.3–96.3%], p–value Conclusions RV–PA uncoupling is common among patients with CA, and it is a marker of advanced disease and worse outcomes. This study suggest that TAPSE/PASP ratio has the potential to improve risk stratification and guide management strategies in patients with CA.

Aims Hypertension (HT) is one of the most frequent comorbidities reported in patients with Takotsubo syndrome (TTS). However, the clinical outcome as well as the effect of pharmacological treatment on long-term follow-up have never been investigated in this cohort. To investigate the impact of the pharmacological treatment with beta-blocker (BB) and/or renin–angiotensin–aldosterone system inhibitor (RAASi) on long-term outcome of TTS patients with and without HT. Methods and results This study included TTS patients prospectively included in the Takotsubo Italian Network register from January 2007 to December 2018. The study population was divided in two groups according to the presence or not of HT. The effect of BB and RAASi at discharge was evaluated in these groups. The primary outcome was the composite of all-cause death and TTS recurrence; secondary outcomes were the single components of the primary outcome. The propensity score weighting technique was employed to account for potential selection bias in treatment assignment at discharge. The study population included 825 patients [median age 72 (63–78) years; 8.1% were males]; 525 (63.6%) patients had history of HT and 300 (36.4%) patients did not. At median follow-up of 24.0 months (11.0–38.0), the primary outcome occurred in 102 patients (12.4%); all-cause death and TTS recurrence were reported in 76 (9.2%) and 33 (4.0%), respectively. There were no differences in terms of the primary outcome (adjusted HR: 1.082; 95% CI: 0.689–1.700; P = 0.733), all-cause death (adjusted HR: 1.214; 95% CI: 0.706–2.089; P = 0.483) and TTS recurrence (adjusted HR: 0.795; 95% CI: 0.373–1.694; P = 0.552) between patients with vs. without HT. Among patients with HT, those receiving BB at discharge showed a significantly lower risk of the primary outcome (adjusted HR: 0.375; 95% CI: 0.228–0.617; P Conclusions TTS patients with HT patients experienced a survival benefit from BB treatment in terms of both all-cause death and TTS recurrence; this effect was not confirmed in patients without HT. Conversely, RAASi did not affect long-term outcome, independently from the coexistence of HT. Albeit hypothesis-generating, a such evidence supports a tailored pharmacological therapy after discharge in TTS patients taking into account the coexistence of HT.

Aims After 1 year of dual antiplatelet therapy (DAPT) for acute coronary syndrome (ACS), clinicians face the dilemma of choosing between prolonged DAPT with aspirin and ticagrelor 60 mg twice daily (PEGASUS strategy) or aspirin and rivaroxaban 2.5 mg twice daily (COMPASS strategy). In recent years, there has been a widespread discussion about the optimal duration of DAPT and the best combination of drugs. To analyse the prevalence and clinical implications of the eligibility criteria for prolonged dual antithrombotic therapy with ticagrelor 60 mg twice daily and/or rivaroxaban 2.5 mg twice daily in a contemporary real-world ACS registry. Methods and results Patients from the START-ANTIPLATELET registry (NCT02219984) were stratified according to the eligibility criteria of the PEGASUS and COMPASS studies to investigate the proportion of patients eligible for prolonged dual antithrombotic therapy at discharge and after 1-year of DAPT. Net adverse clinical events (NACE), defined as all-cause death, myocardial infarction, stroke, and major bleeding, at 1 year were also evaluated and compared among groups. 1844 were considered for the analysis at baseline. Out of 849 event-free patients continually receiving dual antiplatelet therapy for at least 1 year, 577 (68%) and 583 (68.7%) met at least one eligibility criterion for ticagrelor and rivaroxaban, respectively. In the PEGASUS-like patients, age was the most common criterion (71% of cases). The presence ≥2 cardiovascular risk factors was the most common eligibility criterion in the COMPASS-like patients (80.8%). At 1-year follow-up, 211 (11.4%) and 119 (6.5%) patients experienced NACE and MACE, respectively. The incidence of NACEs was higher in the PEGASUS-only group (15.4% vs. 8.4%; P = 0.008) and numerically higher in the COMPASS-only group (10.9% vs. 8.4%; P = 0.299). Conclusions In a contemporary real-world ACS cohort, approximately two-thirds of patients that complete 1-year DAPT met the eligibility criteria for ticagrelor 60 mg twice daily or rivaroxaban 2.5 mg twice daily, showing a higher risk of NACEs.

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy. ispartof: EUROPEAN HEART JOURNAL vol:39 issue:22 pages:2032-2046 ispartof: location:England status: published

Aims: Life-threatening complications occur during transcatheter aortic valve implantation (TAVI) which can require emergent cardiac surgery (ECS). Risks and outcomes of patients needing ECS during or immediately after TAVI are still unclear. Methods and results: Incidence, risk factors, management, and outcomes of patients requiring ECS during transfemoral (TF)-TAVI were analysed from a contemporary real-world multicentre registry. Between 2013 and 2016, 27 760 patients underwent TF-TAVI in 79 centres. Of these, 212 (0.76%) patients required ECS (age 82.4 ± 6.3 years, 67.5% females, logistic EuroSCORE: 17.1%, STS-score 5.8%). The risk of ECS declined from 2013 (1.07%) to 2014 (0.70%) but remained stable since. Annual TF-TAVI numbers have more than doubled from 2013 to 2016. Leading causes for ECS were left ventricular perforation by the guidewire (28.3%) and annular rupture (21.2%). Immediate procedural mortality ( 85 years [odds ratio (OR) 1.87, 95% confidence interval (95% CI) (1.02–3.45), P = 0.044], annular rupture [OR 1.96, 95% CI (0.94–4.10), P = 0.060], and immediate ECS [OR 3.12, 95% CI (1.07–9.11), P = 0.037]. One year of survival of the 114 patients surviving the in-hospital period was only 40.4%. Conclusion: Between 2014 and 2016, the need for ECS remained stable around 0.7%. Left ventricular guidewire perforation and annular rupture were the most frequent causes, accounting for almost half of ECS cases. Half of the patients could be salvaged by ECS—nevertheless, 1 year of all-cause mortality was high even in those ECS patients surviving the in-hospital period.

Funding Acknowledgements Type of funding sources: None. Purpose. Cardiovascular involvement in systemic sclerosis (SSc) is frequent, often subtle, and is associated with poor prognosis. Our aim was to compare echocardiographic data of SSc patients to controls, and to assess parameters able to predict the development of cardiovascular involvement. Methods. We enrolled 756 SSc patients (Group 1) without a previous diagnosis of cardiac involvement nor pulmonary arterial hypertension (PAH), and 614 healthy controls (Group 2) matched for age (Group 1 54.9 ± 14.6 years vs Group 2 54.4 ± 12.1, p = 0.6), sex (7.3% vs 7.2%, p = 0.8), and prevalence of hypertension (17.8% vs 19.8%, p = 0.2). All subjects underwent a comprehensive transthoracic 2D and Doppler echocardiography, including tissue Doppler imaging analysis (TDI). Five hundred and two SSc patients were followed-up and the development of PAH, left-sided heart failure (LHF), right-sided heart failure (RHF), and need of implantable cardioverter defibrillator (ICD) were considered as events. Results. Compared to controls, SSc patients showed worse left and right ventricular systolic and diastolic function, hemodynamics and right ventricle-arterial coupling (tricuspid annulus plane systolic excursion over systolic pulmonary artery pressure, TAPSE/sPAP) (Table). After a median follow-up with of 35 moths, 45 composite events (PAH, LVH, RHF and ICD) occurred. In a multivariate model, only ejectioin fraction (EF) and TAPSE/sPAP had independent prognostic value (Table). Conclusions. SSc patients without overt cardiovascular involvement and no PAH display subtle impairments in biventricular systo-diastolic function and right ventricle-arterial coupling. Left ventricular EF and TAPSE/sPAP can predict further cardiovascular events. Descriptive analysis and Cox regression Descriptive Univariate Multivariate VARIABLE Group 1 (Ssc) n = 756 Group 2 (controls) n = 614 p HR (95 % CI) p HR (95% CI) p Ejection fraction (%) 63 ± 5.7 63.7 ± 5.9 0.038 0.94 (0.88 - 0.99) 0.024 0.91 (0.85 - 0.98) 0.017 E/A 1.0 ± 0.46 1.2 ± 0.51

Background Takotsubo syndrome (TTS) is an increasingly recognized form of transient left ventricular dysfunction, often completely reversible. The exact pathogenesis is not fully understood, but central role of adrenergic dysfunction has been widely accepted. A possible link between hyperthyroidism and TTS has been hypothesized, since thyroid and adrenergic systems are in closely connection. Nevertheless, clinical study to define the association between hyperthyroidism and TTS is still lacking. Purpose This study aimed to assess prevalence, clinical features and long-term outcomes of hyperthyroidism at presentation in TTS patients. Methods Overall, 590 TTS patients from 23 centers were included in this prospective registry. Thyroid profile was available for 314 patients at time of TTS admission. Patients in hypothyroid state (n=32) according to TSH value were excluded. The remaining 282 patients were divided in normal thyroid state and hyperthyroid state according to TSH value, respectively 240 (85%) and 42 (15%) patients. Results The median age was 73±10 and the female rate was 93%. TTS related to physical trigger was mostly detected in hyperthyroidism patients (52% vs 30%, respectively in hyperthyroid state and normal thyroid state; p=0.005); while, TTS related to emotional trigger was less common (19%, vs 38%, respectively in hyperthyroid state and normal thyroid state; p=0.016). In TTS unprovoked by a stress factor, there was no statistical difference in thyroid state (29% vs 31%, respectively in hyperthyroid state and normal thyroid state; p=0.690). Follow-up rate was 95% and follow-up length was 41±36 months. At long-term follow-up, mortality rate was 39% and 20% in hyperthyroidism and normal thyroid state, respectively (p=0.008; Figure 1) and adverse event rates (the composite of all-cause death, myocardial infarction and stroke) were 39% and 24% in hyperthyroid state and normal thyroid state, respectively (p=0.034). At multivariable analysis, hyperthyroidism resulted as a strong predictor of mortality (OR 3.82, 95% CI: 1.71–8.50; p=0.001) and of adverse event rates (OR 2.18, 95% CI: 1.19–3.98; p=0.011). Conclusion Hyperthyroidism at presentation is relatively common in TTS patients and associated with physical triggers and unfavorable long-term prognosis. Figure 1. Kaplan-Meier curves Funding Acknowledgement Type of funding source: None

Klinefelter syndrome (KS) is the most frequently occurring sex chromosomal aberration in males, with an incidence of about 1 in 500–700 newborns. Data acquired from large registry-based studies revealed an increase in mortality rates among KS patients when compared with mortality rates among the general population. Among all causes of death, metabolic, cardiovascular, and hemostatic complication seem to play a pivotal role. KS is associated, as are other chromosomal pathologies and genetic diseases, with cardiac congenital anomalies that contribute to the increase in mortality. The aim of the current study was to systematically review the relationships between KS and the cardiovascular system and hemostatic balance. In summary, patients with KS display an increased cardiovascular risk profile, characterized by increased prevalence of metabolic abnormalities including Diabetes mellitus (DM), dyslipidemia, and alterations in biomarkers of cardiovascular disease. KS does not, however, appear to be associated with arterial hypertension. Moreover, KS patients are characterized by subclinical abnormalities in left ventricular (LV) systolic and diastolic function and endothelial function, which, when associated with chronotropic incompetence may led to reduced cardiopulmonary performance. KS patients appear to be at a higher risk for cardiovascular disease, attributing to an increased risk of thromboembolic events with a high prevalence of recurrent venous ulcers, venous insufficiency, recurrent venous and arterial thromboembolism with higher risk of deep venous thrombosis or pulmonary embolism. It appears that cardiovascular involvement in KS is mainly due to chromosomal abnormalities rather than solely on low serum testosterone levels. On the basis of evidence acquisition and authors’ own experience, a flowchart addressing the management of cardiovascular function and prognosis of KS patients has been developed for clinical use.

Acute cardiothoracic and respiratory diseases frequently remain a challenge to diagnose and differentiate in the emergency setting. The main diseases that manifest with chest pain include ischaemic heart disease, myocarditis, acute pericarditis, aortic dissection/rupture and pulmonary embolism (PE). Diseases that primarily present with dyspnoea include heart failure (HF), acute respiratory distress syndrome (ARDS), pneumonia, asthma exacerbations and chronic obstructive pulmonary disease. Pre-test probabilities of clinical findings play a vital part in diagnostic decisions, and the use of a Bayesian approach to these greatly improves the ability to stratify patients more accurately. However, blood tests (biomarkers) are increasingly used to assist in rapid decision-making in the emergency setting in combination with imaging methods such as chest radiograph, ultrasound and increasingly computed tomography, as well as physiological tests such as the electrocardiogram in addition to physical examination. Specific tests for ischaemic heart disease and myocarditis (cardiac troponins), HF (B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)), aortic dissection (smooth muscle markers) and PE (D-dimer) have been developed. Surfactant protein-D and interleukin-8 have been developed for ARDS. Additionally, circulating microRNAs have emerged as promising biomarker candidates in cardiovascular disease. With this increasing array of biochemical markers to aid in the diagnosis of chest diseases presenting with chest pain and dyspnoea, we herein review the clinical usefulness of these markers, in particular in differentiating cardiac from pulmonary diseases. A symptom-oriented assessment as necessary for use in the critical setting is described in addition to discussion of individual biomarkers.

Introduction Left ventricular hemodynamic forces (LV-HDF) have been recently demonstrated to be promising markers of sub-clinical dysfunction and potential predictors of disease outcome. However, there is a lack of reference values in healthy subjects. Knowledge of physiologic ranges is mandatory towards the use of LV-HDF-based indices for disease assessment in future clinical applications. Purpose Aim of the current study is to define the normal reference values for LV-HDF parameters in a large cohort of healthy adults. Here we present preliminary results for the initial set of enrolled subjects. Methods We enrolled 82 healthy subjects [mean age 44 ± 13.2 years (range 18-88), 41 men]. All participants underwent standard transthoracic echocardiography (TTE) examination, as recommended by current guidelines, including apical two-, three- and four-chamber windows, acquired at a frame rate above 40 Hz. These were then analyzed by tri-plane tissue tracking, measuring LV volume and LV ejection fraction (EF) as reference parameters. The same tracking method was used to evaluate the global hemodynamic force by a novel mathematical calculation technique applied to the three-dimensional endocardial contour. Physical-based LV-HDF parameters were then extracted for clinical application; these included the amplitude (root mean square) of the longitudinal and transversal force components (FL and FT) and their alignment angle relative to the LV axis. Parameters were computed as average over the whole cardiac cycle as well as limited to the systolic phase. Forces were normalized with LV volume to reduce variability with LV dimension, and divided by specific weight to yield a dimensionless measure. Results Mean EF was 63 ± 9%. Whole cycle LV-HDF parameters were: FL = 16.0 ± 5.6%, FT = 2.3 ± 0.8%, with significant longitudinal alignment FT/FL = 0.15 ± 0.04, angle = 13.0°±3.1°. Systolic HDF parameters were: FL = 22.7 ± 8.2%, FT = 2.9 ± 1.1%, with longitudinal alignment FT/FL = 0.13 ± 0.04, angle = 11.2°±3.1°. Importantly, dimensionless physical-based LV-HDF parameters showed no significant variation with age, gender or BSA. Conclusions We report the physiologic range of LV-HDF parameters measured by TTE. Knowledge of age- and gender-specific reference values, for a combination of standard, mechanical and hemodynamic indices, can improve the global assessment of the LV function and may help to detect sub-clinical stages of LV dysfunction.

Introduction The analysis of intracardiac blood flow patterns can significantly contribute to improve the understanding and treatment of cardiovascular disease. In contrast to the substantial literature on the left side of the heart, there is currently a significant lack of knowledge about the fluid mechanics of the right heart – pulmonary circulation unit (RH-PCU), both in healthy and diseased conditions. Purpose It is conjectured that computational modeling can be a key element to enhance current imaging techniques and provide quantitative insights into the unique RH-PCU biomechanics. Here we present a novel methodology that allows personalized numerical simulations of right heart flows, through a proper combination of cardiac magnetic resonance (CMR) with computational fluid dynamics (CFD). Methods and results We developed a patient-specific pipeline from medical images to computational models, as depicted in the figure. First, the RV geometry is reconstructed from time-resolved CMR cine images, comprising short-axis and longitudinal slices of the heart, where feature-tracking techniques are used to extract the motion of the RV endocardium contours. A time-continuous description of the moving geometry is obtained through an image-registration algorithm based on diffeomorphic mappings. The moving model of the RV, including the outflow tract and proximal pulmonary arteries, is finally fed to a dedicated CFD solver. The tool is able to provide a detailed description of the velocity and pressure fields inside the right ventricle and proximal pulmonary arteries during all phases of the cardiac cycle. From these fields, global hemodynamic quantities such as vortex properties, kinetic energy, pressure gradients and hemodynamic forces can be computed. Conclusions CMR-driven computational modeling of intra-ventricular flow enables a promising approach for understanding and evaluating the biomechanical environment of the right heart. This high-fidelity framework can be applied to investigate the RV response and adaptation to abnormal pressure and/or volume load conditions. It can also be used to reproduce the virtual flow that would realize in hypothetical conditions, and therefore adds predictive capabilities to modern flow imaging. The analysis may allow to determine an association between blood flow patterns and disease progression, and ultimately lead to derive and validate imaging biomarkers of clinical significance. Abstract P1449 Figure. Pipeline for patient-specific modeling

Funding Acknowledgements no funding sources exists OnBehalf RIGHT Heart International NETwork (RIGHT-NET) Purpose Exercise stress echocardiography (ESE) is a well-validated tool in ischemic and valvular heart diseases. The aim of this study is to assess the ESE feasibility for the evaluation of the right heart pulmonary circulation unit (RH-PCU) in a large cohort of subjects, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension. Methods: 954 subjects [mean age 54.2 ± 16.4 years, 430 women] [254 healthy volunteers, 40 elite athletes, 363 patients with cardiovascular risk factors, 25 with pulmonary arterial hypertension, 149 with connective tissue diseases, 81 with left heart and valvular diseases, 42 with lung diseases], underwent standardized semi-recumbent cycle ergometer ESE with an incremental workload of 25 watts every 2 minutes up to symptom-limited maximal tolerated workload. ESE parameters of right heart structure, function and pressures were obtained according current recommendations. Results: The success rate for the evaluation of the RV function at peak exercise was 903/940 (96%) for tricuspid annular plane systolic excursion (TAPSE), 667/751 (89%) for tissue Doppler–derived tricuspid lateral annular systolic velocity (S’) and 425/772 (63%) for right ventricular fractional area change (RVFAC). Right ventricular–right atrial pressure gradient [RV-RA gradient = 4 x tricuspid regurgitation velocity2] was obtained in 894/954 patients (93.7 %) at rest and in 816/954 (85.5%) at peak exercise. At peak exercise, pulmonary acceleration time (AcT) was feasible among 435/545 (82.5%) patients (Table 1). Conclusions: In daily ESE monitoring of TAPSE and S’ resulted to be less challenging than of RV FAC. ESE was a feasible tool for the evaluation of RV-RA gradient and pulmonary AcT. Table 1 Parameters Rest mean ± SD Peak mean ± SD P value Assessed n (%) Feasibility at rest n (%) Feasibility at peak n (%) RVED area (cm2) 17.4 ± 5.7 17.4 ± 5.8 0.9 672 632 (94.0) 425 (63.2) RVES area (cm2) 9.7 ± 4.3 9.6 ± 4.9 0.7 672 632 (94.0) 425 (63.2) TAPSE (mm) 22.9 ± 3.9 27.4 ± 5.5

Funding Acknowledgements None OnBehalf RIGHT-NET Background Exercise Doppler echocardiography (EDE) has been implemented for applications beyond coronary artery disease detection, but its role in assessing subclinical pulmonary vascular disease and right ventricle (RV) impairment is less clear. The RIGHT heart international NETwork (RIGHT-NET) is a prospective clinical and echocardiography observational multicenter study designed to explore the full spectrum of RV function and non-invasive pulmonary circulation hemodynamics during exercise in a large cohort of subjects, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). Right ventricular (RV) exercise contractile reserve (RVECR) can be assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP) and has proved to provide prognostic value in patients with left heart disease (LHD) and pulmonary arterial hypertension (PAH). Methods We enrolled 1424 patients (age 55.4 ± 15 years old, 44.4% males): 353 healthy controls, 40 athletes, 369 patients with cardiovascular risk factors (CVRF: arterial hypertension and/or diabetes mellitus), 46 with PAH (confirmed by right heart catheterization), 487 with systemic sclerosis (SSc) without overt PH, and 129 with LHD (including coronary artery disease and heart failure with reduced or preserved ejection fraction). All enrolled subjects underwent resting and EDE examinations on a semirecumbent cycle ergometer with an incremental workload of 25 Watts every 2 minutes up to the symptom-limited maximal tolerated workload, according to standardised protocols. Key echocardiographic measurements have been acquired at baseline, at 50 Watts, at peak exercise, and after 5-minutes recovery, including but not limited to RV function (TAPSE) and sPAP. Results In all six groups the ratio TAPSE/sPAP was significantly different at peak exercise compared to rest values (all p Conclusions EDE can non-invasively characterise different dynamic behaviours of the RVECR among healthy subjects, athletes and patients with various pathologic conditions. Whether a thorough EDE assessment of non-invasive hemodynamics, RVECR and coupling may predict later development of manifest PH, clinical deterioration or decreased survival will be further investigated during the ongoing follow-up. Abstract P1711 Figure