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Purpose: The extraaortic‐valvular cardiac damage (EVCD) Stage has shown potential for risk stratification for patients with aortic stenosis (AS). This study aimed to examine the usefulness of the EVCD Stage in risk stratification of patients with moderate AS and reduced left ventricular ejection fraction (LVEF). Methods: Clinical data from patients with moderate AS (aortic valve area,.60–.85 cm2/m2; peak aortic valve velocity, 2.0–4.0 m/s) and reduced LVEF (LVEF 20%–50%) were analyzed during 2010–2019. Patients were categorized into three groups: EVCD Stages 1 (LV damage), 2 (left atrium and/or mitral valve damage), and 3/4 (pulmonary artery vasculature and/or tricuspid valve damage or right ventricular damage). The primary endpoint included a composite of cardiac death and heart failure hospitalization, with non‐cardiac death as a competing risk. Results: The study included 130 patients (mean age 76.4 ± 6.8 years; 62.3% men). They were categorized into three groups: 26 (20.0%) in EVCD Stage 1, 66 (50.8%) in Stage 2, and 48 (29.2%) in Stage 3/4. The endpoint occurred in 54 (41.5%) patients during a median follow‐up of 3.2 years (interquartile range, 1.4–5.1). Multivariate analysis indicated EVCD Stage 3/4 was significantly associated with the endpoint (hazard ratio 2.784; 95% confidence interval 1.197–6.476; P =.017) compared to Stage 1, while Stage 2 did not (hazard ratio 1.340; 95% confidence interval.577–3.115; P =.500). Conclusion: The EVCD staging system may aid in the risk stratification of patients with moderate AS and reduced LVEF. [ABSTRACT FROM AUTHOR]

Backgrounds: There are limited data on the clinical relevance of transvalvular flow rate (Qmean) at rest (Qrest) and at peak stress (Qstress) during dobutamine stress echocardiography (DSE) in patients with low‐gradient severe aortic stenosis (LG‐SAS). Methods: We retrospectively analyzed the clinical data of patients with LG‐SAS who underwent DSE. LG‐SAS was defined as an aortic valve (AV) area index of <.6 cm2/m2 and a mean AV pressure gradient (AVPG) of < 40 mm Hg. The primary endpoint included all‐cause death and heart failure hospitalization. Results: Of 100 patients (mean age 79.5 ± 7.3 years; men, 45.0%; resting left ventricular ejection fraction [LVEF] 52.1% ± 15.9%; resting stroke volume index 35.8 ± 7.7 mL/m2; Qrest 171.8 ± 34.9 mL/s), the primary endpoint occurred in 51 patients during a median follow‐up of 2.84 (interquartile range 1.01–5.21) years. When the study patients were divided into three subgroups based on Qrest and Qstress, the multivariate analysis showed that Qrest < 200 mL/s and Qstress ≥200 mL/s (hazard ratio 3.844; 95% confidence interval 1.143–12.930; p =.030), as well as Qrest and Qstress < 200 mL/s (hazard ratio 9.444; 95% confidence interval 2.420–36.850; p =.001), were significantly associated with unfavorable outcomes with Qrest and Qstress ≥200 mL/s as a reference after adjusting for resting LVEF, resting mean AVPG, chronic kidney disease, New York Heart Association functional class III/IV, and AV replacement. Conclusions: Flow conditions based on the combination of Qrest and Qstress are helpful for risk stratification in LG‐SAS patients. [ABSTRACT FROM AUTHOR]

Background: Predictors of worsening atrioventricular valve regurgitation and left ventricular (LV) systolic function after implantation of a leadless pacemaker (LPM) remain unclear compared with those of a transvenous pacemaker (TPM). Methods: We retrospectively analyzed 205 patients who were newly implanted with a permanent pacemaker (119 LPMs and 86 TPMs) and underwent transthoracic echocardiography before and 8 ± 5 months after implantation. We evaluated the worsening of tricuspid and mitral regurgitation (TR and MR), defined as at least one‐grade aggravation in severity, and changes in LV ejection fraction (LVEF). Results: Worsening TR occurred more frequently in the LPM group compared to the TPM group (33% vs. 20%, p =.04); however, there was no significant difference between the two groups regarding worsening MR (26% vs. 18%, p =.18) and LVEF change (–2 ± 10% vs. –3 ± 8%, p =.40). In multivariable analysis, independent predictors for worsening TR, MR, and LVEF after implantation were found to be (1) the change from sinus rhythm at baseline to atrioventricular asynchronous right ventricular (RV) pacing (odds ratio [OR]: 5.68, 95% confidence interval [CI]: 1.94–16.70, p <.01); (2) the change from non‐pacing ventricular contraction at baseline to RV pacing (OR: 2.42, 95% CI: 1.12–5.24, p =.02); and (3) a higher RV pacing burden (β: –0.05, 95% CI: −0.08–−0.02, p <.01), respectively. Conclusion: Worsening TR, MR, and LVEF after pacemaker implantation were not associated with the type of pacing device but loss of atrioventricular synchrony or dependency on RV pacing. [ABSTRACT FROM AUTHOR]

Background: Although Doppler evaluation using a multiplanar method is recommended to assess the severity of aortic stenosis (AS) with transthoracic echocardiography, evidence on the diagnostic significance of a non‐apical method is limited. This study aimed to compare the use of the apical with the use of the right parasternal view (RPV) method to evaluate AS severity and to examine the diagnostic significance of performing the RPV method in addition to the apical method during the evaluation. Methods: This retrospective observational study included 276 consecutive patients (mean age: 79 ± 10 years; women, 56%) with severe AS (aortic valve area [AVA] ≤1.0cm2). The severity of AS according to the apical method and that according to the RPV for all subjects were compared, and the significance of performing the RPV method in addition to the apical method was examined. Furthermore, we compared the concordance group, in which the apical and RPV methods indicated matching in severity, and the discordant group, in which the apical and RPV methods did not indicate matching severity. Results: Peak velocity (Vmax), mean pressure gradient (MG) were significantly higher and the AVA, AVAi, and Doppler velocity index (DVI) were significantly smaller when the RPV was added to the apical view. Performing the RPV method in addition to the apical method significantly decreased the number of low PG AS cases (MG < 40 mmHg) from 69.9% to 65.0% and it increased the number of very severe AS cases (Vmax ≥ 5 m/s) from 8.7% to 14.5%. Deviation of Doppler angle was significantly greater in the discordant group compared to the concordant group (22.5 ±.6 vs. 31.8 ± 1.7, p <.001). Conclusions: By performing the RPV method in addition to the apical method to determine AS severity, the diagnosis of AS to be resolved in approximately 10% of cases. These results suggest that AS severity may be underestimated by using the apical method alone. [ABSTRACT FROM AUTHOR]

Background: The number of patients with chronic heart failure is increasing in Japan. However, the annual number of patients with heart failure who receive cardiac resynchronization therapy (CRT) has been constant in the last few years. In this study, we evaluated patients who did not receive CRT despite being eligible for this treatment to elucidate the clinical impact of CRT administration. Methods: We assessed 214 patients with a left ventricular ejection fraction (LVEF) ≤ 50% (excluding patients treated with CRT) who underwent transthoracic echocardiography between January and May 2020 at our institution. The patients were stratified into two groups: Group A (n = 26; patients eligible for CRT) and Group B (n = 188; patients ineligible for CRT); however, all patients only received pharmacological therapy. We retrospectively analyzed the prognosis of these patients with respect to the cumulative number of hospitalizations for heart failure and cardiogenic deaths. Results: We observed no significant between‐group differences in age, sex, and severity/diagnosis of organic heart disease. Group A had a significantly higher number of hospitalizations for heart failure and cardiogenic deaths than Group B (log‐rank test, P <.01; hazard ratio, 3.05; 95% confidence interval, 1.31‐7.09; average follow‐up period, 675 days). Conclusions: This study shows that 12% of patients were eligible for CRT. However, the implantation rate was low and no one was implanted. CRT is underutilized in patients who have heart failure with reduced LVEF. Therefore, we strongly recommend CRT for patients with indications for CRT. [ABSTRACT FROM AUTHOR]

Objective: Dobutamine stress echocardiography (DSE) is not always feasible in patients with low‐gradient severe aortic stenosis (LG‐SAS), and there are limited data available on the resting echocardiographic predictors for true‐severe aortic stenosis (TSAS). This study investigated resting echocardiographic predictors for TSAS. Methods: Clinical data of 106 LG‐SAS patients who underwent DSE were retrospectively analyzed. LG‐SAS was defined as an aortic valve area index (AVAi) <.6 cm2/m2, and a mean AV pressure gradient < 40 mm Hg. The velocity ratio (VR) was calculated as the peak left ventricular outflow tract velocity/peak AV velocity. TSAS was defined as a projected AVAi <.6 cm2/m2. Results: The mean age was 79.3 ± 7.3 years, and 45 (42.5%) were men. The resting AV data were as follows: AVAi,.50 ±.07 cm2/m2; mean AV pressure gradient, 23.0 ± 7.4 mm Hg; and VR,.25 ±.05. The projected AVAi was.58 ±.09 cm2/m2, and TSAS was documented in 65 (61.3%) patients. In multivariate analysis, the independent predictors of TSAS were AVAi (p = 0.012) and VR (p = 0.004) with respective best cut‐off values of.52 cm2/m2 and.25 on receiver‐operating characteristic curve analysis. According to incremental numbers of the predictors, correct classification percentages of TSAS significantly increased with the Cochran‐Armitage trend test (16.2% in no predictors, 65.2% in one predictor, and 95.7 % in two predictors; p < 0.001). Conclusions: Resting AVAi and VR were independent predictors of TSAS in LG‐SAS patients. The true severity might be predictable using the combination of resting parameters. [ABSTRACT FROM AUTHOR]

Background: A high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown. Hypothesis: We hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI. Methods: We divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non‐LADp] group), and those without CAD (Non‐CAD group). Clinical outcomes were compared among the three groups. Results: The CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all‐cause mortality than the other two groups (log‐rank p =.001 and p =.008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all‐cause mortality. However, PCI for an LM or LAD proximal lesion pre‐TAVI did not reduce the risk of these outcomes. Conclusions: CAD with an LM or LAD proximal lesion is a strong independent predictor of mid‐term MACCEs and all‐cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes. [ABSTRACT FROM AUTHOR]

Background: The risk stratification of hypertrophic cardiomyopathy (HCM) without left ventricular outflow tract (LVOT) obstruction and the utility of exercise stress echocardiography (ESE) remains unclear. We investigated the value of right ventricular (RV) function and RV‐pulmonary artery (PA) coupling during exercise in asymptomatic/minimally symptomatic patients with nonobstructive HCM (nHCM). Method and results: This retrospective study evaluated 74 HCM patients (age 63 ± 13 years, 65% men) without LVOT obstruction (≥30 mmHg) who underwent​ ESE. Eight patients (11%) suffered from HCM‐related cardiac events during a median 2.5 years follow‐up. During exercise, tricuspid annular plane systolic excursion (Ex‐TAPSE) and Ex‐TAPSE/systolic pulmonary artery pressure [SPAP] ratio were more impaired in patients with than in those without events (22 ± 4 vs 26 ± 4 mm, P =.005; and 0.45 [0.41, 0.47] vs 0.56 [0.47, 0.82] mm/mmHg, P =.002). In Cox regression analysis, Ex‐TAPSE (HR: 1.397, P =.002) and the Ex‐TAPSE/SPAP ratio (HR: 2.737, P =.006) were associated with cardiac events. In Kaplan‐Meier analysis, patients with a low Ex‐TAPSE (<24 mm) and Ex‐TAPSE/SPAP ratio (<0.50 mm/mmHg) had a higher incidence of adverse outcomes than those with high Ex‐TAPSE (Log rank, P <.001 and =.001, respectively). Conclusions: A low Ex‐TAPSE and Ex‐TAPSE/SPAP ratio were associated with adverse outcomes in nHCM. Evaluation of RV functional performance during exercise may play a crucial role in the risk stratification of nHCM. [ABSTRACT FROM AUTHOR]

Aims: Older adults at risk for malnutrition are known to have a high mortality rate. This study aimed to investigate whether the Mini Nutritional Assessment—Short Form (MNA‐SF) could predict midterm mortality in patients undergoing transcatheter aortic valve implantation (TAVI). Methods and results: We applied the MNA‐SF in 288 patients who had undergone TAVI from January 2016 to June 2019 at the St. Marianna University School of Medicine hospital. Using the MNA‐SF cut‐off value to indicate the risk of malnutrition, patients were divided into two groups, namely, those with an MNA‐SF score ≤11 (impaired MNA‐SF group) and those with an MNA‐SF score ≥12 (maintained MNA‐SF group). We used this value to investigate the association between the MNA‐SF and all‐cause mortality. Overall, 188 (65%) and 100 (35%) patients comprised the impaired MNA‐SF and maintained MNA‐SF groups, respectively, and 41 patients died after TAVI (mean follow‐up duration, 458 ± 315 days). Kaplan–Meier analyses showed that patients in the impaired MNA‐SF group had a significantly higher incidence of all‐cause mortality (hazard ratio 2.67; 95% confidence interval 1.29–6.21; P = 0.01). Multivariate Cox regression analyses showed that the MNA‐SF score was an independent predictor of all‐cause mortality after adjusting for the Society of Thoracic Surgeons risk score, Katz Index, and brain natriuretic peptide test results (hazard ratio 1.14; 95% confidence interval 1.01–1.28; P = 0.04). Conclusions: The MNA‐SF was useful to screen for the risk of malnutrition in patients with TAVI and in predicting midterm prognoses in patients undergoing TAVI and could predict patient mortality after the procedure. [ABSTRACT FROM AUTHOR]

Takotsubo syndrome is an acute reversible heart failure syndrome that is increasingly recognized in modern cardiology practice. This Position Statement from the European Society of Cardiology Heart Failure Association provides a comprehensive review of the various clinical and pathophysiological facets of Takotsubo syndrome, including nomenclature, definition, and diagnosis, primary and secondary clinical subtypes, anatomical variants, triggers, epidemiology, pathophysiology, clinical presentation, complications, prognosis, clinical investigations, and treatment approaches. Novel structured approaches to diagnosis, risk stratification, and management are presented, with new algorithms to aid decision-making by practising clinicians. These also cover more complex areas (e.g. uncertain diagnosis and delayed presentation) and the management of complex cases with ongoing symptoms after recovery, recurrent episodes, or spontaneous presentation. The unmet needs and future directions for research in this syndrome are also discussed. [ABSTRACT FROM AUTHOR]

Takotsubo syndrome is an acute reversible heart failure syndrome that is increasingly recognized in modern cardiology practice. This Position Statement from the European Society of Cardiology Heart Failure Association provides a comprehensive review of the various clinical and pathophysiological facets of Takotsubo syndrome, including nomenclature, definition, and diagnosis, primary and secondary clinical subtypes, anatomical variants, triggers, epidemiology, pathophysiology, clinical presentation, complications, prognosis, clinical investigations, and treatment approaches. Novel structured approaches to diagnosis, risk stratification, and management are presented, with new algorithms to aid decision-making by practising clinicians. These also cover more complex areas (e.g. uncertain diagnosis and delayed presentation) and the management of complex cases with ongoing symptoms after recovery, recurrent episodes, or spontaneous presentation. The unmet needs and future directions for research in this syndrome are also discussed. [ABSTRACT FROM AUTHOR]

Background Exercise-induced pulmonary hypertension ( PH) is considered as an early preclinical functional phase of resting PH in systemic sclerosis ( SSc). In this study, we investigated the prevalence of exercise-induced PH in patients with SSc and evaluated the influence of pulmonary vascular reserve on exercise-induced PH. Methods This prospective study included 568 SSc patients. The patients with interstitial lung disease and those with left ventricular dysfunction were excluded (n = 50); finally, 518 patients underwent simple exercise echocardiography using a Master's two-step. Systolic pulmonary artery pressure ( SPAP), the ratio of early diastolic transmitral flow velocity to early diastolic mitral annular velocity (E/e') and pulmonary vascular resistance ( PVR) were measured before and after exercise. Δ PVR (the difference between rest and post) was used for the assessment of pulmonary vascular reserve. All patients were stratified into the no exercise-induced PH ( SPAP <50 mmHg) or exercise-induced PH ( SPAP ≥50 mmHg, n = 133) group. Results Of the study patients, 27% patients were identified as having exercise-induced PH. Δ PVR was higher in the exercise-induced PH than no exercise-induced PH group (0.2 ± 0.3 vs. 0.4 ± 0.4 WU, P < 0.0001). A weak correlation was found between postexercise SPAP and postexercise E/e' (r = 0.31, P < 0.0001), whereas a strong correlation was found between postexercise SPAP and postexercise PVR (r = 0.62, P < 0.0001). The analyzed data demonstrated that Δ PVR was independently associated with exercise-induced PH (odds ratio, 3.435; 95% CI, 1.013-11.650, P = 0.033). Conclusions The present study demonstrated that exercise-induced PH was common in patients with SSc. Exercise-induced PH might be closely associated with the factors affecting reduced pulmonary vascular reserve in patients with SSc. [ABSTRACT FROM AUTHOR]

Background: Recently, many cardiologists have recognized the existence of a rapidly reversible form of heart failure of unknown origin characterized by a takotsubo-shaped, dyskinetic left ventricle on left ventriculography.Aim: To determine the detailed clinical features of takotsubo cardiomyopathy.Methods: Thirteen elderly patients (11 women and 2 men with a mean age of 75.3 years) who had normal coronary arteries and takotsubo-like left ventricular dysfunction were prospectively enrolled in this study.Results: Cardiac enzymes did not increase significantly, but the mean plasma norepinephrine level was very high on admission (0.98 microg/l). Coronary angiography revealed normal coronary arteries in all patients, but left ventriculography showed apical akinesis combined with basal hyperkinesis, i.e., a takotsubo (Japanese octopus fishing pot)-shaped ventricle. Left ventricular wall motion normalized within a mean of 16.9 hospital days in 12 patients, but 1 patient died of acute renal failure on hospital day 7. Cardiac events did not recur during a follow-up period of 0.5 to 5 years.Conclusion: Takotsubo cardiomyopathy seems to be a new type of acute heart failure, which generally has a good prognosis and does not recur. Myocardial damage by catecholamine overload, adrenoceptor hypersensitivity, and changes of catecholamine dynamics due to stress may cause this condition. [ABSTRACT FROM AUTHOR]

Background Current guidelines recommend at least 6 months of antithrombotic therapy and antibiotic prophylaxis after septal-occluding device deployment in transcatheter closure of atrial septal defect. It has been estimated that it takes ≈6 months for complete neo-endothelialization; however, neo-endothelialization has not previously been assessed in vivo in humans. Methods and Results The neointimal coverage of septal occluder devices was evaluated 6 months after implantation in 15 patients by angioscopy from the right atrium. Each occluder surface was divided into 9 areas; the levels of endothelialization in each area were semiquantitatively assessed by 4-point grades. Device neo-endothelialization was sufficient in two thirds of patients, but insufficient in one third. In the comparison between patients with sufficiently endothelialized devices of average grade score ≥2 (good endothelialization group, n=10) and those with poorly endothelialized devices of average grade score <2 (poor endothelialization group, n=5), those in the poor endothelialization group had larger devices deployed (27.0 mm [25.0-31.5 mm] versus 17.0 mm [15.6-22.5 mm], respectively) and progressive right heart dilatation. The endothelialization was poorer around the central areas. Moreover, the prevalence of thrombus formation on the devices was higher in the poorly endothelialized areas than in the sufficiently endothelialized areas (Grade 0, 94.1%; Grade 1, 63.2%; Grade 2, 0%; Grade 3, 1.6%). Conclusions Neo-endothelialization on the closure devices varied 6 months after implantation. Notably, poor endothelialization and thrombus attachment were observed around the central areas and on the larger devices.