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Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome and myocardial infarction, more frequent among young women. Invasive coronary angiography (ICA) is the gold standard for the diagnosis of SCAD, although the risk of propagating dissection flap is considerable. Therefore, coronary computed tomography angiography (CCTA) is an emerging alternative modality to diagnose SCAD with the advantage of being a non-invasive technique. Clinicians should be aware of the predisposing conditions and pathophysiology to raise the pre-test probability of SCAD and select the most appropriate diagnostic tools. In recent times, improvements in spatial and temporal resolution and the use of semi-automated software providing quantitative assessment make CCTA a valid alternative to ICA also for the follow-up. Moreover, CCTA may be helpful to screen and evaluate extra-coronary arteriopathies closely related to SCAD. In this review, we illustrate the current and the potential role of CCTA in the diagnosis of SCAD, highlighting advantages and disadvantages of this imaging modality compared to ICA.

Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational–retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82–89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25–87), with 73 patients (70%) reaching the invasive procedure

Whether balloon aortic valvuloplasty (BAV) may provide an effective palliation in symptomatic high-risk patients is uncertain. Therefore, we aimed to evaluate outcomes in symptomatic high-risk patients with severe aortic stenosis (AS), who underwent BAV. All-cause mortality and length of hospitalization for heart failure (HF) up to death or to 1-year follow up were collected after BAV. One hundred thirty-two (132) patients (62% women), mean age 85±7 years, underwent BAV with a substantial reduction of the peak-to-peak aortic gradient from 53±21 to 29±15 mmHg (p

The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.

Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.

Echocardiography is the most validated, non-invasive and used approach to assess left ventricular hypertrophy (LVH). Alternative methods, specifically magnetic resonance imaging, provide high cost and practical challenges in large scale clinical application. To include a wide range of physiological and pathological conditions, LVH should be considered in conjunction with the LV remodeling assessment. The universally known 2-group classification of LVH only considers the estimation of LV mass and relative wall thickness (RWT) to be classifying variables. However, knowledge of the 2-group patterns provides particularly limited incremental prognostic information beyond LVH. Conversely, LV enlargement conveys independent prognostic utility beyond LV mass for incident heart failure. Therefore, a 4-group LVH subdivision based on LV mass, LV volume, and RWT has been recently suggested. This novel LVH classification is characterized by distinct differences in cardiac function, allowing clinicians to distinguish between different LV hemodynamic stress adaptations in various cardiovascular diseases. The new 4-group LVH classification has the advantage of optimizing the LVH diagnostic approach and the potential to improve the identification of maladaptive responses that warrant targeted therapy. In this review, we summarize the current knowledge on clinical value of this refinement of the LVH classification, emphasizing the role of echocardiography in applying contemporary proposed indexation methods and partition values.

Introduction We aimed to assess mitral valvular/annular/ventricular dynamics in mitral valve prolapse (MVP) stratified by mitral annular disjunction (MAD) presence, in the context of mitral surgery. Method In 61 patients (62 ± 11 years; 25% women) with MVP and severe mitral-regurgitation undergoing mitral-surgery between 2009-2016, 2D transthoracic and 4D-transesophageal echocardiographic characteristics and left ventricular (LV) dimensions/dynamics were analyzed, stratified by to MAD presence, pre and post-surgery. Results MAD (8 ± 3 mm) was diagnosed in 27 (44%) patients [ERO of 0.50(0.36–65)cm2], more frequently in bileaflet MVP (52 vs.19%, P = 0.007), involving consistently P2 (P = 0.03). MAD displayed larger diastolic annular area (1646 ± 410 vs. 1380 ± 348 mm2, P = 0.008), circumference (150 ± 19 vs. 137 ± 16 mm, P = 0.005) and intercommissural diameter (48 ± 7 vs. 43 ± 6 mm, P = 0.03) vs. no-MAD. Dynamically, early-systolic annular contraction and saddle shape accentuation were unaffected but mid- and late-systolic excess inter-commissural diameter, annular area and circumference enlargement were associated with MAD (all P 0.07). However, despite similar ejection fraction (65 ± 5 vs. 62 ± 8%, P = 0.1), systolic basal posterior thickness was increased in MAD (19 ± 2 vs. 15 ± 2 mm, P 0.50) ( Fig. 1 ). Conclusion MAD is frequent in MVP, mostly associated with bileaflet/deep MVP and compounds profound annular alterations. MAD myocardial/annular slippage masquerades stronger LV function without benefit post-surgery. Hence, MAD valvular/ventricular alterations warrant careful detection and interpretation.

Il contributo riporta i risultati di una ricerca realizzata dalle Università di Bologna e di Parma con gli Uffici di esecuzione penale esterna (UEPE) di Bologna, Modena e Reggio-Emilia. La ricerca ha inteso indagare le finalità della c.d. probation, nonché la conoscenza e l’opinione degli operatori giuridici e sociali sulla ‘messa alla prova’, dispositivo penale esteso di recente ai maggiorenni (L. 67/2014), dopo essere stato appannaggio, per trent’anni, del settore minorile. Lo studio ha preso avvio dalla constatazione del mutamento normativo, per cui il reato non viene più considerato (solo) come lesione dell’ordine giuridico astratto, ma piuttosto dei beni e degli interessi concreti di una persona e della comunità in cui vive. Si introduce così la formulazione di dispositivi che appartengono al modello della cosiddetta Giustizia riparativa (Restorative Justice), tramite cui l’esecuzione penale può tendere (anche) al coinvolgimento diretto dell’autore del reato, per considerare (finalmente) i vissuti e le aspettative di un soggetto finora rimasto “dietro le quinte” della scena processuale: la vittima. Il sistema della probation, com’è noto, prevede la compresenza di tre elementi: la sospensione dell’azione penale, l’imposizione di oneri e prescrizioni all’imputato e soprattutto l’affiancamento di questo da parte dei Servizi sociali, durante la “prova” (l’etimo probation fa riferimento appunto alla prova, da affrontare e valutare). La probation - e la messa alla prova, nello specifico - si presta quindi ad essere indagata per osservare le dinamiche che interessano l’intreccio tra la metodologia del servizio sociale e le procedure giudiziarie. La ricerca ha permesso l’analisi di 192 fascicoli di imputati adulti ‘messi alla prova’, realizzata tramite il Software SPSS; la somministrazione di un questionario standardizzato rivolto ai funzionari del Servizio Sociale degli UEPE dell’Emilia-Romagna diretto a rilevare prassi e finalità dell’ operato dei servizi; e la conduzione di 13 interviste semi-strutturate con testimoni privilegiati (operatori giuridici e operatori sociali) focalizzate sulla riparazione, sulla mediazione e sull’utilizzo del lavoro di pubblica utilità.

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.

The need for multiple transducer positions, especially from right parasternal windows, is consistently mentioned in the recommendations for the accurate measurement of peak velocities across a stenotic aortic valve, but yet poorly adopted.We performed a subanalysis of the largest prospective series on the right parasternal acoustic windows in patients with aortic stenosis (330 consecutive) to calculate the degree of misalignment and estimate the potential outcome implication of this often-forgotten approach.The right parasternal view was highly feasible with an average estimated misalignment from the apical view of 14 ± 16 degree; in 10 cases, an estimated misalignment >40 degree. Right parasternal assessment (vs. apical alone) provided a significant reclassification from moderate to severe or even very-severe aortic valve stenosis. Considering a wellestablished survival benefit provided by either percutaneous or surgical valve replacement in patients with severe aortic stenosis the reclassification would result in approximately 1 life-year saved for every 30-35 patients in whom parasternal view were effectively utilized.

Background: Low-gradient aortic stenosis (LG-AS) is characterized by the combination of an aortic valve area compatible with severe stenosis and a low transvalvular mean gradient with low-flow state (i.e., indexed stroke volume

Introduction: Despite current guidelines provide recommendations for the optimal management of degenerative mitral regurgitation (MR), this condition remains often undertreated with delay in surgical referral and dismal effect on outcomes. Areas covered: This review focuses on the role of echocardiography in guiding mitral valve (MV) surgical repair in degenerative MR due to leaflet prolapse. Expert opinion: A stepwise protocol-driven echocardiography shared by referring physician and surgeon may help to guide referral to surgical repair in degenerative MR. This protocol particularly is useful to identify the ideal patho-anatomy for a successful and durable repair especially when early surgery is proposed and to refer the patient to centers of excellence in case of complex anatomy. Nearly 100% repair rate can be achieved when the surgical technique is adapted to the lesions seen in each valve. Three-dimensional echocardiography predicts repair complexity may be useful and should therefore be implemented. However, the current literature is far from comprehensive deriving from small, single-center studies. Therefore, reproducibility and external validation, especially with newly developed quantitative automated software, are still needed.

A recently developed algorithm for 3D analysis based on machine learning (ML) principles detects left ventricular (LV) mass without any human interaction. We retrospectively studied the correlation between 2D-derived linear dimensions using the ASE/EACVI-recommended formula and 3D automated, ML-based methods (Philips HeartModel) regarding LV mass quantification in unselected patients undergoing echocardiography. We included 130 patients (mean age 60 ± 18 years, 45% women). There was only discrete agreement between 2D and 3D measurements of LV mass (r = 0.662, r2 = 0.348, p &lt, 0.001). The automated algorithm yielded an overestimation of LV mass compared to the linear method (Bland–Altman positive bias of 13.1 g with 95% limits of the agreement at 4.5 to 21.6 g, p = 0.003, ICC 0.78 (95%CI 0.68−8.4). There was a significant proportional bias (Beta −0.22, t = −2.9) p = 0.005, the variance of the difference varied across the range of LV mass. When the published cut-offs for LV mass abnormality were used, the observed proportion of overall agreement was 77% (kappa = 0.32, p &lt, 0.001). In consecutive patients undergoing echocardiography for any indications, LV mass assessment by 3D analysis using a novel ML-based algorithm showed systematic differences and wide limits of agreements compared with quantification by ASE/EACVI- recommended formula when the current cut-offs and partition values were applied.

Objectives The purpose of this study was to compare women and men with organic mitral regurgitation (MR) using pre- and post-operative comprehensive imaging and to analyze the effect on outcome. Background Management of organic MR has no sex-specific guideline recommendation, and sex differences on the basis of comprehensive imaging and links to outcome remain largely unknown. Methods Comprehensive imaging (MR cause, quantitation, ventricular and atrial measures, and post-operative reverse cardiac remodeling) was analyzed in 217 women and 447 men who underwent operations for organic MR from 1990 to 2000 with long-term follow-up analysis. Results Pre-operatively, women and men had similar age and ejection fraction. In women, a smaller left ventricle (LV) more often labeled as normal size (23% vs. 13%), left atrium size, and regurgitant volume (all p 0.06). During follow-up (10.4 ± 3.7 years) women had similar survival as men (p = 0.5) but experienced more heart failure (at 15 years: 36 ± 7% vs. 19 ± 3%; p = 0.03; adjusted hazard ratio 1.63 [95% confidence interval: 1.08 to 2.43]; p = 0.02) linked to more frequent pre-operative heart failure symptoms (p Conclusions Women who undergo mitral surgery for organic MR receive similar repair for similar degenerative lesions defined by echocardiography and enjoy similar survival and reverse cardiac remodeling, but they incur excess post-operative heart failure linked to worse pre-operative presentation. Imaging that does not account for body size shows smaller absolute cardiac dimensions and regurgitant volumes, which tends to underestimate MR severity in women.

Background: Data on stress echocardiography (SE) time-related changes in referral patterns and diagnostic yield for detection of inducible ischemia could enhance Echo Lab quality benchmarks and performance measures. Aim: This study aims to evaluate temporal trends in SE test results among ambulatory patients with suspected or known coronary artery disease (CAD) in a tertiary care referral center with moderate (>100/year) volume SE activities and Cath-Lab facility. Methods: From January 2004 to December 2015, 1954 patients (mean age 62 ± 12 years, 42% women, 27% with known CAD) underwent SE (1673 exercise SE, 86%, 246 pharmacological SE, 12%, 35 pacing SE, 2%). Time was grouped into three 4 year periods, where clinical data and test results were evaluated. Results: Our series comprised low-to-intermediate pretest probability of CAD throughout the observation period (overall pretest probability of CAD 19% ± 15%). A progressive decline over time in the rate of pharmacological SE instead of a dramatic increment of exercise SE (79%–96%, P < 0.0001) was noted. The use of beta-blockers increased (from 43% to 66%, P < 0.0001), while the use of nitrates decreased (from 11% to 4%, P < 0.0001) over time. We noted a very uncommon occurrence of abnormal test results with a further decrease in the last period (from 11% to 3%, P < 0.0001). Conclusions: We observed, over a 12-year period, a progressive decrease in the frequency of inducible myocardial ischemia among patients with known or suspected CADe referred to our Echo Lab for SE with Cath-Lab facility, and this trend was parallel to changes in SE referral practice. These findings are particularly relevant if we consider the practical implications on diagnostic SE accuracy and risk assessment.

Despite its high prevalence, little is known about mechanisms of mitral regurgitation in degenerative mitral valve disease apart from the leaflet prolapse itself. Mitral valve is a complex structure, including mitral annulus, mitral leaflets, papillary muscles, chords, and left ventricular walls. All these structures are involved in physiological and pathological functioning of this valvuloventricular complex but up to now were difficult to analyze because of inherent limitations of 2-dimensional imaging. The advent of 3-dimensional echocardiography, computed tomography, and cardiac magnetic resonance imaging overcoming these limitations provides new insights into mechanistic analysis of degenerative mitral regurgitation. This review will detail the contribution of quantitative and qualitative dynamic analysis of mitral annulus and mitral leaflets by new imaging methods in the understanding of degenerative mitral regurgitation pathophysiology.

The timing of surgical correction of mitral regurgitation remains controversial. A major source of dispute regards the potential short- and long-term postoperative outcome penalty associated with the type of guideline-based indication for surgery.Between 1990 and 2000, 1512 patients (aged 64 ± 14 years, mitral prolapse in 89%, valve repair in 88%) underwent surgical correction of pure organic mitral regurgitation. Patients were stratified according to surgical indication into class I triggers (ClassI-T: heart failure symptoms, ejection fraction60%, end-systolic diameter ≥40 mm, n = 794), class II triggers based on clinical complications (ClassII-CompT: atrial fibrillation or pulmonary hypertension, n = 195), or early class II triggers based on a combination of severe mitral regurgitation and high probability of valve repair (ClassII-EarlyT: n = 523).Operative mortality was highest with ClassI-T (1.1% vs 0% and 0%, P = .016). Long-term survival was lower with ClassI-T (15-year 42% ± 2%; adjusted hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.53-2.34; P.0001) and ClassII-CompT (15-year 53% ± 4%, adjusted HR, 1.39; 95% CI, 1.04-1.84; P = .027) versus ClassII-EarlyT (15-year 70% ± 3%, P.0001). Postoperative excess mortality with ClassI-T and ClassII-CompT was confirmed by age stratification, inverse probability weighting, and expected survival adjustment. Excess postoperative heart failure was high with ClassI-T (adjusted HR, 2.49; 95% CI, 1.82-3.47; P.0001) and ClassII-CompT (adjusted HR, 1.98; 95% CI, 1.30-3.00; P = .002).The type of guideline-based indication for surgical correction of organic mitral regurgitation is associated with profound outcome consequences on long-term postoperative mortality and heart failure, despite low operative risk and high repair rates. Conversely, surgical correction of severe mitral regurgitation based on high probability of repair (ClassII-EarlyT) is associated with improved survival and low heart failure risk and should be the preferred strategy in valve centers offering low operative risk and high repair rates.

Background: We evaluated the impact of contrast stress echocardiography (CSE) testing results on cardiovascular (CV) risk behaviors in postmenopausal women presenting with chest pain symptoms. This was a substudy of the Stress Echocardiography in Menopausal Women at Risk for Coronary Artery Disease (SMART) trial. Methods: From 2004 to 2007, 366 women (mean age 54.4±5.5 years, range 40–65; body mass index (BMI) 31.4±6.68; Caucasian in 95%) completed CSE and were invited to participate in the Women's Heart Clinic Risk Assessment Questionnaire (WHCRAQ survey) at the time of CSE and after 2 years. Of the 366, 203 (55%) postmenopausal women completed both the baseline and 2-year follow-up surveys (age 61±5 years; Framingham risk score 6±4%, 81% treadmill CSE, 19% dobutamine CSE). WHCRAQ assessed medical history, hormone therapy (HT), and CV risk behaviors (cigarette smoking history, including current smoking and mean cigarettes smoked per day; physical activity or exercise, including mean exercise minutes per week; and dietary fat intake, alcohol intake, and mean alcohol drinks per week). Abnormal CSE was defined as a new or worsening stress wall motion abnormality. Post-CSE changes in CV risk behaviors were determined by comparing baseline versus 2-year data. Results: Of the 203 women who completed the survey at baseline and 2-year CSE, 29 were excluded to avoid confounding effect (coronary angiography [CA] was performed during follow-up). Of 174 women (55% hypertensive, 10% diabetic, 76% hyperlipidemic, and 25% on HT), CSE was abnormal in 10%. Baseline characteristics were not significantly different in normal versus abnormal CSE, apart from diabetes (8% vs. 24%, p=0.04). Slightly more women with normal CSE were taking HT than not (27% vs. 12%, p=0.19). CV risk behaviors that were different in normal versus abnormal CSE included current smoking, alcohol drinks per week, and higher fat diet (8% vs. 24%, p=0.03; 2.5±3.5 vs. 1.94±5.2, p=0.031; and 92% vs. 76%, p=0.03, respectively). Cigarette smoking decreased (mean difference of −1.5 cigarettes per day, p=0.014) in the abnormal-CSE group, whereas number of alcohol drinks per week increased (mean difference +0.38, p=0.009) in the normal-CSE group. Conclusion: We observed an association of lifestyle changes with CSE test results in postmenopausal women

The purpose of this study was to compare women and men with organic mitral regurgitation (MR) using pre- and post-operative comprehensive imaging and to analyze the effect on outcome.Management of organic MR has no sex-specific guideline recommendation, and sex differences on the basis of comprehensive imaging and links to outcome remain largely unknown.Comprehensive imaging (MR cause, quantitation, ventricular and atrial measures, and post-operative reverse cardiac remodeling) was analyzed in 217 women and 447 men who underwent operations for organic MR from 1990 to 2000 with long-term follow-up analysis.Pre-operatively, women and men had similar age and ejection fraction. In women, a smaller left ventricle (LV) more often labeled as normal size (23% vs. 13%), left atrium size, and regurgitant volume (all p 0.01) contrasted with higher pulmonary pressure and more heart failure symptoms (41% vs. 19%), which more often triggered surgery (all p 0.01). However, normalizing for body size, LV and left atrial diameters and regurgitant volume were at least as large in women versus men. Similar normalized MR severity was confirmed by similar post-operative reverse cardiac remodeling in women and men (all p0.06). During follow-up (10.4 ± 3.7 years) women had similar survival as men (p = 0.5) but experienced more heart failure (at 15 years: 36 ± 7% vs. 19 ± 3%; p = 0.03; adjusted hazard ratio 1.63 [95% confidence interval: 1.08 to 2.43]; p = 0.02) linked to more frequent pre-operative heart failure symptoms (p 0.001).Women who undergo mitral surgery for organic MR receive similar repair for similar degenerative lesions defined by echocardiography and enjoy similar survival and reverse cardiac remodeling, but they incur excess post-operative heart failure linked to worse pre-operative presentation. Imaging that does not account for body size shows smaller absolute cardiac dimensions and regurgitant volumes, which tends to underestimate MR severity in women.

Background: Echocardiography plays a central role in diagnosing infective endocarditis (IE). Accordingly, the European Society of Cardiology (ESC) has proposed a diagnostic echocardiographic algorithm. However, new studies are still needed to evaluate the degree of implementation of these guidelines in clinical practice and their consequences on incidence and prognosis of IE. Aim: This study aims to investigate the diagnostic yield of the ESC proposed echocardiographic algorithm in patients with suspected IE. We also examined the association among IE diagnosis and clinical outcomes. Methods: Retrospective analysis of a series of patients undergoing the ESC algorithm for clinical suspicion of IE at our institution. Results: Between 2009 and 2013, 323 cases were managed by a multidisciplinary team for clinical suspicion of IE. Following ESC algorithm, 26 (8%) patients were diagnosed with IE and 297 (92%) had IE excluded. In 92% of patients with a good-quality negative transthoracic echocardiography (TTE) and low level of clinical suspicion, the first TTE was considered sufficient to rule out IE. During a mean follow-up of 2.3 ± 1.4 years, patients who had a final diagnosis of IE showed similar mortality (P = 0.2) and rates of combined endpoint (all-cause death, stroke/transient ischemic attack, advanced atrioventricular block, and heart failure) compared to patients without echocardiographic diagnosis of IE (P = 0.5). Only 1% of the patients who had IE excluded experienced IE in the following 3 months, none of them in the subgroup of patients, in which a first negative TTE was considered sufficient to rule out IE. Conclusions: In spite of the current ESC recommendation TTE is used as part of a routine fever screen. Consequently, only a minority of patients had a final echocardiographic diagnosis of IE. Although in patients with low clinical suspicion a first negative TTE is sufficient to rule out IE, the incidence of clinical events is similar regardless the final diagnosis of IE.

Background— Fibro-elastic deficiency (FED) and diffuse myxomatous degeneration (DMD) are phenotypes of degenerative mitral valve disease defined morphologically. Whether physiological differences in annular and valvular dynamics exist between these phenotypes remains unknown. Methods and Results— We performed triple quantitation of cardiac remodeling and of mitral regurgitation severity and of annular and valvular dimensions by real-time 3-dimensional-transesophageal-echocardiography. Forty-nine patients with degenerative mitral valve disease classified as FED (n=31) and DMD (n=18) by surgical observation showed no difference in age (65±10 versus 59±13; P =0.5), body surface area (2.0±0.2 versus 2.0±0.2 m 2 ; P =0.5), left ventricular and atrial dimensions (all P >0.55), and mitral regurgitation regurgitant orifice ( P =0.62). On average, annular dimensions were larger in DMD versus FED, but height was similar resulting in lower saddle shape. Dynamically, annular DMD versus FED display poorer contraction and saddle-shape accentuation in early systole and abnormal enlargement, particularly intercommissural, in late-systole (all P P P Conclusions— Our novel observations show that FED and DMD, although both labeled myxomatous, display considerable physiological phenotypic differences. In DMD, the annular increased size and profoundly abnormal dynamics demonstrate DMD-specific annular degeneration compared with the enlarged but relatively normal FED annulus. DMD does not incur more severe mitral regurgitation, despite larger prolapse and valve redundancy, underscoring potential compensatory role of tissue redundancy of DMD (or aggravating role of tissue paucity of FED) on mitral regurgitation severity.

Objectives Cleft-like indentations (CLI) are deep separations between scallops of the mitral posterior leaflet observed in myxomatous mitral valve disease (MMVD), but their diagnosis, mechanisms and implications are unknown. Using 3D transoesophageal echocardiography (3DTOC), we aimed at assessing diagnostic accuracy and defining mechanisms of CLI in patients undergoing surgery for MMVD. Methods 3DTOC of mitral valve was acquired in 49 patients with MMVD and severe regurgitation prior to valve repair. Qualitative review compared 3DTOC diagnosis of CLI with surgical inspection. Mitral, annular and leaflet dimensions were quantified with dedicated software and compared between those with and without CLI. Results Diagnosis of CLI was made by 3DTOC in 17 (35%) while none was identified by 2D and was confirmed in 15 (88%) by surgical inspection. Mechanistically, LV diameters and mitral regurgitant volume (RVol) were similar with and without CLI (p>0.49). Conversely, mitral annulus was smaller with CLI (anteroposterior diameter 42.2±7.1 vs 47.0±7.5 mm, p=0.04; circumference 133±16 vs 148±19 mm, p=0.009; area 1289±326 vs 1619±427 mm 2 , p=0.008). Prolapse volume tended to be smaller with CLI (1.9±1.2 vs 4.0±4.3 mL, p=0.06) involving single posterior scallop at surgery (82% vs 44%, p=0.007) with smaller 3DTOC leaflet area (1574±409 vs 2019±652 mm 2 , p=0.01). During valve repair, surgical closure of all surgically diagnosed CLI was required. Conclusions Posterior leaflet CLI are frequent in MMVD, are identified by 3DTOC with high accuracy and require closure during valve repair. CLI are mechanistically not related to excess annular enlargement or excess prolapse. Conversely, CLI occur in the context of single scallop prolapse with tissue paucity causing excess separation of scallops. These 3DTOC data enhance diagnostic and mechanistic comprehension of the diversity of MMVD phenotypical presentation.

Background: Mitral annular disjunction (MAD) is a localized detachment of annulus supporting the posterior leaflet from ventricular wall, described in myxomatous valve disease (MMVD). Whether this localized detachment causes physiologic consequences for annular and valvular dynamics is unknown.

a negative peak supine bicycle exercise stress echocardiography (ESE) was shown to have a long-term favourable prognostic value. Data on the long-term prognosis of ischaemic electrocardiographic (ISECG) changes in the setting of a negative peak supine bicycle ESE are lacking.we evaluated the prognostic value of negative peak supine bicycle ESE with or without concomitant ISECG changes in a referral population evaluated for chest pain after an inconclusive first-line work-up including clinical evaluation and exercise ECG stress.from 2003 to 2010, patients who underwent a peak supine bicycle ESE and were deemed to be negative were evaluated. Two groups based on concomitant stress ECG tracing were analysed - those with normal stress ECG and those with ISECG changes. The primary endpoint was cumulative incidence of cardiovascular death, hospitalizations for acute coronary syndrome and coronary revascularizations.a total of 371 patients (mean age 59.1 ± 12.1 years, 49.9% women) were studied. Of those, 141 (38.0%) had concomitant ISECG changes. Mean follow-up was 3.46 ± 1.76 years. The primary endpoint occurred in 3.0% of patients, (2.2% in those with normal stress ECG, and in 4.3% with ISECG changes, p = 0.251); with unadjusted hazard ratio for primary endpoint of 2.04 (95%CI 0.62-6.69, p = 0.239) in patients with ISECG changes compared to those with normal stress ECG.in an outpatient population without known CAD evaluated for chest pain after inconclusive first-line work-up, a negative peak supine bicycle ESE confers an excellent prognosis regardless of the nature of concomitant stress ECG abnormalities.

We thank Drs Mewton and Bresson for their interest in our article.1 The issues raised by the authors are essentially 3: the diagnosis being based on subjective criteria, the exclusion of patients with systemic inflammatory diseases, and the rationale for the definition of perimyocarditis and myopericarditis not being based on solid pathophysiological evidence. First, in clinical practice, a spectrum of myopericardial syndromes can be encountered, ranging from pure pericarditis to increasing degrees of inflammatory myocardial involvement (myopericarditis and perimyocarditis) to pure myocarditis.2,3 Diagnostic criteria for acute pericarditis are well recognized and established.3–5 Although not supported by guidelines and consensus documents, myopericarditis and perimyocarditis definitions also have been proposed on the basis of clinical criteria.3 Myopericarditis is a primarily pericardial inflammatory syndrome occurring when clinical diagnostic criteria …

The natural history of myopericarditis/perimyocarditis is poorly known and recently published data have presented contrasting results on their outcomes. The aim of the present article is to assess their prognosis in a multicenter, prospective cohort study. A total of 486 patients (median age 39

Background— The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study. Methods and Results— A total of 486 patients (median age, 39 years; range, 18–83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P Conclusions— The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting.

Aims Despite the American Society of Echocardiography (ASE)/European Association of Echocardiography (EAE) recommended the use of left ventricular (LV) mass to diagnose left ventricular hypertrophy (LVH), several laboratories continue to use only the septal thickness by M-mode because it appears easier to measure. Aim of the study was to investigate the discrepancy between the categorization of LVH severity based on measurement of septal thickness and indexed LV mass and the relative prognostic utility of these two methods. Methods and results Observational cohort study. Unselected adults (>18 years) referred to the echocardiography laboratory for any indication had septal thickness and LV mass measured by the ASE/EAE formula using LV linear dimensions indexed to body surface area. LVH was categorized as absent, mild, moderate, and severe according to the ASE/EAE guideline sex-specific categorization cut-offs for septal thickness and LV mass. Follow-up for death was obtained from the national death index. A total of 2545 subjects (mean age 61.9 ± 15.8, 53% women, mean diastolic septal thickness 10.3 ± 2.2 mm, and mean indexed LV mass 107.5 ± 37.3 g/m2) were enrolled. Agreement between the two methods in classifying LVH degree across the four categories was 52.6% (Kappa = 0.29, 95% confidence interval (CI): 0.26–0.32, P < 0.001). Of the 2513 subjects without severely thickened septum, 472 (18.9%) had severely abnormal indexed LV mass. Vice versa, of the 2045 individuals without severely abnormal indexed LV mass, only 4 (0.1%) were classified as severe LVH by septal thickness. After a mean follow-up of 2.5 ± 1.2 years 121 (4.7%) deaths occurred. Using indexed LV mass partition values there was a graded association between LVH degree and survival. Compared with patients with normal indexed LV mass, the adjusted hazard ratio (HR) for death from all causes was 2.17 for mild (95% CI: 1.23–3.81, P = 0.007), 3.04 for moderate (95% CI: 1.76–5.24, P < 0.001), and 3.81 for severe (95% CI: 2.43–5.97, P < 0.001) LVH by indexed LV mass. The area under the receiver-operator characteristic (ROC) curve for the four degrees of LVH by indexed LV mass was superior [area under the curve (AUC) = 0.66] to that of the septal thickness partition values (AUC = 0.58, P = 0.0004). Conclusion In a large cohort study of unselected adult outpatients referred to the echocardiography laboratory, the measurements of indexed LV mass applying the ASE/EAE recommended cut-offs yielded remarkable discrepancy in the diagnosis of LVH severity and offered prognostic information beyond that provided by septal thickness only criteria.

The American Society of Echocardiography (ASE) and European Association of Echocardiography (EAE) recommend the use of quantitative estimation of left ventricular (LV) mass and defined partition values for mild, moderate, and severe hypertrophy. However, the prognostic implications associated with this categorization are unknown.In this observational cohort study of unselected adults undergoing echocardiography for any indication, LV hypertrophy was assessed using the ASE/EAE-recommended formula and measurement convention from LV linear dimensions indexed to body surface area. Mortality and incident hospitalizations for cardiovascular disease were the outcomes of this study.Of 2,545 subjects (mean age, 61.9 ± 15.8 years; 56.3% women), 52.9% had normal LV mass, and 15.4% had mild, 12.1% moderate, and 19.6% severe LV hypertrophy. During a mean follow-up period of 2.5 ± 1.2 years, 121 deaths and 292 incident hospitalizations for cardiovascular disease occurred. In multivariate models including age, gender, LV ejection fraction, wall motion score index, significant valvular disease, and atrial fibrillation, the adjusted hazard ratios for death were 1.81 (95% confidence interval [CI], 1.03-3.20; P = .041) for mild, 2.31 (95% CI, 1.33-4.01; P = .003) for moderate, and 2.30 (95% CI, 1.39-3.79, P = .001) for severe LV hypertrophy. The adjusted hazard ratios for incident cardiovascular hospitalizations were 1.24 (95% CI, 0.84-1.82; P = .277) for mild, 2.02 (95% CI, 1.42-2.88; P = .0001) for moderate, and 2.38 (95% CI, 1.75-3.22, P.0001) for severe LV hypertrophy. After adjustment for known risk predictors, there was a 1.3-fold risk for death and cardiovascular disease events per category of LV mass (P = .001).In a cohort study of unselected adult outpatients, the categorization of LV mass according to the ASE/EAE recommendations offered prognostic information independently of age, gender, and other known predictors.

Figure 1. Magnetic resonance imaging: A. heart displaced into the left hemithorax and interposition of the lung between the heart and diaphragm (arrow) both in B. coronal and C. sagittal axis. Because of an occasional finding of extreme leftward and posterior rotation of the cardiac apex on chest radiograph, a 16-year-old man was referred to our hospital for further investigation with magnetic resonance imaging (1.5 Tesla MRI scanner; General Electric Medical System, Waukesha, Wisconsin, USA) to look for pericardial tissue and to rule out other causes of cardiac displacement. His medical history, family history, and physical examination were unremarkable. Electrocardiography demonstrated right axis deviation and an incomplete right bundle branch. Magnetic resonance imaging confirmed the heart displaced into the left hemithorax and showed the distinct pathognomonic feature of interposition of the lung in the usually