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Objectives The aim of this study was to evaluate the impact of echocardiographic guidance on the safety and efficacy of left atrial appendage closure (LAAC). Background Expert consensus documents recommend intraprocedural imaging by means of either transesophageal echocardiography or intracardiac echocardiography to guide LAAC. However, no evidence exists that intraprocedural echocardiographic guidance in addition to fluoroscopy improves the safety and efficacy of LAAC. Methods Consecutive LAAC procedures performed at a high-volume center between January 2009 and October 2020 were stratified on the basis of intraprocedural imaging modalities, including fluoroscopic guidance (FG) only or intraprocedural echocardiographic guidance (EG) in addition to fluoroscopy. The primary safety endpoint was the composite of procedure-related complications occurring within 7 days after the procedure. Technical success at 7 days and at follow-up were secondary endpoints. Results Among 811 LAAC procedures, 549 (67.7%) and 262 (32.3%) were assigned to the FG and EG groups, respectively. After adjusting for confounders, EG remained associated with a lower rate of the primary safety endpoint (3.4% vs 9.1%; P = 0.004; adjusted odds ratio [OR]: 0.31; 95% CI: 0.11-0.90; P = 0.030). Technical success trended higher at 7 days (92.1% vs 87.2%; P = 0.065; adjusted OR: 1.68; 95% CI: 0.95-3.01; P = 0.079) and was significantly improved with EG compared with FG (87.6% vs 79.9%; P = 0.018; OR: 4.06; 95% CI: 1.60-10.27; P = 0.003) after a median follow-up period of 4.9 months (interquartile range: 3.4 months-6.2 months). Conclusions In a large cohort of consecutive LAACs, the use of intraprocedural echocardiography to guide intervention in addition to standard fluoroscopy was associated with lower risks for procedural complications and higher mid-term technical success rates.

The purpose of this paper was to evaluate the impact of proportionality of secondary mitral regurgitation (SMR) in a large real-world registry of transcatheter edge-to-edge mitral valve repair (TMVr) BACKGROUND: Differences in the outcomes of recent randomized trials of TMVr for SMR may be explained by the proportionality of SMR severity to left ventricular (LV) volume.The ratio of pre-procedural effective regurgitant orifice area (EROA) to LV end-diastolic volume (LVEDV) was retrospectively assessed in patients undergoing TMVr for severe SMR between 2008 and 2019 from the EuroSMR registry. A recently proposed SMR proportionality scheme was adapted to stratify patients according to EROA/LVEDV ratio in 3 groups: MR-dominant (MD), MR-LV-co-dominant (MLCD), and LV-dominant (LD). All-cause mortality was assessed as a primary outcome, secondary heart failure (HF) outcomes included hospitalization for HF (HHF), New York Heart Association (NYHA) functional class, N-terminal pro-B-type natriuretic peptide (NT-proBNP), 6-min-walk distance, quality of life and MR grade.A total of 1,016 patients with an EROA/LVEDV ratio were followed for 22 months after TMVr. MR was reduced to grade ≤2+ in 92%, 96%, and 94% of patients (for MD, MLCD, and LD, respectively; p = 0.18). After adjustment for covariates including age, sex, diabetes, kidney function, body surface area, LV ejection fraction, and procedural MR reduction (grade ≤2+), adjusted rates of 2-year mortality in MD patients did not differ from those for MLCD patients (17% vs. 18%, respectively), whereas it was higher in LD patients (23%; p = 0.02 for comparison vs. MD+MLCD). The adjusted first HHF rate differed between groups (44% in MD, 56% in MLCD, 29% in LD; p = 0.01) as did the adjusted time for first death or HHF rate (66% in MD, 82% in MLCD, 68% in LD; p = 0.02). Improvement of NYHA functional class was seen in all groups (p 0.001). Values for 6-min-walk distances, quality of life and NT-proBNP improved in most patients.MD and MLCD patients had a comparable, adjusted 2-year mortality rate after TMVr which was slightly better than that of LD patients. Patients treated with TMVr had symptomatic improvement regardless of EROA/LVEDV ratio.

Introduction: Secondary mitral regurgitation (SMR) is one of the most common valvulopathies and is associated with poor prognosis. Over the past years, medical management and mitral valve repair op...

Zusammenfassung. Die schwere Trikuspidalklappeninsuffizienz kann durch klinische Beschwerden und Beeinträchtigung von Organfunktionen zu erhöhter Morbidität und Sterblichkeit führen. Durch die Entwicklung neuer interventioneller Behandlungsmöglichkeiten gewinnt die lange Zeit als vernachlässigte Trikuspidalklappe zunehmend an Aufmerksamkeit. Der folgende Beitrag soll einen Überblick über die Ursachen, Diagnostik und therapeutischen Möglichkeiten bei schwerer Trikuspidalklappeninsuffizienz geben.

BACKGROUND Among current transcatheter therapies for the treatment of mitral regurgitation, the MitraClip (MC; Abbott Vascular, Abbott Park, IL) system is the most commonly used. MitraClip implantation is usually contraindicated in patients with a mitral valve area (MVA)��

Doppler echocardiography is widely used in everyday clinical practice for the detection of pulmonary hypertension (PH) in symptomatic patients and in populations particularly at risk of pulmonary arterial hypertension (PAH). It allows accurate estimation of systolic pulmonary arterial pressure but may lack precision in particular situations. In addition, echocardiography can help to distinguish between pre- and post-capillary PH and is a very good tool to evaluate right ventricular systolic function, which is of great prognostic interest in PAH. This article reviews the current knowledge about methodologic aspects of assessing pulmonary pressure and PH origin by echo, including a discussion about abnormal thresholds. It also details advanced techniques like right ventricular strain imaging and new concepts like right ventricle – pulmonary artery coupling evaluation that have become “matured” enough to be definitely brought to routine evaluation.

Objectives The purpose of this study was to evaluate procedural and 1-year clinical and echocardiographic outcomes of patients treated with tricuspid edge-to-edge repair. Background Transcatheter edge-to-edge repair has been successfully performed in selected patients with symptomatic tricuspid regurgitation (TR) and high risk for surgery, but outcome data are sparse. Methods This analysis of the multicenter international TriValve (Transcatheter Tricuspid Valve Therapies) registry included 249 patients with severe TR treated with edge-to-edge repair in compassionate and/or off-label use. Clinical and echocardiographic outcomes were prospectively collected and retrospectively analyzed. Results In 249 patients (mean age 77 ± 9 years; European System for Cardiac Operative Risk Evaluation II score 6.4% [interquartile range: 3.9% to 13.9%]), a successful procedure with TR reduction to grade ≤2+ was achieved in 77% by placement of 2 ± 1 tricuspid clips. Concomitant treatment of severe TR and mitral regurgitation was performed in 52% of patients. At 1-year follow-up, significant and durable improvements in TR severity (TR ≤2+ in 72% of patients) and New York Heart Association functional class (≤II in 69% of patients) were observed. All-cause mortality was 20%, and the combined rate of mortality and unplanned hospitalization for heart failure was 35%. Predictors of procedural failure included effective regurgitant orifice area, tricuspid coaptation gap, tricuspid tenting area, and absence of central or anteroseptal TR jet location. Predictors of 1-year mortality were procedural failure, worsening kidney function, and absence of sinus rhythm. Conclusions Transcatheter tricuspid edge-to-edge repair can achieve TR reduction at 1 year, resulting in significant clinical improvement. Predictors of procedural failure and 1-year mortality identified here may help select patients who will benefit most from this therapy.

Objectives The aim of this study was to investigate the technical success and efficacy of mitral valve edge-to-edge repair using extended clip arms. Background A new iteration of the MitraClip system, the MitraClip XTR, was introduced in 2018 with the aim of addressing technical limitations observed with previous versions. Methods Patients having received at least 1 new implant for the treatment of symptomatic mitral regurgitation (MR) were eligible for this study. Results Among the 107 patients (mean age 76 ± 9 years, 69% men) included in this study, the etiology of MR was balanced, with one-half (n = 53 [50%]) classified as secondary and the remaining 54 patients having either primary (n = 40 [37%]) or mixed (n = 14 [13%]) disease. The mean number of devices implanted was 1.5 ± 0.6. Multiple device implantation was required in 46 patients (43%). Single-leaflet device attachment occurred in 4 patients and leaflet injury in 2 additional patients, requiring surgical conversion in 4 patients. Among the 102 patients discharged alive without mitral valve surgery, 95 (93%) had MR ≤2+ and 79 (77%) had MR ≤1+. The mean transmitral gradient increased from 1.9 ± 1.0 mm Hg at baseline to 3.5 ± 1.8 mm Hg at discharge (p Conclusions Technical success with the new mitral valve repair system with extended clip arm was achieved in 93% of the patients. MR ≤2+ was obtained in 95 patients (93%) and MR ≤1+ in 79 (77%). The main reasons for procedural failure were acute single-leaflet device attachment associated with leaflet damage or isolated leaflet injury and often required surgical correction.

Aims A new staging classification of aortic stenosis (AS) characterizing the extent of cardiac damage was established and validated in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to validate an updated classification system in patients undergoing TAVI. Methods and results In a prospective TAVI registry, AS patients were categorized into the following stages: no cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular (RV) damage or low-flow state (Stage 4). Stage 3 was sub-divided into Stage 3a (≤moderate pulmonary hypertension) and Stage 3b (severe pulmonary hypertension). Stage 4 was sub-divided into Stage 4a (low-flow without RV dysfunction), Stage 4b (RV dysfunction without low-flow), and Stage 4c (RV dysfunction with low-flow). The primary endpoint was all-cause death at 1 year. Among 1156 eligible patients, 14 were classified as Stage 0, 38 as Stage 1, 105 as Stage 2278 as Stage 3, and 721 as Stage 4. There was a stepwise increase in mortality according to advancing stages of cardiac damage: 3.9% (Stage 0–1), 9.6% (Stage 2), 14.1% (Stage 3), and 17.4% (Stage 4) (P = 0.002). After multivariable adjustment, only Stage 3b, Stage 4b, and Stage 4c conferred a significantly increased risk of mortality compared to Stage 0–1. Conclusion More than one-third of patients had advanced cardiac damage (severe pulmonary hypertension or RV dysfunction) before TAVI, associating with a five- to seven-fold increased risk of mortality at 1 year. Clinical trial registration https://www.clinicaltrials.gov. NCT01368250.

OBJECTIVES To investigate whether the integrative echocardiographic criteria used in the cardiovascular outcomes assessment of the mitraclip percutaneous therapy (COAPT) for heart failure patients with functional mitral regurgitation study predict outcomes after edge-to-edge trancatheter mitral valve repair (TMVr) for the treatment of secondary mitral regurgitation (SMR). BACKGROUND Two randomized controlled trials comparing TMVr to medical treatment reported conflicting findings. Differences in patient selection criteria may have contributed to these diverging results. METHODS Patients undergoing TMVr were stratified following the integrative COAPT echocardiographic criteria in noneligible and eligible patients who were further classified into three tiers according to effective regurgitant orifice (EROA) (Tier 1: EROA ≥ 0.3cm2 ; Tier 2: EROA 0.2cm2 and 0.29cm2 ; Tier 3: EROA

Residual or newly acquired leaks are routinely appraised after left atrial appendage closure (LAAC). The Watchman and the Amulet are the two most frequently used devices for LAAC but no randomized study has so far assessed their comparative leak rates after intervention. The "Comparison of Amplatzer Amulet vs Watchman devices in patients undergoing left atrial appendage closure" (Swiss-Apero, clinicaltrial.gov NCT03399851) is an academic-sponsored multicenter, randomized clinical trial comparing Amulet versus Watchman/FLX devices among patients undergoing a clinically indicated LAAC. The study is designed to assess the superiority of Amulet vs. Watchman/FLX in terms of leaks detected by cardiac computed tomography angiography (CCTA) at 45 days (primary endpoint) and 13 months (secondary endpoint) after intervention by an imaging Core Laboratory. The Swiss-Apero study is the first randomized clinical trial comparing Amulet and Watchman/FLX with respect to the prevalence of post-procedural leak as assessed with CCTA.

Aims The ESC/EACTS guidelines propose criteria that determine the likelihood of true-severe aortic stenosis (AS). We aimed to investigate the impact of the guideline-based criteria of the likelihood of true-severe AS in patients with low-flow low-gradient (LFLG) AS with preserved ejection fraction (pEF) on outcomes following transcatheter aortic valve replacement (TAVR). Methods and results In a prospective TAVR registry, LFLG-AS patients with pEF were retrospectively categorized into high (criteria ≥6) and intermediate (criteria 70% of LFLG-AS patients had functional improvement, impaired functional status [New York Heart Association (NYHA III/IV)] persisted more frequently at 1 year in LFLG-AS than in high-gradient AS patients (7.8%), irrespective of the likelihood (high: 17.4%, P = 0.006; intermediate: 21.1%, P Conclusion Patients with LFLG-AS with pEF had comparable survival but worse functional status at 1 year than high-gradient AS with pEF, irrespective of the likelihood of true-severe AS. Clinical Trial Registration https://www.clinicaltrials.gov. NCT01368250.

Background: Cardiac arrhythmias are very common but underdiagnosed due to their transient and asymptomatic nature. An optimization of arrhythmia detection would permit to better treat patients and could substantially reduce morbidity and mortality. The SmartCardia ScaAI wireless patch is a novel CE IIa approved, single-lead electrocardiographic (ECG) ambulatory monitor designed for cardiac arrhythmias detection., Hypothesis: The accuracy of the new SmartCardia wireless patch to detect arrhythmias is comparable to the conventional Holter monitoring., Methods: Patients referred for a suspicion of arrhythmia between February and March 2020 were included in the trial. Simultaneous ambulatory ECG were recorded using a conventional 24-h Holter and the SmartCardia. The primary endpoint was the detection of cardiac arrhythmias over the total wear time of the devices, defined as premature atrial contraction (PAC), supraventricular tachycardia >= 3 beats, premature ventricular contraction (PVC), and ventricular tachycardia >= 3 beats. Conduction abnormalities, pause >= 2 s and atrioventricular block (AVB), were also tracked. McNemar's test was used to compare the matched pairs of data from both devices., Results: A total of 40 patients were included in the trial. Over the total wear time, there was no significant difference between the devices for ventricular and supraventricular arrhythmias detection. Pauses and AVB were equally identified by the two devices in three patients., Conclusion: Over the total wear time, the SmartCardia device showed an accuracy to detect arrhythmia similar to the 24-h Holter monitoring: single-lead, adhesive-patch monitoring might become an interesting alternative to the conventional Holter monitoring.

Introduction During edge-to-edge therapy using MitraClip (MC) for severe mitral regurgitation (MR) the interventional cardiologists usually rely on the mean transmitral gradient to decide if they “go for” a second clip in case of suboptimal MR reduction or to stabilise the first MC in the context of prolapse or flail leaflet. The value of this parameter to detect low mitral valve area (MVA) is unknown. Method During each intervention of the last two years, high quality volumes focused on the MV were acquired. Using a dedicated 3-D analysis software and a new planimetry method, we measured the MVA before and after the implantation of one MC (each orifice was evaluate independently on the most optimal plane). The usual transmitral CW-Doppler parameters (mean gradient (MG), VTI, PHT) were evaluated. Results We included 120 patients, 69 primary (PMR) and 51 secondary (SMR) mitral regurgitation. For all the parameters, the best model for the curve fitting was y = a + b / x and the two parameters who best correlated with the MVA after MC were PHT (R2 0.67, p=0.0001) and MG (R2 0.28, p. 0001). Looking at SMR, the correlation with PHT was even better but there was no correlation with MG. In PMR, the correlation with MG was good but still lower than with PHT (Figure 1). The ROC analysis for PHT showed an AUC of 0.948 and defined an optimal cut-off of 127ms with sensibility and specificity 91% to detect a MVA Conclusion The transmitral MG appears as a poor parameter to predict low MVA after the implantation of one MC, especially in SMR probably because in this population the MG depends more on the flow than on the MVA. In the contrary PHT appears as a robust parameter. Figure 1 Funding Acknowledgement Type of funding source: None

BACKGROUND Mitral annular calcification (MAC) has been associated with mitral valve (MV) disease and cardiovascular events in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence and impact of mitral calcium volume (MCV) quantified by multidetector computed tomography (MDCT) on MV function and clinical outcomes after TAVI. METHODS Consecutive patients with exploitable echocardiography and MDCT performed during TAVI screening were enrolled in this retrospective analysis. Mitral calcium was assessed visually and measured using a semi-automatic tool developed for the aortic valve in an off-label fashion. RESULTS MCV >0 mm3 was found in 65% of the 875 included patients. Patients with calcification were older (82 ± 6 versus 81 ± 7; P = 0.002) and had high prevalence of renal dysfunction (69% versus 61%; P = 0.017) and mitral stenosis (25% versus 4%, P

PURPOSE OF REVIEW This review article describes the technical features of the novel Edwards PASCAL transcatheter valve repair system as well as the evidence accumulated so far. RECENT FINDINGS Transcatheter mitral and tricuspid valve leaflet approximation enable treatment of patients with mitral and tricuspid regurgitation who are not eligible for surgery. The PASCAL device offers an alternative that may allow to overcome some of the limitations of previous systems and open the path for an approach adapted to individual patient's anatomy. Early data show similar safety and efficacy compared with the Abbott MitraClip system. The PASCAL system is a valuable addition to the armamentarium of transcatheter mitral and tricuspid valve repair devices. Randomized head-to-head comparisons and long-term data are needed to confirm the promising results observed so far.

Background Structural disarray of hypertrophied myocytes and interstitial fibrosis characterize hypertrophic cardiomyopathy (HCM). These morphological changes also affect atrial myocytes and, together with hemodynamic alterations because of HCM, may lead to atrial cardiomyopathy. Purpose To investigate the incremental value of P-wave parameters to differentiate left ventricular hypertrophy (LVH) because of HCM from LVH in hypertensive heart disease (HHD) and athletes heart. Methods In a prospective study, we compared electrocardiographic (including signal-averaged ECG of the P wave) and echocardiographic data of patients with HCM, HHD and athletes heart. We developed a predictive model with a simple scoring system to identify HCM. Results We compared data of 27 patients with HCM (70% males, 49.8 ± 14.5 years), 324 patients with HHD (52% males, 74.8 ± 5.5 years), and 215 subjects with athletes heart (72% males, 42.3 ± 7.5). The table shows the significant differences among the 3 groups. We included the following parameters into a predictive score to differentiate HCM from other forms of LVH: QRS width (>88ms = 1 point), P-wave integral (>688µVs = 1 point) and septum thickness (>12mm = 2 points). A score >2 (Youden index 0.626) correctly classified HCM in 81% of the cases with a sensitivity and specificity of 82% an 81%, respectively. Conclusion Differentiation of HCM from other forms of LVH is improved by including atrial parameters. A simple scoring system including septum thickness, QRS width and P wave integral allowed identification of patients with HCM with a sensitivity and specificity of >80%. This score needs to be validated prospectively. Table 1 HCM HHD Athletes P-value HCM vs HHD* HCM vs Athletes* 95%-CI P-value 95%-CI P-value P-wave duration [ms] 152.7 ± 25.8 143.9 ± 16.5 133.5 ± 14.2 Abstract Figure 1

Aims Mitral annular calcification (MAC) has been associated with adverse outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) but has been investigated in isolation of co-existent mitral regurgitation or mitral stenosis, which may represent important confounders. This study sought to investigate the effect of MAC with and without concomitant mitral valve disease (MVD) on clinical outcomes in patients treated with TAVR. Methods and results Computed tomography (CT) and echocardiographic data in consecutive TAVR patients enrolled into a prospective registry were categorized according to presence or absence of severe MAC and significant MVD, respectively. A total of 967 patients with adequate CT and echocardiography data were included between 2007 and 2017. Severe MAC was found in 172 patients (17.8%) and associated with MVD in 87 patients (50.6%). Compared to TAVR patients without severe MAC or MVD, all-cause mortality at 1 year was significantly increased among patients with severe MAC in combination with MVD [adjusted hazard ratio (HRadj): 1.97, 95% confidence interval (CI): 1.12–3.44, P = 0.018] and patients with isolated MVD (HRadj: 2.33, 95% CI: 1.56–3.47, P Conclusion We found no effect of isolated MAC on clinical outcomes following TAVR in patients with preserved mitral valve function. Patients with MVD had an increased risk of death at 1 year irrespective of MAC.

Objectives The aim of this study was to investigate the impact of valvular and nonvalvular atrial fibrillation (AF) in patients undergoing transcatheter aortic valve replacement (TAVR). Background AF has been associated with adverse clinical outcomes after TAVR. However, the differential impact of valvular as opposed to nonvalvular AF has not been investigated. Methods In a retrospective analysis of a prospective registry, valvular AF was defined as AF in the setting of concomitant mitral stenosis or the presence of a mitral valve prosthesis. The presence of mitral stenosis was determined by pre-procedural echocardiography. The primary endpoint was a composite of cardiovascular death or disabling stroke at 1 year after TAVR. Results Among 1,472 patients undergoing TAVR between August 2007 and June 2018, AF was recorded in 465 patients (31.6%) and categorized as nonvalvular in 376 (25.5%) and valvular in 89 (6.0%). AF scores including HAS-BLED, CHADS2, and CHA2DS2-VASc were comparable between patients with nonvalvular and valvular AF. The primary endpoint occurred in 9.3% of patients with no AF, in 14.5% of patients with nonvalvular AF (hazard ratio: 1.57; 95% confidence interval: 1.12 to 2.20; p = 0.009), and in 24.2% of patients with valvular AF (hazard ratio: 2.75; 95% confidence interval: 1.71 to 4.41; p Conclusions The presence of valvular AF in patients undergoing TAVR increased the risk for cardiovascular death or disabling stroke compared with both no AF and nonvalvular AF. (SWISS TAVI Registry; NCT01368250)

Recurrent flail leaflet represents an infrequent cause of recurrent mitral regurgitation after MitraClip. This report presents a case of recurrent severe MR due to a ruptured chorda tendineae after edge-to-edge repair.

Left ventricular hypertrophy (LVH) is a physiological adaptation to long-term endurance training. We investigated the impact of age at start of endurance training on LV geometry in a cohort of male, middle-aged, non-elite endurance athletes.A total of 121 healthy, normotensive, Caucasian participants of a 10-mile race were recruited and assessed with an echocardiogram and a comprehensive interview. Athletes were classified based on patterns of LVH.Thirty-five athletes (31%) had LVH. Athletes with eccentric LVH (16%) were significantly younger at start of endurance training compared to athletes with concentric LVH (15%, 14 ± 5 years vs. 31 ± 8 years; P 0.001). Although the yearly volume of endurance training was comparable between athletes with eccentric and concentric LVH, athletes with eccentric LVH had shorter race times. All athletes with an increased LV end diastolic volume index (LVEDVI; ≥74 ml/mIn our cohort of non-elite middle-aged runners, eccentric LVH was found only in athletes with an early start of endurance training. In case of a mature starting age, endurance training may, contrary to what is commonly assumed, also lead to concentric LVH. The consideration of endurance training starting age may lead to a better understanding of morphological adaptations of the heart.

Background The accuracy of the proximal isovelocity surface area (PISA) method for the quantification of mitral regurgitation (MR), in the case of multiple jets, is unknown. The aim of this study was to evaluate different two-dimensional (2D) and three-dimensional (3D) PISA methods using 3D color Doppler data sets. Methods Several regurgitant volumes (Rvols) were simulated using a pulsatile pump connected to a phantom equipped with single and double regurgitant orifices of different sizes and interspaces. A flowmeter served as the reference method. Transthoracic (TTE) and transoesophageal echocardiography (TEE) were used to acquire the 3D data sets. Offline, Rvols were calculated by 2D PISA methods based on hemispheric and hemicylindric assumptions and by 3D integrated PISA. Results A fusion of the PISA was observed in the setting of narrow-spaced regurgitant orifices; compared with flowmeter, Rvol was underestimated using the single hemispheric PISA model (TTE: Bland-Altman bias ± limit of agreement, −17.5 ± 8.9 mL; TEE: −15.9 ± 7.3 mL) and overestimated using the double hemispheric PISA model (TTE: +7.1 ± 14.6 mL; TEE: +10.4 ± 11.9 mL). The combined approach (hemisphere for single orifice, hemicylinder with two bases for nonfused PISAs, and hemicylinder with one base for fused PISAs) was more precise (TTE: −3.4 ± 6.3 mL; TEE: −1.9 ± 5.6 mL). Three-dimensional integrated PISA was the most accurate method to quantify Rvol (TTE: −2.1 ± 6.5 mL; TEE −3.2 ± 4.8 mL). Conclusions In the setting of double MR orifices, the 2D combined approach and integrated 3D PISA appear to be superior as compared with the conventional hemispheric method, thus providing tools for the challenging quantification of MR with multiple jets.

Grading functional mitral regurgitation (FMR) remains challenging. The selection of patients for optimal medical therapy or interventional therapies requires parameters to identify FMR as a consequence or a cause of left ventricular (LV) dilation. In 2014, Grayburn et al. ([1][1]) tried to solve

With the emergence of transcatheter solutions for the treatment of tricuspid regurgitation (TR) increased attention has been directed to the once neglected tricuspid valve (TV) complex. Recent studies have highlighted new aspects of valve anatomy and TR etiology. The assessment of valve morphology along with quantification of regurgitation severity and RV function pose several challenges to cardiac imagers guiding transcatheter valve procedures. This review article aims to give an overview over the role of modern imaging modalities during assessment and treatment of the TV.

Patients with severe symptomatic mitral regurgitation have a poor prognosis if left untreated. In those patients who are not eligible for mitral valve surgery, percutaneous edge-to-edge repair may improve clinical outcomes. Recent clinical trials have added to our knowledge and provide interesting insights into the management of such patients. With an increasingly aging global population, these technologies are likely to represent an important treatment option. This mini-review will examine the technology, the evidence and the latest developments in percutaneous mitral edge-to-edge repair.

Mitral regurgitation is a highly prevalent condition among elderly patients, affecting almost 10% of the general population aged 75 and older. Left untreated, severe mitral regurgitation results in high mortality and frequent hospitalisation for treatment of heart failure. Surgical treatment remains the first-line therapy for symptomatic, severe mitral regurgitation , especially for patients presenting with a primary aetiology. However, a high proportion of patients with mitral regurgitation are turned down for open-heart surgery, mainly due to advanced age, diminished left ventricular function and comorbidities. Thus, percutaneous treatment options have been recently developed as an alternative. In this article, we will review transcatheter interventional techniques at the level of the mitral valve, including implantation technique, indications and clinical results.

Right atrial appendage thrombus is a rare complication of atrial fibrillation that can also lead to cardioembolic pulmonary embolism.

Heart rate variability (HRV) is a widely used marker of cardiac autonomic nervous activity (CANA). Changes in HRV with exercise training have often been interpreted as increases in vagal activity. HRV is strongly associated with heart rate, which in turn, is associated with heart size. There is strong evidence from basic studies that lower heart rate in response to exercise training is caused by morphological and electrical remodeling of the heart. In a cross-sectional study in participants of a 10 mile race, we investigated the influence of endurance exercise on HRV parameters independently of heart size and heart rate. One-hundred-and-seventy-two runners (52 females and 120 males) ranging from novice runners with a first participation to an endurance event to highly trained runners, with up to 15 h of training per week, were included in the analysis. R-R intervals were recorded by electrocardiography over 24 h. Left ventricular end diastolic volume indexed to body surface area (LVEDVI) was assessed by transthoracic echocardiography and peak oxygen consumption (VO2peak) by cardiopulmonary exercise testing. Exercise was quantified by VO2peak, training volume, and race performance. HRV was determined during deep sleep. HRV markers of vagal activity were moderately associated with exercise variables (standardized β = 0.28–0.40, all p < 0.01). These associations disappeared when controlling for heart rate and LVEDVI. Due to the intrinsic association between heart rate and HRV, conclusions based on HRV parameters do not necessarily reflect differences in CANA. Based on current evidence, we discourage the use of HRV as a marker of CANA when measuring the effect of chronic exercise.

Background Long-term endurance sport practice leads to eccentric left ventricular hypertrophy (LVH). We aimed to compare the new 4-tiered classification (4TC) for LVH with the established 2-tiered classification (2TC) in a cohort of normotensive non-elite endurance athletes. Methods Male participants of a 10-mile race were recruited and included when blood pressure (BP) was normal (

OBJECTIVES: Extensive endurance training and arterial hypertension are established risk factors for atrial fibrillation. We aimed to assess the proportion of masked hypertension in endurance athletes and the impact on cardiac remodeling, mechanics, and supraventricular tachycardias (SVT). METHODS: Male participants of a 10-mile race were recruited and included if office blood pressure was normal (

The aim of our study was to evaluate 3-dimensional (3D) color Doppler proximal isovelocity surface area (PISA) as a tool for quantitative assessment of mitral regurgitation (MR) against in vitro and in vivo reference methods. A customized 3D PISA software was validated in vitro against a flowmeter MR phantom. Sixty consecutive patients, with ≥mild MR of any cause, were recruited and the regurgitant volume (RVol) was measured by 2D PISA, 3D peak PISA, and 3D integrated PISA, using transthoracic (TTE) and transesophageal echocardiography (TEE). Cardiac magnetic resonance imaging (CMR) was used as reference method. Flowmeter RVol was associated with 3D integrated PISA as follows: y = 0.64x + 4.7, r(2) = 0.97, p

Aims High altitude exposure for the purpose of tourism is very popular in mountainous regions and is considered to be safe for patients with stable CAD and preserved LV function. The purpose of this study was to evaluate the haemodynamic response to exercise and electrical stability by Holter monitoring in patients with chronic heart failure (HF) and an EF 50% of the predicted (25 men, age 60.0 ± 8.9 years, EF 28.8 ± 5.4%) at 540 and 3454 m after an ascent using public transport. Assessments of exercise capacity (cardiopulmonary exercise test), haemodynamic response (inert gas rebreathing system), and susceptibility to arrhythmias (Holter ECG recording) were performed. None of the patients (19 with ischaemic heart disease, 11 with an implantable cardioverter defibrillator) had to return prematurely to the lowland site. Two patients presented symptoms of mild mountain sickness, and one patient developed a self-limited ventricular tachycardia during maximal exercise at high altitude. Mean peak VO2 at the lowland site was 18.5 ± 3.6 mL/min/kg and decreased by 22.2% (P < 0.001) at high altitude. Mean resting heart rate increased from 74.3 ± 12.3 to 83.3 ± 13.4 b.p.m., P < 0.001. No statistically significant difference in premature ventricular contractions (92 ± 150/h at 540 m vs. 111 ± 196/h at 3454 m, P = 0.284) was noted. Conclusion Patients with stable chronic HF and a peak VO2 >50% of the predicted tolerate a short exposure to an altitude of 3454 m well, even during exercise. However, it cannot be excluded that the susceptibility to ventricular tachyarrhythmias during exercise is increased in some subjects.

Short duration rivaroxaban was effective for the treatment of left ventricular thrombus in a patient under DAPT after drug-eluting stent implantation for STEMI, and at low bleeding risk.

Purpose Marathon running has been linked with higher arterial stiffness. Blood pressure is a major contributor to pulse wave velocity (PWV). We examined indices of arterial stiffness with a blood pressure-independent method in marathon runners and ultra-endurance athletes. Methods Male normotensive amateur runners were allocated to three groups according to former participation in competitions: group I (recreational athletes), group II (marathon runners) and group III (ultra-endurance athletes). Indices of arterial stiffness were measured with a non-invasive device (VaSera VS-1500N, Fukuda Denshi, Japan) to determine the cardio-ankle vascular index (CAVI, primary endpoint) and brachial-ankle PWV (baPWV). Lifetime training hours were calculated. Cumulative competitions were expressed as marathon equivalents. Linear regression analysis was performed to determine predictors for CAVI and baPWV. Results Measurements of arterial stiffness were performed in 51 subjects (mean age 44.6 ± 1.2 years): group I (n = 16), group II (n = 19) and group III (n = 16). No between-group differences existed in age, anthropometric characteristics and resting BP. CAVI and baPWV were comparable between all groups (P = 0.604 and P = 0.947, respectively). In linear regression analysis, age was the only independent predictor for CAVI (R 2 = 0.239, β = 0.455, P = 0.001). Systolic BP was significantly associated with baPWV (R 2 = 0.225, β = 0.403, P = 0.004). Conclusions In middle-aged normotensive athletes marathon running and ultra-endurance sports had no negative impact on arterial stiffness.

Background Sixty minutes of daily moderate-to-vigorous physical activity (PA) are recommended for children. This study investigated the additional impact of high-volume sports club participation on the autonomic nervous system in active children, while controlling for acute effects of short-term PA. Materials and methods Forty-nine children (29 females) aged 10–13 years were investigated. Sports club participation was assessed with a validated questionnaire. Short-term PA and night-time autonomic tone (spectral power and nonlinear analysis of heart rate variability) were measured with an ambulatory device (Actiheart®). Children were dichotomized into two groups, based on their individual weekly time spent in a sports club: low-volume group

Endurance athletes have an increased risk of atrial fibrillation. We performed a longitudinal study on elite runners of the 2010 Jungfrau Marathon, a Swiss mountain marathon, to determine acute effects of long-distance running on the atrial myocardium. Ten healthy male athletes were included and examined 9 to 1 week prior to the race, immediately after, and 1, 5, and 8 days after the race. Mean age was 34.9 ± 4.2 years, and maximum oxygen consumption was 66.8 ± 5.8 mL/kg*min. Mean race time was 243.9 ± 17.7 min. Electrocardiographic-determined signal-averaged P-wave duration (SAPWD) increased significantly after the race and returned to baseline levels during follow-up (128.7 ± 10.9 vs. 137.6 ± 9.8 vs. 131.5 ± 8.6 ms; P

Exercise performance improvement after training in heart failure (HF) can be due to central or peripheral changes.In 70 HF stable patients we measured peak VO(2) and cardiac output (CO, inert gas rebreathing technique) and calculated arteriovenous O(2) differences (a-v O(2)diff) before and after an 8-week training program. Peak VO(2) changed from 1111 ± 403 mL/minute to 1191 ± 441 (P.001), peak workload from 68 ± 29 watts to 76 ± 32 (P.0001), peakCO from 6.6 ± 2.2 L/minute to 7.3 ± 2.5 (P.0001), and peak a-v O(2)diff from 17.5 ± 5.1 mL/100 mL to 16.6 ± 4.1 (P = .081). Changes in peak CO and a-v O(2)diff allowed to identify 4 behaviors: group 1: (n = 15) reduction in peak CO and increase in a-v O(2)diff (peak VO(2) unchanged, peak workload +9.5%); group 2: (n = 16) both peak CO and a-v O(2)diff increased as well as peak VO(2) (23%) and workload (18%); group 3: (n = 4) peak CO and a-v O(2)diff reduced as well as peak VO(2) (-18%) and workload (-5%); group 4: (n = 35) peak CO increased with a-v O(2)diff reduced (increase in peak VO(2) by 5.5 and workload by 8.4%).Exercise training improves peakVO(2) by increasing CO with unchanged a-v O(2)diff. A reduction after training of a-v O(2)diff with an increase in CO is frequent (50% of cases), is suggestive of blood flow redistribution and, per se, not a sign of reduced muscle performance been associated with improved exercise capacity.

Objective Ultra-endurance sports are becoming increasingly popular in middle-aged amateur athletes. Right ventricular (RV) arrhythmogenic remodelling has been described in high-level endurance athletes, like professional cyclists. The clinical relevance for amateurs is unknown. Design We investigated male amateur runners of the 2011 Grand Prix of Bern, a popular 10-mile race in Switzerland. Participants were stratified according to their former participations in long-distance competitions: active controls (leisure-time runners), marathon runners and ultra-endurance athletes (78 and 100 km runners, long-distance triathletes). RV function and morphology were assessed by echocardiography, including two-dimensional speckle tracking. Primary endpoint was RV global strain. Ventricular ectopy was assessed by 24 h ambulatory Holter monitoring. Results were adjusted for lifetime training hours. Results 97 normotensive athletes were included in the final analysis. The mean age was 42±8 years. Compared with active controls and marathon runners, ultra-endurance athletes had significantly more lifetime training hours and participated more often in competitions. Groups showed no differences with regard to RV global strain (–21.8±2.9 vs −23.3±2.8 vs −21.7±2.3%; p=0.973) and RV end-diastolic area (22.1±2.9 vs 22.9±4.2 vs 23.2±3.5 cm 2 ; p=0.694). The number of premature ventricular contractions (PVCs) was weakly associated with the RV size (r=0.208; p=0.042). Overall ventricular ectopy was low (0–486 PVCs/24 h) and equally distributed between the groups. Conclusions In our small sample of amateur athletes, long-term ultra-endurance sport practice was not associated with RV dysfunction or complex ventricular arrhythmias.

This study aimed to systematically assess the importance of left ventricular outflow tract (LVOT) calcification on procedural outcomes and device performances with contemporary transcatheter heart valve (THV) systems.LVOT calcification has been associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR). However, the available evidence is limited to observational data with modest numbers and incomplete assessment of the effect of the different THV systems.In a retrospective analysis of a prospective single-center registry, LVOT calcification was assessed in a semiquantitative fashion. Moderate or severe LVOT calcification was documented in the presence of 2 nodules of calcification, or 1 extending5 mm in any direction, or covering10 % of the perimeter of the LVOT.Among 1,635 patients undergoing TAVR between 2007 and 2018, moderate or severe LVOT calcification was found in 407 (24.9%). Patients with moderate or severe LVOT calcification had significantly higher incidences of annular rupture (2.3% vs. 0.2%; p 0.001), bailout valve-in-valve implantation (2.9% vs. 0.8%; p = 0.004), and residual aortic regurgitation (11.1% vs. 6.3%; p = 0.002). Balloon-expandable valves conferred a higher risk of annular rupture in the presence of moderate or severe LVOT calcification (4.0% vs. 0.4%; p = 0.002) as compared with the other valve designs. There was no significant interaction of valve design or generation and LVOT calcification with regard to the occurrence of bailout valve-in-valve implantation and residual aortic regurgitation.Moderate or severe LVOT calcification confers increased risks of annular rupture, residual aortic regurgitation, and implantation of a second valve. The risk of residual aortic regurgitation is consistent across valve designs and generations. (SWISS TAVI Registry; NCT01368250).