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AIMS The diagnostic performance of the new Peguero-Lo Presti ECG criteria for left ventricular hypertrophy (LVH) has not been validated by cardiac magnetic resonance (CMR). The aim of this study was to evaluate and compare the diagnostic performance of Peguero-Lo Presti, Cornell and Sokolow--Lyon voltage criteria for LVH as defined by CMR in an all-comers European population. METHODS A total of 240 consecutive patients referred for CMR who had a concomitant electrocardiogram for review were evaluated. LVH group patients were defined according to the reference values for sex and age of left ventricular mass index (LVMi). A control group, adjusted by sex, was randomly selected from a population without LVH. We applied the ECG voltage criteria to both groups and evaluated their diagnostic accuracy. Diagnostic sensitivity and specificity were compared. RESULTS Two hundred and forty patients (mean age 63 years; 65% men) were divided into two groups (LVH n = 149; control n = 91). The main causes of LVH were hypertension (24.8%) and hypertrophic cardiomyopathy (21.5%). The remaining patients of this group had a diagnosis of dilated cardiomyopathy (14.8%), valvular heart disease (7.4%) and infiltrative cardiomyopathy (2.0%). Overall, the sensitivity for LVH diagnosis of the Peguero-Lo Presti criteria outperformed both the Cornell (47 vs. 29%, P

Background The prevalence of coronary artery disease (CAD) is high among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR). Indications for TAVR are now expanding to younger and lower risk patients. During their lifetime, these patients will be at risk of developing CAD and it is expected an increase in coronary angiography and percutaneous coronary intervention (PCI). Aortic prosthesis, particularly if in supra-annular position, may pose important technical difficulties in coronary re-engagement after TAVR. Purpose To evaluate the feasibility to reengage the coronary ostia after TAVR, describe complications and compare technical differences between coronary procedures performed before and after TAVR. Methods Retrospective analysis of 714 patients submitted to TAVR from August 2007 to December 2019. Patients who needed coronary angiography after TAVR were selected. The primary endpoint was the rate of successful coronary ostia cannulation after TAVR, defined by the possibility to selectively cannulate and inject both coronary ostia. Secondary endpoint was complications associated with coronary catheterization after TAVR. Results Among 714 patients, 25 (3.5%) patients were submitted to a total of 28 coronary angiography after TAVR. 14 patients were male (56%), mean age 78.2±6.2 years and 9 (36%) had history of previous coronary revascularization. From the 28 coronary angiographies (balloon-expandable Edwards-Sapien n=11, 44%; self-expandable CoreValve n=10, 40%; Portico n=2, 8%; Symetis n=2, 8%), 25 (89%) met the primary endpoint. Only three was semiselective (Symetis, CoreValve Evolut R and CoreValve TAVR in TAVR), with impossibility to cannulate both coronary arteries, right coronary artery and left coronary artery, respectively. 13 (46%) patients had also indication for PCI and all were successfully performed (Edwards-Sapien n=4, 31%; CoreValve n=6, 46%; Portico n=2, 15%; Symetis n=1, 8%). The main indications for coronary angiography was chronic coronary syndrome (n=12, 43%) and acute coronary syndrome without ST segment elevation (n=7, 25%). Circumflex artery was the most frequently treated vessel (n=6), followed by left anterior descending artery (n=4), right coronary artery (n=3) and left main (n=2). There were no complications reported during or post-procedure. Comparing coronary angiographies before and after TAVR, there were no significant differences regarding arterial access site, catheter diameter, fluoroscopy time and quantity of contrast used in coronary angiography. Conclusion Although the need for coronary angiography was rare in patients after TAVR, selective diagnostic coronary angiographies were possible in 89% (25/28) and PCI was feasible in all patients in whom it was indicated, without any reported complications. Further prospective studies are needed to confirm the great feasibility of performing coronary angiography after TAVR. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho

The aim of this study was to evaluate whether fulfilling COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) criteria identifies patients with better outcomes after MitraClip treatment for secondary mitral regurgitation (SMR).To date, COAPT is the only trial showing a prognostic benefit of MitraClip implantation compared with conservative management.Three hundred four patients with SMR undergoing MitraClip placement in addition to optimal medical therapy at 3 European centers were analyzed. A COAPT-like profile was defined as absence of all the following criteria: severe left ventricular impairment, moderate to severe right ventricular dysfunction, severe tricuspid regurgitation, severe pulmonary hypertension, and hemodynamic instability. Freedom from all-cause death and from a composite endpoint (cardiovascular death and heart failure hospitalization) were evaluated at 2- and 5-year follow-up.A COAPT-like profile was observed in 65% of the population. Compared with non-COAPT-like patients, those fulfilling COAPT criteria had greater survival free from all-cause death and from the composite endpoint at both 2 year (75% vs. 55% and 67% vs. 47%; p 0.001 for both) and 5-year (49% vs. 25% and 40% vs. 19%; p 0.001 for both) follow-up. Among the non-COAPT-like patients, similar outcomes were observed in those fulfilling 1 or ≥1 criterion. Left ventricular impairment had a late impact on outcomes, while right ventricular impairment, pulmonary hypertension, and hemodynamic instability had early effects. COAPT-like profile was an independent predictor of long-term outcomes, as well as administration of neurohormonal antagonists, European System for Cardiac Operative Risk Evaluation II score, and previous heart failure hospitalization.A COAPT-like profile, including specific echocardiographic and clinical criteria, identifies patients with SMR who have a better prognosis after MitraClip implantation.

Percutaneous approach for valvular heart disease is accepted as a safe and feasible strategy to treat patients considered at high surgical risk with aortic stenosis and mitral regurgitation. Additionally, the growing experience led to the increasing use of transcatheter aortic valve implantation in several indications, such as in pure aortic regurgitation. The authors present the case of a 72-year-old woman with prohibitive surgical risk due to several comorbidities, including a chronic arterial dissection from the right carotid artery to the femoral arteries bilaterally that presented with signs and symptoms of heart failure, having a transthoracic echocardiography that showed severe functional mitral and aortic regurgitation. Combined percutaneous intervention for multivalvular disease in this clinical scenario is challenging, and the reported experience is still scarce and limited to inoperable patients.

Mitral regurgitation is a common valvular heart disease and its prevalence is expected to increase with population ageing. In the recent years we have witnessed the evolution of several transcatheter devices to correct mitral regurgitation in patients at high-risk for surgery. Most of the evidence of the safety and efficacy of this new therapy comes from MitraClip studies. However, new alternatives have emerged with promising results. The aim of this position paper is to review the current evidence regarding patient selection, expected results and timing for transcatheter mitral valve interventions from the perspective of three European interventional societies. (C) 2017 Elsevier B.V. All rights reserved.

Coronary artery aneurysms are uncommon but potentially hazardous entities found on a small percentage of coronary angiograms. The best management strategy remains to be determined; the coexistence of obstructive coronary artery disease is the main determinant of prognosis.We report the case of a middle-aged woman with mixed aneurysmal and obstructive coronary artery disease presenting as an acute myocardial infarction, probably due to atherosclerosis. The unusual severity and complexity of the angiographic presentation of this case, with involvement of all major coronary arteries, raises important issues in terms of the patient's treatment options. Resumo: Os aneurismas das artérias coronárias são entidades raras, presentes numa pequena percentagem das angiografias coronárias, embora associadas a complicações potencialmente graves. A melhor conduta no tratamento destas situações ainda não foi estabelecida e a coexistência de doença coronária obstrutiva é o principal determinante prognóstico.Reportamos o caso de uma mulher de meia-idade com doença coronária mista, obstrutiva e aneurismática, diagnosticada no contexto de enfarte agudo do miocárdio e de provável etiologia aterosclerótica. A gravidade e a complexidade incomuns da apresentação angiográfica do nosso caso, levantaram aos autores questões importantes no domínio da decisão terapêutica. Keywords: Coronary artery aneurysms, Atherosclerosis, Acute myocardial infarction, Palavras-chave: Aneurismas coronários, Aterosclerose, Enfarte agudo do miocárdio

Background— Cardiovascular magnetic resonance (CMR) myocardial perfusion imaging (MPI) is a state-of-the-art noninvasive modality for detection of myocardial ischemia and coronary artery disease. Magnetic resonance coronary angiography (MRCA) allows visualization of the coronary tree, but its incremental value as part of a CMR protocol including MPI and late gadolinium enhancement (LGE) is not well established. We aimed to evaluate the additive diagnostic value of a 3-dimensional whole-heart MRCA integration into a 1.5T CMR-MPI/LGE protocol for the detection of functionally significant coronary artery disease. Methods and Results— Forty-three symptomatic patients (61±8.3 years; 65% men) with suspected coronary artery disease and intermediate/high-pretest probability underwent CMR (including CMR-MPI, MRCA, and LGE) and x-ray invasive coronary angiography (XA) with fractional flow reserve evaluation. Diagnostic performances of MRCA, CMR-MPI/LGE, and MRCA+CMR-MPI/LGE integration were determined having XA+fractional flow reserve as standard for coronary artery disease (≥90% stenosis/occlusion or fractional flow reserve≤0.80 in vessels>2 mm). MRCA inclusion into the CMR protocol was associated with a mean increase of 7.9±4.69 (0–17.7) minutes in total examination duration (14%). On patient-based analysis, MRCA had 96% sensitivity, 68% specificity, positive predictive value of 79%, and negative predictive value of 93%. CMR-MPI/LGE had 79% sensitivity, 95% specificity, positive predictive value of 95%, and negative predictive value of 78%. Integration of MRCA with CMR-MPI/LGE further improved CMR performance to 96% sensitivity, 89% specificity, positive predictive value of 92%, and negative predictive value of 94%, with a global accuracy of 93%. Conclusions— In this intermediate/high-pretest population, integration of noncontrast-enhanced whole-heart MRCA nonsignificantly improved per-patient diagnostic accuracy of a comprehensive 1.5-T stress-rest CMR-MPI/LGE protocol at a cost of longer scanning times.

Background Cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) is considered a state of the art non-invasive modality for the detection of reversible ischemia. Recent studies have shown its utility in the diagnosis of coronary artery disease (CAD) and superiority over other established techniques. However, only a few studies compared CMR-MPI against the invasive standard including fractional flow reserve (FFR) and clinical validation in non-specialized centers is scarce. The aim of this study was to validate CMR-MPI in a real-world clinical environment and to test its diagnostic accuracy in symptomatic patients with suspected CAD versus FFR as the reference standard of functionally significant disease. Methods and results 103 symptomatic consecutive patients (62±8.0years, 66% males) with suspected CAD and intermediate or high probability of disease underwent sequential CMR and invasive coronary angiography (XA). The CMR protocol included stress-rest adenosine perfusion, SSFP cine imaging and late-enhancement imaging. Functionally significant CAD was defined as occlusive/sub-occlusive stenoses on XA or non-occlusive stenoses with a FFR measurement of 2mm. On a patient-based model, CMR-MPI had sensitivity, specificity, positive and negative predictive values of 89%, 88%, 85%, and 91%, respectively, with a global accuracy of 88%. On a vessel-based analysis, these values were 80%, 93%, 79% and 94%, respectively, with a global accuracy of 90%. Conclusions CMR-MPI had a very high accuracy for detection of functionally significant CAD as assessed by FFR in patients with intermediate to high pretest probability.

The Parachute is a novel left ventricular (LV) partitioning device that is deployed percutaneously in the left ventricle in patients with anteroapical regional wall motion abnormalities, dilated LV and systolic dysfunction after anterior myocardial infarction (MI). The implantable device is a partitioning membrane that isolates the dysfunctional region of the ventricle and decreases chamber volume.Data from the first-in-human clinical trial – the Percutaneous Ventricular Restoration in Chronic Heart Failure (PARACHUTE) trial– has shown that this new device is associated with significant and sustained LV volume reduction and improvement in LV hemodynamics and functional capacity in the 12 months after implantation, with a relatively low rate of clinical events, indicating that it may have a beneficial effect in the treatment of ischemic heart failure.We aim to describe our initial experience with implantation of the Parachute LV partitioning device and its short-term safety, defined as the successful delivery and deployment of the device. Resumo: O dispositivo Parachute é um dispositivo inovador, implantado percutaneamente no ápex do ventrículo esquerdo (VE) em doentes com discinésia ou acinésia antero-apical, dilatação e disfunção sistólica do VE, no decurso de um enfarte do miocárdio envolvendo a artéria descendente anterior esquerda. O dispositivo corresponde a uma membrana de partição, desenhada de forma a isolar a região acinética ou discinética e reduzir o volume do VE.O estudo piloto - the Percutaneous Ventricular Restoration in Chronic Heart Failure (PARACHUTE) trial - mostrou que o dispositivo está associado a uma redução significativa e sustentada do volume do VE, com melhoria hemodinâmica e da capacidade funcional. Estes resultados positivos mantiveram-se durante os 12 meses após a implantação, com uma taxa relativamente baixa de eventos adversos relacionados com o dispositivo. Estes dados indicam que o dispositivo Parachute poderá ser benéfico no tratamento de doentes com insuficiência cardíaca com dilatação e disfunção sistólica do VE secundária a cardiopatia isquémica.Os autores pretendem demonstrar a experiência inicial com a implantação do dispositivo, assim como a segurança do mesmo a curto-prazo relativamente à entrega e deposição do dispositivo no ápex do VE. Keywords: Heart failure, Left ventricular remodeling, Anterior myocardial infarction, Anteroapical wall motion dysfunction, Parachute left ventricular partitioning device, Palavras-chave: Insuficiência cardíaca, Remodelação ventricular, Enfarte agudo do miocárdio da parede anterior, Alterações cinética segmentar antero-apical, Dispositivo de partição ventricular

Background— Multislice computed tomography (MSCT) has shown high negative predictive value in ruling out obstructive coronary artery disease. Preliminary studies in patients with valvular heart disease (VHD) have demonstrated the potential of MSCT angiography (CTA) in such patients, precluding need for invasive angiography (XA). However, larger prospectively designed studies, including patients with atrial fibrillation and incorporating dose reduction algorithms, are needed. Methods and Results— To evaluate the clinical utility of 64-slice CT in the preoperative assessment in patients with VHD, we prospectively studied 452 consecutive patients undergoing routine cardiac catheterization for eligibility. Two hundred thirty-seven patients underwent both MSCT and XA. Segment-based, vessel-based, and patient-based agreement between CTA and XA was estimated assuming that “nonevaluable” segments were positive for significant coronary stenosis. In a patient-based analysis, sensitivity, specificity, positive predictive value, and negative predictive values of CTA were 95%, 89%, 66%, and 99%, respectively; in vessel-based analysis, 90%, 92%, 48%, and 99%, respectively; and in segment-based analysis, 89%, 97%, 38%, and 100%, respectively. No significant differences were found between patients with or without atrial fibrillation. A CAC value of 390 was the best cutoff for the identification of patients with positive or inconclusive CTA (which would not be exempted from XA in the clinical setting). Conclusions— In the preoperative assessment of patients with predominant VHD, the diagnostic accuracy of 64-slice CTA for ruling out the presence of significant coronary artery disease is very good even when including patients with irregular heart rhythm. Using this approach, CAC quantification before CTA can be successfully used to identify patients who should be referred directly to XA, sparing unnecessary exposure to radiation.

Ischemic cardiomyopathy is the leading cause of heart failure. In patients with left ventricular (LV) dilatation, low ejection fraction, and transmural scar in an anteroseptal distribution, surgical ventricular reconstruction (SVR) is a treatment option.We describe our first experience with the Less Invasive Ventricular Enhancement (LIVE) technique using the Revivent™ system (Bioventrix Inc., San Ramon, CA), in the treatment of a large anteroapical aneurysm. Resumo: A cardiomiopatia isquémica é a principal causa de insuficiência cardíaca. A cirurgia de reconstrução ventricular é uma opção terapêutica em doentes com dilatação e disfunção sistólica do ventrículo esquerdo e cicatriz de enfarte transmural da parede anterior e septo.Os autores pretendem descrever a sua experiência inicial com uma técnica menos invasiva de reconstrução ventricular (Less Invasive Ventricular Enhancement [LIVE]) utilizando o sistema Revivent™ (Bioventrix Inc., San Ramon, CA, EUA), no tratamento de um volumoso aneurisma ântero-apical. Keywords: Ischemic cardiomyopathy, Heart failure, Surgical ventricular reconstruction, Off-pump surgery, Palavras-chave: Cardiomiopatia isquémica, Insuficiência cardíaca, Reconstrução ventricular esquerda, Cirurgia sem circulação extracorporal