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Cardiac involvement is the main cause of death in Becker muscular dystrophy (BMD). Identification of left ventricular (LV) function is crucial, but standard echocardiographic measurements such as LV ejection fraction (LVEF) might not be sensitive enough to detect early myocardial dysfunction. We explored the value of LV global longitudinal strain (GLS) as a more accurate echocardiographic parameter to detect and monitor LV dysfunction in BMD. Furthermore, we studied possible factors associated with LV dysfunction and progression. A total of 40 patients with BMD (age 39.0 +/- 13.2 years) and 21 matched controls were included. Clinical variables, pulmonary tests, serum biomarkers, and echocardiograms were collected at baseline and after 2 years. LV systolic function was assessed by LVEF and LV GLS; a significant progression in LV dysfunction was defined as an absolute LV GLS deterioration >= 15%. Responsiveness to cardiac disease progression was determined using standardized response means. Patients showed impaired LVEF and LV GLS compared with controls (p

Aims Women with severe aortic stenosis (AS) have better long-term outcome after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared with men. Whether this is related to sex differences in left ventricular (LV) remodelling is unknown. The aim of this study was to examine the sex differences in LV remodelling with multidetector row computed tomography (MDCT) and outcome in patients with severe AS undergoing TAVI between 2007 and 2018. Methods and results A total of 289 patients (age 80 ± 6 years, 54% male) were included. LV volumes, mass, and function were analysed on pre-procedural MDCT scans. Women showed smaller LV volumes and mass compared with men. Patients were classified into four LV remodelling patterns: concentric hypertrophy (50%) was the most frequent pattern of LV remodelling followed by eccentric hypertrophy (33%), normal geometry (13%), and concentric remodelling (4%). Men showed more concentric remodelling compared with women (91% vs. 9%, respectively, P = 0.011). However, no differences were observed in the remaining LV remodelling patterns. During a median follow-up of 3.8 (IQR 2.2–5.1) years after TAVI, 87 (30%) patients died. Women demonstrated better outcome after TAVI compared with men (log-rank χ2 = 4.29, P = 0.038). No association was observed between the interaction of the LV remodelling patterns and sex with outcome. Conclusion LV concentric hypertrophy and eccentric hypertrophy are similarly observed in men and women with severe AS but concentric remodelling was more common in men. Women demonstrated better outcome after TAVI when compared with men. The interaction between the LV remodelling patterns and sex was not associated with survival.

Calcific aortic valve disease (CAVD) is a common progressive disease of the aortic valves, for which no medical treatment exists and surgery represents currently the only therapeutic solution. The development of novel pharmacological treatments for CAVD has been hampered by the lack of suitable test-systems, which require the preservation of the complex valve structure in a mechanically and biochemical controllable system. Therefore, we aimed at establishing a model which allows the study of calcification in intact mouse aortic valves by using the Miniature Tissue Culture System (MTCS), an ex vivo flow model for whole mouse hearts. Aortic valves of wild-type mice were cultured in the MTCS and exposed to osteogenic medium (OSM, containing ascorbic acid, beta-glycerophosphate and dexamethasone) or inorganic phosphates (PI). Osteogenic calcification occurred in the aortic valve leaflets that were cultured ex vivo in the presence of PI, but not of OSM. In vitro cultured mouse and human valvular interstitial cells calcified in both OSM and PI conditions, revealing in vitro-ex vivo differences. Furthermore, endochondral differentiation occurred in the aortic root of ex vivo cultured mouse hearts near the hinge of the aortic valve in both PI and OSM conditions. Dexamethasone was found to induce endochondral differentiation in the aortic root, but to inhibit calcification and the expression of osteogenic markers in the aortic leaflet, partly explaining the absence of calcification in the aortic valve cultured with OSM. The osteogenic calcifications in the aortic leaflet and the endochondral differentiation in the aortic root resemble calcifications found in human CAVD. In conclusion, we have established an ex vivo calcification model for intact wild-type murine aortic valves in which the initiation and progression of aortic valve calcification can be studied. The in vitro-ex vivo differences found in our studies underline the importance of ex vivo models to facilitate pre-clinical translational studies.

The present study aimed to examine differences in left- and right atrial characteristics between atrial fibrillation (AF) patients with and without chronic obstructive pulmonary disease (COPD). For this, 420 patients (mean age 68 +/- 10 years, 73% female) with first diagnosis of AF and baseline echocardiography were included. Of these, 143 COPD patients were compared with 277 patients without COPD matched by age, gender and body surface area. Additionally 38 healthy controls without cardiovascular risk factors, matched for age, were included. For all 3 groups, left atrial (LA) volumes and diameter, LA reservoir strain (LASr), left ventricular ejection fraction (LVEF), right atrial (RA) area and diameter, RA reservoir strain (RASr) and tricuspid annular plane systolic excursion were evaluated on transthoracic echocardiography. Baseline characteristics were similar in patients with and without COPD except for smoking and a history of heart failure (42% vs 11%, p < 0.001 and 48% vs 37%, p = 0.036 for COPD and non-COPD patients, respectively). Also, COPD patients less often used beta-blockers (63% vs 75%, p = 0.017). There were no significant differences in LVEF, LA volume and RA area between COPD and non-COPD patients. Compared to the controls, AF patients had impaired LVEF, LASr and RASr. Only RASr was significantly worse in COPD patients as compared to non-COPD patients (15.3% [9.0 to 25.1] vs 19.6% [11.8 to 28.5], p = 0.013). Additionally, a trend towards worse RASr was observed with increasing COPD severity. In conclusion, AF patients with concomitant COPD have more impaired RA function compared to patients without COPD but with similar atrial size and LA function. (C) 2020 The Author(s). Published by Elsevier Inc.

Background: Obesity may cause right ventricular (RV) remodeling due to volume overload. However, obesity is also associated with better prognosis compared with normal weight in patients with various cardiac diseases. The aim of this study was to assess the impact of obesity on RV remodeling and long-term prognosis in patients with significant (moderate and severe) tricuspid regurgitation (TR).Methods: A total of 951 patients with significant TR (median age, 70 years; interquartile range, 61-77 years; 50% men) were divided into three groups according to body mass index (BMI): normal weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)), and obese (BMI >= 30 kg/m(2)). Patients with congenital heart disease, peripheral edema, active endocarditis, and BMI < 18.5 kg/m(2) were excluded. RV size and function for each group were measured using transthoracic echocardiography and compared with reference values of healthy study populations. The primary end point was all-cause mortality. Event rates were compared across the three BMI categories.Results: Four hundred seventy-six patients (50%) with significant TR had normal weight, 356 (37%) were over-weight, and 119 (13%) were obese. RV end-diastolic and end-systolic areas were larger in overweight and obese patients compared with normal-weight patients. However, no differences in RV systolic function were observed. During a median follow-up period of 5 years, 358 patients (38%) died. Five-year survival rates were significantly better in overweight and obese patients compared with patients with normal weight (65% and 67% vs 58%, respectively, P < .001 and P = .005). In multivariate analysis, overweight and obesity were independently associated with lower rates of all-cause mortality compared with normal weight (hazard ratios, 0.628 [95% CI, 0.493-0.800] and 0.573 [95% CI, 0.387-0.848], respectively).Conclusions: In patients with significant TR, overweight and obese patients demonstrated more RV remodeling compared with patients with normal weight. Nevertheless, a higher BMI was independently associated with better long-term survival, confirming the obesity paradox in this context.

Background: Noninvasive left ventricular (LV) pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate LV function, integrating longitudinal strain by speckle-tracking analysis and sphygmomanometrically measured blood pressure to estimate myocardial work. The aims of this study were (1) to describe global and segmental myocardial work in patients with hypertrophic cardiomyopathy (HCM), (2) to assess the correlation between myocardial work and other echocardiographic parameters, and (3) to evaluate the association of myocardial work with adverse outcomes.Methods: One hundred ten patients with nonobstructive HCM (mean age, 55 +/- 15 years; 66% men), with different phenotypes (apical, concentric, and septal hypertrophy), and 35 age- and sex-matched healthy control subjects were included. The following myocardial work indices were included: myocardial work index, constructive work (CW), wasted work, and cardiac efficiency. The combined end point included all-cause mortality, heart transplantation, heart failure hospitalization, aborted sudden cardiac death, and appropriate implantable cardioverter-defibrillator therapy.Results: Mean global CW (1,722 +/- 602 vs 2,274 +/- 574 mm Hg%, P < .001), global cardiac efficiency (93% [89%-95%] vs 96% [96%-97%], P < .001), and global MWI (1,534 +/- 551 vs 1,929 +/- 473 mm Hg%) were significantly reduced, while global wasted work (104 mm Hg% [66-137 mm Hg%] vs 71 mm Hg% [49-92 mm Hg%], P < .001) was increased in patients with HCM compared with control subjects. Segmental impairment in CW colocalized with maximal wall thickness (HCM phenotype), and global CW correlated with LV wall thickness (r = -0.41, P < .001), diastolic function (r = -0.27, P = .001), and QRS duration (r = -0.28, P = .001). Patients with global CW > 1,730 mm Hg% (the median value) experienced better event-free survival than those with global CW < 1,730 mm Hg% (P < .001).Conclusions: Myocardial work, assessed noninvasively using echocardiography and blood pressure measurement, is reduced in patients with nonobstructive HCM; it correlates with maximum LV wall thickness and is significantly associated with a worse long-term outcome.

Left ventricular (LV) mechanical dispersion (LVMD), measured with speckle-tracking echocardiography (STE) after ST-segment elevation myocardial infarction (STEMI), has been proposed as a measurement of regional heterogeneity of myocardial contraction and may reflect changes in the myocardial structure (e.g., fibrosis or edema). Further insight into this parameter may aid in the risk stratification of STEMI patients.A total of 1,000 STEMI patients (77% male, 60 ± 12 years) treated with primary percutaneous coronary intervention were retrospectively analyzed. The LVMD was assessed with two-dimensional STE within 48 hours following the index infarction. Patients were followed for the occurrence of all-cause mortality.After a median follow-up of 117 months, 229 (23%) patients died. Nonsurvivors showed worse LV ejection fraction (43% ± 10% vs 48% ± 9%; P .001) and global longitudinal strain (-12.0% ± 3.5% vs -14.2% ± 3.5%; P = .001) and prolonged LVMD (63 [interquartile range, 50-85] msec vs 52 [interquartile range, 42-63] msec; P .001) compared with survivors. Increasing age, systolic blood pressure, and heart rate at discharge as well as diabetes mellitus, anterior STEMI, TIMI flow2, less usage of angiotensin converter enzyme inhibitors or angiotensin receptor blockers, and impaired LV global longitudinal strain were independently associated with more prolonged LVMD. On multivariable analysis, prolonged LVMD was independently associated with increased risk of all-cause mortality (hazard ratio = 1.012; 95% CI, 1.005-1.018; P = .001) and had incremental value for all-cause mortality over clinical and echocardiographic parameters.In contemporary STEMI patients, prolonged LVMD was associated with various clinical and echocardiographic parameters. Prolonged LVMD was associated with worse long-term outcome.

Aims To evaluate the diagnosis and imaging of patients with suspected endocarditis and the management in routine clinical practice across Europe, the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities and multidisciplinary team was explored. Methods and results A total of 100 European Echocardiography Laboratories from 29 different countries responded to the survey, which consisted of 20 questions. For most of the use of echocardiography and advanced imaging, answers from the centres were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, two-thirds of centres report the use of a specific endocarditis team for decision-making. Echocardiography plays a key role in the diagnosis and management of endocarditis. Nuclear imaging modalities are broadly available among the centres and are mainly used in prosthetic valve endocarditis and cardiac device-related infective endocarditis. Computed tomography (CT) is widely available and used to assess for structural valve abnormalities, neurological complications, and to preoperative assessment of the coronary arteries. Most institutions provide structured patients follow-up following hospital discharge. Conclusion In Europe, a relatively homogenous adherence to current recommendation was observed for most diagnostic and management including the follow-up of patients with endocarditis. Decision-making is most commonly performed by a multidisciplinary team. Echocardiography remains the first line and central imaging modality for patient diagnosis and assessment, but 60% of centres also commonly use CT, whilst positron emission tomography imaging is used in patients with prosthetic valve endocarditis or device infection.

Left ventricular (LV) systolic function is a prognostic factor in patients with severe aortic stenosis (AS). Multi-detector row computed tomography (MDCT) data are key in the evaluation of patients undergoing transcatheter aortic valve implantation (TAVI) and when acquired retrospectively, LV systolic function can be assessed. Novel software permits assessment of LV global longitudinal strain (GLS) from MDCT data.The present study investigated the feasibility of feature tracking MDCT-derived LV GLS and its agreement with echocardiographic LV GLS in patients treated with TAVI.LV GLS was measured on transthoracic echocardiography using speckle tracking analysis and on dynamic MDCT using feature tracking technology. Agreement between the measurements of two different modalities was assessed using Bland-Altman analysis.A total of 214 patients (51% male, mean age: 80 ± 7 years) were analysed. Mean LV GLS on echocardiography was -13.91 ± 4.32%, whereas mean feature tracking MDCT-derived GLS was -12.46 ± 3.97%. Correlation of measurements between feature tracking MDCT-derived LV GLS and echocardiographic LV GLS demonstrated a large effect size (r = 0.791, p 0.001). On Bland-Altman analysis, feature tracking MDCT-derived strain analysis underestimated LV GLS compared to echocardiography with a mean difference of 1.44% (95% limits of agreement -3.85% - 6.73%).Assessment of LV GLS on dynamic feature tracking MDCT data is feasible in TAVI patients. Compared to speckle tracking echocardiography, feature tracking MDCT underestimates the value of LV GLS.

Hypo-attenuated leaflet thickening (HALT) of transcatheter aortic valves is detected on multidetector computed tomography (MDCT) and reflects leaflet thrombosis. Whether HALT affects left ventricular (LV) reverse remodeling, a favorable effect of LV afterload reduction after transcatheter aortic valve implantation (TAVI) is unknown. The aim of this study was to examine the association of HALT after TAVI with LV reverse remodeling. In this multicenter case–control study, patients with HALT on MDCT were identified, and patients without HALT were propensity matched for valve type and size, LV ejection fraction (LVEF), sex, age and time of scan. LV dimensions and function were assessed by transthoracic echocardiography before and 12 months after TAVI. Clinical outcomes (stroke or transient ischemic attack, heart failure hospitalization, new-onset atrial fibrillation, all-cause mortality) were recorded. 106 patients (age 81 ± 7 years, 55% male) with MDCT performed 37 days [IQR 32–52] after TAVI were analyzed (53 patients with HALT and 53 matched controls). Before TAVI, all echocardiographic parameters were similar between the groups. At 12 months follow-up, patients with and without HALT showed a significant reduction in LV end-diastolic volume, LV end-systolic volume and LV mass index (from 125 ± 37 to 105 ± 46 g/m2, p = 0.001 and from 127 ± 35 to 101 ± 27 g/m2, p

Global left ventricular (LV) myocardial work (MW) indices (GLVMWI) are derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure measurements. Changes in global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) after ST-segment elevation myocardial infarction (STEMI) have not been explored. The aim of present study was to assess the evolution of GLVMWI in STEMI patients from baseline (index infarct) to 3 months' follow-up. Three-hundred and fifty patients (265 men; mean age 61 +/- 10 years) with STEMI treated with primary percutaneous coronary intervention (PCI) and guideline-based medical therapy were retrospectively evaluated. Clinical variables, conventional echocardiographic measures and GLVMWI were recorded at baseline within 48 hours post-primary PCI and 3 months' follow-up. LV ejection fraction (from 54 +/- 10% to 57 +/- 10%, p < 0.001), GWI (from 1449 +/- 451 mm Hg% to 1953 +/- 492 mm Hg%, p < 0.001), GCW (from 1624 +/- 519 mm Hg% to 2228 +/- 563 mm Hg%, p < 0.001) and GWE (from 93% (interquartile range (IQR) 86%-95%) to 95% (IQR 91%-96%), p < 0.001) improved significantly at 3 months' follow-up with no significant difference in GWW (from 101 mm Hg% (IQR 63-155 mm Hg%) to 96 mm Hg% (IQR 64-155 mm Hg %); p = 0.535). On multivariable linear regression analysis, lower values of troponin T at baseline, increase in systolic blood pressure and improvement in LV global longitudinal strain were independently associated with higher GWI and GCW at 3 months' follow-up. In conclusion, the evolution of GWI, GCW and GWE in STEMI patients may reflect myocardial stunning, whereas the stability in GWW may reflect permanent myocardial damage and the development of non-viable scar tissue. (C) 2021 The Authors. Published by Elsevier Inc.

Coronary artery ectasia (CAE) is described in 5% of patients undergoing coronary angiography. Previous studies have shown controversial results regarding the prognostic impact of CAE. The prevalence and prognostic value of CAE in patients with acute myocardial infarction (AMI) remain unknown. In 4788 patients presenting with AMI referred for coronary angiography the presence of CAE (defined as dilation of a coronary segment with a diameter >= 1.5 times of the adjacent normal segment) was confirmed in 174 (3.6%) patients (age 62 + 12 years; 81% male), and was present in the culprit vessel in 79.9%. Multivessel CAE was frequent (67%). CAE patients were more frequently male, had high thrombus burden and were treated more often with thrombectomy and less often was stent implantation. Markis I was the most frequent angiographic phenotype (43%). During a median follow-up of 4 years (1-7), 1243 patients (26%) experienced a major adverse cardiovascular event (MACE): 282 (6%) died from a cardiac cause, 358 (8%) had a myocardial infarction, 945 (20%) underwent coronary revascularization and 58 (1%) presented with a stroke. Patients with CAE showed higher rates of MACE as compared to those without CAE (36.8% versus 25.6%; p

Background Timing of mitral valve surgery for primary mitral regurgitation (MR) remains challenging. Since MR has a significant hemodynamic impact on the left atrium (LA), assessment of LA function may have prognostic value in these patients which is incremental to LA volume and left ventricular (LV) remodeling parameters. Purpose This study sought to investigate whether preoperative assessment of LA reservoir strain (LASr) by speckle tracking echocardiography is associated with long-term outcome in patients undergoing mitral valve repair for severe primary MR. Methods Echocardiography was performed prior to mitral valve surgery in 566 patients (age 64±12 years, 66% men) with severe primary MR. Complete clinical information was collected and the endpoint was all-cause mortality after operation. The study population was divided based on a cut-off value of LASr (22%) derived from a spline curve analysis (hazard ratio for all-cause mortality >1). Results Patients with LASr ≤22% (n=277) were significantly older, had more impaired renal function and were more symptomatic (NYHA functional class III to IV) compared to patients with LASr >22% (n=289). In terms of echocardiographic data, patients with LASr ≤22% had significantly lower LV ejection fraction and LV global longitudinal strain (LV-GLS) and significantly higher systolic pulmonary artery pressures and LA volume index compared with patients with LASr >22%. During a median follow-up of 95 (56 – 147) months, 129 patients (22.8%) died. Patients with LASr ≤22% experienced significantly higher mortality rates compared to patients with LASr >22% (log rank chi-square 35.1; p Conclusions Preoperative LASr is independently associated with all-cause mortality in patients undergoing mitral valve repair for primary MR, has incremental prognostic value over LA volume and LVEF and might therefore be helpful to guide surgical timing. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Jan Stassen has received an ESC training grant (Appehab724.011364741) Association of LASr and outcome

Background ST-segment elevation myocardial infarction (STEMI) often involves changes in right ventricular (RV) function and size over time. However, the prognostic implications of RV remodeling after STEMI are unknown. The aim of current study was to characterize RV remodeling in post-STEMI patients and to investigate it's prognostic relevance. Methods RV remodeling in post-STEMI patients who underwent primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI, compared to baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis (Figure 1A). The primary endpoint was the composite of all-cause mortality and heart failure (HF) hospitalization. Long term outcomes were compared between patients with and without RV remodeling by means of a log rank test. Results A total of 2280 patients were analyzed (mean age 60±11 years, 76% male) and RV remodeling was present in 320 patients (14%). After a median follow-up of 75 months (interquartile range 50–106 months), the composite endpoint of all-cause mortality and HF hospitalization occurred in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality and HF hospitalization (HR=1.37, 95% CI 1.00–1.87, p=0.049. Finally, patients with RV remodeling were had a significantly lower event-free survival rate compared with patients without RV remodeling during follow-up (log-rank test p=0.009) (Figure 1B). Conclusion RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function. Funding Acknowledgement Type of funding sources: None. Figure 1. A) Spline and B) Kaplan-Meier curve

Background Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Risk assessment in these patients, however, has not been thoroughly investigated. Purpose To investigate the independent determinants of survival in patients with MAS, stratified by left ventricular ejection fraction (LVEF) and severity of symptoms at the time of first diagnosis. Methods Patients with an echocardiographic diagnosis of tricuspid MAS (aortic valve area >1.0 and ≤1.5cm2) were identified. Patients were stratified by LVEF (LVEF ≥60%, LVEF 50–59%, or LVEF Results Of 2003 patients with MAS (mean age 73±10 years, 51% men, AVA 1.22±0.15 cm2), 1063 (53%), had LVEF≥60%, 550 (27%) LVEF 50–59% and 390 (20%) LVEF Conclusions Baseline LVEF and symptom severity are associated with worse outcomes in patients with MAS. Although current guidelines recommend conservative management for MAS, randomized trials appear warranted to determine whether AVR at an earlier stage would be beneficial in these patients. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): ESC Training Grant Appehab724.157064741 Figure 1. Kaplan-Meier outcome curvesFigure 2. Cox regression analysis

OBJECTIVES This study aimed to evaluate the prevalence and prognostic value of the extent of extra-aortic valvular cardiac abnormalities in a large multicenter registry of patients with moderate AS.BACKGROUND The prognostic significance of a new classification system that incorporates the extent of cardiac injury (beyond the aortic valve) has been proposed in patients with severe aortic stenosis (AS). Whether this can be applied to patients with moderate AS is unclear.METHODS Based on the echocardiographic findings at the time of diagnosis of moderate AS (aortic valve area between 1.0 and 1.5 cm(2) and dimensionless velocity index ratio of >= 0.25), a total of 1,245 patients were included and analyzed retrospectively. They were recategorized into 5 groups according to the extent of extra-aortic valvular cardiac abnormalities: none (Group 0), involving the left ventricle (Group 1), the left atrial or mitral valve (Group 2), the pulmonary artery vasculature or tricuspid valve (Group 3), or the right ventricle (Group 4). Patients were followed for all-cause mortality and combined endpoint (all-cause mortality, stroke, heart failure, or myocardial infarction).RESULTS The distribution of patients according to the proposed classification was 13.1%, 26.8%, 42.6%, 10.6%, and 6.9% in Groups 0, 1, 2, 3, and 4, respectively. During a median follow-up of 4.3 (2.4 to 6.9) years, 564 (45.3%) patients died. There was a significant higher mortality rates with increasing extent of extra-aortic valvular cardiac abnormalities (log-rank p < 0.001). On multivariable analysis, the presence of extra-aortic valvular cardiac abnormalities remained independently associated with all-cause mortality and combined outcome, adjusted for aortic valve replacement as a time-dependent covariable. In particular, Group 2 and above were independently associated with all-cause mortality.CONCLUSIONS In patients with moderate AS, the presence of extra-aortic valvular cardiac abnormalities is associated with poor outcome. (C) 2021 Published by Elsevier on behalf of the American College of Cardiology Foundation.

Aims Left ventricular (LV) remodelling after ST-segment elevation myocardial infarction (STEMI) worsens outcome. The effect of sex on LV post-infarct remodelling is unknown. We therefore investigated the sex distribution and long-term prognosis of LV post-infarct remodelling after STEMI in the contemporary era of primary percutaneous coronary intervention (PCI) and optimal pharmacotherapy.Methods and results Data were obtained from an ongoing primary PCI STEMI registry. LV remodelling was defined as >= 20% increase in LV end-diastolic volume at either 3, 6, or 12 months post-infarct, and LV remodelling impact on outcome was evaluated with a log-rank test. A total population of 1995 STEMI patients were analysed (mean age 60 +/- 12 years): 1527 (77%) men and 468 (23%) women. The mean age of male patients was 60 +/- 11 versus 63 +/- 13 years for women (P < 0.001). A total of 953 (48%) patients experienced LV remodelling in the first 12 months of follow-up, and it was equally frequent amongst men (n = 729, 48%) and women (n = 224, 48%). After a median follow-up of 94 (interquartile range 69-119) months, 225 patients died: 171 (11%) men and 54 (12%) women. No survival difference was seen between remodellers and non-remodellers in the male (P = 0.113) and female (P = 0.920) groups.Conclusion LV post-infarct remodelling incidence, as well as long-term survival of LV remodellers and non-remodellers, was similar in men and women who were treated with primary PCI and optimal pharmacotherapy post-STEMI.

Systemic sclerosis (SSc) is associated with increased mortality mostly due to cardiovascular or pulmonary causes [(1,2)][1]. Diagnosis of cardiac involvement remains challenging, especially at an early stage because standard echocardiography lacks sensitivity to detect subtle myocardial dysfunction

Background: Right ventricular (RV) systolic function in patients admitted with ST-segment elevation myocardial infarction (STEMI) with chronic obstructive pulmonary disease (COPD) and its impact on prognosis have not been characterized. The present study aims to compare the prevalence of RV systolic dysfunction in COPD versus non-COPD patients with STEMI and evaluate the prognostic implications.Methods: One hundred seventeen STEMI patients with COPD with transthoracic echocardiography performed within 48 hours of admission were retrospectively selected. Matched on age, gender, and infarct size (determined by cardiac biomarkers and left ventricular ejection fraction [LVEF]), 207 non-COPD patients were selected. RV dysfunction was defined based on tricuspid annular plane systolic excursion -20%. Patients were followed for the occurrence of all-cause mortality.Results: RV assessment was feasible in 112 COPD and 199 non-COPD patients (mean age, 69 +/- 10; 74% male; mean, LVEF 47% +/- 8%). Patients with COPD had significantly lower RV FAC (38% +/- 11% vs 40% +/- 9%; P = .04), equal TAPSE and S' (17.9 +/- 3.7 vs 18.1 +/- 3.8 mm, P = .72; and 8.4 +/- 2.2 vs 8.5 +/- 2.2 cm/sec, P = .605, respectively) and more impaired RV FWSL (-21.1% +/- 6.6% vs -23.4% +/- 6.5%, P = .005), compared with patients without COPD. RV dysfunction was more prevalent in patients with COPD, particularly when assessed with RV FWSL (46% vs 32%; P = .021). During a median followup of 30 (interquartile range 1.5-44) months, 49 patients died (16%). Multivariate models stratified for COPD status showed that RV FWS >-20% was independently associated with 5-year all-cause mortality (hazard ratio, 2.05; 95% CI, 1.12-3.76; P = .020), after adjusting for age, diabetes, peak troponin level, and LVEF. Interestingly, RV FAC < 35%, S'< 6 cm/sec, and TAPSE < 17 mm were not independently associated with survival.Conclusion: In a STEMI population with relatively preserved LVEF, COPD patients had significantly worse RV FWSL compared with patients without COPD. Moreover, RV FWSL > -20% was independently associated with worse survival. In contrast, conventional parameters were not associated with survival.

Objectives This study sought to evaluate the effect of early intravenous metoprolol on left ventricular (LV) strain assessed with feature-tracking cardiovascular magnetic resonance (CMR). Background Early intravenous metoprolol before primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) portends better outcomes in the METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial. Methods A total of 197 patients with acute anterior STEMI who were enrolled in the METOCARD-CNIC trial (100 allocated to intravenous metoprolol before primary PCI and 97 control patients) were evaluated. LV global circumferential strain (GCS) and global longitudinal strain (GLS) were measured with feature-tracking CMR at 1 week and 6 months after STEMI and compared between randomization groups. Results Patients who received early intravenous metoprolol had significantly more preserved LV strain compared with the control patients at 1 week after STEMI (GCS −13.9 ± 3.8% vs. −12.6 ± 3.9%, respectively; p = 0.013; GLS −11.9 ± 2.8% vs. −10.9 ± 3.2%, respectively; p = 0.032). In both groups, LV strain significantly improved during follow-up (mean difference between 6-month and 1-week strain for the metoprolol group: GCS −2.9%, 95% confidence interval [CI]: −3.5% to −2.4%; GLS: −2.9%, 95% CI: −3.4% to −2.4%; both p Conclusions In patients with anterior STEMI, early administration of intravenous metoprolol before primary PCI was associated with significantly fewer patients with severely depressed LV GCS and GLS, both at 1 week and 6 months. Feature-tracking CMR represents a complementary tool to evaluate the benefits of cardioprotective therapies. (Effect of METOprolol in CARDioproteCtioN During an Acute Myocardial InfarCtion [METOCARD-CNIC]: NCT01311700)

Aims Pressure overload in aortic stenosis (AS) and both pressure and volume overload in aortic regurgitation (AR) induce concentric and eccentric hypertrophy, respectively. These structural changes influence left ventricular (LV) mechanics, but little is known about the time course of LV remodelling and mechanics after aortic valve surgery (AVR) and its differences in AS vs. AR. The present study aimed to characterize the time course of LV mass index (LVMI) and LV mechanics [by LV global longitudinal strain (LV GLS)] after AVR in AS vs. AR. Methods and results Two hundred and eleven (61 ± 14 years, 61% male) patients with severe AS (63%) or AR (37%) undergoing surgical AVR with routine echocardiographic follow-up at 1, 2, and/or 5 years were evaluated. Before AVR, LVMI was larger in AR patients compared with AS. Both groups showed moderately impaired LV GLS, but preserved LV ejection fraction. After surgery, both groups showed LV mass regression, although a more pronounced decline was seen in AR patients. Improvement in LV GLS was observed in both groups, but characterized by an initial decline in AR patients while LV GLS in AS patients remained initially stable. Conclusion In severe AS and AR patients undergoing AVR, LV mass regression and changes in LV GLS are similar despite different LV remodelling before AVR. In AR, relief of volume overload led to reduction in LVMI and an initial decline in LV GLS. In contrast, relief of pressure overload in AS was characterized by a stable LV GLS and more sustained LV mass regression.

Several studies have shown an association between aortic valve stenosis (AS), atherosclerosis and cardiovascular risk factors. These risk factors are frequently encountered in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to evaluate the prevalence and the prognostic implications of AS in patients presenting with STEMI. A total of 2041 patients (61 +/- 12 years old, 76% male) admitted with STEMI and treated with primary percutaneous coronary intervention were included. Patients with previous myocardial infarction and previous aortic valve replacement were excluded. Echocardiography was performed at index admission. Patients were divided in 3 groups: 1) any grade of AS, 2) aortic valve sclerosis and 3) normal aortic valve. Any grade of AS was defined as an aortic valve area = 85 years, respectively). Patients with AS showed a significantly higher mortality rate when compared to the other two groups (p < 0.001) and AS was independently associated with all-cause mortality, with a HR of 1.81 (CI 95%: 1.02 to 3.22; p = 0.04). In conclusion, AS is not uncommon in patients with STEMI, and concomitant AS in patients with first STEMI is independently associated with all-cause mortality at long-term follow up. (C) 2021 The Author(s). Published by Elsevier Inc.

Aims Secondary mitral regurgitation (MR) is more frequent in men than in women. However, little is known about differences in prognosis between men and women with secondary MR. The objective of this study is to investigate the sex distribution of secondary MR and the prognostic differences between sexes. Methods Patients with significant secondary MR, of both ischaemic and non‐ischaemic aetiologies, were identified through the departmental electronic patient files and retrospectively analysed. The primary endpoint was all‐cause mortality. Results A total of 698 patients (mean age 66 ± 11 years) with significant secondary MR were included: 471 (67%) men and 227 (33%) women. Ischaemic heart failure was significantly more common in men (61%), whereas non‐ischaemic heart failure was more prevalent in women (63%). Women had significantly smaller left ventricular (LV) volumes when compared with men and more preserved LV systolic function when assessed with LV global longitudinal strain (GLS; 8.5 ± 4.1% vs. 7.5 ± 3.6%; P = 0.004). Women more often underwent surgical mitral valve repair (34%) when compared with men (26%), although no differences were observed for transcatheter mitral valve repair. During a median follow‐up of 57 [interquartile range 29–110] months, 373 (53%) patients died. Women showed significantly lower mortality rates at 1‐, 2‐ and 5‐year follow‐up (9%, 16% and 33% vs. 10%, 20% and 42%) when compared with men (P = 0.001). Conclusions Significant secondary MR is more frequently observed in men as compared with women and is associated with worse prognosis.

Multilayer (epi-, mid- and endocardium) left ventricular (LV) global longitudinal strain (GLS) reflects the extent of myocardial damage after ST-segment myocardial infarction (STEMI). However, the prognostic implications of multilayer LV GLS remain unclear. We studied the association between multilayer LV GLS and prognosis in patients with mildly reduced or preserved LV ejection fraction (EF) after STEMI. Patients with first STEMI and LVEF>45% were evaluated retrospectively. Baseline multilayer (endocardial, mid-myocardial and epicardial) LV GLS were measured on 2-dimensional speckle tracking echocardiography. Patients were followed up for of all-cause mortality. A total of 569 patients (77% male, 60 +/- 11 years) were included. After a median follow-up of 117 (interquartile range 106-132) months, 95 (17%) patients died. We observed no differences in baseline LVEF and peak troponin levels between survivors and non-survivors. However, non-survivors showed more impaired GLS at all layers (epicardium: -11.9 +/- 2.8% vs. -13.4 +/- 2.8%; mid-myocardium: -14.2 +/- 3.2% vs. -15.6 +/- 3.2%; endocardium: -16.5 +/- 3.7% vs. -17.7 +/- 3.6%, p

This study investigates the relation of non-invasive myocardial work and myocardial viability following ST-segment elevation myocardial infarction (STEMI) assessed on late gadolinium contrast enhanced cardiac magnetic resonance (LGE CMR) and characterizes the remote zone using non-invasive myocardial work parameters. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were included. Several non-invasive myocardial work parameters were derived from speckle tracking strain echocardiography and sphygmomanometric blood pressure, e.g.: myocardial work index (MWI), constructive work (CW), wasted work (WW) and myocardial work efficiency (MWE). LGE was quantified to determine infarct transmurality and scar burden. The core zone was defined as the segment with the largest extent of transmural LGE and the remote zone as the diametrically opposed segment without LGE. A total of 53 patients (89% male, mean age 58 +/- 9 years) and 689 segments were analyzed. The mean scar burden was 14 +/- 7% of the total LV mass, and 76 segments (11%) demonstrated transmural hyperenhancement, 280 (41%) non-transmural hyperenhancement and 333 (48%) no LGE. An inverse relation was observed between segmental MWI, CW and MWE and infarct transmurality (p < 0.05). MWI, CW and MWE were significantly lower in the core zone compared to the remote zone (p

The formation of superimposed tissue (SIT), a layer on top of the original valve leaflet, has been described in patients with mitral regurgitation as a major contributor to valve thickening and possibly as a result of increased mechanical stresses. However, little is known whether SIT formation also occurs in aortic valve disease. We therefore performed histological analyses to assess SIT formation in aortic valve leaflets (n = 31) from patients with aortic stenosis (n = 17) or aortic regurgitation due to aortic dilatation (n = 14). SIT was observed in both stenotic and regurgitant aortic valves, both on the ventricular and aortic sides, but with significant differences in distribution and composition. Regurgitant aortic valves showed more SIT formation in the free edge, leading to a thicker leaflet at that level, while stenotic aortic valves showed relatively more SIT formation on the aortic side of the body part of the leaflet. SIT appeared to be a highly active area, as determined by large populations of myofibroblasts, with varied extracellular matrix composition (higher collagen content in stenotic valves). Further, the identification of the SIT revealed the presence of foldings of the free edge in the diseased aortic valves. Insights into SIT regulation may further help in understanding the pathophysiology of aortic valve disease and potentially lead to the development of new therapeutic treatments.

Chronic pressure-overload induces right ventricular (RV) adaptation to maintain RV -pulmonary arterial (PA) coupling. RV remodeling is frequently associated with secondary tricuspid regurgitation (TR) which may accelerate uncoupling. Our aim is to determine whether the non-invasive analysis of RV-PA coupling could improve risk stratification in patients with secondary TR. A total of 1,149 patients (median age 72[IQR, 63 to 79] years, 51% men) with moderate or severe secondary TR were included. RV-PA coupling was estimated using the ratio between two standard echocardiographic measurements: tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). The risk of all-cause mortality across different values of TAPSE/PASP was analyzed with a spline analysis. The cut-off value of TAPSE/PASP to identify RV-PA uncoupling was based on the spline curve analysis. At the time of significant secondary TR diagnosis the median TAPSE/PASP was 0.35 (IQR, 0.25 to 0.49) mm/mm Hg. A total of 470 patients (41%) demonstrated RV-PA uncoupling (< 0.31 mm/mm Hg). Patients with RV-PA uncoupling presented more frequently with heart failure symptoms had larger RV and left ventricular dimensions, and more severe TR compared to those with RV-PA coupling. During a median follow-up of 51 (IQR, 17 to 86) months, 586 patients (51%) died. The cumulative 5-year survival rate was lower in patients with RV-PA uncoupling compared to their counterparts (37% vs 64%, p < 0.001). After correcting for potential confounders, RV-PA uncoupling was the only echocardiographic parameter independently associated with all-cause mortality (HR 1.462; 95% CI 1.192 to 1.793; p < 0.001). In conclusion, RV-PA uncoupling in patients with secondary TR is independently associated with poor prognosis and may improve risk stratification. (C) 2021 The Author(s). Published by Elsevier Inc.

Aims Peak left atrial longitudinal strain (PALS) is a marker of the left atrial (LA) reservoir function. Novel feature tracking (FT) software allows assessment of LA strain from multidetector computed tomography (MDCT) data. This study aimed at evaluating the agreement between speckle tracking echocardiography (STE) and FT MDCT for the measurement of PALS in patients with sinus rhythm (SR) and with atrial fibrillation (AF). Methods and results The current study included 318 patients (80 ± 7 years, 54% male) with dynamic MDCT data acquired prior to transcatheter aortic valve implantation. PALS was measured by transthoracic echocardiography using STE (PALSecho) and MDCT using dedicated FT software (PALSCT). In the overall population, the median values of PALSecho and PALSCT were 19.0 [interquartile range (IQR) 12.0–25.0] % and 15.3 (IQR 9.2–19.7) %, respectively. High correlation between PALSecho and PALSCT was observed (r = 0.789, P Conclusion PALSecho and PALSCT showed a good agreement in patients with severe aortic stenosis (AS) regardless of the cardiac rhythm. FT MDCT may be an important adjuvant modality for assessing LA reservoir function in patients with severe AS.

Aims An echocardiographic staging system of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography (MDCT) is key in the evaluation of AS patients undergoing TAVI and can potentially detect extra-valvular cardiac damage. This study aimed at evaluating the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. Methods and results A total of 405 patients (80 ± 7 years, 52% men) who underwent full-beat MDCT prior to TAVI were included. The extent of cardiac damage was assessed by MDCT and classified in five categories; Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (left atrium and mitral valve damage), Stage 3 (right atrial damage), and Stage 4 (right ventricular damage). Twenty-seven (7%) patients were stratified as Stage 0, 96 (24%) as Stage 1, 152 (38%) as Stage 2, 78 (19%) as Stage 3, and 52 (13%) as Stage 4. During a median follow-up of 3.7 (IQR 1.7–5.5) years, 150 (37%) died. On multivariable Cox regression analysis, cardiac damage Stage 3 (HR vs. Stage 0: 4.496, P = 0.039) and Stage 4 (HR vs. Stage 0: 5.565, P = 0.020) were independently associated with all-cause mortality. Conclusion The MDCT-based staging system of cardiac damage in severe AS effectively identifies the patients who are at higher risk of death after TAVI.

Aims The aim of this study is to analyse how current recommendations on left ventricular (LV) diastolic function assessment have been adopted. Identifying potential discrepancies between recommendations and everyday clinical practice would enable us to better understand and address the remaining challenges in this controversial and complex field. Methods and results A total of 93 centres, mainly from tertiary care settings, responded to the survey. More than three-quarters (77%) of centres follow the 2016 ASE/EACVI recommendations for LV diastolic function evaluation in patients with preserved ejection fraction based upon e′, E/e′, tricuspid regurgitation velocity, and left atrial (LA) volume. These recommendations were generally preferred to the previous 2009 version. Many centres also consider strain assessments in the LV (48%) and left atrium (53%) as well as diastolic stress echocardiography (33%) to be useful as additional assessments of LV diastolic function. Echocardiographic assessments of LV diastolic function were used frequently to guide therapy in 72% of centres. Conclusion There is widespread adoption of current recommendation on the evaluation of LV diastolic function and these are frequently used to guide patient management. Many centres now also consider LV and LA strain assessments useful in the clinical assessment of diastolic function. These may be considered in future recommendations.

Aims Tricuspid regurgitation (TR) has been associated with outcome in patients treated with transcatheter aortic valve implantation (TAVI). Tricuspid annulus (TA) dimensions are associated with TR. However, the TA is highly dynamic during the cardiac cycle, and the interaction between the TA dimensions, TR, and patient prognosis has never been evaluated. This study aimed to characterize the dynamics of the TA along with the cardiac cycle and its association with prognosis in patients undergoing TAVI. Methods and results Patients with severe aortic stenosis who underwent whole-beat computed tomography (n = 393, mean age 80 ± 7 years, 53% male) were included. The ratio between anterior-posterior (AP) and septal-lateral (SL) diameter of the TA was calculated at end-systole (ES), mid-diastole (MD), and end-diastole (ED) to characterize the TA shape throughout the cardiac cycle. The primary endpoint was all-cause mortality. During a median follow-up of 3.6 (1.7–5.5) years, 146 patients died. While all the TA parameters at ES and MD were not associated with all-cause mortality, a low AP/SL ratio at ED (more circular geometry) was independently related with all-cause mortality (hazard ratio: 4.717, 95% confidence interval: 1.481–15.152; P = 0.009). In addition, a more circular TA shape at ED (AP/SL ratio Conclusion Circular remodelling of the TA shape at ED is associated with more right atrial and ventricular dilation, and a higher long-term mortality after TAVI. The evaluation of the TA shape at ED may be a useful parameter in the risk stratification of patients undergoing TAVI.

Background: Left ventricular (LV) global longitudinal strain has demonstrated incremental prognostic value over LV ejection fraction in patients with ST-segment–elevation myocardial infarction. However, LV global longitudinal strain does not take into consideration the effect of afterload. Novel speckle-tracking echocardiographic indices of myocardial work integrate blood pressure measurements (afterload) with LV global longitudinal strain. The present study aimed to investigate the prognostic value of global LV myocardial work efficiency (GLVMWE; reflecting LV performance) obtained from pressure-strain loops with echocardiography in patients with ST-segment–elevation myocardial infarction. Methods: A total of 507 ST-segment–elevation myocardial infarction patients (mean age, 61±11 years; 76% men) were retrospectively analyzed. LV ejection fraction and GLVMWE were measured by transthoracic echocardiography within 48 hours of admission. GLVMWE was defined as the ratio of constructive work divided by the sum of constructive and wasted work in all LV segments and expressed as a percentage. Spline curve analysis was used to define the association between reduced GLVMWE and all-cause death. Results: After a median follow-up of 80 months (interquartile range, 67–97 months), 40 (8%) patients died. Patients with reduced GLVMWE (P P Conclusions: Reduced GLVMWE (

Degenerative mitral valve disease causing mitral valve prolapse is the most common cause of primary mitral regurgitation, with two distinct phenotypes generally recognized with some major differences, i.e., fibroelastic deficiency (FED) and Barlow’s disease. The aim of this review was to describe the main histological, clinical and echocardiographic features of patients with FED and Barlow’s disease, highlighting the differences in diagnosis, risk stratification and patient management, but also the still significant gaps in understanding the exact pathophysiology of these two phenotypes.

Aims This study aimed to determine whether lower values of left ventricular (LV) global work index (GWI) at baseline were associated with a reduction in LV functional recovery and poorer long-term prognosis in patients with reduced LV ejection fraction (LVEF ≤40%) following ST-segment elevation myocardial infarction (STEMI). Methods and results A total of 197 individuals (62 ± 12 years, 75% male) with STEMI treated with primary percutaneous coronary intervention and reduced LVEF were evaluated. All patients were followed up for the occurrence of all-cause mortality and the presence of LVEF normalization at 6 months (LVEF ≥50%). The median LVEF was 36% (interquartile range 32–38) and the mean value of LV GWI was 1041 ± 404 mmHg% at baseline. At 6-month follow-up, 41% of patients had normalized LVEF. On multivariable logistic regression, higher values of LV GWI were independently associated with LVEF normalization at 6 months of follow-up (odds ratio 1.32 per 250 mmHg%, P = 0.038). Over a median follow-up of 112 months, 40 patients (20%) died. LV GWI Conclusion In individuals with an LVEF ≤40% following STEMI, higher values of LV GWI were associated with a greater probability of LVEF normalization at 6-month follow-up. In addition, lower values of LV GWI were independently associated with increased all-cause mortality at long-term follow-up, providing incremental prognostic value over LVEF and minor incremental prognostic value over LV global longitudinal strain.

ObjectiveMitral valve prolapse (MVP) has been associated with ventricular arrhythmias (VA), but little is known about VA in patients with significant primary mitral regurgitation (MR). Our aim was to describe the prevalence of symptomatic VA in patients with MVP (fibro-elastic deficiency or Barlow’s disease) referred for mitral valve (MV) surgery because of moderate-to-severe MR, and to identify clinical, electrocardiographic, standard and advanced echocardiographic parameters associated with VA.Methods610 consecutive patients (64±12 years, 36% female) were included. Symptomatic VA was defined as symptomatic and frequent premature ventricular contractions (PVC, Lown grade ≥2), non-sustained or sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) without ischaemic aetiology.ResultsA total of 67 (11%) patients showed symptomatic VA, of which 3 (4%) had VF, 3 (4%) sustained VT, 27 (40%) non-sustained VT and 34 (51%) frequent PVCs. Patients with VA were significantly younger, more often female and showed T-wave inversions; furthermore, they showed significant MV morphofunctional abnormalities, such as mitral annular disjunction (39% vs 20%, pConclusionIn patients with MVP with moderate-to-severe MR, symptomatic VA are relatively frequent and associated with significant MV annular abnormalities, subtle left ventricular function impairment and heterogeneous contraction. Assessment of these parameters might help decision-making over further diagnostic analyses and improve risk-stratification.

BackgroundThe criteria to define the grade of aortic stenosis (AS)—aortic valve area (AVA) and mean gradient (MG) or peak jet velocity—do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown.ObjectivesTo investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG MethodsFrom an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG ResultsOf 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0–8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, pConclusionDiscordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality.

ObjectivesTo develop a prediction model to guide annual assessment of systemic sclerosis (SSc) patients tailored in accordance to disease activity.MethodsA machine learning approach was used to develop a model that can identify patients without disease progression. SSc patients included in the prospective Leiden SSc cohort and fulfilling the ACR/EULAR 2013 criteria were included. Disease progression was defined as progression in ≥1 organ system, and/or start of immunosuppression or death. Using elastic-net-regularisation, and including 90 independent clinical variables (100% complete), we trained the model on 75% and validated it on 25% of the patients, optimising on negative predictive value (NPV) to minimise the likelihood of missing progression. Probability cutoffs were identified for low and high risk for disease progression by expert assessment.ResultsOf the 492 SSc patients (follow-up range: 2–10 years), disease progression during follow-up was observed in 52% (median time 4.9 years). Performance of the model in the test set showed an AUC-ROC of 0.66. Probability score cutoffs were defined: low risk for disease progression (0.223, NPV:0.78; 44%). The relevant variables for the model were: previous use of cyclophosphamide or corticosteroids, start with immunosuppressive drugs, previous gastrointestinal progression, previous cardiovascular event, pulmonary arterial hypertension, modified Rodnan Skin Score, creatine kinase and diffusing capacity for carbon monoxide.ConclusionOur machine-learning-assisted model for progression enabled us to classify 29% of SSc patients as ‘low risk’. In this group, annual assessment programmes could be less extensive than indicated by international guidelines.

Mitral valve prolapse (MVP) is a common valvular disease, which may remain a benign condition for a long period of time. However, some patients experience malignant ventricular arrhythmias and sudden cardiac death (SCD). It is still largely unknown how to risk-stratify these patients, and no specific recommendations have been proposed to help the clinical decision-making. We present the case of a young man whose first clinical presentation was an out-of-hospital cardiac arrest and was subsequently diagnosed with MVP. We highlighted the possible risk factors for SCD and the challenges in the clinical management of these patients.

© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ., Objective: To investigate the prognostic value of left atrial volume index (LAVI) in patients with moderate to severe aortic regurgitation (AR) and bicuspid aortic valve (BAV). Methods: 554 individuals (45 (IQR 33-57) years, 80% male) with BAV and moderate or severe AR were selected from an international, multicentre registry. The association between LAVI and the combined endpoint of all-cause mortality or aortic valve surgery was investigated with Cox proportional hazard regression analyses. Results: Dilated LAVI was observed in 181 (32.7%) patients. The mean indexed aortic annulus, sinus of Valsalva, sinotubular junction and ascending aorta diameters were 13.0±2.0 mm/m2, 19.4±3.7 mm/m2, 16.5±3.8 mm/m2 and 20.4±4.5 mm/m2, respectively. After a median follow-up of 23 (4-82) months, 272 patients underwent aortic valve surgery (89%) or died (11%). When compared with patients with normal LAVI (

Objectives: The impact of atrial ischemia in the occurrence of atrial arrhythmiasmay vary based on the amount of jeopardized myocardium. We sought to determine the association between coronary flow impairment in dominant coronary atrial branches (CAB) and atrial arrhythmias at 1-year follow-up in ST-segment elevation myocardial infarction (STEMI) patients.Methods: Patients with STEMI involving the right or circumflex coronary artery were included. Dominant CAB was defined as the most developed CAB. Patients were followed-up during 1 year, including 24-h Holter ECG at 3 and 6months. Atrial arrhythmiaswere defined as atrial fibrillation/flutter, atrial tachycardia (>= 3 consecutive supraventricular ectopic beats) and excessive supraventricular ectopic activity (>30 supraventricular beats/h or runs >= 20 beats).Results: A dominant CAB was identified in 897 of 900 patients STEMI (age 61 +/- 12 years, 79% male). TIMI flow b 3 at the dominant CAB was present in 69 (8%) patients. Compared to those with dominant CAB preserved flow, patients with dominant CAB flow impairment presented with higher levels of troponin T (3.9 [2.2-8.2] vs. 3.1 [1.3-5.8], P= 0.008)and higher rates of atrial tachycardia at 3months (68% vs. 37%, P= 0.007) and more supraventricular ectopic beats both at 3 months (58 [21-235] vs. 33 [12-119], P = 0.02) and at 6 months (62 [24-156] vs. 32 [12-115]; P = 0.04) on 24-h Holter ECG. Age and an impaired coronary flow at the dominant CAB were independently related to a higher risk of developing atrial arrhythmias at 1-year follow-up.Conclusion: Dominant CAB flow impairment is infrequent and is associatedwith the occurrence of atrial arrhythmias, in the form atrial tachycardia and supraventricular ectopic beats, at follow-up. (C) 2020 Elsevier Inc. All rights reserved.

The aim of this study was to assess differences in etiology, comorbidities, echocardiographic parameters, and prognosis between men and women with significant tricuspid regurgitation (TR). Clinical and echocardiographic characteristics of 1569 patients (age 71 [62 to 78] years) at first diagnosis of significant TR were compared between men and women. Patients with congenital heart disease or previous tricuspid valve surgery were excluded. TR etiologies were defined as primary, left valvular disease related, left ventricular (LV) dysfunction related, pulmonary hypertension related, or isolated. The primary endpoint was all-cause mortality. Sex-specific differences in outcomes were compared in the total population and after propensity score matching. There were 798 (51%) women and 771 (49%) men in the study population. Women were diagnosed with significant TR at an older age compared with men (72 [62 to 79] years vs. 70 [61 to 77] years; p = 0.003). The TR etiology in women was more often left valvular disease related and isolated whereas men more often had LV dysfunction related TR. In the total population women had better 10-year survival compared with men (49% vs. 39%; p=0.001). After propensity score matching, the influence of sex on survival was neutralized (p = 0.228) but the TR etiologies remained significantly associated with all-cause mortality. Patients with left valvular disease or LV dysfunction related TR had lower survival compared with patients with primary TR (p = 0.004 and p = 0.019, respectively). In conclusion, long-term survival of patients with significant TR was similar between men and women after propensity score matching, while the etiology of TR remained significantly associated with all-cause mortality.

Background Studies evaluating the relationship between baseline left ventricular (LV) volumes and long-term prognosis in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT) are lacking. Purpose To evaluate the association of LV end-systolic and end-diastolic volumes (ESV and EDV) with long-term prognosis in patients with HF treated with CRT. Methods Patients from an ongoing institutional HF registry who received CRT according to contemporary guidelines were included. All patients underwent standard transthoracic echocardiography. LV volumes were measured using the biplane method during off-line analysis. Primary end-point included all-cause mortality, implantation of left ventricular assist device or heart transplantation, which were assessed according to the national death registry and case records. Results In total, 1165 patients with feasible LV volume assessment were included (mean age 67±10 years; 74.8% males; 55.3% with non-ischemic aetiology of HF). After a median follow-up of 75 (40; 123) months, the primary end-point occurred in 708 (60.8%) patients. Median baseline LV ESV was 151 (108; 198) ml and EDV was 202 (156; 258) ml. All patients were divided into quartiles according to the baseline EDV and ESV: those with larger volumes were significantly younger, more frequently male and had longer QRS durations (p0.05). To investigate the association between long-term prognosis and baseline LV volumes (EDV and ESV), a Cox proportional hazards model was constructed with variables known to influence the mortality of HF patients (age, gender, aetiology, QRS duration, and estimated glomerular filtration rate). When separately included in a multivariate analysis, baseline LV ESV and LV EDV were both independently associated with the primary end-point (p Conclusion LV volumes before CRT implantation are independently associated with prognosis during long-term follow-up. Our findings indicate the importance of taking baseline LV remodelling into consideration to identify patients at high mortality risk after CRT implantation. Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): The author acknowledges funding received from the European Society of Cardiology in form of an ESC Training Grant

Aims Cardiac damage in severe aortic stenosis (AS) can be classified according to a recently proposed staging classification. The present study investigated the incremental prognostic value of left ventricular (LV) global longitudinal strain (GLS) over stages of cardiac damage in patients with severe AS. Methods and results From an ongoing registry, a total of 616 severe symptomatic AS patients with available LV GLS by speckle tracking echocardiography were selected and retrospectively analysed. Patients were categorized according to cardiac damage on echocardiography: Stage 0 (no damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage), or Stage 4 (right ventricular damage). LV GLS was divided by quintiles and assigned to the different stages. The endpoint was all-cause mortality. Over a median follow-up of 44 [24–89] months, 234 (38%) patients died. LV GLS was associated with all-cause mortality independent of stage of cardiac damage. After incorporation of LV GLS by quintiles into the staging classification, Stages 2–4 were independently associated with outcome. LV GLS showed incremental prognostic value over clinical characteristics and stages of cardiac damage. Conclusion In this large single-centre cohort of severe AS patients, incorporation of LV GLS by quintiles in a novel proposed staging classification resulted in refinement of risk stratification by identifying patients with more advanced cardiac damage. LV GLS was shown to provide incremental prognostic value over the originally proposed staging classification.

Aims Left ventricular (LV) mechanical dispersion (MD) may result from heterogeneous electrical conduction and is associated with adverse events. The present study investigated (i) the association between LV MD and the extent of LV scar as assessed with contrast-enhanced cardiac magnetic resonance (CMR) and (ii) the prognostic implications of LV MD in patients after ST-segment elevation myocardial infarction. Methods and results LV MD was calculated by echocardiography and myocardial scar was analysed on CMR data retrospectively. Infarct core and border zone were defined as ≥50% and 35–50% of maximal signal intensity, respectively. Patients were followed for the occurrence of the combined endpoint (all-cause mortality and appropriate implantable cardioverter-defibrillator therapy). In total, 96 patients (87% male, 57 ± 10 years) were included. Median LV MD was 53.5 ms [interquartile range (IQR) 43.4–62.8]. On CMR, total scar burden was 11.4% (IQR 3.8–17.1%), infarct core tissue 6.2% (IQR 2.0–12.7%), and border zone was 3.5% (IQR 1.5–5.7%). Correlations were observed between LV MD and infarct core (r = 0.517, P 53.5 ms showed higher event rates as compared to their counterparts. Finally, LV MD showed the highest area under the curve for the prediction of the combined endpoint. Conclusion LV MD is correlated with LV scar burden. In addition, patients with prolonged LV MD showed higher event rates. Finally, LV MD provided the highest predictive value for the combined endpoint when compared with other parameters.

Background Left ventricular (LV) remodelling after ST-segment elevation myocardial infarction (STEMI) is a complex pathological process which has been associated with long-term cardiovascular adverse events. The current definition of LV remodelling is usually based on the change in LV end-diastolic volume (LVEDV). An increase in LVEDV, however, may also be considered an adaptive response to maintain effective LV ejection fraction (LVEF) in LV remodelling. Purpose To reclassify post-infarct LV remodelling according to the change in LVEDV and LVEF from baseline and to determine the prognostic relevance of integrated LV remodelling and systolic function groups. Methods A total of 1859 patients with STEMI who received primary percutaneous coronary intervention (PCI) and guideline-directed medical treatment, were retrospectively evaluated. Four LV remodelling subgroups were identified, based on the change in LVEDV and LVEF from baseline to 6 months post-infarct. ≥20% increase in LVEDV, compared to baseline, was defined as LV dilatation, while any increase or decrease in LVEF compared to baseline was used to categorise remodelling further according to systolic function. Study endpoints were all-cause mortality and the composite of all-cause mortality and heart failure (HF) hospitalisation. Results The mean age of the study population was 60±11 years and the majority were men (76.4%). 402 patients showed LVEDV≥20% and LVEF increase (Group 1), 952 patients LVEDV≤20% and LVEF increase (Group 2), 325 patients LVEDV≤20% and LVEF decrease (Group 3) and 180 patients LVEDV≥20% and LVEF decrease (Group 4). During a median follow-up of 89 (IQR 64; 113) months, all-cause mortality occurred in 256 patients (13.8%), HF hospitalisation in 40 patients (2.2%) and the composite endpoint in 279 patients (15.0%). All-cause mortality was significantly higher in Group 4 (21.7%, chi-square p=0.002) compared to other groups (15.4% in Group, 12.9% in Group 2 and 9.8% in Group 3). The composite endpoint was also significantly more frequent in Group 4 (25.6%, chi-square p Conclusion Patients with LVEDV≥20% and a LVEF decrease at 6 months after STEMI experienced all-cause mortality and the composite endpoint of all-cause mortality and HF hospitalisation more frequently compared to other LV remodelling groups. Patients with an increase in LVEDV and a decrease in LVEF 6 months after STEMI, may benefit from careful surveillance and preventative strategies. KM comparison for study endpoints. Funding Acknowledgement Type of funding source: None

The aim of the present study was to investigate the long-term impact of early intravenous metoprolol in ST-segment elevation myocardial infarction (STEMI) patients in terms of left ventricular (LV) strain with feature-tracking cardiovascular magnetic resonance (CMR) and its association with prognosis. A total of 270 patients with first anterior STEMI enrolled in the randomized METOCARD-CNIC clinical trial, assigned to receive up to 15 mg intravenous metoprolol before primary percutaneous coronary intervention versus conventional STEMI therapy, were included. LV global circumferential (GCS) and longitudinal (GLS) strain were assessed with feature-tracking CMR at 1 week after STEMI in 215 patients. The occurrence of major adverse cardiac events (MACE) at 5-year follow-up was the primary end point. Among 270 patients enrolled, 17 of 139 patients assigned to metoprolol arm and 31 of 131 patients assigned to control arm experienced MACE (hazard ratio [HR] 0.500, 95% confidence interval [CI] 0.277 to 0.903; p = 0.022). Impaired LV GCS and GLS strain were significantly associated with increased occurrence of MACE (GCS: HR 1.208, 95% CI 1.076 to 1.356, p =0.001; GLS: HR 1.362, 95% CI 1.180 to 1.573, p < 0.001). On multivariable analysis, LV GLS provided incremental prognostic value over late gadolinium enhancement (LGE) and LV ejection fraction (LVEF) (LGE + LVEF chi-square = 12.865, LGE + LVEF + GLS chi-square = 18.459; p =0.012). Patients with GLS ≥-11.5% (above median value) who received early intravenous metoprolol were 64% less likely to experience MACE than their counterparts with same degree of GLS impairment (HR 0.356, 95% CI 0.129 to 0.979; p = 0.045). In conclusion, early intravenous metoprolol has a long-term beneficial prognostic effect, particularly in patients with severely impaired LV systolic function. LV GLS with feature-tracking CMR early after percutaneous coronary intervention offers incremental prognostic value over conventional CMR parameters in risk stratification of STEMI patients. METOCARD-CNIC trial work was partially supported by the Centro Nacional de Investigaciones Cardiovasculares (CNIC), through CNIC Translational Grant 01-2009. Other sponsors were the Spanish Ministry of Health and Social Policy (EC10-042), the MutuaMadrileña Foundation (AP8695-2011), and a Master Research Agreement (MRA) between Philips healthcare and the CNIC. Dr Ibáñez is recipient of the ISCIII Fondo de Investigación Sanitaria grants and ERDF/FEDER funds (PI16/02110, DTS17/00136, PI13/01979, SAF2015-71613-REDI) related to this topic. The CNIC is supported by the Ministerio de Ciencia, Innovación y Universidades (MICINN) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (MINECO award SEV-2015-0505). Dr. Bucciarelli-Ducci is supported by the Bristol National Institute of Health Research (NIHR) Biomedical Research Centre (BRC). Sí

Background: Assessment of left ventricular (LV) remodeling after ST-segment elevation myocardial infarction (STEMI) is pivotal for patient management. Noninvasive myocardial work indices obtained from echocardiography-derived strain-pressure loops provide a new tool that permits characterization of LV mechanics. We aimed at characterizing myocardial work indices in patients with LV remodeling after STEMI versus patients without remodeling.Methods: Six-hundred STEMI patients were retrospectively analyzed (456 men, mean age: 61 +/- 11 years) and divided according to the presence of LV remodeling 3 months after the index admission (>= 20% increase in LV end-diastolic volume). Noninvasive myocardial work indices were measured at 3 months after STEMI.Results: LV remodeling was observed in 150 patients (25%) who showed more impaired global myocardial work indices compared with their counterparts: work index (1,708 +/- 522 mm Hg% vs 1,979 +/- 450 mm Hg %; P < .001), constructive work (1,941 +/- 598 mm Hg% vs 2,272 +/- 519 mm Hg%; P < .001), and work efficiency (92% [range 88%-96%] vs 95% [range 93%-96%]; P < .001). In addition, patients with LV remodeling had significantly increased wasted work (116 mm Hg% [range 73-184 mm Hg%] vs 91 mm Hg% [range 61-132 mm Hg%]; P < .001). The frequency of impaired global work index, constructive and work efficiency, and increased wasted work was significantly higher among patients with LV remodeling compared with their counterparts: 21.3%, 34.7%, 34.7%, and 14.0%, respectively, versus 5.3%, 9.6%, 8.9%, and 4.9%, respectively (P < .001).Conclusions: At 3-month follow-up after STEMI, patients with LV remodeling revealed more impaired myocardial work indices compared with patients without LV remodeling. The prevalence of impaired myocardial work indices was higher among patients with LV remodeling compared with patients without.

OBJECTIVES Mitral valve repair in native active infective endocarditis is technically challenging. The survival benefit over valve replacement is poorly established and possibly absent because of the high risk of repair failure and reoperation. In this study, we explore the results of our structured approach in these patients. METHODS Between January 2000 and January 2017, 149 patients underwent surgery for native mitral infective endocarditis. Among them, 97 (66%) patients underwent valve repair and 52 (34%) underwent valve replacement. Our structured approach consisted of early surgery, radical resection of infected tissue, liberal use of prosthetic materials and ‘patch’ repair techniques. A critical assessment of expected repair durability was made intraoperatively and repair was not performed if concerns of long-term durability existed. To study the effects of valve repair on overall survival, landmark analysis was performed. RESULTS In-hospital mortality was 15.4% (14 repair vs 9 replacement patients; P = 0.642). There were no residual infective endocarditis cases or early reoperations. On Cox proportional hazards analysis, valve replacement was not inferior to repair within 1-year post-surgery [hazard ratio (HR) 1.134, 95% confidence interval (CI) 0.504–2.540; P = 0.76]. Beyond 1 year post-surgery, replacement was associated with decreased survival (HR 2.534, 95% CI 1.002–6.406; P = 0.049). There were no differences in freedom from recurrent infective endocarditis (P = 0.47) and mitral valve reintervention (P = 0.52). CONCLUSIONS Active mitral valve endocarditis remains a complex disease with significant early and late morbidity and mortality. A structured approach allows valve repair in two-thirds of patients. Clinical results could be improved by focussing on early surgery, prior to extensive valve destruction, to enable durable repairs and improve late outcomes.