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Percutaneous left atrial appendage (LAA) occlusion is an emerging treatment option for patients with non-valvular atrial fibrillation who cannot tolerate oral anticoagulation. The Watchman device (Boston Scientific Corporation, Natick, MA, USA) is deployed at the ostium of the LAA, and an appropriately sized device is critical for successful occlusion. However, standardized imaging protocols for device sizing have not been established.We investigated the clinical utility of a standardized imaging protocol, with pre-procedural multi-detector cardiac computed tomography (MDCT), and intra-procedural transesophageal echocardiography (TEE), for Watchman device sizing.Patients who underwent Watchman device implantation between 2010 and 2016 at our center, and who had pre-procedural MDCT and intra-procedural TEE were included. MDCT measurements (CTmax, CTmin, CTmean), and TEE measurement (TEEmax) of the LAA ostium were determined for each case, and correlated with the final size of the Watchman device implanted. Demographic data and clinical outcomes were collected.The study included 80 patients (mean age: 75 ± 9.6 years; male: 68%; mean CHA2DS2-VASc score: 4.5 ± 1.4). CTmax of the LAA ostium correlated strongly with the final deployed Watchman device size (Spearman's rho: 0.81, p 0.001), while TEEmax of the LAA ostium showed only moderate correlation with the final deployed Watchman device size (Spearman's rho: 0.61, p 0.001). Implantation success rate was 100%. At a mean duration of follow-up of 197 days, there were no device-related complications (device embolization, cardiac perforation and pericardial tamponade). At follow-up, the vast majority of patients (76 patients; 95%) had either no or trivial (≤3 mm) residual peri-device leak on TEE.A standardized imaging protocol for assessment of Watchman device implantation incorporating pre-procedural MDCT and intra-procedural TEE, was associated with excellent procedural outcomes at a mean duration of follow-up of 197 days.

Objectives This study sought to determine if indexed effective orifice area (EOAi), using left ventricular outflow tract measured from computed tomography (EOAiCT), reclassified prosthesis–patient mismatch (PPM) compared with conventional echocardiogram-defined measurements (EOAiTTE). Background PPM does not predict mortality following transcatheter aortic valve replacement (TAVR). However, it is unknown if the EOAiCT of the left ventricular outflow tract improves risk stratification. Methods A total of 765 TAVR patients from the PARTNER II (Placement of Aortic Transcatheter Valves II) trial S3i cohort were evaluated. EOAi was calculated using the continuity equation, and the left ventricular outflow tract area was derived from baseline computed tomography. Traditional echocardiographic categories defined PPM: absent (>0.85 cm2/m2), moderate (≥0.65 and ≤0.85 cm2/m2), or severe (≤0.65 cm2/m2). Correlation of EOAiCT and EOAiTTE to 1-year outcomes was performed. Results The incidence of PPM was 24% with EOACT compared with 45% with EOAiTTE. Only 6% of PPM was graded severe by EOAiCT compared with 9% by EOAiTTE. EOAiTTE, but not EOAiCT, defined PPM showed association with reduced left ventricular mass regression (p = 0.03 vs. p = 0.52). There was no association between PPM and death or rehospitalization at 1 year with either modality. EOACT was associated with minor stroke at 1 year (log-rank p = 0.04), and EOAiTTE with stroke/transient ischemic attack (log-rank p = 0.030). Furthermore, when subjects with mild or greater paravalvular regurgitation were excluded, the presence of PPM did not show association with any outcome. Conclusions EOAiCT downgrades frequency and severity of PPM in patients after TAVR, and was not associated with mortality 1 year after TAVR. EOAiTTE, but not EOAiCT, was associated with less left ventricular mass regression.

Background Hereditary forms of amyloidosis are rare, but diagnosis will impact the treatment course of the patient and have lasting implications for other family members. Case 77 year old gentleman of Italian descent with a history of systolic heart failure (ejection fraction of 41%), hypertension, bilateral carpal tunnel syndrome, persistent atrial fibrillation (pulmonary vein isolation in 2013), history of mixed aortic valve disease status post 24 mm homograft presents with homograft degeneration. He subsequently underwent an aortic valve replacement with #23 CE valve and a 30 mm hemashield graft, mitral valve replacement and Left atrial appendage ligation. Left atrial appendage and mitral valve tissue were positive for amyloid on thioflavin S stain and immunohistochemical staining with strong reactivity to transthyretin. TTR genotyping confirmed an Italian variant c.252T>G; p.Phe84Leu (old nomenclature Phe64Leu). A technetium pyrophosphate (TcPYP) scan was not suggestive of cardiac amyloidosis (H/CL ratio G; p.Phe84Leu mutation. He has been referred to neuromuscular clinic for further evaluation and potential initiation of a medical therapy. Conclusion The two brothers highlight some of the difficulty associated with the diagnosis of amyloidosis given its variable clinical phenotype. Additionally, it is known that myocardial uptake in bone compound scintography scans can be falsely negative for unclear reasons in patients with c.252T>G; p.Phe84Leu mutations. Lastly, the isolated left atrial uptake on TcPYP scans should be further investigated as an early manifestation of cardiac amyloidosis.

The aims of this study were to assess outcomes of pulmonary vein isolation (PVI) performed on athletes at a tertiary care center and to characterize its efficacy and physiological effects.The incidence of atrial fibrillation (AF) is increased in highly trained athletes and poses unique management challenges.Athletes were identified through a database of patients undergoing PVI from January 2000 through October 2015. Outcomes of AF ablation were defined in accordance with published guidelines. Available electrocardiographic, echocardiographic, and exercise treadmill testing data were also analyzed.The study population included 144 athletes (93% men; mean age 50.4 ± 8.6 years; 97 paroxysmal, 38 persistent, and 9 long-standing persistent) with median follow-up of 3 years. Single-procedure freedom from arrhythmia was 75%, 68%, and 33% at 1 year for paroxysmal, persistent, and long-standing persistent AF, respectively. Multiple-procedure freedom from arrhythmia off antiarrhythmic drugs was 86%, 76%, and 56% in respective groups at the end of follow-up (mean 1.4 ± 0.7 ablations per athlete). Compared with a matched cohort of nonathletes who underwent PVI, there was no difference in arrhythmia recurrence (log-rank p = 0.23). Excluding long-standing persistent AF, longer diagnosis-to-ablation time was the only variable in Cox proportional hazards analyses associated with arrhythmia recurrence (adjusted heart rate per log increase: 1.92; 95% confidence interval: 1.40 to 2.73; p 0.0001), and PVI within 2 years of diagnosis was notably associated with successful outcomes (log-rank p = 0.002). Sinus rate increased following the index ablation (mean 54 beats/min vs. 64 beats/min at1 year; p 0.0001), but maximum metabolic equivalents on exercise treadmill testing were unchanged (13.1 ± 1.2 vs. 12.7 ± 1.4; p = 0.44).PVI is an effective therapy in athletes with paroxysmal and persistent AF, and arrhythmia recurrence was no different from that among matched nonathletes. Early ablation was associated with improved success rates. Sustained cardioautonomic effects were observed following ablation, but exercise capacity was preserved.

Fabry disease is a lysosomal storage disease with a variety of cardiac manifestations. Although not specific for a diagnosis of Fabry disease, certain cardiac imaging findings may be highly suggestive of the diagnosis of Fabry disease in previously undiagnosed patients or cardiac involvement for patients with a known diagnosis of Fabry disease. In this review, we explore the current applications of multimodality cardiac imaging in the diagnosis and monitoring of patients with Fabry disease. Additionally, data regarding tissue characterization by cardiac magnetic resonance imaging and novel nuclear imaging techniques and their role in evaluating phenotype development is discussed.

Background: Morbid obesity is associated with unacceptable high recurrence rates following atrial fibrillation ablation. The role of risk-factor modification including weight loss and improved glycemic control in reducing arrhythmia recurrence following ablation has been highlighted in recent years. In this study, we compared arrhythmia recurrence rates in morbidly obese patients who underwent prior bariatric surgery (BS) with those of nonobese patients following atrial fibrillation ablation in addition to morbidly obese patients who did not undergo BS. Methods: This was a single-center observational cohort study. We matched 51 morbidly obese patients [body mass index ≥40 kg/m 2 ] who had undergone prior BS in a 2:1 manner with 102 nonobese patients and 102 morbidly obese patients without prior BS on the basis of age, sex, and timing of atrial fibrillation ablation. Our primary outcome of interest was arrhythmia recurrence. Results: From the time of BS to ablation, BS was associated with a significant reduction in body mass index (47.6±9.3 to 36.7±7; P P P P Conclusions: Bariatric surgery is associated with a reduction in arrhythmia recurrence following atrial fibrillation ablation in morbidly obese patients to those of nonobese patients. Morbidly obese patients should be considered for BS before atrial fibrillation ablation.

Background A variety of exercise stress testing protocols with various workloads are available. The test protocol is typically selected according to patient's expected exercise performance. Purpose We sought to assess whether the choice of the protocol is by itself independently associated with mortality even after adjusting for clinical variables and estimated workload achieved in metabolic equivalents of task (METS). Methods In a 25-year stress testing registry spanning from 1991 to 2015, we identified 120,705 patients who underwent 7 different standardized exercise protocols: Bruce, Modified Bruce, Cornell 0%, 5%, and 10%, Naughton, and modified Naughton. The choice of the protocol was dependent on the supervising exercise physiologist, mainly according to patient's expected exercise performance. The primary outcome was all-cause mortality. Results Mean age was 53.3±12.5 years and 59% were male. There were 74953 Bruce, 8368 modified Bruce, 2648 Cornell 0%, 9972 Cornell 5%, 20425 Cornell 10% 1226 Naughton, and 3113 modified Naughton protocols. A total of 8426 death occurred over 8.7 years of mean follow-up duration. Table 1 presents the baseline characteristics by protocol. After adjusting for the number of METs, age, gender, hypertension, diabetes, coronary disease, end-stage renal disease, smoking, and statin use, the protocol selected remained predictive of mortality. Figure 1 shows the adjusted HR for death by protocol selected when compared to Bruce. Baseline characteristics by protocol Variable Bruce (n=74953) Modified Bruce (n=8368) Cornell 0% (n=2648) Cornell 5% (n=9972) Cornell 10% (n=20425) Naughton (n=1226) Modified Naughton (n=3113) Age, mean ± SD 49.4±11.3 61.3±10.3 66.4±11.7 62.5±11.8 57.2±11.5 67.5±9.8 55.5±11.9 Male, % 64.6 51.8 37.8 42.3 51.7 49 66.7 Coronary disease, % 8.7 32.5 31.7 26.7 21.1 49.7 45.6 Diabetes mellitus, % 7.6 16.5 25.3 20 14.2 27.2 26.2 Hypertension, % 41.7 64 85.4 77.9 67.1 82.5 97.5 Smoker, % 40.9 55 50.7 50.9 50.8 56.9 60.6 ESRD, % 0.7 1 3.7 2.4 1.6 2.7 8.1 Mets, mean ± SD 10.3±2.4 7.2±1.7 5.2±1.6 6.7±1.5 8.3±1.9 4.8±1.5 4.6±1.5 Statin use, % 22.4 15.2 41.8 38.3 35.1 19 40.1 ESRD = end-stage renal disease; METS = metabolic equivalents of task. Adjusted HR by protocol selected Conclusion The choice of the stress testing protocol, which is in large part dependent on patient's expected exercise performance is in itself independently associated with mortality even after adjustment for METs achieved and patients' demographics and comorbidities. The choice of the modified-Naughton is associated with the greatest risk of mortality, likely chosen based on limited functional capacity

Background While the Bruce protocol has been extensively validated, other modified exercise protocols with less workload burden are commonly used, though their prognostic value is not well established. Purpose We sought to assess whether exercise capacity (or workload achieved in metabolic equivalents of task [METs]) remains predictive of mortality across various exercise stress testing protocols. Methods In a 25-year stress testing registry spanning from 1991 to 2015, we identified 120,705 patients who underwent 7 different standardized symptom-limited exercise stress testing protocols: Bruce, Modified Bruce, Cornell 0%, Cornell 5%, Cornell 10%, Naughton, and modified Naughton. The choice of the protocol was dependent on the supervising exercise physiologist according to purpose of the test and the individual patient. The primary outcome was all-cause mortality. Results Mean age was 53.3±12.5 years and 59% were male. There were 74953 Bruce, 8368 modified Bruce, 2648 Cornell 0%, 9972 Cornell 5%, 20425 Cornell 10% 1226 Naughton, and 3113 modified Naughton individual protocols. A total of 8426 death occurred over 8.7 years of mean follow-up duration. Figure 1 shows that there was an inverse relationship between peak METs achieved and mortality across all 7 protocols. On multivariable analysis, increasing METs remained protective against death [adjusted HR of 0.46; 95% CI (0.44 - 0.48); p METS vs. mortality by protocol Conclusion Across 7 different exercise protocols with various workloads, the predicted exercise capacity remained predictive of mortality irrespective of the protocol chosen, patients' demographics and comorbidities. Different testing choices likely represent different estimated functional capacity.

The northern and southern Patagonian ice fields (NPI and SPI) have been subject to accelerated retreat during the last decades, with considerable variability in magnitude and timing among individual glaciers. We derive spatially detailed maps of surface elevation change (SEC) of NPI and SPI from bistatic synthetic aperture radar (SAR) interferometry data of the Shuttle Radar Topography Mission (SRTM) and TerraSAR-X add-on for Digital Elevation Measurements (TanDEM-X) for two epochs, 2000–2012 and 2012–2016, and provide data on changes in surface elevation and ice volume for the individual glaciers and the ice fields at large. We apply advanced TanDEM-X processing techniques allowing us to cover 90 % and 95 % of the area of NPI and 97 % and 98 % of SPI for the two epochs, respectively. Particular attention is paid to precisely co-registering the digital elevation models (DEMs), accounting for possible effects of radar signal penetration through backscatter analysis and correcting for seasonality biases in case of deviations in repeat DEM coverage from full annual time spans. The results show a different temporal trend between the two ice fields and reveal a heterogeneous spatial pattern of SEC and mass balance caused by different sensitivities with respect to direct climatic forcing and ice flow dynamics of individual glaciers. The estimated volume change rates for NPI are -4.26±0.20 km3 a−1 for epoch 1 and -5.60±0.74 km3 a−1 for epoch 2, while for SPI these are -14.87±0.52 km3 a−1 for epoch 1 and -11.86±1.99 km3 a−1 for epoch 2. This corresponds for both ice fields to an eustatic sea level rise of 0.048±0.002 mm a−1 for epoch 1 and 0.043±0.005 mm a−1 for epoch 2. On SPI the spatial pattern of surface elevation change is more complex than on NPI and the temporal trend is less uniform. On terminus sections of the main calving glaciers of SPI, temporal variations in flow velocities are a main factor for differences in SEC between the two epochs. Striking differences are observed even on adjoining glaciers, such as Upsala Glacier, with decreasing mass losses associated with slowdown of flow velocity, contrasting with acceleration and increase in mass losses on Viedma Glacier.

Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized cause of heart failure that results from extracellular deposition of misfolded transthyretin (TTR) or pre-albumin. Atrial fibrillation (AF) is common in ATTR-CA, occurring in as many as 70% of patients; thrombus may even occur

The 14th International Conference on Nuclear Cardiology and Cardiac Computed Tomography was held from 12 May to 14 May 2019 in Lisbon, Portugal. In this article, the three Congress Programme Committee Chairs summarize selected highlights of the presented abstracts and lectures.

Background: Cardiomyopathies with increased left ventricular wall thickness such as cardiac amyloidosis, septal hypertrophic cardiomyopathy (HCM), and apical HCM exhibit characteristic regional longitudinal strain (LS) patterns. However, between-vendor agreement of segmental and regional LS has not been tested in these diseases. We sought to assess LS values among vendors in specific cardiomyopathies that exhibit regional strain variation: cardiac amyloidosis, septal HCM, and apical HCM. Methods: This was a prospective, cross-sectional study of 69 patients (18 amyloidosis, 30 septal HCM, 6 apical HCM, and 15 controls) who underwent clinically indicated outpatient echocardiography at the Cleveland Clinic. Peak systolic segmental, regional (basal, mid, and apical), and global LS were evaluated using GE (EchoPAC), Siemens (Velocity Vector Imaging), and Phillips (QLab) systems in the same imaging session. Between-vendor, differences were analyzed using correlation coefficients, Bland Altman plots, and a mixed model. Results: Global LS was highly correlated among the 3 software packages and most abnormal in patients with amyloidosis ( P P Conclusions: Global and regional variations in LS exist between-vendors in patients with cardiomyopathies with increased left ventricular wall thickness (amyloidosis, septal HCM, and apical HCM). It is important to be aware of these differences for diagnosis, prognosis, and serial examinations in these conditions.

Aims Atrial fibrillation (AF) occurs in as many as 70% of patients with transthyretin cardiac amyloidosis (ATTR CA). The aim of our study was to investigate the impact of AF ablation on freedom from recurrent arrhythmia, hospitalization for AF or heart failure (HF), and mortality. Methods and results This was a retrospective observational cohort study of 72 patients with ATTR CA and AF, of whom 24 underwent AF ablation and were matched in a 2:1 manner based on age, gender, ATTR CA stage, New York Heart Association functional class, ejection fraction, and date of AF diagnosis with 48 patients with ATTR CA and AF undergoing medical management. During a mean follow-up of 39 ± 26 months, 10 (42%) patients remained free of recurrent arrhythmia following ablation. Ablation was significantly more effective in those with Stage I or II ATTR CA, with 9/14 (64%) patients with Stage I or II ATTR CA remaining free of recurrent arrhythmia compared to only 1/10 (10%) patients with Stage III disease (P = 0.005). Death occurred in 7 (29%) patients in the ablation group compared to 36 (75%) in the non-ablation arm (P = 0.01). Rates of ischaemic stroke were similar in both groups. Ablation was associated with a significant reduction in the frequency of hospitalization for HF/arrhythmia (1.7 ± 2.4 hospitalizations vs. 4 ± 3.5, P = 0.005). On Cox proportional hazards analyses, ablation was associated with improved survival (hazard ratio 0.38, 95% confidence intervals 0.17–0.86; P = 0.02). Conclusion Atrial fibrillation ablation is associated with reduced mortality in ATTR CA and is most effective when performed earlier during the disease process.

Background Balloon postdilation ( BPD ) has emerged as an effective strategy to reduce paravalvular regurgitation ( PVR ) during transcatheter aortic valve replacement ( TAVR ). We investigated the utility of a time‐integrated aortic regurgitation index ( TIARI ) to guide balloon postdilation ( BPD ) after valve deployment. Methods and Results All consecutive patients who had echocardiography, aortography, and hemodynamic tracings recorded immediately after valve deployment during TAVR were included in the study. Catheter‐derived invasive hemodynamic parameters were calculated offline. Among 157 patients who underwent TAVR , 49 (32%) patients required BPD to reduce significant PVR after valve deployment. Two experienced operators decided whether the patients required BPD for significant PVR . Median TIARI measured immediately after valve deployment was significantly lower in patients who required BPD when compared with patients who did not require BPD ( P TIARI (odds ratio: 0.81; P =0.003) and higher PVR grade on aortography and echocardiography ( P BPD . Adding TIARI to echocardiography and aortographic PVR assessment resulted in a significant increase in global χ 2 ( P P =0.002), and combined C‐statistics of 0.99 for predicting BPD . Higher TIARI after valve deployment was associated with better survival (hazard ratio: 0.94, P =0.014), while other hemodynamic and imaging parameters did not predict mortality after TAVR . Conclusions Among patients undergoing TAVR , a TIARI measured immediately after valve deployment adds incremental value to guide BPD over aortography and echocardiography. Higher residual TIARI is associated with better survival after TAVR .

Background Little is known about the role of left atrial appendage closure using the Watchman device (Boston Scientific) in patients who are at very high risk for stroke. Objective The purpose of this study was to assess the role of Watchman in patients with CHA2DS2-VASc ≥5. Methods All patients undergoing procedures for Watchman implant at our institution were enrolled in a prospective registry. All 104 consecutive recipients with CHA2DS2-VASc ≥5 were included. Results Median patient age was 78.5 ± 6.4 years, 56% were male, mean CHA2DS2-VASc was 5.7 ± 0.9, and mean HASBLED was 4.0 ± 1.0. Indications for implantation were significant prior bleeding (73%), unacceptable bleeding risk (21%), and unacceptable stroke and bleeding risk (6%). Watchman implantation was successful in all patients. All but 2 patients completed 45 days of postprocedural anticoagulation; 56% used warfarin and 44% used a novel oral anticoagulant. Transesophageal echocardiogram at 45 days revealed no significant peridevice leak. One patient was found to have a small mobile, filamentous echodensity attached on the medial aspect of the Watchman device. This resolved with longer anticoagulation with dabigatran and did not result in adverse outcome. At 1-year follow up, ischemic stroke had occurred in 3 patients (2.8%) at 96, 119, and 276 days after the procedure. Conclusion In a population of patients with mean CHA2DS2-VASc of 5.7, Watchman implantation seemed to be safe and efficacious, with a residual annual ischemic stroke risk of 2.8%. In an atrial fibrillation population with a similar CHA2DS2-VASc score, the estimated annual risk of stroke is ≈12% off anticoagulation and >4% on warfarin.

This study sought to evaluate the effects of the Carillon device on mitral regurgitation severity and left ventricular remodeling.Functional mitral regurgitation (FMR) complicates heart failure with reduced ejection fraction and is associated with a poor prognosis.In this blinded, randomized, proof-of-concept, sham-controlled trial, 120 patients receiving optimal heart failure medical therapy were assigned to a coronary sinus-based mitral annular reduction approach for FMR or sham. The pre-specified primary endpoint was change in mitral regurgitant volume at 12 months, measured by quantitative echocardiography according to an intention-to-treat analysis.Patients (69.8 ± 9.5 years of age) were randomized to either the treatment (n = 87) or the sham-controlled (n = 33) arm. There were no significant differences in baseline characteristics between the groups. In the treatment group, 73 of 87 (84%) had the device implanted. The primary endpoint was met, with a statistically significant reduction in mitral regurgitant volume in the treatment group compared to the control group (decrease of 7.1 ml/beat [95% confidence interval [CI]: -11.7 to -2.5] vs. an increase of 3.3 ml/beat [95% CI: -6.0 to 12.6], respectively; p = 0.049). Additionally, there was a significant reduction in left ventricular volumes in patients receiving the device versus those in the control group (left ventricular end-diastolic volume decrease of 10.4 ml [95% CI: -18.5 to -2.4] vs. an increase of 6.5 ml [95% CI: -5.1 to 18.2]; p = 0.03 and left ventricular end-systolic volume decrease of 6.2 ml [95% CI: -12.8 to 0.4] vs. an increase of 6.1 ml [95% CI: -1.42 to 13.6]; p = 0.04).The Carillon device significantly reduced mitral regurgitant volume and left ventricular volumes in symptomatic patients with functional mitral regurgitation receiving optimal medical therapy. (Carillon Mitral Contour System for Reducing Functional Mitral Regurgitation [REDUCE FMR]; NCT02325830).

Diagnosis of low-gradient severe aortic stenosis (AS) is challenging. We hypothesized that the time between left ventricular (LV) and aortic systolic pressure peaks (TLV-Ao) is associated with aortic stenosis (AS) severity and may have additive value in diagnosing severe AS, especially in patients with low-gradient AS.To investigate the diagnostic utility of measuring catheter-based TLV-Ao in patients with severe AS.We studied 123 patients with severe AS at the Cleveland Clinic Foundation, a tertiary referral center, who underwent transcatheter aortic valve replacement (TAVR) via femoral access and had pre-TAVR cardiac computed tomography assessment and hemodynamic measurements recorded during a TAVR procedure. All patients received hemodynamic evaluation, echocardiographic assessment, and quantification of aortic valve calcification (AVC) by multidetector computed tomography. Hemodynamic data were collected via left heart catheterization done just before TAVR, and TLV-Ao was calculated offline. Data were analyzed between October 5, 2015, and July 20, 2016.The association between TLV-Ao and AVC or other conventional imaging parameters was analyzed.Of the included patients, the mean (SD) age was 81 (9) years, and 65 (54%) were men (54%). Among 123 patients, 48 patients (39%) had low-gradient AS (40 mm Hg) and mean (SD) TLV-Ao was 69 (39) milliseconds. In multivariable logistic regression analyses, higher TLV-Ao (odds ratio [OR], 1.02; 95% CI, 1.01-1.04; P = .002) and higher peak aortic valve (AV) velocity (OR, 1.01; 95% CI, 1.00-1.02; P = .008) were independently associated with severe AVC (AVC1000 AU). Adding TLV-Ao to the peak AV velocity and AV area showed significant incremental value to be associated with AVC, with a net reclassification improvement of 0.61 (95% CI, 0.23-0.99; P = .002) and integrated discriminatory improvement of 0.09 (95% CI, 0.03-0.16; P = .003). In a subgroup of patients with low-grade AS, higher TLV-Ao was the only parameter associated with severe AVC (OR, 1.02; 95% CI, 1.001-1.04; P = .03).Prolonged TLV-Ao was associated with severe AVC. This catheter-based hemodynamic index may be an additional surrogate to differentiate low-gradient true severe AS. Larger, prospective studies investigating the role of TLV-Ao as a marker of clinical outcomes in patients undergoing TAVR are required.

Aims Obesity decreases arrhythmia-free survival after atrial fibrillation (AF) ablation by mechanisms that are not fully understood. We investigated the impact of pre-ablation bariatric surgery (BS) on AF recurrence after ablation. Methods and results In this retrospective observational cohort study, 239 consecutive morbidly obese patients (body mass index ≥40 kg/m2 or ≥35 kg/m2 with obesity-related complications) were followed for a mean of 22 months prior to ablation. Of these patients, 51 had BS prior to ablation, and our primary outcome was whether BS was associated with a lower rate of AF recurrence during follow-up. Adjustment for confounding was performed with multivariable Cox proportional hazard models and propensity-score based analyses. During a mean follow-up of 36 months after ablation, 10/51 patients (20%) in the BS group had recurrent AF compared with 114/188 (61%) in the non-BS group (P Conclusion Bariatric surgery is associated with a lower AF recurrence after ablation. Morbidly obese patients should be considered for BS prior to AF ablation, though prospective multicentre studies should be performed to confirm our novel finding.

In primary prevention, addition of C-reactive protein and family history to standard risk factor assessment (Reynolds Risk Score or RRS) provides superior risk stratification for future cardiovascular (CV) events. We sought to assess whether addition of functional capacity to RRS provided incremental prognostic value. This was a prospective observational cohort study of 3,964 consecutive asymptomatic adults without documented CV disease (mean age 51 years, 78% men) evaluated between 2005 and 2013, who underwent clinical and treadmill stress testing at baseline. RRS was calculated; % age-gender predicted metabolic equivalents (AGP-METs) achieved and heart rate recovery (HRR) were recorded. End point was death and myocardial infarction. Findings were tested in derivation (n = 1,982) and validation samples (n = 1,982). Mean RRS and C-reactive protein were 3.7 ± 4 and 2 ± 4 mg/dl. Nine percent had family history of premature CV disease. %AGP-METs achieved, and HRR were 113 ± 20 and 24 ± 8 beats/min. Forty-six percent achieved110% AGP-METs, whereas 41% had RRS ≥3. At 7.3 ± 3 years, there were 83 (2%) events (39 in derivation and 44 in validation samples). In derivation group, on multivariable survival analysis, higher RRS (Hazard ratio or HR 1.27 [1.07 to 1.39]), lower % AGP METs (HR 1.21 [1.09 to 1.34]) achieved and abnormal (12 beats/min) HRR (HR 1.15 [1.02 to 1.23]) were associated with increased longer-term events (all p0.01). Findings were similar in validation group. Cutoffs of RRS3 and %AGP-METs110 were associated with increased longer-term events on spline analysis in the derivation group. The continuous net reclassification improvement for longer-term events, when %AGP-METs was added to RRS was 0.79 (95% confidence interval 0.52 to 1.05; p0.01). Findings were confirmed in validation group. In conclusion, in primary prevention, addition of exercise capacity to RRS (incorporating traditional risk factors, family history, and inflammation) provides incremental prognostic value.

Objectives The aim of this study was to investigate the impact of improved glycemic control on atrial fibrillation (AF) recurrence rates after ablation. Background Diabetes is associated with increased rates of AF. The impact of improved pre-ablation glycemic control remains unknown. Methods The 12-month pre-ablation trends in glycemic control were studied in 298 patients with diabetes undergoing AF ablation. Recurrence data were obtained during a mean follow-up period of 25.92 ± 20.26 months post-ablation. Results Higher glycated hemoglobin (HbA1c) at the time of ablation was associated with higher post-ablation recurrence rates. More than two-thirds (68.75%) of patients with HbA1c >9% at the time of ablation developed recurrent AF, compared with 32.4% of those with HbA1c Conclusions The trend in glycemic control prior to ablation predicts arrhythmia recurrence after ablation. A multidisciplinary approach to reduce HbA1c is imperative in patients with diabetes with AF to reduce recurrence rates after ablation.

Summary Background Transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve demonstrates good 30 day clinical outcomes in patients with severe aortic stenosis who are at intermediate risk of surgical mortality. Here we report longer-term data in intermediate-risk patients given SAPIEN 3 TAVR and compare outcomes to those of intermediate-risk patients given surgical aortic valve replacement. Methods In the SAPIEN 3 observational study, 1077 intermediate-risk patients at 51 sites in the USA and Canada were assigned to receive TAVR with the SAPIEN 3 valve [952 [88%] via transfemoral access) between Feb 17, 2014, and Sept 3, 2014. In this population we assessed all-cause mortality and incidence of strokes, re-intervention, and aortic valve regurgitation at 1 year after implantation. Then we compared 1 year outcomes in this population with those for intermediate-risk patients treated with surgical valve replacement in the PARTNER 2A trial between Dec 23, 2011, and Nov 6, 2013, using a prespecified propensity score analysis to account for between-trial differences in baseline characteristics. The clinical events committee and echocardiographic core laboratory methods were the same for both studies. The primary endpoint was the composite of death from any cause, all strokes, and incidence of moderate or severe aortic regurgitation. We did non-inferiority (margin 7·5%) and superiority analyses in propensity score quintiles to calculate pooled weighted proportion differences for outcomes. Findings At 1 year follow-up of the SAPIEN 3 observational study, 79 of 1077 patients who initiated the TAVR procedure had died (all-cause mortality 7·4%; 6·5% in the transfemoral access subgroup), and disabling strokes had occurred in 24 (2%), aortic valve re-intervention in six (1%), and moderate or severe paravalvular regurgitation in 13 (2%). In the propensity-score analysis we included 963 patients treated with SAPIEN 3 TAVR and 747 with surgical valve replacement. For the primary composite endpoint of mortality, strokes, and moderate or severe aortic regurgitation, TAVR was both non-inferior (pooled weighted proportion difference of −9·2%; 90% CI −12·4 to −6; p Interpretation TAVR with SAPIEN 3 in intermediate-risk patients with severe aortic stenosis is associated with low mortality, strokes, and regurgitation at 1 year. The propensity score analysis indicates a significant superiority for our composite outcome with TAVR compared with surgery, suggesting that TAVR might be the preferred treatment alternative in intermediate-risk patients. Funding None.

Quality control is pervasive in most modern business, but, surprisingly, is in its infancy in medicine in general-and cardiovascular imaging in particular. The increasing awareness of the cost of cardiovascular imaging, matched by a desire to show benefits from imaging to patient outcome, suggests that this deficiency should be reassessed. Demonstration of improved quality has been proposed to require a focus on several domains: laboratory organization, patient selection, image acquisition, image interpretation, and results communication. Improvement in these steps will require adoption of a variety of interventions, including laboratory accreditation, appropriate use criteria, and continuous quality control and enhancements in reporting, but the evidence base for the benefit of interventions on these steps has been sparse. The purpose of this review is to evaluate the current status and future goals of developing the evidence base for these processes in cardiovascular imaging.

End-stage renal disease (ESRD) has a negative impact on left ventricular (LV) remodeling, whereas kidney transplantation has a positive impact on LV reverse remodeling [(1,2)][1]. Reduced LV global longitudinal strain (GLS) has been associated with increased mortality in hemodialysis patients [(3)][

ObjectivesTo investigate timing and age distribution of atrial fibrillation (AF) in selected oncology patients, and the impact of AF timing, CHA2DS2-VASc score and cancer therapeutics on mortality.MethodsThis is a retrospective cohort study of oncology patients referred to the cardio-oncology service from 2011 to 2018 for echocardiographic cardiosurveillance and/or pre-existing cardiovascular risk factor/disease management. Rates of first AF diagnosis was assessed using a parametric multiphase hazard model (predictive modelling) and non-parametrically by Kaplan-Meier with transformations tested using a bootstrap methodology.ResultsAmong 6754 patients identified, 174 patients had their first AF diagnosis before cancer while 609 patients had their first diagnosis of AF after cancer. Most first AF diagnosis occurred at/early after cancer diagnosis. Increasing AF prevalence at time of cancer diagnosis was seen across older age groups ranges. Diagnosis of cancer at an older age and exposure to cardiotoxic treatment (anthracyclines, HER2-neu inhibitors, tyrosine kinase inhibitors including ibrutinib and radiation) were associated with an increased risk of AF.Modelling of the hazard function of AF identified a high left-skewed peak within 3 years after cancer diagnosis (‘early phase’), followed by a gradual late slight rise 3 years after cancer diagnosis (‘late phase’). AF diagnosis was only associated with death in the early phase (p2DS2-VASc score was only associated with death in the late phase (pConclusionsThis study reports a nuanced/complex relationship between AF and cancer. First diagnosis of AF in patients with cancer was more common at/early after cancer diagnosis, especially in older patients and those exposed to cardiotoxic treatment. Pre-existing AF or a diagnosis of AF within 3 years after cancer diagnosis carried a negative prognosis. CHA2DS2-VASc score did not relate to mortality in those that developed AF within 3 years of cancer diagnosis.