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Aims To assess the progression of the disease and evolution of the main echocardiographic variables for quantifying AS in patients with severe low-flow low-gradient (LFLG) AS compared to other severe AS subtypes. Methods and results Longitudinal, observational, multicenter study including consecutive asymptomatic patients with severe AS (aortic valve area, AVA < 1.0 cm²) and normal left ventricle ejection fraction (LVEF ≥ 50%). Patients were classified according to baseline echocardiography into: HG (high gradient; mean gradient ≥ 40 mmHg), NFLG (normal-flow low-gradient; mean gradient < 40 mmHg, indexed systolic volume (SVi) > 35mL/m2), or LFLG (mean gradient < 40 mmHg, SVi ≤ 35 mL/m²). AS progression was analyzed by comparing patients’ baseline measurements and their last follow-up measurements or those taken prior to aortic valve replacement (AVR). Of the 903 included patients, 401 (44.4%) were HG, 405 (44.9%) NFLG, and 97 (10.7%) LFLG. Progression of the mean gradient in a linear mixed regression model was greater in low-gradient groups: LFLG vs. HG (regression coefficient 0.124, P = 0.005) and NFLG vs. HG (regression coefficient 0.068, P = 0.018). No differences were observed between the LFLG and NFLG groups (regression coefficient 0.056, P = 0.195). However, AVA reduction was slower in the LFLG group compared to the NFLG (P < 0.001). During follow-up, in conservatively-managed patients, 19.1% (n = 9) of LFLG patients evolved to having NFLG AS and 44.7% (n = 21) to having HG AS. In patients undergoing AVR, 58.0% (n = 29) of LFLG baseline patients received AVR with a HG AS. Conclusion LFLG AS shows an intermediate AVA and gradient progression compared to NFLG and HG AS. The majority of patients initially classified as having LFLG AS changed over time to having other severe forms of AS, and most of them received AVR with a HG AS.

[Abstract] Aims. In the absence of previous direct comparative studies, we aimed to evaluate the effectiveness of spironolactone and eplerenone in patients with heart failure and reduced ejection fraction (HFrEF) in a real-world clinical setting. Methods. Using Fine-Gray´s competing risk regression, we compared the clinical outcomes of 293 patients with chronic HF and left ventricular ejection fraction

INTRODUCTION AND OBJECTIVES Economic studies may help decision making in the management of multivessel disease in the setting of myocardial infarction. We sought to perform an economic evaluation of CROSS-AMI (Complete Revascularization or Stress Echocardiography in Patients With Multivessel Disease and ST-Segment Elevation Acute Myocardial Infarction) randomized clinical trial. METHODS We performed a cost minimization analysis for the strategies (complete angiographic revascularization [ComR] and selective stress echocardiography-guided revascularization [SelR]) compared in the CROSS-AMI clinical trial (N=306), attributable the initial hospitalization and readmissions during the first year of follow-up, using current rates for health services provided by our health system. RESULTS The index hospitalization costs were higher in the ComR group than in SelR arm (19 657.9±6236.8 € vs 14 038.7±4958.5 €; P

Resumen Introduccion El sincope es motivo de numerosas pruebas diagnosticas, entre las que esta el ecocardiograma transtoracico (ETT). Existe evidencia previa que sugiere escasa utilidad de esta prueba. Nuestro objetivo fue evaluar su rendimiento diagnostico en el sincope, analizando el efecto de la edad y el sexo. Materiales y metodos Estudio observacional en el que se incluyeron pacientes con sincope y ETT entre 1990 y 2015. Se definieron hallazgos diagnosticos relacionados con el sincope. Realizamos un analisis descriptivo evaluando el rendimiento diagnostico en global, y en funcion de edad y sexo. Resultados Se incluyeron 3.302 pacientes, siendo el rendimiento diagnostico del 8,8%; el hallazgo mas frecuente fue disfuncion ventricular (4,5%). La probabilidad de ETT diagnostico aumento significativamente con la edad (p Conclusiones El rendimiento diagnostico del ETT en pacientes con sincope es moderado, siendo bajo en edades inferiores a 50 anos, y menor en mujeres que en hombres. Estos factores deben ser tenidos en cuenta a la hora del estudio diagnostico de los pacientes con sincope.

OBJECTIVES This study aims to analyse the risks associated with valve-in-valve procedures for treating structural valve deterioration in Mitroflow bioprostheses, as well as to determine the impact of the original Mitroflow size on the patients’ long-term outcomes. METHODS Between January 2012 and September 2019, 21 patients (61.9% males; mean age 82.4 ± 5.4 years) were treated for Mitroflow deterioration with valve-in-valve procedures (12 transapical and 9 transfemoral). RESULTS Mean EuroSCORE I and EuroSCORE II were 28.2% ± 13.6% and 10.5% ± 6.1%, respectively. Six patients presented an indexed aortic root diameter CONCLUSIONS Valve-in-valve procedures with balloon-expandable transcatheter valves associate a high risk of coronary occlusion in patients with indexed aortic root diameter

Three inhibitors targeting different microorganisms, both from Archaea and Bacteria domains, were evaluated for their effect on CO2 biomethanation: sodium ionophore III (ETH2120), carbon monoxide (CO), and sodium 2-bromoethanesulfonate (BES). This study examines how these compounds affect the anaerobic digestion microbiome in a biogas upgrading process. While archaea were observed in all experiments, methane was produced only when adding ETH2120 or CO, not when adding BES, suggesting archaea were in an inactivated state. Methane was produced mainly via methylotrophic methanogenesis from methylamines. Acetate was produced at all conditions, but a slight reduction on acetate production (along with an enhancement on CH4 production) was observed when applying 20 kPa of CO. Effects on CO2 biomethanation were difficult to observe since the inoculum used was from a real biogas upgrading reactor, being this a complex environmental sample. Nevertheless, it must be mentioned that all compounds had effects on the microbial community composition.

Introduction and objectives This study aimed to compare stress echocardiography (SE) and multidetector computed tomography (MCT) in patients admitted to a chest pain unit to detect acute coronary syndrome (ACS). Methods A total of 203 patients with ≥ 1 cardiovascular risk factor, no ischemic electrocardiogram changes and negative biomarkers were randomized to SE (n = 103) or MTC (n = 100). The primary endpoint was a combination of hard events (death and nonfatal myocardial infarction), revascularizations, and readmissions during follow-up. The secondary endpoint was the cost of the 2 strategies. Results Invasive angiography was performed in 61 patients (34 [33%] in the SE group and in 27 [27%] in the MCT group, P = .15). A final diagnosis of ACS was made in 53 patients (88% vs 85%, P = .35). There were no significant differences between groups in the primary endpoint (42% vs 41%, P = .91), or in hard events (5% vs 7%, P = .42). There were no significant differences in overall cost, but costs were lower in patients with negative SE than in those with negative MCT (€557 vs €706, P Conclusions No significant differences were found in efficacy and safety for the stratification of patients with a low to moderate probability of ACS admitted to a chest pain unit. The cost of the 2 strategies was similar, but cost was significantly lower for SE on comparison of negative studies.

Resumen Introduccion y objetivos Actualmente existen diferentes estrategias para la deteccion del sindrome coronario agudo (SCA) en una unidad de dolor toracico. Nuestro objetivo es comparar el ecocardiograma de estres (EcoE) y la tomografia computarizada con multidetectores (TCMD) en este escenario. Metodos Se aleatorizo a 203 pacientes con al menos 1 factor de riesgo cardiovascular y con electrocardiograma y troponinas normales a EcoE (103) o a TCMD (100). El objetivo primario era un combinado de eventos graves (muerte e infarto de miocardio no mortal), revascularizaciones y readmisiones. El objetivo secundario fue el coste. Resultados Se realizaron 61 coronariografias, 34 (33%) en el grupo de EcoE y 27 (27%) en el de TCMD (p = 0,15). Se confirmo sindrome coronario agudo en 53 pacientes (el 88 y el 85%; p = 0,35). No hubo diferencias significativas en el objetivo primario (el 42 y el 41%; p = 0,91) ni en el numero de eventos graves entre grupos (el 5 y el 7%; p = 0,42). El coste medio en la sala de urgencias fue menor en el grupo con EcoE negativo comparado con el grupo con TCMD negativa (557 y 706 euros; p = 0,02), aunque no se encontraron diferencias significativas con respecto al coste total. Conclusiones No se encontraron diferencias significativas en cuanto a eficacia y seguridad entre el EcoE y la TCMD en el cribado del dolor toracico agudo en pacientes con probabilidad baja-intermedia de SCA. El coste medio en la sala de urgencias fue menor en el subgrupo con EcoE negativo.

Aims To evaluate the burden of tricuspid regurgitation (TR) in a large cohort, determine the right ventricle involvement of patients with TR and determine the characteristics of isolated TR. Methods and results Prospective study where consecutive patients undergoing an echocardiographic study in 10 centres were included. All studies with significant TR (at least moderate) were selected. We considered that patients with one of pulmonary systolic hypertension >50 mmHg, left ventricular ejection fraction Conclusion Significant TR is a prevalent condition and a high proportion of these patients have an indication for valve intervention. More than a half of patients with severe, massive, or torrential TR had a high surgical risk. Massive/torrential TR may have implications regarding selection and monitoring patients for percutaneous treatment.

Coronary angiography and eventual revascularization have become the most common approaches for patients with acute coronary syndromes. Ischemia detection in this scenario is usually regarded as unnecessary for most of the patients. In fact, current guidelines recommend complete revascularization for patients with multivessel disease in the context of ST-elevation myocardial infarction, although it is in contrast with previous recommendations. However, some recent data suggested that ischemia could have a role for the decision of revascularization in these patients. The CROSS-AMI study randomized patients with ST-elevation myocardial infarction treated with primary angioplasty and who also had multivessel disease to a complete anatomic revascularization of the non-infarct related artery lesions vs subsequent revascularization of the non-infarct related artery lesions only if ischemia was demonstrated by stress echocardiography. The main findings were that only 30% of the patients in the ischemia arm needed a second revascularization and that the outcome was similar in both arms. Regarding non-ST-elevation acute coronary syndrome, coronary angiography is in general warranted for most of the patients. However, recent long-term published studies on patients randomized to an invasive or less aggressive approach based on ischemia detection have found no differences in outcome. The ultimate study in non-ST-elevation acute coronary syndrome comparing ischemia detection with an invasive approach is pending. Therefore, ischemia detection might have a role for stratifying these subjects. This is particularly true in the current era of imaging of high quality and sensitivity, last generation stents, radial access and modern antithrombotic therapy.

Aims Exercise echocardiography (ExE) may evaluate left ventricular (LV) systolic and diastolic function. We aimed to assess the value of diastolic parameters at exercise [early LV inflow velocity to early tissue Doppler annulus velocity (E/e′)] in patients with normal or abnormal resting diastolic function (DF) referred for a clinically indicated ExE. Methods and results LV systolic and DF according to ASE/EACVI guidelines and mitral regurgitation (MR) were evaluated at rest in 772 patients (age 67 ± 12 years) with preserved LV ejection fraction (LVEF ≥ 50%). We assessed regional/global LV systolic function at peak exercise, while MR and E/e′ where evaluated in the immediate post-exercise period. Abnormal ExE was defined as ischaemia or fixed wall motion abnormalities, and raised E/e′ values as >15 at rest and at exercise (e′ at the septal level). Patients were grouped as complaining or not of dyspnoea. Events were overall mortality, myocardial infarction, admission for unstable angina or cardiac failure, and coronary revascularization. DF was abnormal at rest in 221 patients (29%) and indeterminate in 77 (10%), with similar percentages in patients with and without dyspnoea. Exercise E/e′ >15 was found in 37% of patients with abnormal DF, 21% with indeterminate DF, and 6% with normal DF (P < 0.001). Patients with abnormal ExE had more often abnormal resting DF (39% vs. 25%, P = 0.001) and exercise E/e′ >15 (25% vs. 13%, P < 0.001) than those with normal ExE. During a median follow-up of 1.68 years, there were 132 events. Independent predictors included peak exercise LVEF [hazard ratio (HR) = 0.93, 95% confidence interval (CI) = 0.91–0.94, P < 0.001], and exercise E/e′ (HR= 1.04, 95% CI = 1.01–1.07, P = 0.01). Neither resting E/e′ values nor resting abnormal DF by ASE/EACVI guidelines, were independent predictors. Annualized event-rates were 43.2% in patients with (+) ExE plus (+) exercise E/e′, 23.8% in those with (+) ExE and (−) exercise E/e′, 7.9% in (−) ExE and (+) exercise E/e′, and 3.6% with both variables normal. Conclusions The results of diastolic dysfunction at rest and at exercise were similar between patients with or without dyspnoea referred for ExE, but they were associated with abnormal ExE. Exercise E/e′ reclassified 21% of patients with indeterminate DF and further predicted outcome on top of ExE results.

Background Exercise echocardiography (ExE) may assess left ventricular (LV) systolic and diastolic function. We aimed to assess the value of diastolic parameters at exercise (early LV inflow velocity to early tissue Doppler annulus velocity [E/e']) in patients with normal or abnormal resting diastolic function (DF) referred for a clinically indicated ExE. Methods LV systolic and DF according to EACVI Guidelines-2016, and mitral regurgitation (MR) were evaluated at rest in 773 patients (age 67±12 years) with preserved LVEF (≥50). At peak exercise we assessed regional/global LV systolic function, MR and E/e'. Abnormal ExE was defined as ischemia or fixed wall motion abnormalities and raised E/e'values as >15 at rest and at exercise (e' at the septal level). Patients were grouped as complaining or not of dyspnea. Events were overall mortality, myocardial infarction, admission for unstable angina or cardiac failure, coronary revascularization, pulmonary thromboembolism, and stroke. Results Abnormal resting DF was present in 221 patients (29%), indeterminate in 78 (10%). Percentages were similar among the 431 patients with dyspnea (27%/11%) and the 342 without (31%/ 9%), as they were E/e values >15 at rest and at exercise (16% and 18% with dyspnea; 16% and 21% without). Exercise E/e' >15 was found in 37% of patients with abnormal DF, 21% with undeterminate DF, and 6% with normal DF (p Conclusions Diastolic dysfunction results at rest and at exercise were similar between patients with or without dyspnea referred for ExE, but they were associated to abnormal ExE. Exercise E/e' reclassified 21% of patients with indeterminate DF and further predicted outcome on top of ExE results. Funding Acknowledgement Type of funding sources: None.

Background Exercise echocardiography (ExE) may assess LV systolic and diastolic function (DF). We aimed to assess the diagnostic and prognostic value of diastolic parameters at exercise (ratio of early LV inflow velocity to early tissue Doppler septal annulus velocity [E/e'] and systolic pulmonary artery pressure [sPAP]) in patients with indeterminate or abnormal resting DF referred for a clinically indicated ExE. Methods Data from 299 patients (72±9 years, 50% women) with LV-DF evaluated according to EACVI-Guidelines 2016, and LVEF ≥50 were extracted from our database. LV systolic and DF and mitral regurgitation (MR) were evaluated at rest. At peak exercise we assessed regional/global LV systolic function, MR, E/e', and sPAP. Abnormal ExE was defined as ischemia or fixed wall motion abnormalities, elevated E/e'values as >15 at rest and at exercise. Considered events were overall mortality, myocardial infarction, admission for unstable angina or cardiac failure, revascularization, pulmonary thromboembolism, and stroke. Results Abnormal resting DF was present in 221 patients (29%), indeterminate in 78 (10%). Exercise E/e' >15 was found in 37% of patients with abnormal DF, and in 21% with indeterminate DF; exercise E/e >15 plus sPAP>51 mmHg in 13% with abnormal DF, and in 9% with indeterminate DF. Based on exercise E/e' >15 (n=16), change from altered relaxation to restrictive pattern with exercise (n=8), or maintenance of a restrictive pattern for >65 years (n=4), indeterminate DF was reclassified to abnormal DF in 28/78 patients (36%). Among the other 50 patients with indeterminate DF and exercise E/e' ≤15, sPAP>51 mmHg was found in 21, having these subjects altered relaxation at rest and at exercise (n=19) or atrial fibrillation (n=2). Abnormal ExE was seen in 18% of patients with indeterminate resting DF, in 30% with abnormal resting DF, and in 40% with raised exercise E/e'. During median follow-up of 1 year (25th-75th percentiles 0.4–1.7) there were 53 events including 12 deaths, 6 myocardial infarctions, and 18 cardiac failures. Independent predictors were history of coronary disease (HR=2.50, 95% CI=1.31–4.75, p=0.005), ACEI/ARAII (HR=0.43, 95% CI=0.23–0.81, p=0.008), positive clinical or exercise ECG testing (HR=2.42, 95% CI=1.33–4.40, p=0.004), peak LVEF (HR=0.94, 95% CI=0.92–0.96, p Conclusions ExE reclassified 21 to 36% of patients with indeterminate DF to abnormal DF, and was able to detect non-cardiac exercise-induced pulmonary hypertension. E/e'at postexercise further predicted outcome on top of ExE results in patients with indeterminate or abnormal resting DF. Funding Acknowledgement Type of funding sources: None.

Introduction: To reduce contacts during the COVID-19 pandemic, we elaborated a protocol for ambulatory referrals for exercise testing that included discharges from the stress test laboratory (STL). Methods and Results: From 403 patients referred for chest pain (68%) or dyspnea (32%), 219 were straight discharged from the STL (54%), without findings of coronary artery disease in 192 (88%), whereas in 120 (29.5%), further visits were recommended. Medical treatment was modified after the tests in 116 patients (29%). Conclusions: A strategy consisting of discharge from the STL for patients with negative/spurious stress test results, making therapeutic recommendations, seems feasible, effective, and overall opportune in the current situation.

Hipertermia maligna (HM) é uma das mais devastadoras síndromes relacionadas à anestesia. Em indivíduos suscetíveis, a exposição a anestésicos halogenados e relaxante muscular despolarizante (succinilcolina) desencadeia elevação descontrolada dos níveis de cálcio intracelular das células musculares esqueléticas e consequente contração muscular contínua associada à hipermetabolismo. Caracteriza-se por elevação importante da temperatura, taquicardia, taquipneia, hipercarbia, rigidez muscular, acidose e hipercalemia. O tratamento consiste na interrupção imediata do agente gatilho e administração de dantrolene sódico intravenoso. Retardo no diagnóstico e no tratamento está associado à elevada mortalidade.

Objectives: A preserved contractile reserve is a marker of favorable outcome in different cardiac diseases. In some studies, using drugs, an increase in left ventricular (LV) systolic function was associated to better prognosis in patients with dilated cardiomyopathy. We aimed to assess whether a positive contractile reserve (CR) to physical exercise is a marker of good outcome in patients with LV systolic dysfunction not related to coronary artery disease (CAD). Design: From our exercise echocardiography database we extracted patients with LV systolic dysfunction (LVEF ≤45), negative coronary angiography, and absence of a history of CAD. A positive CR was considered when peak LVEF was higher that resting LVEF. The endpoint was overall mortality. Results and Conclusions: Among the 225 patients included, 105 had a positive CR and 120 a negative CR. Resting LV function was similar in patients with positive and negative CR (LVEF 35±8 vs. 34±9; wall motion score index 1.81±0.34 vs. 1.80±0.29; both p=NS). During a follow up of 6.2+4.7 years (25-75th percentiles 2.2-9.5), there were 71 deaths. Ten-year mortality rates were 34% for patients with CR and 67% for patients without CR (p=0.003). After multivariate adjustment that included clinical variables, medications, resting LV function, and exercise testing variables the only predictors of death were age (hazard ratio (HR) 1.07, 95% Confidence Interval (CI) 1.04-1.10, p

Introduction Mitochondrial DNA (mtDNA) is gaining increasing interest as a marker of cellular damage and could also act as an inflammatory mediator in cardiopulmonary bypass induced postoperative inflammatory response. Although minimally invasive heart valve surgery reportedly reduces inflammation, the mtDNA and cytokine profile in this context remains unclear.Materials and Methods Here, we report a prospective series of 40 elderly patients with aortic stenosis who underwent bioprosthetic aortic valve replacement (AVR) through upper ministernotomy with either a sutureless (n = 20) or a conventional (n = 20) valve. Primary end points included serial plasma levels of mtDNA (T1: at baseline; T2: 4 hours after surgery; and T3: 24s hour after surgery), cytokines (interleukin-6 [IL-6], tumor necrosis factor-α [TNF-α]), and myocardial necrosis biomarkers (MNBs), whereas secondary end points included clinical and echocardiographic data.Results Significant increases in the postoperative plasma levels (T2) of mtDNA, cytokines, and MNBs were observed in all patients. The postoperative plasma levels of mtDNA, TNF-α, and MNBs showed no significant differences between the treatment groups, although there was a trend toward lower levels in the sutureless group. The decreases in aortic cross-clamp and cardiopulmonary bypass times seen in the sutureless group were associated with significant lower postoperative levels (T2 and T3) of IL-6.Conclusion AVR through upper ministernotomy was associated with a significant increase in postoperative plasma levels of mtDNA and cytokines. There was no difference in the mtDNA levels between the sutureless and conventional valve groups, suggesting a similar level of inflammation in both groups. However, the shorter operation time observed in the sutureless valve group was associated with significantly lower postoperative levels of IL-6, indicating potential clinical benefits.

During the last years two questions have been continuously asked in chronic coronary syndromes: (1) Do revascularization procedures (coronary artery bypass grafting or percutaneous coronary intervention) really improve symptoms of angina? and (2) Do these techniques improve outcomes, i.e. do they prevent new myocardial infarction events and cardiovascular death? Therefore, there was a need for a large definitive trial. This study was the ISCHEMIA trial, a large, multicentric trial sponsored by the National Heart, Lung, and Blood Institute. The main trial compared coronary revascularization and optimal medical treatment (OMT) vs OMT alone in 5179 patients enrolled after a stress test. During a median 3.2-year follow-up, 318 primary outcome events occurred; the adjusted hazard ratio for the invasive strategy as compared with the conservative strategy was 0.93 (95% confidence interval 0.80-1.08, P = 0.34). The ISCHEMIA trial deeply disrupted many of our prior attitudes regarding management strategies for patients with stable coronary artery disease. The findings underscore the benefits of disease-modifying OMT for stable coronary artery disease patients. The main purposes of ischemia assessment before this trial were: Diagnostic purposes, assessment of outcome, and adding to decision-making processes. Obviously, this changed after the trial results. The results of ISCHEMIA might challenge the current diagnostic approach for stable angina patients recommended in the last European Society of Cardiology guidelines on chronic coronary disease that were based on studies published before the ISCHEMIA trial. In this editorial we propose our approach based on the ISCHEMIA study and the pretest probability for a positive test in patients with chronic coronary syndromes.

Background No data are available about whether Coronavirus disease 2019 (COVID‐19) pandemic have led to changes in clinical profiles or results of exercise testing once the usual activity was reassumed, as well as if wearing a facemask has any impact on the tests. The aim of this study is to evaluate differences in the patients referred to exercise stress testing in the context of COVID‐19 pandemic and analyse the feasibility and results of these tests wearing a facemask. Methods We included all patients referred for an exercise test from 1 June to 30 September 2020 and compared them with the patients attended within the same period in 2019 before and after propensity score matching. All patients referred in 2020 wore a facemask. Results A total of 854 patients were included: 398 in the 2020 group and 456 in 2019. No significant differences in baseline characteristics of the patients were observed, with the exception of dyspnoea, which was nearly twice as high in 2020 as compared with 2019. Regarding the results of the tests, no differences were observed, with almost 80% of maximal tests, similar functional capacity and over a 20% of positive exercise tests in both groups. These results remained after propensity score matching. Conclusion COVID‐19 pandemic has not changed the clinical profile of patients referred to exercise testing. In addition, performing exercise testing wearing a facemask is feasible, with no influence in functional capacity and clinical results.

Funding Acknowledgements Type of funding sources: None. Introduction The evaluation of right ventricular (RV) function in patients with tetralogy of Fallot (TF) is important as it could impact outcome. Further exhaustive assessments with exercise might offer added information. We aimed to evaluate different parameters of RV function and their changes during exercise echocardiography (ExE) in patients with TF, and to correlate them with functional capacity Methods Treadmill ExE was performed in 31 consecutive patients with corrected TF (mean age 36 ± 11, 22 male), all of them asymptomatic. Left ventricular function was studied at peak exercise, whereas RV function parameters were acquired during the immediate post-exercise period ( Results Only 1 patient had symptoms during ExE (dyspnea). Achieved METs were 13 ± 3.5 and 10 patients (32%) had BFC. LV ejection fraction (%) changed with exercise from 58 ± 10 to 63 ± 9 (p = 0.05) and E/e´ from 11 ± 4 to 10 ± 3 (p = 0.04). TAPSE did not change (19 ± 5 at rest; 21 ± 7 at exercise; p = NS), neither RV area change (41 ± 11 cm2 at rest; 39 ± 12 cm2 at exercise; p = NS), whereas TDI-S increased from 10.5 ± 2.8 to 13.8 ± 3.1 cm2/s (p In conclusion, TDI-S assessment at the tricuspid annulus is a useful parameter for assessing RV function during exercise in subjects with TF. Abstract Figure.

[Abstract] Introduction and objectives. Light-chain amyloidosis (AL-CA) and transthyretin amyloidosis (ATTR-CA) are the most common types of cardiac amyloidosis (CA). We sought to study the clinical characteristics and prognosis of both diseases. Methods. We conducted a single-centre, retrospective review of all patients diagnosed with CA between 1998 and 2018. Clinical characteristics, complementary tests, survival and other adverse clinical events were studied. Results. We identified 105 patients with CA, 65 ATTR-CA and 40 AL-CA. Mean age was 74.4 years; 24.8% were women. In both groups, heart failure was the most frequent clinical presentation (55.2%). The most prevalent electrocardiographic findings were the pseudoinfarct pattern (68.5%) and a Sokolow-Lyon index

Funding Acknowledgements Type of funding sources: None. Background The achievement of a maximal workload of 10 metabolic equivalents (METs) is associated to good outcome with hard cardiac events of just around 1%/year. However, there is no much information on common daily exercises that can be quantitatively measured and give information about this exercise performance. We aimed to assess the capacity of stepping up stairs in patients submitted for an exercise testing (ExT). Methods A total of 165 consecutive ambulatory patients submitted for a clinically indicated ExT with ECG (ExT-ECG, n = 15) or echocardiography (ExT-E, n = 150) were included. At least 15 minutes after the test patients were asked to step up 4 flights of stairs (60 stairs) at fast pace without stopping but also without running and the time to do it was counted. Results Patients who achieved 10 METs during exercise (n = 69) made the stairs test in 46 ± 11 secs, those who achieved 8-10 METs (n = 37) in 58 ± 21 secs, and those who achieved Conclusions Most subjects able to step up 4 flights of stairs in 45 secs will perform well during exercise testing. On the contrary, those unable to make the stairs test in 1 and a half minutes are expected to have bad functional capacity and worse exercise test performance. Abstract Figure.

OBJECTIVES This study aims to evaluate the efficacy, safety and long-term outcomes of a renoprotective non-contrast, transoesophageal echocardiography-guided transapical (TA) transcatheter aortic valve replacement (TAVR) strategy with a balloon-expandable prosthesis, as well as to determine its impact on renal function. METHODS Between 2009 and 2019, 200 consecutive patients underwent a non-contrast, transoesophageal echocardiography-guided TA TAVR with a balloon-expandable prosthesis. RESULTS The device success rate was 95.5%. Transoesophageal echocardiography-guided deployment demonstrated a low rate of procedure-related complications: 9.5% of acute kidney injury, 8% postoperative bleeding, 6% low-cardiac output, 4.5% postprocedural aortic regurgitation ≥+2, 4% implantation of permanent pacemaker and 2% stroke. There were no significant differences between preoperative and on discharge estimated glomerular filtration rate (53.9 ± 22.2 vs 54.3 ± 22.9 ml/min/1.73 m2, P = 0.60). Logistic regression analysis confirmed postoperative bleeding as an independent predictor for acute kidney injury (odds ratio (OR) 11.148, 95% confidence interval 3.537–35.140, P CONCLUSIONS Non-contrast, transoesophageal echocardiography-guided TA TAVR is a safe and reproducible technique with a low incidence of periprocedural complications that avoids the use of contrast and mitigates the incidence of acute kidney injury.

Introduction Isolated tricuspid regurgitation (TR) prevalence is increasing in the last decades. Its presence is associated with a worse prognosis when EROA is >40 mm2. Because of high surgery risk and increasing incidence, isolated TR is a challenge in modern cardiology. Purpose To evaluate the prevalence and characteristics of isolated TR compared to other TR aetiologies in a large cohort of patients. Methods Prospective study where consecutive patients undergoing an echocardiographic study within a three-month period were included. All studies with at least moderate TR were selected. Isolated TR was defined as TR with no likely pulmonary hypertension (>50 mmHg), no overt TR cause (no intrinsic tricuspid disease, LVEF ≥50%, no pacemaker/defibrillator wire across the tricuspid, no other significant valve disease, no disease that may cause TR, no congenital or pericardial heart disease); and no previous valve surgery. Patients with isolated TR and other aetiologies were compared. Results 2121 patients with at least moderate TR were included. Isolated TR was found in 398 patients (18.8%). Basal characteristics are shown in table 1. Patients with isolated TR did not have a higher prevalence of AF (47.5% vs. 48.6% p=0.362). Isolated TR was less severe (20.5% vs. 32.1% of patients with severe TR; p After selecting patients with at least severe TR, patients with isolated TR were also less symptomatic (NYHA≥II in 47.8% of patients vs. 70.7%; p We found that patients with isolated severe TR had a larger tricuspid annulus diameter (25.4±0.8 mm/m2 vs. 24.0±0.3 mm/m2; p=0.047). Conclusions In this large prospective study, isolated TR is present in 18.8% of significant TR. Isolated TR was less severe, was associated with less RV dilatation (but with larger tricuspid annulus diameter) and patients had a better functional class compared to other TR aetiologies. Differeces in NYHA and RV function Funding Acknowledgement Type of funding source: None

[Resumen] Introducción y objetivos. Los estudios económicos pueden ayudar a tomar decisiones en el tratamiento de la enfermedad multivaso en el infarto. Se planteó realizar una evaluación económica del ensayo clínico CROSS-AMI (Complete Revascularization or Stress Echocardiography in Patients With Multivessel Disease and ST-Segment Elevation Acute Myocardial Infarction). Métodos. Se realizó un análisis de comparación de costes económicos de las estrategias (revascularización angiográfica completa [RCom] y revascularización selectiva guiada por isquemia en ecocardiograma de estrés [RSel]) comparadas en el ensayo clínico CROSS-AMI (N = 306), derivados de la hospitalización inicial y del primer año de seguimiento, según las tarifas oficiales vigentes en nuestro sistema de salud. Resultados. El coste de la hospitalización inicial resultó superior en el grupo de RCom que en la rama de RSel (19.657,9 ± 6.236,8 frente a 14.038,7 ± 4.958,5 euros; p < 0,001). No hubo diferencias entre ambos grupos en el coste del primer año de seguimiento (RCom, 2.423,5 ± 4.568,0 euros; Rsel, 2.653,9 ± 5.709,1 euros; p = 0,697). El coste total fue 22.081,3 ± 7.505,6 euros en la rama de RCom y 16.692,6 ± 7.669,9 euros en la rama de RSel (p < 0,001). Conclusiones. En el ensayo clínico CROSS-AMI, el sobrecoste inicial de la RCom frente a la RSel no se vio compensado por un ahorro significativo en el seguimiento. La RSel parece ser una estrategia más eficiente que la RCom para los pacientes con síndrome coronario agudo con elevación del segmento ST y enfermedad multivaso tratados mediante angioplastia emergente. [Abstract] Introduction and objectives. Economic studies may help decision making in the management of multivessel disease in the setting of myocardial infarction. We sought to perform an economic evaluation of CROSS-AMI (Complete Revascularization or Stress Echocardiography in Patients With Multivessel Disease and ST-Segment Elevation Acute Myocardial Infarction) randomized clinical trial. Methods. We performed a cost minimization analysis for the strategies (complete angiographic revascularization [ComR] and selective stress echocardiography–guided revascularization [SelR]) compared in the CROSS-AMI clinical trial (N = 306), attributable the initial hospitalization and readmissions during the first year of follow-up, using current rates for health services provided by our health system. Results. The index hospitalization costs were higher in the ComR group than in SelR arm (19 657.9 ± 6236.8 € vs 14 038.7 ± 4958.5 €; P < .001). There were no differences in the costs of the first year of follow-up rehospitalizations between both groups for (ComR 2423.5 ± 4568.0 vs SelR 2653.9 ± 5709.1; P = .697). Total cost was 22 081.3 ± 7505.6 for the ComR arm and 16 692.6 ± 7669.9 for the SelR group (P < .001). Conclusions. In the CROSS-AMI trial, the initial extra economic costs of the ComR versus SelR were not offset by significant savings during follow-up. SelR seems to be more efficient than ComR in patients with ST-segment elevation acute coronary syndrome and multivessel disease treated by emergent angioplasty.

Prosthetic valve endocarditis is a rare but serious complication of cardiac valve replacement, and echocardiography plays a fundamental role in its diagnosis and management. However, there is not much information about the use of the 3D transillumination rendering in this context. In this report, we present an unusual case of prosthetic valve endocarditis that exemplifies the utility of this new tool.