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Background: The gold-standard treatment for end-stage heart failure is heart transplantation, but the lack of organ donors remains an important limitation in this field. An accurate selection of marginal hearts is fundamental to increase organ availability. Purpose: In our study we analyzed if recipients receiving marginal donor (MD) hearts, selected by dipyridamole stress echocardiography according to the ADOHERS national protocol, had different outcomes compared to recipients with acceptable donor (AD) hearts. Methods: Data were collected and retrospectively analyzed from patients who received an orthotopic heart transplant at our institution between 2006 and 2014. Dipyridamole stress echo was performed on identified marginal donors and selected hearts were eventually transplanted. Clinical, laboratory and instrumental features of the recipients were evaluated and patients with homogenous baseline characteristics were selected. Results: Eleven recipients transplanted with a selected marginal heart and eleven recipients transplanted with an acceptable heart were included. Mean donor age was 41 ± 23. The median follow-up was 113 months (IQR 86–146 months). Age, cardiovascular risk and morpho-functional characteristics of the left ventricle were comparable between the two populations (p > 0.05). Left atrial size was significantly higher in patients with marginal hearts (acceptable atrial volume: 23 ± 5 mL; marginal atrial volume: 38 ± 5 mL; p = 0.003). Acceptable donor recipients showed a higher impact of Cardiac Allograph Vasculopathy (p = 0.019). No rejection differences were found between the two groups. Four patients deceased, three were standard donor recipients and one was from the marginal donor group. Conclusions: Our study shows how cardiac transplant (Htx) from selected marginal donor hearts through a non-invasive bedside technique can alleviate the shortage of organs without a difference in survival compared to acceptable donor hearts.

The electrocardiographic (ECG) definition of Brugada syndrome (BS) can be challenging because benign ECG abnormalities, such as right bundle branch block (RBBB), may mimic pathological ECG characteristics of BrS. However, although myocardial delay and deformation can be quantified by advanced imaging, it has not yet been used to differentiate between BrS and RBBB. The aim of this study was to characterize the electro-mechanical behavior of the heart of patients with type-1 BrS and isolated complete RBBB in order to differentiate these conditions.In this two-center study, 66 subjects were analyzed by standard and speckle-tracking echocardiography (STE): 22 type-1 BrS, 24 isolated complete RBBB, and 20 healthy subjects. The participants were not treated by any drug potentially influencing myocardial conduction.Standard echocardiographic parameters did not differ among the groups. The greatest right ventricular (RV) mechanical dispersion was found in RBBB. Mean absolute deviations (MADs) of time-to-peak longitudinal strain calculated for each left ventricular (LV) region were greater in patients with RBBB as compared to BrS (p .01). No differences were found between BrS and controls (p = .36). MADs in the basal segments in RBBB group were greater than MADs found in BrS group and controls (37.3 ms vs. 26.7 ms and 29.0 ms, respectively, p .05). The greatest differences were found in the antero-septal, anterior, lateral, and infero-septal basal segments.Advanced echocardiographic techniques may help to differentiate between BrS and RBBB. Indeed, STE allows to identify an electro-mechanical conduction delay in RBBB patients that is not found in patients affected by type-1 BrS.

Background Antibody-mediated rejection of the transplanted heart is still currently diagnosed by endomyocardial biopsy whereas clinical elements, anti-Human Leukocite Antigens (HLA) antibody and graft dysfunction represents supplementary components. Purpose The aim of the study was to identify though a non-invasive imaging technique, such as advanced transthoracic echocardiography, early signs of altered cardiac function in patients with anti-HLA antibodies and no histological signs of antibody-mediated rejection. Methods The study population included 117 heart transplanted patients, in whom both acute and chronic rejection was excluded. They were divided into two groups “HLA+`' (45 patients) and “HLA−” (72 patients), based on the presence and the absence of circulating anti-HLA antibodies, respectively. The echocardiographic exam was performed within one week from the biopsy, including Speckle Tracking analysis. Results Deceleration Time of E wave was the strongest traditional echocardiographic parameter which correlated with circulating anti-HLA antibodies (165±39,5 vs 196,5±25; p Conclusion The presence of circulating anti-HLA antibodies seems to be correlated with a mild cardiac dysfunction, even in the absence of antibody-mediated rejection. This subtle dysfunction is not completely detectable by standard echocardiographic parameters, whereas strain analysis has showed promising results since it revealed more clearly an impaired function of both ventricles in heart transplanted HLA+ patients, with potentially important clinical repercussion. Funding Acknowledgement Type of funding sources: None. Figure 1

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implant is associated with increasing morbidity and mortality. The aim of this study was to identify the best predictors of RVF post LVAD-implant among biochemical, haemodynamic and echocardiographic parameters. From 2009 to 2019, 38 patients who underwent LVAD implantation at our centre were prospectively enrolled. Preoperative clinical, laboratory, echocardiographic and haemodynamic parameters were reported. Overall, eight patients (21%) developed RVF over time, which revealed to be strongly related to overall mortality. Pulmonary artery pulsatility index (PAPi) resulted to be the most significant right heart catheterization index in discriminating RVF vs no RVF patients [(1.32 ± 0.26 vs. 3.95 ± 3.39 respectively) p = 0.0036]. Regarding transthoracic echocardiography, RVF was associated with reduced free wall right ventricular longitudinal strain (fw-RVLS) (− 7.9 ± 1.29 vs. − 16.14 ± 5.83) (p

Background The electrocardiographic (ECG) definition of Brugada syndrome (BS) can be challenging because benign ECG abnormalities, such as right bundle branch block (RBBB), may mimic pathological ECG characteristics of BrS. However, although myocardial delay and deformation can be quantified by advanced imaging, it has not yet been used to differentiate between BrS and RBBB. Purpose The aim of this study was to characterize the electro-mechanical behavior of the heart of patients with type-1 BrS and subjects with isolated complete RBBB in order to differentiate these conditions. Methods In this two-center study, 66 subjects were analyzed by standard and speckle-tracking echocardiography (STE): 22 type-1 BrS, 24 isolated complete RBBB, and 20 healthy subjects. The participants were not treated by any drug potentially influencing myocardial conduction. Results Standard echocardiographic parameters did not differ among the groups. STE demonstrated that right ventricular (RV) mechanical dispersion (MD) was greater in RBBB as compared to BrS and controls (p Conclusions Advanced echocardiographic techniques may help to differentiate between BrS and RBBB. Indeed, STE allows to identify an electro-mechanical conduction delay in RBBB patients that is not found in patients affected by type-1 BrS. Electromechanical delay by STE Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Italian Society of Cardiology

Background Antibody-mediated rejection of the transplated heart is essentially diagnosed through endomyocardial biopsy whereas clinical elements, anti- Human Leukocite Antigens (HLA) antibody and graft dysfunction are supplementary components. Over the years, several studies have tried to define early diagnostic markers, but to date a univocal consensus has not been achieved. Purpose The aim of the study was to identify though a non-invasive technique, such as transthoracic echocardiography, early signs of impaired cardiac function in heart transplanted patients, in presence of anti-HLA antibodies but without any histological sign of antibody-mediated rejection, assessed through endomyocardial biopsy. Methods In the study 29 heart transplanted patients were enrolled, and they were divided into two groups ‘HLA+’ (15 patients) and ‘HLA-’ (14 patients), based on the presence and the absence of circulating anti-HLA antibodies, respectively. None of the patients had evidence of either coronary allograft vasculopathy or antibody-mediated rejection, attested by endomyocardial biopsy. Each patient underwent through echocardiographic exam, within one month from the biopsy, analysing standard parameters of both systolic and diastolic function, together with strain analysis of right and left ventricle (RV and LV) and left atrium (LA). Results Clinical and demographic characteristics did not different significantly between the two groups, and neither did standard echocardiographic parameters. The only significant parameter that show a statistically significant different was Deceleration Time of E wave (DecT E), which resulted to be lower in the ‘HLA+’ group. Regarding strain analysis, peak atrial longitudinal strain was significantly different between HLA+ and HLA- patients (10,9 ± 5,6 vs 14,9 ± 4,5; p Conclusion The presence of circulating anti-HLA antibodies seems to be correlated with a mild cardiac dysfunction, even in the absence of antibody-mediated rejection. This subtle dysfunction is not completely detectable by standard echocardiographic parameters, whereas strain analysis has showed promising results since it revealed more clearly an impaired function of both ventricles in heart transplanted HLA+ patients, with potentially important clinical repercussion. Abstract P890 Figure.

Right ventricular (RV) evaluation represents one of the major clinical tasks in the follow-up of repaired tetralogy of Fallot patients (rToF) with pulmonary valve regurgitation, as both severe RV dilatation and dysfunction are key factors in defining the need of pulmonary valve replacement. The aim of our study was to report the diagnostic accuracy of echocardiography in the identification of rToF patients with severely dilated and/or depressed RV as compared to cardiac magnetic resonance (CMR). Among our patients with rToF, a subgroup of 95 (17.6 ± 6.8 years; 60% male), who underwent right ventricular qualitative and quantitative evaluation with CMR following echocardiographic suspicion of severe dilation/dysfunction, were included in the analysis. When comparing echocardiographic RV functional parameters to CMR findings, we found no association between CMR-ejection fraction (EF) and either tricuspid annulus plane systolic excursion (TAPSe) nor tissue Doppler systolic tricuspid excursion velocity (all p = ns). In contrast RVFAC was strongly associated with CMR-EF (r = 0.44; p

Left atrial (LA) fibrosis with increased stiffness has been assumed to be the substrates for occurrence of atrial arrhythmias in athletes. However, this hypothesis has not yet been confirmed in humans. Aim of this study was, therefore, to assess LA remodeling and stiffness in competitive athletes. 150 competitive athletes and 90 age and sex-matched sedentary subjects were analyzed by speckle-tracking echocardiography to measure peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). LA stiffness was determined using E/e’ ratio in conjunction with PALS. Left ventricular (LV) stiffness was also calculated. LA volume index was greater in athletes as compared with controls (24.6 ± 7.3 vs. 18.4 ± 7.8 mL/m2, p

Aims Little is known about the adaptation of the right ventricle (RV) to endurance exercise in children. The aim of this study was to assess the effects of 5months of intensive training on RV morphology and function in preadolescent endurance athletes. Methods Ninety-four children were evaluated in this study. Fifty-seven male competitive swimmers (aged 10.8±0.2years) were evaluated before (baseline) and after 5months of the training (peak-training), and compared to 37 age- and sex-matched non-athlete children evaluated at baseline and after 5months of natural growth. All subjects were asymptomatic, with negative family history for cardiomyopathies. Results At baseline no differences were found between athletes and controls for indexed RV outflow tract (RVOT) (18.5±2.7 vs. 16.8±5.0mm/m 2 , p =0.18) and RV basal end-diastolic diameter (EDD) (24.9±4.1 vs. 23.6±3.0mm/m 2 , p =0.15). After 5months, indexed RVOT and RV basal EDD significantly increased in athletes (20.2±2.9mm/m 2 and 25.4±3.3mm/m 2 , p p =0.84 and p =0.25). Despite the increase in RV size, RV function remained normal in athletes, with no changes in RV fractional area change ( p =0.97), s′ value ( p =0.22), and RV longitudinal strain ( p =0.28). Conclusions Endurance training influences the growing heart of male preadolescent athletes with an addictive increase in RV dimensions, with a preserved RV function. Therefore, in children engaged in endurance sports the increase in RV size associated with normal RV function represents a physiological expression of the athlete's heart and should not be misinterpreted as an expression of incipient RV cardiomyopathy.

Aims Conflicting evidence exists concerning right ventricular (RV) morphological and functional remodelling in trained athletes, with a very few longitudinal data prospectively investigating the RV changes. The aim of this study was to assess the morphological and functional RV changes occurring during the competitive season in young athletes engaged in the most popular team sports. Methods and results Twenty-nine top-level athletes (age: 20.9 ± 6.7 years), practicing basketball and volleyball, were evaluated at pre-season, mid-season, and end-season time-points, using tissue Doppler imaging and 2D speckle-tracking echocardiography. RV basal and mid-cavity end-diastolic diameters (EDDs; overall P = 0.011 and P < 0.0001, respectively), and RV diastolic area (overall P < 0.0001) increased during the season. Conversely, RV outflow tract did not vary (overall P = 0.96). During the season, no significant differences were observed in RV diastolic functional indexes and in RV fractional area change (overall P = 0.35). Global RV longitudinal strain did not significantly change (overall P = 0.52), although apical longitudinal strain significantly increased (overall P = 0.017). In association, left ventricular (LV) volume and mass increased during the season (overall P = 0.007). On multivariate analysis, LV mass was the only independent predictor of RVEDD at pre-season ( β = 0.69, P < 0.0001) and at end-season (β = 0.82, P < 0.0001). Conclusions Right ventricular chamber size increases during the competitive season in top-level athletes, with no significant changes in the outflow tract. RV morphological adaptation in top-level athletes practicing team sports is not associated with a reduction in RV function or in myocardial deformation and occurs in close association with changes on the left ventricle, suggesting a physiological remodelling of the right ventricle.

Previous cross-sectional studies have demonstrated that fat-free mass (FFM) is an important determinant of left ventricular mass (LVM) in athletes. However, cross-sectional investigations have not the ability to detect the dynamic adaptation occurring with training. We hypothesized that LVM adapts concurrently with the increase of FFM induced by exercise conditioning. We sought to study the relationship between the variations of LVM and of FFM occurring in top-level soccer players during the season.Twenty-three male top-level athletes were recruited. LVM was assessed by echocardiography and FFM by dual-energy X-ray absorptiometry. Serial measurements were performed pre-season, after 1 month, at mid- and end-season, and after 2 months of detraining.LVM significantly increased at mid-season versus pre-season values, reaching the highest value at the end of the season (p0.05). While body weight did not vary during the study period, FFM significantly increased (p0.05 for mid-/end-season vs. pre-season data). After the detraining, no significant differences were observed between pre-season and detraining echocardiographic data. The only independent predictors of LVM were left ventricular stroke volume and FFM (R = 0.36, p = 0.005; R = 0.35, p = 0.005, respectively). When ΔLVM index was set as dependent variable, the only independent predictor was ΔFFM (R = 0.87, p = 0.002).Changes in LVM occur in close association with changes in FFM, suggesting that the left ventricle adapts concurrently with the increase of the metabolically active tissue induced by training, i.e. the FFM. Therefore, the dynamic changes in FFM and LVM may reflect a physiological adaptation induced by intensive training.

Although left atrial (LA) enlargement is a recognized component of athlete's heart, dynamic cavity changes occurring during the training period remain to be elucidated. We aimed to investigate the adaptive changes of LA reservoir, conduit, and active volumes in elite athletes vs. controls and their response to different training loads.LA maximum, pre-P, and minimum volumes were assessed in 26 top-level athletes and 23 controls. In athletes, LA volumes were measured at pre-, mid-, end-training, and post-detraining time points using conventional 2D echocardiography.Athletes had larger maximum (27.5 ± 3.2 vs. 20.3 ± 5.8 mL/m(2), p = 0.001), pre-P (11.5 ± 0.9 vs. 9.8 ± 2.2 mL/m(2), p = 0.001), and minimum (6.6 ± 0.9 vs. 5.0 ± 1.2 mL/m(2), p0.001) LA indexed volumes, compared with controls. Total and passive emptying volume indices were also larger in athletes compared with controls (18.7 ± 3.1 vs. 15.3 ± 4.9 mL/m(2), p0.05 and 13.8 ± 2.9 vs. 10.5 ± 4.6 mL/m(2), p0.05, respectively), while active emptying volume was similar (p = 0.74). During training, LA maximum (p0.0001), pre-P (p0.0001), minimum (p0.0001), total (p0.005), and passive (p0.05) emptying volume indices progressively increased, while active emptying volume (p = 0.10) and E/e' ratio (p = 0.32) remained unchanged. After detraining, LA volume measurements were not different from pre-training ones. End-training left ventricular mass index was the only independent predictor of the respective maximum LA volume (β = 0.74, p0.005).Top-level athletes exhibit a dynamic morphological and functional LA remodeling, induced by training, with an increase in reservoir and conduit volumes, but stable active volume. LA remodeling is closely associated with left ventricular adaptation to exercise and both completely regress after detraining.

Background— Exercise is able to induce atrial remodeling in top-level athletes. However, evidence is mainly limited to men and based on cross-sectional studies. The aim of this prospective, longitudinal study was to investigate whether exercise is able to influence left and right atrial morphology and function also in female athletes. Methods and Results— Two-dimensional echocardiography was performed before season and after 16 weeks of intensive training in 24 top-level female athletes. Left and right atrial myocardial deformation was assessed by two-dimensional speckle-tracking echocardiography. Left atrial volume index (24.0±3.6 versus 26.7±6.9 mL/m 2 ; P 2 ; P P P E / e ′ ratio nor biatrial stiffness changed after training, suggesting that biatrial remodeling occurs in a model of volume rather than pressure overload. Conclusions— Exercise is able to induce biatrial morphological and functional changes in female athletes. Biatrial enlargement, with normal filling pressures and low atrial stiffness, is a typical feature of the heart of female athletes. These findings should be interpreted as physiological adaptations to exercise and should be considered in the differential diagnosis with cardiomyopathies.

Although many echocardiographic studies are available about the adaptation of left ventricle to intensive training, right heart function has been poorly investigated and no data are available about the right atrial (RA) function in top-level athletes. The aim of the study was to investigate RA function and dimension by standard echocardiography and 2D speckle tracking echocardiography (STE). One hundred top-levels athletes were recruited from professional sports team and were compared with 78 normal subjects. Athletes during an off-training period or during prolonged forced rest resulting from injuries were excluded. Top-level athletes had higher BSA as compared with controls and, as expected, a lower resting heart rate (p ≤ 0.001). RA area, volume, and volume index were significantly greater in athletes than in controls (p ≤ 0.001). This increase was associated with greater right ventricular and inferior vena cava diameters (p ≤ 0.001). Peak atrial longitudinal strain and peak atrial contraction strain values were significantly lower in athletes in comparison with controls (40.92 ± 9.86 % vs. 48.00 ± 12.68 %, p ≤ 0.001; 13.05 ± 4.84 % vs. 15.99 ± 5.74 %, p ≤ 0.001, respectively). Interestingly, while athletes presented a higher E/A ratio (p ≤ 0.001) and a lower peak A velocity (p ≤ 0.001), the E/e′ ratio did not differ between the two groups. In top-level athletes the RA presents a physiological adaptation to intensive exercise conditioning which determines not only a morphological but also a functional remodeling. We reported for the first time reference values of RA strain in elite athletes, demonstrating that 2D STE is a useful tool to investigate RA longitudinal myocardial deformation dynamics in athlete’s heart.

In patients with severe mitral regurgitation (MR) referred for cardiac surgery, left atrial (LA) remodeling and enlargement are accompanied by mechanical stress, mediated cellular hypertrophy, and interstitial fibrosis that finally lead to LA failure. Speckle tracking echocardiography is a novel non-Doppler-based method that allows an objective quantification of LA myocardial deformation, becoming useful for LA functional analysis. We conducted a study to evaluate the relation between the traditional and novel atrial indexes and the extent of ultrastructural alterations, obtained from patients with severe MR who were undergoing surgical correction of the valvular disease. The study population included 46 patients with severe MR, referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery. The global peak atrial longitudinal strain (PALS) was measured in all subjects by averaging all atrial segments. LA tissue samples were obtained from all patients. Masson's trichrome staining was performed to assess the extent of the fibrosis. The LA endocardial thickness was measured. A close negative correlation between the global PALS and grade of LA myocardial fibrosis was found (r = -0.82, p0.0001), with poorer correlations for the LA indexed volume (r = 0.51, p = 0.01), LA ejection fraction (r = 0.61, p = 0.005), and E/E' ratio (0.14, p = NS). Of these indexes, global PALS showed the best diagnostic accuracy to detect LA fibrosis (area under the curve 0.89), and it appears to be a strong and independent predictor of LA fibrosis. Furthermore, we also demonstrated an inverse correlation between the global PALS and LA endocardial thickness (r = -0.66, p = 0.0001). In conclusion, in patients with severe MR referred for cardiac surgery, impairment of LA longitudinal deformation, as assessed by the global PALS, correlated strongly with the extent of LA fibrosis and remodeling.

atrial (LA) enlargement and improved myo- cardial diastolic properties are a component of athlete's heart. We performed a longitudinal study involving adolescent athletes to investi- gate the impact of training on LA remodelling and diastolic function. 21 competitive adoles- cent soccer players were enrolled and engaged in an 8-month training program. Echocardio- graphic analysis was performed at baseline, after 4 and 8 months. We assessed diastolic function by Doppler tissue imaging and we analyzed LA adaptations by 2D speckle-tracking echocardio- graphy. After 4 months, LA mean volume index signifi cantly increased (Δ = 5.47 ± 4.38 mL/m 2 , p ≤ 0.0001). After 8 months, a further increase occurred (Δ = 8.95 ± 4.47 mL/m 2 , p ≤ 0.0001). A higher E velocity (p = 0.001; p = 0.001), a greater E/A ratio (p = 0.002; p = 0.0009), a higher e' peak (p = 0.005; p = 0.001), and a greater e'/a' ratio (p = 0.01; p = 0.0006) were observed at 4 and at 8 months, respectively. E/e' ratio signifi cantly decreased after 8 months (p ≤ 0.005). Global peak atrial longitudinal strain and global peak atrial contraction strain values signifi cantly decreased after 8 months (p = 0.0004, p = 0.01, respectively). An 8-month training program is associated with LA dimensional and functional training-specifi c adaptations in competitive adolescent soccer players. Myocardial diastolic properties can improve after training also in subjects already presenting with features of athlete's heart.

The incremental value of left atrial (LA) deformation analysis by speckle tracking echocardiography compared with LA volume or LA ejection fraction as a cardiovascular risk marker has not been evaluated prospectively. We sought to compare LA function by speckle tracking echocardiography to other conventional LA parameters for prediction of adverse cardiovascular outcomes. This prospective study included 312 adults (mean age 71 ± 6 years, 56% men) in sinus rhythm who were followed for development of first atrial fibrillation, congestive heart failure, stroke, transient ischemic attack, myocardial infarction, coronary revascularization, and cardiovascular death. Global peak atrial longitudinal strain (PALS) by speckle tracking echocardiography was measured in all subjects by averaging all atrial segments. Left atrium was assessed with biplane LA volume, LA ejection fraction, 4-chamber LA area, and M-mode dimension. Of 312 subjects at baseline, 43 had 61 new events during a mean follow-up of 3.1 ± 1.4 years. All LA parameters, traditional parameters, and parameters derived by speckle tracking echocardiography were independently predictive of combined outcomes (p

66 3D speckle-tracking echocardiography in acute myocardial infarction: relationship between contrast-enhanced magnetic resonance imaging and myocardial deformation {#article-title-2} Speckle analysis of 3D echocardiography improves information on left ventricle (LV) segmental and global deformation by avoiding loss of speckles as it is the case in monoplane 2D analysis. Our goal was to evaluate the accuracy of 3D deformation parameters to detect myocardial delayed enhancement (MDE) transmural extent by cardiac magnetic resonance imaging (CMR) in myocardial infarction (MI). Methods: We included 72 patients (57.3±12.4yo) with first acute MI who underwent within 3 days following revascularization both CMR (GE 3T) and echocardiography (GE Vivid E9) including a 3D acquisition of full LV volume. Furthermore, 31 normal subjects (56.5±8.2yo) underwent a complete echocardiography. Automated analysis of 3D allowed the calculation of 3D global LV area (3DGAS), longitudinal (3DGLS), circumferential (3DGCS) and radial (3DGRS) strains (S%). Peak systolic 2D and 3D S values from the 17 LV myocardial segments were recorded. For each segment MDE was defined as transmural (MDE>66%), intermediate (33–66%) and subendocardial (