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Background Up to 40% of patients with severe aortic stenosis (SAS; indexed aortic valve area (AVAi) Objectives To compare outcome of patients with paradoxical low gradient SAS (PLG-SAS; i.e., mean gradient 0.6 cm2/m2) and high gradient SAS (HG-SAS; i.e. mean gradient >40 mmHg and AVAi Methods 2582 consecutive patients with aortic stenosis (PLG-SAS, n=933; MAS, n=876 and HG-SAS, n=773) and a preserved EF (>50%) from an international multicentric registry were studied. Five years mortality between groups was compared using Kaplan Meier analysis. Inverse probability weighting was used to adjust for clinical and imaging baseline characteristics. Additionally, to explore the impact of MG (40 mmHg) in patients with AVAi 0.6 cm2/m2) in patients with MG Results Overall, during 23 [IQR,10–47] months of follow-up 1003 patients died and 770 patients underwent aortic valve replacement. IPW-adjusted natural history was significantly better in patients with MAS, intermediate for patients with PLG-SAS and worst in patients with HG-SAS (59 vs. 47 vs. 41%, p Conclusions In this large multicentric cohort, survival of PLG-SAS patients was better than that of HG-SAS patients and worse than that of MAS patients. Furthermore, with a comparable mean gradient, the smaller the calculated AVAi, the worse the prognosis whereas with a comparable AVAi, the higher the mean gradient, the worse the prognosis. Taking together, these data demonstrate that PLG-SAS is an intermediate form in the disease continuum, HG-SAS being the most malignant form of AS. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds National de la Recherche Scientifique (F.R.S.–FNRS)

OBJECTIVES: The authors sought to characterize the functional and structural myocardial phenotypes of patients with moderate-to-severe aortic stenosis (AS) and to determine whether severe paradoxical low-gradient AS (LG-AS) is specifically associated with left ventricular (LV) remodeling and fibrosis. BACKGROUND: Recently, it was suggested that severe paradoxical LG-AS is a more advanced form of AS, with greater reduction of longitudinal deformation, adverse LV remodeling, and more interstitial fibrosis. METHODS: The study population includes 147 patients with moderate-to-severe AS and a normal LV ejection fraction, and 75 normal control subjects. They prospectively underwent 2-dimensional speckle-tracking echocardiography and cardiac magnetic resonance to evaluate myocardial deformation, LV remodeling, and age- and sex-adjusted extravascular volume fraction (ECV, %). Among AS patients, 18 had moderate AS, 74 had severe high-gradient AS (HG-AS), and 55 had severe paradoxical LG-AS. RESULTS: Reduced longitudinal and circumferential deformation was observed in 21% and 6% of the AS patients, respectively. Multivariate analyses identified increased ECV (ß = 1.99; p = 0.001) and the absence of normal LV geometry (ß = -1.37; p = 0.007) and as independent predictors of reduced longitudinal deformation. Increased ECV was an independent predictor of reduced circumferential deformation (ß = 2.19; p = 0.001). Over a median follow-up of 29 months, reduced longitudinal deformation (hazard ratio: 0.82; p = 0.023) and higher transvalvular gradients (hazard ratio: 1.05; p < 0.001) increased the risk of death or need for aortic valve replacement. LV hypertrophy was more frequently observed among patients with severe HG-AS (65%) than among the other AS patients (14%; p < 0.001). On average, ECV was within normal limits and did not differ among gradient-area subgroups. When present, increased ECV was associated with reduced longitudinal deformation. CONCLUSIONS: This study's data show that patients with severe paradoxical LG-AS less frequently display reduced longitudinal deformation, LV hypertrophy, or myocardial fibrosis than patients with HG-AS. Also, interstitial fibrosis only occurs when reduced longitudinal deformation and severe HG-AS are present together. Finally, this study suggests that reduced longitudinal deformation and higher transvalvular gradients adversely affect patients' outcomes.

Background: Exercise training has shown beneficial effects in the management of radiotherapy-related side effects in prostate cancer (PCa) patients undergoing radiation therapy (RT). However, the optimal modality of the exercise programs have not been yet determined. The aim of this randomized controlled trial was to investigate the effects of high-intensity interval training (HIIT) and resistance training (RES) compared to usual care (UC) on cancer-treatment-related fatigue (CTRF) (primary outcome), quality of life, depression, daytime sleepiness, insomnia, sleep quality, functional exercise capacity and executive function in PCa patients during RT. Methods: PCa patients undergoing RT with or without ADT were randomized in HIIT, RES or UC. Both exercise programs included three sessions per week during 5–8 weeks. HIIT consisted of 8–15 × 60 s intervals (≥85% maximal heart rate). RES was performed with 1–3 sets of 8–12 repetitions for each large muscle groups. The primary outcome was changed in CTRF measured with the Functional Assessment of Chronic Illness Therapy–Fatigue. Results: Seventy-two subjects (69.1 ± 8.2 years) completed the study. No exercise-related adverse events occurred. HIIT (p = 0.012) and RES (p = 0.039) training attenuated increases in CTRF compared to UC. Functional exercise capacity, evaluated by the 6-min walk test, increased after HIIT (p = 0 = 0.43) and RES (p = 0.041) compared to UC (+0.1%). No other secondary variables were different between groups. Conclusions: Both intervention groups displayed beneficial effects on CTRF and functional exercise capacity in PCa patients undergoing RT. In addition, HIIT and RES are both safe with an excellent attendance rate to the exercise sessions.

Objectives This study sought to compare the prognostic value of 2-dimensional (2D) right ventricular (RV) speckle tracking (STE) against cardiac magnetic resonance (CMR) RV ejection fraction (EF) and feature tracking (FT) and conventional echocardiographic parameters on overall and cardiovascular (CV) survival in patients with heart failure with reduced EF (HFrEF). Background Prior works showed that RV systolic function predicts prognosis in HFrEF. 2D RVSTE had recently been proposed as new echocardiographic method to evaluate RV dysfunction. Methods A total of 266 patients with HFrEF (mean LVEF 23 ± 7%, 60 ± 14 years of age; 29% women) underwent RV function assessment using CMR and 2D echocardiography and were followed for a primary endpoint of overall death and secondary endpoint of CV death. Results Average CMR-RVEF was 42 ± 15%, average STE RV global longitudinal strain (STE-RVGLS) was −18.0 ± 4.9%, and average CMR-FT-RVGLS was −11.8 ± 4.3%. After a median follow-up of 4.7 years, 102 patients died, 84 of a CV cause. RVEF, FT-RVGLS, tricuspid annulus plane systolic excursion (TAPSE), fractional area change (FAC), and STE-RVGLS were significant univariate predictors of overall and cardiac death. In multivariate Cox regression, age, ischemic etiology, diabetes, New York Heart Association functional class III to IV, and beta-blocker treatment were independent clinical predictors of overall mortality. CMR-RVEF (chi-square to enter = 3.9; p 15 mm, 1.6 (95% CI: 1.02 to 2.49) for FAC >39%, 1.93 (95% CI: 1.25 to 2.99) for RVEF >41%, and 1.87 (95% CI: 1.10 to 3.19) for CMR-FT-RVGLS Conclusions 2D RVGLS provides strong additional prognostic value to predict overall and CV mortality in HFrEF, with higher predictive value than CMR-RVEF, CMR-FT-RVGLS, TAPSE, or FAC. This supports use of STE-RVGLS to identify higher-risk HFrEF patients.

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Funds Pierre Masure, Alphonse and Marie Walckiers & De Winter-Vermant, by King Baudouin Foundation Background Radiation therapy (RXT) is a keystone in breast cancer (BC) treatment which allows to reduce risk of local recurrence and cancer related mortality. Yet these benefits may be offset by increases in cardiovascular mortality due to late radiation induced cardiotoxicity. Indeed, prior works in patients exposed to high cardiac radiation dose demonstrated development of diffuse and focal myocardial fibrosis by cMR. However, whether such effects may also occur after contemporary BC-RXT with lower cardiac dose exposure, has not yet been evaluated. Purpose To evaluate the long-term cardiac safety of contemporary RXT for BC, we sought to estimate the prevalence of cardiac functional and structural focal and myocardial abnormalities in BC survivors treated by RXT 10 years earlier, in direct relation to measured local radiation dose exposure. Methods In a prospective cross-sectional study, we studied 27 women (mean age 62 ± 7 years) treated with adjuvant RXT but without chemotherapy for a first left (n= 12) or right sided (n= 15) BC between 2009 and 2011, which had no history of coronary artery or cardiac disease and compared them to 20 age matched (64 ± 10 years) healthy female controls (without history of BC or RXT). All subjects underwent 3T cMR to measure LV volumes, function, global longitudinal (GLS), circumferential (GRS) and radial strains (GRS) as well as extracellular volume (ECV) and late gadolinium enhancement (LGE). Functional and structural abnormalities in women with BC were compared to healthy controls. We also compared abnormalities among patients with left vs right BC and related them to mean heart radiation dose measured at the time of RXT (Figure). Results Mean cardiac radiation exposure in BC survivors was 1.87 ± 1.7 Gy (range 0-7.9 Gy). Exposure was significantly (p Conclusions In this preliminary work, patients with BC treated by adjuvant RXT 10 years ago, presented no significant structural or functional abnormalities in relation to cardiac dose exposure nor in comparison to healthy controls. This suggests that current RXT protocols for BC are safe without long-term functional or morphological cardiac side effects.

Background: Assessing the true severity of aortic stenosis (AS) remains a challenge, particularly when echocardiography yields discordant results. Recent European and American guidelines recommend measuring aortic valve calcium (AVC) by multidetector row computed tomography (MDCT) to improve this assessment.Aim: To define, using a standardized MDCT scanning protocol, the optimal AVC load criteria for truly severe AS in patients with concordant echocardiographic findings, to establish the ability of these criteria to predict clinical outcomes, and to investigate their ability to delineate truly severe AS in patients with discordant echocardiographic AS grading.Methods and Results: Two hundred and sixty-six patients with moderate-to-severe AS and normal LVEF prospectively underwent MDCT and Doppler-echocardiography to assess AS severity. In patients with concordant AS grading, ROC analysis identified optimal cut-off values for diagnosing severe AS using different AVC load criteria. In these patients, 4-year event-free survival was better with low AVC load (60–63%) by these criteria than with high AVC load (23–26%, log rank p < 0.001). Patients with discordant AS grading had higher AVC load than those with moderate AS but lower AVC load than those with severe high-gradient AS. Between 36 and 55% of patients with severe LG-AS met AVC load criteria for severe AS. Although AVC load predicted outcome in these patients as well, its prognostic impact was less than in patients with concordant AS grading.Conclusions: Assessment of AVC load accurately identifies truly severe AS and provides powerful prognostic information. Our data further indicate that patients with discordant AS grading consist in a heterogenous group, as evidenced by their large range of AVC load. MDCT allows to differentiate between truly severe and pseudo-severe AS in this population as well, although the prognostic implications thereof are less pronounced than in patients with concordant AS grading.

Myocardial tissue tracking imaging techniques have been developed for a more accurate evaluation of myocardial deformation (i.e. strain), with the potential to overcome the limitations of ejection fraction (EF) and to contribute, incremental to EF, to the diagnosis and prognosis in cardiac diseases. While most of the deformation imaging techniques are based on the similar principles of detecting and tracking specific patterns within an image, there are intra- and inter-imaging modality inconsistencies limiting the wide clinical applicability of strain. In this review, we aimed to describe the particularities of the echocardiographic and cardiac magnetic resonance deformation techniques, in order to understand the discrepancies in strain measurement, focusing on the potential sources of variation: related to the software used to analyse the data, to the different physics of image acquisition and the different principles of 2D vs. 3D approaches. As strain measurements are not interchangeable, it is highly desirable to work with validated strain assessment tools, in order to derive information from evidence-based data. There is, however, a lack of solid validation of the current tissue tracking techniques, as only a few of the commercial deformation imaging softwares have been properly investigated. We have, therefore, addressed in this review the neglected issue of suboptimal validation of tissue tracking techniques, in order to advocate for this matter.

Aims Reproducible evaluation of left (LV) and right ventricular (RV) function is crucial for clinical decision-making and risk stratification. We evaluated whether speckle-tracking echocardiography (STE) and cardiac magnetic resonance feature-tracking (cMR-FT) global longitudinal (GLS) and circumferential strains allow better test–retest reproducibility of LV and RV systolic function than conventional cMR and echocardiographic parameters. Methods and results Thirty healthy volunteers and 20 chronic heart failure patients underwent cMR and STE twice on separate days to evaluate test–retest coefficient of variation (CV), intraclass correlation coefficient (ICC) and estimated sample sizes for significant changes in LV and RV function. Among LV parameters, cMR-left ventricular ejection fraction (LVEF) had the highest reproducibility (CV = 6.7%, ICC = 0.98), significantly better than cMR-FT-GLS (CV = 15.1%, ICC = 0.84), global circumferential strains (CV = 11.5%, ICC = 0.94) and echocardiographic LVEF (CV = 11.3%, ICC = 0.93). STE-LV-GLS (CV = 8.9%, ICC = 0.94) had significantly better reproducibility than cMR-FT-LV-GLS. Among RV parameters, STE-RV-GLS (CV = 7.3%, ICC = 0.93) had significantly better CV than cMR-right ventricular ejection fraction (RVEF) (CV = 13%, ICC = 0.82). cMR-FT-RV-GLS (CV = 43%, ICC = 0.39) performed poorly with significantly lower reproducibility than all other RV parameters. Owing to their superior interstudy reproducibility, cMR-LVEF (n = 12), cMR-RVEF (n = 41), STE-LV-GLS and STE-RV-GLS (both n = 14) were the parameters allowing the lowest calculated sample sizes to detect 10% change in LV or RV systolic function. Conclusion STE-LV-GLS and STE-RV-GLS showed higher test–retest reliability than other echocardiographic measurements of LV and RV function. They also allowed smaller calculated sample sizes, supporting the use of STE-LV and RV-GLS for longitudinal follow-up of LV and RV function.

Background Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome, with several underlying etiologic and pathophysiologic factors. The presence of diabetes might identify an important phenotype, with implications for therapeutic strategies. While diabetes is associated with worse prognosis in HFpEF, the prognostic impact of glycemic control is yet unknown. Hence, we investigated phenotypic differences between diabetic and non-diabetic HFpEF patients (pts), and the prognostic impact of glycated hemoglobin (HbA1C). Methods We prospectively enrolled 183 pts with HFpEF (78 ± 9 years, 38% men), including 70 (38%) diabetics (type 2 diabetes only). They underwent 2D echocardiography (n = 183), cardiac magnetic resonance (CMR) (n = 150), and were followed for a combined outcome of all-cause mortality and first HF hospitalization. The prognostic impact of diabetes and glycemic control were determined with Cox proportional hazard models, and illustrated by adjusted Kaplan Meier curves. Results Diabetic HFpEF pts were younger (76 ± 9 vs 80 ± 8 years, p = 0.002), more obese (BMI 31 ± 6 vs 27 ± 6 kg/m2, p = 0.001) and suffered more frequently from sleep apnea (18% vs 7%, p = 0.032). Atrial fibrillation, however, was more frequent in non-diabetic pts (69% vs 53%, p = 0.028). Although no echocardiographic difference could be detected, CMR analysis revealed a trend towards higher LV mass (66 ± 18 vs 71 ± 14 g/m2, p = 0.07) and higher levels of fibrosis (53% vs 36% of patients had ECV by T1 mapping > 33%, p = 0.05) in diabetic patients. Over 25 ± 12 months, 111 HFpEF pts (63%) reached the combined outcome (24 deaths and 87 HF hospitalizations). Diabetes was a significant predictor of mortality and hospitalization for heart failure (HR: 1.72 [1.1–2.6], p = 0.011, adjusted for age, BMI, NYHA class and renal function). In diabetic patients, lower levels of glycated hemoglobin (HbA1C Conclusion Our study highlights phenotypic features characterizing diabetic patients with HFpEF. Notably, they are younger and more obese than their non-diabetic counterpart, but suffer less from atrial fibrillation. Although diabetes is a predictor of poor outcome in HFpEF, intensive glycemic control (HbA1C

Due to aging of the population and the increase of cardiovascular risk factors, heart failure and preserved ejection fraction (HFpEF) is a rising health issue. Few data exist on the phenotype of HFpEF patients in Belgium and on their prognosis.We describe clinical characteristics and outcomes of Belgian HFpEF patients.We prospectively enrolled 183 HFpEF patients. They underwent clinical examination, comprehensive biological analysis and echocardiography, and were followed for a combined outcome of all-cause mortality and first HF hospitalisation.Belgian patients with HFpEF were old (78 ± 8 years), predominantly females (62%) with multiple comorbidities. Ninety-five per cent were hypertensive, 38% diabetic and 69% overweight. History of atrial fibrillation was present in 63% of population, chronic kidney disease in 60% and anaemia in 58%. Over 30 ± 9 months, 55 (31%) patients died, 87 (49%) were hospitalised and 111 (63%) reached the combined outcome. In multivariate Cox analysis, low body mass index (BMI), NYHA class III and IV, diabetes, poor renal function and loop diuretic intake were independent predictors of the combined outcome (Belgian patients with HFpEF are elderly patients with a high burden of comorbidities. Their prognosis is poor with high rates of hospitalisation and mortality. Although obesity is a risk factor for developing HFpEF, low BMI is the strongest independent predictor of mortality in those patients.

Objectives The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques. Methods The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence. Results Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation. Conclusions Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve–sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.

Coronavirus disease 2019 (COVID-19) is commonly associated with kidney damage, and the angiotensin converting enzyme 2 (ACE2) receptor for SARS-CoV-2 is highly expressed in the proximal tubule cells. Whether patients with COVID-19 present specific manifestations of proximal tubule dysfunction remains unknown. To test this, we examined a cohort of 49 patients requiring hospitalization in a large academic hospital in Brussels, Belgium. There was evidence of proximal tubule dysfunction in a subset of patients with COVID-19, as attested by low-molecular-weight proteinuria (70-80%), neutral aminoaciduria (46%), and defective handling of uric acid (46%) or phosphate (19%). None of the patients had normoglycemic glucosuria. Proximal tubule dysfunction was independent of pre-existing comorbidities, glomerular proteinuria, nephrotoxic medications or viral load. At the structural level, kidneys from patients with COVID-19 showed prominent tubular injury, including in the initial part of the proximal tubule, with brush border loss, acute tubular necrosis, intraluminal debris, and a marked decrease in the expression of megalin in the brush border. Transmission electron microscopy identified particles resembling coronaviruses in vacuoles or cisternae of the endoplasmic reticulum in proximal tubule cells. Among features of proximal tubule dysfunction, hypouricemia with inappropriate uricosuria was independently associated with disease severity and with a significant increase in the risk of respiratory failure requiring invasive mechanical ventilation using Cox (adjusted hazard ratio 6.2, 95% CI 1.9-20.1) or competing risks (adjusted sub-distribution hazard ratio 12.1, 95% CI 2.7-55.4) survival models. Thus, our data establish that SARS-CoV-2 causes specific manifestations of proximal tubule dysfunction and provide novel insights into COVID-19 severity and outcome., Graphical abstract

Funding Acknowledgements Fondation de Recherche Scientifique Belge FRSM PDR 19488731 BACKGROUND 2D-speckle-tracking (ST) echocardiography is currently widely used for estimation of global (G) and regional myocardial deformation. In previous works, we showed good correlation between global longitudinal (LS) and circumferential strain (CS) from one 2DST vendor with cMR-Tagging, however with significant bias between both methods. Also, we found poorer agreement between 2DST and cMR-Tagging on regional basis. However it is unknown how 2DST from other vendors would comparte to cMR tagging. PURPOSE To asssess vendor differences in global and regional strain assessment and compare 1) the agreement of 2 different 2DST softwares for global and regional LS and CS among each other and against cMR-Tagging as reference; and 2) the accuracy of both softwares to detect infarcted segments. METHODS 100 subjects with different cardiac disease (among which 31 with chronic infarct) underwent 2DST and tagging and LGE cMR on the same day. Global and regional CS (16 AHA segments) and LS (18 AHA segments) was computed using 2 different ST vendor softwares and compared to cMR-Tagging with HARP. Accuracy of regional 2D-ST by both vendors to detect infarcted segments (ie >75% transmurality of late gadolinium) was compared using ROC analysis. RESULTS Global LS (ICC = 0.87) and CS 2DST (ICC = 0.83, p Agreement for regional strains is shown in the figure below. Overall, regional LS and CS agreed adequately among both vendors. Agreement of regional LS and CS vs cMR-tagging was slightly better for vendor 1, with less bias than for vendor 2, and disagreement was similarly located (ie agreement with cMR-Tagging for LS in inferolateral inferior and inferoseptal basal segments). The predictive accuracy of regional CS and LS for detecting segments with infarct was higher for vendor 2 (AUC 0.76 and 0.68) than for vendor 1 (AUC 0.70 and 0.63) . CONCLUSION GLS agreed well among both vendors and with cMR-Tagging, confirming the universal validity of this measurement. However vendor 2 provided significantly greater GCS values and had higher bias against cMR-Tagging than vendor 1. On regional basis CS and LS agreed moderately well among both vendors, however vendor 2 agreed less with cMR-Tagging than vendor 1, but astoundingly had higher diagnostic accuracy for detecting infarct. Overall this findings call for further efforts in standardization of 2DST CS and regional strain. Abstract P1393 Figure.

Aims Besides regulating calcium‐phosphate metabolism, fibroblast growth factor 23 (FGF‐23) has been associated with incident heart failure (HF) and left ventricular hypertrophy. However, data about FGF‐23 in HF and preserved ejection fraction (HFpEF) remain limited. The aim of this study was to assess the association between FGF‐23 levels, clinical and imaging characteristics, particularly diffuse myocardial fibrosis, and prognosis in HFpEF patients. Methods and results We prospectively included 143 consecutive HFpEF patients (78 ± 8 years, 61% female patients) and 31 controls of similar age and gender (75 ± 6 years, 61% female patients). All subjects underwent a complete two‐dimensional echocardiography and cardiac magnetic resonance with extracellular volume (ECV) assessment by T1 mapping. FGF‐23 was measured at baseline. Among the patients, differences in clinical and imaging characteristics across tertiles of FGF‐23 levels were analysed with a trend test across the ordered groups. Patients were followed over time for a primary endpoint of all‐cause mortality and first HF hospitalization and a secondary endpoint of all‐cause mortality. Median FGF‐23 was significantly higher in HFpEF patients compared with controls of similar age and gender (247 [115; 548] RU/mL vs. 61 [51; 68] RU/mL, P

Background The importance of right ventricular remodeling in a wide range of cardiovascular diseases has recently been highlighted. Cardiovascular magnetic resonance (cMR) is currently the gold standard to evaluate RV function and is emerging as an important modality to assess myocardial deformation parameters. Purpose We sought to analyze RV longitudinal strain (RVLS) by cMR feature-tracking (cMR-FT) and 2D speckle-tracking echocardiography (STE) in controls and HFpEF patients, and to evaluate feasibility of both techniques. Methods Between January 2015 and June 2017, we prospectively enrolled 163 consecutive patients with HFpEF (78±9 years, 62% women) and 27 age and sex matched controls (76±5 years, 67% women). All underwent complete 2D echography. Of those, 99 patients and 25 controls underwent a 3Tesla cMR. Right ventricular myocardial deformation was assessed using dedicated feature-tracking (Segment) and speckle-tracking softwares on cMR and echographic images respectively. Results Due to insufficient tracking quality, STE RVLS was not feasible in 14 patients (7.4%) and 19 HFpEF patients (19%) and 5 controls (20%) were excluded from the cMR-FT analysis. Mean RVLS was significantly altered in HFpEF patients compared to controls with both STE (−21.7±5% vs −25.9±4%; p RVLS by cMR-FT was moderately correlated to RVLS by STE (r=0.44, p In univariate linear regression analysis, history of atrial fibrillation (r=0.23, p=0.002 and r=0.24, p=0.018), NTproBNP (r=0.34, p Multiple regression analysis showed that RV FAC and NTproBNP (B −29.9 [−38.4; −21.5], p≤0.001 and B 0.613 [0.12; 1.12], p=0.018 respectively) were significant predictors of RV strain when evaluated by STE. On the other hand, only the cMR parameters RVEF (B −0.17 [−0.289; −0.057], p=0.004) and index LV mass (B 0.09 [0.02; 0.15], p=0.008) were independent predictors of RV strain by cMR-FT. Conclusion While cMR-FT is an emerging technique to measure RVLS, it could only be done in 80% of the study population because of insufficient tracking quality. Furthermore, it showed a moderate correlation with RVLS by STE, showing similar trends but an important bias. Further studies are needed to assess if cMR–FT has an additional diagnostic or prognostic value over classical parameters of RV function.

Background Right ventricle (RV) strain has emerged as an accurate and sensitive tool for RV function assessment and is a powerful predictor of survival in heart failure with reduced ejection fraction. The impact of impaired RV strain on prognosis of HFpEF patients however, remains unclear. Purpose We sought to analyze RV global longitudinal strain (RV-GLS) by 2D speckle tracking echocardiography (STE) in controls and HFpEF patients and determine its prognostic value. Methods Between January 2015 and June 2017, we prospectively enrolled 163 consecutive patients with HFpEF (78±9 years, 62% women) and 27 age and sex matched controls (76±5 years, 67% women). All patients underwent complete 2D echography. Myocardial deformation was assessed on a dedicated four chambers view, with a speckle tracking software. Due to poor tracking quality, RV-GLS could not be analyzed in 14 patients (7.4%). Impaired RV-GLS was defined as a GLS above −17.5% corresponding to the mean + 2 SD of age and sex matched controls. HFpEF patients were followed up for a combined outcome of all-cause mortality and first HF hospitalization. Results Mean RV-GLS was significantly altered in HFpEF patients compared to controls (−21.7±4.9% vs −25.9±4.2%; p During a mean follow-up of 19±9months, 73 HFpEF patients (49%) reached the combined outcome (15 all cause deaths and 58 first HF hospitalization). In univariate Cox regression analysis, loop diuretic medication (HR 1.92 [1.10–3.32], p=0.021), low hemoglobin (HR 0.85 [0.75–0.97], p=0.013), low eGFR (HR 0.97 [0.96–0.99], p In multivariate Cox analysis, hemoglobin levels (HR 0.83 [0.72–0.96], p=0.01), eGFR (HR 0.98 [0.97–0.99]; p=0.009) and impaired RV-GLS (HR 2.48 [1.38–4.44], p=0.002), were independent predictors of the combined outcome. Kaplan-Meier event free survival curves show that HFpEF patients with RV-GLS above −17.5% had worse prognosis than those with better myocardial deformation (p=0.009, Figure). Conclusions RV-GLS is significantly different between controls and HFpEF patients. In HFpEF, impaired RV-GLS is associated with worse prognosis.

BACKGROUND: The aim of this study was to evaluate the accuracy of mitral regurgitation (MR) volume quantified on three-dimensional (3D) color Doppler transesophageal echocardiography (TEE) using new semiautomated software compared with conventional two-dimensional (2D) proximal isovelocity surface area (PISA) transthoracic echocardiography (TTE) and TEE and cardiac magnetic resonance imaging (CMR). METHODS: Fifty-one patients (mean age, 63 ± 16 years; 35 men) prospectively underwent TTE, TEE, and CMR for MR evaluation. Regurgitant volume (RVol) by 3D MR flow quantification was compared with 2D TTE, TEE, and CMR, and the accuracy of evaluation of severe MR by 3D MR flow quantification was compared against guideline criteria by TEE. RESULTS: Twenty-nine patients had severe MR, 16 had moderate MR, and six had mild MR. Three-dimensional MR flow quantification was feasible in all patients, including prolapse (n = 37), restriction (n = 9), functional MR (n = 5), and eccentric or multiple jects (n = 41). RVol on 3D MR flow quantification correlated well with RVol on 2D PISA TTE (interclass correlation coefficient [ICC] = 0.75, P < .001), quantitatively estimated RVol (ICC = 0.74, P < .001), and 2D PISA TEE (ICC = 0.79, P < .001). Three-dimensional MR flow quantification agreed better with CMR (ICC = 0.86, P < .001) than did RVol on 2D PISA TTE (ICC = 0.66, P < .001) and 2D PISA TEE (ICC = 0.69, P < .001), with narrower limits of agreement on Bland-Altman analysis. Three-dimensional MR flow quantification had high accuracy for diagnosing severe MR using TEE (area under the curve = 0.85, 95% CI 0.74-0.96, P < .001) or CMR (area under the curve = 0.95; 95% CI, 0.89-1.00; P < .001) as the criterion. CONCLUSIONS: The new software enabled semiautomated 3D MR flow quantification in complex MR with multiple and eccentric jets and showed better agreement with CMR than 2D PISA TTE or TEE, suggesting that this method is more accurate than conventional 2D PISA TTE and TEE.

OBJECTIVES: The present study aimed at investigating the respective contribution of afterload and myocardial fibrosis to pre- and post-operative left ventricular (LV) function by using stress-strain relationships. BACKGROUND: Separating the effect of myocardial dysfunction and afterload on pump performance has important implications for the prognosis and management of patients with severe aortic stenosis (AS). METHODS: A total of 101 patients with isolated severe AS (57% men; mean age 71 years) and 75 healthy control subjects underwent resting 2-dimensional and speckle-tracking echocardiography to measure global circumferential strain (GCS) and global longitudinal strain (GLS), as well as end-systolic wall stress (ESWS). Normal stress-strain relationships were constructed using control subjects' data and fitted to linear regression. End-systolic stress-strain indexes (the number of SDs from the mean regression line) were used as an afterload-independent index of myocardial function and compared with myocardial fibrosis, measured on transmural myocardial biopsies harvested at the time of surgery. RESULTS: GCS and GLS were afterload-dependent in both control subjects and patients. The GLS-ESWS relationship of patients was shifted downward compared with control subjects. Patients with reduced pre-operative end-systolic stress-strain indexes exhibited larger degrees of interstitial myocardial fibrosis than patients without (3.8 ± 2.9% vs. 8.3 ± 6.3%, p < 0.001; and 4.9 ± 4.4% vs. 9.5 ± 6.4%; p < 0.001, for GLS and GCS, respectively). By multivariate analysis, pre-operative end-systolic stress-strain indexes were the only predictors of post-operative longitudinal and circumferential end-systolic stress-strain indexes (ß = 0.49 and ß = 0.60, respectively; p < 0.001). CONCLUSIONS: Myocardial strains are afterload-dependent. In patients with severe AS, pre-operative stress-strain indexes allow identification of patients with increased myocardial fibrosis and predict the extent of functional recovery after aortic valve replacement.

OBJECTIVES: The present study examines whether improvements have reduced the negative impact of guideline triggers on postoperative outcomes. BACKGROUND: European and American guidelines for the management of severe aortic regurgitation (AR) define the triggers for AR surgery. These triggers are based on the results of studies performed in the 1990s analyzing outcomes of patients who underwent AR surgery in the 1980s. Although these triggers are used to indicate surgery, they have all been associated with poorer postoperative outcomes. In the meantime, innovations in operative techniques, including aortic valve repair, have allowed reducing the risk of surgery. METHODS: A total of 356 consecutive patients undergoing surgical correction of severe AR were included in this study. Among them, 204 were operated on for a Class I, 17 for a Class IIa, 49 for a Class IIb, and 86 without any guideline triggers. Cox proportional hazards regression models and Kaplan-Meier survival curves were used to compare postoperative outcomes in the different groups. Inverse probability weighing was used to adjust for mismatched baseline characteristics. RESULTS: Adjusted 10-year survival was better among patients without operative triggers (89 ± 4%) or with Class II triggers (85 ± 6%) than in patients with Class I triggers (71 ± 4%, p = 0.010). Similar results were obtained for cardiovascular survival and hospitalizations for heart failure. Spline function analyses indicated that mortality started to increase for left ventricular (LV) ejection fraction 20 to 22 mm/m2. LV end-diastolic dimensions did not influence outcomes. CONCLUSIONS: Guideline-based Class I triggers for AR surgery carry major risks for long-term outcomes. This suggests that patients with severe AR should be operated on before the onset of these triggers; that is, at an asymptomatic stage, before LV ejection fraction falls below 55% or LV end-systolic dimensions exceeds 20 to 22 mm/m2.

Background Limited data are available regarding the prognostic value of right ventricular (RV) systolic dysfunction (RVSD) in patients with coronary artery disease. Our objective was to evaluate the effect of RVSD assessed by cardiac magnetic resonance on survival of patients with low left ventricular (LV) ejection fraction (EF) undergoing coronary bypass grafting (CABG). Methods We prospectively assessed overall and cardiovascular death of 107 consecutive patients (94 men; age, 66 ± 10 years) undergoing CABG who had a LVEF of 0.35 or less by cardiac magnetic resonance before CABG. Results Mean LVEF was 0.25 ± 0.07, and mean RVEF was 0.46 ± 0.16. RVSD, defined by RVEF of 0.35 or less, was present in 32 patients (30%). In-hospital mortality rate (n = 8) was significantly higher in patients with RVSD (18.7% vs 2.7%, p = 0.004). Over a median follow-up of 4.7 years, 44 patients died, 33 of a cardiovascular cause. The primary end point of cardiovascular death was reached by 15 of 32 patients with RVSD and 18 of 75 patients without RVSD (47% vs 24%, p = 0.019). Univariate survival analysis showed that age, New York Heart Association Functional Classification, diabetes, estimated glomerular filtration rate, LVEF, LV indexed end-diastolic volume, RVEF, RV indexed end-diastolic volume, RV systolic function, and The Society of Thoracic Surgeons risk score were independent predictors of the primary end point of cardiovascular death. By multivariable analysis, the Society of Thoracic Surgeons risk score (hazard ratio, 1.32; 95% confidence interval, 1.13 to 1.55; p = 0.001) and RVSD (hazard ratio, 2.14; 95% confidence interval, 1.06 to 4.31; p = 0.034) remained significant independent predictors of cardiovascular death. Conclusions RVSD strongly and independently predicts cardiovascular death in patients with coronary artery disease and low EF undergoing CABG. Evaluation of RV function should thus be part of preoperative evaluation of such patients.

Objectives The management of asymptomatic patients with severe aortic regurgitation remains controversial. Accordingly, the aim of the present study was to assess the long-term outcomes and incidence of cardiac complications among asymptomatic patients with severe aortic regurgitation who underwent operation early, in the absence of any class I or class IIa guideline triggers, or were managed conservatively and eventually underwent operation whenever these triggers appeared. Methods A total of 160 consecutive asymptomatic patients (50 ± 17 years) with severe aortic regurgitation were prospectively followed up for a median of 7.2 years. Overall and cardiovascular survivals and the need for repeat aortic regurgitation surgery were evaluated in an "early surgery" group (n = 91) and a "conservatively managed" group (n = 69). Results Ten-year overall (91% ± 4% vs 89% ± 5%, P = .87) and cardiovascular (96% ± 2% vs 96% ± 3%, P = .79) survivals were similar among the early surgery and conservatively managed groups. Conservatively managed patients were further sub-stratified according to the regularity and quality of their follow-up. Patients who were regularly followed up by a certified cardiologist had a better 10-year overall survival than patients undergoing no or a looser follow-up (95% ± 5% vs 79% ± 10%, P = .045). Multivariate Cox proportional hazards analysis identified age ( P = .003) and male gender ( P = .024) as independent predictors of survival. Early surgical management was not a predictor of outcome ( P = .45). Conclusions Our results show that the outcome of asymptomatic patients with severe aortic regurgitation is not different between an early surgical and a more conservative strategy, provided that the conservatively managed patients are regularly followed up and timely referred to surgery as soon as operative triggers develop. This suggests that surgery should not be recommended in patients with aortic regurgitation who do not meet current guidelines for intervention.

Right ventricular (RV) strain has emerged as an accurate tool for RV function assessment and is a powerful predictor of survival in patients with heart failure with reduced ejection fraction. However, its prognostic impact in patients with heart failure with preserved ejection fraction (HFpEF) remains unclear. The aim of this study was to compare the prognostic value of RV global longitudinal strain (RVGLS) by two-dimensional speckle-tracking echocardiographic (STE) imaging in patients with HFpEF against conventional RV function parameters. Patients with HFpEF were prospectively recruited, and 149 of 183 (81%) with analyzable STE RVGLS images constituted the final study population (mean age, 78 ± 9 years; 61% women), compared with 28 control subjects of similar age and sex. All control subjects and 120 patients also underwent cardiac magnetic resonance imaging. Patients were followed up for a primary end point of all-cause mortality and first heart failure hospitalization, and Cox regression analysis was performed. Mean STE RVGLS was significantly altered in patients with HFpEF compared with control subjects (-21.7 ± 4.9% vs -25.9 ± 4.2%, P -17.5%). During a mean follow-up period of 30 ± 9 months, 91 patients with HFpEF (62%) reached the primary end point. A baseline model was created using independent predictors of the primary end point: New York Heart Association functional class III or IV, hemoglobin level, estimated glomerular filtration rate, and the presence of moderate or severe tricuspid regurgitation. Impaired STE RVGLS provided significant additional prognostic value over this model (χ to enter = 7.85, P = .005). Impaired tricuspid annular plane systolic excursion and fractional area change, however, did not. In patients with HFpEF, impaired RVGLS has strong prognostic value. STE RVGLS should be considered for systematic evaluation of RV function to identify patients at high risk for adverse events.

Background Increased myocardial fibrosis may play a key role in heart failure with preserved ejection fraction (HFpEF) pathophysiology. The study aim was to evaluate the presence, associations, and prognostic significance of diffuse fibrosis in HFpEF patients compared to age- and sex-matched controls. Methods We prospectively included 118 consecutive HFpEF patients. Diffuse myocardial fibrosis was estimated by extracellular volume (ECV) quantified by cardiovascular magnetic resonance with the modified Look-Locker inversion recovery sequence. We determined an ECV age- and sex-adjusted cutoff value (33%) in 26 controls. Results Mean ECV was significantly higher in HFpEF patients versus healthy controls (32.9 ± 4.8% vs 28.2 ± 2.4%, P 33% demonstrating significant prediction of risk and validated this score in a validation cohort of 53 patients. Kaplan–Meier curves showed a significant difference according to tertiles of the probability score (P

This study sought to compare the prognostic value of 2-dimensional (2D) right ventricular (RV) speckle tracking (STE) against cardiac magnetic resonance (CMR) RV ejection fraction (EF) and feature tracking (FT) and conventional echocardiographic parameters on overall and cardiovascular (CV) survival in patients with heart failure with reduced EF (HFrEF).Prior works showed that RV systolic function predicts prognosis in HFrEF. 2D RVSTE had recently been proposed as new echocardiographic method to evaluate RV dysfunction.A total of 266 patients with HFrEF (mean LVEF 23 ± 7%, 60 ± 14 years of age; 29% women) underwent RV function assessment using CMR and 2D echocardiography and were followed for a primary endpoint of overall death and secondary endpoint of CV death.Average CMR-RVEF was 42 ± 15%, average STE RV global longitudinal strain (STE-RVGLS) was -18.0 ± 4.9%, and average CMR-FT-RVGLS was -11.8 ± 4.3%. After a median follow-up of 4.7 years, 102 patients died, 84 of a CV cause. RVEF, FT-RVGLS, tricuspid annulus plane systolic excursion (TAPSE), fractional area change (FAC), and STE-RVGLS were significant univariate predictors of overall and cardiac death. In multivariate Cox regression, age, ischemic etiology, diabetes, New York Heart Association functional class III to IV, and beta-blocker treatment were independent clinical predictors of overall mortality. CMR-RVEF (chi-square to enter = 3.9; p 0.05), FT-RVGLS (chi-square to enter 3.7; p = 0.05), FAC (chi-square to enter 6.2; p = 0.02), and TAPSE (chi-square to enter = 4.1; p = 0.04) provided additional prognostic value over these baseline parameters, but the additional predictive value of STE-RVGLS (chi-square to enter = 10.8; p 0.001) was significantly (p 0.05) higher than the other tests. Additional hazard ratio to predict overall mortality was 2.5 (95% confidence interval [CI]: 1.6 to 3.9) for STE-RVGLS -19%, 2.15 (95% CI: 1.34 to 3.43) for TAPSE15 mm, 1.6 (95% CI: 1.02 to 2.49) for FAC39%, 1.93 (95% CI: 1.25 to 2.99) for RVEF41%, and 1.87 (95% CI: 1.10 to 3.19) for CMR-FT-RVGLS -15%.2D RVGLS provides strong additional prognostic value to predict overall and CV mortality in HFrEF, with higher predictive value than CMR-RVEF, CMR-FT-RVGLS, TAPSE, or FAC. This supports use of STE-RVGLS to identify higher-risk HFrEF patients.

Objective To analyze our long-term experience with valve-sparing reimplantation technique for the treatment of isolated root aneurysm, aneurysm with significant aortic regurgitation, and for isolated aortic regurgitation. Methods Between 1999 and 2017, 440 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 49 ± 15 years. Time-to-event analysis was performed with the Kaplan-Meier method, whereas significant predictors of late outcomes were explored with Cox proportional hazard model. Results In-hospital mortality was 0.7% (n = 3). Four hundred fourteen patients were available for long-term analysis. Median duration of follow-up was 5 years (interquartile range, 2-8.5 years). Thirty-six patients (8.5%) died during follow-up; therefore, survival was 79.7% ± 3.8% at 10 years. During follow-up we observed a linearized rate of 0.37%, 0.73%, and 0.2% patient-year, respectively, for major bleeding, thromboembolic events, and infective endocarditis. Nineteen patients required late aortic valve reoperation and freedom from valve reoperation was 89.6% ± 2.9% at 10 years and was not significantly different between groups or between tricuspid or bicuspid valve phenotypes. Conclusions Our study shows that valve-sparing reimplantation is associated with low perioperative mortality, a remarkably low rate of valve-related complications, and excellent long-term durability. Further, it can be safely performed also in patients with isolated aortic regurgitation and the durability of valve repair is similar regardless of the indication for surgery of valve phenotype.

BACKGROUND: In prior work, the authors demonstrated that two-dimensional speckle-tracking (2DST) correlated well but systematically overestimated global longitudinal strain (LS) and circumferential strain (CS) compared with two-dimensional cardiac magnetic resonance tagging (2DTagg) and had poor agreement on a segmental basis. Because three-dimensional speckle-tracking (3DST) has recently emerged as a new, more comprehensive evaluation of myocardial deformation, this study was undertaken to evaluate whether it would compare more favorably with 2DTagg than 2DST. METHODS: In a prospective two-center trial, 119 subjects (29 healthy volunteers, 63 patients with left ventricular dysfunction, and 27 patients with left ventricular hypertrophy) underwent 2DST, 3DST, and 2DTagg. Global, regional (basal, mid, and apical), and segmental (18 and 16 segments per patient) LS and CS by 2DST and 3DST were compared with 2DTagg using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Test-retest reproducibility of 3DST and 2DST was compared in 48 other patients. RESULTS: Both global LS and CS by 3DST agreed better with 2DTagg (ICC = 0.89 and ICC = 0.83, P < .001 for both; bias = 0.5 ± 2.3% and 0.2 ± 3%) than 2DST (ICC = 0.65 and ICC = 0.55, P < .001 for both; bias = -5.5 ± 2.5% and -7 ± 5.3%). Unlike 2DST, 3DST did not overestimate deformation at the regional and particularly the apical levels and at the segmental level had lower bias (LS, 0.8 ± 2.8% vs -5.3 ± 2.4%; CS, -0.01 ± 2.8% vs -7 ± 2.8%, respectively) but similar agreement with 2DST (LS: ICC = 0.58 ± 0.16 vs 0.56 ± 0.12; CS: ICC = 0.58 ± 0.12 vs 0.51 ± 0.1) with 2DTagg. Finally, 3DST had similar global LS, but better global CS test-retest variability than 2DST. CONCLUSIONS: Using 2DTagg as reference, 3DST had better agreement and less bias for global and regional LS and CS. At the segmental level, 3DST demonstrated comparable agreement but lower bias versus 2DTagg compared with 2DST. Also, test-retest variability for global CS by 3DST was better than by 2DST. This suggests that 3DST is superior to 2DST for analysis of global and regional myocardial deformation, but further refinement is needed for both 3DST and 2DST at the segmental level.

To evaluate the ability of chest computed tomography (CT) to predict pulmonary hypertension (PH) and outcome in chronic heart failure with reduced ejection fraction (HFrEF). We reviewed 119 consecutive patients with HFrEF by CT, transthoracic echocardiography (TTE) and right heart catheterization (RHC). CT-derived pulmonary artery (PA) diameter and PA to ascending aorta diameter ratio (PA:A ratio), left atrial, right atrial, right ventricular (RV) and left ventricular volumes were correlated with RHC mean pulmonary arterial pressure (mPAP) . Diagnostic accuracy to predict PH and ability to predict primary composite endpoint of all-cause mortality and HF events were evaluated. RV volume was significantly higher in 81 patients with PH compared to 38 patients without PH (133 ml/m2 vs. 79 ml/m2, p < 0.001) and was moderately correlated with mPAP (r=0.55, p < 0.001). Also, RV volume had higher ability to predict PH (area under the curve: 0.88) than PA diameter (0.79), PA:A ratio (0.76) by CT and tricuspid regurgitation gradient (0.83) and RV basal diameter by TTE (0.84, all p < 0.001). During the follow-up period (median: 3.4 years), 51 patients (43%) had HF events or died. After correction for important clinical, TTE and RHC parameters, RV volume (adjusted hazard ratio [HR]: 1.71, 95% CI 1.31–2.23, p < 0.001) and PA diameter (HR: 1.61, 95% CI 1.18–2.22, p = 0.003) were independent predictors of the primary endpoint. In patients with HFrEF, measurement of RV volume and PA diameter on ungated CT are non-invasive markers of PH and may help to predict the patient outcome. • Right ventricular (RV) volume measured by chest CT has good ability to identify pulmonary hypertension (PH) in patients with chronic heart failure (HF) and reduced ejection fraction (HFrEF). • The accuracy of pulmonary artery (PA) diameter and PA to ascending aorta diameter ratio (PA:A ratio) to predict PH was similar to previous studies, however, with lower cut-offs (28.1 mm and 0.92, respectively). • Chest CT-derived PA diameter and RV volume independently predict all-cause mortality and HF events and improve outcome prediction in patients with advanced HFrEF.