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Treatments for structural heart diseases (SHD) have been considerably evolved by the widespread of transcatheter approach in the last decades. The progression of transcatheter treatments for SHD was feasible due to the improvement of devices and the advances in imaging techniques. In this setting, the cardiovascular imaging is pivotal not only for the diagnosis but even for the treatment of SHD. With the aim of fulfilling these tasks, a multimodality imaging approach with new imaging tools for pre-procedural planning, intra-procedural guidance, and follow-up of SHD was developed. This review will describe the current state-of-the-art imaging techniques for the most common percutaneous interventions as well as the new imaging tools. The imaging approaches will be addressed describing the use in pre-procedural planning, intra-procedural guidance, and follow-up.

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance in real-world clinical practice.We analyzed ECG and angiographic data from 419 consecutive STEMI patients submitted to primary percutaneous coronary intervention over a one-year period, dividing the overall population into derivation (314 patients) and validation (105 patients) cohorts. In the derivation cohort, we tested60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance in the validation cohort.In the derivation cohort, the algorithm correctly predicted the IRA in 88% of cases and both the IRA and its occlusion level (proximal vs mid-distal) in 71% of cases. When applied to the validation cohort, the algorithm resulted in 88% and 67% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (P = .026 vs best cardiologist and P.001 vs best emergency medicine doctor).Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

Transcatheter aortic valve implant (TAVI) is gaining momentum in the treatment of severe, symptomatic aortic valve stenosis, and its indication is expanding to lower surgical risk individuals, who are generally younger and have a long life expectancy. Therefore, transcatheter bioprostheses durability appears of critical importance. Aim of the present study is to evaluate mid-term outcomes of TAVI in a high-volume single center cohort.We analyzed all consecutive patients (n = 408) who underwent transfemoral TAVI at a single, high-volume center, between 2007 and 2014. Study objectives were all-cause death and bioprosthetic valve failure (BVF) at long term follow-up. Structural valve deterioration (SVD), BVF and valve-related death were defined according to current international standards. Follow-up was performed by in person visit and transthoracic echocardiography, which was obtained only in a minority of patients, or phone call as per patient preference.At a median follow-up of 1821 days, overall mortality was 64.5%, with cardiovascular disease accounting for roughly half of total deaths. Valve-related deaths occurred in 10 patients. Seventeen patients were diagnosed with BVF, and 15 required repeat intervention. Moderate and severe SVD were observed in 10 and 7 patients, respectively. In the subgroup of patients with echocardiographic mid-term follow-up (n = 76), no significant increase of transprosthetic gradients nor increase of significant regurgitation was detected.In the present unselected, all-comers cohort, TAVI bioprostheses appeared to have excellent durability at long-term follow-up.

AimsTranscatheter aortic valve implantation (TAVI) is the treatment of choice for high-risk patients with severe aortic stenosis (AS). A portion of TAVI recipients has no long-term clinical benefit, and myocardial fibrosis may contribute to unfavourable outcomes. We aimed to assess the prognostic value of an interstitial fibrosis marker, extracellular volume fraction (ECV), measured at planning computed tomography (CT) before TAVI.Methods and resultsFrom October 2020 to July 2021, 159 consecutive patients undergoing TAVI planning CT were prospectively enroled. ECV was calculated as the ratio of myocardium and blood pool differential attenuations before and 5 min after contrast administration, pondered for haematocrit. A composite endpoint including heart failure hospitalization (HFH) and death was collected by telehealth or in-person follow-up visits in the 113 patients constituting the final study population. Cox proportional hazards model was used to assess association between ECV and the composite endpoint.Median follow-up was 13 (11–15) months. The composite endpoint occurred in 23/113 (20%) patients. These patients had lower aortic valve mean pressure gradient [39 (29–48) vs. 46 (40–54) mmHg, P = 0.002] and left ventricular and right ventricular ejection fraction [51 (37–69) vs. 66 (54–74)%, P = 0.014; 45 (31–53) vs. 49 (44–55)%, P = 0.010] and higher ECV [31.5 (26.9–34.3) vs. 27.8 (25.3–30.2)%, P = 0.006]. At multivariable Cox analysis, ECV higher than 31.3% was associated to increased risk of death or HFH at follow-up (hazard ratio = 5.92, 95% confidence interval 2.37–14.75, P < 0.001).ConclusionIn this prospective observational cohort study, ECV measured at TAVI planning CT predicts the composite endpoint (HFH or death) in high-risk severe AS patients.

Aims The procedural planning of transcatheter mitral valve replacement (TMVR) requires a specific imaging assessment to establish patient eligibility. Computed tomography (CT) is considered the reference method. In this setting, data regarding the role of transoesophageal echocardiography (TOE) are lacking. We evaluated the feasibility and reliability of a comprehensive 3D-TOE screening in TMVR candidates. Methods and results We performed a retrospective observational study including 72 consecutive patients who underwent a pre-procedural CT and 3D-TOE for TMVR evaluation. The measurements of mitral annulus (MA), length of anterior mitral leaflet (AML), native left ventricular outflow tract (LVOT), and predicted neo-LVOT acquired with CT and 3D-TOE were compared using a novel semi-automated software for post processing analysis (3 mensio Structural Heart 10.1—3mSH, Pie Medical Imaging, Bilthoven, Netherlands). The final suitability decision was given by the valve manufacturer based on CT measurements and clinical conditions. Among 72 patients screened, all patients had adequate image quality for 3D-TOE analysis. 3D-TOE and CT measurements for AML length (r = 0.97), MA area (r = 0.90), perimeter (r = 0.68), anteroposterior (r = 0.88), and posteromedial-anterolateral (r = 0.74) diameters were found highly correlated, as well as for native LVOT (r = 0.86) and predicted neo-LVOT areas (r = 0.96) (all P-values Conclusion 3D-TOE appraisements showed good correlations with CT measurements and high accuracy to predict TMVR screening success.

Aims To evaluate the prognostic impact of pre-procedural right ventricular longitudinal strain (RVLS) in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge repair (TEER) in comparison with conventional echocardiographic parameters of RV function. Methods and results This is a retrospective study including 142 patients with SMR undergoing TEER at two Italian centres. At 1-year follow-up 45 patients reached the composite endpoint of all-cause death or heart failure hospitalization. The best cut-off value of RV free-wall longitudinal strain (RVFWLS) to predict outcome was −18% [sensitivity 72%, specificity of 71%, area under curve (AUC) 0.78, P < 0.001], whereas the best cut-off value of RV global longitudinal strain (RVGLS) was −15% (sensitivity 56%, specificity 76%, AUC 0.69, P < 0.001). Prognostic performance was suboptimal for tricuspid annular plane systolic excursion, Doppler tissue imaging-derived tricuspid lateral annular systolic velocity and fractional area change (FAC). Cumulative survival free from events was lower in patients with RVFWLS ≥ −18% vs. RVFWLS < −18% (44.0% vs. 85.4%; < 0.001) as well as in patients with RVGLS ≥ −15% vs. RVGLS < −15% (54.9% vs. 81.7%; P < 0.001). At multivariable analysis FAC, RVGLS and RVFWLS were independent predictors of events. The identified cut-off of RVFWLS and RVGLS both resulted independently associated with outcomes. Conclusion RVLS is a useful and reliable tool to identify patients with SMR undergoing TEER at high risk of mortality and HF hospitalization, on top of other clinical and echocardiographic parameters, with RVFWLS offering the best prognostic performance.

The procedural planning of transcatheter mitral valve replacement (TMVR) requires a specific imaging assessment to establish patient eligibility. Computed tomography (CT) is considered the reference method. In this setting, data regarding the role of transesophageal echocardiography (TEE) are lacking. Aims To evaluate the feasibility and reliability of a comprehensive 3D-TEE screening in TMVR candidates. Methods we performed a retrospective observational study including 72 consecutive patients who underwent a pre-procedural CT and 3D-TEE for TMVR evaluation. The measurements of mitral annulus (MA), length of anterior mitral leaflet (AML), native left ventricular outflow tract (LVOT) and predicted neo-LVOT acquired with CT and 3DTEE were compared using a novel semi-automated software for post processing analysis (3mensio Structural Heart 10.1 - 3mSH, Pie Medical Imaging, Bilthoven, Netherlands). The final suitability decision was given by the valve manufacturer based on CT measurements and clinical conditions. Results Among 72 patients screened, all patients had adequate image quality for 3D-TEE analysis. 3D-TEE and CT measurements for AML length (r=0.97), MA area (r=0.90), perimeter (r=0.68), anteroposterior (r=0.88) and posteromedial-anterolateral (r=0.74) diameters were found highly correlated, as well as for native LVOT (r=0.86) and predicted neo-LVOT areas (r=0.96) (all P -values Conclusions 3D-TEE appraisements showed good correlations with CT measurements and high accuracy to predict TMVR screening success. Central Illustration. Mitral annulus segmentation and neo-LVOT area measurement performed by means of the 3mensio software (Pie Medical Imaging, Bilthoven, Netherlands) in a step-by-step fashion by TEE and CT imaging. After the virtual simulation of a valve implantation, the minimal systolic neo-LVOT area is manually measured by planimetry on a plane orthogonal to the centerline.

Background Although, in recent years, the indications for left atrial appendage occlusion (LAAO) have expanded, its role for patients that during oral anticoagulant (OAC) therapy suffer from ischemic events or present LAA sludge is still to be defined. Moreover, data on the best anticoagulant regiment post-LAAO for these patients is scarce. Purpose Aim of this study was to present our experience with a hybrid approach consisting of LAAO+ lifelong OAC therapy in this cohort of high-ischemic risk patients. Methods At our center, from January 2013 to June 2022, 102 patients underwent percutaneous LAAO because, despite optimal OAC, suffered from ischemic events or were found to have LAA sludge. In the absence of a high bleeding risk, patients were then discharged with the aim of maintaining lifelong OAC. Moreover, to confirm the feasibility and the long-term efficacy of LAAO in this cohort, the group was matched 1:1 to a patient population who underwent LAAO in our center to prevent ischemic events and without sludge at preprocedural TEE. The primary endpoint was the composite of all-cause death (ACD) and major adverse cardiovascular events (MACE) consisting of ischemic stroke, systemic embolism (SE) and major bleeding Results Procedural success was achieved in 98% of patients. 70% of patients were discharged with anticoagulant therapy, while 30% only with antiplatelet therapy. After a median follow-up of 47.2 months, none of the patients discharged with OAC had stroke, SE or device-related thrombosis. The primary composite endpoint of ACD+ MACE occurred in 27 patients (26%). Patients affected by the primary outcome had more history of coronary artery disease (CAD, p Conclusions We report our experience on the management of patients with ischemic events or LAA sludge despite OAC. Percutaneous LAAO was feasible with a high procedural success. Our hybrid therapeutical approach consisting of LAAO+ lifelong OAC, if feasible in the absence of high bleeding risk, was safety and effective in reducing clinical ischemic events after a long-term follow-up.

Background Intra-Aortic Balloon Pump (IABP) efficacy is critically affected by the inflation/deflation timing. Balloon deflation may cause a sucking effect, and a steal phenomenon on carotid flow. Delaying IABP deflation reduces the degree of this flow reversal, but at the same time exposes patients to the risk of increased proto-systolic afterload with detrimental effects on the LV. Hypothesis To investigate the effects of a delayed IABP deflation timing on cerebral blood flow and LV hemodynamics. Methods We prospectively evaluated 20 consecutive patients who received transfemoral IABP for cardiogenic shock (CS). Central aortic pressures (augmented diastolic [ADP], end-diastolic [EDP], assisted systolic [ASP] and mean aortic [MAP] pressures) were recorded from the IABP console simultaneously with ultrasound data. First ultrasound and haemodynamic measurements were collected during conventional IABP deflation timing (balloon deflation completed before onset of LV systole by automated ECG gating). Then, IABP deflation was manually delayed to the beginning of the QRS (early LV systole). After adjustment, counterpulsation was performed for a minimum of 2 minutes to achieve steady hemodynamics, then the same ultrasound and haemodynamic measurements were recollected. Results Mean age was 67±13 years, LVEF was 25±11%. At the carotid ultrasound, the delayed deflation increased the net forward velocity time integral (VTI) in the common carotid artery (18±9 vs 15±8 cm; p=0.001), by reducing the end-diastolic backward VTI (1±1 vs 4±2 cm; p Conclusions In our cohort, a delayed IABP deflation strategy, evaluated by a multi-parametric yet relatively simple approach, demonstrated to be safe and was associated with both an increase cerebral perfusion and an improvement in cardiac mechanics.

During transcatheter edge-to-edge repair (TEER), the reduction of functional mitral regurgitation (FMR) severity, compared with baseline evaluation, is not uncommon. Because the procedural strategies are mainly guided by the location and severity of the regurgitant jets, intraprocedural downgrading (ID) of regurgitation severity could affect the procedural strategy and the results. The aim of this study was to evaluate the prevalence of ID during TEER and to compare early and midterm outcomes in patients with and without ID. All patients with moderate-to-severe or severe FMR who underwent TEER in San Raffaele Hospital between 2018 and 2020 were evaluated in this single-center, retrospective study. ID was defined as mild (1+) or moderate (2+) regurgitation degree during intraprocedural evaluation. The outcomes, assessed at discharge and at 2 years of follow-up, were all-cause mortality, heart failure hospitalization, and recurrence of mitral regurgitation2+. The final study cohort included 55 patients: 42% presented with ID. At discharge, 85.5% of patients achieved regurgitation reduction to 2+ or less: 100% in patients with ID versus 75% in patients without ID, p0.009. At 2 years, no significant difference in the incidence of all-cause mortality, heart failure hospitalization, and the recurrence of mitral regurgitation2+ between patients with ID or without ID was found. In conclusion, ID is frequent during TEER in FMR. No baseline characteristics were found to identify this group of patients. In patients with ID, the combination of live intraprocedural imaging and baseline ambulatory assessment of regurgitant jets seems effective in the procedural guiding to achieve a successful and durable mitral repair.

Aims The aim of this study is to analyse the prognostic implications of right ventricular (RV) dysfunction as detected by strain analysis in patients with severe tricuspid regurgitation (TR). The evaluation of RV systolic function in presence of severe TR is of paramount importance for operative risk stratification; however, it remains challenging, as conventional echocardiographic indexes usually lead to overestimation. Methods and results We enrolled 250 consecutive patients with severe TR referred to our centre. Baseline clinical and echocardiographic data and follow-up outcomes were collected. Patients were predominantly female, with multiple cardiovascular risk factors and comorbidities, history of heart failure, and atrial fibrillation. Most of them had presented with clinical signs of RV heart failure (RVHF) and advanced New York Heart Association class. The RV strain analysis [both RV free wall longitudinal strain (RVFWLS) and RV global longitudinal strain (RVGLS)] reclassified ∼42–56% of patients with normal RV systolic function according to conventional parameters in patients with impaired RV systolic function. RVFWLS ≤17% (absolute values, AUC: 0.66, P = 0.002) predicted the presence of RVHF [odds ratio (OR) 0.93, P = 0.01]. At follow-up, patients with RVFWLS >14% (absolute values, AUC: 0.70, P = 0.001, sensitivity 72%, specificity 54%) showed a better survival (P = 0.01). Conclusion Different ranges of RVFWLS have different implications in patients with severe TR, allowing to identify a preclinical and a clinical window, with correlations to RVHF and survival.

ObjectiveTo assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19).MethodsThis single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion ResultsA total of 200 patients were included in the final analysis (median age 62 (IQR 52–74) years, 65.5% men). The prevalence of PH and RVD was 12.0% (24/200) and 14.5% (29/200), respectively. Patients with PH were older and had a higher burden of pre-existing cardiac comorbidities and signs of more severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (radiological lung involvement, laboratory findings and oxygenation status) compared with those without PH. Conversely, patients with RVD had a higher burden of pre-existing cardiac comorbidities but no evidence of more severe SARS-CoV-2 infection compared with those without RVD. The presence of PH was associated with a higher rate of in-hospital death or ICU admission (41.7 vs 8.5%, pConclusionsAmong hospitalised non-ICU patients with COVID-19, PH (and not RVD) was associated with signs of more severe COVID-19 and with worse in-hospital clinical outcome.Trial registration numberNCT04318366

Aims The planning of transcatheter mitral valve replacement (TMVR) requires cardiac imaging assessment to establish patient eligibility according to mitral valve anatomy, device characteristics and risk of left ventricular outflow tract (LVOT) obstruction. In this setting, computed tomography (CT) is considered the reference method. Although recent studies demonstrated that three-dimensional transesophageal echocardiographic (3D-TEE) assessment of mitral anatomy presents a good agreement compared to CT, its potential role in the TMVR planning has never been fully evaluated. To test feasibility and reliability of a comprehensive 3D-TEE screening in candidates for TMVR. Methods We performed a single-centre retrospective observational study including 59 consecutive patients referred to our centre for TMVR due to high surgical risk, who performed a pre procedural CT and 3D-TEE screening. The measurements of mitral annulus (MA), native LVOT and predicted Neo-LVOT, assessed with CT and 3D-TEE were collected in order to evaluate their concordance in the assessment of TMVR eligibility. The final suitability decision was given by the valve manufacturer based on CT measurements and then compared with the screening results obtained with 3D-TEE evaluation. 3D-TEE measurements were obtained with a post processing analysis using a novel automated software platform (3mensio Structural Heart 10.1 - 3mSH, Pie Medical Imaging, Bilthoven, Netherlands). Results Excellent correlation was found between 3D-TEE and CT measurements for MA area (r =0.85), antero-posterior diameters (r= 0.81), native LVOT (r=0.82) and Neo-LVOT areas (r=0.95) (all P-values 0.80. Conclusions 3D-TEE appraisements of MA dimensions, native LVOT and Neo-LVOT are feasible in patients candidate for TMVR, showing good correlations with CT measurements and high accuracy to predict TMVR screening success.

Aims The epidemiological and clinical burden of tricuspid regurgitation (TR) has lately gained much attention from the scientific community. In fact, recent epidemiological studies report a prevalence of moderate and severe TR in population over the age of 65 screened for valve disease ranging from 2.7% to 4%, with an independent prognostic role clearly worsening long-term survival along with the increasing severity of TR grade. Particularly, as TR is often clinically unsuspected until an advanced stage of congestive heart failure (HF), there is a great need of early diagnosis and long-term appropriate follow-up and management. Nonetheless, data focusing on the clinical and echocardiographic course of a cohort of patients suffering from moderate TR, although eagerly awaited, are lacking. To evaluate and clarify the evolution and the long-term independent clinical outcome of a cohort of patients suffering from moderate functional or organic TR. Methods We electronically searched for ambulatory and in-patients who underwent transthoracic and/or transesophageal echocardiography with a diagnosis of moderate TR, along with a complete clinical evaluation, in our centre between January 2014 and December 2019. Patients were considered eligible if a second echocardiographic examination including a careful evaluation of the severity of TR and clinical information were available for a minimum follow-up of 6 months. The primary endpoint was all-cause mortality; secondary endpoints were hospitalization for HF and TV intervention, either surgical or percutaneous. Results We enrolled 130 patients, predominantly female with multiple comorbidities, cardiovascular risk factors and history of atrial fibrillation; TR aetiology was functional in most cases (93 patients, 72%). Over a mean follow-up of 5 years, TR grade progressed to at least severe in 55 patients (42%): at multivariate analyses, diabetes mellitus (P=0.003), anaemia (P=0.03) and at least moderate mitral regurgitation or aortic stenosis (P=0.039) were all predictors of TR severity progression. The primary endpoint occurred in 41(32%) of patients and was significantly more frequent (P Conclusions Our results show that moderate TR, over a long-term follow-up period, worsens to at least severe grade in a relevant proportion of patients, conveying a significant independent risk of hard events such as all-cause death, HF hospitalization and TV intervention. Therefore, this cohort of patients should be appropriately managed and closely followed-up in order to avoid adverse clinical events related to the natural course of this valvulopathy.

Aims Infection by SARS‐CoV‐2 may result in a systemic disease and a proportion of patients ranging 15%–44% experienced cardiac injury (CI) diagnosed by abnormal troponin levels. The aim of the present study was to analyse the clinical characteristics of a large series of hospitalized patients for COVID‐19 in order to identify predisposing and/or protective factors of CI and the outcome. Methods and results This is an observational, retrospective study on patients hospitalized in two Italian centres (San Raffaele Hospital and Cremona Hospital) for COVID‐19 and at least one high‐sensitivity cardiac troponin (hs‐cTnt) measurement during hospitalization. CI was defined if at least one hs‐cTnt value was above the 99th percentile. The primary end‐point was the occurrence of CI during hospitalization. We included 750 patients (median age 67, IQR 56–77 years; 69% males), of whom 46.9% had history of hypertension, 14.7% of chronic coronary disease and 22.3% of chronic kidney disease (CKD). Abnormal troponin levels (median troponin 74, IQR 34–147 ng/l) were detected in 390 patients (52%) during the hospitalization. At multivariable analysis age, CKD, cancer, C‐reactive protein (CRP) levels were independently associated with CI. Independent predictors of very high troponin levels were chronic kidney disease and CRP levels. Patients with CI showed higher rate of all‐cause mortality (40.0% vs. 9.1%, p = 0.001) compared to those without CI. Conclusion This large, multicentre Italian study confirmed the high prevalence of CI and its prognostic role in hospitalized patients with COVID‐19, highlighting the leading role of systemic inflammation for the occurrence of CI.

Objectives The aim of this study was to evaluate the impact of edge-to-edge PMVR on short and mid-term clinical outcomes in patients with CS and severe MR.Background Severe mitral regurgitation (MR) in the setting of cardiogenic shock (CS) is associated with three times higher risk of 1-year mortality. In refractory CS, edge-to-edge percutaneous mitral valve repair (PMVR) can be a potential therapeutic option.Methods We retrospectively included consecutive patients with refractory CS and concomitant severe MR treated with MitraClip (R) system. CS was defined according to the criteria used in the SHOCK trial and procedural success according to Mitral Valve Academic Research Consortium (MVARC) criteria. The 30-day and 6-month mortality were the primary and secondary endpoints respectively.Results Thirty-one patients (median age 73 years [interquartile range, IQR 66-78], 25.8% female), STS mortality score 37.9 [IQR 30.4-42.4]), with CS and concomitant severe MR treated with edge-to-edge PMVR were retrospectively enrolled. Procedural success was 87.1%. Thirty-day and 6-month survival rates were 78.4 and 45.2% respectively. Univariate Cox Regression Model analysis showed that procedural success was a predictor of both 30-day (HR = 0.12, 95% CI 0.03-0.55, p < .01) and 6-month survival (HR = 0.22, 95% CI 0.06-0.84, p = .027).Conclusions Edge-to-edge PMVR in patients with CS and concomitant severe MR was associated with good procedural safety and success with acceptable short and mid-term survival rates. It could be considered a bailout option in this setting of patients.

Funding Acknowledgements Type of funding sources: None. Background - Mitral regurgitation (MR) is a frequent finding in patients with aortic stenosis (AS). Moderate or severe MR is present in up to one-third of pts undergoing TAVR and it is a negative prognostic factor as well as the presence of residual MR after TAVR. However, whether different etiologies/mechanisms of MR have different effects on outcome and MR degree changes after TAVR is yet unknown. Aim – The aim of the study is to evaluate the prognostic impact of baseline MR degree and its changes after TAVR procedures according to different etiologies of MR in patients who underwent TAVR. Methods - We performed a retrospective observational study on a cohort of patients who underwent TAVR between January 2015 and December 2019. During the index period 947 pts underwent TAVR. To better characterize the mechanism of MR only pts with pre-procedural 3D transesophageal echocardiographic and at least one follow-up available study were included. The final study population consisted of 224 pts. MR severity was evaluated by multiparametric approach and classified in 4 degrees. The study population was further divided in 4 groups: Group I: fibro-calcific degeneration of the leaflets (78.6% pts); 2. Group II: prolapse or flail (4.4% pts); Group III: functional MR (FMR) due to leaflets tethering (5.6% pts); Group IV: FMR due to annular dysfunction or dilatation (11.3% pts). Primary outcome was all-cause of death. Results and Discussion – MR was absent in 15 pts (6.7%), mild in 79 pts (35.7%), mild-to-moderate in 109 in pts (49.3%), moderate-to-severe in 7 pts (3.1%) and severe in 11 pts (4.9%). Patients with > moderate MR degree at baseline had a worse outcome than patients with < moderate MR degree (p log rank = 0.029). FMR (groups III and IV) was associated with better outcome than organic MR (groups I and II) (p log rank = 0.035). Moreover, group IV showed a better outcome compared groups I (p log rank = 0.047) and II (p log rank = 0.038). Patients who showed improvement of MR of at least 1 degree post TAVR showed better outcome compared to patients without improvement (p log rank = 0.04). At multivariate analysis, including pre procedural MR > 2+, pre procedural TR > 2+, organic vs functional etiology and MR improvement after TAVR as covariates, only baseline MR > moderate was an independent predictor of mortality (HR 6.3; 95% CI 1.4 -27.0; p Conclusion - This study confirms the prognostic role of the baseline degree of MR in patients with AS undergoing TAVR. Moreover, this is the first study demonstrating that FMR due to annular dilatation but not due to leaflet tethering is associated with better outcome compared to organic etiologies.

Background: Myocardial injury (MI) can be detected during the acute phase of Coronavirus disease 19 (COVID-19) and is associated with a dismal prognosis. Recent imaging studies described the persistence of cardiac abnormalities after the recovery. The aim of the study was to investigate the spectrum of cardiac abnormalities at mid-term follow-up in patients recovered from COVID-19 using clinical assessment, laboratory tests, and imaging evaluation with comprehensive echocardiography. Methods: This is an observational, cross-sectional study assessing an unselected cohort of consecutive patients recovered from COVID-19. MI was defined by elevated plasma levels of high sensitive troponin T (hsTnT). At the follow-up, a complete examination including echocardiography was performed. Results: The 123 patients included were divided into two groups according to the presence of MI during hospitalization: group A (without MI) and group B (with MI). After a median of 85 days, group B patients were more frequently symptomatic for dyspnea and had significantly higher values of hsTnT and N-Terminal prohormone of Brain Natriuretic Peptide (NT-proBNP), compared to Group A. No differences between the two groups in left nor right ventricle dimension and ejection fraction were found. However, in group B a significant reduction of mean left ventricle global longitudinal strain was observed (-15.7±.7vs -18.1±.3 in group A, p&nbsp

Mitral regurgitation is the most prevalent valve disease worldwide. Percutaneous mitral valve interventions are emerging as alternative options for high-risk patients with severe mitral regurgitation not eligible for conventional surgery. Accurate patient selection is based on a detailed pre-procedural multimodality imaging evaluation. Morphology and functional anatomy of the mitral valve should be evaluated to determine the feasibility of treatments and to identify the best therapeutic approach. The procedures are guided by fluoroscopy, transoesophageal echocardiography and fusion imaging, ensuring a continuous communication between the interventionalist and the imaging specialist. The present review will cover the pre-procedural planning and the intra-procedural guidance of the most used transcatheter approaches in the setting of native mitral valve regurgitation: edge to edge repair, percutaneous direct and indirect annuloplasty, transapical beating-heart chordal implantation and transcatheter mitral valve replacement.

Background Whether fluoroscopic-echocardiographic fusion imaging (FI) might offer added value for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair is yet unknown, and few data exist regarding the safety and feasibility of this novel technology. Methods The aim of this single-center study was to test and validate a FI protocol for intraprocedural monitoring of transcatheter edge-to-edge mitral valve repair and assess its clinical usefulness. Eighty patients underwent MitraClip implantation using FI guidance (FI+) for either degenerative (35%) or functional (65%) mitral regurgitation and were compared with the last 80 patients before FI introduction, treated using conventional echocardiography and fluoroscopic monitoring (FI−). Results The number of patients treated for functional and degenerative mitral regurgitation was similar between the FI+ and FI− groups, as well as the number of devices implanted (1.51 ± 0.5 vs 1.58 ± 0.6, P = .46). The prevalence of complex mitral anatomy for percutaneous repair was high (32.5%, up to 39.2% in the hybrid arm). Fluoroscopy time was significantly lower in FI+ patients (37.3 ± 14.6 vs 48.3 ± 28.3 min, P = .003), but not kerma area product (91.5 ± 74.1 vs 108.8 ± 105.0 Gy · cm2, P = .23) or procedural time (92.2 ± 36.1 vs 103.1 ± 42.7 min, P = .086). After adjusting for confounding factors (MitraClip XT device and complex anatomy), FI reduced fluoroscopy time (coefficient = −10.4 min; 95% CI, −18.03 to −2.82; P = .007) and improved procedural success at the end of the procedure (odds ratio, 2.87; 95% CI, 1.00 to 8.24; P = .049) and discharge (odds ratio, 2.24; 95% CI, 1.04 to 4.80; P = .039). Rates of periprocedural complications were similar in both groups (8.9% vs 13.0%, P = .40). Conclusions The authors describe the systematic use of an FI protocol for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair, demonstrating a reduction in fluoroscopy time and an improvement in procedural success in a population with a high prevalence of challenging mitral anatomy for percutaneous repair.

Background/Introduction Cardiogenic shock (CS) is a medical emergency and a frequent cause of death. CS can be complicated by mitral regurgitation (MR). The presence of at least moderate MR in the setting of shock was associated with about three-times higher odds of 1-year mortality. In the setting of refractory CS, percutaneous mitral valve repair (PMVR) can be a potential therapeutic option. Purpose The aim of the study was to evaluate the efficacy of percutaneous approach of severe MR in patients with CS assessing short-term clinical outcomes. Methods In this study we retrospectively included patients with CS and concomitant severe MR treated with Mitraclip system. We enrolled 28 patients from 5 Italian centers between 2012 and 2019. MitraClip implantation was performed according to each hospital standard care. CS was defined utilizing the Diagnostic Criteria of Cardiogenic Shock used in the SHOCK trial. Procedural success was defined as the presence of moderate or less MR after MitraClip implantation. Results All patients presented at least severe MR. All treated patients were at high surgical risk (STS mortality score 36.4±11.7%). Procedural success was obtained in 24 patients (86%). A mean of 1.71±0.76 clips per patients were implanted. In-hospital complications occurred in 13 patients (46%): 7 minor bleedings (25% of patients), 7 major bleedings (25%), 8 acute kidney injuries (28%). In-hospital mortality was 25% and the reported causes of death were cardiovascular in all patients. At Cox multivariate analysis procedural success was a strong predictor of in-hospital survival (HR 0.11, CI 95% 0.02–0.67, p=0.017). Conclusions PMVR with Mitraclip system in patients with CS and concomitant MR demonstrated high procedural success and acceptable safety. It can be considered a bailout option in this setting of patients with high short-term mortality. Larger prospective studies are needed. In-hospital mortality predictors Funding Acknowledgement Type of funding source: None

Pulmonary Vein Thrombosis (PVT) is a rare and insidious condition with only few case series and case reports described in literature. PVT effects on pulmonary circulation is similar to mitral stenosis and its haemodynamic consequences depend on the number of veins involved, the obstruction severity and the pulmonary vessels compliance. Here we present a case in which a multimodality approach with Transesophageal Echocardiography (TEE) and Computed Tomography (CT) imaging helped to guide therapeutic decisions. Specifically, a post-processing reconstruction of TEE projection directly from CT imaging was performed.

Aims: Aortic stenosis (AS) grading by 2D-transthoracic echocardiography (2D-TTE) aortic valve area (AVA) calculation is limited by left ventricular outflow tract (LVOT) area underestimation. The combination of Doppler parameters with 3D LVOT area obtained by multidetector computed tomography (MDCT) can improve AS grading, reconciling discordant 2D-TTE findings. This study aimed to systematically evaluate the role of 3D-transesophageal echocardiography (3D-TEE) in AS grading using MDCT as reference standard. Methods and results: 288 patients (81±6.3years, 52.4% female) with symptomatic AS underwent 2D-TTE, 3D-TEE, and MDCT for transcatheter aortic valve implantation. Doppler parameters were combined with 3D LVOT areas measured by manual and semi-automated software 3D-TEE and by MDCT to calculate AVA, reassessing AS severity. Both 3D-TEE modalities demonstrated good correlation with MDCT, with excellent intra-observer and inter-observer variability. Compared to MDCT, 3D-TEE measurements significantly underestimated AVA (PANOVA&nbsp

This case shows how interaction between imaging experts and interventionists allowed us to overcome the challenge of plug-prosthesis interaction in a complex procedure.

SARS-CoV-2 outbreak has rapidly reached a pandemic proportion and has become a major threaten to global health. Although the predominant clinical feature of COVID-19 is an acute respiratory syndrome of varying severity, ranging from mild symptomatic interstitial pneumonia to acute respiratory distress syndrome, the cardiovascular system can be involved with several facets. As many as 40% hospitalized patients presenting with COVID-19 have pre-existing history of cardiovascular disease and current estimates report a proportion of myocardial injury in COVID-19 patients ranging up to 12%. Multiple pathways have been advocated to explain this finding and the related clinical scenarios, encompassing local and systemic inflammatory response and oxygen supply-demand imbalance. From a clinical point of view, cardiac involvement during COVID-19 may present a wide spectrum of severity ranging from subclinical myocardial injury to well-defined clinical entities (myocarditis, myocardial infarction, pulmonary embolism and heart failure), whose incidence and prognostic implications are currently largely unknown due to a significant lack of imaging data. The use of integrated heart and lung multimodality imaging plays a central role in different clinical settings and is essential in diagnosis, risk stratification and management of COVID-19 patients. Aim of this review is to summarize imaging-oriented pathophysiological mechanisms of lung and cardiac involvement in COVID-19 and to provide a guide for an integrated imaging assessment in these patients., Graphical abstract, Highlights • Although lung injury is predominant, cardiac involvement is present in up to 12% of COVID-19 patients. • Heart and lung multimodality imaging plays an essential role in different clinical settings in COVID-19 patients. • Multimodality imaging findings are useful in diagnosis, risk stratification and management of COVID-19 patients. • Strategies for preventing SARS-CoV-2 transmission during examinations in Imaging Departments must be adopted.

The echocardiographic-fluoroscopic fusion imaging tool is able to acquire imaging data from both fluoroscopy and transesophageal images and co-register and align them in the three-dimensional space and time by putting onto the same coordinate system. In this way the soft tissues that are well visualized by echocardiography and the metallic materials (catheters and devices), better imaged by fluoroscopy, are displayed in the standard fluoroscopic projections in a hybrid image in real time. In this review, we describe the basic technical aspects and its main applications in transcatheter structural heart interventions.

ObjectivePulmonary congestion is the main cause of hospital admission in patients with heart failure (HF). Lung ultrasound (LUS) is a useful tool to identify subclinical pulmonary congestion. We evaluated the usefulness of LUS in addition to physical examination (PE) in the management of outpatients with HF.MethodsIn this randomised multicentre unblinded study, patients with chronic HF and optimised medical therapy were randomised in two groups: ‘PE+LUS’ group undergoing PE and LUS and ‘PE only’ group. Diuretic therapy was modified according to LUS findings and PE, respectively. The primary endpoint was the reduction in hospitalisation rate for acute decompensated heart failure (ADHF) at 90-day follow-up. Secondary endpoints were reduction in NT-proBNP, quality-of-life test (QLT) and cardiac mortality at 90-day follow-up.ResultsA total of 244 patients with chronic HF and optimised medical therapy were enrolled and randomised in ‘PE+LUS’ group undergoing PE and LUS, and in ‘PE only’ group. Thirty-seven primary outcome events occurred. The hospitalisation for ADHF at 90 day was significantly reduced in ‘PE+LUS’ group (9.4% vs 21.4% in ‘PE only’ group; relative risk=0.44; 95% CI 0.23 to 0.84; p=0.01), with a reduction of risk for hospitalisation for ADHF by 56% (p=0.01) and a number needed to treat of 8.4 patients (95% CI 4.8 to 34.3). At day 90, NT-proBNP and QLT score were significantly reduced in ‘PE+LUS’ group, whereas in ‘PE only’ group both were increased. There were no differences in mortality between the two groups.ConclusionsLUS-guided management reduces hospitalisation for ADHF at mid-term follow-up in outpatients with chronic HF.

A sixty-two years old female presents with shortness of breath. She has Marfan syndrome (c.6448C > T mutation variant) with a previous history relevant for type A aortic dissection which was treated by Bentall procedure with a mechanical aortic prosthesis and ascending aorta prosthesis, coronary artery bypass graft on the right coronary artery and pacemaker for third degree AV block; subsequent aortic arch reconstruction and endovascular repair of the descending aorta for thoracic aorta aneurism rupture. Upon visit she is in NYHA class III, blood pressure of 145/85 mmHg and heart rate of 75 bpm. A systolic murmur with a prosthetic second tone was heard at heart auscultation and bilateral crackles were heard at pulmonary auscultation. Peripheral pulses were symmetrical. ECG showed sinus rhythm, right bundle branch block with left anterior hemiblock and left ventricular hypertrophy. Blood tests were within normal range. Chest X-ray showed bilateral pulmonary congestion. She underwent transesophageal echocardiography which showed severe mitral regurgitation (MR) with a normal bi-ventricular systolic function. Posterior mitral leaflet (PML) was severely hypoplastic especially at the level of P1 which was confirmed by CT (see picture). Diuretic therapy together with an ACE inhibitor was introduced with a decrease in MR severity. The patients was sent home with an indication for strict follow up visits. Congenital mitral valve defects are very rare and can be isolated or associated with other cardiac malformations. Limited data are available about hypoplastic posterior mitral leaflet (PML) including singular case reports or anecdotal descriptions, therefore its etiology, association with other cardiac or systemic syndromes and prognosis is not well understood. However, it is suggested that absence of PML has a high fetal or infant mortality due to severe mitral regurgitation (MR). The degree of MR varies among patients and in the same patient at different timepoints as it depends on anatomical variations of the anterior mitral leaflet, residual PML tissue, posterior ventricular wall conformation and other associated cardiac abnormalities. We showed a case of a patient with hypoplastic PML and advanced age with a concomitant history of Marfan syndrome. Picture legend (A) Mid-esophageal 4-chamber view shows severe hypoplasia of PML (red arrow) and the posterior ventricular myocardial shelf (green arrow). (B) Mid-esophageal commissural view shows a large central MR jet. (C) 3D ventricular perspective of the mitral valve: an almost complete absence of the PML can be appreciated in the central and lateral scallops (grey arrows). (D) CT 3 chamber view shows the myocardial shelf which takes the role of the posterior mitral annulus (blue arrow) and direct PML chordal insertion into the ventricular wall (yellow arrow). (E) CT reconstruction of the mitral valve shows a virtually absent P1 (< 1mm), a P2 length of 4.1 mm, and a P3 length of 5 mm. Abstract P271 Figure. Hypoplastic posterior mitral leaflet

Introduction Mitral regurgitation (MR) severity affects prognosis and a correct quantification is key for surgical indication. A multiparametric approach (MPA) is recommended, as singular parameters suffer pitfalls. Recently suggested three-dimensional echocardiographic (3DE) parameters lack clear reference values. No studies have assessed the feasibility of regurgitant volume (RV) and fraction (RF) using the 3D planimetric area of the mitral annulus (MAA) and of the left ventricular outflow tract (LVOTA). Purpose To assess the feasibility and reliability of 3DE, RV and RF obtained by doppler volumetric method using MAA and LVOTA, compare results with 2DE and 3D vena contracta area (VCA) and propose cut-offs for these parameters using MPA as gold standard. Methods Patients referred to our Department for MR assessment were enrolled from September 2018 to February 2019 without more than mild aortic regurgitation or severe stenosis, mitral stenosis and previous valvular surgery. Transthoracic 2DE was used to calculate a multiparametric index of MR severity including: jet area/left atrium (LA) area, CW characteristics, 2D vena contracta, PISA, pulmonary vein flow, LA volume and systolic pulmonary artery pressure. Transoesophageal 3DE was used to assess MAA and LVOTA from a 3D dataset. RV and RF were calculated by Doppler volumetric method using the planimetric areas instead of diameters. VCA 3D was calculated from a 3D color dataset as the cross-sectional area of the regurgitant jet. We compared the results between 2DE and 3DE and between functional and organic MR. ROC curves were analyzed to assess diagnostic performance and identify cut-offs for severity prediction. Intraclass correlation coefficient was calculated to assess variability in measurements. Results Population was composed by 87 patients (56 male, 65 ± 13 years), 72% organic MR. MAA was larger in 2DE (10.4 ± 3.2 vs 9.8 ± 2.9 cm2,) as was the RV (76.6 ± 36.1 vs 66.4 ± 31.9 ml) and RF (55.4 ± 12.4 vs 50.4 vs 10.9%, all p < 0.0001), while LVOTA was smaller (3.9 ± 0.98 vs 4.1 ± 1.0 cm2, p < 0.0001). RV 2D and RF 2D were larger in the organic MR group (p < 0.0001), meanwhile VCA 3D, RV 3D and RF 3D did not show a significant difference (all p > 0.1). VCA 3D had a good correlation with RV 3D (r = 0.593, p < 0.0001) and RF 3D (r = 0.576, p < 0.0001). We proposed a cut-off value of 41.5 mm2 for VCA 3D (94% sens, 96% spec, AUC 0.978), 52 ml for RV 3D (84% sens, 78% spec, AUC 0.901) and 47.6% for RF 3D (91% sens, 90% spec, AUC 0.966) to predict MR severity as assessed by MPA. Intraclass correlation coefficient was 0.980 for MAA and 0.985 for LVOTA for intra-observer variability, while for inter-observer variability it was 0.951 for MAA and 0.962 for LVOTA. Conclusion 2DE overestimates MA dimensions and underestimates LVOT dimensions thus overestimating RV and RF. 3DE measures are relatively simple and reproducible. Proposed cut-offs for RV, RF and VCA 3D have a good diagnostic power.

With the contemporary development of structural interventional cardiology the prevalence of perivalvular leaks (PVL) is expected to grow. Advanced multimodality imaging is necessary for the guidance of transcatheter closure of PVL. We describe the case of a 57 year-old woman who underwent transcatheter mitral PVL closure. Past clinical history included a lymphoma treated with chemio and radiotherapy. Six months before she underwent a surgical replacement of the aortic and mitral valves with two mechanical prosthesis for severe aortic and mitral stenosis. Because of the calcium burden in both the annuluses, undersized mitral valve prosthesis was implanted leading to the presence of two moderate mitral PVL. The patient subsequently required hospitalization for acute HF and hemolytic anemia and received multiple blood transfusions. TEE confirmed the presence of a large antero-lateral PVL and a small medial PVL (3D VCA 0,32 cm2 and 0,2 cm2 respectively, associated with reverse flow in the pulmonary veins) with an extension of 33% of the circumference of the prosthesis. The regurgitation was considered severe and a percutaneous closure was planned with 3D-TEE and fluoroscopy image fusion guidance. Under general anesthesia a transeptal puncture was performed and the medial leak was closed with two vascular plugs (6mm each). During the deployment of the plugs an intermittent blockage of the medial disk of the prosthesis was noticed, which resolved completely after the removal of the wires previously positioned for the engagement of the leak. The lateral leak was then engaged and a second plug (10mm) was advanced causing a discontinuous interference with the two disks. The direct interference with the lateral disk caused a blockage in the closing position (leading to moderate stenosis, medium gradient 7mmHg) and in the opening position (leading to a massive regurgitation). The medial disk was intermittently blocked in the closing position due to the bulky effect of the devices provoking a traction and displacement of the prosthesis towards the medial region of the valve. To avoid this interference the plug was released with a marked atrial protrusion. Notably, after the removal of the wires no malfunctioning of the disks was noticed and the mild residual shunts appeared further decreased. The procedure was considered successful and at follow-up no residual leak was found. The percutaneous closure of PVL is a safe and effective intervention. Multimodality imaging is essential for the diagnosis, planning and procedural guidance. The knowledge of possible complications is warranted for the achievement of an optimal result. This case clearly show the possibility of interference with the prosthesis and overestimation of residual leaks. Abstract P1251 Figure. PVL closure:procedure and complications

Background Aortic stenosis (AS) grading is mainly based on aortic valve area (AVA) calculation by 2D transthoracic echocardiography (2D-TTE), using continuity equation (CE). However, 2D-TTE shows several limits, mainly due to left ventricular outflow tract (LOVT) underestimation. Different 3D imaging modalities have been proposed to overcome 2D-TTE limitations, including 3D transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) and multidetector computed tomography (MDCT). The AVA cut-off value generally used to define severe AS has been established and validated by outcome studies in which AVA was measured by 2D-TTE. This cut-off value cannot be directly extrapolated to the 3D-TEE combined approach that systematically measures larger LVOT compared with 2D-TTE. Purpose.To evaluate the diagnostic accuracy of 3D transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) in AS grading, compared with multidetector computed tomography (MDCT) as gold standard, and to identify a new cut-off for AS severity assessment. Methods 218 patients (81 ± 5.4 years, 54% male) with symptomatic normal-flow AS underwent 2D-TTE, 3D-TTEm, 3D-TEEs and MDCT within the same hospitalization. 3D-TEE LVOT reconstruction was performed manually and with semi-automated software (EchoPAC version 201). 3D-TEEm, 3D-TEEs and MDCT LVOT areas were combined with 2D-TTE Doppler parameters to calculate AVA by CE. Using Doppler parameters (Vmax >4 m/s and MPG >40 mmHg) to define AS severity, a receiving-operating curve (ROC) was calculated for AVA obtained with different 3D imaging modalities. Results There was a good correlation between both 3D-TEEm and 3D-TEEs and MDCT measurements (r = 0.800 and r = 0.814, respectively) and excellent agreement between 3D-TEEm and 3D-TEEs with minimum bias. 2D-TTE significantly underestimated AVA compared to 3D-TEEm, 3D-TEEs and MDCT. On the other hand, both 3D-TEEm and 3D-TEEs underestimated AVA compared to MDCT (mean AVA difference = 0.13 and =0.06 cm2, respectively). ROC curve analysis demonstrated 91% sensibility and 34% specificity for 2D-TTE AVA using a cut-off of 1 cm2 (AUC 0.732). For 3D-TEEm and 3D-TEEs, a 1 cm2cut-off resulted in 74% sensibility and 59% specificity, while a 1.2 cm2cut-off resulted in 91% sensibility and 31% specificity (AUC 0.715). MDCT showed 59% sensibility and 70% specificity using a 1 cm2 cut-off and 83% sensibility and 45% specificity using a 1.2 cm2 cut-off (AUC 0.708). Conclusion 3D-TEE represents a valuable tool for AS grading using a combined approach incorporating 3D LVOT measurements and 2D Doppler parameters in the CE. Both 3D-TEEm and 3D-TEEs AVA measurements demonstrated good correlation with MDCT and excellent reproducibility. 3D-TEE measurements underestimate AVA compared to MDCT. Given the multiparametric assessment of AS severity, a 1.2 cm2 AVA cut-off could be considered to define AS severity with emerging 3D imaging modalities.