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Background and Aims The question of when and how to treat truly asymptomatic patients with severe aortic stenosis (AS) and normal left ventricular (LV) systolic function is still subject to debate and ongoing research. Here, the results of extended follow-up of the AVATAR trial are reported (NCT02436655, ClinicalTrials.gov). Methods The AVATAR trial randomly assigned patients with severe, asymptomatic AS and LV ejection fraction ≥ 50% to undergo either early surgical aortic valve replacement (AVR) or conservative treatment with watchful waiting strategy. All patients had negative exercise stress testing. The primary hypothesis was that early AVR will reduce a primary composite endpoint comprising all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure (HF), as compared with conservative treatment strategy. Results A total of 157 low-risk patients (mean age 67 years, 57% men, mean Society of Thoracic Surgeons score 1.7%) were randomly allocated to either the early AVR group (n = 78) or the conservative treatment group (n = 79). In an intention-to-treat analysis, after a median follow-up of 63 months, the primary composite endpoint outcome event occurred in 18/78 patients (23.1%) in the early surgery group and in 37/79 patients (46.8%) in the conservative treatment group [hazard ratio (HR) early surgery vs. conservative treatment 0.42; 95% confidence interval (CI) 0.24–0.73, P =.002]. The Kaplan–Meier estimates for individual endpoints of all-cause death and HF hospitalization were significantly lower in the early surgery compared with the conservative group (HR 0.44; 95% CI 0.23–0.85, P =.012, for all-cause death and HR 0.21; 95% CI 0.06–0.73, P =.007, for HF hospitalizations). Conclusions The extended follow-up of the AVATAR trial demonstrates better clinical outcomes with early surgical AVR in truly asymptomatic patients with severe AS and normal LV ejection fraction compared with patients treated with conservative management on watchful waiting. [ABSTRACT FROM AUTHOR]

Background and Objectives: Over the past decade, there has been increasing attention paid to advanced and innovative cardiovascular magnetic resonance (CMR) modalities, such as T1 and T2 mapping, which play a major role in diagnosing diffuse myocardial disease. There is little data summarizing the current evidence regarding the diagnostic accuracy of T1 and T2 mapping, and extracellular volume (ECV) in acute myocarditis. The aim of our study was to select, analyze, and systematically review the recent scientific literature on the diagnostic value of CMR T1 and T2 parametric mapping in clinically suspected acute myocarditis. Materials and Methods: The literature search was performed in the PubMed database. Articles published in the years 2014–2024 were included in the analysis. At the initial stage, 458 articles were reviewed, and 13 exploratory research studies were further analyzed and presented in this systematic literature review. Results: The analysis included 686 patients with clinically suspected myocarditis and 372 subjects in the control group. The average age of patients with suspected myocarditis was 40.25 years; 26% of them were women. Prolonged native myocardial T1 relaxation time provides diagnostic accuracy in the setting of suspected acute myocarditis ranging from 69 to 99%, with sensitivity from 64 to 98% and specificity from 87 to 100%. Diagnostic accuracy of prolonged T2 relaxation time ranges from 47 to 87%, with sensitivity being from 48% to 94% and specificity from 60% to 92%. ECV alone showed moderate diagnostic performance, with diagnostic accuracy ranging from 62% to 76%, sensitivity from 47% to 73%, and specificity from 76% to 90%. T1 and T2 mapping and ECV, combined with the late gadolinium enhancement (LGE) technique, increases the probability of detecting myocardial inflammatory changes at various stages of the disease, improving the diagnostic accuracy to 96%. Conclusions: New quantitative CMR techniques, i.e., T1 and T2 mapping, have an advantage over conventional CMR sequences in detecting inflammatory myocardial structural changes and play an important role in diagnosing acute myocarditis. Incorporating these sequences in daily clinical practice increases the diagnostic value of CMR in acute myocarditis and becomes an alternative to endomyocardial biopsy, which has been considered the gold standard until now. [ABSTRACT FROM AUTHOR]

Background and Objectives: The aim of this study was to evaluate the effectiveness and safety of balloon pulmonary angioplasty (BPA) in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) in the Vilnius Pulmonary Hypertension (PH) Referral Centre and to provide a comparative analysis with other centres. Materials and Methods: This study included all BPA procedures performed between 2019 and 2024 in a single tertiary centre. Invasive haemodynamic parameters and clinical variables were assessed at baseline; at the end of invasive treatment; and at the conclusion of follow-up, an average of 8.6 months after the last BPA. A literature review was also performed. Results: Twenty-six patients with inoperable CTEPH were enrolled. The mean age of the patients was 61.6 (40–80) years. Each patient underwent a mean of 3.84 (1–9) procedures. Follow-up data were available for 12 patients with an average of 6.08 (3–9) procedures. Mean pulmonary arterial pressure decreased by 32% (p < 0.001) and pulmonary vascular resistance by 41% (p = 0.001) at follow-up compared with the baseline measurements. There was also a significant 80% (p < 0.001) reduction in brain natriuretic peptide levels and a 30% (p = 0.04) increase in 6-min walk distance. The BPA procedures were generally safe in this low-volume centre setting, with only 17% of procedures having non-severe and non-fatal procedure-related complications. The most common complications included vessel dissection (10%), pulmonary vascular injury with haemoptysis (3%), and hyperperfusion pulmonary oedema (1%), which was successfully treated in all patients. Conclusions: The results of the present study demonstrate that the BPA procedure is an effective and safe treatment for individuals with inoperable CTEPH, being associated with significant improvements in hemodynamic parameters and functional capacity and a low risk of major complications in the low-volume tertiary PH centre setting. [ABSTRACT FROM AUTHOR]

Cardiovascular damage is a common complication of sepsis, with an incidence of 10% to 70%. Septic cardiomyopathy (SCM) occurs in ICUs as a reversible myocardial damage in sepsis patients. Despite various proposed diagnostic tools, none are specifically tailored for SCM. This study aims to evaluate different echocardiography-based diagnostic tools and determine the SCM rate in our population. A single-centre, prospective observational study was conducted at a tertiary reference hospital from March to May 2024. Patients meeting Sepsis-3 criteria, aged over 18 years, and treated in the ICU were included. Ethical approval was obtained from the regional ethical committee. Transthoracic echocardiogram (TTE) and hemodynamic measurements were performed within 48 hours of patient identification and repeated within 10 days. A diagnosis of septic cardiomyopathy (SCMP) was evaluated using three different diagnostic tools: left ventricular ejection fraction (LVEF <50% or >10% decrease from baseline), cardiac power output (CPO <0.6W), and afterload-related cardiac performance (ACP <80%) based on values reported in the literature. Demographic and descriptive data were extracted from electronic medical records. Results: Thirty-eight patients (mean age 61±13 years; 63.2% males) were enrolled. The median SOFA score was 9.5 [IQR, 8-11], APACHE II score 19 [16-22], and SAPS II 42 [32-51]. Median lactate levels were 3.1 [2.1-4.9] mmol/L, WBC count 16 [12-21] x10^9/L, PCT 11.2 [3.5–31.7] ng/mL, CRP 300 [179-407] mg/L, and troponin I 214 [47-627] ng/L. The median time between TTEs was 6 [4-9] days. In patients diagnosed with SCMP based on LVEF, seven (19.4%) had SCMP, showing significantly lower velocity time integral (VTI: 13.2±3.3 vs 18.1±4.7 cm, p=0.013) and stroke volume (SV: 50.4±13.8 vs 67.7±18.5 ml, p=0.026), and higher heart rate (HR: 106±14 vs 87±20 bpm, p=0.028) compared to non-SCMP patients (n=31, 80.6%). For CPO-based diagnosis, six patients (20.7%) had SCMP, with significantly lower VTI (13.2±2.8 vs 17.9±4.9, p=0.029), SV (47.2±11.5 vs 67.5±18.5 ml, p=0.015), and cardiac output (CO: 3.9±0.5 vs 6.1±1.7 L/min, p<0.001), and a trend towards lower cardiac index (CI: 1.7±0.5 vs 2.6±0.8 L/min/m2, p=0.07) compared to twenty-nine non-SCMP patients. The prevalence of SCMP based on ACP was higher than in the LVEF or CPO group, with eighteen patients (51.4%) diagnosed with SCMP. Seventeen patients had slightly restricted cardiac function (ACP 60-80%) and one had moderately restricted cardiac function (ACP 40-60%). Comparatively, ACP-based SCMP patients had significantly lower mean arterial pressure (MAP: 98±17 vs 109±12 mmHg, p=0.025), CI (2.2±0.7 vs 2.8±0.8 l/min/m2, p=0.011), CO (4.6 [4.0-5.5] vs 6.4 [5.5-7.1] L/min, p=0.005), and SV (55 [43-66] vs 70 [59-82] ml, p=0.013), but higher central venous pressure (CVP: 15±6 vs 11±6 mmHg, p=0.032) than the seventeen non-SCMP patients. No significant differences were observed in lactate levels, VIS score, and survival rates between SCMP and non-SCMP groups. Based on the three diagnostic tools, the prevalence of SCM in our study group varied from 19.4% to 51.4% and did not differ from the rates reported in the literature. Further analysis is necessary to determine the best diagnostic tool for SCM, requiring a larger sample group. [ABSTRACT FROM AUTHOR]

Abstract Background This study sought to prospectively and directly compare three cardiovascular magnetic resonance (CMR) viability parameters: inotropic reserve (IR) during low-dose dobutamine (LDD) administration, late gadolinium enhancement transmurality (LGE) and thickness of the non-contrast-enhanced myocardial rim surrounding the scar (RIM). These parameters were examined to evaluate their value as predictors of segmental left ventricular (LV) functional recovery in patients with LV systolic dysfunction undergoing surgical or percutaneous revascularisation. The second goal of the study was to determine the optimal LDD-CMR- and LGE-CMR-based predictor of significant (≥ 5%) LVEF improvement 6 months after revascularisation. Methods In 46 patients with chronic coronary artery disease (CAD) (63 ± 10 years of age, LVEF 35 ± 8%), wall motion and the above mentioned CMR parameters were evaluated before revascularisation. Wall motion and LGE were repeatedly assessed 6 months after revascularisation. Logistic regression analysis models were created using 333 dysfunctional segments at rest. Results An LGE threshold value of 50% (LGE50) and a RIM threshold value of 4 mm (RIM4) produced the best sensitivities and specificities for predicting segmental recovery. IR was superior to LGE50 for predicting segmental recovery. When the areas under the ROC curves is compared, the combined viability prediction model (LGE50 + IR) was significantly superior to IR alone in all analysed sets of segments, except the segments with an LGE from 26% to 75% (p = 0.08). The RIM4 model was not superior to the LGE50 model. A myocardial segment was considered viable if it had no LGE or had any LGE and produced IR during LDD stimulation. ROC analysis demonstrated that ≥ 50% of viable segments from all dysfunctional and revascularised segments in a patient predict significant improvement in LVEF with a 69% sensitivity and 70% specificity (AUC 0.7, p = 0.05). The cut-off of ≥ 3 viable segments was a less useful predictor of significant global LV recovery. Conclusions LDD-CMR is superior to LGE-CMR as a predictor of segmental recovery. The advantage is greatest in the segments with an LGE from 26% to 75%. The RIM cut-off value of 4 mm had no superiority over the LGE cut-off value of 50% in predicting the segmental recovery. Patients with ≥ 50% of viable segments from all dysfunctional and revascularised had a tendency to improve LVEF by ≥ 5% after revascularisation.

In this case report we describe the delayed diagnosis of a very rare congenital anomaly - isolated partial anomalous pulmonary venous connection. This congenital anomaly should be suspected at any age in the clinical setting of right heart volume overload, especially in the absence of a large atrial septal defect. Tomographic imaging modalities (computed tomography or cardiovascular magnetic resonance) not only allow the comprehensive structural and functional assessment of this anomaly, but also help assess the patient's suitability for surgical treatment. Surgery is the definitive treatment of a patient with a significant left-to-right shunt due to partial anomalous pulmonary venous connection. [ABSTRACT FROM AUTHOR]

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA syndrome) is a rare congenital coronary abnormality carrying a poor prognosis. We present a clinical case series of ALCAPA-related anterior mitral valve leaflet prolapse and discuss its mechanism as a key to suspicion of ALCAPA syndrome. [ABSTRACT FROM AUTHOR]

Competing Interests: Conflict of interest: None declared.

Background: Primary iron overload cardiomyopathy is an important and potentially preventable cause of heart failure (HF), usually manifesting in the 4-5th decade of life. Patients may be asymptomatic early in the disease with hidden progression of cardiac dysfunction. The challenge of timely detection is an awareness of this systemic disorder and an adequate degree of clinical vigilance., Case Summary: A 48-year-old man was referred to the university clinic due to the episode of atrial fibrillation. The specific features of bronze skin and yellow eyes together with a combination of syndromes (cardiomyopathy, cirrhosis, ascites and portal hypertension, diabetes mellitus, and chronic kidney disease) stimulated the testing of iron metabolism markers, which were far above the normal range. Echocardiography and cardiac magnetic resonance (CMR) showed the dilatation of all cardiac cavities and biventricular systolic dysfunction. CMR T2* mapping was consistent with the diagnosis of myocardial and hepatic siderosis. Hereditary Type I haemochromatosis was confirmed by a genetic test. After 6 months of standard HF treatment, chelation therapy with deferiprone and regular phlebotomies imaging tests showed a reduction of ventricular and atrial volumes, an improvement in the cardiac systolic function and a decrease of iron accumulation., Discussion: In this case, complicating syndromes were detected earlier than underlying disease of primary haemochromatosis. Cardiac haemochromatosis should be considered in any patient with unexplained HF, especially in the case of a positive family history, abnormal liver enzymes, endocrinopathies, or evidence of involvement of other organ systems. Screening for systemic iron overload with transferrin saturation and serum ferritin is the first step. Further non-invasive imaging tests should be done to confirm organ involvement., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: Rupture of the ventricular septum complicates acute myocardial infarction in 0.2% of cases in the thrombolytic era. Ventricular septal defect (VSD) has a mortality of 90-95% in medically managed and 19-60% in surgically treated patients., Methods: A retrospective analysis was performed of 41 patients, 26 females (63.4%) and 15 males (36.6%), average age 67.5 ± 15 years, with post-infarction VSD who were treated in the VUL SK intensive cardiology unit between 1991 and 2007., Results: Thirty-seven patients had hypertension (90.2%); anterior wall acute myocardial infarction (AMI) was found in 27 patients (68%). VSD was more frequent in women than in men (p=0.043). In 36 patients (87%) treatment was started 24 hours or later after the development of AMI symptoms. In 34 patients (83%) the rupture occurred during the first episode of AMI and in the majority of these (19 patients, 46.3%), preoperative coronary angiography demonstrated disease of only one coronary artery. During the first 10 days after the onset of AMI, 5 patients (12.2%) were treated surgically but did not survive the operation; 33 patients (80.5%) underwent operation 3-4 weeks after the onset of AMI and all survived., Conclusions: Female sex, advanced age, arterial hypertension, anterior wall AMI, absence of previous AMI, and late arrival at hospital are associated with a higher risk of mortality from acute VSD. The most important factor that determines operative mortality and intra-hospital survival is the time from the onset of AMI to operation.

Isolated noncompaction of the ventricular myocardium is defined as a rare cardiomyopathy caused by intrauterine arrest of compaction of the myocardial fibers and meshwork, an important process in myocardial development, in absence of any coexisting congenital heart lesions. A lot of controversies exist about diagnostic criteria, nomenclature, origin, pathogenesis, and prognosis of this disease. Here, we describe an adult patient with isolated left ventricular noncompaction who presented with worsening congestive heart failure and was successfully treated with heart transplantation.

Chronic ischemic left ventricular dysfunction is present in number of clinical syndromes in which myocardial revascularization results in an improvement of left ventricular function, patients' functional class, and their survival. Coronary arteriography is of limited value in diagnosis of viability. Noninvasive testing, traditionally nuclear imaging, stress echocardiography and (stress) electrocardiography have been the clinical mainstays for assessing myocardial viability as well as to detect myocardial ischemia. However, cardiovascular magnetic resonance is a rapidly emerging noninvasive imaging technique, providing high-resolution images of the heart in any desired plane and without radiation. Rather than a single technique, cardiovascular magnetic resonance consists of several techniques that can be performed separately or in various combinations during a patient examination. Whereas, no single cardiovascular magnetic resonance technique has a perfect, or near perfect, sensitivity and specificity, therefore, a combination of various cardiovascular magnetic resonance techniques are needed for the assessment of myocardial viability. The aim of this review article is to summarize our current understanding of the concept of myocardial viability, to discuss the clinical value of cardiovascular magnetic resonance (in particular the different cardiovascular magnetic resonance techniques to assess viability) for the evaluation of patients with coronary artery disease and chronic left ventricular dysfunction and to present the current place of cardiovascular magnetic resonance among other techniques for the assessment of viable myocardium.