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Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular events. Although the association between NAFLD and aortic valve sclerosis has been described, the prevalence and prognostic implications of NAFLD among patients with severe aortic stenosis (AS) have not been described. In addition, the effect of the presence of severe tricuspid regurgitation (TR) on the prevalence of NAFLD remains unexplored. Accordingly, we investigated the prognostic implications of NAFLD among patients with severe AS with and without concomitant significant TR. A total of 538 patients (aged 80 ± 7 y, 49.6% men) who underwent noncontrast computed tomography before transcatheter aortic valve implantation (TAVI) between 2007 and 2019 were included. NAFLD was defined as a liver-to-spleen attenuation ratio1.0 on noncontrast computed tomography. NAFLD was present in 118 patients (21.9%). There were no significant differences in pulmonary arterial pressure, right atrial pressure, or the prevalence of significant TR between patients with and without NAFLD. During a median follow-up of 47 months (interquartile range 20 to 70 months), 224 patients (41.6%) died. Univariate Cox regression analysis demonstrated that NAFLD was not significantly associated with all-cause death among patients treated with TAVI (hazard ratio 1.32, 95% confidential interval 0.97 to 1.79, p = 0.07). In conclusion, among patients with severe AS who underwent TAVI, the prevalence of significant TR and the clinical outcomes were similar in patients with and without NAFLD.

Several studies have shown an association between aortic stenosis (AS) and coronary atherosclerosis. This study aimed to evaluate the gender differences in aortic valve calcium (AVC) and coronary artery calcium (CAC) and the association between CAC and allcause mortality in patients with severe AS. A total of 260 patients (80 7 years, 39% men) with severe AS who were scheduled for transcatheter aortic valve implantation (TAVI) were included. AVC and CAC before TAVI were assessed by noncontrast cardiac computed tomography. Patients with coronary intervention or aortic valve replacement before cardiac computed tomography were excluded. Standard reference values of CAC score were used to classify the percentile groups and the distribution of AVC was assessed. The primary end point was all-cause mortality. In men, the AVC score was 3,911 Hounsfield units (HUs) (interquartile range [IQR] 2,525 to 5,259) and in women, 2,409 HU (IQR 1,588 to 3,359) (p

Background Atrial fibrillation (AF) and aortic stenosis (AS) are both highly prevalent and often coexist. Various studies have focused on the prognostic value of AF in patients with AS, but rarely considered left ventricular (LV) diastolic function as a prognostic factor. Objective To evaluate the prognostic impact of AF in patients with AS while correcting for LV diastolic function. Methods Patients with first diagnosis of significant AS were selected and stratified according to history of AF. The endpoint was all-cause mortality. Results In total, 2849 patients with significant AS (mean age 72 ± 12 years, 54.8% men) were evaluated, and 686 (24.1%) had a history of AF. During a median follow-up of 60 (30–97) months, 1182 (41.5%) patients died. Ten-year mortality rate in patients with AF was 46.8% compared to 36.8% in patients with sinus rhythm (SR) (log-rank P Conclusion Patients with significant AS and AF have a reduced survival as compared to patients with SR. Nonetheless, when correcting for markers of LV diastolic function, AF was not independently associated with outcomes in patients with significant AS.

Copyright © 2022 by the American Society of Echocardiography, Background: Significant (moderate or greater) mitral regurgitation (MR) could augment the hemodynamic effects of aortic valvular disease in patients with bicuspid aortic valve (BAV), imposing a greater hemodynamic burden on the left ventricle and atrium, possibly culminating in a faster onset of left ventricular dilation and/or symptoms. The aim of this study was to determine the prevalence and prognostic implications of significant MR in patients with BAV. Methods: In this large, multicenter, international registry, a total of 2,932 patients (mean age, 48 ± 18 years; 71% men) with BAV were identified. All patients were evaluated for the presence of significant primary or secondary MR by transthoracic echocardiography and were followed up for the end points of all-cause mortality and event-free survival. Results: Overall, 147 patients (5.0%) had significant primary (1.5%) or secondary (3.5%) MR. Significant MR was associated with all-cause mortality (hazard ratio [HR], 2.80; 95% CI, 1.91-4.11; P < .001) and reduced event-free survival (HR, 1.97; 95% CI, 1.58-2.46; P < .001) on univariable analysis. MR was not associated with all-cause mortality (adjusted HR, 1.33; 95% CI, 0.85-2.07; P = .21) or event-free survival (adjusted HR, 1.10; 95% CI, 0.85-1.42; P = .49) after multivariable adjustment. However, sensitivity analyses demonstrated that significant MR not due to aortic valve disease retained an independent association with mortality (adjusted HR, 1.81; 95% CI, 1.04-3.15; P = .037). Subgroup analyses demonstrated an independent association between significant MR and all-cause mortality for individuals with significant aortic regurgitation (HR, 2.037; 95% CI, 1.025-4.049; P = .042), although this association was not observed for subgroups with significant aortic stenosis or without significant aortic valve dysfunction. Conclusions: Significant MR is uncommon in patients with BAV. Following adjustment for important confounding variables, significant MR was not associated with adverse prognosis in this large study of patients with BAV, except for the patient subgroup with moderate to severe aortic regurgitation. In addition, significant MR not due to aortic valve disease demonstrated an independent association with all-cause mortality.

Aims Women with severe aortic stenosis (AS) have better long-term outcome after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared with men. Whether this is related to sex differences in left ventricular (LV) remodelling is unknown. The aim of this study was to examine the sex differences in LV remodelling with multidetector row computed tomography (MDCT) and outcome in patients with severe AS undergoing TAVI between 2007 and 2018. Methods and results A total of 289 patients (age 80 ± 6 years, 54% male) were included. LV volumes, mass, and function were analysed on pre-procedural MDCT scans. Women showed smaller LV volumes and mass compared with men. Patients were classified into four LV remodelling patterns: concentric hypertrophy (50%) was the most frequent pattern of LV remodelling followed by eccentric hypertrophy (33%), normal geometry (13%), and concentric remodelling (4%). Men showed more concentric remodelling compared with women (91% vs. 9%, respectively, P = 0.011). However, no differences were observed in the remaining LV remodelling patterns. During a median follow-up of 3.8 (IQR 2.2–5.1) years after TAVI, 87 (30%) patients died. Women demonstrated better outcome after TAVI compared with men (log-rank χ2 = 4.29, P = 0.038). No association was observed between the interaction of the LV remodelling patterns and sex with outcome. Conclusion LV concentric hypertrophy and eccentric hypertrophy are similarly observed in men and women with severe AS but concentric remodelling was more common in men. Women demonstrated better outcome after TAVI when compared with men. The interaction between the LV remodelling patterns and sex was not associated with survival.

Permanent pacemaker implantation (PPI) and left bundle branch block (LBBB) fre-quency after transcatheter aortic valve implantation (TAVI) and their effect on left ven-tricular ejection fraction (LVEF) remain controversial. We evaluated the incidence of PPI and new-onset LBBB after TAVI and their impact on LVEF at 6-month follow-up. More-over, the impact of right ventricular (RV) pacing burden on changes in LVEF after TAVI was analyzed. The electrocardiograms of 377 patients (age 80 +/- 7 years, 52% male) treated with TAVI were collected at baseline, after the procedure, at discharge, and at each outpatient follow-up. LVEF was measured at baseline before TAVI and 6 months after the procedure. Patients were divided into 3 groups according to the occurrence of LBBB, the need for PPI, or the absence of new conduction abnormalities. In patients with PPI, the influence of RV pacing burden on LVEF was analyzed. New-onset LBBB after TAVI occurred in 92 patients (24%), and PPI was required in 55 patients (15%). In patients without new conduction abnormalities, LVEF significantly increased during fol-low-up (56 +/- 14% to 61 +/- 12%, p < 0.001). Patients with a baseline LVEF

BACKGROUND: The prognostic impact of left ventricular ejection fraction (LVEF) in patients with bicuspid aortic valve (BAV) disease has not been previously studied. & nbsp; OBJECTIVES: The purpose of this study was to determine the prognostic impact of LVEF in BAV patients according to the type of aortic valve dysfunction. & nbsp; METHODS: We retrospectively analyzed the data collected in 2,672 patients included in an international registry of patients with BAV. Patients were classified according to the type of aortic valve dysfunction: isolated aortic stenosis (AS) (n = 749), isolated aortic regurgitation (AR) (n = 554), mixed aortic valve disease (MAVD) (n = 190), or no significant aortic valve dysfunction (n =1,179; excluded from this analysis). The study population was divided according to LVEF strata to investigate its impact on clinical outcomes. & nbsp; RESULTS: The risk of all-cause mortality and the composite endpoint of aortic valve replacement or repair (AVR) and all-cause mortality increased when LVEF was < 60% in the whole cohort as well as in the AS and AR groups, and when LVEF was < 55% in MAVD group. In multivariable analysis, LVEF strata were significantly associated with increased rate of mortality (LVEF 50%-59%: HR: 1.83 [95% CI: 1.09-3.07]; P = 0.022; LVEF 30%-49%: HR: 1.97 [95% CI: 1.13-3.41]; P = 0.016; LVEF < 30%: HR: 4.20 [95% CI: 2.01-8.75]; P < 0.001; vs LVEF 60%-70%, reference group). & nbsp; CONCLUSIONS: In BAV patients, the risk of adverse clinical outcomes increases significantly when the LVEF is < 60%. These findings suggest that LVEF cutoff values proposed in the guidelines to indicate intervention should be raised from 50% to 60% in AS or AR and 55% in MAVD. (J Am Coll Cardiol 2022;80:1071 & ndash;1084) (c) 2022 by the American College of Cardiology Foundation.

Aims Aortic stenosis (AS) induces left atrial (LA) remodelling through the increase of left ventricular (LV) filling pressures. Peak LA longitudinal strain (PALS), reflecting LA reservoir function, has been proposed as a prognostic marker in patients with AS. Feature-tracking (FT) multi-detector computed tomography (MDCT) allows assessment of LA strain from MDCT data. The aim of this study is to investigate the association between PALS using FT MDCT and survival in patients with severe AS who underwent transcatheter aortic valve implantation (TAVI). Methods and results A total of 376 patients (mean age 80 ± 7 years, 53% male) who underwent MDCT before TAVI and had suitable data for assessment of PALS using dedicated FT software, were included. The patients were classified into four groups according to PALS quartiles; PALS > 19.3% (Q1, highest reservoir function), 15.0–19.3% (Q2), 9.1–14.9% (Q3), and ≤9.0% (Q4, lowest reservoir function). The primary outcome was all-cause mortality. During a median of 45 (22–68) months follow-up, 148 patients (39%) died. On multivariable Cox regression analysis, PALS was independently associated with all-cause mortality [hazard ratio (HR): 1.044, 95% confidence interval (CI): 1.012–1.076, P = 0.006]. Compared with patients in Q1, patients in Q3 and Q4 were associated with higher risk of mortality after TAVI [HR: 2.262 (95% CI: 1.335–3.832), P = 0.002 for Q3, HR: 3.116 (95% CI: 1.864–5.210), P < 0.001 for Q4]. Conclusion PALS assessed with FT MDCT is independently associated with all-cause mortality after TAVI.

BACKGROUND The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown.OBJECTIVES The purpose of this study was to investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS.METHODS Patients with moderate AS (aortic valve area >1.0 and = 20 mm Hg) and discordant moderate AS including 3 subgroups: normal-flow, lowgradient moderate AS (MG = 35 mL/m(2), and LVEF >= 50%); "paradoxical" low-flow, low-gradient moderate AS (MG < 20 mm Hg, SVi = 50%) and "classical" low-flow, low-gradient moderate AS (MG

Background: Recent data showed poor long-term survival in patients with moderate AS. Although sex differences in left ventricular (LV) remodeling and outcome are well described in severe AS, it has not been evaluated in moderate AS. Methods: In this retrospective, multicenter study, patients with a first diagnosis of moderate AS diagnosed between 2001 and 2019 were identified. Clinical and echocardiographic parameters were recorded at baseline and compared between men and women. Patients were followed up for the primary endpoint of all-cause mortality with censoring at the time of aortic valve replacement. Results: A total of 1895 patients with moderate AS (age 73 +/- 10 years, 52% male) were included. Women showed more concentric hypertrophy and had more pronounced LV diastolic dysfunction than men. During a median follow-up of 34 (13-60) months, 682 (36%) deaths occurred. Men showed significantly higher mortality rates at 3 -and 5-year follow-up (30% and 48%, respectively) than women (26% and 39%, respectively) (p = 0.011). On multivariable analysis, male sex remained independently associated with mortality (hazard ratio 1.209; 95% CI: 1.024-1.428; p = 0.025). LV remodeling (according to LV mass index) was associated with worse outcomes (hazard ratio 1.003; CI: 1.001-1.005; p = 0.006), but no association was observed between the interaction of LV mass index and sex with outcomes. Conclusions: LV remodeling patterns are different between men and women having moderate AS. Male sex is associated with worse outcomes in patients with medically treated moderate AS. Further studies investigating the management of moderate AS in a sex-specific manner are needed.

Reduced left ventricular (LV) systolic function is associated with worse prognosis in patients with severe aortic stenosis (AS) treated with transcatheter aortic valve implanta-tion (TAVI). We aimed to examine the changes in left ventricular ejection fraction (LVEF) after TAVI among patients with varying baseline LVEF. Moreover, variables associated with lack of LVEF improvement were identified and the association with long-term outcomes was investigated. A total of 560 patients (age 80 +/- 7 years, 53% men) with severe AS who underwent transfemoral TAVI between 2007 and 2019 were selected. LVEF was assessed from transthoracic echocardiography at baseline (before TAVI) and at 6 and 12 months after TAVI. Patients were stratified according to baseline LVEF: (1) LVEF >= 50%, (2) LVEF 40% to 49%, and (3) LVEF < 40%. The clinical end point was >= 5% LVEF improvement. The primary outcome was all-cause mortality. Patients with baseline LVEF < 40% showed greater increase in LVEF than those with baseline LVEF 40% to 49% and LVEF >= 50% (from 33% +/- 6% to 43% +/- 10%, p < 0.001; from 45% +/- 3% to 52% +/- 8%, p < 0.001; and from 58% +/- 5% to 59% +/- 7%, p = 0.012, respectively, p for interaction < 0.001). Coronary artery disease (odds ratio [OR] 1.80 [95% confidence interval (CI) 1.06 to 3.06], p = 0.031), myocardial infarction (OR 2.07 [95% CI 1.19 to 3.61], p = 0.010), and permanent pacemaker (OR: 1.93 [95% CI 1.25 to 3.00], p = 0.003) were independently associated with the lack of >= 5% LVEF improvement. During a median follow-up of 3.8 (interquartile range 2.6 to 5.2) years, 176 patients died (31%). Patients with >= 5% LVEF improvement had similar outcomes compared with those with < 5% LVEF improvement (log-rank p = 0.89). In conclusion, patients with severe AS and baseline LVEF < 40% had the greatest improvement in LVEF at 1-year follow-up after TAVI. Coronary artery disease, myocardial infarction, and permanent pacemaker were associated with lack of LVEF improvement. However, LVEF improvement at 12 months was not associated with long-term outcomes. (c) 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/ licenses/by/4.0/) (Am J Cardiol 2022;177:90-99)

Introduction Chronic obstructive pulmonary disease (COPD) and aortic stenosis (AS) are the most common diseases in aging population that their prevalence and percental change in mortality increase over the years. In severe AS, aortic valve replacement (AVR) is the only treatment that has demonstrated to improve survival, however the presence of comorbidities increases the operative risk and influences negatively on the outcomes after AVR. Therefore, the definition of COPD varies across the studies and is not always based on the use of pulmonary functional tests. Accordingly, the aim of the present study is to evaluate the association between pulmonary functional parameters and all-cause mortality after AVR in a large cohort of patients with severe AS. Methods Total of 400 patients (78.0 year-old, 56.7% men) with severe AS and documented preoperative pulmonary functional test (PFT) were retrospectively analyzed. Demographic and clinical characteristics were collected from electronic medical records while echocardiography was performed and measured according to the recommendations. PFTs were performed prior to AVR and categories defined in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database: normal pulmonary function was defined by an FEV1 >75% of predicted; mild COPD if FEV1 was 60–75% of predicted; moderate COPD if FEV1 was 50–59% of predicted and severe COPD when FEV1 Results Mild, moderate and severe COPD were documented in 75 (19%), 31 (8%) and 22 (5%) while the remaining 68% had normal PFTs. Patients with moderate and severe COPD had significantly larger LV mass and LV end-systolic volume whereas LV ejection fraction was significantly lower. The FVC, FEV1, Tiffeneau index, VC, PEF, and IC were the worst among patients with moderate and severe COPD (per definition) (p Conclusion Patients with moderate and severe COPD had higher LV hypertrophy and reduced LV ejection fraction while PFT parameters were the worst among these patients. The survival rates were significantly lower in patients with moderate and severe COPD compared with patients without COPD. In addition to other clinical factors, any grade of COPD was associated with 2-fold increased risk of all cause-mortality. Funding Acknowledgement Type of funding sources: None.

ObjectiveTo investigate the prognostic impact of left ventricular (LV) diastolic dysfunction in patients with moderate aortic stenosis (AS) and preserved LV systolic function.MethodsPatients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm2) and preserved LV systolic function (LV ejection fraction ≥50%) were identified. LV diastolic function was evaluated using echocardiographic criteria according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR).ResultsOf 1247 patients (age 74±10 years, 47% men), 535 (43%) had LV diastolic dysfunction at baseline. Patients with LV diastolic dysfunction showed significantly higher mortality rates at 1-year, 3-year and 5-year follow-up (13%, 30% and 41%, respectively) when compared with patients with normal LV diastolic function (6%, 17% and 29%, respectively) (pConclusionsLV diastolic dysfunction is independently associated with all-cause mortality and the composite endpoint of all-cause mortality and AVR in patients with moderate AS and preserved LV systolic function. Assessment of LV diastolic function therefore contributes significantly to the risk stratification of patients with moderate AS. Future clinical trials are needed to investigate whether patients with moderate AS and LV diastolic dysfunction may benefit from earlier valve intervention.

Background: Sex-specific thresholds of computed tomography (CT)-derived aortic valve calcification (AVC) or AVC density (AVCd) to identify severe aortic stenosis (AS) have been established in populations that consisted mainly of Caucasians with a tricuspid aortic valve. The objective of this study was to evaluate the accuracy (i.e., sensitivity and specificity) of previously established thresholds to identify severe AS in patients with bicuspid aortic valve (BAV) and according to ethnicity: Caucasian vs. Asian. Methods: We built a multicenter registry of echocardiographic and CT data collected in BAV patients with at least mild AS and preserved left ventricular ejection fraction from 7 different centers. Anatomic severity of AS obtained by CT-derived AVC and AVCd was compared to hemodynamic severity of AS obtained by echocardiography. Results: Among 485 BAV patients (60% men, 73% Asians), the best thresholds of AVC and AVCd to identify severe AS in BAV patients were 2315 arbitrary units (AU) (sensitivity [Se]/specificity [Spe] = 82/78%) in men, 1103 AU (Se/Spe = 80/82%) in women, and 561 AU/cm2 (Se/Spe = 86/91%) in men, and 301 AU/cm2 (Se/Spe = 83/ 82%) in women, respectively. According to ethnicity, thresholds for severe AS in Caucasian patients were, respectively, in men and women: 2208 AU (Se/Spe = 83/83%) and 1230 AU (Se/Spe = 87/82%) for AVC and 474 AU/cm2 (Se/Spe = 88/83%) and 358 AU/cm2 (Se/Spe = 80/82%) for AVCd. In Asian patients, they were 2582 AU (Se/Spe = 76/78%) and 924 AU (Se/Spe = 84/80%) for AVC and 640 AU/cm2 (Se/Spe = 82/89%) and 255 AU/cm2 (Se/Spe = 86/80%) for AVCd. Conclusions: The optimal thresholds to identify hemodynamically severe AS in BAV patients are similar in Caucasians but appear to be higher in Asian men, compared with thresholds previously reported in tricuspid aortic valve patients. Nonetheless, the thresholds currently proposed in the guidelines have good accuracy and can be applied in BAV patients to confirm AS severity.

Hypo-attenuated leaflet thickening (HALT) of transcatheter aortic valves is detected on multidetector computed tomography (MDCT) and reflects leaflet thrombosis. Whether HALT affects left ventricular (LV) reverse remodeling, a favorable effect of LV afterload reduction after transcatheter aortic valve implantation (TAVI) is unknown. The aim of this study was to examine the association of HALT after TAVI with LV reverse remodeling. In this multicenter case–control study, patients with HALT on MDCT were identified, and patients without HALT were propensity matched for valve type and size, LV ejection fraction (LVEF), sex, age and time of scan. LV dimensions and function were assessed by transthoracic echocardiography before and 12 months after TAVI. Clinical outcomes (stroke or transient ischemic attack, heart failure hospitalization, new-onset atrial fibrillation, all-cause mortality) were recorded. 106 patients (age 81 ± 7 years, 55% male) with MDCT performed 37 days [IQR 32–52] after TAVI were analyzed (53 patients with HALT and 53 matched controls). Before TAVI, all echocardiographic parameters were similar between the groups. At 12 months follow-up, patients with and without HALT showed a significant reduction in LV end-diastolic volume, LV end-systolic volume and LV mass index (from 125 ± 37 to 105 ± 46 g/m2, p = 0.001 and from 127 ± 35 to 101 ± 27 g/m2, p

Moderate aortic stenosis (AS) is associated with an increased risk for adverse events. Although reduced left ventricular (LV) global longitudinal strain (GLS) is associated with worse outcomes in patients with severe AS, its prognostic value in patients with moderate AS is unknown. The aim of this study was to investigate the prognostic implications of LV GLS in patients with moderate AS. Methods: LV GLS was evaluated using speckle-tracking echocardiography in patients with moderate AS (aortic valve area 1.0-1.5 cm(2)) and reported as absolute (i.e., positive) values. Patients were divided into three groups: LV ejection fraction (LVEF) < 50% (group 1), LVEF >= 50% but LV GLS < 16% (group 2), and LVEF >= 50% and LV GLS >= 16% (group 3). The LV GLS value of 16% was based on spline curve analysis. The primary end point was all-cause mortality. Results: A total of 760 patients (mean age, 71 +/- 12 years; 61% men) were analyzed. During a median follow-up period of 50 months (interquartile range, 26-94 months), 257 patients (34%) died. Patients with LVEF < 50% and LVEF >= 50% but LV GLS < 16% showed significantly higher mortality rates at 1-, 3-, and 5-year follow-up (82%, 71%, and 58%; and 92%, 77%, and 58%, respectively) compared with those with LVEF >= 50% and LV GLS >= 16% (96%, 91%, and 85%, respectively; P < .001). Long-term outcomes were not different between patients with LVEF < 50% and those with LVEF >= 50% but LV GLS < 16% (P = .592). LV GLS discriminated higher risk patients even among those with LVEF >= 60% (P < .001) or those who were asymptomatic (P < .001). On multivariable analysis, LVEF < 50% (hazard ratio, 2.384; 95% CI, 1.614-3.522; P < .001) and LVEF >= 50% but LV GLS < 16% (hazard ratio, 2.467; 95% CI, 1.802-3.378; P < .001) were independently associated with all-cause mortality. Conclusions: In patients with moderate AS, reduced LV GLS is associated with an increased risk for all-cause mortality, even if LVEF is still preserved. European Society of Cardiology (ESC Training Grant) [T-2018-17405]

Aims Moderate aortic stenosis (AS) is associated with an increased risk of adverse events. Because outcomes in patients with AS are ultimately driven by the condition of the left ventricle (LV) and not by the valve, assessment of LV remodelling seems important for risk stratification. This study evaluated the association between different LV remodelling patterns and outcomes in patients with moderate AS. Methods and results Patients with moderate AS (aortic valve area 1.0–1.5 cm2) were identified and stratified into four groups according to the LV remodelling pattern: normal geometry (NG), concentric remodelling (CR), concentric hypertrophy (CH), or eccentric hypertrophy (EH). Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement (AVR). Of 1931 patients with moderate AS (age 73 ± 10 years, 52% men), 344 (18%) had NG, 469 (24%) CR, 698 (36%) CH, and 420 (22%) EH. Patients with CH and EH showed higher 3-year mortality rates (28% and 32%, respectively) when compared with patients with NG (19%) (P < 0.001). After multivariable adjustment, CH remained independently associated with mortality (HR 1.258, 95% CI 1.016–1.558; P = 0.035), whereas both CH (HR 1.291, 95% CI 1.088–1.532; P = 0.003) and EH (HR 1.217, 95% CI 1.008–1.470; P = 0.042) were associated with the composite endpoint of death or AVR. Conclusion In patients with moderate AS, those who develop CH already have an increased risk of all-cause mortality. Assessment of the LV remodelling patterns may identify patients at higher risk of adverse events, warranting closer surveillance, and possibly earlier intervention.

Aims: Left ventricular ejection fraction is the conventional measure used to guide heart failure management, regardless of underlying etiology. Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) is a more sensitive measure of intrinsic myocardial function. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on cardiovascular magnetic resonance (CMR) and validate the prognostic value of LV-GLS thresholds associated with fibrosis. Methods and results: LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57 ± 10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71 ± 12 years; 58% males; NYHA functional class I–II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, and myocardial infarction. In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74 [0.66–0.83]; P < 0.001) and calibration (Hosmer-Lemeshow χ2 = 6.37; P = 0.605) for replacement fibrosis. In the outcome cohort, 47 events occurred over 16 [3.3, 42.2] months. Patients with LV-GLS > −15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS < −21.0% (corresponding to 95% sensitivity to rule-out myocardial fibrosis) and those between −21.0 and −15.0% (log-rank P < 0.001). LV-GLS offered independent prognostic value over clinical variables, AS severity and echocardiographic LV mass and E/e′. Conclusion: LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF., Graphical Abstract Thresholds of echocardiographic left ventricular global longitudinal strain (GLS) that are associated with replacement myocardial fibrosis risk-stratify patients with aortic stenosis and preserved left ventricular ejection fraction. Some images in the figure were created with BioRender.com.

Background Aortic stenosis (AS) induces left atrial (LA) remodeling through the increase of left ventricular (LV) filling pressure. Peak left atrial longitudinal strain (PALS) has been proposed as a prognostic marker in patients with AS. Novel feature-tracking (FT) software allows to assess LA strain from multidetector computed tomography (MDCT) dataset. Purpose To investigate the association between PALS using FT MDCT and moratlity in patients who underwent transcatheter aortic valve implantation (TAVI). Methods A total of 369 Patients (mean 80±7 years, 51% male) who underwent preprocedual MDCT before TAVI and had suitable data for measureing PALS using dedicated FT software were included. Patients were classified into 4 groups according to PALS quartiles; PALS more than 19.3% (Q1), 19.3% or less to more than 15.0% (Q2), 15.0% or less to more than 9.1% (Q3), and 9.1% or less (Q4). The primary outcome was all-caurse mortality. Results During median follow-up of 45 [22 - 68] months, 124 patients (34%) were died. On multivariable Cox regression analysis, PALS is an independently associated with all-cause mortality (HR: 0.958 [95% CI: 0.925–0.993], P=0.006). Kaplan-Meier analysis showed the worse outcome of the quatile with more impaired PALS (Logrank P Conclusion In this retrospective study, PALS measured with FT MDCT was strongly associated with all-cause mortality after TAVI. LA functial assessment using MDCT may have a importan role for risk stratification in patients referred to TAVI. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 K-M curve according to PALS quartiles

Background Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) reflects intrinsic myocardial function, influenced by interstitial abnormalities. Cardiovascular magnetic resonance (CMR) detects myocardial fibrosis non-invasively, but it is limited for widespread use. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on CMR and validate the prognostic value of LV-GLS thresholds associated with fibrosis. Methods LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57±10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR for replacement myocardial fibrosis. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71±12 years; 58% males; NYHA functional class I-II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, myocardial infarction and cerebrovascular events. Results In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74; 95% confidence interval: 0.66–0.83; P−15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS Conclusions LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF (Figure 2). Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Figure 1Figure 2

Background Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Risk assessment in these patients, however, has not been thoroughly investigated. Purpose To investigate the independent determinants of survival in patients with MAS, stratified by left ventricular ejection fraction (LVEF) and severity of symptoms at the time of first diagnosis. Methods Patients with an echocardiographic diagnosis of tricuspid MAS (aortic valve area >1.0 and ≤1.5cm2) were identified. Patients were stratified by LVEF (LVEF ≥60%, LVEF 50–59%, or LVEF Results Of 2003 patients with MAS (mean age 73±10 years, 51% men, AVA 1.22±0.15 cm2), 1063 (53%), had LVEF≥60%, 550 (27%) LVEF 50–59% and 390 (20%) LVEF Conclusions Baseline LVEF and symptom severity are associated with worse outcomes in patients with MAS. Although current guidelines recommend conservative management for MAS, randomized trials appear warranted to determine whether AVR at an earlier stage would be beneficial in these patients. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): ESC Training Grant Appehab724.157064741 Figure 1. Kaplan-Meier outcome curvesFigure 2. Cox regression analysis

Background Sex-differences in left ventricular (LV) remodeling in patients with aortic valve disease have been reported. However, sex-differences in LV remodeling and mechanics in response to aortic valve replacement (AVR) remained largely unexplored. Purpose The present study aimed to evaluate the sex-differences during the time course of LV remodeling and LV mechanics (by LV global longitudinal strain (GLS)) after aortic valve replacement. Methods Patients with severe aortic valve disease (aortic stenosis (AS) or aortic regurgitation (AR)) undergoing AVR with echocardiographic follow-up at 1,2, and/or 5 years were evaluated. LV mass index, LV ejection fraction, LV GLS and stroke volume (SV) were measured. Linear mixed models analyses were used to assess changes in LV mass index, LVEF, LV GLS and SV between time points. The models were corrected for age, LV end-diastolic diameter at baseline and time between echocardiograms. Results A total of 211 patients (61±14 years, 61% male) with severe aortic valve disease (AS 63% or AR 39%) were included. Before AVR, men had larger LV mass index and higher SV compared to women. Both men and women had a preserved LV ejection fraction (54±12 and 56±9, P=0.102, respectively), but moderately impaired LV GLS (14.6±4.1 and 16.1±4.1, P=0.009, respectively). After AVR, both groups showed LV mass regression, improvement in LV ejection fraction and LV GLS. LV mass index and SV remained higher in men. During follow-up women showed significantly better LV GLS compared to men (P=0.030, figure 1). Conclusion In men and women with severe aortic valve disease undergoing AVR, the time course of changes in LV mass regression, LV ejection fraction, LV GLS and SV are similar. During follow-up LV mass index remained larger in men and women showed significantly better LV GLS. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The department of Cardiology received unrestricted research grants from Abbott Vascular, Bayer, Bioventrix, Biotronik, Boston Scientific, Edwards Lifesciences, GE Healthcare and Medtronic. Victoria Delgado received speaker fees from Abbott Vascular, Edwards Lifesciences, GE Healthcare, MSD and Medtronic. Nina Ajmone Marsan received speakers fees from Abbott Vascular and GE healthcare. Jeroen J Bax received speaker fees from Abbott Vascular. The remaining authors have nothing to disclose.

Aims The aim of this study is to investigate the independent determinants of survival in patients with moderate aortic stenosis (AS), stratified by severity of symptoms and left ventricular ejection fraction (LVEF). Methods and results Patients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm2) were identified. Patients were stratified by New York Heart Association (NYHA) functional class (NYHA I, NYHA II, or NYHA III–IV) and LVEF (LVEF ≥60%, LVEF 50–59%, or LVEF Conclusion Moderate AS is associated with poor long-term survival. Baseline symptom severity and LVEF are associated with worse outcomes in these patients. Patients with low-normal LVEF (

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model), Aims: Characterization of left ventricular (LV) geometric pattern and LV mass could provide an important insight into the pathophysiological adaptations of the LV to pressure and/or volume overload in patients with bicuspid aortic valve (BAV) and significant (≥moderate) aortic valve (AV) disease. This study aimed to characterize LV remodelling and its prognostic impact in patients with BAV according to the predominant type of valvular dysfunction. Methods and results: In this international, multicentre BAV registry, 1345 patients [51.0 (37.0-63.0) years, 71% male] with significant AV disease were identified. Patients were classified as having isolated aortic stenosis (AS) (n = 669), isolated aortic regurgitation (AR) (n = 499) or mixed aortic valve disease (MAVD) (n = 177). LV hypertrophy was defined as a LV mass index >115 g/m2 in males and >95 g/m2 in females. LV geometric pattern was classified as (i) normal geometry: no LV hypertrophy, relative wall thickness (RWT) ≤0.42, (ii) concentric remodelling: no LV hypertrophy, RWT >0.42, (iii) concentric hypertrophy: LV hypertrophy, RWT >0.42, and (iv) eccentric hypertrophy: LV hypertrophy, RWT ≤0.42. Patients were followed-up for the endpoints of event-free survival (defined as a composite of AV repair/replacement and all-cause mortality) and all-cause mortality. Type of AV dysfunction was related to significant variations in LV remodelling. Higher LV mass index, i.e. LV hypertrophy, was independently associated with the composite endpoint for patients with isolated AS [hazard ratio (HR) 1.08 per 25 g/m2, 95% confidence interval (CI) 1.00-1.17, P = 0.046] and AR (HR 1.19 per 25 g/m2, 95% CI 1.11-1.29, P < 0.001), but not for those with MAVD. The presence of concentric remodelling, concentric hypertrophy and eccentric hypertrophy were independently related to the composite endpoint in patients with isolated AS (HR 1.54, 95% CI 1.06-2.23, P = 0.024; HR 1.68, 95% CI 1.17-2.42, P = 0.005; HR 1.59, 95% CI 1.03-2.45, P = 0.038, respectively), while concentric hypertrophy and eccentric hypertrophy were independently associated with the combined endpoint for those with isolated AR (HR 2.49, 95% CI 1.35-4.60, P = 0.004 and HR 3.05, 95% CI 1.71-5.45, P < 0.001, respectively). There was no independent association observed between LV remodelling and the combined endpoint for patients with MAVD. Conclusions: LV hypertrophy or remodelling were independently associated with the composite endpoint of AV repair/replacement and all-cause mortality for patients with isolated AS and isolated AR, although not for patients with MAVD.

Several studies have shown an association between aortic valve stenosis (AS), atherosclerosis and cardiovascular risk factors. These risk factors are frequently encountered in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to evaluate the prevalence and the prognostic implications of AS in patients presenting with STEMI. A total of 2041 patients (61 +/- 12 years old, 76% male) admitted with STEMI and treated with primary percutaneous coronary intervention were included. Patients with previous myocardial infarction and previous aortic valve replacement were excluded. Echocardiography was performed at index admission. Patients were divided in 3 groups: 1) any grade of AS, 2) aortic valve sclerosis and 3) normal aortic valve. Any grade of AS was defined as an aortic valve area = 85 years, respectively). Patients with AS showed a significantly higher mortality rate when compared to the other two groups (p < 0.001) and AS was independently associated with all-cause mortality, with a HR of 1.81 (CI 95%: 1.02 to 3.22; p = 0.04). In conclusion, AS is not uncommon in patients with STEMI, and concomitant AS in patients with first STEMI is independently associated with all-cause mortality at long-term follow up. (C) 2021 The Author(s). Published by Elsevier Inc.

Aims Pressure overload in aortic stenosis (AS) and both pressure and volume overload in aortic regurgitation (AR) induce concentric and eccentric hypertrophy, respectively. These structural changes influence left ventricular (LV) mechanics, but little is known about the time course of LV remodelling and mechanics after aortic valve surgery (AVR) and its differences in AS vs. AR. The present study aimed to characterize the time course of LV mass index (LVMI) and LV mechanics [by LV global longitudinal strain (LV GLS)] after AVR in AS vs. AR. Methods and results Two hundred and eleven (61 ± 14 years, 61% male) patients with severe AS (63%) or AR (37%) undergoing surgical AVR with routine echocardiographic follow-up at 1, 2, and/or 5 years were evaluated. Before AVR, LVMI was larger in AR patients compared with AS. Both groups showed moderately impaired LV GLS, but preserved LV ejection fraction. After surgery, both groups showed LV mass regression, although a more pronounced decline was seen in AR patients. Improvement in LV GLS was observed in both groups, but characterized by an initial decline in AR patients while LV GLS in AS patients remained initially stable. Conclusion In severe AS and AR patients undergoing AVR, LV mass regression and changes in LV GLS are similar despite different LV remodelling before AVR. In AR, relief of volume overload led to reduction in LVMI and an initial decline in LV GLS. In contrast, relief of pressure overload in AS was characterized by a stable LV GLS and more sustained LV mass regression.

Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR.

Aims Peak left atrial longitudinal strain (PALS) is a marker of the left atrial (LA) reservoir function. Novel feature tracking (FT) software allows assessment of LA strain from multidetector computed tomography (MDCT) data. This study aimed at evaluating the agreement between speckle tracking echocardiography (STE) and FT MDCT for the measurement of PALS in patients with sinus rhythm (SR) and with atrial fibrillation (AF). Methods and results The current study included 318 patients (80 ± 7 years, 54% male) with dynamic MDCT data acquired prior to transcatheter aortic valve implantation. PALS was measured by transthoracic echocardiography using STE (PALSecho) and MDCT using dedicated FT software (PALSCT). In the overall population, the median values of PALSecho and PALSCT were 19.0 [interquartile range (IQR) 12.0–25.0] % and 15.3 (IQR 9.2–19.7) %, respectively. High correlation between PALSecho and PALSCT was observed (r = 0.789, P Conclusion PALSecho and PALSCT showed a good agreement in patients with severe aortic stenosis (AS) regardless of the cardiac rhythm. FT MDCT may be an important adjuvant modality for assessing LA reservoir function in patients with severe AS.

Aims An echocardiographic staging system of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography (MDCT) is key in the evaluation of AS patients undergoing TAVI and can potentially detect extra-valvular cardiac damage. This study aimed at evaluating the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. Methods and results A total of 405 patients (80 ± 7 years, 52% men) who underwent full-beat MDCT prior to TAVI were included. The extent of cardiac damage was assessed by MDCT and classified in five categories; Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (left atrium and mitral valve damage), Stage 3 (right atrial damage), and Stage 4 (right ventricular damage). Twenty-seven (7%) patients were stratified as Stage 0, 96 (24%) as Stage 1, 152 (38%) as Stage 2, 78 (19%) as Stage 3, and 52 (13%) as Stage 4. During a median follow-up of 3.7 (IQR 1.7–5.5) years, 150 (37%) died. On multivariable Cox regression analysis, cardiac damage Stage 3 (HR vs. Stage 0: 4.496, P = 0.039) and Stage 4 (HR vs. Stage 0: 5.565, P = 0.020) were independently associated with all-cause mortality. Conclusion The MDCT-based staging system of cardiac damage in severe AS effectively identifies the patients who are at higher risk of death after TAVI.

Introduction: Patients with secondary mitral regurgitation (SMR) often show extra-mitral valvular cardiac damage which can influence the prognosis. SMR can be defined according to stages of extra-mitral valvular cardiac damage. The present study evaluated the prevalence of different stages of extra-mitral valvular cardiac damage and the prognostic implications in moderate and severe SMR patients. Methods: A total of 648 patients with moderate and severe SMR were classified according to the extent of cardiac damage on echocardiography: left ventricular damage (Stage 1), left atrial damage (Stage 2), pulmonary artery vasculature damage (Stage 3) or right ventricular damage (Stage 4). Cox proportional hazards analyses were performed, both on, non-censored and censored data (included till the occurrence of mitral valve intervention). The primary endpoint was all-cause mortality. Results: The prevalence of each stage of the proposed classification was, 10% in Stage 1, 7% in Stage 2, 16% in Stage 3 and 67% in Stage 4. In the censored data, cardiac damage classification was independently associated with all-cause mortality (HR: 1.182, CI :1.019-1.370; P=0.027), and this was mainly driven by Stage 4 (HR: 1.726 CI: 1.034-2.881; p=0.037, Figure 1A). The non-censored data, showed that Stage 3 was independently associated with all-cause mortality (HR: 1.795 CI:1.121-2.876; P= 0.015), whereas Stage 4 showed an increased non-significant risk for all-cause mortality (HR: 1.472 CI:0.973-2.227; P=0.067, Figure 1B). Conclusions: A new proposed staging classification for moderate and severe SMR showed, that cardiac damage staging was independently associated with all-cause mortality in patients censored for mitral valve intervention, and this was mainly determined by RV dysfunction.

Introduction A staging of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multi-detector row computed tomography (MDCT) has a central role in the evaluation of AS patients undergoing TAVI and can detect extra-valvular cardiac damage. Purpose To evaluate the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. Methods Patients who underwent full-beat MDCT prior to TAVI were included. Patients with intra-cardiac devices, prior valvular surgery, and insufficient image quality were excluded. The extent of cardiac damage was assessed by MDCT and classified into following 5 groups; stage 0 (no cardiac damage), stage 1 (left ventricular damage), stage 2 (left atrium and mitral valve damage), stage 3 (right atrial damage), stage 4 (right ventricular damage). The primary end-point was all-cause mortality. Results A total of 405 patients (80±7 years, 52% men) were stratified according to the MDCT staging system: 27 (7%) were in stage 0, 96 (24%) in stage 1, 152 (38%) in stage 2, 78 (19%) in stage 3, and 52 (13%) in stage 4 (left panel). During follow-up (median 3.7 years, IQR: 1.7–5.5 years), 150 (37%) died (right panel). On multivariable analysis, cardiac damage stage, presence of chronic obstructive pulmonary disease, NYHA ≥3, eGFR, and transapical approach were independently associated with all-cause mortality. When evaluating each stage, stage 3 (HR: 4.725, P=0.033) and stage 4 (HR 5.678, P=0.018) were independently associated with worse outcomes as compared to the other stages. Conclusion MDCT-based staging system of severe AS identifies the patients who are at higher risk of death after TAVI. MDCT staging and the mortality Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant

Background Hypo-attenuated leaflet thickening (HALT) of transcatheter aortic valves can be observed on multidetector computed tomography (MDCT) and is considered as an early marker of leaflet thrombosis. Preliminary data has suggested that HALT will prevent or delay reverse left ventricular (LV) remodeling after transcatheter aortic valve implantation (TAVI). Purpose The purpose of the present study was to assess the association of HALT to reverse LV remodeling after TAVI. Methods In this multicenter study, patients who underwent MDCT after TAVI were evaluated. The presence of HALT was assessed with MDCT. Transthoracic echocardiograms were performed to assess LV dimensions and function before and 12 months after TAVI; transcatheter valve hemodynamics were assessed immediately after TAVI and at 12 months follow-up. Results A total of 169 patients (mean age 81±7 years, 53% male) who underwent MDCT performed 35 days [IQR 32–52] after TAVI were analyzed. HALT was observed in 42 (33%) patients. Before TAVI, LV mass (LVM) and LV mass index (LVMi) did not differ between patients with or without HALT: 227±80 vs. 234±62 g (p=0.568) and 121±37 vs. 126±32 g/m2 (p=0.35), respectively. Also LV ejection fraction (LVEF) was comparable between groups, 51±10 vs. 50±12%, p=0.64. LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) were lower in patients with HALT: 75 (67–115) vs. 99 (77–127) ml (p=0.030) and 39 (30–53) vs. 46 (33–65) ml (p=0.050), respectively. At 12 months follow-up, we found no differences in LVM or LVMi regression, decrease of LV volumes or transprosthetic gradients between groups (Figure 1). Conclusion Patients who presented with HALT had significantly lower LV volumes before TAVI. LV mass and volumes regressed significantly at 12 months after TAVI, however LV remodeling was not associated to the presence of HALT. Funding Acknowledgement Type of funding source: None

Background Sepsis recognition in older emergency department (ED) patients is difficult due to atypical symptom presentation. We therefore investigated whether the prognostic and discriminative performance of the five most commonly used disease severity scores were appropriate for risk stratification of older ED sepsis patients (≥70 years) compared to a younger control group (