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Introduction Myxomas are the most common heart tumors. Although, myxomas are often diagnosed incidentally in asymptomatic patients, they are frequently associated with embolic events, becoming an important cause of morbidity and mortality. Whether some myxomas' characteristics predict more embolic risk is not well established. Objectives This analysis aims to describe the clinical and echocardiographic data in a long cohort of patients with cardiac myxomas and to establish potential predictors of embolic events int these patients. Methods Between 1990 and 2021, 88 patients were diagnosed with cardiac myxoma. 84 were included in this analysis. Baseline characteristics, echocardiographic findings and embolic events were noted retrospectively. A binary logistic regression analysis using SPSS statistics software, version 25.0 was performed to establish possible embolic predictors. Results 84 patients (mean age 63.1±12.9 years old, 75% female) with cardiac myxoma (sporadic type in 100%) were analyzed (table 1). The majority were located in the left atrium (88.1%, n=74), followed by right atrium (10.7%, n=9) and right ventricle (1.2%, n=1). The average dimension (longer axis) was 36.8±17.4mm. 9.6% of the patients (n=8) had Atrial Fibrillation (AF) rhythm. 22.6% of the patients (n=19) experienced embolic events, the majority to the central nervous system (19.0%, n=6), followed by peripheric/limbs (2.4%, n=2), renal (1.2%, n=1) and coronary (1.2%, n=1). The presence of irregular borders (papillary, bosselated) was the only parameter independently associated with increased risk of embolic events, by 6 times (OR 6.78, 95% confidence interval of 2.14–21.51, p-value 0.001). Neither the presence of AF, myxoma dimensions, presence of calcifications, pediculated insertion, myxoma mobility or heterogeneous aspect predicted embolic events with statistical significance (table 2). Conclusions Cardiac myxomas are frequently associated with embolic events (22.6% in our population), posing an important cause of morbidity and mortality in these patients. Besides the presence of irregular borders, the other myxoma's characteristics did not consistently predict the occurrence of embolic events. This data supports the well-recognized fact that all cardiac myxomas have the potential to embolic events, and therefore, should be excised, although those with very irregular borders are at much higher risk of embolization. Funding Acknowledgement Type of funding sources: None.

Introduction Oral anticoagulants are the standard treatment for prevention of stroke in patients with atrial fibrillation (AF). However, some patients still have stroke despite anticoagulation or have contraindications to anticoagulation. The left atrial appendage occlusion (LAAO) is an option for those patients. The use of intracardiac echocardiography (ICE) instead of Transesophageal echocardiography guiding LAAO procedures has increased, allowing to reduce the use of general anesthesia. Objectives The aim of this study is to describe data regarding safety and efficacy in patients submitted to ICE-guided LAAO. Methods In a tertiary center, patients submitted to ICE-guided LAAO were identified. Information regarding baseline characteristics, procedure technical success, complications, hospitalization and follow-up data was noted retrospectively. The registered stroke and bleeding rates were compared with predicted rates using CHA2DS2-VASc and HAS-BLED scores, respectively. Results 45 patients underwent ICE-guided LAAO, mean age 75.5±9.6 years old, 71.1% male (detailed characteristics in table 1). Permanent AF was present in 68.9% (n=31), with average CHA2DS2-VASc and HAS-BLED scores of 4.0±1.4 and 3.6±1.1, respectively (predicting a stroke risk of 4.0% per year and a major bleeding risk of 8.7% per year). The LAAO indication was previous major bleeding in 64.4% (n=29), high bleeding risk in 24.4% (n=11) and embolic events despite therapeutic anticoagulation in 11.1% (n=5). The LAAO devices were implanted successfully in 96% of the patients (n=43). It was noted a complication rate of 8.8% (n=4), perforation in 4.4% (n=2), device embolization in 4.4% (n=2, one of them leading to cardiac arrest and death) and no major vascular complications occurred. No other procedure-related deaths occurred. The average duration of hospitalization after the procedure was 5.7 days. All patients were followed-up for a mean period of 19.0 months. During that period, another death (2.2%) occurred with a non-cardiac cause and the re-hospitalization rate was 26.7% (n=12), 11.1% (n=5) for cardiac causes. During the same period, 1 stroke (2.2%) and 6 major bleeding (13.3%) occurred – yearly rates of 1.4% and 8.4%, respectively. The stroke rate is markedly inferior to predicted by the score and the major bleeding is slightly inferior to predicted. Conclusions This study provides data about the safety and mainly about the efficacy of the LAAO guided by ICE in a cohort of patients with high hemorrhagic and embolic risk. Funding Acknowledgement Type of funding sources: None.

Introduction Cardiac myxoma (CM) is the most common primary cardiac tumour. It can manifest in a variety of clinical presentations or it can be asymptomatic and, ultimately, be detected with image techniques. The only successful treatment of these tumours is surgical excision, with low complications and recurrence rate. Objectives This analysis aims to describe the clinical forms of presentation and echocardiographic characteristics of cardiac myxomas, establish myxoma features associated with obstructive symptons, as well as describe the postoperative outcome and long-term recurrence in a tertiary center. Methods Between 1990 and 2021, 88 patients were diagnosed with cardiac myxoma. 84 were included in this analysis. Baseline characteristics, clinical presentation, echocardiographic findings and outcomes were noted retrospectively. A binary logistic regression analysis using SPSS statistics software, version 25.0 was performed to establish myxoma features associated with atrioventricular valves obstruction. Results Mean age was 63±12 years old, 75% female. All CM were sporadic. The majority of the patients (52.4%, n=44) were asymptomatic, embolic events were present in 22.9% of the patients (n=19), with the most common site being central nervous system (19.0%, n=16) and constitutional symptoms in 16.7% (n=14), the most frequent fatigue (11.9%, n=10). Atrial fibrilation was present in 9.6% of the patients (n=8). The majority of the myxomas were located in the left atrium (88.1%), followed by right atrium (10.7%) and right ventricle (1.2%). Mean myxoma dimension was 36.8±17.4mm (longer axis), with heterogeneous aspect in 63.1%, presence of calcification in 11.9%, pediculated insertion in 40.5%, mobility in 70.2% and irregular borders in 52.4%. Moderate or severe ventricular inflow obstruction was present in 13.1% (n=11), 13.6% with mitral obstruction in the left atrial myxomas and 11.1% with tricuspid obstruction in the right atrial myxomas. CM longer axis 40–59mm and superior to 60mm were independently associated with obstruction (OR 5.1, 95% CI 1.4–18.4, p0.014 and OR 11.5, 95% CI 2.9–45.4, p0.001, respectively). No other morphologic features were associated with mitral or tricuspid obstruction. All but 3 patients had the myxoma surgically removed because of advanced age and comorbidities (96.4% surgical rate). There was no in-hospital or 1 year mortality in these patients. During the follow-up period, 3.6% patients had recurrence of the myxoma, with a men period of 5 years after the first surgery (one, two and twelve years), all of them re-submitted to surgical excision. Conclusion Despite being asymptomatic in the majority of the patients and often diagnosed incidentally, cardiac myxomas are frequent source of morbidity and mortality due to embolic events, obstructive and constitutional symptoms. Surgery is the treatment of choice for cardiac myxomas and in most cases it is curative, with low complications and low recurrence rate. Funding Acknowledgement Type of funding sources: None.

Introduction Myocardial work is a dynamic non-invasive method for assessing myocardial deformation. Microvascular dysfunction is a hallmark of hypertrophic cardiomyopathy (HCM). We hypothesized that there is an association between impaired myocardial work, evaluated by echocardiography, and left ventricular (LV) ischemia, detected by cardiac magnetic resonance (CMR). Methods Prospective assessment of HCM patients' (P) myocardial strain parameters with 2D speckle-tracking echocardiography. All P underwent CMR protocol (1.5-T) for the analysis of stress perfusion and late gadolinium enhancement (LGE). Perfusion defects were quantified as burden of ischemia (% of LV mass). Results were stratified according to obstructive (oHCM) and nonobstructive (nHCM) HCM as well as according to the presence of significant replacement fibrosis (LGE of ≥15% or Results 75 P with HCM (63% male, age 55±15 years), 61% with asymmetric septal LVH, 29% with apical LVH, 8% with concentric LVH and 28% exhibiting LV outflow tract obstruction (mean maximal LVOT gradient of 89±60 mmHg). Perfusion defects were found in 68 P (90.7%), with a mean of 22.5±16.9% of LV mass and 29 P (38.7%) had LGE ≥15% of LV mass. A lower global work index (GWI) significantly correlated with higher burden of myocardial perfusion defects (r=−0.520, β-estimate −0.019, 95% CI −0.028 to −0.010, p GWI showed a higher correlation with perfusion defects in oHCM P (r=−0.518, p=0.019) vs. nHCM P (r=−0.492, p In P with LGE ≥15%, GWI showed a better correlation with perfusion defects (r=−0.489, p=0.007) vs. P with LGE of Conclusion In our cohort of P with HCM, impaired GWI, GWE and GCW and a higher GWW were significantly correlated with the presence of myocardial ischemia in CMR. This correlation was greater in P with oHCM and in P with LGE of ≥15% of LV mass. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Introduction Myocardial deformation parameters, derived from three-dimensional (3D) speckle-tracking echocardiography (3DSTE) are useful tools to determine left ventricular (LV) systolic function, and are often abnormal before a decline in ejection fraction (EF). Aims To study the correlation between systolic function evaluated by myocardial deformation parameters obtained by 3DSTE and functional capacity in patients with HCM. Methods HCM patients seen prospectively at outpatient cardiomyopathy clinic at a tertiary centre were included. Systolic function was assessed by strain measures – global longitudinal, circumferential and radial strain - obtain by 3DSTE, LVEF by 2D and 3D echocardiography were also assessed. Functional capacity was evaluated by CPET. Results Of 67 P with HCM (mean age 57 ± 14 years, 41 males), 38 P (56.7%) were in New York Heart Association (NYHA) functional class I, 24 (35.8%) in class II and 5 (7.5%) in class III. 46P (68.7%) had obstructive (HCM), with a maximum LV wall thickness (MWT) of 20 (7) mm. 3DSTE and CPET parameters are reported in Table 1. Absolute values of 3D global radial strain showed correlation with pVO2 (r=-0.336, p = 0.006), as well as longitudinal strain (r=-0.280, p= 0.024). No association was found between LVEF and pVO2. MWT did not correlate with 3DSTE strain measures. Conclusion Impaired myocardial deformation was associated with worse functional capacity assessed by peak oxygen consumption.

Funding Acknowledgements Type of funding sources: None. Introduction Three-dimensional (3D) echocardiography is an emerging tool for assessment of left ventricular function, with a promising role in the evaluation of cardiomyopathies. Hypertrophic cardiomyopathy (HCM) is often associated with reduced exercise capacity. The aim of this study was to evaluate the importance of 3D myocardial deformation parameters as predictors of exercise capacity in HCM patients (P). Methods This prospective study enrolled P with HCM. Each P underwent a comprehensive transthoracic echocardiogram including 3D speckle-tracking to measure global longitudinal, radial and circumferential strain, twist, torsion and global area strain. Functional capacity was objectively assessed by treadmill cardiorespiratory exercise testing. Results 83 patients with HCM, 50 (60%) male, mean left ventricular ejection fraction (LVEF) of 68 ± 7%, 27 (33%) with obstructive HCM (LV outflow tract [LVOT] gradient of 89 ± 60 mmHg). Impairment in LV myocardial deformation parameters was significantly correlated with lower peak VO2: global longitudinal 3D strain (r=-0.397, p Impaired LV twist was significantly correlated with inferior peak VO2 (r = 0.264, p = 0.033) (Fig.2) and peak circulatory power (r = 0.371, p = 0.003). Torsion impairment also significantly associated with lower peak VO2 (r = 0.285, p = 0.021), circulatory power (r = 0.380, p = 0.002), time to ventilatory anaerobic threshold (VAT) (r = 0.369, p = 0.003) and (VE/VCO2 slope)/peak VO2 ratio (r=-0.316, p = 0.012). Furthermore, global area strain impairment showed significant relation with decreased peak VO2 (r=-0.368, p = 0.001), lower exercise duration (r=-0.384, p = 0.001), time to VAT (r=-0.404, p Conclusion Although P with HCM often have supranormal LVEF, 3D speckle-tracking echocardiographic imaging has the potential to demonstrate subclinical impairment of LV function. Impaired LV 3D strain, twist, torsion and global area strain were associated with reduced exercise capacity, particularly in nHCM P. Abstract Figure. Peak VO2 and 3D strain parameters Abstract Figure. LV twist, torsion and global area strain

Funding Acknowledgements Type of funding sources: None. Introduction Myocardial work is a novel dynamic non-invasive method for assessing myocardial deformation providing incremental information to left ventricular ejection fraction (LVEF) and strain imaging. The aim of this study was to assess left ventricular myocardial work in hypertrophic cardiomyopathy (HCM) and compare patients with obstructive HCM (oHCM) and nonobstructive HCM (nHCM). Methods Prospective assessment of HCM patients’ myocardial strain parameters with 2D speckle-tracking echocardiography, stratified according to LV segments (basal, midcavity and apical regions). Results were compared between oHCM and nHCM patients. Results 83 patients with HCM, 60% male, 33% oHCM (with a LVOT gradient of 89 ± 60 mmHg). There was no significant difference between groups in mean age (56 ± 13 years vs. 55 ± 15 years, p = 0.719), LV mass index (186 ± 75 g/m2 vs. 158 ± 65 g/m2, p = 0.103), maximum wall thickness (21 ± 4 mm vs. 19 ± 5 mm, p = 0.425) or left ventricular ejection fraction (LVEF) (68 ± 8% vs. 67 ± 11%, p = 0.584). Regarding global work index (GWI) there was no significant difference between oHCM and nHCM (1206 ± 431 mmHg% vs. 1384 ± 437 mmHg%, p = 0.090), although oHCM patients had a significantly inferior GWI in the basal (921 ± 383 mmHg% vs. 1364 ± 419 mmHg%, p Global constructive work (GCW) (1443 ± 449 mmHg% vs. 1604 ± 426 mmHg%, p = 0.123) and global wasted work (GWW) (197 ± 140 mmHg% vs. 154 ± 107 mmHg%, p = 0.137) were not significantly different between groups. Global work efficiency (GWE) was significantly reduced in oHCM patients vs. nHCM (84.1 ± 7% vs. 88.3 ± 7.3%, p = 0.017), particularly in the basal (80.2 ± 11.2% vs. 88.3±.7.2%, p = 0.033) and midcavity segments (85.4 ± 9.2% vs. 90.0 ± 8.5%, p = 0.044) (Figure 2). No significant difference was noted in the apical segments (88.2 ± 9.9% vs. 87.0 ± 12%, p = 0.679). Myocardial work efficiency in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.389, p = 0.002) and maximum provoked LVOT gradient (r=-0.446, p Conclusion Myocardial work is a promising tool to evaluate myocardial function in patients with oHCM and nHCM. oHCM patients had a significantly inferior GWI and GWE particularly in the basal and midcavity segments versus nHCM patients. Abstract Figure 1: Myocardial Work Index Abstract Figure 2: Myocardial Work Efficiency

Funding Acknowledgements Type of funding sources: None. Introduction Alcohol septal ablation (ASA) has been widely accepted as an alternative to surgical myectomy in patients with symptomatic obstructive hypertrophic cardiomyopathy (OHCM) despite optimal medical treatment. The aim of this study was to analyse the effect of ASA on anatomical and functional features analysed by echocardiography, as well as its clinical impact. We further evaluated the safety of procedure. Methods and results Retrospective analysis of consecutive patients submitted to ASA (2009 – 2019) in a single tertiary centre. A dedicated echocardiogram was performed at 3 and 6 months after procedure. Echocardiographic primary endpoint was a > 50% reduction in left ventricular outflow tract (LVOT) gradient (the definition used for successful procedure). Echocardiographic secondary endpoint was improvement in mitral regurgitation. Clinical primary endpoint was defined as a combined endpoint of cardiac death or hospitalization during follow-up (FU). 110 patients were included, 66.4% women, mean age 65.1 ± 12.2 years. Functional class NHYA class III/IV, angina CCS class II/III and syncope were present in 87.3%, 52.7% and 10.0%, respectively. Baseline LVOT gradients at rest and at Valsalva manoeuvre were 93.6 ± 39.8 mmHg and 118.9 ± 44.2 mmHg. Maximum septal thickness was 21.0 ± 3.3 mm, 24.5% had moderate mitral regurgitation and 52.7% showed systolic anterior motion of mitral valve. During hospitalization for ASA, peak creatine kinase after procedure was 1306 ± 816 U/l. 17 (17.1%) patients required permanent PM due to induction of permanent complete heart block. There was one case of inferior myocardial infarction and one case of cardiac tamponade. Echocardiographic primary endpoint was achieved by 83.6% of patients. At 3 and 6-months follow up, LVOT gradients was significantly decreased in successful comparing with unsuccessful procedure group (24.6 ± 23.9 vs 82.0 ± 28.7 mmHg, p = 0.003 and 31.8 ± 34.5 vs 68.6 ± 27.8 mmHg, p = 0.027, respectively). There was no difference in baseline clinical or echocardiographic parameters between both groups. Regarding the echocardiographic secondary endpoint, among patients with moderate mitral regurgitation, 80% improved to mild regurgitation. A significant reduction in basal septal thickness was achieved in most patients, from 21.0 ± 3.3mm to 16.4 ± 2.7 mm after ASA (p = 0.001). During mean FU of 3.4 ± 2.1 years, clinical primary endpoint occurred in 25.5%, mainly in unsuccessful procedure group (50.0% vs 20.7%, p = 0.013). Reintervention was performed for recurrence of symptoms in 14 (12.7%) patients, surgical myectomy in 3 (3.6%) and repeated ASA in 10 (9.1%). Conclusion ASA allows a significant reduction in LVOT gradient and improvement of mitral regurgitation in the majority of patients with OHCM. Systematic and comprehensive echocardiographic evaluation assumes a paramount importance for the evaluation of procedural success. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Background Left ventricular (LV) global longitudinal strain has demonstrated incremental prognostic value over LV ejection fraction (LVEF) in patients with ST-segment-elevation acute myocardial infarction. However, LV global longitudinal strain (GLS) does not take into consideration the effect of afterload. Myocardial work (MW) by speckle-tracking echocardiography integrates blood pressure measurements (afterload) with LV GLS and it has been recently demonstrated that Global Work Efficiency (GWE) predicts long-term all-cause mortality. It remains to be demonstrated if MW indices are associated with hard cardiovascular endpoints. The present study aimed to investigate the prognostic value of LV MW obtained from pressure-strain loops with echocardiography in patients with ST-segment-elevation myocardial infarction. Methods A total of 132 consecutive patients admitted with an ST-segment-elevation acute myocardial infarction (mean age 62 ± 12 years; 76% men) that survived to discharge were retrospectively analysed. LVEF, GLS and all LVMW indices were measured by transthoracic echocardiography before discharge (4.9 ± 2.4 days after admission). All patients had at least a two-year follow-up (mean follow-up of 820 ± 155 days). Outcomes: all-cause mortality, major acute cardiovascular events (a composite of cardiovascular mortality, myocardial infarction, stroke, unplanned cardiovascular admission) and heart failure hospitalization. Results In the two-year follow-up, 6 patients died, there were 18 patients with MACE, and 3 patients were hospitalized with heart failure. We confirmed that for all-cause mortality, GWE and GWI showed better discrimination compared to GLS (Table), with a cut-off of 83% and 1066 mmHg% (log-rank < 0,001) respectively. However, ROC curve comparisons were not significantly different. For MACE, the performance of all methods is suboptimal, with an AUC < 0.65 for all variables, except for GLS. For heart failure admission, performance is slightly better, but GLS is still the best parameter to predict this event. Conclusions LVGWE and GWI are better predictors of all-cause mortality compared to GLS, but MW indices failed to demonstrate a prognostic impact in long-term cardiovascular events. Prospective studies are warranted to confirm this finding. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Background In the era of innovative transcatheter valve interventions, percutaneous balloon mitral valvuloplasty (PBMV) remains the primary treatment option in anatomic suitable patients. Purpose This study aimed to evaluate longterm follow-up (FU) of PBMV and to determine predictors of MACE. Methods Between 1991 and June 2021, 202 consecutive patients underwent PBMV in a single tertiary centre. Clinical data, echocardiographic parameters, and MACE (cardiovascular mortality, need for percutaneous or surgical mitral reintervention and hospitalization for heart failure) were analysed. Predictors of MACE were determined by Cox regression analysis. Results Mean age was 47.3 ± 13.6 years, 89.6% female, 47.3% patients presenting atrial fibrillation. Mean Wilkins score was 7.6 ± 1.4, 51.5% had mild or moderate mitral regurgitation and mean pulmonary artery systolic pressure (PASP) of 46.7 ± 17.1 mmHg. Mean pre MVA and mean mitral valve (MV) gradient were 1.1 ± 0.2 cm2 and 10.8 ± 5.6 mmHg, respectively. Successful PMBV was achieved in 89.1%. During a mean FU of 12.0 ± 8.8 years, there were 25 deaths (12.4%) and 33.3% needed MV reintervention (6.5% underwent PBMV and 29.7% needed MV surgery). At univariate analysis, previous MV intervention [HR = 1.95 (1.02–3.72), p 45 mmHg [HR = 3.29 (1.13–9.55), p Conclusions PBMV remains a reliable and efficient therapeutic option of mitral stenosis, warranting event-free survival at 10 years in most patients selected for the procedure. Mean MV gradient after procedure was independent predictor of MV reintervention and MACE during follow-up. Abstract Figure. Abstract Figure.

Background Left ventricular (LV) global longitudinal strain has demonstrated incremental prognostic value over LV ejection fraction (LVEF) in patients with ST-segment-elevation acute myocardial infarction. However, LV global longitudinal strain (GLS) does not take into consideration the effect of afterload. Myocardial work (MW) by speckle-tracking echocardiography integrates blood pressure measurements (afterload) with LV GLS and it has been recently demonstrated that Global Work Efficiency (GWE) is associated with long-term all-cause mortality. It remains to be demonstrated if MW indices are associated with hard cardiovascular endpoints. The present study aimed to investigate the prognostic value of global LV MW obtained from pressure-strain loops with echocardiography in patients with ST-segment-elevation myocardial infarction. Methods A total of 100 consecutive ST-segment-elevation myocardial infarction patients (mean age, 61±12 years; 75% men) that survived to discharge were retrospectively analysed. LVEF, GLS and all LVMW indices were measured by transthoracic echocardiography before discharge (4.6±2.0 days after admission). All patients had at least a two-year follow-up (mean follow-up of 833±172 days). Outcomes: all-cause mortality, major acute cardiovascular events (a composite of cardiovascular mortality, myocardial infarction, stroke, unplanned cardiovascular admission) and heart failure hospitalization. Results In the two-year follow-up, 6 patients died, there were 17 patients with MACE, and 3 patients were hospitalized with heart failure. We confirmed that for all-cause mortality, GWE showed higher discrimination, compared to GLS (Table 1), with a cut-off of 83% (log-rank Conclusions LVGWE is a better predictor of all-cause mortality compared to GLS, but MW indices failed to demonstrate a prognostic impact in long-term cardiovascular events. Prospective studies are warranted to confirm this finding. Funding Acknowledgement Type of funding sources: None. Table 1

Background Primary cardiac tumors are extremely rare and are usually diagnosed late due to the nonspecific symptoms. Surgery is the main treatment option, and despite chemotherapy, the prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. The aim of this study was to review patients (P) with malignant cardiac tumors that were diagnosed by transthoracic echocardiogram (TTE) or transoesophageal echocardiogram (TOE) in a tertiary center between 1995 and 2020. Methods Retrospective analysis of clinical data, echocardiographic assessment of tumor location and morphology, histology results and survival outcomes. Results A total of 44 malignant cardiac tumors were diagnosed: 12 primary tumors (A) and 32 metastatic tumors (B). A: Regarding primary cardiac tumors, the most common types were angiosarcomas (6), undifferentiated pleomorphic sarcomas (2), fibrosarcomas (2), myxofibrosarcoma (1) and primary cardiac lymphoma (1). The mean age of P at time of diagnosis was 43±15 years, 50% male. The most frequent presentation was heart failure symptoms (50%) followed by arrhythmias (20%). 1 P presented with pruritus and polyarthralgias. On TTE, the most prevalent tumor location was in the right-heart chambers (70%) – mostly the right atrium (50%), with mean dimensions of 40±18x27±11 mm. 85% of P had preserved biventricular systolic function and there was severe pericardial effusion in 38%. The most frequent metastatic involvement at diagnosis was pulmonary (33%) and hepatic (33%). 50% of P were submitted to tumor resection and 40% to chemotherapy. Regarding angiosarcomas, the most common immunohistochemical markers were vimentin, CD31 and CD34. The authors found a mortality rate of 10P (83%) in P with primary cardiac tumors, with a median time to mortality of 5.5 (IQR 2–10) months (Figure 1), in a median follow-up of 6.2 (IQR 2.5–15) months (minimum of 20 days and maximum of 19 years). In the latter case, the P was submitted to heart transplantation after diagnosis of a fibrosarcoma and is still alive and well. B: Regarding secondary cardiac invasion, there was a diagnosis of the following primary tumor sites: 12 lung carcinomas, 7 thymomas, 4 lymphomas, 3 hepatocellular carcinomas, 2 bladder carcinomas, 1 parathyroid carcinoma, 1 soft tissue sarcoma, 1 uterine sarcoma and 1 melanoma. The mean age of P was 57±19 years, 57% male. On TTE/TOE the authors found a right-sided chambers predominance (12 P, 38%) vs left-sided chambers in (8 P, 25%), with pericardial metastasis also present in 13 P (41%). Cardiac tamponade occurred in 6P (19%). The mortality rate was 75% (24P), with a median time to mortality of 1.1 (IQR 0.6–3.8) months (minimum of 7 days, maximum of 44 months), in a median follow-up of 2.3 (IQR 0.8–14) months. Conclusion Cardiac malignant tumors generally present in a late stage with a dismal prognosis. When possible, heart transplantation can be an option with a favourable outcome. Funding Acknowledgement Type of funding sources: None. Figure 1. Kaplan-Meier analysis

Introduction Transthoracic Doppler echocardiography (TTE) remains the standard imaging method to evaluate cancer therapeutics-related cardiac dysfunction (CTRCD). 3D-TTE with strain analysis is a novel technique, proved useful for earlier detection of left ventricular (LV) function impairment. However, diastolic and left atrial (LA) function impact is less studied. Purpose To assess LA volumetric and LA strain (LAS) features by 3D-TTE in cardio-oncology patients. Methods A prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D and 3D-TTE. Standard 2D, 3D-TTE and LAS parameters were evaluated, including longitudinal (LALS) and circumferential strain (LACS) during conduit (cd), contraction (ct) and reservoir (r) phases. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). CTRCD was defined as an absolute decrease in 2D LVEF >10% to a value 15%, according to literature. P with previous cancer treatment, coronary artery disease, significant valvular disease, and atrial arrhythmias were excluded. Results 98 P (mean age 54.6±12.0 years-old), mostly treated with anthracyclines (78.6%, cumulative dose 268.2±77.6mg/m2), anti-HER (70.4%) and radiotherapy (80.6%) were included. 2D LV and LA volumes had a significantly raise from baseline to T1 (2D LVEDV 82.2±18.8 vs 91.9±18.8 mL, p=0.019 and LA 43.3±12.9 vs 49.8±13.3 mL, p=0.005). 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality. 2D GLS was also impaired at T1 (−19.9±2.6% vs −18.6±3.1%, p=0.009). During a mean follow-up of 14.1±8.1months, 31 P (31.6%) developed CTRCD. 3D LV and LA volumes also globally increased at T1 comparing to baseline with partially recovery at T2. Maximum LA volume was significantly higher at T1 (39.1±9.3 vs 43.6±10.6 ml, p=0.024). 3D LA ejection fraction (T0 53.7±9.7%, T1 53.4±8.6%, T2 49.9±8.6%, pT0-T2=0.039) and LAS values tended to progressively worse during TH. LA dilation (vol>34ml/m2) at baseline was correlated to dysfunction in contraction phase at T1 (LACSct −19.6±8.6 vs −17.3±4.6%, p=0.024). LACSr has substantially decreased from baseline to T2 (31.4±11.6 vs 27.0±10.4%, p=0.05). In univariate analysis, delta LALSr (T1-T0) was a predictor of CTRCD (mean −5.2% vs 1.9%, p=0.05). Conclusion CTRCD was frequent during the earlier phase of breast cancer treatment. LA function was also affected, mirroring LV volumetric and functional changes. Diastolic dysfunction, assessed through LA reservoir strain, was impaired in association with CTRCD. 3D-TTE usefulness in the surveillance and monitoring of CTRCD goes beyond systolic LV function assessment, allowing a detailed LA function analysis. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Introduction Identification of predictors of arrhythmia recurrence after catheter ablation of atrial fibrillation (AF) is a clinically relevant issue. Transthoracic echocardiography (TTE) is a readily accessible exam that can be useful in estimating left atrial (LA) mechanical function. The aim of this study was to evaluate LA structure and LA strain imaging at baseline and its association with AF recurrence after an index AF catheter ablation. Methods: Analysis of patients with symptomatic paroxysmal and persistent AF who underwent a single-procedure for AF ablation between 2015 and 2019 and had performed TTE in our centre prior to AF ablation. LA parameters were assessed by 2D speckle-tracking at baseline. LA diameter index (LAVi), LA ejection fraction, LA phasic strain: reservoir (LASr), conduit (LAScd) and contraction phases (LASct), as well as integrated backscatter (IBS) values were analysed. AF recurrence was documented with 12-lead ECG, 24h Holter monitoring, external loop recorder or pacemaker analysis during a 12-month follow-up period. Results: Of a total of 106 patients, 28 patients were excluded due to poor image quality. We studied 78 patients who underwent pulmonary veins isolation (PVI) (age 59 ± 14 years, 65% male, 40% with structural heart disease, 69% paroxysmal AF) with cryoballoon ablation in 53% and radiofrequency ablation in 47%. In a 12-month follow-up there was a 28% (22 patients) AF recurrence rate. Patients with AF recurrence had a baseline significantly superior LAVi (47 ± 17 mL/m2 vs. 36 ± 12 mL/m2, adjusted HR 1.04 [95% CI 1.01-1.06], p = 0.002) and lower estimated LA ejection fraction (25 ± 19.7% vs. 45.4 ± 21%, adjusted HR 0.96 [95% CI 0.94-0.98], p = 0.001). Multivariate analysis showed that baseline LA strain parameters were independent predictors of AF recurrence, as patients with AF recurrence showed impaired LASr (9.81 ± 5.79% vs 22.94 ± 9.98%, adjusted HR 0.81 [95% CI 0.73-0.89], p

Funding Acknowledgements Type of funding sources: None. Introduction Serial echocardiographic assessment of 2D left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) is the gold standard screening method for cancer therapeutics-related cardiac dysfunction (CTRCD). Non-invasive left ventricular (LV) pressure-strain loop (PSL) provides a novel method of quantifying myocardial work (MW) with potential advantages, as it incorporates measurements of myocardial deformation and LV pressure. Purpose To evaluate the impact of cardiotoxic treatments in MW indices. Methods Prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D, 3D transthoracic echocardiography (TTE) and concomitant blood pressure assessment. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). PSL analysis allowed the calculation of the following indices: Global Work Index (GWI), Global Constructive Work (GCW), Global Work Waste (GWW) and Global Work Efficiency (GWE). CTRCD was defined as an absolute decrease in 2D LVEF > 10% to a value < 54% or a relative decrease in 2D GLS > 15%, according to literature. Results 122 patients (mean age 54.7 ± 12.0 years), mostly treated with anthracyclines (77.0%, cumulative dose 268.6 ± 71.8mg/m2), anti-HER (75.4%) and radiotherapy (77.0%) were included. 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality (2D LVEF T0-T1 64.2 ±7.6 vs 61.1 ± 8.2%, p = 0.006 and 3D LVEF T0-T1 60.2 ± 6.7 vs 56.9 ±6.3%, p = 0.022). 2D GLS was also more impaired at T1 (-19.8 ± 2.7% vs -18.5 ± 3.0%, p = 0.003). All MW indices were significantly reduced at T1 compared to baseline (GWI 1756.9 ± 319.2 vs 1614.3 ± 338.5mmHg%, p = 0.005; GCW 2105.6 ± 352.0 vs 1970.5 ± 376.2 mmHg%, p = 0.015; GWW 121.1 ± 66.6 vs 161.1 ± 84.1 mmHg%, p = 0.001; GWE 93.5 ± 3.1 vs 91.1 ± 4.5%, p = 0.001). Between T1 and T2 no statistical difference was found but a partial recovery of parameters was observed when comparing T2 to T0 (GWI (T2) 1650.6 ± 357.5 mmHg%, p = 0.035; GCW (T2) 2013.3 ± 379.3 mmHg%, p = 0.086; GWW (T2) 148.0 ± 85.0 mmHg%, p = 0.02 and GWE (T2) 92.0 ± 4.7%, p = 0.012). During a mean follow-up of 14.9 ± 9.3 months, 36 patients (29.5%) developed CTRCD. P presenting CTRCD revealed a significant decrease in GWI and GWE at T1 comparing with women without CTRCD (GWI 1.8 ± 21.6 vs -14.2 ± 18.5%, p = 0.004 and GWE -1.0 ±3.0 vs -3.6 ±3.9%, p = 0.005). GWW had a substantially increase at T1 in P with cardiotoxicity (27.6 ± 76.3% vs 64.1 ± 68.0%, p = 0.051). Conclusion Left ventricular systolic function study with MW showed a reduction in cardiac performance with a peak at 6 months from the start of chemotherapy and partial recovery after term. Assessment of myocardial deformation parameters, namely MW, proved to be a useful tool for a better characterisation of cardiac remodelling, and could enhance patient selection for cardioprotective therapeutics. Abstract Figure. TTE parameters

Aims Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) adds prognostic information in patients with hypertrophic cardiomyopathy (HCM). Whether Myocardial work (MW), a new parameter on transthoracic echocardiographic (TTE), can predict significant fibrosis in HCM patients is unknown. Methods Single-centre evaluation of consecutively recruited HCM patients in which TTE and CMR were performed. MW and related indices were calculated from global longitudinal strain (GLS) and from estimated left ventricular pressure curves. The extent of LGE was quantitatively assessed. LGE ≥15% was chosen to define significant fibrosis. Logistic regression analysis was used to find the variables associated with LGE ≥15% and cut-off values were determined. Results Among the thirty-two patients analysed mean age was 57±16 years, 18 (56%) were male patients and the mean left ventricular ejection fraction by TTE was 67±8%. Global constructive work (GCW), global work index and GLS were significant predictors of LGE ≥15%. A cut-off ≤1550 mmHg% of GCW was able to predict significant fibrosis with a sensitivity of 92% and a specificity of 79%, while the best cut-off for GLS (>−15%) had a sensitivity of 86% and a specificity of 72%. Conclusion GCW was the best parameter to predict significant left ventricular myocardial fibrosis in CMR, suggesting its utility in patients who may not be able to have a CMR study. Myocardial Work and LGE in CMR in HCM Funding Acknowledgement Type of funding source: None

Background The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information. Purpose To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis. Methods 94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull's eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio. Results Mean age was 82.2±5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57±15% and 26.6% presented EF1 was identified in 22 P (23.4%). An EF/GLS ratio >4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4±25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred. The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p=0.002) and MACE (48.7% vs 22.2%, p=0.01). RALS>1 correlated also with all-cause mortality (31.8% vs. 12.5%, p=0.04) and with new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p=0.05). P with GLS>−14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p=0.003) and MACE (p=0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR=4.49, p=0.039). Conclusions Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation. Funding Acknowledgement Type of funding source: None

Case Report A 53-year-old female patient from the North Region of Brazil with a past medical history of Chagas Disease (CD) with esophageal involvement and permanent atrial fibrillation (AF) presented to the Emergency Department (ED) due to complaints of retrosternal discomfort and dizziness. The patient reported multiple recent syncopal episodes and had performed a recent 24-hour Holter monitoring revealing AF with predominantly slow ventricular rate and frequent ventricular premature beats. Her sister had recently been diagnosed with obstructive hypertrophic cardiomyopathy. During the ED stay, the patient developed a syncopal monomorphic ventricular tachycardia, requiring synchronized electrical cardioversion. Post cardioversion EKG revealed a sinus rhythm with a right bundle branch block, left anterior fascicular block and 1st degree AV block. The patient was admitted in the Cardiology Department for further investigation. Transthoracic echocardiogram revealed a dilated left ventricle with a reduced systolic function (LVEF of 38%, GLS of -7.1%), with an aneurysm of the basal inferior and posterior walls and a markedly dilated left atrium (68mL/m2). Cardiac magnetic resonance imaging showed a marked dilation of both atriums and ventricles, with biventricular systolic dysfunction, hypertrabeculation of the left ventricular wall and the presence of diffuse intramural and subepicardic fibrosis. These features were compatible with chagasic cardiomyopathy. Due to biventricular systolic dysfunction, the documentation of AV conduction disturbance, the natural history of the disease and the need for antiarrhythmic therapy, the patient underwent cardiac resynchronization therapy–defibrillator implantation. 1 week after the procedure, the patient experienced an arrhythmic storm with a total of 6 CRT-D shocks. Amiodarone was initiated and beta-blocker was titulated to the maximum tolerated dose, with no recurrence of ventricular tachycardia. On the 3 month follow-up visit the patient denied symptoms of congestive heart failure. Device interrogation revealed a high percentage of biventricular pacing and no arrhythmic events. Conclusion This case describes the most remarkable and characteristic features of chagasic cardiomyopathy. It is almost always progressive and is associated with a worse outcome comparing with other cardiomyopathies. The prevalence of CD is growing in traditionally nonendemic areas and its timely recognition is fundamental.

Introduction The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients. Case report We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock. Conclusion Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.

Background Surgical mitral valve repair currently remains a good option in both organic or functional mitral valve regurgitation (MVR). However, a significant number of patients (P) have comorbidities that can contribute to adverse outcomes. Objective To determine clinical and echocardiographic predictors of adverse outcomes in P submitted to MV repair surgery in our center, notably MVR recurrence and new MV replacement surgery or all-cause mortality. Methods Retrospective analysis of 262 P who underwent MV repair surgery between 2008 and 2017, with a mean follow-up of 30 months. P were included with both organic or functional MV regurgitation. P who underwent simultaneous coronary artery bypass grafting (CABG), atrial fibrillation (AF) surgery and tricuspid valve repair were also included. However, P with simultaneous surgical aortic valve replacement or previous endocarditis were excluded and the remaining 204 P were analysed. We evaluated whether MVR etiology, simultaneous surgery (tricuspid valve repair, AF or CABG), body mass index (BMI), gender, chronic obstructive pulmonary disease (COPD), diabetes mellitus, renal dysfunction (measured by serum creatinine levels), baseline left ventricular ejection fraction (LVEF) and left ventricle end-diastolic diameter (LVED) were predictors of a composite endpoint (follow-up MV replacement surgery or all-cause mortality) and secondary endpoints: MV replacement surgery and all-cause mortality. Results 204 P who underwent MV repair surgery, 67.2% male, mean age of 62 ± 14 years. 80.4% had organic MVR and 19.6% functional MVR (mostly ischemic – 72.4%). 7P (3.4%) had rheumatic MVR. 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation. 30-day mortality was 0%. The composite endpoint occurred in 40P (20%) and there was MVR recurrence with follow-up MV replacement surgery in 15P (7.5%) and all-cause mortality in 28P (13.7%). The authors found that elevated serum creatinine levels (OR 4.66; p = 0.003), COPD (OR 3.00; p = 0.035) and functional etiology (OR 2.22; p = 0.049) were predictors of the composite endpoint. Both COPD (OR 2.823; p = 0.024) and renal dysfunction (OR 6.901; p = 0.001) were also found to be independent predictors of all-cause mortality. Simultaneous CABG was a predictor of all-cause mortality (OR 2.82; p = 0.024). Female gender was a predictor of future MV replacement surgery (13.4% vs 4.7%, p = 0.023). However, echocardiographic variables (baseline LVEF and LVED) were not found to be significant predictors of adverse outcomes in MV repair surgery. Likewise, simultaneous AF or tricuspid valve surgery, rheumatic/ischemic etiology, high BMI or diabetes were not associated with poorer prognosis. Conclusion In P undergoing MV repair surgery, renal dysfunction and COPD were independent predictors of all-cause mortality. Functional etiology and simultaneous CABG surgery were also predictors of adverse outcomes. Baseline LVEF and LVED were not correlated with prognosis.

Introduction Serial echocardiographic assessment of 2D/3D left ventricular ejection fraction (LVEF) and 2D global longitudinal strain (GLS) is the gold standard for screening for cancer therapeutics-related cardiac dysfunction (CTRCD). Although 3D speckle tracking echocardiography (STE) has several technical advantages, is more reproducible, and has a better correlation to magnetic resonance than 2D STE, it is still not currently used in this setting. We aimed to investigate the usefulness of 3D STE in evaluating left ventricle mechanics and its relation to CTRCD. Methods Prospective study of female breast cancer patients submitted to anthracycline chemotherapy who underwent one transthoracic echocardiography (ETT) before and at least one ETT during/after chemotherapy. Standard ETT parameters and 3D volumetric measurements were assessed. STE was used to estimate 2D GLS – average and 18 segments – and 3D GLS, global circumferential strain (GCS), global radial strain (GRS) and global area strain (GAS) – average and 17 segments. CTRCD was defined as an absolute decrease in 2D or 3D LVEF >10% to a value 15%. Results 105 patients (mean age 53.8 ± 12.5 years, 52.4% immunotherapy, 77.2% radiotherapy, 2.8 echocardiograms/patient) were included. During a mean follow-up of 12.1 months, 24 patients (22.9%) developed CTRCD. During anthracycline therapy, there was a significant worsening of 2D LVEF (65.6 vs. 57.8), 3D LVEF (61.5 vs. 54.4), 2D GLS (-21.1 vs. -18.0), 3D GLS (-15.6 vs. -10.9), 3D GCS (-14.0 vs. -11.0), 3D GRS (42.0 vs. 28.5) and 3D GAS (-27.0 vs. -20.0) [all p Conclusion 3D strain parameters worsened during anthracycline therapy, with predominant involvement of septal, anterior and inferior walls. Variations of 3D GCS and GRS were predictive of subsequent CTRCD, and thus can be considered an earlier sign of CTRCD, with added value over the currently recommended 2D/3D LVEF and 2D GLS. Routine application of this technique should be considered in order to offer targeted monitoring and timely initiation of cardioprotective treatment.

Background Although heart disease in haemoglobinopathy have dramatically reduced with modern therapy, cardiac complications are still a leading cause of morbimortality. It became essential to detect cardiac complications in early stages in order to provide specific therapy and to improve prognosis. Transthoracic echocardiography (TTE) has a paramount role in this field. Purpose To evaluate cardiac function in haemoglobinopathy patients and to correlate echocardiographic parameters with haematological determinants. Methods Retrospective analysis of haemoglobinopathy patients (pts) referred to a tertiary centre for cardiac evaluation and transthoracic echocardiography. Epidemiological, clinical, laboratory and echocardiographic data were analysed. Comparations between echocardiographic data and haemoglobin and serum ferritin levels were performed (independent T test). P value Results 55 pts were included: 58% female, mean age 37.9 ± 10.9 years, 85% with sickle cell disease, 13% (N = 7) with previous thromboembolic event and 20% (N = 11) with documented hemosiderosis. 36% (N = 20) were symptomatic (9 pts with palpitations, 6 pts with thoracic pain and 5 pts with exertion dyspnea – New York Heart Association class II). The mean haemoglobin level was 8.96 ± 1.91 g/dL and serum ferritin 1335.5 ± 2452 ng/mL. All patients had preserved left and right ventricular systolic function (TAPSE 27.1 ± 4.9mm) The mean left ventricular (LV) end-diastolic diameter indexed to body surface area (female 32.2 ± 4.7mm/m2; male: 31.2 ± 4.0mm/m2) and LV mass index (female 105.6 ± 31.4g/m2; male: 134.7 ± 97.3g/m2) were increased in both genders, although interventricular septum thickness was in the superior normal range (mean 9.3 ± 1.6mm). Left atrium enlargement was also present (29.9 ± 8.4mm/m2). The mean global ratio between early mitral inflow velocity and mean (septal and lateral) mitral annular early diastolic velocity (E/e") was 7.5 ±2.3, and 12 pts (21.8%) had impairment of LV diastolic function. Global longitudinal strain (GLS) was assessed in 35 pts, with a mean value of 19.6 ± 2.9%. 40% (14 pts) had GLS > -18%, being the septal wall the most frequently affected. Pulmonary hypertension was rare (3 pts), with mean arterial pulmonary pressure of 27.7 ± 7.0mmHg. An agreement was found between serum ferritin levels and GLS impairment defined as GLS > -18% (2649ng/ml vs 549ng/ml, p = 0.04). Pts with diastolic dysfunction had a trend to higher serum ferritin levels (2753ng/ml vs 1001ng/ml, p = 0.06). The haemoglobin levels did not correlate with echocardiographic parameters. Conclusion In the study population of haemoglobinopathy pts, mainly constituted by cardiac asymptomatic individuals, LV diastolic dysfunction and LV global longitudinal strain were impaired in 22% and 40%, respectively. These echocardiographic parameters revealed to be related to serum ferritin levels.

Background Mitral regurgitation (MR) is a marker of bad prognosis in heart failure (HF) patients (pts). Mitraclip implantation (MI) leads to a clinical improvement. Purpose To characterize the adult population submitted to MI and evaluate its mid-term results. Methods Prospective analysis of 40 pts with moderate to severe MR (grades III-IV) submitted to MI between 2013 and 2018. Paired sample t-test to assess the procedure’s effect on several variables. P-values Results 40pts, 60% male, with a mean age of 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months (M), of which 67.5% presented with grade IV MR (mean regurgitant volume - 43.5 ± 29 ml; mean EROA - 34.8 ± 13 mm2 ) and 75% with functional MR. Mean LVEF of 35%±10.3, with 55% presenting a LVEF Conclusion MI is a safe procedure with a low rate of periprocedural complications. It’s associated with a functional class improvement and a significant reverse left ventricular remodeling.

Introduction Thymoma is the most common primary neoplasm of the anterior mediastinum. Most invasive thymomas are limited to the pericardium. Only few cases of transcaval extension with intracardiac involvement have been reported. Case report We present the case of a 15-year-old boy with previous history of infectious cerebelitis without neurologic sequelae. He presented with interscapular pain for 6 weeks (not improving with symptomatic therapy) and fever for 3 days. On admission, chest radiograph exhibited an opacification in the right hilum (Figure A). He was discharged with antibiotic prescription for presumptive pneumonia. Due to persistence of complaints he was revaluated after 5 days. Signs of superior vena cava (SVC) syndrome were noted. A computerized tomography showed a large soft tissue mass of the anterior mediastinum, in right antero-lateral topography, measuring 12.5x10x9.5 cm with central calcification and extension to the right lung (Figure B). Transthoracic and transoesophageal echocardiography showed an anterior mass compressing the pulmonary artery branch (PA) and SVC with marginal invasion of the right atrium (RA) (Figure C and D). Cardiac MRI confirmed a large mass of the anterior mediastinum with extension and invasion of the right superior lobe, invasion of the superior vena cava with extension into the RA (Figure E). Transthoracic core-needle biopsy was performed and histopathological diagnosis confirmed an invasive thymoma. The case was discussed at joint cardiothoracic surgery and oncology multidisciplinary meeting and it was agreed to neoadjuvant chemotherapy regimen followed by surgery. Intraoperatively, a large tumor invading the SVC and proximal RA was found, in accordance with the echocardiographic and MRI findings. Due to unforeseen metastatic implants on the adventitia of the main PA and ascending aorta, resection of the tumor was not performed. Palliative decompression of the venous system was performed with interposition of a ringed vascular prosthesis between the left brachiocephalic vein and the right atrial appendage. (Figure F). The patient received postoperative radiotherapy and is asymptomatic without signs of SVC syndrome for 3 months. Discussion and conclusion This report illustrates a rare case of an invasive thymoma with extension to cardiac structures. Multimodality imaging for quality decision-making was imperative in the management and for surgical planning of this case. Transthoracic and transoesophageal echocardiography remain the exams of choice for the diagnosis of intracardiac disease. As demonstrated, a high index of suspicion is needed because clinical symptoms are unspecific and late diagnosis of potentially resectable tumors are associated with a poor prognosis. Abstract P1250 Figure. Multimodality imaging

Introduction Sacubitril/Valsartan (LCZ696) significantly reduced sudden cardiac death in the PARADIGM-HF trial. However, there is little published data regarding the possible explanations for the antiarrhythmic effects found with LCZ696 therapy. Previous trials have shown that mechanical dispersion by strain echocardiography can predict arrhythmic events in Heart Failure (HF) patients. The aim of this study was to compare electrocardiographic (ECG) parameters and mechanical dispersion index with left ventricular (LV) global longitudinal strain (GLS) analysis before and after LCZ696 therapy. Methods Prospective evaluation of chronic HF patients with LV ejection fraction ≤ 40% despite optimized standard of care therapy, in which LCZ696 therapy was started and no additional HF treatment was expected to change. ECG and transthoracic echocardiographic data were gathered in the week before starting LCZ696 therapy and 6 months after therapy. A semiautomated analysis of LV GLS was made and mechanical dispersion index was defined as the standard deviation from the 16 time intervals corresponding to each LV segment. Results Of the 42 patients, 35 (83.3%) completed the 6 months of follow-up, since 2 (4.8%) patients died and 5 (11.9%) discontinued treatment for adverse events. Mean age was 58.6 ± 11.1 years. QTc interval (451.9 vs 426.0msec, p Conclusion LCZ696 therapy is associated with antiarrhythmic effects with a reduction in QTc and QRS intervals in ECG and a reduction in mechanical dispersion index as assessed by LV GLS. Abstract P1433 Figure.

Introduction Primary cardiac tumors are rare entities and 75% are benign. Angiosarcoma is the most common malignant primary cardiac tumor. We report the case of cardiac angiosarcoma presenting with an atrial arrhythmia. Clinical case A 39-year-old female patient with no past medical history presented to the emergency department with heart palpitations and atypical chest pain. Electrocardiogram on admission showed atrial flutter with a heart rate of 153 beats per minute. Laboratory analysis were performed showing elevated D-dimer levels (2210 ug/L). A thoracic CT scan was performed, which ruled out pulmonary embolism, but showed multiple pulmonary nodules and a right atrial (RA) mass measuring 48 mm that could correspond to a thrombus or neoplasia. The patient was admitted in the Cardiology ICU of our hospital and was started on beta-blocker and amiodarone with conversion to sinus rhythm. Additional exams were performed: - Transthoracic echocardiogram (TTE) revealed an heterogenous 32,6 x 17,7 mm mass in the lateral wall of the RA with an adherent mobile mass near the tricuspid valve with 28 mm diameter (possible adherent thrombus). - Cardiac magnetic resonance imaging confirmed a RA tumor with invasion of the atrial free wall and compression of the superior vena cava. Due to the unclear etiology of the RA mass, ultrasound-guided intracardiac biopsy was performed. Pathological examination revealed spindle cell proliferation, consistent with the diagnosis of angiosarcoma. Immunohistochemical staining was positive for Vimentin, CD34 and CD31, with 70% Ki67 expression. Later on, the patient developed melena with significant drop of hemoglobin levels, requiring daily red blood cell transfusions and anticoagulation had to be stopped. The patient was transferred to the Internal Medicine ward and thoracic-abdomen-pelvis staging computed tomography (CT) scan showed a significant increase in the number of pulmonary nodules, bilateral ovarian masses, 4 hepatic nodules and ileum metastization. During hospitalization, the patient developed right leg deep venous thrombosis and thoracic CT scan revealed bilateral pulmonary embolism. After improvement of the clinical status, palliative chemotherapy was started and the patient was discharged, maintaining regular outpatient follow-up in the Oncology Department for 1 month. Cardiac angiosarcoma generally presents in a late stage of the disease with metastatic involvement. When surgical treatment is not possible, despite agressive chemotherapy, the prognosis remains poor. Abstract P229 Figure. Echocardiogram: right atrium mass

Background Transeophageal echocardiography (TEE) is an essential tool to diagnose cardiac source of embolism (CSE) and to define treatment approach. Purpose: To review the identified CSE in 25 years experience in TEE at a tertiary centre. Methods: Retrospective study of consecutive patients (pts) who underwent TEE to search for CSE, from 1994 to 2019. Results: 2936 pts (55% males, mean age 53 ± 13 years). Ischemic cerebral event (96%) was the main location of embolism. TEE identified potential CSE in 41.5% and 7% had more than one diagnostic. The most frequent CSE were patnt foramen ovale (PFO) (16.3%) and atrial septal aneurysm (ASA), among these 65% had concomitant PFO or atrial septal defect (ASD) (14.1%). Aortic plaques ≥ 4mm were noted in 9.6%, followed by valve disease or prosthesis (5.4%), intracavitary thrombi (3.9%), vegetations (1.6%), ASD (1.5%), dilated cardiomyopathy (1.4%) and tumors (0.7%). In the last 15 years, the diagnostic effectiveness increased (35.6% vs 45.95%) and there was a shift in etiologies with an increased in the diagnose of PFO/ASD (26.8% vs 38.5%) and valve disease or prosthesis became less frequent (29.9% vs 3.7%). Overall, in elderly pts there was a preponderance of atherosclerotic plaques in the aorta, contrasting with younger pts who presented a predominance of PFO (Table1). The prevalence of spontaneous echo contrast increased with age. Pts with ischemic cerebral event were younger, mostly male and PFO was the main source of embolism (17%), while in pts with peripheral embolism the most frequent etiologies were intracavitary trombi (16%) and aortic plaques ≥ 4mm (14%). Conclusion: The main cause to perform a TEE to search for CSE was cerebral embolism, with a diagnostic effectiveness overall of 41.5%, that increased in the last 15years. Table 1 Characteristics

Introduction Dobutamine stress echocardiography (DSE) is an established exam for evaluation of extent and severity of coronary artery disease. Purpose To analyse the results and complications of DSE and identify prognostic predictors in patients (P) who underwent DSE for myocardial ischemia detection. Methods 220P who underwent consecutive DSE from 2013 to 2017. P with significant valvular disease were excluded. Clinical data, echocardiographic parameters and data from follow up (FU) regarding all-cause mortality and MACEs were analysed. Mean age 64.8 ± 12.0 years(Y), 143 men (65%). Results 88P (40%) had positive, 102 had negative and 30 had inconclusive DSE; complications rate of 15%. Prevalence of hypertension, diabetes mellitus (DM), dyslipidemia, prior MI, percutaneous coronary interventionc (PCI), coronary arterial bypass graft (CABG) and HF was 82.7%, 42.3%, 67.7%, 35.9%, 31.8%, 10.9% and 9.5%, respectively. Mean left ventricular endsystolic (LVSD) and enddiastolic dimensions were 33.7 ± 8.9 and 52.8 ± 7.1 mm. Mean resting wall motion score index (rWMSI) and peak (pWMSI) were 1.16 ± 0.28 and 1.24 ± 0.34. Mean resting GLS (rGLS) and peak GLS (pGLS) were -16.3 ± 4.3 and -16.6 ± 4.3. Mean no. of ischemic segments was 1.7 ± 2.4 and 16.8% had ischemia >3 segments. There was ischemia in left anterior descending (LAD) coronary in 53P and in circumflex and right coronary territories in 18 and 68P. 22.6% had more than one ischemic territory. 43P (49.4%) underwent intervention, 38 with PCI and 5 with CABG. During a mean FU of 38.8 ± 16.8 months, 47 MACEs were observed, including 32 deaths (14.5%). Positive DSE (p = 0.012), no. of ischemic segments (p = 0.019), ischemia in the LAD (p = 0.003), rGLS (p = 0.038) and pGLS (p = 0.038) were related to the occurrence of MACEs. In Cox regression analysis, age (p = 0.005), DM (p = 0.005), HF (p = 0.006), prior CABG (p = 0.015), LVSD (p = 0.026), rWMSI (p = 0.029), pWMSI (p = 0.013) and pGLS (p = 0.038) were associated with increased all-cause mortality. Kaplan–Meier survival analysis showed that survival was significantly worse for ischemia > 3 segments (log rank 0.005), ischemia of more than one territory (log rank 0.025) and pWMSI >1.5 (log rank 65Y (HR 4.22, p = 0.004), DM (HR 2.49,p = 0.038) and pWMSI > 1.5 (HR 9.73,p = 0.007) were independently associated with all-cause mortality. Conclusion In patients who underwent DSE there were some baseline and DSE-related independent predictors of long-term prognosis: age, DM and peak WMSI. Abstract P1787 Figure. Kaplan–Meier curves

Introduction Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR. Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms. Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic. Conclusion Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.

Introduction Arteriovenous coronary fistulae are a rare coronary anomaly, which can be congenital or acquired. They can be diagnosed in older adults with heart failure symptoms, atherosclerosis or cardiac arrhythmias. The authors report the case of an adult patient with an extremely large coronary artery fistula of the left main coronary artery (LMCA). Clinical case A 57-year-old caucasian male with known background of arterial hypertension, obesity, pulmonary emphysema and bronchiectasis presented to a Cardiology outpatient appointment with symptoms of congestive heart failure and new-onset atrial fibrillation. A transthoracic echocardiogram was performed which revealed a possible coronary fistula with multiple rosary-like folds between the LMCA and the coronary sinus. Other echocardiographic findings were left ventricular and biatrial enlargement with biventricular systolic dysfunction (left ventricular ejection fraction 44%) and a GLS of -7.8% as well as mild pericardial effusion. The patient was referred to our hospital for further diagnostic work-up and clarification of the coronary anatomy. A cardiac computed tomography (CT) scan was done which showed ectasia and calcification of the LMCA, left anterior descending and circumflex arteries and a large caliber tortuous coronary fistula between the LMCA, the right atrium and the coronary sinus comprised of multiple folds covering from the pulmonary artery to the left atrium. A coronary artery angiography was also performed, which confirmed the detailed anatomy and dimensions of the coronary fistula. Follow-up magnetic resonance imaging revealed dilation of both left and right cardiac chambers with no significant shunt (QP/QS = 1) The patient was started on heart failure medical therapy and was referred to the Cardiac Surgery Department and is currently asymptomatic awaiting for surgical correction of the coronary fistula. Abstract P1330 Figure. CT scan: large caliber coronary fistula

Background Mitraclip implantation (MI) is a well-established option for patients (P) with severe mitral regurgitation (MR) noneligible to surgery. Its impact on long term prognosis is being addressed by several recent studies. Purpose To identify predictors of morbidity and mortality in P undergoing MI and evaluate if the COAPT, Everest and MITRAFR exclusion criteria (EC) had any impact on the outcome of our population. Methods prospective study of P who underwent MI between 2013 and 2018 in one medical center. EC: COAPT: LVEF 70mm or pulmonary artery systolic pressure > 70mmHg; Everest: LVEF 55mm; MITRA-FR: LVEF 40% or primary MR. An univariate analysis was performed followed by a multivariate Cox analysis to evaluate overall mortality (M), overall mortality/ heart failure hospitalization (MH) and mortality in the first year post-MI(M1). Survival analysis using Kaplan-Meier plots. p Results 40P, 60% male, mean age 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months. 67.5% presented with MR grade IV and 75% had functional MR. Successful implantation in 97.5%, with 55% presenting mild MR post-procedure. Overall mortality was 30% (12P), mostly due to cardiovascular causes, with 9P dying in the first year (30%). There was no difference between pts with functional and primary MR: M- 33%vs20% (p = 0.6); MH– 53.3%vs30% (p = 0.5). P who met the COAPT exclusion criteria (N-22) presented an inferior 1Ysurvival (64.5%vs86.7%, p = 0.046). The overall outcome was comparable between P who matched and didn"t match Everest and MITRA-FR exclusion criteria. Basal BNP value (p = 0.037), mean preprocedural MAGGIC score (p = 0.040) and EROA (p = 0.039) were associated to M1. Multivariate Cox analysis revealed that basal BNP was an independent predictor of M (p = 0.017), whereas a higher distance in the pre-procedural 6 minute walk test (p = 0.008) and the "reduction in the MR severity and PASP" (p = 0.008) presented a protective effect. LVESD > 55mm was an independent predictor of MH (p = 0.017), but MR of grade 2 or less after procedure was protective (p = 0.006). Conclusion There was no M difference between P with functional and primary MR. P with COAPT exclusion criteria had worse 1Ysurvival. A higher distance in 6MWT and a reduction in MR severity and PASP were protective. An LVESD > 55 mm had a worse prognosis. Careful P selection may be crucial to improve MI"s results Abstract P198 Figure. Kaplan-Meier Plots

Rendu-Osler-Weber (ROW) syndrome or hereditary hemorrhagic telangiectasia is a rare autossomic dominant disease characterized by vascular dysplasia involving multiple systems and associated with an increased bleeding risk. The presence of atrial fibrillation in this population becomes a challenge, regarding the evaluation of bleeding and thrombotic risks and the best approach for the patient management. A 72 years-old female with ROW syndrome, atrial fibrillation and a CHA2DS2-VASc risk score of four, was admitted to our hospital for left atrial appendage (LAA) closure after a period of novel oral anticoagulation crowed with multiple haemorrhagic events and blood transfusions. After the implantation of a Watchman LAA number 33 closure device (Image 1A), and because of the concomitant diagnose of chronic pulmonary embolism, she was restarted on anticoagulation therapy in lower doses, with initial tolerance. For evaluation of LAA closure device during follow-up, after an unsuccessful attempt of transoesophageal echocardiography (TEE) because of severe epistaxis subsequent to oropharyngeal anaesthesia, the patient underwent a Cardiac Computed Tomography (CT) that showed a moderate peri-device leak (4.4x11mm, 0.73cm2) – (Image 1B). For better characterization, the patient underwent a new attempt of TEE with the support of an anaesthesiologist and the need of local vasoconstrictor agents and tranexamic acid for epistaxis and oropharyngeal bleeding control. TEE confirmed a moderate posterior device-leak (7.1mm) with absence of cavitary thrombus (Image 1C). After a year of anticoagulation with new significant bleeding events, TEE was repeated with the anaesthetic and pharmacologic preparation. This TEE showed a decrease in peri-device leak ( Abstract P182 Figure. Image 1

Background Myocardial strain analysis is a tool that allows a more precise assessment of cardiac performance. However, strain is relatively load dependent. New tools have been developed, with afterload adjustment. It was our objective to assess myocardial work (MW) in patients with repaired aortic coartation (ACo). Methods Study of consecutive adult patients with corrected ACo submitted to a routine transthoracic echocardiogram in 2018 at our centre. Patients with an aortic valve prosthesis, more than mild aortic stenosis / regurgitation, with pacemakers, with other non-corrected congenital heart diseases (with the exception of bicuspid aortic valve) were excluded from the analysis. A semi-automated strain analysis was performed with speckle tracking technology and both global longitudinal strain (GLS) and MW were estimated using GE software™. Blood pressure was simultaneously measured in the patient’s right arm. We specifically assessed: Global Work Index (GWI), Global Constructive Work (GCW), Global Work Waste (GWW) and Global Work Efficiency (GWE) Results Twenty patients were included in the study, mean age of 36 ± 9 years, 30% males. Mean body surface area was 1.7. In this group of patients, 40% were hypertensives and in 55% there was a concomitant bicuspid aortic valve. Mean maximum aortic valve gradient was 11 mmHg and mean descending aortic gradient was 19 mmHg. Compared to recently published reference values for a normal population, repaired ACo patients had lower values of MW (Table). In multivariate linear regression analysis, independent predictors of GWI are systolic blood pressure (β=0.441) and let atrial volume indexed (LAVI) (β=0.507). For GCW, male gender (β=-0.605), LAVI (β=0.530) and diastolic blood pressure (β=-0.742). For GWE, the only predictor was LAVI (β=0.498) and no predictor was identified for GWW. The presence of bicuspid aortic valve, aortic valve gradient and descending aortic gradient did not have any influence in MW parameters, although higher aortic valve gradients were excluded from this study. Conclusion Adult patients with repaired ACo, present lower MW indices and the main determinant for that difference are LAVI and blood pressure. GWW is the most independent parameter. Results Variable Reference population n = 226 Patients with repaired ACo n = 20 p-value GWI (mmHg%) 1896 ± 308 1782 ± 389

Background The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information. Purpose To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis. Methods 94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull’s eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio. Results Mean age was 82.2 ± 5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57 ± 15% and 26.6% presented EF 1 was identified in 22 P (23.4%). An EF/GLS ratio > 4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4 ± 25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred. The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p = 0.002), new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p = 0.05) and MACE (48.7% vs 22.2%, p = 0.01). All-cause mortality was also higher in P with RALS (31.8% vs. 12.5%, p = 0.04). P with GLS>-14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p = 0.003) and MACE (p = 0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR = 4.49, p = 0.039). Conclusions Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation. Abstract 1226 Figure. Kaplan–Meier curves and ASPB

Background Mitral valve regurgitation (MVR) represents the second most frequent valvular heart disease. MV surgical repair is often the preferred treatment when MV anatomy is suitable. Purpose To characterize the population who underwent MV repair surgery and evaluate the outcomes of residual MVR, allcause mortality and functional classification. Methods Retrospective analysis of 262 patients (P) admitted between 2008 and 2017 for MV repair surgery. P who undergone simultaneous coronary artery bypass graft (CABG) surgery, atrial fibrillation (AF) surgery and tricuspid valve repair were also included. P with endocarditis, P who underwent simultaneous aortic valve replacement and P with rheumatic predominant MV stenosis were excluded, the remaining 204 P were analysed. Clinical and echocardiographic characteristics were evaluated in a mean follow-up of 30 months. Results 204 P, 67.2% male, mean age 62 + 14 years. The most frequent etiology was organic (80.4%), mostly of degenerative cause. Functional etiology was present in 19.6%, mostly ischemic (72.4%). 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation. Hypertension was significantly associated with functional etiology (90% vs 72.8%, p = 0.022), as well as hypercholesterolemia (80% vs 48.2%, p 50% in 78.4%, reduced (30-50%) 18.1% and poor ( Functional etiology was significantly associated with LVEF 161P (78.9%) had MV prolapse: 120P (74.5%) posterior, 29P (18%) anterior and 7.4% (12P) of both leaflets. P2 was the most frequently involved scallop, in 92P (57.1%), followed by P3, in 41P (25.4%). There was MV chordae rupture in 94P (58.3%). Post-surgery echocardiography revealed that 93.8% had mild or no residual MVR. 30-day mortality rate was 0%. There was MVR recurrence with MV replacement surgery in 15P (7.5%), mean time 37.1 months. All-cause mortality was registered in 28P (13.7%), with a mean time of 43.7 months after MV surgery. Of the P without MVR recurrence or mortality, 111P (70%) were in NYHA class I, 41P (26%) in NYHA class II and 6P (4%) in NYHA class III. 6P were lost to follow-up. Upon echocardiographic revaluation there was no residual MVR in 53P (39%), mild MVR in 67P (49%) and moderate MVR in 16P (11.8%). Conclusion In P who underwent MV repair surgery, there was 7.5% recurrence rate with follow-up MV replacement surgery and an all-cause mortality of 13.7%. In a mean follow-up of 30 months, 70% of P were in NYHA I class and there was none or mild residual MVR in 88% of P.

Background Primary cardiac tumors are extremely rare and are usually diagnosed late due to the non-specific symptomatology. Surgery is the main treatment option and despite chemotherapy, the prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. Purpose To review patients (P) with malignant cardiac tumours that were diagnosed by transthoracic echocardiography (TTE) or by transesophageal echocardiogram (TEE) in a tertiary center between 1997 and 2019. Methods Retrospective analysis of clinical data from the digital files, echocardiographic assessment of tumor location and morphology, histology results and survival outcomes. Results A total of 33 malignant cardiac tumors were diagnosed: 12 primary tumors (A) and 21 metastatic tumors (B). A Regarding primary cardiac tumors, the most common types were angiosarcomas (6 cases), 2 undifferentiated pleomorphic sarcomas, 1 right ventricle (RV) sarcoma, 1 primary cardiac lymphoma, 1 myxofibrosarcoma and 1 fibrosarcoma. The mean age of the P at time of diagnosis was 43 ± 15 years, 50% female gender. The most frequent presentation was heart failure symptoms (50% of P) followed by arrhythmias (20%). One patient had a rare presentation with pruritus and polyarthralgias. On TTE, the most prevalent tumor location was in the right-heart chambers (70%) - mostly the right atrium (50%), with mean dimensions of 40 ± 18 mm x 27 ± 11 mm. 85% of patients had preserved systolic left ventricular function and there was moderate or severe pericardial effusion in 38%. The most frequent distant metastatic involvement of primary tumors at diagnosis was pulmonary (33%) and hepatic (33%). 50% of P were submitted to tumor resection and 40% were submitted to chemotherapy. In the case of angiosarcomas, the most common immunohistochemical markers were vimentin, CD31 and CD34. The authors found a mortality rate of 81% in P with primary cardiac tumors, with a median time of follow-up of 6 months (minimum of 20 days and maximum of 18 years). In the latter case, the P was submitted to heart transplantation after diagnosis of a sarcoma of the RV and is still alive and well. B Regarding secondary cardiac invasion, there was a diagnosis of the following primary tumor sites: 6 thymomas, 4 cases of lymphoma, 3 lung carcinomas, 3 hepatocellular carcinomas, 2 bladder carcinomas, 1 parathyroid carcinoma, 1 soft tissue sarcoma and 1 melanoma. The mean age of P with metastastic involvement of the heart was 57 ± 22 years, 65% male. On TTE/TEE the authors also found a right-sided chambers predominance (60%), with pericardial metastasis in 35%. As expected, the mortality rate was also extremely high (90%), with a median time of follow up of 1.5 months (minimum of one week, maximum of 44 months) Conclusion Cardiac malignant tumors generally present in a late stage with a dismal prognosis. When possible, heart transplantation can be an option with a good outcome.

Case Report A 25 year-old male patient with an unremarkable past medical history presented to the Emergency Department due to a hemodynamically stable wide complex tachycardia at 260bpm with no response to adenosine, which was successfully treated with synchronized electrical cardioversion. Post cardioversion EKG revealed a pre excitation pattern and the transthoracic echocardiogram showed a large pericardial effusion with diastolic right atrial collapse. The patient was admitted in the Cardiology Department for emergent pericardiocentesis and further investigation. A total of 800 mL of bloody pericardial fluid was removed, compatible with an exudate, but fluid culture and cytology were inconclusive. Due to a rapid reaccumulation of pericardial fluid, the patient underwent a pericardial window, after which he developed an intractable pleuritic thoracalgia, refractory to the combination of ibuprofen, colchicine and oral steroid, despite the resolution of the pericardial effusion. He was also submitted to an electrophysiologic study with successful ablation of a right sided accessory pathway. Analysis of the pericardial fluid and biopsy were inconclusive once again, including a low level of adenosine deaminase and negative acid-fast bacilli test and nucleic acid amplification test for Mycobacterium tuberculosis. The patient was afebrile and denied any constitutional symptoms or relevant epidemiological context. The remainder etiological study was unremarkable, with the exception of fluctuating antibody titers for adenovirus, Borrelia burgdorferi and Mycoplasma pneumoniae, which were interpreted as a result of cross-reactivity. Nevertheless, a course of 21 days of doxycycline was tried without any significant improvement. Thoracic-abdominal-pelvic CT and PET scan were normal. Direct inoculation in guinea pig led to positive results for Mycobacterium tuberculosis and antituberculous therapy was started. Despite pathogen directed antibiotic treatment, there was no clinical improvement and the pericardial effusion gradually relapsed, evolving to cardiac tamponade requiring emergent drainage. Histologic examination of pericardial fragments finally revealed massive infiltration by an undifferentiated malignant tumor compatible with a malignant epithelioid hemangioendothelioma. Due to the patient’s poor performance status and rapidly deteriorating clinical course, it was decided not to start chemotherapy. The patient eventually died, 6 months after his admission to the ED and 2 weeks after the neoplasm’s diagnosis. Conclusion In regions with a high Tuberculosis incidence, there should be a high degree of suspicion for tuberculous pericarditis, especially in cases of recurrent pericardial effusion. Immunosuppressed individuals, such as oncologic patients, are at an increased risk for tuberculosis. The management of relapsing pericardial effusion remains a diagnostic challenge as described in this clinical case.

Introduction Myocardial work (MW) is a new transthoracic echocardiographic (TTE) parameter that enhances the information provided through left ventricular (LV) global longitudinal strain (GLS), allowing to investigate LV performance even in cases of changes in afterload. None is known about the effects of Sacubitril-Valsartan (LCZ696) therapy in MW parameters. Purpose Compare the changes in MW parameters between ischemic and non-ischemic segments after LCZ696 therapy. Methods The study was a prospective evaluation of chronic Heart Failure (HF) patients with optimized standard of care therapy and LV ejection fraction ≤40%, in which LCZ696 therapy was started and no other HF treatment was expected to change. A TTE study was performed before and 6 months after LCZ696 therapy, using the GE Vivid E95 ultrasound system. A semiautomated analysis of GLS was performed after two-dimensional images were acquired in the standard apical 4-, 3- and 2 chamber views. MW and related indices were estimated using custom software. Two groups were created according to the 17 segment model TTE study before LCZ696 therapy: G1 (ischemic group): dyskinesia/akinesia/hypokinesia segments in patients with ischemic HF etiology; G2 (non-ischemic group): normokinesia segments in patients with ischemic and all segments in patients with non-ischemic HF etiology; Results Of the 42 patients, 35 (83.3%) completed the six-months follow-up with LCZ696, since 2 patients (4.8%) died and 5 patients (11.9%) discontinued treatment for adverse events. Mean age was 58.6 ± 11.1 years, with ischemic etiology in 15 (42.9%), resulting in a total of 26.5% segments for G1. Baseline global MW index (GWI) had no statistical difference between G1 and G2 (566.1 VS 584.8mmHg%, p = 0.257), but baseline MW efficiency (GWE) were significantly lower in G1 (71.9 VS 78.8%, p The table represents the mean values for MW parameters in G1 and G2 before and 6 months after LCZ696 therapy, with a significantly increase in GWI and GWE values in both groups. Despite no difference in the increase in GWE (p = 0.872), the increase in GWI were higher in G2 than G1 (p Conclusion MW seems to be a new tool providing signs of reverse remodelling and better cardiac performance in ischemic and non-ischemic segments after LCZ696 therapy. Table 1 Time 0 6 months p GWI in ischemic segments (mmHg%) 566.1 ± 364.0 696.5 ± 445.2

Background Patients (pts) with reduced left ventricular (LV) systolic function have high risk of sudden cardiac death and benefit from implantable cardioverter-defibrillators (ICDs/CRT-Ds). However, the risk for arrhythmic events and device therapies is extremely heterogeneous in this population, so more accurate tools for risk stratification are required. Purpose To assess predictors of mortality and arrhythmic events in pts receiving primary prevention ICDs/ CRTs. Methods Retrospective analysis of 150 pts submitted to primary prevention ICD/ CRT-D implantation with remote monitoring between 2014-2018. Demographic, clinical and echocardiographic data from implantation and follow-up period were retrieved. Arrhythmic events and device therapies were retrieved from remote monitoring and clinic visits. Univariate analysis was performed followed by a multivariate Cox analysis to evaluate predictors of events. p Results 150 pts, 80.7% male, with a mean age of 64.30 ± 12.9 years (Y) and a mean follow-up (FU) time of 38 ± 15 months. 66% of pts implanted an ICD. 52.0% of pts presented with an ischemic cardiomyopathy and 41.3% had atrial fibrillation. 35.3% had chronic kidney disease (GFR Conclusion Baseline diabetes and PASP were independent predictors of mortality in our population of ICD/CRT-D pts implanted in primary prevention setting. An increased percentage of biventricular pacing was associated to improved clinical outcomes in patients receiving cardiac resynchronization therapy. Identification of predictors of events in this population can help individualize its management.

Background and Purpose-Tricuspid valve (TV) apparatus parameters can vary significantly with demographic and anthropometric factors and could be useful for clinical decision making. Our aim was to (1) establish the reference values for TV apparatus parameters using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on TV anatomy. Methods-A total of 180 healthy subjects referred in 2015 to our institution for a screening transthoracic echocardiography were enrolled (mean age 49.7+17.4 years, range 20 to 80 years: 30 subjects per age decade were included in the study, 15 for each gender). A real-time zoom 3D image of the TV and full volume 3D data set were collected from an apical window including TV using Philips iE33 and GE Vivid E9 Ultrasound Machines. After acquisition, the 3D data sets were analysed using 3D Qlab and EchoPAC PC softwares. The volumetric data set was analysed with multiplanar reformatting function to obtain three simultaneous orthogonal 2D slices (sagittal, coronal and axial planes). The following TV parameters were obtained and measured: 1. the 3D diastolic annular diameters (Major and Minor diameters); 2. the 3D diastolic annular area (TDAA); 3. the Tricuspid annular fractional area changes (TAFAC). Results are presented as mean ± SD. Differences between and among groups were tested for significance using the independent samples t-test and ANOVA test for continuous variables. Univariate Pearson correlation was used to assess the relation between these parameters and age, and body size. A p 0.05) and normalized MDD (18.1±2.4 vs 18.4±2.3 mm/m2, p>0.05) did not differ significantly between males and females. TTDAA and TAFAC in overall population were 76.7±17.3 mm2 and 29.6±8.6%. TDAA was significantly different between males and females (82.5±18.3 vs 69.7±13.0 mm2, respectively; p 0.05). After normalization for BSA, TDAA in overall population was 43.3±9.0 mm2/m2. Also normalized TDAA was significantly different between males and females (44.4±9.4 vs 42.0±8.4 mm2/m2, p < 0.05). mDD, MDD, TDAA and TAFAC showed no correlation with age (r = 0.16, p 0.04; r = 0.028, p 0.7; r = 0.17, p 0.27; r = 0.16, p 0.16; respectively). Conclusion- This study can provide normal reference values for TV anatomic parameters that may be useful in the clinical practice, considering the effects of age, sex, and body size.

Background Measurement of left ventricular outflow tract (LVOT) diameter and area for estimation of aortic valve area (AVA) using transthoracic echocardiography (TTE) and the continuity equation assumes circular LVOT. The use of direct planimetric measurement of LVOT area by gated-CT can theoretically improve accuracy of AVA calculation. Purpose We aim to assess reproducibility of LVOT echo measurement and its correlation and agreement with Gated CT measurements. In the subgroup with aortic stenosis (AS) we secondarily assessed the potential change in AS severity using LVOT area by CT instead of TTE in the continuity equation. Methods We retrospectively studied 93 patients, 43 of whom with severe AS. LVOT Area was measured with 2D TTE by 2 expert echocardiographers and gated-CT by 2 expert radiologists; inter-reader agreement and inter-method (Echo vs gated CT) agreement and correlation were measured. Finally we used the measurement of CT scan in the continuity equation instead of TTE measurement to assess potential reclassification of AS severity. Results Mean age was 78±11. Table shows inter-reader and inter-method agreement and correlation. The correlation between 2 echocardiophers for LVOT measurements was good (rho = 0,77) although not perfect. Out of 43 severe AS, defined as AVA

Background Arterial stiffness is associated with increased risk for cardiovascular disease. The purpose of this study is to investigate the arterial stiffness and myocardial deformation in patients with poorly controlled diabetes mellitus type 2 before and after glycemic control by optimal medication. Methods In 50 patients with uncontrolled type 2 diabetes(age:52±10years)and 25 controls of similar age and sex and no atherosclerotic risk factors we measured at baseline and 6 months after glycemic control a) carotid-femoral pulse wave velocity(PWVc m/sec-Complior SP ALAM),central systolic blood pressure(cSBP -mmHg),augmentation index(AI%), of the aortic pulse wave(ArteriographTensioMed) b)S',E'(m/sec)andE'/A'of mitral annulus by Tissue Doppler c)LV longitudinal strain(GLS-%),systolic(LongSr-l/sec)and diastolic(LongSrE-l/sec)strain rate, twisting(Tw-deg),peak twisting(Tw)and untwisting(unTw-deg/sec)velocity using speckle tracking echocardiography.The degree of LV untwisting was calculated as the percentage difference between peak twisting and untwisting at MVO(%dp PeakTw-UntwMVO)and between peak twisting and untwisting at peak and end of the mitral inflow E wave d)perfusion boundary region(PBR- micrometers)of the sublingual arterial microvessels(ranged from 5-25 micrometers)using Sideview,Darkfield imaging(Microscan,Glycocheck).Increased PBR is considered an accurate index of reduced endothelial glucocalyx thickness because of a deeper RBC penetration in the glucocalyx e) Flow mediated dilatation(FMD) of the brachial artery and percentage difference of FMD (FMD%). Results Compared to controls,diabetics had higher PWVa(10.3±2.2 vs. 8.1±1.9), AI(27.9±15 vs. 19.4±14.7), PWVc(11.8±3.2 vs. 8.8±1.3),cSBP(136±20 vs. 119±18),PBR (2.1±0.2 vs 1.89±0.1)and lower GLS(-15±3 vs. -18±3),LongSr(-0.78±0.1 vs. -0.96±0.2),LongSrE(0.77±0.29 vs. 1.2±0.3),S',E' and E/A(p

Background Mitral valve resistance (MVR) is a hemodynamic consequence of mitral stenosis but it has no clear threshold and it has a shortage of data to be reliable. Purpose is to investigate match and mismatch between opening area and resistance especially in patients with moderate and mild mitral stenosis. Materials This cross section case control study comprised 88 patients with moderate and mild rheumatic mitral stenosis. Transthorathic echocardiographic study estimated: mitral valve area (MVA) both by planimerty (2D) and pressure half time (PHT), mitral valve score (MVS), mean transmitral pressure gradient (MPG), diastolic filling time(DFT), left ventricular out flow tract diameter (LVOTd) and velocity time integral (LVOT vti) , the MVR was calculated as: MPG/aortic flow ratio [(LVOTd) (LVOTvti)/ DFT] in dynes.sec.cm5, NYHA function class of all patients was estimated. We classified our patients into 2 groups, group 1 (51 patients) with matched MVR and group 2 (37 patients) with unmatched MVR (unexpected high MVR in relation to valve area). Methods Patients with moderate mitral stenosis have MVR less than 105 dynes.sec/cm5, while patient with mild mitral stenosis have MVR less than 76 dynes.sec/cm5 this is in the matched group, but there are patients with unmatched higher MVR. Group 2 compared to group 1; had higher NYHA function class (1.4±0.6 vs. 1.2±0.4, P < 0.05), MVS (8.1±1.8 vs 7±0.9, P < 0.05), MPG (11,3±3.7 vs.7.8±2.5 mmHg, P < 0.01) and higher MVR (122.37±29.87 vs. 67.18±20.12 dynes.sec/cm5 , P < 0.01), MVR showed positive correlation with MVS (r=0.5, P < 0.05), Step wise logistic regression analysis showed that MVS is the only independent predictor of the MVR severity in the mismatched (unexpected high) group , so the higher the MVS the higher the expected MVR whatever the MVA is ; (B±SE=6.997±2.826, t=2.476, 95% CI 1.241±12.752 with an odds ratio=0.412, P < 0.05). Conclusion It would make much more sense to investigate match and mismatch between opening area and resistance in rheumatic mitral stenosis, the only independent predictor of mismatch is the mitral valve score.

Background Outcome of Mitral Valve Prolapse (MVP) was controversial for long time. Many studies reported great differences in the incidence of cardiovascular events due, above all, to heterogeneous and small studied populations. Most of theme were also published to late '80 of the last century till early '00. Purpose To make a contemporary survey on the incidence of cardiovascular events in a selected population of patients affected by primary MVP referred to a tertiary cardiovascular center for the medical and surgical care of valvular heart disease. Methods We reviewed our MVP database; patients with at least 2 cardiologic evaluations inclusive of echocardiographic examination and at least 6 months follow up were enrolled. A total of 250 patients (126 F) were selected. Their mean age was 52.1 years (ranging from 13 to 88 yo). The average follow-up time was 100 months (8,33 yrs). Results At the first medical and echocardiographic examination 8 patients (3,2%) had no mitral regurgitation (MR), 104 (41.6%) have a trace/mild MR, 93 (37,2%) a moderate MR and 46 (18,4%) a severe MR. They were widely asymptomatic (NYHA I 205-82%, NYHA II 44-17.60%, NYHA III 1- 0.40%). Most of theme presented a bileaflet (140-55.8%) or a posterior MVP (94 - 37.6%); an isolated anterior MVP was rare (16 - 6,4%). Flail leaflet was present in 8 (3,2%) and 25 (10%) had a chordal rupture. Respectively 165 (65,6%) and 115 (46,1%) patients had thick and redundant leaflets. Mean antero-posterior mitral annulus diameter was 37 mm. During the follow up 7 patients died of non-cardiac cause and 5 (2%) of suspected cardiac cause (2 because of acute coronary syndrome and 3 died suddenly). MR progresses in 43 (17,2%) patients and finally we observed 81 (32,4%) moderate/severe and severe MR. 12 new chordal rupture occurred during the follow up in most cases concerning mitral chordae linked to posterior mitral leaflet (10 cases-83,3%). The worsening of MR provoked an evolution of the clinical condition of 48 patients (19.2%) which developed Dyspnea On Excertion (DOE) with 42 new NYHA II and 6 new NYHA III. At the end of the follow up the amount of patients symptomatic for DOE was 93 (37.2% vs 18% at the initial evaluation). A total of 45 patients (18%) underwent mitral valve surgery. 40 needed in-hospital treatment in most cases due to the development of atrial fibrillation (19 -7.6%) or heart failure ( 8- 3,2%). Endocarditis occurred in 4 patients (1.6%) and cerebrovascular accidents/cardioembolic event in 6 (2.4%). The overall cardiovascular event rate was 4,33/100 patients-year, significantly higher than reported in community based studies. Conclusions The prognosis of a MVP population referred to a tertiary cardiovascular center is not benign. The most frequent complications are progression of MR and MV surgery. Sudden death is also more frequent than in general population. More studies are needed to identify what patients with MVP are at risk for it.

Introduction Serial echocardiographic assessment of left ventricular ejection fraction (LVEF) and 2D left ventricular global longitudinal strain (GLS) is the gold standard in screening for cancer therapeutics-related cardiac dysfunction (CTRCD). Myocardial deformation assessed with 3D speckle tracking is not currently used in this setting, because of the lack of standardization and cut-off values, in spite of a potential for a greater reliability. Methods Prospective study of female breast cancer patients submitted to anthracycline chemotherapy with or without adjuvant immunotherapy and/or radiotherapy who underwent serial monitoring by 2D and 3D transthoracic echocardiography (ETT). Standard ETT measures and 3D-derived volumetric measures were assessed. Speckle tracking was used to estimate 2D-derived GLS – average and 18 segments – and 3D-derived GLS, global circumferential strain (GCS), global area strain (GAS) and global radial strain (GRS) – average and 17 segments. CTRCD was defined as an absolute decrease in 2D or 3D LVEF >10% to a value 15%. Variables were compared using the t-student paired test and the Wilcoxon sign-rank test, when appropriate. Results 106 patients (mean age 54.6±12.9 years, 33.0% immunotherapy, 16.5% radiotherapy, baseline LVEF 64.5% ± 8.5%, baseline 2D GLS −21.0±2.8) were included. During a mean follow-up of 16.5±9.6 months, an average of 3.9 echocardiographic examinations were performed per patient and 28 patients (26.4%) developed CTRCD. Overall, 3D regional longitudinal strain was determined in 88.9% of the segments analyzed, with lower success rates in the inferobasal (75.0%), the posterobasal (77.7%) and the laterobasal (82.4%) walls. When comparing variables before and during treatment, there was a significant difference in 2D-derived LVEF (64.5 vs. 57.6 p Segmental analysis of 2D and 3D strain Conclusion In this population, there was worsening of 3D GLS and GRS, besides conventional values, such as LVEF and 2D GLS, during anthracycline-based cancer treatment. 3D-derived myocardial deformation parameters show promise in the setting of CTRCD, since 2D and 3D regional strain parameters might shed a light onto the mechanisms of CTRCD, such that subendocardial myocardial fibers seem to be more affected than medial and subepicardial fibers.

Introduction Sacubitril/Valsartan (LCZ696) had prognosis benefit demonstrated in PARADIGM-HF trial, however less is known about his effects in cardiac dimensions and function. Myocardial work (MW) is a new transthoracic echocardiographic (TTE) parameter. None is known about the effects of LCZ696 therapy in MW parameters. Purpose The aim of this study was to prospectively compare several TTE parameters, including MW, before and after LCZ696 therapy. Methods Prospective evaluation of chronic HF patients with optimized standard of care therapy and LVEF≤40%, in which LCZ696 therapy was started. TTE study was performed before and 6 months after LCZ696 therapy. A semiautomated analysis of GLS was performed and MW were estimated using custom software of GE Vivid E95 ultrasound system. Results Of the 42 patients, 35 (83.3%) completed the 6 months follow-up, since 2 patients (4.8%) died and 5 patients (11.9%) discontinued treatment for adverse events. Mean age was 58.6±11.1 years with 82.9% of male patients. LV dimensions and atrial volumes were significantly lower at 6 months of treatment. LVEF had a mean absolute raise of 8.9% and GLS a relative decrease of 27.8%. MW had a significant increase in constructive work (720.2mmHg VS 900.6mmHg, p=0.016) and work efficiency (78.6% VS 86.6%, p=0.027), with a non-significant decrease in the wasted work (150.2mmHg VS 136.8mmHg, p=0.441). TTE data before and after 6 months of LCZ696 treatment Time 0 6 months p LV end-diastolic diameter (mm) 71.3±8.4 66.9±7.6 0.001 LV end-systolic diameter (mm) 57.8±9.4 53.1±9.3 0.002 Interventricular septum (mm) 9.6±1.7 9.9±1.9 0.280 LVEF (%) 29.3±6.4 38.2±8.9 Conclusion LCZ696 therapy is associated with signs of reverse remodelling in TTE, including an increase in constructive work and work efficiency.