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Funding Acknowledgements Type of funding sources: None. Background Percutaneous balloon mitral valvuloplasty (PBMV) is the cornerstone of the treatment of rheumatic mitral stenosis (MS) in suitable patients. Pulmonary hypertension (PH) is a common coexisting finding and an indication for intervention. We sought to assess the influence of PH in PBMV immediate results and in very longterm outcome. 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) were analysed. Results Mean age was 47.3 ± 13.6 years and 89.6% were women. A previous commissurotomy or PBMV was found in 10.4% and mean Wilkins score was 7.6 ± 1.4. PH, defined as pulmonary artery systolic pressure (PASP) ≥45mmHg, was present in 32.7% of patients. A successful procedure was achieved in 89.1% of total population. Mean mitral valve (MV) gradient decreased from 13.1 to 5.0 mmHg (p Conclusions PBMV in patients with MS and PH is a safe and effective intervention, achieving a significant decrease in PASP after procedure. Baseline PH was not associated with success or MACE. However, PH persistence after PBMV, correlated with worse prognosis in longterm follow up. Special attention and further investigation for this subgroup is needed. Abstract Figure.

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 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.

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 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

Aim In patients (pts) with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve pt selection for invasive coronary angiography (ICA) as alternative to functional testing. However. the role of CTA in symptomatic pts after abnormal functional test (FT) is incompletely defined. Methods and results This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic pts with mild to moderately abnormal FT referred to ICA to receive either the originally intended ICA (n=103) or CTA (n=115). CTA interpretation and subsequent care decisions were made by the clinical team. Pts with high risk features on FT, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR (UP) and symptomatic status (SS) were also evaluated. Pts averaged 68±9 years of age, 60% were male, 29% were diabetic. Nuclear perfusion stress test was used in 33.9% in CTA group and 31.1% in control group (p=0.655). Mean post (functional) test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 32.1%. In the CTA group, ICA was cancelled by referring physicians in 83 of the pts (72.2%) after receiving CTA results. For those undergoing ICA, non-obstructive CAD was found in 5 pts (15.6%) in the CTA-guided arm and 60 (58.3%) in the usual care arm (p Conclusions In pts with suspected CAD and mild to moderately abnormal ischemia test, a diagnostic strategy including CTA as gatekeeper is safe, effective and significantly improves diagnostic and revascularization yields of ICA. Funding Acknowledgement Type of funding source: None

Background Percutaneous Patent Foramen Ovale (pPFO) closure benefits for secondary prevention after cardio-embolic stroke have recently been proved. With the increasing number of cases and procedures, a concern with new onset atrial fibrillation (NOAF) has been raised. Purpose To evaluate long-term outcome regarding NOAF rate and to identify its predictors and clinical impact, in a real population submitted to pPFO closure. Methods From 2000 to 2017, consecutive patients (P) submitted to pPFO closure in a tertiary centre were prospectively enrolled. The primary endpoint was NOAF rate and secondary endpoints were all-cause, neurologic and cardiac mortality rates and recurrent ischemic events. Previous and follow-up electrocardiographic, echocardiographic and 24-hour heart rhythm monitoring data were analysed. Follow-up was performed through medical visits, medical charts consultation and a phone call based system, in order to assess clinical status, on-going treatment and events. Results 496 patients were submitted to pPFO. Immediate success was achieved in 98.8% and 9.1% presented a residual shunt on the 1st year TEE. Mean age was 45.0±11.2 years-old with 50.2% of males. The prevalence of hypertension, hypercholesterolemia and atrial septum aneurysm (ASA) was 25.7%, 45.0% and 46.3%, respectively. Pre-procedural mean left atrial (LA) diameter was 36.0±5.3 mm. FU data was available for 490 (98.6%), for a mean FU time of 7.41±3.51 years. 34 P (6.9%) presented ischemic events recurrence (26 strokes and 8 TIA). The primary endpoint was observed in 21 P (4.3%) during the FU period. Median time to 1st AF episode since PFO closure was 5.90±5.53 years. 11 P (52.3%) initiated oral anticoagulation. In univariate analysis, age (44.6±11.3 vs 51.8±6.0 years, p=0.005) and hypertension (24.7% vs 47.6%, p=0.019) were predictors of NOAF in this population. In multivariated analysis, only age remained a predictor of NOAF (OR 1.05 (1.007–1.101), p=0.025). LA pre pPFO closure dimensions, ASA, device type or size and the presence of residual shunt in TEE were not determinants of AF occurrence. The incidence of NOAF was associated with the need for hospitalization due to cardiac causes (19% vs 3.2%, p=0.001) and a trend towards higher rate of recurrent stroke (4.9% vs 14.3%, p=0.06). Conclusion Despite being a highly successful and safe procedure in most patients, pPFO closure was associated with a non-negligenciable rate of NOAF during long-term follow-up. NOAF predictors were related with classical cardiovascular risk factors, such as age and hypertension. None of the procedure or device features were associated with NOAF. Yet, a clinical impact was attributed to NOAF, with more hospitalizations and a trend towards ischemic events recurrence. As young patients submitted to pPFO closure grow older, prevention strategies to diagnose and treat NOAF should be endeavoured. Funding Acknowledgement Type of funding source: None

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.

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

Aim In patients with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve patient selection for invasive coronary angiography (ICA) as alternative to functional testing. However, the role of CTA in symptomatic patients after abnormal functional test is incompletely defined. Methods and results This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic patients (pts) with mild to moderately abnormal functional test referred to invasive coronary to receive either the originally intended ICA (n=103) or CTA (n=115). CTA interpretation and subsequent care decisions were made by the clinical team. Patients with high risk features on functional tests, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR Conclusions In patients with suspected CAD and mild to moderately abnormal functional test, a diagnostic strategy including computed tomographic angiography as gatekeeper is effective and significantly improves diagnostic and revascularization yields of invasive coronary angiography.

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.

Purpose: Deformation analysis from 3D echocardiography results in a considerable amount of parameters, for which the conventional statistical approach is cumbersome. We investigate local motion and deformation patterns to determine the parameters of relevance for the study of LV myocardial deformation in the presence of LAD infarct. Methods: The study included 46 patients acquired at max. 5 days after LAD infarct (37 sequences) and at 1-year follow-up (33 sequences), and 46 controls. Patients were selected if they had a LVEF