Search

Objective: To assess the accuracy of a virtual stenting tool based on coronary CT angiography (CCTA) and fractional flow reserve (FFR) derived from CCTA (FFRCT Planner) across different levels of image quality. Materials and methods: Prospective, multicenter, single-arm study of patients with chronic coronary syndromes and lesions with FFR ≤ 0.80. All patients underwent CCTA performed with recent-generation scanners. CCTA image quality was adjudicated using the four-point Likert scale at a per-vessel level by an independent committee blinded to the FFRCT Planner. Patient- and technical-related factors that could affect the FFRCT Planner accuracy were evaluated. The FFRCT Planner was applied mirroring percutaneous coronary intervention (PCI) to determine the agreement with invasively measured post-PCI FFR. Results: Overall, 120 patients (123 vessels) were included. Invasive post-PCI FFR was 0.88 ± 0.06 and Planner FFRCT was 0.86 ± 0.06 (mean difference 0.02 FFR units, the lower limit of agreement (LLA) − 0.12, upper limit of agreement (ULA) 0.15). CCTA image quality was assessed as excellent (Likert score 4) in 48.3%, good (Likert score 3) in 45%, and sufficient (Likert score 2) in 6.7% of patients. The FFRCT Planner was accurate across different levels of image quality with a mean difference between FFRCT Planner and invasive post-PCI FFR of 0.02 ± 0.07 in Likert score 4, 0.02 ± 0.07 in Likert score 3 and 0.03 ± 0.08 in Likert score 2, p = 0.695. Nitrate dose ≥ 0.8mg was the only independent factor associated with the accuracy of the FFRCT Planner (95%CI − 0.06 to − 0.001, p = 0.040). Conclusion: The FFRCT Planner was accurate in predicting post-PCI FFR independent of CCTA image quality. Clinical relevance statement: Being accurate in predicting post-PCI FFR across a wide spectrum of CT image quality, the FFRCT Planner could potentially enhance and guide the invasive treatment. Adequate vasodilation during CT acquisition is relevant to improve the accuracy of the FFRCT Planner. Key Points: • The fractional flow reserve derived from coronary CT angiography (FFRCT) Planner is a novel tool able to accurately predict fractional flow reserve after percutaneous coronary intervention. • The accuracy of the FFRCT Planner was confirmed across a wide spectrum of CT image quality. Nitrates dose at CT acquisition was the only independent predictor of its accuracy. • The FFRCT Planner could potentially enhance and guide the invasive treatment. [ABSTRACT FROM AUTHOR]

Background: Magnetic resonance imaging (MRI) is an accurate method for the quantitative assessment of organic mitral regurgitation (OMR). The aim of the present study was to compare the discriminative power of MRI quantification and the recommended Doppler echocardiography (ECHO)-derived integrative approach to identify asymptomatic patients with OMR and adverse outcome.Methods: The study population consisted of 258 asymptomatic patients (63±14 years, 60% men) with preserved left ventricular ejection fraction (>60%) and chronic moderate and severe OMR (flail 25%, prolapse 75%) defined by using the ECHO-derived integrative approach. All patients underwent MRI to quantify regurgitant volume (RV) of OMR by subtracting the aortic forward flow volume from the total left ventricular stroke volume. Severe OMR was defined as RV≥60 mL.Results: Mean ECHO-derived RV was on average 17.1 mL larger than the MRI-derived RV (P<0.05). Concordant grading of OMR severity with both techniques was observed in 197 (76%) individuals with 62 (31%) patients having severe OMR (MRI SEV-ECHO SEV) and 135 (69%) patients having moderate OMR (MRI MOD-ECHO MOD). The remaining 61 (24%) individuals had discordant findings (MRI SEV-ECHO MOD or MRI MOD-ECHO SEV) between the 2 techniques. The majority of these differences in OMR classification were observed in patients with late systolic or multiple jets (both κ<0.2). Patients with eccentric jets showed moderate agreement (κ=0.53; 95% confidence interval, 0.41-0.64). In contrast, a very good agreement (κ=0.90; 95% confidence interval, 0.82-0.98) was observed in a combination of holosystolic, central, and single jet. During a median follow-up of 5.0 years (interquartile range, 3.5-6.0 years), 38 (15%) patients died and 106 (41%) either died or developed indication for mitral valve surgery. In separate Cox regression analyses, the MRI-derived left ventricular end-systolic volume index, RV, and OMR category (severe versus moderate), and the ECHO-derived OMR category were independent predictors of all-cause mortality (all P<0.05). The MRI-derived RV showed the largest area under the curve to predict mortality (0.72) or its combination with the development of indication for mitral valve surgery (0.83).Conclusions: The findings of the present study suggest that the MRI-derived assessment of OMR can better identify patients with severe OMR and adverse outcome than ECHO-derived integrative approach warranting close follow-up and perhaps, early mitral valve surgery. [ABSTRACT FROM AUTHOR]

Background Clinical impact of the minimally invasive surgical mitral valve annuloplasty (MVA) of functional mitral regurgitation (FMR) in systolic heart failure on top of the state-of-the-art standards of care remains controversial. Therefore, we aimed to compare clinical outcomes of isolated MVA using the mini-invasive videothoracoscopic approach versus the state-of-the-art (CON = conservative) treatment in patients with chronic systolic heart failure and symptomatic FMR. Methods The study population consisted of 379 patients (age 68.9 ± 11.0 years, 62.8% males) with left ventricular (LV) systolic dysfunction, symptomatic FMR and previous heart failure hospitalization. A total of 167 patients underwent undersized MVA and 212 patients were treated conservatively. A concomitant MAZE was performed in 53 (31.7%) patients. Results In the MVA group, the periprocedural and the 30-day mortality were 1.2% and 4.8%, respectively. During the median follow-up of 7.1 years (IQR 3.5–9.8 years) a total of 74 (44.3%) and 138 (65.1%) died in the MVA and the CON group, respectively ( p < 0.001). The lowest mortality was observed in MVA combined with MAZE (22.6%; p < 0.01). In Cox regression analysis, age, MVA with MAZE emerged as independent predictors of both all-cause mortality and rehospitalizations for heart failure (all p < 0.05). MVA was associated with significantly greater symptomatic improvement and reduction of FMR than the conservative treatment (both p < 0.001). Reverse LV remodeling was observed only in the MVA combined with MAZE group ( p < 0.01). Conclusions In patients with symptomatic FMR, minimally invasive MVA, in particular in combination with MAZE, confers an independent long-term survival benefit compared with the state-of-the-art treatment. [ABSTRACT FROM AUTHOR]

The article focuses on the role of clinical Doppler echocardiography in the diagnosis of heart failure with preserved ejection fraction (HFPEF). Topics discussed are the preserved left ventricular (LV) ejection fraction, challenges associated with HFPEF in elderly patients with equivocal symptoms and several case studies on HFPEF.

Objectives: The aim of the present study was to diagnose heart failure with preserved ejection fraction (HFPEF) in outpatients with unexplained chronic dyspnea and to elucidate its underlying mechanisms in this population using invasive pressure-volume loop analysis. Background: The diagnosis of HFPEF in stable outpatients with unexplained dyspnea is difficult. Methods: Thirty patients (age 67 ± 8.6 years, 27% males) with preserved left ventricular (LV) ejection fraction (>50%) and unexplained chronic New York Heart Association functional class II to III dyspnea underwent heart catheterization. Patients with significant coronary artery stenosis (>50%) were excluded. Pressure-volume loops were assessed using a conductance catheter at rest, hand-grip exercise, leg lifting, and nitroprusside and dobutamine infusion. Results: Twenty (66%) patients showed LV end-diastolic pressure >16 mm Hg (HFPEF), whereas the remaining 10 patients served as controls. Patients with HFPEF had significantly higher end-diastolic stiffness (0.205 ± 0.074 vs. 0.102 ± 0.017, p < 0.001) at rest, and their end-diastolic pressure-volume relationship showed a consistent upward and leftward shift during all hemodynamic interventions compared with controls. Regarding the underlying mechanism of HFPEF, 14 (70%) patients had markedly increased end-diastolic stiffness, which was considered a sufficient single pathology to induce increased LV end-diastolic pressure. Four (20%) patients showed a concomitant presence of moderately increased stiffness and severe LV dyssynchrony, and the remaining 2 (10%) patients, with normal stiffness, showed significant exercise-induced mitral regurgitation at hand-grip exercise. If the invasive pressure measurements were absent, only 5 (25%) of the outpatients with HFPEF fulfilled the European Society of Cardiology definition of HFPEF. Conclusions: A significant proportion of stable outpatients with unexplained chronic dyspnea may have HFPEF. In the patients whom we studied, increased LV stiffness, dyssynchrony, and dynamic mitral regurgitation were the major mechanisms underlying development of HFPEF. [Copyright &y& Elsevier]

Abstract: Very little is known about the accuracy of intravenous myocardial contrast echocadiography (MCE) in the detection of myocardial hibernation. There are also currently no data on the comparison of MCE to late gadolinium-enhanced magnetic resonance (LGE-MR) in this clinical setting. The aim of this pilot study was to predict recovery of regional function in patients with ischemic LV dysfunction undergoing bypass surgery and to compare the accuracy of MCE with LGE-MR in this clinical setting. The sensitivity of preserved myocardial perfusion during MCE for segmental function recovery (hibernating myocardium) of akinetic segments was 78% and was similar to LGE-MR (87%, p—NS). Specificity of MCE was higher than for LGE-CMR (72%, and 52%, respectively; p <0.01). This pilot study has showed good diagnostic accuracy of MCE for prediction of function recovery after bypass surgery, which is comparable to “gold standard” in assessing myocardial viability — LGE-MR. [Copyright &y& Elsevier]

Abstract: Background: Pulsed-wave tissue Doppler imaging (TDI) was shown to predict short-term left ventricular functional recovery after cardiac resynchronization therapy (CRT). However, few data are available regarding the baseline cardiac asynchrony and clinical outcome after CRT. Therefore, we aimed to investigate the prognostic value of pre-CRT cardiac asynchrony on clinical outcome after CRT. Methods: The study population consisted of 48 consecutive patients with moderate to severe heart failure and a wide QRS complex undergoing implantation of biventricular pacemaker. Cardiac asynchrony was assessed at pulsed-wave TDI from measurements of regional electromechanical coupling times in basal segments of both ventricles (Sum asynchrony). Clinical end-points were cardiac mortality and hospitalization for worsening heart failure. Results: During a follow-up period of 970±319 days, clinical end-point (9 deaths, 15 hospitalizations) occurred in 24 patients (clinical nonresponders). At baseline, responders showed higher asynchrony than nonresponders (153±57 ms vs. 103±58 ms, p <0.01). Sum asynchrony of >98 ms showed the highest accuracy (AUC=0.80, sensitivity 92%, specificity 67%) to identify responders. In contrast, baseline NYHA class, conventional echo-Doppler indices and QRS complex duration were similar in both groups. Eight end-point events (3 deaths) occurred in 30 patients with significant Sum asynchrony (>98 ms) as compared to 16 events (6 deaths) in 18 patients with smaller Sum asynchrony (27% vs. 89%; HR 0.14; 95% CI 0.04 to 0.46; p <0.001). Favorable clinical outcome was associated with larger left ventricular functional recovery at 2 years follow-up (p <0.001). Conclusions: TDI-derived index of baseline intra- and interventricular asynchrony appears to predict long-term clinical outcome after CRT. [Copyright &y& Elsevier]

Objectives: The objective of the present study was to assess the relationship between the presence of left ventricular (LV) dyssynchrony and clinical outcome in patients with moderate systolic heart failure undergoing coronary artery bypass graft (CABG) surgery. Background: The presence of LV dyssynchrony is associated with poor prognosis in patients with LV dysfunction. Methods: The study consisted of 215 consecutive patients with ischemic cardiomyopathy and dyspnea (age 65 ± 9 years, 81% male) undergoing CABG. Dyssynchrony was calculated by tissue Doppler imaging from regional time intervals in basal LV segments before and 1 month after CABG. Myocardial viability was assessed using single-photon emission computed tomography (SPECT) before CABG. Results: Twenty-five patients (11.6%) died within 30 days (in-hospital mortality) of CABG. The presence of pre-CABG dyssynchrony ≥119 ms had the highest predictive accuracy for in-hospital mortality, with a sensitivity of 84% and a specificity of 71%. During the median follow-up period of 359 days (interquartile range 219 to 561), an additional 19 patients (10.3%) died and 34 patients (18.5%) were hospitalized for worsening heart failure. At Cox regression analysis, post-CABG dyssynchrony ≥72 ms and ≥5 viable segments were identified as independent predictors of clinical events, with a hazard ratio (HR) of 5.02, 95% confidence interval (CI) 2.57 to 10.02 (p < 0.001), and an HR of 0.63, 95% CI 0.55 to 0.75 (p < 0.001), respectively. Patients without post-CABG dyssynchrony and with viable myocardium had excellent prognosis compared with patients with severe post-CABG dyssynchrony and nonviable myocardium (event rate 3% vs. 64%; p < 0.001). Conclusions: The presence of severe LV dyssynchrony is associated with poor clinical outcomes despite revascularization. These results advocate a routine assessment of both LV dyssynchrony and viability to predict outcome in systolic heart failure patients undergoing CABG surgery. [Copyright &y& Elsevier]

Background: β2-adrenergic receptor Thr164Ile (threonine (Thr) is replaced by an isoleucine (Ile) at codon 164) polymorphism was postulated to contribute to lower exercise tolerance and poor prognosis in patients with congestive heart failure. However, heart failure is associated with several abnormalities of β receptor signalling, and underlying mechanisms are not clear. Objectives: To investigate whether Thr164Ile polymorphism negatively modulates myocardial contractile performance and is associated with adverse long-term prognosis of patients with congestive heart failure. Methods: Among 55 subjects, cardiac contractile response to the 132-adrenergic receptor agonist terbutaline was assessed from the peak myocardial velocity of systolic shortening (Sm) in 18 subjects with the Ile-164 variant and 37 matched controls. In total, 24 subjects had normal left ventricular (LV) function and 31 presented with congestive heart failure due to idiopathic dilated cardiomyopathy. Results: In patients with normal LV function, peak terbutaline-induced increase (~\) in Sm was lower in subjects with the Ile-164 variant than in controls (Δ33% (4%) vs Δ56% (4%), p<0.01). In patients with heart failure, subjects with Ile-164 showed further severe reduction of β2-adrenergic-mediated increase in Sm as compared with controls with heart failure (Δ20% (5%) vs Δ39% (4%), p<0.05). Patients with heart failure with Ile-164 showed a severely blunted force-frequency relationship in response to agonist Stimulation. At 2-years of follow-up, patients with heart failure with the Ile-164 variant showed higher incidence of adverse events than controls with heart failure (75% (6/8)] vs 30% (7/23), p<0.05). Conclusions: The β2-adrenergic Thr164Ile polymorphism directly modulates adrenergic-mediated cardiac responses in patients with normal and failing myocardium. Furthermore, blunted β2 adrenergic-mediated myocardial contractile response in patients with Ile-164 variant seems to adversely modulate the course of congestive heart failure. [ABSTRACT FROM AUTHOR]

: ObjectivesWe tested the hypothesis that the tissue Doppler imaging (TDI)-derived positive preejection velocity (+VIC) can predict the recovery of contractile function after revascularization in patients with a recent myocardial infarction.: BackgroundIn experimental studies, the presence and extent of TDI-derived +VIC correlated with the extent of viable myocardium.: MethodsForty-three patients with a large myocardial infarction and an occluded left anterior descending (n = 38) or dominant right coronary (n = 5) artery were selected. The median duration of occlusion was 24 h. Longitudinal myocardial velocities were recorded at rest by pulsed-wave TDI echocardiography 6 ± 2 h after revascularization. Functional recovery was defined as an increase in segmental chordal shortening ≥10% at three-month follow-up left ventricular angiogram as compared with baseline.: ResultsA good quality TDI signal was obtained in 309 of 324 analyzed segments (95.4%). Severe dysfunction was present in 198 segments of which 126 (64%) showed recovery at three-month follow-up. Sampling of all dysfunctional segments lasted 11 ± 4 min per patient. Sensitivity, specificity, and accuracy of the +VIC to predict segmental recovery were 91%, 71%, and 84%, respectively. The percentage of segments that were dysfunctional at angiography but showed a +VIC correlated with improvement of both global left ventricular ejection fraction (r = 0.60, p = 0.001) and wall motion score index (r = −0.78, p < 0.0001) at follow-up.: ConclusionsAssessment of +VIC by pulsed-wave TDI is a simple and accurate method that predicts recovery of contractile function after revascularization in patients with a recent myocardial infarction. [Copyright &y& Elsevier]

Valvular heart disease leads to ventricular pressure and/or volume overload. Pressure overload leads to fibrosis, which might regress with its resolution, but the limits and details of this reverse remodeling are not known. To gain more insight into the extent and nature of cardiac fibrosis in valve disease, we analyzed needle biopsies taken from the interventricular septum of patients undergoing surgery for valve replacement focusing on the expression and distribution of major extracellular matrix protein involved in this process. Proteomic analysis performed using mass spectrometry revealed an excellent correlation between the expression of collagen type I and III, but there was little correlation with the immunohistochemical staining performed on sister sections, which included antibodies against collagen I, III, fibronectin, sarcomeric actin, and histochemistry for wheat germ agglutinin. Surprisingly, the immunofluorescence intensity did not correlate significantly with the gold standard for fibrosis quantification, which was performed using Picrosirius Red (PSR) staining, unless multiplexed on the same tissue section. There was also little correlation between the immunohistochemical markers and pressure gradient severity. It appears that at least in humans, the immunohistochemical pattern of fibrosis is not clearly correlated with standard Picrosirius Red staining on sister sections or quantitative proteomic data, possibly due to tissue heterogeneity at microscale, comorbidities, or other patient-specific factors. For precise correlation of different types of staining, multiplexing on the same section is the best approach. [ABSTRACT FROM AUTHOR]

Background: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated.Methods: The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries.Results: Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23-0.90]; P=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome.Conclusions: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655. [ABSTRACT FROM AUTHOR]

This case describes a middle-aged patient with normal ejection fraction (64%) and significant dyspnoea which could not be explained by results from routine examinations. A pressure–volume loop analysis revealed severe left ventricular (LV) dyssynchrony to be the underlying mechanism of heart failure. The patient underwent implantation of a biventricular pacemaker. Cardiac resynchronization therapy (CRT) was associated with an immediate reduction in LV dyssynchrony from 32 to 13%, decrease in LV end-diastolic pressure from 19 to 8 mmHg, and increased exercise tolerance during follow-up. Thus, CRT may be considered a causal therapy in selected patients with heart failure and preserved ejection fraction. [ABSTRACT FROM PUBLISHER]

Aims: Obesity is causally related to the development of heart failure with preserved ejection fraction (HFpEF) but complicates the diagnosis and treatment of this disorder. We aimed to determine the relationship between severity of obesity and clinical, echocardiographic and haemodynamic parameters in a large cohort of patients with documented HFpEF. Methods and results: The REDUCE LAP‐HF II trial randomized 626 patients with ejection fraction ≥40% and exercise pulmonary capillary wedge pressure (PCWP) ≥25 mmHg to atrial shunt or sham procedure. We tested for associations between body mass index (BMI), clinical characteristics, cardiac structural and functional abnormalities, physical limitations, quality of life and outcomes with atrial shunt therapy. Overall, 60.9% of patients had BMI ≥30 kg/m2. As the severity of obesity increased, symptoms (Kansas City Cardiomyopathy Questionnaire score) and 6‐min walk distance worsened. More severe obesity was associated with lower natriuretic peptide levels despite more cardiac remodelling, higher cardiac filling pressures, and higher cardiac output. Lower cut points for E/e′ were needed to identify elevated PCWP in more obese patients. Strain measurements in all four chambers were maintained as BMI increased. Pulmonary vascular resistance at rest and exercise decreased with higher BMI. Obesity was associated with more first and recurrent heart failure events. However, there was no significant interaction between obesity and treatment effects of the atrial shunt. Conclusions: Increasing severity of obesity was associated with greater cardiac remodelling, higher right and left ventricular filling pressures, higher cardiac output and increased subsequent heart failure events. Despite significant obesity, many HFpEF patients have preserved right heart and pulmonary vascular function and thus, may be appropriate candidates for atrial shunt therapy. [ABSTRACT FROM AUTHOR]

Background: The response to cardiac resynchronization therapy (CRT) depends on septal viability and correction of abnormal septal motion. This study investigates if cardiac magnetic resonance (CMR) as a single modality can identify CRT responders with combined imaging of pathological septal motion (septal flash) and septal scar. Methods: In a prospective, multicenter, observational study of 136 CRT recipients, septal scar was assessed using late gadolinium enhancement (LGE) (n = 127) and septal flash visually from cine CMR sequences. The primary endpoint was CRT response, defined as ≥15% reduction in LV end-systolic volume with echocardiography after 6 months. The secondary endpoint was heart transplantation or death of any cause assessed after 39 ± 13 months. Results: Septal scar and septal flash were independent predictors of CRT response in multivariable analysis (both p < 0.001), while QRS duration and morphology were not. The combined approach of septal scar and septal flash predicted CRT response with an area under the curve of 0.86 (95% confidence interval (CI): 0.78–0.94) and was a strong predictor of long-term survival without heart transplantation (hazard ratio 0.27, 95% CI: 0.10–0.79). The accuracy of the approach was similar in the subgroup with intermediate (130–150 ms) QRS duration. The combined approach was superior to septal scar and septal flash alone (p < 0.01). Conclusions: The combined assessment of septal scar and septal flash using CMR as a single-image modality identifies CRT responders with high accuracy and predicts long-term survival. [ABSTRACT FROM AUTHOR]

Background and aim: The presence of mechanical dyssynchrony on echocardiography is associated with reverse remodelling and decreased mortality after cardiac resynchronization therapy (CRT). Contrarily, myocardial scar reduces the effect of CRT. This study investigated how well a combined assessment of different markers of mechanical dyssynchrony and scarring identifies CRT responders. Methods: In a prospective multicentre study of 170 CRT recipients, septal flash (SF), apical rocking (ApRock), systolic stretch index (SSI), and lateral-to-septal (LW-S) work differences were assessed using echocardiography. Myocardial scarring was quantified using cardiac magnetic resonance imaging (CMR) or excluded based on a coronary angiogram and clinical history. The primary endpoint was a CRT response, defined as a ≥15% reduction in LV end-systolic volume 12 months after implantation. The secondary endpoint was time-to-death. Results: The combined assessment of mechanical dyssynchrony and septal scarring showed AUCs ranging between 0.81 (95%CI: 0.74–0.88) and 0.86 (95%CI: 0.79–0.91) for predicting a CRT response, without significant differences between the markers, but significantly higher than mechanical dyssynchrony alone. QRS morphology, QRS duration, and LV ejection fraction were not superior in their prediction. Predictive power was similar in the subgroups of patients with ischemic cardiomyopathy. The combined assessments significantly predicted all-cause mortality at 44 ± 13 months after CRT with a hazard ratio ranging from 0.28 (95%CI: 0.12–0.67) to 0.20 (95%CI: 0.08–0.49). Conclusions: The combined assessment of mechanical dyssynchrony and septal scarring identified CRT responders with high predictive power. Both visual and quantitative markers were highly feasible and demonstrated similar results. This work demonstrates the value of imaging LV mechanics and scarring in CRT candidates, which can already be achieved in a clinical routine. [ABSTRACT FROM AUTHOR]

Aim: we sought to test the inter‐center reproducibility of 16 echo laboratories involved in the EACVI‐Afib Echo Europe. Methods: This was done on a dedicated setting of 10 patients with sinus rhythm (SR) and 10 with persistent atrial fibrillation (AF), collected by the Principal Investigator. Images and loops of echo‐exams were stored and made available for labs. The tested measurements included main echo‐Doppler parameters, global longitudinal strain (GLS) and peak atrial longitudinal strain (PALS). Results: Single measures interclass correlation coefficients (ICCs) of left ventricular mass and ejection fraction were suboptimal in both patients with SR and AF. Among diastolic parameters, ICCs of deceleration time were poor, in particular in AF (=.50). ICCs of left atrial size and function, besides optimal in AF, showed an acceptable despite moderate concordance in SR. ICC of GLS was.81 and.78 in SR and AF respectively. ICCs of PALS were suitable but lower in 4‐chamber than in 2‐chamber view. By depicting the boxplot of the 16 laboratories, GLS distribution was completely homogeneous in SR, whereas GLS of AF and PALS of both SR and AF presented a limited number of outliers. GLS mean ± SE of the 16 labs was 19.7 ±.36 (95% CI: 18.8‐20.4) in SR and 16.5 ±.29 (95% CI: 15.9‐17.1) in AF, whereas PALS mean ± SE was 43.8 ±.70 (95% CI: 42.3‐45.3) and 10.2 ±.32 (95% CI: 9.5‐10.9) respectively. Conclusion: While the utilization of some standard‐echo variables should be discouraged in registries, the application of GLS and PALS could be largely promoted because their superior reproducibility, even in AF. [ABSTRACT FROM AUTHOR]

Serial transthoracic echocardiographic (TTE) assessment of LVEF and GLS are the gold standard in screening Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD). Non-invasive left-ventricle (LV) pressure–strain loop (PSL) emerged as a novel method to quantify Myocardial Work (MW). This study aims to describe the temporal changes and longitudinal trajectories of MW indices during cardiotoxic treatment. We included 50 breast cancer patients with normal LV function referred for anthracycline therapy w/wo Trastuzumab. Medical therapy, clinical and echocardiographic data were recorded before and 3, 6, and 12 months after initiation of the chemotherapy. MW indices were calculated through PSL analysis. According to ESC guidelines, mild and moderated CTRCD was detected in 10 and 9 patients, respectively (20% CTRCDmild, 18% CTRCDmod), while 31 patients remained free of CTRCD (62% CTRCDneg). Prior to chemotherapy MWI, MWE and CW were significantly lower in CTRCDmod than in CTRCDneg and CTRCDmild. Overt cardiac dysfunction in CTRCDmod at 6 months was accompanied by significant worse values in MWI, MWE and WW compared to CTRCDneg and CTRCDmild. MW features such as low baseline CW, especially when associated with a rise in WW at follow-up, may identify patients at risk for CTRCD. Additional studies are needed to explore the role of MW in CRTCD. [ABSTRACT FROM AUTHOR]

Response to cardiac resynchronization therapy (CRT) is reduced in patients with high left ventricular (LV) scar burden, in particular when scar is located in the LV lateral wall or septum. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can identity scar, but is not feasible in all patients. This study investigates if myocardial metabolism by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and contractile function by echocardiographic strain are alternatives to LGE-CMR. In a prospective multicenter study, 132 CRT candidates (91% with left bundle branch block) were studied by speckle tracking strain echocardiography, and 53 of these by FDG-PET. Regional myocardial FDG metabolism and peak systolic strain were compared to LGE-CMR as reference method. Reduced FDG metabolism (<70% relative) precisely identified transmural scars (≥50% of myocardial volume) in the LV lateral wall, with area under the curve (AUC) 0.96 (95% confidence interval (CI) 0.90–1.00). Reduced contractile function by strain identified transmural scars in the LV lateral wall with only moderate accuracy (AUC = 0.77, CI 0.71–0.84). However, absolute peak systolic strain >10% could rule out transmural scar with high sensitivity (80%) and high negative predictive value (96%). Neither FDG-PET nor strain identified septal scars (for both, AUC < 0.80). In CRT candidates, FDG-PET is an excellent alternative to LGE-CMR to identify scar in the LV lateral wall. Furthermore, preserved strain in the LV lateral wall has good accuracy to rule out transmural scar. None of the modalities can identify septal scar. The present study is part of the clinical study "Contractile Reserve in Dyssynchrony: A Novel Principle to Identify Candidates for Cardiac Resynchronization Therapy (CRID–CRT)", which was registered at clinicaltrials.gov (identifier NCT02525185). The ability of peak systolic strain by echocardiography and glucose metabolism by FDG-PET to identify transmural LV lateral and septal scar in CRT candidates compared to LGE-CMR, illustrated in three representative patients. LGE-CMR (left images) allows for direct scar identification independent of wall motion, and was used as reference standard for scar. Peak systolic strain by echocardiography (middle images) was generally inconclusive of scar, but absolute strain >10% in the LV lateral wall implies that transmural scar in this region is unlikely. Glucose metabolism by FDG-PET (right images) accurately identified transmural LV lateral wall scar, but was unable to distinguish transmural septal scar from septal hypo-metabolism due to left bundle branch block in itself. FDG-PET = 18F-fluorodeoxyglucose Positron Emission Tomography; LV = left ventricular; CRT = cardiac resynchronization therapy; LGE = late gadolinium enhancement; CMR = cardiac magnetic resonance. [Display omitted] • FDG-PET is a good alternative to CMR to identify transmural left ventricular lateral wall scars in patients referred for CRT. • Strain by echocardiography is only moderately accurate, but relatively preserved strain (>10%) in the lateral wall strain means that transmural scar in this region is unlikely. • Contrary to preserved strain, reduced strain in the lateral wall is inconclusive with regard to scar. • Neither FDG-PET nor echocardiographic strain identifies septal scar. [ABSTRACT FROM AUTHOR]

Aim: To investigate the value of prospective in-hospital registry data and the impact of an infectious endocarditis heart team approach (IEHT) on improvement in quality of care and monitor outcomes in hospitalized patients with IE. Methods: Between December 2014 and the end of 2019, 160 patients were hospitalized in one centre with the definite diagnosis of infectious endocarditis (IE) and entered in a prospective registry. From 2017, an IEHT was introduced. Propensity score matching was used to assess the impact of an IEHT approach on clinical outcomes. Results: Median age was 72.5 y (62.75–80.00), diabetes was present in 33.1%, chronic kidney disease in 27.5%, COPD in 17.5%, and a history of ischaemic heart disease in 30.6%. Prosthetic valve IE was observed in 43.8% and device-related IE in 16.9% of patients. Staphylococcus (37.5%) was the most frequent pathogen followed by streptococcus (24.4%) and enterococcus (23.1%). Overall, 30-day and 1-year mortality were 19.4% and 37.5%, respectively. The introduction of prospective data collection and IE heart team was associated with a trend towards reduction of adjusted 1-year mortality (26.5% IEHT vs. 41.2% controls, p = 0.0699). An IEHT clinical decision-making approach was independently associated with a shorter length of stay (p = 0.04). Conclusions: Use of a prospective registry of IE coupled with a heart team approach was associated with more efficient patient management and a trend towards lower mortality. Prospective data collection and dedicated IEHT have the potential to improve patient care and clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: In patients at risk of cancer therapy-related cardiac dysfunction (CTRCD), initiation of cardioprotective therapy (CPT) is constrained by the low sensitivity of ejection fraction (EF) for minor changes in left ventricular (LV) function. Global longitudinal strain (GLS) is a robust and sensitive marker of LV dysfunction, but existing observational data have been insufficient to support a routine GLS-guided strategy for CPT.Objectives: This study sought to identify whether GLS-guided CPT prevents reduction in LVEF and development of CTRCD in high-risk patients undergoing potentially cardiotoxic chemotherapy, compared with usual care.Methods: In this international, multicenter, prospective, randomized controlled trial, 331 anthracycline-treated patients with another heart failure risk factor were randomly allocated to CPT initiation guided by either ≥12% relative reduction in GLS (n = 166) or >10% absolute reduction of LVEF (n = 165). Patients were followed for EF and development of CTRCD (symptomatic EF reduction of >5% or >10% asymptomatic to <55%) over 1 year.Results: Of 331 randomized patients, 2 died, and 22 withdrew consent or were lost to follow-up. Among 307 patients (age: 54 ± 12 years; 94% women; baseline LVEF: 59 ± 6%; GLS: -20.6 ± 2.4%) with a median (interquartile range) follow-up of 1.02 years (0.98 to 1.07 years), most (n = 278) had breast cancer. Heart failure risk factors were prevalent: 29% had hypertension, and 13% had diabetes mellitus. At the 1-year follow-up, although the primary outcome of change in LVEF was not significantly different between the 2 arms, there was significantly greater use of CPT, and fewer patients met CTRCD criteria in the GLS-guided than the EF-guided arm (5.8% vs. 13.7%; p = 0.02), and the 1-year EF was 57 ± 6% versus 55 ± 7% (p = 0.05). Patients who received CPT in the EF-guided arm had a larger reduction in LVEF at follow-up than in the GLS-guided arm (9.1 ± 10.9% vs. 2.9 ± 7.4%; p = 0.03).Conclusions: Although the change in LVEF was not different between the 2 arms as a whole, when patients who received CPT were compared, those in the GLS-guided arm had a significantly lower reduction in LVEF at 1 year follow-up. Furthermore, GLS-guided CPT significantly reduced a meaningful fall of LVEF to the abnormal range. The results support the use of GLS in surveillance for CTRCD. (Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes [SUCCOUR]; ACTRN12614000341628). [ABSTRACT FROM AUTHOR]

Introduction: Ejection fraction (EF) has been widely used in the assessment of LV function but global longitudinal strain (GLS) is more reproducible and has been adopted in cardio-oncology recommendations. The assessment of systolic function in clinical trials needs concordance both between sites and over time, and we sought whether GLS was preferable to EF. Hypothesis: The concordance between sites and core laboratory (CL) of GLS exceeds that of EF over the medium to long-term. Methods: In order to standardize LV function measurement before starting an international multicenter randomised controlled trial in cardio-oncology (SUCCOUR), all readers completed a two-staged calibration sessions with tailored feedback. GLS at baseline, 3 and 6 month follow-up (3MFU & 6MFU) were measured at 18 different sites and CL. Coefficient of variation (CV) was used to determine concordance between each site and CL. Results: During the calibration sessions, the CV of 1st and 2nd sessions were 4.5±3.1% and 4.0±2.9%. Sites enrolled their first participant within 4.5±5.5 months after the calibration session. First 74 patients (53±13 years, 67 female; 67 breast ca and 7 lymphoma) who completed their 6MFU (ie 10.5 months from baseline) were used to assess long-term concordance. GLS measured by CL and site were similar at baseline (-21.0±2.4 and -20.1±2.0%), 3MFU (-19.6±2.2 and -19.2±2.1%), and 6MFU (-19.5±2.5 and -19.0±2.6%), respectively. The CV of GLS at baseline, 3MFU and 6MFU remained stable at 5.1±3.6, 4.1±3.5 and 4.6±3.1%. In contract, the CV of EF at baseline, 3MFU and 6MFU gradually and continuously increased from 4.5±3.4 to, 5.1±3.5% and 5.8±4.7%. The trends in CVs of GLS and EF were statistically significantly different (p=0.03, Figure). Conclusion: After initial quality control and training, the robustness of GLS remained stable with good precision between core laboratory and site readers compared with those of EF. [ABSTRACT FROM AUTHOR]

Since the first report on biventricular pacing in 1994, cardiac resynchronization therapy (CRT) has become standard for patients with advanced heart failure (HF) and ventricular conduction delay. CRT improves myocardial function by resynchronizing myocardial contraction, which results in reverse left ventricular remodeling and improves symptoms and clinical outcomes. Despite the accelerated development of CRT device technology and its increased application in treating HF patients, almost one-third of these patients do not respond to the therapy or gain any clinical benefit from device implantation. Over the last decade, multiple cardiac imaging modalities have provided a deeper understanding of myocardial pathophysiology, thereby improving HF treatment management. However, the optimal strategy for improving the CRT response remains debatable. This article provides an updated overview of the electropathophysiology of myocardial dysfunction in ventricular conduction delay and the diagnostic approaches involving the use of multiple modalities. [ABSTRACT FROM AUTHOR]

Patients with severe aortic stenosis (AS) show progressive fibrotic changes in the myocardium, which may impair cardiac function and patient outcomes even after successful aortic valve replacement. Detection of patients who need an early operation remains a diagnostic challenge as myocardial functional changes may be subtle. In recent years, speckle tracking echocardiography (STE) and cardiac magnetic resonance mapping have been shown to provide complementary information for the assessment of left ventricular mechanics and identification of subtle damage by focal or diffuse myocardial fibrosis, respectively. Little is known, however, about how focal and diffuse myocardial fibrosis occurring in severe AS are related to measurable functional changes by echocardiography and to which extent both parameters have prognostic and diagnostic value. The aims of this review are to discuss the occurrence of focal and diffuse myocardial fibrosis in patients with severe AS and to explore their relation with myocardial function, determined by STE, as well as the prognostic and diagnostic potential of both parameters. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To investigate whether and in which patients with catheter-derived low pressure gradient (PG, <40 mmHg) severe (aortic valve area ≤1 cm²) aortic stenosis and preserved left ventricular ejection fraction, early aortic valve replacement (AVR) might improve survival. METHODS: We investigated a total of 506 consecutive patients (age 75 ± 9 years, 58% men) with either moderate aortic stenosis (MAS) or severe aortic stenosis (SAS) and preserved left ventricular ejection fraction (≤50%) as defined at catheterization. Propensity score matching was used to select matched pairs of patients with and without AVR in each group. A 100% complete follow-up of all cause death was obtained after a median of 6.6 years (interquartile range 3.4-8.8 years). RESULTS: There were 62 (12%) patients with MAS, 119 (24%) patients with SAS and low (<40 mmHg) PG and 325 (64%) patients with SAS and high PG. Significantly less patients with MAS and low-gradient SAS underwent AVR compared to patients with high gradient SAS (58% vs 60% vs 83%, P < 0.001). In propensity score-matched patients, AVR was independently associated with a decrease in all-cause mortality in all groups (P < 0.05) regardless of the PG, stroke volume or aortic valve area. CONCLUSIONS: The present data indicate a that AVR improves survival in SAS regardless of the gradient and flow. This advocates an 'early-AVR' rather than a 'watchful waiting' strategy. [ABSTRACT FROM AUTHOR]

Background: In nonrandomized, open-label studies, a transcatheter interatrial shunt device (IASD, Corvia Medical) was associated with lower pulmonary capillary wedge pressure (PCWP), fewer symptoms, and greater quality of life and exercise capacity in patients with heart failure (HF) and midrange or preserved ejection fraction (EF ≥40%). We conducted the first randomized sham-controlled trial to evaluate the IASD in HF with EF ≥40%.Methods: REDUCE LAP-HF I (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure) was a phase 2, randomized, parallel-group, blinded multicenter trial in patients with New York Heart Association class III or ambulatory class IV HF, EF ≥40%, exercise PCWP ≥25 mm Hg, and PCWP-right atrial pressure gradient ≥5 mm Hg. Participants were randomized (1:1) to the IASD versus a sham procedure (femoral venous access with intracardiac echocardiography but no IASD placement). The participants and investigators assessing the participants during follow-up were blinded to treatment assignment. The primary effectiveness end point was exercise PCWP at 1 month. The primary safety end point was major adverse cardiac, cerebrovascular, and renal events at 1 month. PCWP during exercise was compared between treatment groups using a mixed-effects repeated measures model analysis of covariance that included data from all available stages of exercise.Results: A total of 94 patients were enrolled, of whom 44 met inclusion/exclusion criteria and were randomized to the IASD (n=22) and control (n=22) groups. Mean age was 70±9 years, and 50% were female. At 1 month, the IASD resulted in a greater reduction in PCWP compared with sham control (P=0.028 accounting for all stages of exercise). Peak PCWP decreased by 3.5±6.4 mm Hg in the treatment group versus 0.5±5.0 mm Hg in the control group (P=0.14). There were no peri-procedural or 1-month major adverse cardiac, cerebrovascular, and renal events in the IASD group and 1 event (worsening renal function) in the control group (P=1.0).Conclusions: In patients with HF and EF ≥40%, IASD treatment reduces PCWP during exercise. Whether this mechanistic effect will translate into sustained improvements in symptoms and outcomes requires further evaluation.Clinical Trial Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT02600234. [ABSTRACT FROM AUTHOR]

Background: Automatic accurate measuring of the aortic annulus and determination of the optimal angulation of X-ray projection are important for the trans-catheter aortic valve replacement (TAVR) procedure. The objective of this study was to present a novel fully automatic methodology for the quantification of the aortic annulus in computed tomography angiography (CTA) images.Methods: CTA datasets of 26 patients were analyzed retrospectively with the proposed methodology, which consists of a knowledge-based segmentation of the aortic root and detection of the orientation and size of the aortic annulus. The accuracy of the methodology was determined by comparing the automatically derived results with the reference standard obtained by semi-automatic delineation of the aortic root and manual definition of the annulus plane.Results: The difference between the automatic annulus diameter and the reference standard by observer 1 was 0.2±1.0mm, with an inter-observer variability of 1.2±0.6mm. The Pearson correlation coefficient for the diameter was good (0.92 for observer 1). For the first time, a fully automatic tool to assess the optimal projection curves was presented and validated. The mean difference between the optimal projection curves calculated based on the automatically defined annulus plane and the reference standard was 6.4° in the cranial/caudal (CRA/CAU) direction. The mean computation time was short with around 60s per dataset.Conclusion: The new fully automatic and fast methodology described in this manuscript not only provided precise measurements about the aortic annulus size with results comparable to experienced observers, but also predicted optimal X-ray projection curves from CTA images. [ABSTRACT FROM AUTHOR]

The load dependence of global longitudinal strain (GLS) means that changes in systolic blood pressure (BP) between visits may confound the diagnosis of cancer-treatment-related cardiac dysfunction (CTRCD). We sought to determine whether the estimation of myocardial work, which incorporates SBP, could overcome this limitation. In this case–control study, 44 asymptomatic patients at risk of CTRCD underwent echocardiography at baseline and after oncologic treatment. CTRCD was defined on the basis of the change in the ejection fraction. Those with CTRCD were divided into subsets with and without a follow-up SBP increment >20 mmHg (CTRCD+BP+ and CTRCD+BP−), and matched with patients without CTRCD (CTRCD−BP+ and CTRCD−BP−). The work index (GWI), constructive work (GCW), wasted work (GWW), and work efficiency (GWE) were assessed in addition to the GLS. The largest increases in the GWI and GCW at follow-up were found in CTRCD−BP+ patients. The CTRCD+BP− patients demonstrated significantly larger decreases in GWI and GCW than their CTRCD+BP+ and CTRCD−BP− peers. ROC analysis for the discrimination of LV functional changes in response to increased afterload in the absence of cardiotoxicity revealed higher AUCs for GCW (AUC = 0.97) and GWI (AUC = 0.93) than GLS (AUC = 0.73), GWW (AUC = 0.51), or GWE (AUC = 0.63, all p-values < 0.001). GCW (OR: 1.021; 95% CI: 1.001–1.042; p < 0.04) was the only feature independently associated with CTRCD−BP+. Myocardial work is superior to GLS in the serial assessments in patients receiving cardiotoxic chemotherapy. The impairment of GLS in the presence of an increase in GWI and GCW indicates the impact of elevated afterload on LV performance in the absence of actual myocardial impairment. [ABSTRACT FROM AUTHOR]

The article presents the images used to diagnose the endocarditis of left ventricular apical patch in an 82-year-old man. The patient presented with septic fever and chills in May 2005. He had undergone an aneurysmectomy of the left ventricular apial aneurysm in September 2004. The echocardiography had poor image quality but cardiac magnetic resonance showed apical pseudoaneurysm. Another cavity was observed distally from the pseudoaneurysm.

The article presents a letter to the editor in response to the articles "Dopamine agonists and the risk of cardiac-valve regurgitation," by R. Schade and colleagues and "Valvular heart disease and the use of dopamine agonists for Parkinson's disease," by R. Zanettini and colleagues in the January 4, 2007 issue.

Stem cell therapy has emerged as a potential therapeutic option for cell death-related heart diseases. Preclinical and a number of early phase human studies suggested that cell therapy may augment perfusion and increase myocardial contractility. The rapid translation into clinical trials has left many issues unresolved, and emphasizes the need for specific techniques to visualize the mechanisms involved. Furthermore, the clinical efficacy of cell therapy remains to be proven. Imaging allows for in vivo tracking of cells and can provide a better understanding in the evaluation of the functional effects of cell-based therapies. In this review, a summary of the most promising imaging techniques for cell tracking is provided. Among these are direct labeling of cells with super-paramagnetic agents, radionuclides, and the use of reporter genes for imaging of transplanted cells. In addition, a comprehensive summary is provided of the currently available studies investigating a cell therapy-related effect on left ventricular function, myocardial perfusion, scar tissue, and myocardial viability. [Copyright &y& Elsevier]

The in vivo cardiac differentiation and functional effects of unmodified adult bone marrow mesenchymal stem cells (MSCs) after myocardial infarction (MI) is controversial. We postulated that ex vivo pretreatment of autologous MSCs using cardiomyogenic growth factors will lead to cardiomyogenic specification and will result in superior biological and functional effects on cardiac regeneration of chronically infarcted myocardium. We used a chronic dog MI model generated by ligation of the coronary artery (n = 30). Autologous dog bone marrow MSCs were isolated, culture expanded, and specified into a cardiac lineage by adding growth factors, including basic FGF, IGF-1, and bone morphogenetic protein-2. Dogs underwent cell injection >8 wk after the infarction and were randomized into two groups. Group A dogs (n = 20) received MSCs specified with growth factors (147 ± 96 X 106), and group B (n = 10) received unmodified MSCs (168 ± 24 X 106). After the growth factor treatment, MSCs stained positive for the early muscle and cardiac markers desmin, antimyocyte enhancer factor-2, and Nkx2-5. In group A dogs, prespecified MSCs colocalized with troponin I and cardiac myosin. At 12 wk, group A dogs showed a significantly larger increase in regional wall thickening of the infarcted territory (from 22 ± 8 to 32 ± 6% in group A; P < 0.05 vs. baseline and group B, and from 19 ± 7 to 21 ± 7% in group B, respectively) and a decrease in the wall motion score index (from 1.60 ± 0.05 to 1.35 ± 0.03 in group A; P < 0.05 vs. baseline and group B, and from 1.58 ± 0.07 vs. 1.56 ± 0.08 in group B, respectively). The biological ex vivo cardiomyogenic specification of adult MSCs before their transplantation is feasible and appears to improve their in vivo cardiac differentiation as well as the functional recovery in a dog model of the chronically infarcted myocardium. [ABSTRACT FROM AUTHOR]

Introduction: There are no data about the prevalence of masked/latent coronary artery disease (CAD) in asymptomatic patients with severe aortic stenosis (AS) and normal exercise testing (ET) Hypothesis: We hypothesized there will be masked CAD in asymptomatic severe AS patients with normal ET. Importantly, this phenomena could influence the choice and timing of treatment in these patients Methods: We analyzed patients from the cohort screened for Avatar trial eligibility (NCT02436655). ET was performed on semi-supine ergobicycle.Cardiopulmonary analysis during ET (CPET) as well as comprehensive echo and laboratory analysis at rest was done.Standard clinical and ECG criteria were assessed for symptoms and signs of ischemia during and after ET. At least 80% of maximal heart rate had to be achieved in order for ET to be conclusive. In patients with normal ET, coronary angiography (CA) was performed using the standard percutaneous femoral/radial approach. Coronary stenosis was considered significant if >70% of vessel diameter or 50-70% with Fractional Flow Reserve ≤0.8 Results: Total of 92 patients with normal ET were included in this analysis (mean age 67.62±9.68, 51.4% males). During the testing or recovery phase no patient had any complication or adverse event. The Pmean was 52.71±11.67 mmHg, mean AVAi 0.36±0.08cm2/m2, mean LVEF 69.51%±7.51%. 18/92 patients (19.54%) had CAD on CA. There was no difference in analyzed CPET, echo parameters and valvulo-arterial impedance between patients with and without CAD (p>0.05). When we compared patients depending on whether they had one-vessel (10/18 pts) or multivessel/left main CAD there was no difference in any of the parameters (p>0.05).According to multivariate logistic regression analysis BNP and blood glucose were independent predictors of masked CAD. The BNP value of 118 pg/ml had sensitivity and specificity of 63 and 73% for predicting CAD in asymptomatic severe AS patients with normal LVEF (AUC 0.727, p=0.006), figure 1. Conclusions: Results of this study are the first to show the prevalence of masked CAD in asymptomatic patients with severe AS, normal LVEF and normal ET. Even in patients with normal ET, significant CAD is present in as many as 1/5 patients. BNP might be of help to suspect patients with latent CAD [ABSTRACT FROM AUTHOR]