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Right ventricular-pulmonary artery coupling (RVPAC) is a predictor of outcome in pulmonary hypertension. However, the role of this parameter in dilated cardiomyopathy (DCM) remains to be established. The aim of this study was to assess the contribution of RVPAC to the occurrence of severe heart failure (HF) symptoms in patients with DCM using three-dimensional (3D) echocardiography.We prospectively screened 139 outpatients with DCM, 105 of whom were enrolled and underwent 3D echocardiographic assessment. RVPAC was estimated non-invasively as the 3D right ventricular stroke volume (SV) to end-systolic volume (ESV) ratio. Severe HF symptoms were defined by New York Heart Association (NYHA) class III or IV. We evaluated differences in RVPAC across NYHA classes and the ability of RVPAC to predict severe symptoms.Mean left ventricular (LV) ejection fraction was 28±7%. Mean RVPAC was 0.77±0.30 and it was significantly more impaired with increasing symptom severity (p = 0.001). RVPAC was the only independent determinant of severe HF symptoms, after adjusting for age, diuretic use, LV systolic function, LV diastolic function, and pulmonary artery systolic pressure (OR 0.035 [95% CI, 0.004-0.312], p = 0.003). By receiver-operating characteristic analysis, the RVPAC cut-off value for predicting severely symptomatic status was 0.54 (area under the curve = 0.712, p 0.001).3D echocardiographic SV/ESV ratio is an independent correlate of severe HF symptoms in patients with DCM. 3D RVPAC might prove to be a useful risk stratification tool for these patients, should it be further validated in larger studies.

BACKGROUND Right ventricular - arterial (RV-PA) coupling can be estimated by echocardiography using the ratio between (TAPSE) and pulmonary arterial systolic pressure (PASP). TAPSE/PASP ratio proved to be a prognostic parameter in patients with heart failure and reduced ejection fraction (HFrEF). OBJECTIVE To evaluate the significance of RV-PA coupling in patients with HFrEF undergoing cardiac resynchronization therapy (CRT). METHODS Patients undergoing CRT in our center between January 2017 and November 2019 were eligible. Response to CRT was defined by a reduction of more than 15% of left ventricle systolic volume (LVESV) one year after CRT. Primary endpoint was a composite of HF hospitalizations and death during follow-up. RESULTS 54 patients (Age 64.0 ± 13.8 years; 58% male; left ventricular ejection fraction (LVEF) 28.4 ± 1.3%) were prospectively included. After a mean follow-up of 31 ± 12.9months, the primary endpoint had occurred in 18 (33.3%) patients. A lower TAPSE/PASP ratio was associated with baseline worse HF symptoms, lower LVEF and long-term less LV reverse remodeling (P

Objectives To provide preliminary data on practice of stress perfusion cardiovascular magnetic resonance (CMR) in a single center in Romania. Methods We retrospectively reviewed the clinical files and CMR reports of patients who underwent stress perfusion CMR in our institution between January 2018 and December 2020. Results A total of 1036 patients underwent CMR examinations during this period in our institution. Of these, 120 patients had stress perfusion CMR. The most common indication was the assessment of myocardial ischaemia in patients with established coronary artery disease (CAD) (77 patients, 64.16%), with either a history of myocardial infarction or previous coronary revascularization, or with intermediate lesions on invasive coronary angiography (ICA). The other indications consisted in detection of ischaemia in patients with suspected CAD (36 patients, 30%), characterization of the substrate of ventricular arrhythmia (5 patients, 4.16%) and assessment of the etiology of dilated cardiomyopathy (DCM) (4 patients, 3.33%). All patients had vasodilator stress with adenosine and an adequate stress response was obtained in 113 patients (94.16%). There were 21 patients (18.58%) with an abnormal stress test and patients with intermediate lesions on ICA had the highest prevalence of positive reports (24.32%). Sixty-three patients had myocardial fibrosis (52.5%): 49 patients (40.83%) had subendocardial (ischaemic) scars, while 14 patients (11.66%) had non-ischaemic scars. There were no serious adverse events related to the procedure. Conclusions This is the first report in Romania on the use of stress perfusion CMR in clinical practice. We report our experience on stress efficiency, acquisition protocol, artifacts, prevalence of positive tests and safety. Most stress CMRs were requested in patients with established CAD.

Degenerative aortic valve (AV) disease is the most frequent valvular heart disease slowly progressing to severe aortic stenosis (AS) which usually requires aortic valve replacement. Another frequent condition, especially among elderly people, is cardiac amyloidosis (CA), particularly the wild-type transthyretin cardiac amyloidosis (ATTRwt). Since both of these diseases are considered a marker of ageing, there is a significant proportion of elderly patients who associate both severe AS and CA. Recent studies reported a high prevalence of both severe AS and CA (AS-CA) in elderly patients referred for TAVR of 13-16%, carrying a worse prognosis. The present case illustrates the diagnostic algorithm and the management of ATTRwt CA in an elderly patient with severe paradoxical low-flow low-gradient AS, accompanied by a review of the current literature about the red flags which help identifying CA in patients with severe AS, as well as the prognosis and management of these disease association.

Background Ventricular arrhythmias are the most frequent cause of sudden cardiac death in individuals with hypertrophic cardiomyopathy (HCM). In the present study we investigated if combined left ventricular (LV) and right ventricular (RV) mechanical dispersion (MD) are correlated with ventricular arrhythmias. We aimed also to analyze if MD enhances the arrhythmic risk stratification in HCM. Methods The cohort included 47 subjects with HCM and 36 healthy individuals. All the studied population underwent clinical, 24-h electrocardiographic (ECG) monitoring for detection and description of non-sustained ventricular tachycardia (NSVT) in terms of number of events, maximal rate and length and comprehensive transthoracic echocardiography, including strain rate imaging. MD was calculated as standard deviation of time from the peak of R wave on ECG to maximum LV or RV shortening in 17 LV and 3 RV segments. Results HCM subjects with NSVT on ECG monitoring had increased LVMD (81 ± 18 ms vs 42 ± 8 ms) and RVMD (52 ± 26 vs 25 ± 23 ms) compared with the HCM group without NSVT or compared with the healthy controls. On receiver operating characteristic curves the cut-off values associated with optimal specificity and sensitivity were 62 ms for LVMD and 39 ms for RVMD. LVMD (OR = 1.86, 95% CI 1–1.06, p = 0.01) and RVMD (OR = 1.04, 95% CI 1.01–1.07, p = 0.003) were the only independent variables that correlated with longer and faster NSVT and furthermore improved the risk stratification of NSVTs. Conclusions In a cohort of subjects with HCM, LVMD and RVMD correlates with the presence of NSVT on ECG monitoring. Combined LVMD and RVMD may improve the risk stratification of HCM with NSVT.

Atrial phasic function can be assessed using speckle-tracking and three-dimensional (3D) echocardiography. The extent and role of right atrial (RA) dysfunction in left-sided heart failure (HF) is incompletely understood. We aimed to characterize RA phasic function in HF with reduced ejection fraction (HFrEF) and to assess its prognostic significance.We prospectively enrolled 60 patients with HFrEF and 29 normal controls. RA phasic function was assessed using strain curves derived from speckle-tracking echocardiography and 3D volumetric analysis. Patients were followed for a composite endpoint of cardiac death or rehospitalization for HF.After a mean follow-up of 19 (9) months, 33 patients reached the primary endpoint. Patients with HFrEF and adverse outcomes showed an impairment of both reservoir, conduit, and booster pump RA function when compared to controls. After adjustment for age, left ventricular systolic and diastolic function, right ventricular systolic function and pulmonary artery pressure, RA maximal and minimal volumes, as well as passive emptying fraction, remained independent predictors of death or rehospitalization (hazard ratio [HR], 3.207; 95% confidence interval [CI], 1.288-7.984; P = 0.012; HR, 2.362, 95% CI, 1.004-5.552; P = 0.049; and HR, 2.367; 95% CI, 1.066-5.259; P = 0.034, respectively).All three components of RA phasic function are impaired in left-sided HF. 3D RA maximal and minimal volumes, as well as 3D RA passive emptying fraction, are independent predictors of adverse outcomes in HFrEF.

Right ventricular (RV) pulmonary artery coupling (RVPAC) is a predictor of outcome in left-sided heart failure (HF). Several echocardiographic estimates for RVPAC have been proposed.This study aimed to compare multiple non-invasive methods to calculate RVPAC and to assess its prognostic role in patients with dilated cardiomyopathy (DCM).We prospectively enrolled 60 stable patients with DCM. RVPAC was estimated using five methods: as the tricuspid annular plane excursion/pulmonary artery systolic pressure (PASP) ratio; as the RV global longitudinal strain/PASP ratio; as the RV free wall strain (RVFW-LS)/PASP ratio; as the three-dimensional (3D) RV ejection fraction (RVEF)/PASP ratio; and as the 3D RV stroke volume (SV)/end-systolic volume (ESV) ratio. Patients were followed for a mean period of 18 (9) months for the endpoint of HF rehospitalizations.Twenty-nine patients (48%) reached the endpoint. All RVPAC estimates were more impaired in those patients reaching the endpoint (P0.001 for all) and all predicted rehospitalizations in un-adjusted analysis. RVFW-LS/PASP and RVEF/PASP remained independent predictors of events, after adjustment for clinical and echocardiographic confounders. Using cut-offs obtained from receiver operating characteristic (ROC) analysis, we found that patients with RVFW-LS/PASP-0.40 and patients with RVEF/PASP1.30 had a higher risk of HF rehospitalization (log-rank P = 0.001 and P = 0.002, respectively).RVFW-LS/PASP and RVEF/PASP as non-invasive estimates of RVPAC are independent predictors of HF rehospitalization in patients with DCM.

Background: Right ventricular-pulmonary artery coupling (RVPAC) is a predictor of outcome in pulmonary hypertension. However, the role of this parameter in dilated cardiomyopathy (DCM) remains to be established. The aim of this study was to assess the contribution of RVPAC to the occurrence of severe heart failure (HF) symptoms in patients with DCM using three-dimensional (3D) echocardiography. Methods: We prospectively screened 139 outpatients with DCM, 105 of whom were enrolled and underwent 3D echocardiographic assessment. RVPAC was estimated non-invasively as the 3D right ventricular stroke volume (SV) to end-systolic volume (ESV) ratio. Severe HF symptoms were defined by New York Heart Association (NYHA) class III or IV. We evaluated differences in RVPAC across NYHA classes and the ability of RVPAC to predict severe symptoms. Results: Mean left ventricular (LV) ejection fraction was 28±7%. Mean RVPAC was 0.77±0.30 and it was significantly more impaired with increasing symptom severity (p=0.001). RVPAC was the only independent correlate of severe HF symptoms, after adjusting for age, diuretic use, LV systolic function, LV diastolic function and pulmonary artery systolic pressure (OR 0.035 [95% CI, 0.004 – 0.312], p=0.003). By receiver-operating characteristic analysis, the RVPAC cut-off value for predicting severely symptomatic status was 0.54 (area under the curve=0.712, p

We present the case of a male patient, 34 years old, non-smoker, presenting repeatedly in the past 2 years in emergency and cardiology departments for episodes of palpitation accompanied by faitness. One of the electrocardiograms recorded in emergency department captures bigeminated ventricular premature heartbeats. A cardiac magnetic resonance imaging (MRI) examination in May 2019 showed increased thickness of left ventricle during systole and contrast enhancement in the middle of cardiac wall at the base of the heart, considered initially as hypertrophic non-obstructive cardiomyopathy. The reinterpretation of MRI suggested that the changes were typical for cardiac sarcoidosis. Investigations performed later showed increased angiotensin-converting enzyme (ACE); thoracic computed tomography (CT) scan showed nodules and micronodules bilateral in upper lobes with moderate mediastinal lymph node enlargement and bronchoalveolar lavage (BAL) showed lymphocytic alveolitis with normal CD4/CD8 ratio, normal lung function with normal diffusing capacity. Even without biopsy, but based on CT scan, BAL and ACE, the patient was diagnosed as sarcoidosis with lung and cardiac involvement and was started on oral corticosteroids (methylprednisolone 32 mg/day). The diagnosis of cardiac involvement as initial presentation of sarcoidosis is difficult, due to limited knowledge about the disease among cardiologists and radiologists. Though, a recurrent arrhythmia, potentially severe, in a young patient in the absence of an alternative cause, should raise the suspicion for sarcoidosis with cardiac involvement, with a potential severe outcome in the absence of treatment.

Background: Recent data suggest that the mechanisms contributing to ischaemic mitral regurgitation (IMR) in the setting of acute myocardial infarction (MI) are different compared to chronic IMR. However, little is known about the dynamic changes over time of mitral valve (MV) geometry after acute MI. Methods and results:Comprehensive three-dimensional (3D) assessment of the MV geometry was performed in 30 patients in the first 7 days after a first ST elevation myocardial infarction (STEMI), and after 4 years of follow-up. The MV annulus diameters and area remained unchanged over time, however the MA became progressively flatter (mean difference of annular height 0.19±0.33 cm, p

Hypertrophic cardiomyopathy (HCM) and arterial hypertension (HTN) are conditions with different pathophysiology, but both can result in left-ventricular hypertrophy (LVH). The role of left-atrial (LA) functional changes detected by two-dimensional speckle-tracking echocardiography (STE) in indicating LVH etiology is unknown. Methods: We aimed to characterize LA mechanics using STE in LVH patients with HCM and HTN. LA 2D volumetric and STE parameters were analyzed in 86 LVH patients (43 HCM and 43 isolated HTN subjects) and 33 age- and sex-matched controls. Results: The volumetric study showed that LA reservoir and conduit function were impaired in the HCM group compared to controls, while, in the HTN group, only LA conduit function was deteriorated. The HCM group had all three STE-derived LA functions impaired compared to controls. The HTN group, consistently with volumetric analysis, had solely LA conduit function reduced compared to controls. Ratios of LA booster-pump strain (S) and strain rate (SR) to interventricular septum (IVS) thickness were the most accurate parameters to discriminate between HCM and HTN. The subgroup harboring sarcomeric pathogenic (P)/likely pathogenic (LP) variants had reduced LA booster-pump S and SR compared with the genotype-negative subgroup. Conclusions: LA reservoir, conduit, and pump functions are decreased in HCM compared to HTN patients with similar LVH. We report the ratios between LA contraction S/SR and IVS thickness as novel parameters with high accuracy in discriminating LVH due to HCM. The presence of P/LP variants in sarcomeric or sarcomeric-associated genes could be associated with more severe LA dysfunction.

Several studies showed that right ventricular (RV) dysfunction is a powerful predictor in heart failure (HF). Advanced echocardiographic techniques such as speckle-tracking imaging and three-dimensional (3D) echocardiography proved to be accurate tools for RV assessment, but their clinical significance remains to be clarified. The aim of this study was to evaluate the role of two-dimensional (2D) RV strain and 3D ejection fraction (RVEF) in predicting adverse outcome in patients with non-ischemic dilated cardiomyopathy (DCM). We prospectively screened 81 patients with DCM and sinus rhythm, 50 of whom were enrolled and underwent comprehensive echocardiography, including RV strain and 3D RV volumetric assessment. Patients were followed for a composite endpoint of cardiac death, nonfatal cardiac arrest and acute worsening of HF requiring hospitalization. After a median follow-up of 16 months, 29 patients reached the primary endpoint. Patients with events had more impaired RV global longitudinal strain (− 10.5 ± 4.5% vs. − 14.3 ± 5.2%, p = 0.009), RV free wall longitudinal strain (− 12.9 ± 8.7% vs. − 17.5 ± 7.1%, p = 0.046) and 3D RVEF (38 ± 8% vs. 47 ± 9%, p = 0.001). By Cox proportional hazards multivariable analysis, RV global longitudinal strain and RVEF were independent predictors of outcome after adjustment for age and NYHA class. RVEF remained the only independent predictor of events after further correction for echocardiographic risk factors. By receiver-operating characteristic analysis, the optimal RVEF cut-off value for event prediction was 43.4% (area under the curve = 0.768, p = 0.001). Subjects with RVEF > 43.4% showed more favourable outcome compared to those with RVEF

During the last decade, studies have raised awareness of the crucial role that the right ventricle plays in various clinical settings, including diseases primarily linked to the left ventricle. The assessment of right ventricular performance with conventional echocardiography is challenging. Novel echocardiographic techniques improve the functional assessment of the right ventricle and they show good correlation with the gold standard represented by cardiac magnetic resonance. This review summarizes the traditional and innovative echocardiographic techniques used in the functional assessment of the right ventricle, focusing on the role of right ventricular dysfunction in heart failure with reduced ejection fraction and providing a perspective on recent evidence from literature.

Background Right ventricular-pulmonary artery coupling (RVPAC) reflects the mechanical efficiency of the interaction between the right ventricle (RV) and the pulmonary circulation unit. Although it has been traditionally assessed with right heart catheterisation (RHC), modern imaging techniques enable the non-invasive estimation of the RVPAC, which proved to correlate well with measurements derived from RHC. Methods We used three-dimensional (3D) echocardiography to study 88 consecutive patients (60.4±13.4 years, 69 men) with dilated cardiomyopathy (DCM) and left ventricular ejection fraction Results Patients with DCM showed larger RV end-diastolic volume (163±60.9 ml vs. 91.3±13.2 ml; p Conclusions 3D echocardiography provides useful insights in the functional assessment of the cardiopulmonary unit. Non-invasive RVPAC is impaired in patients with DCM, and it is more impaired when signs of right-sided heart failure are present. Severe symptoms are associated with more pronounced decoupling of the RV and the pulmonary circulation. The prognostic significance of non-invasive RVPAC in a disease primarily involving the left ventricle remains to be clarified. Funding Acknowledgement Type of funding source: Other. Main funding source(s): This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF

The gender effects in arterial hypertension (HT) epidemiology remain poorly clarified to date. We present an up-to-date review of the data regarding gender disparities in HT’s prevalence, awareness, treatment, and control. Based on the data from three consecutive national-representative SEPHAR (Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk in Romania) surveys conducted between 2005 and 2016, we provide insights into gender differences in HT’s epidemiology and their 11- years the evolutionary trend in a high-CV risk European country. Our data displays gender effects in different age-dependent epidemiological patterns in terms of hypertension prevalence, awareness, treatment, and control, mainly due to hormonal status. Hypertension’s prevalence is higher in younger men and older women. Although women are more often aware of their hypertensive condition and receive more often antihypertensive treatment, BP control is lower in older women compared to men of the same age, mainly due to a higher treatment side-effect rate. There is no solid evidence that different antihypertensive drugs exhibit different effects in lowering BP values between genders. In high CV risk European countries like Romania, if all the influencing conditions remain similar to those in the past 11 years, gender discrepancies in terms of HT's prevalence will diminish over time, awareness and treatment of hypertension will continue to be higher in females than in men, with an upward trend of BP control predicted only for women, while in men HT treatment control rate is expected to stagnate.

Funding Acknowledgements This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF Background The prognostic value of LV function in the setting of an acute ST elevation myocardial infarction (STEMI) is well established, but data regarding the association between RV function and adverse events in this population of patients are still scarce, especially for the cases with anterior wall localization of necrosis. Two-dimensional speckle tracking echocardiography (STE) is able to detect subclinical changes in local or regional RV function. AIMS To evaluate the relation between STE parameters of RV global and regional function recorded 24 hours after admission and the occurrence of major non-fatal cardiovascular adverse events (MACE) in anterior STEMI patients treated by primary percutaneous intervention (PCI) Methods We have prospectively analyzed a cohort of 80 consecutive patients (mean age 61.17 years, 68.8% males) presenting with a first STEMI treated successfully by PCI. Patients with history of cardiac or pulmonary disease were excluded. All patients underwent conventional echocardiography and STE, 24 hours after the index event. RV strain was assessed as RV free wall strain (RVFWS) representing the average of peak strain values encountered in three segments of the RV free wall and RV global longitudinal strain (RVGLS) obtained by averaging peak strain values in six segments including RV free wall and interventricular septum . The mean follow-up duration was 8.2 ± 0.69 months.The combined endpoint of non fatal MACE was defined as recurrent myocardial infarction, need for repeat revascularization, hospitalization for heart failure or stroke. Results In the study population 45 patients (56%) had the culprit lesion on the anterior descendent artery. In this group we observed that RVGLS was predictive for non fatal MACE independent of LVEF or extension of necrosis expressed by wall motion score index with OR 0.89 95 % CI 0.7-0.9, p = 0.042, with a ROC curve with a sensitivity 73% and specificity 53%, AUC =0.7. In addition, in anterior STEMI complicated by LVEF Conclusions In anterior STEMI patients treated by primary PCI, global RV longitudinal dysfunction assessed by STE early after the index event is predictive for non fatal MACE independently of LV function or the infarct size. In addition, RV regional longitudinal dysfunction provides incremental prognostic information in patients with anterior STEMI with moderate or severe LV systolic dysfunction. These data highlight the importance of the assessment of subclinical RV dysfunction in this setting.

Funding Acknowledgements This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF. Background Left ventricule (LV) function plays an important role in the pathophysiology of decompensation after acute ST elevation myocardial infarction (STEMI). LV remodeling (LVR) after STEMI is associated with development of heart failure, predicting poor clinical outcome therefore its identification is of clinical importance to set up preventive strategies. Prediction of the left ventricular remodeling (LVR) after STEMI in patients treated by primary PCI is challenging. Purpose Finding an echocardiographic parameter that can predict left ventricular remodeling in time after STEMI. Materials and methods In this prospective study we included 30 consecutive patients, median age 60 (37-79), 76% male, with STEMI treated by primary PCI. We performed conventional 2D transthoracic echocardiography for all included patients. In addition to conventional parameters we measured LV global longitudinal strain (GLS) and LV mechanical dispersion using 2D speckle tracking imaging technique. For morphological and functional analysis of LV we used 3D echocardiography (volumes, LVEF) considering its superiority in assessment of LV. All measurements were performed at baseline (up to 7 days after STEMI) and at 5 year follow up. LVR was defined as an increase of over 15% of the LV end diastolic volume (LVEDV) in time, at 5 years after the STEMI. Results We obtained significant differences in time (up to 7 days after STEMI vs at 5 years) between 3D LVEF (46,48 vs 51,68, p = 0.002), LVEDV (97,12 vs 107,76, p = 0.000), 2D global strain (-11.76 vs - 14,1, p = 0.00), and mechanical dispersion (65,06 vs 57,66, p = 0.00) in all patients. LV remodeling at 5 years (15% increase in LVEDV) was observed in 36,6% of the included patients. At 5 years follow up, LVEDV mean value in the remodeling group was 130 ml and in the no remodeling group 90,21 ml (p = 0.002), 3D LVEF was 48,18 vs 54,42 (p = 0.05), global strain was - 12,33 vs -15,35 (p = 0.02) and LV mechanical dispersion 66,27 vs 55,55 (p = 0.05). Therefore patients with LV remodeling in time had lower LVEF, lower global strain and higher LV mechanical dispersion at baseline. Using ROC analysis we identified two cut off values, one of -11.55 for global LV strain measured at baseline (Sb 81.8%, Sp 77%, AUC 0.776, CI 95%, p = 0.022) and the other one of 63.7 for LV mechanical dispersion at admission (Sb 72,7%, Sp 62%, AUC 0.734, p 0.05) to discriminate between patients with or without LV adverse remodeling at 5 years after STEMI. We also found, using regression analysis, that GLS and LV mechanical dispersion are able to predict LV remodeling in time. Conclusion Global longitudinal strain and left ventricular mechanical dispersion measured in the acute phase can predict which patient is likely to undergo LV remodeling at 5 years after STEMI. GLS and LV dispersion could be used as predictors for future LV adverse remodeling after STEMI. Larger scale studies are needed to validate these findings.

Amyloidosis is a systemic infiltrative disease, in which unstable proteins misfold, form aggregates and amyloid fibrils which can deposit in various organs: heart, kidneys, liver, gastrointestinal tract, nervous system structures, lungs, or soft tissue. Cardiac amyloidosis (CA) diagnosis requires awareness, high level of clinical suspicion and expertise in integrating clinical, electrocardiographic, and multimodality imaging data. The overall scenario is complex and no single test emerges over the others, but different techniques are useful at various stages of the diagnostic workup. After a clinical suspicion of CA is raised by various non-imaging red-flags, eligible patients should undergo complete echocardiography and multiparametric cardiovascular magnetic resonance imaging. Even though the clinical suspicion of CA is confirmed by cardiac imaging, the accurate differentiation between the two most frequent and treatable amyloid types, i.e. light chain (AL) and transthyretin (ATTR) requires further work-up including phosphate scintigraphy. This article reviews the latest and essential data on multimodality imaging of patients with suspected or confirmed CA in a useful and practical manner for the general and imaging cardiologists.

Funding Acknowledgements Funding Acknowledgements : This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by theERDF Background The prognostic value of right ventricular (RV) function assessed by echocardiography in patients with acute ST elevation myocardial infarction ( STEMI ) treated by primary percutaneous coronary intervention (PCI) remains controversial, especially in terms of long term follow up . AIMS To evaluate the relation between RV function assessed by various echocardiographic parameters in patients presenting with STEMI and the occurrence of major cardiovascular adverse events (MACE) whithin a long period of follow-up. Methods We have prospectively analyzed a cohort of 37 patients (mean age: 62.49+/- 1.67 years, 28 males) presenting with a first STEMI treated successfully by PCI. Patients with history of cardiac or pulmonary diseases were excluded. All patients underwent serial conventional 2D echocardiography, tissue Doppler imaging ( TDI ), speckle tracking echocardiography (STE) and 3D echocardiography at 24 hours after the acute event, at discharge, at 6 month, 1 year and 4 years of follow up. We measured in each patient the following RV functional parameters : tricuspid annular plane systolic excursion (TAPSE) , RV free wall systolic velocity (St ) assessed by TDI , RV free wall strain (RVFWS) and RV global longitudinal strain (RVGLS), RV myocardial performance index assessed by pulsed wave Doppler (RV MPI -PW) and right ventricular ejection fraction (RVEF). The mean follow up duration was 36 +/-4 months . The combined end-point of MACE was defined as all cause mortality, recurrent myocardial infarction, need for repeat revascularization or stroke. Results During the follow-up period 8 patients ( 18.9 % ) reached the combined end-point . In the analyzed group we observed that of all the studied parameters that reflect RV function, only RV MPI –PW and St at discharge were predictors of worse outcomes independent of LVEF or the culprit coronary artery. RV MPI was predictive at a cut-off value greater than 0,56 with a sensitivity of 66,6% and a specificity of 85,7 % ( 95% CI 0.51 to 0.67, p = 0.017, AUC= 0.71), respectively St at a cut -off value lower than 0,13 m/s with a sensitivity of 92 % and a specificity of 41 % ( 95% CI 0.12 to 0.16 p = 0.012, AUC = 0.64 ). Conclusions In STEMI patients treated by primary PCI, RV global function and RV regional systolic function evaluated at discharge provide prognostic information for long term MACE, independendent of infarct size or location. Our results need to be confirmed in larger cohorts of patients.

Funding Acknowledgements This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF Background Mechanical dispersion assessed by myocardial strain reflects a susceptibility for arrhythmia development. While the contractile heterogeneity of both ventricles has been assessed in different clinical settings, the incidence and significance of right atrial (RA) dyssynchrony in dilated cardiomyopathy (DCM) are unknown. Methods 50 consecutive patients with DCM were divided in 2 groups according to the etiology: group I had 26 patients with ischemic DCM (68 ± 10 years, 23 men), group N had 24 patients with non-ischemic DCM (52 ± 12 years, 18 men). We assessed the RA strain by 2D speckle-tracking analysis, and we calculated RA mechanical dispersion as the standard deviation of the time-to-peak contraction strain in 6 RA segments. 20 healthy individuals served as controls. Data were compared between groups with one-way analysis of variance and using a post-hoc Bonferroni correction. Results The RA strain was reduced in DCM patients, both in group I and in group N. All three components of the RA strain were most reduced in group I (p Conclusion Mechanical dispersion of the RA is pronounced in patients with DCM and it is higher in patients with documented supraventricular arrhythmias. Patients with ischemic DCM have a more pronounced mechanical dispersion of the RA than patients with non-ischemic DCM, reflecting a more heterogenous RA contraction in ischemic heart disease when compared to other forms of DCM. The prognostic significance of RA dyssynchrony in a disease primarily involving the left heart warrants further studies. Group I Group N Controls P value Reservoir RA strain (%) 12.9 ± 7.4§ 17.6 ± 12.9§ 30.1 ± 9.9

Funding Acknowledgements This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF Ventriculo-arterial coupling (VAC) reflects the interaction between the ventricle and the arterial system and its prognostic role was studied in different clinical settings. VAC can be assessed with echocardiography as the ratio between the arterial elastance (Ea) and the end-systolic left ventricular elastance (EES). Data concerning the role of VAC in severe aortic stenosis (AS) are scarce. We aimed to determine VAC in patients (pts) with severe AS and assess its relationship with symptoms. We included 61 consecutive pts with severe AS (vave area There were no significant differences in age (p = 0.08) and aortic valve area (p = 0.18) between groups. Variations of Ea and EES between groups were not significant (p = 0.08 and p = 0.94, respectively). However, VAC differed significantly between the 3 groups, being most impaired in group A (1.11 ± 0.69), followed by 0.77 ± 0.23 in group B and 0.73 ± 0.16 in group C (p = 0.03). The left ventricular ejection fraction (EF) also differed significantly between groups: 41 ± 13% in group A, 51 ± 11% in group B and 57 ± 3% in group C (p VAC is impaired in patients with severe AS and acute heart failure and it differs significantly from VAC in severe AS with chronic, stable symptoms and from VAC in asymptomatic severe AS. This suggests that the progression of symptoms in severe AS might be related to the interactions between the left ventricle and the vascular load, making thus VAC a potential therapeutic target and a parameter to be considered in the thorough evaluation of patients with severe AS. Group A Group B Group C Ea 2.69 ± 1.31 2.09 ± 0.94 1.95 ± 0.60 p = 0.08 EES 2.93 ± 1.90 2.87 ± 1.33 2.71 ± 0.73 p = 0.94 VAC 1.11 ± 0.69 0.77 ± 0.23* 0.73 ± 0.16* p = 0.03 EF 41 ± 13% 51 ± 11%* 57 ± 3%* p

Current echocardiographic data reporting the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve replacement (TAVR) are conflicting. Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MR severity on cardiac reverse remodeling and patient outcome. 85 patients undergoing TAVR with CMR pre- and 6 m post-TAVR were evaluated. The CMR protocol included cines for left (LV) and right ventricular (RV) volumes, flow assessment, and myocardial scar assessment by late gadolinium enhancement (LGE). Patients were dichotomised according to CMR severity of MR fraction at baseline (‘non-significant’ vs ‘significant’) and followed up for a median duration of 3 years. Forty-two (49%) patients had ‘significant MR’ at baseline; they had similar LV and RV size and function compared to the ‘non-significant MR’ group but had greater LV mass at baseline. In those with significant MR at baseline, 77% (n = 32) had a reduction in MR post-TAVR, moving them into the ‘non-significant’ category at 6-months, with an overall reduction in MR fraction from 34 to 17% (p

Left ventricular hypertrophy (LVH) is frequently encountered in daily practice representing the macroscopic phenotype of various conditions such as hypertensive heart disease, aortic stenosis, sarcomeric hypertrophic cardiomyopathy (HCM), or infiltrative cardiomyopathies such as cardiac amyloidosis (CA) or Anderson-Fabry disease (AFD). Functional and structural alterations of the coronary microcirculation are widely recognized across the entire spectrum of LVH etiologies. Most frequently, coronary microvascular dysfunction (CMD) in LVH manifests as a low coronary blood flow reserve during vasodilator stress. However, the most dramatic form of CMD is represented by microvascular obstruction (MVO). Among LVH etiologies, MVO has been reported in CA on histology specimens; however, currently there are no reports of MVO diagnosis by non-invasive imaging in CA. The role of cardiovascular magnetic resonance (CMR) in MVO identification is well established in the setting of acute myocardial infarction. We present a case of AL-type CA, in which the diagnosis of MVO is suggested by contrast-enhanced CMR. We take this opportunity to briefly discus the coronary microcirculation alterations in the setting of other LVH etiologies such as sarcomeric HCM or AFD.

Ventriculo-arterial coupling (VAC) represents a comprehensive expression of the mechanical efficiency and performance of the ventriculo-vascular system. It is defined as the ratio between the arterial elastance (Ea) and the end-systolic ventricular elastance (EES) and it has potential clinical applicability in different settings. The interaction between the ventricle and the aorta in the setting of acute heart failure has been insufficiently investigated. We sought to assess the VAC in patients with acute pulmonary edema (PE) and to establish its relationship with the ejection fraction (EF) and clinical outcome. We included 120 consecutive patients (mean age 74±12 years, 61 men) admitted for acute PE, with either preserved or reduced EF. The control group consisted of 50 subjects (mean age 40±13 years, 35 men) with no previous cardiac history. All patients underwent standard echocardiography on admission and we assessed the VAC non-invasively. We followed the patients for a composite endpoint of death, recurrent PE and acute coronary syndrome (ACS) for a month after hospitalisation. The VAC was significantly impaired in the acute PE group: 1.05±0.49 vs. 0.84±0.16 (p 14 patients (12%) in the study group had at least one in-hospital major cardiovascular event (MACE): in the low EF subgroup, there were 7 recurrent PE (11.5%) and 1 death (1.6%), while in the preserved EF subgroup, there were 5 recurrent PE (8.5%) and 1 ACS (1.7%). There was no significant difference in VAC between patients with in-hospital MACE and MACE-free patients (p=0.55 for low EF subgroup, p=0.59 for preserved EF subgroup). 10 patients (8.3%) in the study group had at least one MACE in the first month after discharge: in the low EF subgroup, there were 4 recurrent PE (6.6%) and 1 death (1.6%), while in the preserved EF subgroup, there were 2 deaths (3.4%) and 3 recurrent PE (5.1%). VAC was more impaired in low EF patients with MACE at 1 month (2.27±0.85) vs. low EF patients MACE-free at 1 month (1.21±0.44, p=0.04). No differences in VAC were noticed for the preserved EF subgroup (p=0.97). Ventriculo-vascular interaction is decoupled in acute PE, with VAC being more impaired when the EF is reduced. Furthermore, for patients with acute PE and low EF, VAC was worse in those who suffered a MACE at 30 days. This suggests the prognostic value of VAC in acute PE and it highlights the importance of integrating this easy-to-obtain parameter in the echocardiographic evaluation of acute heart failure patients. Acknowledgement/Funding This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC-A2-0.2.2.1-2013-1 cofinanced by the ERDF

Background The left atrium (LA) is a highly dynamic chamber that has 3 mechanical functions (reservoir, conduit, booster pump), as well as additional endocrine and regulatory properties. It is a marker of both the severity and chronicity of diastolic dysfunction and its remodelling has been shown to be a reliable predictor of clinical outcome in patients with heart disease. While LA function has been extensively studied in chronic heart failure, information about LA mechanics in patients with acute heart failure and preserved left ventricular ejection fraction (EF) are scarce. Purpose We sought to assess LA mechanics in a cohort of patients with acute pulmonary edema and preserved EF and compare it with a normal reference group. Methods We included 50 consecutive patients (22 men) with acute pulmonary edema, preserved EF and sinus rhythm in our study. Patients with significant mitral or aortic valve disease were not considered eligible. The control group consisted of 30 subjects (18 men) with no previous cardiovascular disease. We performed conventional transthoracic echocardiography for all patients and we assessed various parameters of LA mechanics. To evaluate the reservoir function, we determined the total ejection volume (EV), the total EF, the LA expansion index (LAEI) and the LA function index (LAFI). To evaluate the conduit function, we determined the passive EV and passive EF. For the booster pump function, we determined the active EV, active EF, the atrial filling fraction, the ejection force and the LA kinetic energy (LAKE). We used T-test to compare the parameters between the two groups. Results The mean age in the study group was 72±14 years, while in the control group the mean age was 56±16 years (p=0.06). The total EV did not differ significantly between groups (p=0.44). The total LA ejection fraction was lower in the study group: 29±10% vs. 51±9% (p Conclusion All three integrated phases of left atrial mechanics (reservoir, conduit, booster pump) are impaired in patients with acute pulmonary edema and preserved left ventricular EF. These findings highlight the importance of diastolic dysfunction in the pathogenesis of acute heart failure for these patients and they suggest that LA dysfunction might be a potential therapeutic target in this clinical setting. Acknowledgement/Funding This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC-A2-0.2.2.1-2013-1 cofinanced by the ERDF

The concepts underlying hypertrophic cardiomyopathy (HCM) pathogenesis have evolved greatly over the last 60 years since the pioneering work of the British pathologist Donald Teare, presenting the autopsy findings of “asymmetric hypertrophy of the heart in young adults”. Advances in human genome analysis and cardiac imaging techniques have enriched our understanding of the complex architecture of the malady and shaped the way we perceive the illness continuum. Presently, HCM is acknowledged as “a disease of the sarcomere”, where the relationship between genotype and phenotype is not straightforward but subject to various genetic and nongenetic influences. The focus of this review is to discuss key aspects related to molecular mechanisms and imaging aspects that have prompted genotype−phenotype correlations, which will hopefully empower patient-tailored health interventions.

We aimed to find new predictive parameters for atrial fibrillation (AF) onset in hypertensive patients using two-dimensional (2D) conventional and speckle tracking echocardiography of the left atrium (LA). One hundred and eight patients with essential hypertension (HTN) were prospectively enrolled, from which 67 patients had no other important comorbidities (HTN group), while 41 patients had a recent AF episode, but were in sinus rhythm at the moment of enrollment (HTN and AF group). LA diameters and maximal volume, LV mass, LV ejection fraction and diastolic function were assessed through 2D conventional echocardiography. Moreover, peak longitudinal and contractile strain of LA walls (PALS and PACS, respectively) were analyzed by speckle tracking technique. Patients were followed up for 1 year and recurrent 24-h rhythm monitoring was done, in order to identify atrial fibrillation. Age and time from diagnosis of HTN were higher in HTN and AF group than in HTN group (68.02 ± 19 years versus 57.2 ± 1.52 years, p = 0.001 and 62.2 ± 9.2 months versus 40.4 ± 6.4 months, p = 0.04). All LA diameters and LA maximal volume were significantly larger in HTN and AF group (for LA antero-posterior diameter p = 0.02, for all the rest p