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BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

BACKGROUND Renal dysfunction, an important predictor of cardiovascular mortality, is paradoxically associated with a lower incidence of positive coronary fractional flow reserve (FFR) values, possibly due to renal disease-associated myocardial microvascular dysfunction. It is unknown if this relationship is influenced by arterial hypertension, a condition strongly associated with renal- and microvascular dysfunction. METHODS The incidence of positive (

Heart failure is nowadays a common condition associated with high mortality and increased healthcare-related costs. Over the years, the research on heart failure management has been extensive in order to better diagnose and treat the condition. Since the progression of left ventricular dysfunction is a consequence of myocardial inflammation, apopotosis, and fibrosis leading to myocardium remodelling, several molecules that are involved in the inflammation pathways have been explored as possible biomarkers for the condition. The study of biomarkers and their key roles in inflammation could allow early identification of patients with heart failure, improve prognostic assessment, and provide a target for future therapies. Among currently studied biomarkers, extensive research has been conducted on galectin-3, a galactoside-binding lectin, which is synthetised and secreted when cardiomyocytes and fibroblasts are submitted to mechanical stress. Accordingly, it has been hypothesised that galectin-3 could be a promoter of left ventricular dysfunction. Galectin-3 has been shown to mediate inflammation by several different pathways which are further detailed in the current review. Also, we aimed to provide a comprehensive overview of existing evidence on the utility of galectin-3 in clinical settings associated with heart failure.

Background Inflammation plays a major role in the development of metabolic syndrome (MetS) and its progression. Recent studies have shown that pentraxin-3 (PTX-3), osteoprogerin (OPG), and tumor necrosis factor-alpha (TNF-α) are key factors in MetS pathophysiology, but evidence for endorsing their clinical use is currently unclear and insufficient. Aim The study aimed to evaluate the association between the inflammatory biomarkers’ levels and the severity of MetS. Methods The study was observational, transversal, prospective, cohort, and analytical type. We enrolled 80 patients (M:F = 1, mean age = 55 ± 10.77 years) who met MetS criteria. The study protocol included: medical history, physical examination, 6-min walk test distance (6MWTD), biochemical tests, electrocardiogram, echocardiography, and carotid ultrasonography. We also performed plasmatic measurement of PTX-3, OPG, and TNF-α, in addition to standard biochemical tests. Results Subjects with severe MetS had higher values of body mass index (BMI) and waist circumference (p p = 0.001). PTX-3 levels were significantly higher in patients with severe MetS (p = 0.03) and the values were not influenced by age or gender. OPG positively correlated with BMI (r = 0.264, p = 0.018). 6MWTD was lower in patients with severe MetS (p = 0.005), whereas CCA-IMT was higher in this group of patients (p = 0.005). In addition, the receiver operating characteristic (ROC) curve analysis for PTX-3 identified a cut-off value of 10.7 ng/dl that differentiates between mild and severe MetS [AUC 0.656; sensitivity =47.1% (95% CI = 36.1%–62.3%); specificity = 78.9% (95% CI = 54.4%–93.9%)]. Conclusion PTX-3 was correlated with the severity of MetS, with other inflammatory parameters and cardiovascular tests. CCA-IMT and 6MWTD are useful in differentiating between mild and severe MetS.

Aims: We aimed to assess the relationship between right ventricle (RV) dysfunction parameters and the soluble IL-1 receptor family member (sST2) in patients with secondary pulmonary hypertension owing to chronic obstructive pulmonary disease. Materials & methods: A total of 36 patients with chronic obstructive pulmonary disease and secondary pulmonary hypertension (mean age: 59 ± 7 years) and 36 healthy volunteers (mean age: 59 ± 8 years) were enrolled in the study. sST2 and NT-proBNP levels, as well as specific echocardiographic parameters were measured. Results: Both sST2 and NT-proBNP levels were greater in the test group. The sST2 levels were inversely associated with RV fractional area change (r = -0.762; p < 0.001), as well as with the RV ejection fraction (r = -0.799; p < 0.001), tricuspid annular plane systolic excursion (r = -0.773; p < 0.001) and increased pulmonary artery systolic pressure (r = 0.603; p < 0.001). Receiver operating characteristic curve analysis revealed that sST2 had lower sensitivity for identifying RV dysfunction when compared with NT-proBNP (71.4 vs 100%), despite having the same specificity (84%). Conclusion: The current study reveals correlations between sST2 levels and echocardiographic parameters of RV dysfunction, suggesting that use of sST2 and NT-proBNP may improve diagnosis and risk stratification in patients with secondary pulmonary hypertension owing to chronic obstructive pulmonary disease.

To analyse the predictive ability and incremental value of left ventricular longitudinal axis strain (LAS) and late gadolinium enhancement (LGE) using standard cardiovascular magnetic resonance (CMR) imaging for the diagnosis and prognosis of severe aortic stenosis (AS) in patients with an indication for aortic valve replacement. We conducted a prospective study on 52 patients with severe AS and 52 volunteers. The evaluation protocol included standard biochemistry tests, novel biomarkers of myocardial fibrosis, 12-lead electrocardiograms and 24-hour Holter, the 6-minute walk test and extensive echocardiographic and CMR imaging studies. Outcomes were defined as the composite of major cardiovascular events (MACEs). Among AS patients, most (n = 17, 77.2%) of those who exhibited LGE at CMR imaging had MACEs during follow-up. Kaplan&ndash, Meier curves for event-free survival showed a significantly higher rate of MACEs in patients with LGE (p &lt, 0.01) and decreased LAS (p &lt, 0.001). In Cox regression analysis, only reduced LAS (hazard ratio 1.33, 95% CI (1.01 to 1.74), p &lt, 0.01) and the presence of LGE (hazard ratio 11.3, 95% CI (1.82 to 70.0), p &lt, 0.01) were independent predictors for MACEs. The predictive value increased if both LGE and reduced LAS were added to left ventricular ejection fraction (LVEF). None of the biomarkers of increased collagen turnover exhibited any predictive value for MACEs. LAS by CMR is an independent predictor of outcomes in patients with AS and provides incremental value beyond the assessment of LVEF and the presence of LGE.

Left atrium remodeling is a physiological response to pressure overload in hypertensive patients. The aim of this study is to determine the relationship between left atrium remodeling and left ventricle diastolic dysfunction in hypertensive patients with preserved systolic function. Materials and Methods: We conducted a prospective study on 96 hypertensive patients (48.75 ± 5.01 years, 50 men) and 96 healthy control subjects (48.17 ± 8.52 years, 56 men), whose data were all evaluated by echocardiography measuring left atrium volumes during the reservoir, conduit and pump phases. Standard indices reflecting left ventricular filling were also prossessed. Results: Medium left atrium volume indexed for body surface was significantly higher in hypertensive patients – 30.87 (6.38) mL/m² vs. 21.72 (2.52) mL/m². Indexed left atrium volume was strongly associated with left ventricle diastolic function (p < 0.0001). When compared to normal subjects, patients with mild diastolic dysfunction had lower corrected passive emptying volumes (p < 0.0001) and higher corrected active emptying volumes (p = 0.001), thus leading to similar corrected total emptying volumes (p < 0.001). However, patients with moderate diastolic dysfunction had smaller active emptying volumes, but higher passive and total emptying volumes when compared to normal controls and patients with mild diastolic dysfunction. Conclusions: Left atrium indexed volumes evaluation during the reservoir, conduit and pump phases proved to be essential for early diastolic dysfunction assessment in hypertensive patients.

Aim : To evaluate the association between echocardiographic right ventricular (RV) structural and functional parameters and galectin-3 levels in patients with chronic obstructive pulmonary disease (COPD) and associated pulmonary hypertension presenting with acutely aggravated dyspnoea. Material and methods : We conducted a prospective study on forty patients with COPD and forty healthy volunteers matched for age and sex (mean age 59±6 years), measuring galectin-3 and NT-proBNP serum levels and specific echocardiographic parameters. Results : Galectin-3 was significantly higher in patients with COPD and elevated systolic pulmonary artery pressure than in healthy volunteers and discriminated better between patients with likely and possible pulmonary hypertension when compared to NT-proBNP. In multivariate analysis, the global model was better related to galectin-3 than to NT-proBNP levels (R²=0.61 vs. 0.31, p

Aims: Left ventricular global longitudinal strain (GLS) was shown to predict outcomes after valve replacement in patients with aortic stenosis (AS). In the current study, we aimed to test the combined use of GLS and a marker of fibrosis – Galectin-3 – for predicting major cardiovascular adverse events (MACEs) in patients with severe AS.Materials and methods: We conducted a prospective study on 42 patients with severe AS and 42 volunteers. Patient evaluation included biochemistry tests, electrocardiogram, 24-hour Holter monitoring, the 6-minute walk test, and echocardiography. Outcomes of AS patients were defined as the composite of MACEs – sudden cardiac death, non-fatal myocardial infarction, sustained ventricular arrhythmias,atrial arrhythmias, and hospitalization for heart failure.Results: Patients with severe AS had lower GLS, and increased levels of both biomarkers compared to the control group. Both biomarkers correlated to echocardiographic parameters such as left ventricular (LV) mass index, relative wall thickness, GLS, as well as with the 6-minute walk test distance, and glomerular filtration rate (eGFR). GLS and NT-proBNP predicted MACEs reasonably well, while Galectin-3 did not, after adjustments for confounding factors. Kaplan–Meier analysis showed that the probability of freedom from MACEs was significant in patients who exhibited lower GLS [HR 2.73 (95% CI 1.01-7.53), p

Coronary computed tomography angiography (CCTA) is used extensively nowa‐ days as a non-invasive imaging method for the evaluation of patients suspected of coronary artery disease, providing data on calcium burden, the presence of coro‐ nary artery stenoses, but also, more recently, on coronary atherosclerotic plaque morphology and composition. Plaque morphology analysis by CCTA aims to accu‐ rately identify vulnerable plaques, in an attempt to reduce the number of ischemic events triggered by high-risk atherosclerotic lesions. Recent research provides CCTA descriptions of vulnerable plaques and a particular radiological sign shows promising perspectives. The napkin-ring sign refers to a rupture-prone plaque in a coronary artery, comprising a necrotic core covered by a thin cap fibro-atheroma. The napkin-ring sign is described on CCTA in cross-sectional images of coronary arteries as a central low-attenuation area surrounded by an open ring area of high attenuation, having a high specificity and positive predictive value for the presence of advanced lesions. These lesions have been designated as vulnerable plaques, in‐ dicating an increased probability of rupture, and were shown to correlate with a higher incidence of cardiovascular events. In acute coronary syndromes, the loca‐ tion of the napkin-ring sign was shown to correspond to the culprit lesions. The aim of the current paper is to provide an overview of the current literature on available methods for quantitative measurement of atherosclerotic plaque features from CCTA and to discuss the clinical implications of the napkin-ring sign as detected by CCTA.

Systemic sclerosis (SSc) is a chronic autoimmune disease that, beside skin involvement, may affect peripheral vessels and several organs, such as the lungs, kidneys or heart. Cardiac impairment usually becomes symptomatic in the late stages of the disease and is associated with poor prognosis. We report the case of a 80-year-old woman presenting with symptoms of heart failure, subsequently diagnosed with limited SSc. Cardiac function was evaluated using a combined approach based on echocardiography and cardiac magnetic resonance imaging with late gadolinium enhancement. This case shows that the late diagnosis of SSc may have fatal consequences.

Heart failure is a commonly encountered condition associated with increased morbidity, mortality, and healthcare cost. For years, its management has been strongly influenced by the use of B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide biomarkers. In some cases, this approach does not always identify patients with heart failure accurately and may not provide the best prognostic assessment, particularly in the presence of comorbidities. Biomarkers that help refine diagnosis and risk stratification are needed. Soluble ST2, a peptide belonging to the interleukin-1 receptor family, is secreted when cardiomyocytes and cardiac fibroblasts are subjected to mechanical strain. Although preliminary results on this novel biomarker are encouraging, additional and more comprehensive studies are clearly needed to establish its role in the management of patients with heart failure. The purpose of this chapter is to provide an overview of data currently available.

Heart failure is a commonly encountered condition associated with increased morbidity, mortality, and healthcare cost. For years, its management has been strongly influenced by the use of B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide biomarkers. In some cases, this approach does not always identify patients with heart failure accurately and may not provide the best prognostic assessment, particularly in the presence of comorbidities. Biomarkers that help refine diagnosis and risk stratification are needed. Soluble ST2, a peptide belonging to the interleukin-1 receptor family, is secreted when cardiomyocytes and cardiac fibroblasts are subjected to mechanical strain. Although preliminary results on this novel biomarker are encouraging, additional and more comprehensive studies are clearly needed to establish its role in the management of patients with heart failure. The purpose of this chapter is to provide an overview of data currently available.

Left atrium enlargement is a pathophysiological response to volume and pressure overload associated with a wide range of cardiovascular disorders leading to left ventricle systolic and diastolic dysfunction. Physiological factors contribute to significant differences in left atrium size in normal individuals. Moreover, left atrium enlargement was shown to have a significant prognostic value for cardiovascular events such as heart failure, atrial fibrillation or stroke, and increased cardiovascular and all-cause mortality rates. Current imaging techniques such as two- and three dimensional echocardiography, cardiac magnetic resonance imaging and multi-detector computed tomography allow a detailed assessment of the left atrium. The current paper aims to offer an overview of two-dimensional echocardiography parameters which provide data concerning left atrium dimensions and phasic functions and may lead to a better understanding of left atrium physiology and pathology.

Ischemic coronary artery disease represents one of the major contemporary health problems because of its elevated vital risk. Nowadays, atherosclerosis-related cardiovascular disease is the most significant non-traumatic mortality factor and the prime “killer” of the 21st century. Increased morbidity and mortality in coronary artery disease (Rosamond et al., 2008), the significant impact on quality of life, negatively affecting the physical, psychological and social well-being of the patient (Xie et al., 2008) as well as the high costs of diagnosis and treatment for this disease (Rosamond et al., 2008) have lead to developing new imaging techniques in order to explore such patients more efficiently. Cardiac imaging has developed greatly since the chest radiograph was first used to describe the heart’s shape. Nowadays, non-invasive imaging, including echocardiography, Single Photon Emission Computer Tomography (SPECT), coronary angiography and, more recently, Positron Emission Tomography (PET), multidetector computed tomography angiography as well as cardiac magnetic resonance imaging (MRI), represent standard procedures in clinical practice (Budoff et al., 2008) (Gaemperli et al., 2008). The latter, especially, have a crucial importance in approaching patients with suspected or known coronary artery disease, as well as in assessing risk stratification, prognosis and reperfusion indications in patients with ischemic coronary artery disease (Mark et al., 2010). The purpose of this chapter is to help promote new ways of integrating the non-invasive diagnostic imaging in the diagnosis and management of coronary artery disease patients.

Renovascular hypertension is defined as elevated blood pressure levels due to the stenosis/ occlusion of the renal artery caused by fibromuscular dysplasia or atherosclerosis. We present the case of a 59-year old female patient with recently diagnosed arterial hypertension due to renal artery occlusion through intimal fibromuscular dysplasia. In this case, arterial blood pressure levels have not been controlled by maximum doses of antihypertensive drugs, used in association; rapid deterioration of the renal function, as well as important kidney damage, proven by imaging explorations, motivated the laparoscopic nephrectomy.

Homocysteine is considered to be a risk factor for the development of cardiovascular disease. Several observations suggest that there might be links between hyperhomocysteinemia and insulin resistance, its clinical surrogate of metabolic syndrome. The aim of the present study is to determine whether the presence of the metabolic syndrome is associated with elevated levels of homocysteine in patients with prior myocardial infarction.We studied 104 consecutive patients with prior myocardial infarction undergoing coronary angiography. Patients were divided into two groups according to the presence or absence of metabolic syndrome, as certified by Adult Treatment Panel III. The dosage of homocysteine was measured by high performance liquid chromatography. The relationship between homocysteine levels and metabolic syndrome was assessed by multivariable regressions after adjustment on the basis of recognized predictive factors: age and sex.Out of a total numbers of patients with myocardial infarction (104; 63.6 +/- 9.2 years of age, 45.1% males) taken in study, 32 (30.1%) had metabolic syndrome. The mean level of homocysteine was significantly higher in the metabolic syndrome group (14.8 micromol/L) than in the free metabolic syndrome group (17.9 micromol/L) (por = 0.001). We found a positive correlation between plasma homocysteine levels and metabolic syndrome parameters.Elevated homocysteine levels were correlated to the metabolic syndrome in patients with prior myocardial infarction. These data indicate that elevated plasma homocysteine levels are not a risk factor for cardiovascular events in metabolic syndrome patients in contrast to patients without the metabolic syndrome.

Homocysteine is considered to be a risk factor, or an indicator of risk, for the development of cardiovascular disease. Little data is available on its significance in patients with previous myocardial infarction. The aim of our study was to assess the plasma level of homocysteine and its relationship with the severity of heart failure in patients with chronic myocardial infarction.We studied 144 patients with previous myocardial infarction. Patients were divided into two groups according to the presence or absence of heart failure, as certified by clinical evidence of heart failure and by echocardiographic criteria for left ventricular systolic dysfunction.Of the patients with prior myocardial infarction (144; 63.6 ± 9.6 years) included in the study, 65 had heart failure. The mean level of homocysteine was significantly higher in the heart failure group (18.9 mmol/L) than in the non-heart failure group (14.1 mmol/L; p ≤ 0.001). Our study demonstrated that there is a statistically significant correlation between homocysteine plasma levels and the severity of heart failure in patients with prior myocardial infarction. Homocysteine levels have proved to become higher with NYHA class progression. A significant cross-sectional correlation has been assessed between homocysteine and tissue Doppler echocardiography parameters.Increased plasma homocysteine levels independently correlate with the severity of heart failure in patients with chronic myocardial infarction. We suggest that homocysteine can be used in clinical practice as a valuable heart failure risk marker in patients with chronic myocardial infarction.