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Background: Low longitudinal strain of the ascending aorta (AAo) by cardiac magnetic resonance (CMR) predicts dilation and aortic events in Marfan syndrome (MFS) [1], possibly reflecting aortic stiffness [2]. Speckle-tracking is established for cardiac deformation, but proximal aorta applications are challenging due to wall thickness and substantial motion. We aimed to validate a purpose-specific speckle-tracking tool for root longitudinal strain analysis by comparison with CMR-derived AAo longitudinal strain and as predictor of dilation in MFS patients. Methods: CMR feature-tracking [1] and echocardiography speckle-tracking where applied to 25 MFS patients free from previous aortic surgery by a single observer blind to clinical data. For echocardiography, two regions of interests were manually created covering both walls in a parasternal long-axis view and tracked along the cardiac cycle. Longitudinal strain was computed as the average of maximum increase in relative distance of several sub-regions covering both walls. Aortic diameter was measured on CMR images. Results: Both techniques were successfully applied to all patients. Aortic root longitudinal strain by echocardiography was linearly related to CMR-derived AAo longitudinal strain (R = 0.573, p = 0.003, Figure A) and was higher (20.4 ± 8.4 vs 10.5 ± 3.8), especially at higher absolute values (Figure B). After a mean follow up of 45 ± 13 months, aortic root diameter growth rate was 0.27 ± 0.3 mm/year. In multivariable analysis corrected for root diameter and heart rate (p = 0.083 and 0.005, respectively), baseline longitudinal strain by echocardiography was independently related to progressive dilation (B = −0.017, p = 0.005). Conclusion: Aortic root longitudinal strain by echocardiography is related to CMR-derived AAo longitudinal strain and is an independent predictor of progressive dilation in MFS patients.

Background: Impaired ascending aorta (AAo) longitudinal strain, a marker of AAo deformation due to aorto-ventricular mechanical interaction, is related to progressive dilation and aortic events in Marfan syndrome [1]. Whether the high prevalence of dilation in bicuspid aortic valve (BAV) is due to intrinsically-altered aortic wall properties [2] or hemodynamic [3] is widely-discussed [4]. Whether AAo longitudinal strain is altered in BAV patients has never been assessed. Methods: One-hundred five BAV patients, 47 patients with AAo dilation and tricuspid aortic valve (TAV) and 31 healthy volunteers, free from previous cardiac/aortic surgery, dissection and moderate/severe valvular disease had cine MR images to compute AAo longitudinal strain [1]. Results: Compared to healthy volunteers, the 25 non-dilated (z-score < 2) BAV patients were older (p < 0.001), had higher systolic blood pressure (SBP, p = 0.001), clinically-meaningless (BAV z-score = 0.74 ± 1.1) larger AAo diameter (p < 0.001) and similar diastolic blood pressure (DBP), BSA, stroke volume and heart rate. AAo longitudinal strain was lower in non-dilated BAV compared to healthy volunteers (13.7 vs 10.3%, p = 0.008) but this difference was not significant after correction for age. Compared to dilated TAV, dilated BAV patients were younger (p < 0.001), had lower BSA (p = 0.010) and AAo diameter (p = 0.003), higher DBP (p = 0.032) and similar SBP, stroke volume and heart rate. AAo longitudinal strain was higher in dilated BAV compared to dilated TAV (10 vs 7.2%, p < 0.001) but this difference was not significant after correction for age, BSA and DBP. Conclusion: AAo longitudinal strain is similar in BAV and TAV matched for aortic dilation.

Abstract Background Patency of the false lumen in chronic aortic dissection (AD) is associated with aortic dilation and long-term aortic events. However, predictors of adverse outcomes in this population are limited. The aim of this study was to evaluate the relationship between aortic growth rate and false lumen flow dynamics and biomechanics in patients with chronic, patent AD. Methods Patients with a chronic AD with patent false lumen in the descending aorta and no genetic connective tissue disorder underwent an imaging follow-up including a contrast-enhanced 4D flow cardiovascular magnetic resonance (CMR) protocol and two consecutive computed tomography angiograms (CTA) acquired at least 1 year apart. A comprehensive analysis of anatomical features (including thrombus quantification), and false lumen flow dynamics and biomechanics (pulse wave velocity) was performed. Results Fifty-four consecutive patients with a chronic, patent false lumen in the descending aorta were included (35 surgically-treated type A AD with residual tear and 19 medically-treated type B AD). Median follow-up was 40 months. The in-plane rotational flow, pulse wave velocity and the percentage of thrombus in the false lumen were positively related to aortic growth rate (p = 0.006, 0.017, and 0.037, respectively), whereas wall shear stress showed a trend for a positive association (p = 0.060). These results were found irrespectively of the type of AD. Conclusions In patients with chronic AD and patent false lumen of the descending aorta, rotational flow, pulse wave velocity and wall shear stress are positively related to aortic growth rate, and should be implemented in the follow-up algorithm of these patients. Further prospective studies are needed to confirm if the assessment of these parameters helps to identify patients at higher risk of adverse clinical events.

BackgroundAtrial fibrillation (AF) increases the risk of ischemic stroke in asymptomatic individuals and may be the underlying cause of many cryptogenic strokes. We aimed to test the usefulness of candidate blood-biomarkers related to AF pathophysiology in two prospective cohorts representative of those populations.MethodsTwo hundred seventy-four subjects aged 65–75 years with hypertension and diabetes from the AFRICAT cohort, and 218 cryptogenic stroke patients aged >55 years from the CRYPTO-AF cohort were analyzed. AF was assessed by 4 weeks of monitoring with a wearable Holter device (NuuboTM™). Blood was collected immediately before monitoring started. 10 candidate biomarkers were measured by automated immunoassays (Roche, Penzberg) in the plasma of all patients. Univariate and logistic regression analyses were performed in each cohort separately.ResultsAtrial fibrillation detection rate was 12.4% (AFRICAT cohort) and 22.9% (CRYPTO-AF cohort). 4 biomarkers were significantly increased in asymptomatic individuals with AF [Troponin-T, Angiopoietin-2 (Ang-2), Endocan, and total N-terminal pro-B type natriuretic peptide (NT-proBNP)] and 7 biomarkers showed significantly higher concentrations in cryptogenic stroke patients with AF detection [growth differentiation factor 15, interleukin 6, Troponin-T, Ang-2, Bone morphogenic protein 10, Dickkopf-related protein 3 (DKK-3), and total NT-proBNP]. The models including Ang-2 and total NT-proBNP [AUC 0.764 (0.665–0.863)], and Ang-2 and DKK-3 [AUC = 0.733 (0.654–0.813)], together with age and sex, showed the best performance to detect AF in high-risk asymptomatic individuals, and in cryptogenic stroke patients, respectively.ConclusionBlood-biomarkers, in particular, total NT-proBNP, DKK-3, and Ang-2, were associated with AF reflecting two mechanistically different pathways involved in AF pathophysiology (AF stretch and vascular changes). The combination of these biomarkers could be useful in AF screening strategies in the primary care setting and also for searching AF after cryptogenic stroke.

ObjectivesTo determine the risk of mortality and need for aortic valve replacement (AVR) in patients with low-flow low-gradient (LFLG) aortic stenosis (AS).MethodsA longitudinal multicentre study including consecutive patients with severe AS (aortic valve area [AVA] < 1.0 cm2) and normal left ventricular ejection fraction (LVEF). Patients were classified as: high-gradient (HG, mean gradient ≥ 40 mmHg), normal-flow low-gradient (NFLG, mean gradient < 40 mmHg, indexed systolic volume (SVi) > 35 ml/m2) and LFLG (mean gradient < 40 mmHg, SVi ≤ 35 ml/m2).ResultsOf 1,391 patients, 147 (10.5%) had LFLG, 752 (54.1%) HG, and 492 (35.4%) NFLG. Echocardiographic parameters of the LFLG group showed similar AVA to the HG group but with less severity in the dimensionless index, calcification, and hypertrophy. The HG group required AVR earlier than NFLG (p < 0.001) and LFLG (p < 0.001), with no differences between LFLG and NFLG groups (p = 0.358). Overall mortality was 27.7% (CI 95% 25.3–30.1) with no differences among groups (p = 0.319). The impact of AVR in terms of overall mortality reduction was observed the most in patients with HG (hazard ratio [HR]: 0.17; 95% CI: 0.12–0.23; p < 0.001), followed by patients with LFLG (HR: 0.25; 95% CI: 0.13–0.49; p < 0.001), and finally patients with NFLG (HR: 0.29; 95% CI: 0.20–0.44; p < 0.001), with a risk reduction of 84, 75, and 71%, respectively.ConclusionsParadoxical LFLG AS affects 10.5% of severe AS, and has a lower need for AVR than the HG group and similar to the NFLG group, with no differences in mortality. AVR had a lower impact on LFLG AS compared with HG AS. Therefore, the findings of the present study showed LFLG AS to have an intermediate clinical risk profile between the HG and NFHG groups.

Background: Atrial fibrillation (AF) is one of the most prevalent causes of cryptogenic stroke. Also, apart from AF itself, structural and remodelling changes in the atria might be an underlying cause of cryptogenic stroke. We aimed to discover circulating proteins and reveal pathways altered in AF and atrial cardiomyopathy, measured by left atrial volume index (LAVI) and peak atrial longitudinal strain (PALS), in patients with cryptogenic stroke. Methods: An aptamer array (including 1310 proteins) was measured in the blood of 20 cryptogenic stroke patients monitored during 28 days with a Holter device as a case-control study of the Crypto-AF cohort. Protein levels were compared between patients with (n = 10) and without AF (n = 10) after stroke, and the best candidates were tested in 111 patients from the same cohort (44 patients with AF and 67 without AF). In addition, in the first 20 patients, proteins were explored according to PALS and LAVI values. Results: Forty-six proteins were differentially expressed in AF cases. Of those, four proteins were tested in a larger sample size. Only DPP7, presenting lower levels in AF patients, was further validated. Fifty-seven proteins correlated with LAVI, and 270 correlated with PALS. NT-proBNP was common in all the discovery analyses performed. Interestingly, many proteins and pathways were altered in patients with low PALS. Conclusions: Multiple proteins and pathways related to AF and atrial cardiomyopathy have been revealed. The role of DPP7 as a biomarker for stroke aetiology should be further explored. Moreover, the present study may be considered hypothesis-generating.

Purpose: To compare performance of visual and quantitative analyses for detecting myocardial ischaemia from single- and dual-energy computed tomography (CT) in patients with suspected coronary artery disease (CAD). Methods: Eighty-four patients with suspected CAD were scheduled for dual-energy cardiac CT at rest (CTA) and pharmacological stress (CTP). Myocardial CT perfusion was analysed visually and using three parameters: mean attenuation density (MA), transmural perfusion ratio (TPR) and myocardial perfusion reserve index (MPRI), on both single-energy CT and CT-based iodine images. Significant CAD was defined in AHA-segments by concomitant myocardial hypoperfusion identified visually or quantitatively (parameter

Abstract Background In patients with bicuspid valve (BAV), ascending aorta (AAo) dilatation may be caused by altered flow patterns and wall shear stress (WSS). These differences may explain different aortic dilatation morphotypes. Using 4D-flow cardiovascular magnetic resonance (CMR), we aimed to analyze differences in flow patterns and regional axial and circumferential WSS maps between BAV phenotypes and their correlation with ascending aorta dilatation morphotype. Methods One hundred and one BAV patients (aortic diameter ≤ 45 mm, no severe valvular disease) and 20 healthy subjects were studied by 4D-flow CMR. Peak velocity, flow jet angle, flow displacement, in-plane rotational flow (IRF) and systolic flow reversal ratio (SFRR) were assessed at different levels of the AAo. Peak-systolic axial and circumferential regional WSS maps were also estimated. Unadjusted and multivariable adjusted linear regression analyses were used to identify independent correlates of aortic root or ascending dilatation. Age, sex, valve morphotype, body surface area, flow derived variables and WSS components were included in the multivariable models. Results The AAo was non-dilated in 24 BAV patients and dilated in 77 (root morphotype in 11 and ascending in 66). BAV phenotype was right-left (RL-) in 78 patients and right-non-coronary (RN-) in 23. Both BAV phenotypes presented different outflow jet direction and velocity profiles that matched the location of maximum systolic axial WSS. RL-BAV velocity profiles and maximum axial WSS were homogeneously distributed right-anteriorly, however, RN-BAV showed higher variable profiles with a main proximal-posterior distribution shifting anteriorly at mid-distal AAo. Compared to controls, BAV patients presented similar WSS magnitude at proximal, mid and distal AAo (p = 0.764, 0.516 and 0.053, respectively) but lower axial and higher circumferential WSS components (p

Acute aortic syndrome (AAS) comprises a range of interrelated conditions caused by disruption of the medial layer of the aortic wall, including aortic dissection, intramural haematoma and penetrating aortic ulcer. Since mortality from AAS is high, a prompt and accurate diagnosis using imaging techniques is paramount. Both transthoracic (TTE) and transoesophageal echocardiography (TEE) are useful in the diagnosis of AAS. TTE should be the first imaging technique to evaluate patients with thoracic pain in the emergency room. Should AAS be suspected, contrast administration is recommended when images are not definitive. TEE allows high-quality images in thoracic aorta. The main drawback of this technique is that it is semi-invasive and the presence of a blind area that limits visualisation of the distal ascending aorta near. TEE identifies the location and size of the entry tear, secondary communications, true lumen compression and the dynamic flow pattern of false lumen. Although computed tomography (CT) is the most used imaging technique in the diagnosis of AAS, echocardiography offers complementary information relevant for its management. The best imaging strategy for appropriately diagnosing and assessing AAS is to combine CT, mainly ECG-gated contrast-enhanced CT, and TTE. Currently, TEE tends to be carried out in the operating theatre immediately before surgical or endovascular therapy and in monitoring their results. The aims of this review are to establish the current role of echocardiography in the diagnosis and management of AAS based on its advantages and limitations.

Background: Left atrial deformation (LAD) parameters are new markers of atrial structural remodelling that seem to be affected in atrial fibrillation (AF) and atrial flutter (AFL). This study aimed to determine whether LAD can identify patients with a higher risk of thrombosis and unsuccessful electrical cardioversion (ECV). Methods: Retrospective study including 56 patients with AF or AFL undergoing ECV, with previous transthoracic (TTE) and transoesophageal echocardiography (TEE) studies. Echocardiographic parameters analysed were as follows: left ventricle function, left atrium (LA) dimensions, LAD parameters (positive and negative strain peaks), left atrial appendage (LAA) filling and emptying velocities and the presence of thrombi. Strain values were analysed according to thrombotic risk and success of ECV. Results: Lower mean values of peak-positive strain (PPS) in patients with prothrombotic velocities (

Introducción y objetivos: El Grupo de Trabajo en Reparación Valvular de la Sociedad Española de Cirugía Torácica y Cardiovascular presenta el cuarto Registro anual de actividad en cirugía reparadora de las válvulas mitral, aórtica y tricúspide realizada en España durante el año 2014. Material y métodos: La recogida de datos se realizó mediante cuestionario on-line, de forma retrospectiva, voluntaria, anónima y no auditada. Se detalla la actividad reparadora y de recambio valvular por grupos. En el grupo mitral se clasificaron las intervenciones de acuerdo con su etiología y se recogieron como variables mortalidad y riesgo quirúrgico, tanto en el grupo total como en pacientes electivos. Resultados: Veintisiete centros participaron en la elaboración de registro. El 70% aportó datos sobre mortalidad. El número de procedimientos de reparación global fue del 22% (36,6% mitrales, 3,5% aórticas y 92,5% tricúspides). La cirugía mitral reparadora fue posible en el 60% de las valvulopatías degenerativas, isquémicas y funcionales, y solo en el 2,8% de las reumáticas. La mortalidad global fue del 1,95%. El porcentaje de reparaciones aórticas oscila por grupos entre el 0 y el 48%. La cirugía reparadora tricúspide se mantiene en cifras similares a años previos. Las técnicas miniinvasivas fueron empleadas en el 3,4% de las cirugías mitrales y el 11,8% de las aórticas. Conclusiones: La actividad reparadora valvular mitral está actualmente consolidada en España, siendo especialmente infrecuente cuando la etiología de la valvulopatía es reumática. La cirugía reparadora aórtica difiere mucho entre grupos y parece encontrarse estabilizada.

Introducción y objetivos: El Grupo de Trabajo en Reparación Valvular de la Sociedad Española de Cirugía Torácica y Cardiovascular presenta el tercer Registro anual de actividad en cirugía reparadora de las válvulas mitral, aórtica y tricúspide realizadas en España en el año 2013. Métodos: Los datos se obtuvieron mediante encuesta por vía web. La participación fue voluntaria. Se contabiliza el número de intervenciones valvulares (reparaciones y recambios). Se detallan las reparaciones valvulares mitrales por etiologías. Se reporta la mortalidad. Se realiza una comparación de resultados de la cirugía valvular con años anteriores. Resultados: Se ofrecen datos de 25 centros (48% de la actividad quirúrgica del país). El volumen de reparación valvular global sigue incrementándose. La actuación sobre la válvula mitral degenerativa es mayoritariamente reparadora (61,7%). El 46% de todas las válvulas mitrales fueron reparadas. En la válvula aórtica esta técnica es todavía incipiente (2,7%). La etiología degenerativa sigue siendo la más habitual en caso de reparación valvular mitral; no obstante, en nuestro país la etiología reumática no acaba de desaparecer, siendo causa de gran cantidad de implantes protésicos. La mortalidad en la reparación fue del 1,5% ± 1,9, frente al 5,3% ± 3,5 en caso del recambio, aunque la comorbilidad asociada a los grupos fue también claramente diferente (Euroscore de 6,0 ± 3,0 frente a 8,9 ± 2,4). Conclusiones: El porcentaje de pacientes que se benefician de las técnicas de reparación valvular sigue aumentando, con unos resultados satisfactorios en términos de mortalidad.