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Background: Due to medical and surgical advancements, the population of adult patients with congenital heart disease (ACHD) is growing. Despite successful therapy, ACHD patients face structural sequalae, placing them at increased risk for heart failure and arrhythmias. Left and right ventricular function are important predictors for adverse clinical outcomes. In acquired heart disease it has been shown that echocardiographic deformation imaging is of superior prognostic value as compared to conventional parameters as ejection fraction. However, in adult congenital heart disease, the clinical significance of deformation imaging has not been systematically assessed and remains unclear., Methods: According to the Preferred Reporting Items for Systematic Reviews checklist, this systematic review included studies that reported on the prognostic value of echocardiographic left and/or right ventricular strain by 2-dimensional speckle tracking for hard clinical end-points (death, heart failure hospitalization, arrhythmias) in the most frequent forms of adult congenital heart disease., Results: In total, 19 contemporary studies were included. Current data shows that left ventricular and right ventricular global longitudinal strain (GLS) predict heart failure, transplantation, ventricular arrhythmias and mortality in patients with Ebstein's disease and tetralogy of Fallot, and that GLS of the systemic right ventricle predicts heart failure and mortality in patients post atrial switch operation or with a congenitally corrected transposition of the great arteries., Conclusions: Deformation imaging can potentially impact the clinical decision making in ACHD patients. Further studies are needed to establish disease-specific reference strain values and ranges of impaired strain that would indicate the need for medical or structural intervention., (© 2024 The Authors. European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for Clinical Investigation Journal Foundation.)

Aims: To evaluate the prognostic implications of left atrial reservoir strain-defined diastolic dysfunction (LARS-DD) grade in patients undergoing TAVI for severe aortic stenosis (AS) and to determine if post-TAVI LARS was more closely associated with new-onset atrial fibrillation than pre-TAVI LARS., Methods and Results: Pre-TAVI LARS-DD was evaluated by speckle-tracking echocardiography and was assigned as grade 0 to 1 (LARS≥24%), grade 2 (LARS≥19 to <24%) and grade 3 (LARS<19%). Patients were followed-up for the primary endpoint of all-cause mortality from the date of TAVI. For the secondary endpoint, patients with pre- and post-TAVI LARS measurements and no history of atrial fibrillation were evaluated for the occurrence of new-onset atrial fibrillation. A total of 601 patients (median age 81 [76-85] years, 53% male) were included. Overall, 169 patients (28%) were LARS-DD grade 0/1, 96 patients (16%) were LARS-DD grade 2 and 336 (56%) were LARS-DD grade 3. Over a median follow-up of 40 (IQR 26-58) months, a total of 258 (43%) patients died. In a comprehensive multivariable Cox regression model, LARS-DD grade was independently associated with all-cause mortality (adjusted HR 1.28 per one-grade increase, 95%CI 1.07-1.53, P=0.007). For the secondary endpoint of new-onset atrial fibrillation, a total of 285 patients were evaluated. Post-TAVI LARS (SDHR 1.14 per 1%<20%, 95%CI 1.05-1.23, P=0.0009), but not pre-TAVI LARS (P=0.93) was independently associated with new-onset atrial fibrillation., Conclusions: Increasing LARS-DD grade was independently associated with long-term post-TAVI survival in patients with severe AS. Post-TAVI LARS was closely related to the occurrence of new-onset atrial fibrillation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background and Aims: Arrhythmic mitral valve prolapse (AMVP) is linked to life-threatening ventricular arrhythmias (VAs), and young women are considered at high risk. Cases of AMVP in women with malignant VA during pregnancy have emerged, but the arrhythmic risk during pregnancy is unknown. The authors aimed to describe features of women with high-risk AMVP who developed malignant VA during the perinatal period and to assess if pregnancy and the postpartum period were associated with a higher risk of malignant VA., Methods: This retrospective international multi-centre case series included high-risk women with AMVP who experienced malignant VA and at least one pregnancy. Malignant VA included ventricular fibrillation, sustained ventricular tachycardia, or appropriate shock from an implantable cardioverter defibrillator. The authors compared the incidence of malignant VA in non-pregnant periods and perinatal period; the latter defined as occurring during pregnancy and within 6 months after delivery., Results: The authors included 18 women with AMVP from 11 centres. During 7.5 (interquartile range 5.8-16.6) years of follow-up, 37 malignant VAs occurred, of which 18 were pregnancy related occurring in 13 (72%) unique patients. Pregnancy and 6 months after delivery showed increased incidence rate of malignant VA compared to the non-pregnancy period (univariate incidence rate ratio 2.66, 95% confidence interval 1.23-5.76)., Conclusions: The perinatal period could impose increased risk of malignant VA in women with high-risk AMVP. The data may provide general guidance for pre-conception counselling and for nuanced shared decision-making between patients and clinicians., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Progression from paroxysmal to persistent atrial fibrillation (AF) is associated with increased morbidity and mortality. We examined the association of left atrial (LA) remodeling by serial echocardiography, and AF progression over an extended follow-up period. Two-hundred ninety patients (mean age 61  ±  11 years, 73% male) who underwent transthoracic echocardiography performed at first presentation for non-valvular paroxysmal AF (PAF) and repeat echocardiogram 1-year later, were followed for progression to persistent AF. LA and left ventricular (LV) dimensions, volumes, LA reservoir, conduit and booster pump strains, LV global longitudinal systolic strain (GLS) assessed by 2D speckle tracking, and PA-TDI (time delay between electrical and mechanical LA activation- reflecting the extent of LA fibrosis) were compared on serial echocardiography. Sixty-nine (24%) patients developed persistent AF over a mean follow-up period of 6.3 years. At baseline, patients with subsequent persistent AF had larger LA dimensions (46 mm vs. 42 mm, p < 0.001), indexed LA volumes (41 ml/m 2 vs. 34 ml/m 2 , p < 0.001), lower LA reservoir and conduit strain (17.6% vs. 27.6%, p < 0.001; 10.5% vs. 16.3%, p < 0.001; respectively) and longer PA-TDI (155 ms vs. 132 ms, p < 0.001) compared to the PAF group. Patients with subsequent persistent AF showed over time significant enlargement in LA volumes (from 37.7 ml/m 2 to 42.4 ml/m 2 , p < 0.001), lengthening of PA-TDI (from 142.2 ms to 162.2 ms, p = 0.002), and decline in LA reservoir function (from 21.9% to 18.1%, p = 0.024) after adjusting for age, gender, diabetes and LV GLS. There were no changes in LA diameter, LA conduit or booster pump function. Conversely, the PAF group showed no decline in LA function. Patients who developed persistent AF had larger LA size and impaired LA function and atrial conduction times at baseline, compared to patients who remained PAF. Over the 1-year time course of serial echocardiographic evaluation, there was progression of LA remodeling in patients who subsequently developed persistent AF, but not in patients who remained in PAF., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Multivalvular heart disease (MVD) implies the presence of concomitant valvular lesions on two or more heart valves. This condition has become common in the few last years, mostly due to population aging. Every combination of valvular lesions uniquely redefines the hemodynamics of a patient. Over time, this may lead to alterations in left ventricle (LV) dimensions, shape and, eventually, function. Since most of the echocardiographic parameters routinely used in the valvular assessment have been developed in the context of single valve disease and are frequently flow- and load-dependent, their indiscriminate use in the context of MVD can potentially lead to errors in judging lesion severity. Moreover, the combination of non-severe lesions may still cause severe hemodynamic consequences, and thereby systolic dysfunction. This review aims to discuss the most frequent combinations of MVD and their echocardiographic caveats, while addressing the opportunities for a multimodality assessment to achieve a better understanding and treatment of these patients., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2024 The Author(s). Published by IMR Press.)

Aims: Left atrial (LA) volume and LA epicardial fat are both substrates for atrial fibrillation (AF), but may relate with AF at different (early vs. late) stages in the AF disease process. We evaluated associations between LA epicardial fat and LA volume in patients with sinus rhythm (SR), paroxysmal AF (PAF), and persistent/permanent AF., Methods and Results: In total, 300 patients (100 with SR, 100 with PAF, and 100 with persistent/permanent AF) who underwent cardiac computed tomography angiography (CTA) were included. The epicardial fat mass posterior to the LA and the LA volume were quantified from CTA and compared between patients with SR, PAF, and persistent/permanent AF. Furthermore, four groups were created by classifying LA epicardial fat and LA volume into large or small according to their median. The mean age of the population was 58.9 ± 10.5 years and 69.7% was male. Left atrial epicardial fat mass was larger in patients with PAF compared with SR, but did not further increase from PAF to persistent/permanent AF. Left atrial volume increased significantly from SR to PAF and to persistent/permanent AF. Left atrial epicardial fat and LA volume were both concordantly large or small in 184 (61%) patients, and discordant in 116 (39%). When both were small, 65.2% of the patients had SR, 23.9% PAF, and 10.9% persistent/permanent AF. When the LA epicardial fat mass was large and the LA volume small (compared with both being small), patients were significantly more often in PAF (55.2 vs. 23.9, P < 0.05), less frequently in SR (32.8% vs. 65.2%, P < 0.05) but showed comparable rates of persistent/permanent AF (12.0% vs. 10.9%, P < 0.05). When the LA volume was large, most patients had persistent/permanent AF., Conclusion: Left atrial epicardial fat mass was larger in PAF vs. SR, possibly indicating a marker of early disease, while large LA volumes were associated with a high prevalence of persistent/permanent AF. Elevated LA epicardial fat mass without large LA volume may reflect the early AF disease process., Competing Interests: Conflict of interest: The Department of Cardiology of the Leiden University Medical Center received unrestricted research grants from Edwards Lifesciences, Biotronik, Medtronic, and Boston Scientific., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Aims: Tricuspid regurgitation (TR) has been associated with outcome in patients treated with transcatheter aortic valve implantation (TAVI). Tricuspid annulus (TA) dimensions are associated with TR. However, the TA is highly dynamic during the cardiac cycle, and the interaction between the TA dimensions, TR, and patient prognosis has never been evaluated. This study aimed to characterize the dynamics of the TA along with the cardiac cycle and its association with prognosis in patients undergoing TAVI., Methods and Results: Patients with severe aortic stenosis who underwent whole-beat computed tomography (n = 393, mean age 80 ± 7 years, 53% male) were included. The ratio between anterior-posterior (AP) and septal-lateral (SL) diameter of the TA was calculated at end-systole (ES), mid-diastole (MD), and end-diastole (ED) to characterize the TA shape throughout the cardiac cycle. The primary endpoint was all-cause mortality. During a median follow-up of 3.6 (1.7-5.5) years, 146 patients died. While all the TA parameters at ES and MD were not associated with all-cause mortality, a low AP/SL ratio at ED (more circular geometry) was independently related with all-cause mortality (hazard ratio: 4.717, 95% confidence interval: 1.481-15.152; P = 0.009). In addition, a more circular TA shape at ED (AP/SL ratio < 1.20) was also associated with more right atrial and ventricular dilation, more frequently significant TR, and a higher prevalence of atrial fibrillation., Conclusion: Circular remodelling of the TA shape at ED is associated with more right atrial and ventricular dilation, and a higher long-term mortality after TAVI. The evaluation of the TA shape at ED may be a useful parameter in the risk stratification of patients undergoing TAVI., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

[Figure: see text].

Assessment of right ventricular (RV) systolic function in patients with significant secondary tricuspid regurgitation (STR) remains challenging. In patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI), STR and RV enlargement have been associated with poor outcomes. In these patients, speckle tracking echocardiography (STE) may detect RV systolic dysfunction better than 3-dimensional (3D) RV ejection fraction (EF). The purpose of this study was to investigate the prevalence of RV dysfunction when assessed with STE in patients with significant STR (≥3+) compared with patients without significant STR (<3+) matched for 3D RV dimensions and RVEF on dynamic computed tomography (CT). Patients with dynamic CT data before TAVI were evaluated retrospectively. To assess the performance of RV-free wall strain (RVFWS) for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 based on age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and left ventricular ejection fraction (LVEF). In a total 267 patients (80 ± 8 years, 48% male), significant STR (≥3+) was observed in 67 patients. Patients with STR≥3+ had larger RVEDVi, larger RVESVi, lower LVEF, and more impaired RVFWS compared with patients with STR<3+ (n = 200). After propensity score matching, patients with STR≥3+ (n = 53) had significantly more impaired RVFWS compared with patients with STR<3+ (n = 53): -18.2 ± 5.0% versus -21.1 ± 3.7%, p = 0.001. In conclusion, patients with significant STR have more pronounced RV systolic dysfunction as assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF on dynamic CT., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Valvular atrial fibrillation (AF) is defined as AF in the presence of mitral stenosis or mechanical valve prosthesis. However, there are patients with AF who have significant native valvular heart disease (VHD) others than mitral stenosis that are classified as nonvalvular AF. The characteristics and prognostic implications of these entities have not been extensively studied. Of 1,885 AF patients referred for electrical cardioversion (64 ± 13years, 71% male), 171 (9.1%) had valvular AF (any grade of mitral stenosis or mechanical/biological valve prostheses) and 1,714 patients were identified as nonvalvular AF, of whom 329 (17.5%) had significant left-sided VHD. Patients with nonvalvular AF but with significant left-sided VHD were older, more frequently women and had more co-morbidities compared with the other groups. Furthermore, nonvalvular AF patients with significant left-sided VHD showed the worst left ventricular systolic function and largest left atrial volumes. During a median follow-up of 64 months (interquartile range: 33 to 96 months), 488 patients presented with the combined endpoint of all-cause mortality, heart failure hospitalization, and ischemic stroke. Patients with nonvalvular AF and with significant left-sided VHD had more events of heart failure whereas patients with valvular AF had higher all-cause mortality events. There were no differences in ischemic stroke events. Type of AF was not associated with outcomes after correcting for echocardiographic variables. In conclusion, the frequency of AF patients with significant VHD is relatively high. The consequences of VHD and AF on cardiac structure and function are more important determinants of adverse outcome than the type of AF., (Copyright © 2020 Elsevier Inc. All rights reserved.)

In patients with atrial fibrillation (AF), left atrial (LA) fibrosis is a major determinant of the progression to, and burden of AF. LA reservoir strain and total atrial conduction time (PA-TDI) reflect LA fibrotic content. We aimed to investigate the relation between LA reservoir strain and PA-TDI in AF patients and control subjects. Six-hundred two patients (mean age 56 years, 53% men) with first episode of AF and 342 controls (mean age 64 years, 71% men) without structural heart disease underwent echocardiography. LA volumes, PA-TDI, LA reservoir strain, and left ventricular global longitudinal strain (GLS) were compared. Compared with controls, patients with paroxysmal AF and patients with persistent AF had longer PA-TDI (128 ± 25 millisecond, 140 ± 31 millisecond, and 154 ± 33 millisecond, respectively; p <0.001) and a progressive decline in LA reservoir strain (36.9 ± 11.6%, 29.8 ± 13.4%, 24.2 ± 12.3%, respectively; p <0.001). LA reservoir strain was negatively correlated with PA-TDI (r = -0.43, p <0.001). On multivariate analyses, LA reservoir strain, diabetes mellitus, and burden of AF were independent correlates of PA-TDI (R 2  = 0.23, p <0.001); whereas only PA-TDI was an independent correlate of LA reservoir strain (R 2  = 0.43, p <0.001); controlling for age, hypertension, coronary artery disease, body mass index, severity of mitral regurgitation, left ventricular global longitudinal strain, and LA volume. In conclusion, PA-TDI and LA reservoir strain are negatively correlated in all subjects, irrespective of the presence or burden of AF. Patients with persistent AF have longer PA-TDI and impaired LA reservoir strain compared with paroxysmal AF and controls, suggesting increasing burden of fibrosis and LA structural remodeling in the progression of AF., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: The incidence of new-onset conduction abnormalities requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) with new-generation prostheses remains debated. This systematic review analyses the incidence of PPI after TAVI with new-generation devices and evaluates the electrical, anatomical, and procedural factors associated with PPI. In addition, the incidence of PPI after TAVI with early generation prostheses was reviewed for comparison., Methods and Results: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, this systematic review screened original articles published between October 2010 and October 2017, reporting on the incidence of PPI after implantation of early and new-generation TAVI prostheses. Of the 1406 original articles identified in the first search for new-generation TAVI devices, 348 articles were examined for full text, and finally, 40 studies (n = 17 139) were included. The incidence of a PPI after the use of a new-generation TAVI prosthesis ranged between 2.3% and 36.1%. For balloon-expandable prostheses, the PPI rate remained low when using an early generation SAPIEN device (ranging between 2.3% and 28.2%), and with the new-generation SAPIEN 3 device, the PPI rate was between 4.0% and 24.0%. For self-expandable prostheses, the PPI rates were higher with the early generation CoreValve device (16.3-37.7%), and despite a reduction in PPI rates with the new Evolut R, the rates remained relatively higher (14.7-26.7%). When dividing the studies according to the highest (>26.0%) and the lowest (<12.1%) quintile of PPI rate, patients within the highest quintile were more frequently women when compared with the lowest quintile group (50.9% vs. 46.3%, P < 0.001). Pre-existent conduction abnormalities (electrical factor), calcification of the left ventricular outflow tract (anatomical factor), and balloon valvuloplasty and depth of implantation (procedural factors) were associated with increased risk of PPI., Conclusion: The rate of PPI after TAVI with new-generation devices is highly variable. Specific recommendations for implantation of each prosthesis, taking into consideration the presence of pre-existent conduction abnormalities and anatomical factors, may be needed to reduce the risk of PPI.

Aims: Atrial fibrillation (AF) is an independent risk factor for ischaemic stroke. The CHA2DS2-VASc is the most widely used risk stratification model; however, echocardiographic refinement may be useful, particularly in low risk AF patients. The present study examined the association between advanced echocardiographic parameters and ischaemic stroke, independent of CHA2DS2-VASc score., Methods and Results: One thousand, three hundred and sixty-one patients (mean age 65±12 years, 74% males) with first diagnosis of AF and baseline transthoracic echocardiogram were followed by chart review for the occurrence of stroke over a mean of 7.9 years. Left atrial (LA) volumes, LA reservoir strain, P-wave to A' duration on tissue Doppler imaging (PA-TDI, reflecting total atrial conduction time), and left ventricular (LV) global longitudinal strain (GLS) were evaluated in patients with and without stroke. The independent association of these echocardiographic parameters with the occurrence of ischaemic stroke was evaluated with Cox proportional hazard models. One-hundred patients (7%) developed an ischaemic stroke, representing an annualized stroke rate of 0.9%. The incident stroke rate in the year following the first diagnosis of AF was 2.6% in the entire population and higher than the remainder of the follow-up period. Left atrial reservoir (14.5% vs. 18.9%, P = 0.005) and conduit strains were reduced (10.5% vs. 13.5%, P = 0.013), and PA-TDI lengthened (166 ms vs. 141 ms, P < 0.001) in the stroke compared with non-stroke group, despite similar LV dimensions, LV ejection fraction, GLS, and LA volumes. Left atrial reservoir strain and PA-TDI were independently associated with risk of stroke in a model including CHA2DS2-VASc score, age, and anticoagulant use., Conclusion: The assessment of LA reservoir strain and PA-TDI on echocardiography after initial CHA2DS2-VASc scoring provides additional risk stratification for stroke and may be useful to guide decisions regarding anticoagulation for patients upon first diagnosis of AF.

Background: Transcatheter aortic valve replacement (TAVR) has been shown safe and feasible in patients with bicuspid aortic valve (BAV) morphology. Evaluation of inter-ethnic differences in valve morphology and function and aortic root dimensions in patients with BAV is important for the worldwide spread of this therapy in this subgroup of patients. Comparisons between large European and Asian cohorts of patients with BAV have not been performed, and potential differences between populations may have important implications for TAVR., Aim: The present study evaluated the differences in valve morphology and function and aortic root dimensions between two large cohorts of European and Asian patients with BAV., Methods and Results: Aortic valve morphology was defined on transthoracic echocardiography according to the number of commissures and raphe: type 0 = no raphe and two commissures, type 1 = one raphe and two commissures, type 2 = two raphes and one commissure. Aortic stenosis and regurgitation were graded according to current recommendations. For this study, aortic root dimensions were manually measured on transthoracic echocardiograms at the level of the aortic annulus, sinus of Valsalva (SOV), sinotubular junction (STJ), and ascending aorta (AA). Of 1427 patients with BAV (45.2 ± 18.1 years, 71.9% men), 794 (55.6%) were Europeans and 633 (44.4%) were Asians. The groups were comparable in age and proportion of male sex. Asians had higher prevalence of type 1 BAV with raphe between right and non-coronary cusps than Europeans (19.7% vs. 13.6%, respectively; P < 0.001), whereas the Europeans had higher prevalence of type 0 BAV (two commissures, no raphe) than Asians (14.5% vs. 6.8%, respectively; P < 0.001). The prevalence of moderate and severe aortic regurgitation was higher in Europeans than Asians (44.2% vs. 26.8%, respectively; P < 0.001) whereas there were no differences in BAV with normal function or aortic stenosis. After adjusting for demographics, comorbidities, and valve function, the dimensions of the aortic annulus [mean difference 1.17 mm/m2, 95% confidence interval (CI) 0.96-1.39], SOV (mean difference 1.86 mm/m2, 95% CI 1.47-2.24), STJ (mean difference 0.52 mm/m2, 95% CI 0.14-0.90) and AA (mean difference 1.05 mm/m2, 95% CI 0.57-1.52) were significantly larger among Asians compared with Europeans., Conclusions: This large multicentre registry reports for the first time that Asians with BAV showed more frequently type 1 BAV (with fusion between right and non-coronary cusp) and have larger aortic dimensions than Europeans. These findings have important implications for prosthesis type and size selection for TAVR.

Background: In transcatheter aortic valve replacement (TAVR), multi-detector row computed tomography (MDCT) is currently the standard imaging modality for correct prosthesis sizing, despite risks of radiation and contrast-induced renal injury. Three-dimensional (3D) transesophageal echocardiography (TEE) has been proposed as a potential alternative imaging technique, and recently, automated 3D transesophageal echocardiographic software (Aortic Valve Navigator [AVN], an unreleased prototype from Philips) has been developed for assessment of the aortic annulus and root. The aim of this study was to assess the feasibility, accuracy, and reproducibility of AVN measurements in TAVR candidates by performing a comparison with MDCT., Methods: In 150 patients with severe, symptomatic aortic stenosis referred for TAVR, data on aortic annular and root dimensions prospectively acquired using 3D TEE and MDCT were retrospectively analyzed. Image quality on 3D TEE and the duration of analysis with AVN were recorded, as well as the aortic valve Agatston score on MDCT., Results: Data were obtained using 3D TEE and MDCT in 100% of patients for aortic annular dimensions and in 89% for aortic root dimensions. The mean duration of analysis using AVN was 4.2 ± 1.0 min, but it was significantly shorter with better 3D echocardiographic image quality and lower Agatston score on MDCT. Correlation of measurements between 3D TEE and MDCT was good to excellent for all anatomic locations (sinotubular junction mean diameter, R = 0.71; sinus of Valsalva mean diameter, R = 0.87; aortic annular mean diameter, R = 0.75; aortic annular perimeter, R = 0.83; aortic annular area, R = 0.91), with low inter- and intraobserver variability (intraclass correlation coefficient ≥ 0.93 and r ≥ 0.90 for all locations). Comparison based on conventional prosthesis sizing charts yielded excellent agreement in prosthesis size choice (κ = 0.90)., Conclusions: New automated 3D transesophageal echocardiographic software allows accurate modeling and reproducible quantification of aortic annular and root dimensions with high feasibility. An excellent correlation between measurements with AVN and MDCT and agreement in prosthesis sizing suggests the use of AVN in clinical practice as potential alternative to MDCT before TAVR., (Copyright © 2017 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Aims: It remains unclear whether surgical or transcatheter mitral valve repair for secondary mitral regurgitation (MR) in patients with non-ischaemic cardiomyopathy reverse the underlying left ventricular (LV) pathophysiology. We hypothesized that mitral valve repair improves LV systolic function and forward flow and induces LV reverse remodelling in this group of patients., Methods and Results: Seventy-six patients (65 ± 14 years old, 43% male) with non-ischaemic cardiomyopathy and moderate to severe chronic secondary MR treated successfully with transcatheter or surgical mitral valve repair were evaluated. Transthoracic echocardiography was performed at baseline, discharge and 6 months post-repair. After mitral valve repair, LVEF, and LV global longitudinal strain (GLS) corrected for LV end-diastolic volume remained unchanged over time (P = 0.90 and P = 0.96, respectively). In contrast, LV forward flow increased significantly over time (stroke volume index: from 20 ± 7 to 29 ± 8 and 26 ± 8 mL/m2, P < 0.001; cardiac index: from 1.50 ± 0.44 to 2.36 ± 0.60 and 2.01 ± 0.48 L/min/m2, P < 0.001). In addition, LV end-diastolic and end-systolic volume index significantly reduced over time (from 87 ± 42 to 70 ± 33 and 75 ± 39 mL/m2, P < 0.001; and from 60 ± 35 to 50 ± 30 and 53 ± 36 mL/m2, P = 0.004, respectively). These changes were independent of the type of repair., Conclusion: Surgical and transcatheter mitral valve repair for secondary MR in patients with non-ischaemic dilated cardiomyopathy improved LV forward flow and induced LV reverse remodelling but did not change LV systolic function., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Objectives: This study sought to investigate the prognostic implications of the clinical subtype of atrial fibrillation (AF): paroxysmal or persistent., Background: Underlying structural abnormalities of the left atrium may be responsible for the initial clinical presentation of AF in either paroxysmal or persistent form, yet the prognostic implications of the clinical subtype on presentation are unknown., Methods: Over a median of 7 years, 1,773 patients (age 64 ± 12 years, 74% males) with nonvalvular AF with index presentations for paroxysmal or persistent AF were followed for the occurrence of all-cause mortality. Clinical information including cardiovascular risk factors, comorbid diseases associated with AF, and CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75 [double weight], diabetes, stroke [double weight], vascular disease, age 65-74, and sex category [female]) score was collected and analyzed., Results: In this study, 1,005 patients (57%) had persistent AF. Eighty patients (10%) with paroxysmal AF and 174 patients (17%) with persistent AF died during the follow-up period. Persistent AF compared with paroxysmal AF upon initial AF diagnosis was independently associated with worse survival independent of the CHA 2 DS 2 -VASc score and other high-risk cardiovascular risk factors (hazard ratio: 1.24; 95% confidence interval: 1.11 to 1.38)., Conclusions: In patients with nonvalvular AF, persistent AF compared with paroxysmal AF upon first diagnosis is independently associated with increased mortality., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Accurate aortic annulus sizing is key for selection of appropriate transcatheter aortic valve implantation (TAVI) prosthesis size. The present study compared novel automated 3-dimensional (3D) transesophageal echocardiography (TEE) software and multidetector row computed tomography (MDCT) for aortic annulus sizing and investigated the influence of the quantity of aortic valve calcium (AVC) on the selection of TAVI prosthesis size. A total of 83 patients with severe aortic stenosis undergoing TAVI were evaluated. Maximal and minimal aortic annulus diameter, perimeter, and area were measured. AVC was assessed with computed tomography. The low and high AVC burden groups were defined according to the median AVC score. Overall, 3D TEE measurements slightly underestimated the aortic annulus dimensions as compared with MDCT (mean differences between maximum, minimum diameter, perimeter, and area: -1.7 mm, 0.5 mm, -2.7 mm, and -13 mm 2 , respectively). The agreement between 3D TEE and MDCT on aortic annulus dimensions was superior among patients with low AVC burden (<3,025 arbitrary units) compared with patients with high AVC burden (≥3,025 arbitrary units). The interobserver variability was excellent for both methods. 3D TEE and MDCT led to the same prosthesis size selection in 88%, 95%, and 81% of patients in the total population, the low, and the high AVC burden group, respectively. In conclusion, the novel automated 3D TEE imaging software allows accurate and highly reproducible measurements of the aortic annulus dimensions and shows excellent agreement with MDCT to determine the TAVI prosthesis size, particularly in patients with low AVC burden., (Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Surgical mitral valve repair for severe secondary mitral regurgitation (MR) remains controversial. The association of MR reduction and changes in left ventricular (LV) hemodynamics with survival has not been investigated. We investigated the independent associates of outcomes in heart failure patients with severe secondary MR who underwent surgical mitral valve repair., Methods: Patients (n = 130, 62 ± 12 years old, 55% men) with chronic severe secondary MR and impaired LV ejection fraction (<0.50, mean 0.31 ± 0.10) treated with surgical mitral valve repair were included. Echocardiographic LV forward stroke volume and LV forward ejection fraction were measured at baseline and at discharge. All-cause mortality was the primary endpoint, and the combination of major adverse cardiac-related events and all-cause mortality was the secondary endpoint., Results: At hospital discharge, 77% of patients showed no residual MR and 23% showed mild MR. LV volumes reduced significantly, whereas LV ejection fraction remained unchanged. In contrast, LV forward stoke volume (53 ± 24 mL versus 64 ± 22 mL, p < 0.001) and LV forward ejection fraction (0.32 ± 0.16 versus 0.48 ± 0.24, p < 0.001) significantly increased at discharge. During a median follow-up of 3.44 years, 33 patients (29%) died and 40 had major adverse cardiac-related events. On multivariable analysis, LV forward stroke volume after repair was independently associated with all-cause mortality (hazard ratio 0.98, p = 0.047) and with the combined endpoint (hazard ratio 0.98, p = 0.045) after correcting for other baseline, procedural, and postrepair characteristics., Conclusions: In patients with severe secondary MR treated with surgical repair, LV forward flow was independently associated with better survival and lower risk of the combined endpoint., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Patients who received chest irradiation for treatment of a malignancy are at increased risk for the development of coronary artery atherosclerosis. Little is known about the anatomical coronary artery plaque characteristics of irradiation induced coronary artery disease (CAD). This study aimed to evaluate potential differences in the presence, extent, severity, composition and location of CAD in patients treated with mediastinal irradiation compared with non-irradiated controls matched on age, gender and cardiovascular risk factors., Material and Methods: Seventy-nine asymptomatic Hodgkin and non-Hodgkin lymphoma survivors, all treated with mediastinal irradiation with or without chemotherapy, who underwent coronary computed tomography angiography (CTA) to exclude or detect CAD were included. Patients were 1:3 matched with non-irradiated controls (n=237) for age, gender, diabetes, hypertension, hypercholesterolemia, family history of CAD and currently smoking. Mean age at cancer diagnosis was 26±9years and age at the time of coronary CTA was 45±11years., Results: More patients had an abnormal CTA (defined as any coronary artery atherosclerosis): 59% vs. 36% (P<0.001) and significantly more patients had two vessel CAD: 10% vs. 6% and three vessel/left main CAD: 24% vs. 9% compared with controls (overall P<0.001). The maximum stenosis severity among patients was less often <30% (53% vs. 68%) and more often >70% (7% vs. 0%) (overall P=0.001). Patients had more coronary artery plaques in proximal coronary artery segments: left main (17% vs. 6%, P=0.004), proximal left anterior descending artery (30% vs. 16%, P=0.004), proximal right coronary artery (25% vs 10%, P<0.001) and proximal left circumflex artery (14% vs 6%, P=0.022), whereas the number of plaques in non-proximal segments did not differ between groups., Conclusions: Hodgkin and non-Hodgkin lymphoma survivors treated with mediastinal irradiation with or without chemotherapy showed a higher presence, greater severity, larger extent and more proximally located CAD compared with age, gender and risk factor matched non-irradiated controls. These findings represent features of higher risk CAD and may explain the worse cardiovascular outcome after chest irradiation., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Aims: Quantitative mitral regurgitation (MR) grading remains challenging. This study evaluated the concept of integrating echocardiography and computed tomography for grading MR severity. Specifically, an integrated parameter was developed that combines the true cross-sectional mitral regurgitant orifice area (ROA) assessed with multi-detector row computed tomography (MDCT) with flow data from echocardiography., Methods and Results: Systolic MDCT data of 73 patients, referred for transcatheter aortic valve implantation (TAVI) who also had MR, were evaluated. The MDCT systolic phase with the smaller left ventricular volume and the largest mitral regurgitant orifice was selected. Using planimetry, the mitral ROA was measured. The mitral ROA was multiplied with the velocity time integral of the MR jet on echocardiography for the calculation of the integrated regurgitant volume (RVol). MDCT analysis showed a mean mitral ROA of 11.3 ± 7.4 mm2 and a mean integrated RVol of 21.4 ± 14.7 mL/beat, whereas echocardiography showed a mean effective ROA and RVol of MR of 13.3 ± 8.2 mm2 and 23.9 ± 13.6 mL/beat, respectively. Compared with echocardiography, grading based on integrated mitral RVol resulted in reclassification of 10% of the patients from severe to non-severe MR and 14% of the patients from non-severe to severe MR., Conclusions: Integrated mitral RVol is a quantitative parameter of MR severity by combining the true cross-sectional mitral ROA assessed with MDCT and Doppler mitral haemodynamics which resulted in a significant reclassification of MR grade in patients with severe aortic stenosis undergoing TAVR., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Aims: The presence of hypo-attenuated leaflet thickening (HALT) and/or reduced leaflet motion on multi-detector row computed tomography (MDCT) has been proposed as a possible marker for early transcatheter aortic valve thrombosis. However, its association with abnormal valve haemodynamics on echocardiography (another potential marker of thrombosis) and clinical outcomes (stroke) remains unclear. The present study evaluated the prevalence of HALT on MDCT and abnormal valve haemodynamics on echocardiography. In addition, the occurrence of ischemic stroke and/or transient ischemic attack (TIA) was assessed., Methods and Results: A total of 434 patients (mean age 80 ± 7 years, 51% male) who underwent transcatheter aortic valve replacement (TAVR) were evaluated. Transcatheter valve haemodynamics were assessed on echocardiography at discharge, 6 months, and thereafter yearly (up to 3 years post-TAVR). The presence of HALT and/or reduced leaflet motion was assessed on MDCT performed 35 days [interquartile range 19-210] after TAVR in 128 of these 434 patients. Possible TAVR valve thrombosis was defined by mean transvalvular gradient ≥20 mmHg and aortic valve area (AVA) ≤1.1cm2 on echocardiography or by the presence of HALT or reduced leaflet motion on MDCT. The occurrence of ischemic stroke/TIA at follow-up was recorded. HALT and/or reduced leaflet motion was present in 12.5% of 128 patients undergoing MDCT, and was associated with a slightly higher mean transvalvular gradient (12.4 ± 8.0 mmHg vs. 9.4 ± 4.3 mmHg; P = 0.026) and smaller AVA (1.49 ± 0.39 cm2 vs. 1.78 ± 0.45 cm2, P = 0.017). Only one patient with HALT on MDCT revealed abnormal valve haemodynamics on echocardiography. At 3-year follow-up, abnormal valve haemodynamics on echocardiography were observed in 3% of patients. HALT on MDCT and abnormal valve haemodynamics on echocardiography were not associated with increased risk of ischemic stroke/TIA., Conclusion: On MDCT, 12.5% of patients showed HALT or reduced leaflet motion, whereas only one of these patients had abnormal valve haemodynamics on echocardiography. Neither HALT nor increased transvalvular gradient were associated with stroke/TIA., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Importance: Little is known about the association between bicuspid aortic valve (BAV) morphologic findings and the degree of valvular dysfunction, presence of aortopathy, and complications, including aortic valve surgery, aortic dissection, and all-cause mortality., Objective: To investigate the association between BAV morphologic findings (raphe vs nonraphe) and the degree of valve dysfunction, presence of aortopathy, and prognosis (including need for aortic valve surgery, aortic dissection, and all-cause mortality)., Design, Setting, and Participants: In this large international multicenter registry of patients with BAV treated at tertiary referral centers, 2118 patients with BAV were evaluated. Patients referred for echocardiography from June 1, 1991, through November 31, 2015, were included in the study., Exposures: Clinical and echocardiographic data were analyzed retrospectively. The morphologic BAV findings were categorized according to the Sievers and Schmidtke classification. Aortic valve function was divided into normal, regurgitation, or stenosis. Patterns of BAV aortopathy included the following: type 1, dilation of the ascending aorta and aortic root; type 2, isolated dilation of the ascending aorta; and type 3, isolated dilation of the sinus of Valsalva and/or sinotubular junction., Main Outcomes and Measures: Association between the presence and location of raphe and the risk of significant (moderate and severe) aortic valve dysfunction and aortic dilation and/or dissection., Results: Of the 2118 patients (mean [SD] age, 47 [18] years; 1525 [72.0%] male), 1881 (88.8%) had BAV with fusion raphe, whereas 237 (11.2%) had BAV without raphe. Bicuspid aortic valves with raphe had a significantly higher prevalence of valve dysfunction, with a significantly higher frequency of aortic regurgitation (622 [33.1%] vs 57 [24.1%], P < .001) and aortic stenosis (728 [38.7%] vs 51 [21.5%], P < .001). Furthermore, aortic valve replacement event rates were significantly higher among patients with BAV with raphe (364 [19.9%] at 1 year, 393 [21.4%] at 2 years, and 447 [24.4%] at 5 years) vs patients without raphe (30 [14.0%] at 1 year, 32 [15.0%] at 2 years, and 40 [18.0%] at 5 years) (P = .02). In addition, the all-cause mortality event rates were significantly higher among patients with BAV with raphe (77 [5.1%] at 1 year, 87 [6.2%] at 2 years, and 110 [9.5%] at 5 years) vs patients without raphe (2 [1.8%] at 1 year, 3 [3.0%] at 2 years, and 5 [4.4%] at 5 years) (P = .03). However, on multivariable analysis, the presence of raphe was not significantly associated with all-cause mortality., Conclusions and Relevance: In this large multicenter, international BAV registry, the presence of raphe was associated with a higher prevalence of significant aortic stenosis and regurgitation. The presence of raphe was also associated with increased rates of aortic valve and aortic surgery. Although patients with BAV and raphe had higher mortality rates than patients without, the presence of a raphe was not independently associated with increased all-cause mortality.

Aims: Percutaneous transcatheter tricuspid valve therapy is an evolving treatment option for patients with significant tricuspid regurgitation (TR) deemed too fragile for open heart surgery. The present study proposes comprehensive anatomical evaluation of the tricuspid valve, right ventricle (RV), and vena cavae and its spatial relationships with the right coronary artery (RCA) using computed tomography (CT) and investigates the implications for suitability for current technologies., Methods and Results: A total of 250 patients (mean age 80 ± 7.2 years, 52.4% men) undergoing CT were divided according to the presence of moderate or severe TR (≥3+, n = 40) and less than moderate TR (<3+, n = 210). Tricuspid valve annulus, RV, and vena cavae dimensions and the course of the RCA relative to the tricuspid annulus were evaluated. Patients with TR ≥ 3+ showed significantly larger dimensions of the tricuspid annulus, RV and vena cavae. In 64.8% of patients, the RCA coursed along the tricuspid valve annulus. Patients with TR <3+ showed more frequently a course of the RCA superior to the tricuspid annulus at the levels of the anterior and the posterior tricuspid leaflet compared with their counterparts (12.4% vs. 0%, P = 0.019). A less favourable course of the RCA (≤2.0 mm distance to the annulus) for current annuloplasty techniques was observed at the level of the anterior tricuspid and posterior leaflets in respective 12.5 and 27.5% of patients with TR ≥3+., Conclusion: The present study proposes a first systematic approach based on CT to define the patient suitability for current transcatheter tricuspid valve devices., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For Permissions, please email: journals.permissions@oup.com.)

Background: Epicardial adipose tissue located close to the atrial wall can change the electric conduction of the left atrium, potentially leading to atrial fibrillation (AF). The aim of this study was to assess whether an increased atrial adipose tissue mass posterior to the left atrium is related to AF independent of demographical and cardiovascular risk factors., Methods and Results: Two hundred patients with AF and 200 patients without AF who underwent computed tomographic angiography were included. The posterior left atrial adipose tissue mass was quantified on computed tomographic angiography images as tissue with Hounsfield Units between -195 and -45. The adipose tissue mass was significantly larger in patients with AF compared with patients with sinus rhythm: 10.6±5.5 versus 4.7±3.5 g, P <0.001. In a multiple variable model (including age, body mass index, sex, coronary artery calcium score, diabetes mellitus, hypertension, hypercholesterolemia, family history of coronary artery disease, and known coronary artery disease), each gram increase of posterior left atrial adipose tissue was associated with 1.32 odds ratio of having AF (95% confidence interval, 1.22-1.43; P <0.001). Furthermore, the addition of the adipose tissue mass to the multiple variable analysis significantly increased the discriminatory ability to predict AF: increase in the area under the receiver operating characteristic, 0.88 (95% confidence interval, 0.84-0.91) versus 0.81 (0.76-0.85), P <0.001., Conclusions: Posterior left atrial adipose tissue mass is significantly larger in patients with AF versus without AF. An increase in adipose tissue was independently associated with AF and provided incremental value over well-known predictors of AF. These findings add to the hypothesis that the posterior left atrial adipose tissue mass contributes to structural and electric remodeling leading to AF., (© 2017 American Heart Association, Inc.)

Aims: Conventional aortic valve replacement (AVR), sutureless AVR (su-AVR) and transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) are associated with conduction abnormalities. The aim of the present study was to assess the incidence of left bundle branch block (LBBB) after su-AVR and TAVI, in comparison to conventional AVR., Methods and Results: A total of 501 patients (mean age 74±8 years, 53% male) without preoperative cardiac conduction disturbances who underwent AVR or TAVI were included in the study. Su-AVR patients and TAVI patients had a higher incidence of new-onset LBBB at hospital discharge (23% and 16%, respectively) compared to patients treated with conventional AVR (4%; p<0.001). On multivariate logistic regression analyses, the type of AVR was independently associated with complete LBBB, after correcting for age, preoperative QRS duration and heart rate (su-AVR and TAVI relative to the reference category conventional AVR: odds ratio [OR] 8.5, 95% confidence interval [CI]: 3.7-19.5; p<0.001, and OR 5.8, 95% CI: 2.4-14.1; p<0.001, respectively)., Conclusions: Su-AVR and TAVI were associated with higher risk of developing postoperative LBBB compared to conventional AVR, after adjusting for age, preoperative heart rate and QRS duration.

The aim of this study was to compare the calcium burden of the aortic valve and coronary arteries with multidetector computed tomography (MDCT) in a propensity score-matched population of patients with a bicuspid versus a tricuspid aortic valve. From an ongoing clinical registry of patients who underwent MDCT, 70 patients with bicuspid aortic valve and 210 patients with tricuspid aortic valve were matched based on age, gender, cardiovascular risk factors, chest pain symptoms, and MDCT indication. Aortic valve calcium and the presence and severity of coronary artery disease were analyzed. Patients were divided into age quintiles. The median Agatston coronary artery score (27 [0 to 563] vs 0 [0 to 57], p = 0.003) was higher in patients with a tricuspid aortic valve compared with those with a bicuspid aortic valve. In contrast, patients with bicuspid aortic valve had a significantly larger calcium volume of the aortic valve than those with tricuspid aortic valve (391 [43 to 2,028] mm 3 vs 0 [0 to 1,844] mm 3 , p <0.001). In patients with bicuspid aortic valve, the calcification process of the aortic valve started at an earlier age (second quintile 35 to 51 years) compared with those with tricuspid aortic valve, whereas the coronary atherosclerosis process was similar in both groups. In conclusion, patients with bicuspid aortic valve show larger aortic valve calcium load and at earlier age than those with tricuspid aortic valve, independently from the extent of calcium in the coronary arteries. Calcific deposits were heavier in bicuspid than in tricuspid valves., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The iterations of the SAPIEN prosthesis might impact the incidence and grade of paravalvular regurgitation (PVR). The aim of this study was to assess the impact of iterations of balloon-expandable valves (SAPIEN, SAPIEN XT, and SAPIEN 3) and degree of aortic valve calcification (AVC) on the severity of PVR after transcatheter aortic valve implantation (TAVI). Comprehensive echocardiographic examinations and multidetector computed tomography (MDCT) were performed in 272 patients (127 men, 81 ± 7 years old, logistic EuroScore of 21 ± 13%) who underwent TAVI with 23- and 26-mm balloon-expandable valves. The degree of AVC was assessed with MDCT. PVR grade was assessed with echocardiography. The cover index was calculated as (prosthesis area - MDCT annulus area)/prosthesis area. SAPIEN, SAPIEN XT, and SAPIEN 3 prostheses were implanted in 103 patients (38%), 105 patients (38.5%), and 64 patients (23.5%), respectively. Significant PVR (≥moderate) occurred in 14%, 10%, and 0% of patients receiving the SAPIEN, SAPIEN XT, and SAPIEN 3, respectively (p = 0.010). Across the groups, the aortic annulus size, degree of calcification, and cover index were comparable. Larger burden of AVC was independently associated with significant PVR (odds ratio 3.48, p = 0.006) after adjusting for age, body surface area, gender, aortic annulus area, cover index, and prosthesis iteration. SAPIEN 3 was associated with lower frequency of significant PVR (odds ratio 0.31, p = 0.002). In conclusion, the incidence of significant PVR significantly decreased over time with improvement in valve design. SAPIEN 3 was associated with less significant PVR after TAVI independently of the AVC burden., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To investigate the procedural outcomes and the long-term survival of patients undergoing transcatheter aortic valve implantation (TAVI) and compare study results of patients ≤ 80 years and patients > 80 years old., Methods: A total of 240 patients treated with TAVI were divided into two groups according to age ≤ 80 years (n = 105; 43.8%) and > 80 years (n = 135; 56.2%). The baseline characteristics and the procedural outcomes were compared between these two groups of patients., Results: With the exception of peripheral artery disease and hypercholesterolemia, which were more frequently observed in the older age group, baseline characteristics were comparable between groups. Complication rates did not differ significantly between patients ≤ 80 years and patients > 80 years. There were no differences in 30-day mortality rates between patients aged ≤ 80 years and patients > 80 years old (9.5% vs. 7.4%, respectively; P = 0.557). After a median follow-up of 28 months (interquartile range: 16-42 months), 50 (47.6%) patients aged ≤ 80 years died compared to 57 (42%) deaths in the group of patients > 80 years old (P = 0.404)., Conclusion: The results of the present single center study showed that age did not significantly impact the outcomes of TAVI.

Aims: Multidetector row computed tomography (MDCT) may help to understand the underlying mechanisms of functional tricuspid regurgitation (TR), a highly prevalent valve disease with novel transcatheter therapies under development. The purpose of the present study was to assess the geometrical changes of the tricuspid valve in patients with functional TR using MDCT and to correlate these changes with the TR grade assessed with echocardiography., Methods and Results: In 114 patients undergoing transcatheter aortic valve implantation (47 men, age 81 ± 8 years), including 33 (28.9%) patients with TR ≥ 3+, the tricuspid valve and right ventricle (RV) were geometrically analysed with 320-slice MDCT. The antero-posterior and septal-lateral diameters, perimeter and area of the annulus, degree of tethering of the anterior, septal and posterior tricuspid valve leaflets, and RV volumes and ejection fraction were assessed and subsequently correlated with TR grade in multivariate models. Patients with pacemaker or implantable cardioverter defibrillator leads were excluded.Patients with TR ≥ 3+ had larger tricuspid annulus area (1539.7 ± 260.2 vs.1228.4 ± 243.5 mm(2), P < 0.001), larger septal and anterior leaflet angles, and larger RV end-systolic volumes (93.2 ± 29.8 vs. 64.2 ± 23.6 mL, P < 0.001) compared with patients with TR < 3+.The antero-posterior tricuspid annulus diameter was independently correlated with TR ≥ 3+ (odds ratio 1.35; 95% confidence interval 1.07-1.69, P = 0.010), after adjusting for estimated pulmonary pressure and RV end-systolic volume., Conclusion: In patients with TR ≥ 3+, MDCT demonstrated larger tricuspid annulus and RV dimensions and pronounced tethering of the anterior and septal tricuspid leaflet. The antero-posterior annulus diameter was independently correlated with the grade of functional TR., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Bicuspid aortic valve (BAV) anatomy is associated with increased growth rate of the aortic root compared to tricuspid aortic valves. Statins decrease the growth rate of abdominal aneurysms; however their effect on the aortic root growth rate has not been elucidated. The present study evaluated the association between use of statins and aortic root growth in patients with BAV. A total of 199 patients (43 ± 15 years, 69% male) with BAV who underwent ≥ 2 echocardiographic measurements of the aortic root ≥ 1 year apart were included in this retrospective observational study. Median follow-up duration was 4.7 years (interquartile range 2.7-8.3 years). Growth rate (mm/year) of the aortic root was compared between statin users (n = 41) and non-users (n = 158). Statin users were significantly older and had more cardiovascular risk factors than their counterparts. Ascending aorta diameter was significantly smaller at baseline and at follow-up in statin users compared with non-users when adjusted for coronary artery disease, age and medication. The average annual growth rate was 0.08 mm/year (95% confidence interval 0.03-0.13) for the aortoventricular junction, 0.16 mm/year (0.11-0.21) for the sinus of Valsalva, 0.12 mm/year (0.07-0.17) for the sinotubular junction and 0.45 mm/year (0.37-0.53) for the ascending aorta. The dilation rate of the aortic segments was not different between statin users and non-users. In conclusion, in patients with BAV, although the use of statins was associated with smaller ascending aorta, the annual dilation rate of the aortic root was not influenced by the use of statins.

Global longitudinal strain (GLS) measured by 2-dimensional longitudinal speckle-tracking echocardiography may be a more sensitive measure of left ventricular (LV) mechanics than conventional LV ejection fraction (EF) to characterize adverse post-ST-segment elevation myocardial infarction (STEMI) remodeling. The aim of the present evaluation was to compare changes in LV GLS in patients with versus without diabetes after the first STEMI. Patients with first STEMI and diabetes (n = 143; age 64 ± 12 years; 68% men; 50% left anterior descending artery as culprit vessel) and 290 patients with first STEMI and without diabetes matched on age, gender, and infarct location were included. LV volumes and function and 2-dimensional LV GLS were measured after primary percutaneous coronary intervention (baseline) and at 6-month follow-up. At baseline, patients with and without diabetes had similar LVEF (46.8 ± 0.7% vs 48.0 ± 0.5%, p = 0.19) and infarct size (peak cardiac troponin T: 3.1 [1.2 to 6.5] vs 3.7 [1.3 to 7.3] μg/l, p = 0.10; peak creatine phosphokinase:1,120 [537 to 2,371] vs 1,291 [586 to 2,613] U/l, p = 0.17), whereas LV GLS was significantly more impaired in diabetic patients (-13.7 ± 0.3% vs -15.3 ± 0.2%, p <0.001). Although diabetic patients showed an improvement in LVEF over time similar to nondiabetic patients (52.0 ± 0.8% vs 53.1 ± 0.6%, p = 0.25), GLS remained more impaired at 6-month follow-up compared with nondiabetic patients (-15.8 ± 0.3% vs -17.3 ± 0.2%, p <0.001). After adjusting for clinical and echocardiographic characteristics, diabetes was independently associated with changes in GLS from baseline to 6-month follow-up (β 1.41, 95% confidence interval 0.85 to 1.96, p <0.001). In conclusion, after STEMI, diabetic patients show more impaired LV GLS at both baseline and follow-up compared with a matched group of patients without diabetes, despite having similar infarct size and LVEF at baseline and follow-up., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Transcatheter tricuspid valve repair/replacement is an emerging therapy for patients with symptomatic severe tricuspid regurgitation who are deemed inoperable. Accurate knowledge of the anatomy of the tricuspid valve and right ventricle is key to developing transcatheter techniques. In addition, it is important to understand the mechanistic concept of transcatheter tricuspid valve repair/replacement in order to select the patients who may benefit from it. The severity and mechanism of tricuspid regurgitation, right ventricular function, dimensions of the caval veins and the course of the right coronary artery in relation to the atrioventricular groove are important aspects to be evaluated before embarking on these procedures. The present article reviews current advances in transcatheter approaches for significant tricuspid regurgitation and the role of imaging modalities to characterise the anatomy of the tricuspid valve and right ventricle as well as the underlying pathophysiology of tricuspid regurgitation.

Aims: Low gradient severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) may be attributed to aortic valve area index (AVAi) underestimation due to the assumption of a circular shape of the left ventricular outflow tract (LVOT) with 2-dimensional echocardiography. The current study evaluated whether fusing Doppler and multidetector computed tomography (MDCT) data to calculate AVAi results in significant reclassification of inconsistently graded severe AS., Methods and Results: In total, 191 patients with AVAi < 0.6 cm 2 /m 2 and LVEF ≥ 50% (mean age 80 ± 7 years, 48% male) were included in the current analysis. Patients were classified according to flow (stroke volume index <35 or ≥35 mL/m 2 ) and gradient (mean transaortic pressure gradient ≤40 or >40 mmHg) into four groups: normal flow-high gradient (n = 72), low flow-high gradient (n = 31), normal flow-low gradient (n = 46), and low flow-low gradient (n = 42). Left ventricular outflow tract area was measured by planimetry on MDCT and combined with Doppler haemodynamics on continuity equation to obtain the fusion AVAi. The group of patients with normal flow-low gradient had significantly larger AVAi and LVOT area index compared with the other groups. Although MDCT-derived LVOT area index was comparable among the four groups, the fusion AVAi was significantly larger in the normal flow-low gradient group. By using the fusion AVAi, 52% (n = 24) of patients with normal flow-low gradient and 12% (n = 5) of patients with low flow-low gradient would have been reclassified into moderate AS due to AVAi ≥ 0.6 cm 2 /m 2 ., Conclusion: The fusion AVAi reclassifies 52% of normal flow-low gradient and 12% of low flow-low gradient severe AS into true moderate AS, by providing true cross-sectional LVOT area., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Significant coronary artery disease is highly prevalent in patients who underwent transcatheter aortic valve implantation (TAVI). Timing of staged percutaneous coronary intervention (PCI) in TAVI candidates remains debated. The present study assessed the impact of timing of the staged PCI on TAVI outcomes. Ninety-six patients (age 81 ± 5 years, 57% men) who had undergone staged PCI within 1 year before TAVI were included. The population was dichotomized according to the median time elapsed between PCI and TAVI (<30 and ≥30 days). In-hospital events and 30-day outcomes after TAVI were defined according to Valve Academic Research Consortium-2 definitions. Forty-eight patients underwent PCI <30 days and 48 patients underwent PCI ≥30 days before TAVI. Patients treated with PCI <30 days had lower hemoglobin levels at baseline (7.2 ± 0.9 mmol/L vs 7.9 ± 0.9 mmol/L, p = 0.002), more frequently atrial fibrillation (27% vs 13%, p = 0.018), and a shorter time interval between computed tomography acquisition and TAVI (7 days [2 to 10] vs 22 days [6 to 39], p <0.001) than their counterparts. Minor bleedings (13% vs 0%, p = 0.011) and overall vascular injury (27% vs 8%, p = 0.016 [minor injury: 17% vs 2%, p = 0.014; major injury: 10% vs 6%, p = 0.460]) were more frequently recorded in patients with staged PCI <30 days before TAVI. There were no differences in the incidence of other events and in 2-year survival. In conclusion, shortly (<30 days) or remote (≥30 days) staged PCI before TAVI resulted in comparable outcomes with the exception of minor vascular injury and minor bleeding events which were more frequently observed in patients treated with shortly staged PCI., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: In propensity score-matched patients with severe aortic stenosis treated with surgical aortic valve replacement (AVR) with the 3f Enable sutureless prosthesis (Medtronic, Minneapolis, Minnesota) or transcatheter aortic valve replacement (TAVR), the hemodynamic performance of both valves and mid-term survival of patients were evaluated., Background: Data on hemodynamic performance of surgical sutureless bioprostheses in high operative risk patients with aortic stenosis are scarce., Methods: Of 258 patients undergoing TAVR or surgical aortic valve replacement with the 3f Enable valve, 80 (79 ± 5 years of age, 100% men) were included in the current analysis on the basis of propensity score 1:1 matching for baseline clinical and hemodynamic characteristics. All patients had hemodynamic echocardiographic evaluation at baseline and discharge. Mid-term survival was analyzed., Results: Compared with the 3f Enable valve, TAVR prostheses (Edwards SAPIEN XT [Edwards Lifesciences, Irvine, California] and CoreValve [Medtronic]) had larger effective orifice area index (1.00 ± 0.30 cm(2)/m(2) vs. 0.76 ± 0.22 cm(2)/m(2); p < 0.001), lower pressure gradient (8.14 ± 4.21 mm Hg vs. 10.72 ± 4.01 mm Hg; p = 0.006), less frequent prosthesis-patient mismatch (30.0% vs. 67.5%; p = 0.001), and low flow (46.2% vs. 72.5%; p = 0.02), but more frequent aortic regurgitation (87.5% vs. 20.0%; p < 0.001). The presence of prosthesis-patient mismatch was independently associated with a low-flow state at discharge (odds ratio: 4.70; p = 0.004) and independently associated with the use of the sutureless prosthesis (odds ratio: 3.90; p = 0.02). However, the survival of the 2 groups was comparable after 1.5-year (interquartile range: 0.79 to 2.01 years) follow-up (log-rank test, p = 0.95)., Conclusions: TAVR prostheses demonstrated better hemodynamics than the 3f Enable valve but a higher incidence of aortic regurgitation. However, these differences did not influence mid-term survival of patients., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Atheroembolic renal disease, due to dislodgement of cholesterol crystals during maneuvering of a large catheter across the aorta and deployment of the transcatheter prosthesis within a calcified aortic valve, may be one of the pathophysiological mechanisms of acute kidney injury (AKI) complicating transcatheter aortic valve implantation (TAVI)., Objective: To investigate the association between the atherosclerotic burden and plaque characteristics of the aortic valve and thoracic aorta, evaluated with multidetector CT (MDCT), and the occurrence of AKI after TAVI., Methods: Aortic valve calcification, atherosclerosis burden, and plaque characteristics of the thoracic aorta (including aortic root, ascending aorta, aortic arch, and descending aorta) were analyzed in preprocedural MDCT data of 210 TAVI patients (age, 81 ± 7.1 years; 51.4% men). The thoracic aorta was divided into ascending aorta, aortic arch, and descending thoracic aorta which was further divided into 5 to 8 segments according to the posterior intercostal arteries. Each segment where the maximum wall thickness exceeded ≥ 2 mm was defined as diseased segment with atherosclerotic plaque. Aortic atherosclerosis burden was defined as the proportion of thoracic aortic segments with atherosclerosis. AKI was defined by a creatinine level ≥ 1.5 × baseline or ≥ 26.4 μmol/L above baseline. MDCT data were correlated with the occurrence of postprocedural AKI in a multivariate logistic regression model., Results: Postprocedural AKI occurred in 51 patients (24.3%). In patients with AKI, the burden of overall (87.5% [75%-90%] vs 71.4% [50%-87.5%]; P < .001) and noncalcified atherosclerosis (42.9% [22.2%-62.5%] vs 12.5% [0%-28.6%]; P < .001) and the maximum plaque thickness (5.7 ± 1.8 mm vs 4.5 ± 1.4 mm; P < .001) were larger compared with patients without AKI. The burden of noncalcified atherosclerosis remained independently associated with AKI (odds ratio, 1.03 [per each 1% of increase in aortic segments with noncalcified atherosclerosis]; 95% confidence interval 1.01-1.05; P = .006) after adjusting for baseline renal function, logistic EuroSCORE, and procedural access. In contrast, aortic valve calcification was not independently associated with AKI., Conclusion: In patients undergoing TAVI, occurrence of postprocedural AKI was associated with the extent of noncalcified atherosclerotic plaque burden of the thoracic aorta., (Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the implications of stable coverage of the coronary ostia by the Edwards SAPIEN valve frame in terms of myocardial ischemia and subsequent percutaneous coronary intervention (PCI), following transcatheter aortic valve implantation (TAVI)., Background: Edwards SAPIEN frame is frequently deployed relatively higher than recommended and may overlap the coronary ostia., Methods: A total of 142 patients (age 81 ± 7 years, male 49%) treated with Edwards SAPIEN valve and with multi-detector row computed tomography at 1 month follow-up were evaluated. The position of the frame in relation to the coronary ostia was assessed. Levels of troponin T were measured 12-24 hr after TAVI. PCI events at follow-up were recorded., Results: The left coronary ostium was fully covered in three (2.1%) patients and the right coronary ostium in 11 (7.7%). There were no differences in troponin T levels between patients with fully covered ostia versus patients with partly or non-covered ostia (0.24 (0.13-0.50) μg/L versus 0.35 (0.15-0.55) μg/L, respectively; P = 0.377). At 30 ± 15 months follow up, 10 (7%) patients underwent successful PCI. Rate of subsequent PCI was similar between patients with any covered ostium and patients with non-covered ostia [4 (7.8%) vs. 6 (6.5%), P = 0.780, respectively]., Conclusions: Full overlap of the coronary ostia by Edwards SAPIEN frame is infrequent and in most cases does not limit subsequent PCI., (© 2014 Wiley Periodicals, Inc.)

The prognostic implications of flow, assessed by stroke volume index (SVi), and left ventricular (LV) global longitudinal strain on survival of patients with low-gradient severe aortic stenosis (AS) and preserved LV ejection fraction are debated. The aim of this study was to evaluate the impact of flow and LV global longitudinal strain on survival in these patients treated with aortic valve replacement (AVR). Patients with low-gradient severe AS with preserved LV ejection fraction treated with AVR (n = 134, mean age 76 ± 10 years, 50% men) were included in the present study. Aortic valve hemodynamics and LV function were assessed with 2-dimensional, Doppler and speckle-tracking echocardiography before AVR. Patients were dichotomized on the basis of low (SVi ≤35 ml/m(2)) or normal (SVi >35 ml/m(2)) flow and impaired (>-15%) or more preserved (≤-15%) global longitudinal strain. The end point was all-cause mortality. During a median follow-up period of 1.8 years (interquartile range 0.5 to 3) after AVR, 26 patients (19.4%) died. Survival was better for patients with SVi >35 ml/m(2) or global longitudinal strain ≤-15% compared with those with SVi ≤35 ml/m(2) or global longitudinal strain >-15% (log-rank p = 0.01). Atrial fibrillation (hazard ratio 5.40, 95% confidence interval 1.81 to 16.07, p = 0.002) and chronic kidney disease (hazard ratio 3.67, 95% confidence interval 1.49 to 9.06, p = 0.005) were the clinical variables independently associated with all-cause mortality. The addition of global longitudinal strain (chi-square = 19.87, p = 0.029, C-statistic = 0.74) or SVi (chi-square = 29.62, p <0.001, C-statistic = 0.80) to a baseline model including atrial fibrillation and chronic kidney disease (chi-square = 14.52, C-statistic = 0.68) improved risk stratification of these patients. In conclusion, flow and LV global longitudinal strain are independently associated with survival after AVR in patients with low-gradient severe AS with preserved LV ejection fraction., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The underlying mechanism of mitral regurgitation (MR) because of isolated annulus dilation (Carpentier type I) remains controversial in patients with atrial fibrillation (AF). The present study evaluated changes in mitral valve geometry of patients with AF and structurally and functionally normal left ventricles and mitral leaflets. Grade of MR and left ventricular (LV) function was evaluated with echocardiography. Changes in mitral valve geometry were evaluated with multidetector row computed tomography (MDCT) performed before radiofrequency catheter ablation for AF. From a cohort of 480 patients with drug-refractory AF referred for catheter ablation, 170 patients (mean age 58 ± 10 years, 67% men) with structural and functional normal left ventricles and mitral leaflets were included. The intercommissural and anteroposterior diameter, perimeter, and area of the mitral annulus and left atrial volume were assessed with MDCT and correlated with the grade of MR as assessed with echocardiography. A total of 49 patients (29%) had MR ≥2+. These patients had larger mitral annulus area compared with patients with MR <2+ (665.0 ± 100.6 mm(2)/m(2) vs 530.5 ± 66.6 mm(2)/m(2), p <0.001), whereas LV size and function (ejection fraction 64.9 ± 6.3% vs 63.1 ± 5.7%, p = 0.08) were similar. After adjusting for age, type of AF, hypertension, left atrial volume, and LV end-systolic volume and ejection fraction, the mitral annulus dimensions remained independently correlated with MR ≥2+. In conclusion, in AF patients with structural and functional normal left ventricles and mitral leaflets, MDCT demonstrated that mitral annulus dilation is independently associated with type I MR., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Speckle-tracking-derived global longitudinal strain (GLS) is a more sensitive method of detecting left ventricular (LV) functional recovery after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis. However, it remains unknown whether LV function improves in patients with low-flow, low-gradient severe aortic stenosis (LFLGSAS) after TAVI. The aim of the present was to evaluate LV functional recovery and remodeling after TAVI in patients with LFLGSAS., Methods: Sixty-eight patients (57% men; mean age, 79.1 ± 7.1 years) with LFLGSAS treated with TAVI were evaluated. LV function and remodeling were investigated before TAVI and at 6 and 12 months after TAVI. All echocardiographic data were prospectively collected, and GLS was retrospectively analyzed., Results: Among patients with LFLGSAS, 35 (52%) had low LV ejection fraction (LVEF) (<50%), and 33 (48%) had preserved LVEF (≥50%). The low-LVEF group had significantly more impaired GLS than the group with preserved LVEF (-8.3 ± 2.6% vs -13.3 ± 3.5%, P < .001). LV systolic function improved after TAVI in both groups. Although in the group of patients with low LVEF, all functional parameters improved, in the group of patients with preserved LVEF, only strain-derived parameters significantly improved. There were significant decreases in absolute LV wall thickness and relative wall thickness and a trend toward decreased LV mass index in both LVEF groups. LV volumes decreased significantly in those with low LVEF but not in those with preserved LVEF. Baseline GLS but not LVEF group was independently associated to GLS improvement at 12 months after TAVI., Conclusions: Patients with LFLGSAS with low and preserved LVEF had a significant improvement in LV function after TAVI, as assessed by GLS. Absolute and relative LV wall thickness decreased in both groups of patients, but only those with low LVEF had reductions in LV volumes., (Copyright © 2014 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Aims: To assess the left atrial appendage (LAA) geometry with multidetector-row computed tomography (MDCT) and its implications for selection of closure devices., Methods and Results: One hundred and ninety-seven patients who underwent MDCT prior to catheter ablation for atrial fibrillation were evaluated. Feasibility for Watchman and Amplatzer Cardiac Plug (ACP) devices was assessed based on the maximal cross-sectional diameter and perimeter of the ostium and at 10 mm depth and on the LAA diameter on the MDCT plane resembling the transoesophageal echocardiography (TEE) view. Mean maximal diameters of the ostium and at 10 mm depth were 28.7±4.4 mm and 24.6±4.5 mm, respectively, resulting in feasibilities of 80.7%, 84.8% and 91.4% for the Watchman, the ACP and for either one of the two devices, respectively. Mean perimeters of the ostium and at 10 mm depth were 79.1±12.2 mm and 69.8±11.6 mm, resulting in feasibilities of 87.8%, 92.9% and 96.4% for the Watchman, the ACP and for either one of the two devices, respectively. Mean TEE-like MDCT LAA diameter was 22.0±3.3 mm, resulting in feasibilities of 93.9%, 97% and 99.0% for the Watchman, the ACP and for either one of the two devices, respectively., Conclusions: The feasibility of current devices is high, based on MDCT measurements of the LAA, with no difference for either one of the devices.