See It Best: A Propensity-Matched Analysis of Ultrasound-Guided versus Blind Femoral Artery Puncture in Balloon-Expandable TAVI

Background: Currently, transcatheter aortic valve implantation (TAVI) is the standard procedure recommended for patients over 75 years of age with symptomatic aortic valve stenosis. Percutaneous transfemoral (TF) access is the main route used to perform the procedure. Among periprocedural complications, access-related ones are the most frequent, potentially leading to prolonged in-hospital stays and transfusions. Methods: We performed a retrospective analysis of prospectively collected data on consecutive patients undergoing TF-TAVI with the latest generation balloon-expandable transcatheter valve between 2013 and 2022. Results: A total of 600 patients were analyzed, differentiating the population between ultrasound-guided and blind common femoral artery puncture. Valve Academic Research Consortium 3 (VARC-3)criteria were used to report at 30 days and follow-up. In our propensity-matched comparison of the two groups, we found a strong reduction in access-related complications in the echo-guided group, particularly in terms of reduction of major and minor bleedings. We also found a significant trend in reduction of local complications, such as pseudoaneurysms, hematomas, arterio-venous fistulas, dissection of the femoral or iliac arteries, and stenosis. Conclusions: Although there is a lack of consensus on the role of ultrasound-guided puncture, we found better outcomes for patients having an echo-guided puncture of the main access, particularly with regard to access-related complications, early mobilization, and early discharge home.

Symptomatic post COVID patients have impaired alveolar capillary membrane function and high VE/VCO2

BACKGROUND

Post COVID-19 syndrome is characterized by several cardiorespiratory symptoms but the origin of patients' reported symptomatology is still unclear.

METHODS

Consecutive post COVID-19 patients were included. Patients underwent full clinical evaluation, symptoms dedicated questionnaires, blood tests, echocardiography, thoracic computer tomography (CT), spirometry including alveolar capillary membrane diffusion (DM) and capillary volume (Vcap) assessment by combined carbon dioxide and nitric oxide lung diffusion (DLCO/DLNO) and cardiopulmonary exercise test. We measured surfactant derive protein B (immature form) as blood marker of alveolar cell function.

RESULTS

We evaluated 204 consecutive post COVID-19 patients (56.5 ± 14.5 years, 89 females) 171 ± 85 days after the end of acute COVID-19 infection. We measured: forced expiratory volume (FEV1) 99 ± 17%pred, FVC 99 ± 17%pred, DLCO 82 ± 19%, DM 47.6 ± 14.8 mL/min/mmHg, Vcap 59 ± 17 mL, residual parenchymal damage at CT 7.2 ± 3.2% of lung tissue, peakVO2 84 ± 18%pred, VE/VCO2 slope 112 [102-123]%pred. Major reported symptoms were: dyspnea 45% of cases, tiredness 60% and fatigability 77%. Low FEV1, Vcap and high VE/VCO2 slope were associated with persistence of dyspnea. Tiredness was associated with high VE/VCO2 slope and low PeakVO2 and FEV1 while fatigability with high VE/VCO2 slope. SPB was fivefold higher in post COVID-19 than in normal subjects, but not associated to any of the referred symptoms. SPB was negatively associated to Vcap.

CONCLUSIONS

In patients with post COVID-19, cardiorespiratory symptoms are linked to VE/VCO2 slope. In these patients the alveolar cells are dysregulated as shown by the very high SPB. The Vcap is low likely due to post COVID-19 pulmonary endothelial/vasculature damage but DLCO is only minimally impaired being DM preserved.

Outcomes of Transcatheter Aortic Valve Replacement Patients With Different Transvalvular Flow-Gradient Patterns

Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (LVEF). Both situations represent the most challenging subset of patients to manage and generally have a poor prognosis. Few and controversial data exist on the outcomes of these patients compared with normal flow-high gradient (NF-HG) AS after transcatheter aortic valve replacement (TAVR). We sought to characterize different transvalvular flow-gradient patterns and to examine their prognostic value after TAVR. We enrolled 1,208 patients with severe AS and categorized as follow: 976 patients NF-HG (mean aortic pressure gradient [MPG] ≥40 mm Hg), 107 paradoxical LF-LG (pLF-LG, MPG <40 mm Hg, LVEF ≥50%, stroke volume index <35 ml/m2), and 125 classical LF-LG (cLF-LG) (MPG <40 mm Hg, LVEF <50%, stroke volume index <35 ml/m2). When compared with NF-HG and pLF-LG, cLF-LG had a worse symptomatic status (New York Heart Association III to IV 86% vs 62% and 67%, p <0.001), a higher prevalence of eccentric hypertrophy and a higher level of LV global afterload reflected by a higher valvuloarterial impedance. Valvular function after TAVR was excellent over time in all patients. While 30-day mortality (p = 0.911) did not differ significantly among groups, cLF-LG had a lower 5-year survival rate (LF-LG 50% vs pLF-LG 62% and NF-HG 68%, p <0.05). cLF-LG was associated with a hazard ratio for mortality of 2.41 (95% confidence interval 1.65 to 3.52, p <0.001). In conclusion, TAVR is an effective procedure regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rates than patients with NF-HG, whereas cLF-LG is associated with a twofold increased risk of mortality at 5-year follow-up.

Fluid balance in heart failure

Fluid retention is a major determinant of symptoms in patients with heart failure (HF), and it is closely associated with prognosis. Hence, congestion represents a critical therapeutic target in this clinical setting. The first therapeutic strategy in HF patients with fluid overload is optimization of diuretic intervention to maximize water and sodium excretion. When diuretic therapy fails to relieve congestion, renal replacement therapy represents the only alternative option for fluid removal, as well as a way to restore diuretic responsiveness. On this background, the pathophysiology of fluid balance in HF is complex, with heart, kidney, and lung being deeply involved in volume regulation and management. Therefore, the interplay between these organs should be appreciated and considered when fluid overload in HF patients is targeted.

Early Biological Valve Failure: Structural Valve Degeneration, Thrombosis, or Endocarditis?

Biological valve failure (BVF) is an inevitable condition that compromises the durability of biological heart valves (BHVs). It stems from various causes, including rejection, thrombosis, and endocarditis, leading to a critical state of valve dysfunction. Echocardiography, cardiac computed tomography, cardiac magnetic resonance, and nuclear imaging play pivotal roles in the diagnostic multimodality workup of BVF. By providing a comprehensive overview of the pathophysiology of BVF and the diagnostic approaches in different clinical scenarios, this review aims to aid clinicians in their decision-making process. The significance of early detection and appropriate management of BVF cannot be overstated, as these directly impact patients' prognosis and their overall quality of life. Ensuring timely intervention and tailored treatments will not only improve outcomes but also alleviate the burden of this condition on patients' life. By prioritizing comprehensive assessments and adopting the latest advancements in diagnostic technology, medical professionals can significantly enhance their ability to manage BVF effectively.

Approach to the Patient with Acute Aortic Syndromes in Light of the New Consensus Statement on Multimodality Imaging in Thoracic Aortic Diseases

Acute aortic syndromes comprise a range of interrelated conditions including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and contained or not contained aortic aneurysm rupture. These syndromes are potentially life threatening; therefore, a rapid and accurate diagnosis is crucial. A new Clinical Consensus Statement on Aortic and Peripheral Vascular Disease has recently been published, and we will try to highlight the main innovations in the document.

Diagnosis and treatment of a left atrial myxoma originating from an atrial septal defect closure device: a case report

Background

Ostium secundum atrial septal defect (osASD) is a common congenital heart disease and transcatheter closure is the preferred treatment. Late device-related complications include thrombosis and infective endocarditis (IE). Cardiac tumours are exceedingly rare. The aetiology of a mass attached to an osASD closure device can be challenging to diagnose.

Case summary

A 74-year-old man with atrial fibrillation was hospitalized for evaluating a left atrial mass discovered incidentally 4 months earlier. The mass was attached to the left disc of an osASD closure device implanted 3 years before. No shrinkage of the mass was observed despite optimal intensity of anticoagulation. We describe the diagnostic workup and management of the mass that at surgery turned out to be a myxoma.

Discussion

A left atrial mass attached to an osASD closure device raises the suspect of device-related complications. Poor endothelialisation may promote device thrombosis or IE. Cardiac tumours (CT) are rare, and myxoma is the most common primary CT in adults. Although no clear relationship exists between the implantation of an osASD closure device and a myxoma, the development of this tumour is a possible occurrence. Echocardiography and cardiovascular magnetic resonance play a key role in the differential diagnosis between a thrombus and a myxoma, usually identifying distinctive mass features. Nevertheless, sometimes non-invasive imaging may be inconclusive, and surgery is necessary to make a definitive diagnosis.

Echocardiography vs. CMR in the Quantification of Chronic Mitral Regurgitation: A Happy Marriage or Stormy Divorce?

Quantification of chronic mitral regurgitation (MR) is essential to guide patients’ clinical management and define the need and appropriate timing for mitral valve surgery. Echocardiography represents the first-line imaging modality to assess MR and requires an integrative approach based on qualitative, semiquantitative, and quantitative parameters. Of note, quantitative parameters, such as the echocardiographic effective regurgitant orifice area, regurgitant volume (RegV), and regurgitant fraction (RegF), are considered the most reliable indicators of MR severity. In contrast, cardiac magnetic resonance (CMR) has demonstrated high accuracy and good reproducibility in quantifying MR, especially in cases with secondary MR; nonholosystolic, eccentric, and multiple jets; or noncircular regurgitant orifices, where quantification with echocardiography is an issue. No gold standard for MR quantification by noninvasive cardiac imaging has been defined so far. Only a moderate agreement has been shown between echocardiography, either with transthoracic or transesophageal approaches, and CMR in MR quantification, as supported by numerous comparative studies. A higher agreement is evidenced when echocardiographic 3D techniques are used. CMR is superior to echocardiography in the calculation of the RegV, RegF, and ventricular volumes and can provide myocardial tissue characterization. However, echocardiography remains fundamental in the pre-operative anatomical evaluation of the mitral valve and of the subvalvular apparatus. The aim of this review is to explore the accuracy of MR quantification provided by echocardiography and CMR in a head-to-head comparison between the two techniques, with insight into the technical aspects of each imaging modality.

[A case of aortic stenosis in a young patient with familiar hypercholesterolemia, bicuspid aortic valve and heavy calcification of the ascending aorta]

We report the case of a 28-year-old Caucasian patient symptomatic for low-threshold angina. Coronary angiography ruled out significant coronary stenosis. He was diagnosed with familial hypercholesterolemia and severe aortic stenosis in a setting of bicuspid valve disease. Preoperative evaluation showed diffuse atheromatous disease and severe calcification of the ascending aorta. The patient was treated by endarterectomy of the ascending aorta, non-coronary sinus enlargement patch and aortic valve replacement. This case report emphasizes the role of aortic valve disease in patients with familial hypercholesterolemia and highlights the complexity of surgical management of this condition.

3D echocardiography in mitral valve prolapse

Mitral valve prolapse (MVP) is the leading cause of mitral valve surgery. Echocardiography is the principal imaging modality used to diagnose MVP, assess the mitral valve morphology and mitral annulus dynamics, and quantify mitral regurgitation. Three-dimensional (3D) echocardiographic (3DE) imaging represents a consistent innovation in cardiovascular ultrasound in the last decades, and it has been implemented in routine clinical practice for the evaluation of mitral valve diseases. The focus of this review is the role and the advantages of 3DE in the comprehensive evaluation of MVP, intraoperative and intraprocedural monitoring.

823 MIGRAINE IN PFO PATIENTS: CHARACTERIZATION OF A PLATELET-ASSOCIATED PATHOPHYSIOLOGICAL MECHANISM BEFORE AND AFTER PFO CLOSURE: THE LEARNER STUDY

Background

A strong relationship links migraine with aura (MHA) and patent foramen ovale (PFO). Increased platelet aggregation and oxidative stress were documented in migraineurs. To date, no mechanisms connecting MHA to PFO have been demonstrated.

Objectives

To perform a comprehensive analysis of platelet activation, inflammation, and oxidative stress status in 78 aspirin-treated MHA-patients before (T0) and 6-months after (T1) PFO closure (LEARNER Study-NCT03521193-clinicaltrials.gov). The primary endpoint was migraine regression rate in relation to these parameters.

Methods

P-selectinpos-, activated-glycoprotein IIbIIIa (aGPIIbIIIa)pos-, Tissue Factor (TF)pos-, reactive oxygen species (ROS)pos-platelets, platelet-leukocyte aggregates (PLA) and microvesicles (MVs) were evaluated by flow cytometry; thrombin generation (TG) by Calibrated Automated Thrombogram (CAT) assay; oxidative stress status by mass spectrometry; serotonin and cytokines by ELISA. 12 aspirin-treated-healthy subjects (HS) were enrolled for comparison.

Results

Migraine resolution occurred in 69.7%, a significant reduction in 27%, while no effect was observed in 2 patients (3.2%). Only ROSpos-platelets, and TFpos-platelets and -MVs were significantly higher at T0, sustaining a TG capacity that was associated with an altered blood GSSG/GSH (Oxidized/Reduced Glutathione). This phenotype reverted to HS levels at T1. MHA-PFO plasma, added to HS blood, mirrored the in vivo platelet activation and N-acetylcysteine blunted it. GSSG in vitro reproduced the in vivo condition. Aspirin had little effect on the platelet prothrombotic phenotype which was effectively inhibited by a P2Y12-antagonist.

Conclusion

This study suggests a pathophysiological mechanism linking PFO, or its right-to-left shunt, with MHA. MHA-PFO patients show a platelet-associated prothrombotic phenotype, sustained by altered oxidative stress status. This phenotype, not fully controlled by aspirin but by P2Y12-antagonism, could play a primary role in producing the prodromal symptoms of migraine, and it is reverted after PFO closure together with a complete migraine remission

Utility and futility of MitraClip implantation in secondary mitral regurgitation in a real-world population: the role of 3D transthoracic echocardiography

Introduction

Two recent prospective trials have been published, reporting opposite results on the efficacy and utility of the MitraClip (MC) procedure in patients with secondary mitral regurgitation (SMR). A ratio between the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV) ≥0.150 by two-dimensional (2D) transthoracic echocardiography (TTE) has been proposed to identify patients with disproportionate SMR, who would benefit from MC.

Purpose

To assess the prognostic role of clinical and echocardiographic parameters in a real-world population of SMR patients undergoing the MC procedure at our Institute.

Methods

Ninety-two patients underwent MC implantation. We retrospectively reviewed their clinical, and laboratory data, as well as 2D and three-dimensional (3D) TTE, and intraoperative transoesophageal echocardiography (Figure 1). The primary endpoint was a composite of cardiovascular death and/or hospitalisation for heart failure within 12-months follow-up.

Results

Thirty-one patients reached the endpoint (EP+), 61 did not (EP−). Demographics and anti-remodelling drugs were similar in EP+ and EP. Among comorbidities and laboratory data, EP+ significantly differed from EP− in smoking history, and extracardiac artery disease prevalence (65% vs. 39%, and 39% vs. 16%, respectively); EuroScoreII (12.2% vs. 5.2%); NYHA class ≥3 (94% vs. 69%); haemoglobin (12±2 vs. 13±2 g/dL), and brain natriuretic peptide levels (855 [426–1500] vs. 357 [170–902] pg/mL). At 2D TTE no significant difference emerged, including the SMR grade, except for the tricuspid annular plane systolic excursion (Figure 2). Biventricular 3D ejection fraction was significantly lower in EP+ vs. EP− (Figure 2). Residual intraoperative SMR grade after MC deployment was 1.9±0.6 in EP+ vs. 1.3±0.5 in EP− (p&lt;0.001).

Conclusion

The proposed cut-off for EROA/LVEDV ratio may be suboptimal for predicting the MC utility in real-world populations. Rather, prognosis may be more influenced by the patient's pre-operative clinical status, right ventricular systolic function, 3D left ventricular ejection fraction, and by the success of the procedure.

Funding Acknowledgement

Type of funding sources: None.

Do valve type and post-ballooning affect transprosthetic gradients in patients undergoing transcatheter aortic valve-in-valve procedure?

Introduction

Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is an appealing treatment option for patients with degenerated aortic bioprosthetic valves. However, high post-procedural transprosthetic gradients are very common after ViV-TAVI than after TAVI for native-valve aortic stenosis.

Aim

We sought to evaluate transprosthetic gradients (ΔP) and hemodynamic outcome in patients undergoing ViV-TAVI according to valve type and balloon post-dilation (balloon-expandable vs self-expandable with and without post-dilation).

Material and methods

We retrospectively analyzed 111 patients undergoing ViV-TAVI. A balloon-expandable valve was used in 35 patients (32%, Group 1), a self-expandable valve in 76 cases of which 39 (35%, Group 2) without balloon post-dilation and 37 (33%, Group 3) with balloon post-dilation. A comprehensive transthoracic echocardiography (TTE) was performed in all patients at baseline, at discharge and at 6-months follow-up.

Results

Successful ViV-TAVI was performed in 110 patients (99%). Baseline peak and mean ΔP, left ventricular volumes, ejection fraction, and pulmonary artery systolic pressure were similar among groups. A significant improvement in all echocardiographic parameters was observed in all groups over time (Table 1). In particular, a significant reduction in postprocedural gradients was observed at discharge and at 6-months follow-up compared to baseline in all groups. Immediately after ViV-TAVI procedure, the lowest value of mean ΔP was observed in Group 3 (12±7 mmHg) compared to both Group 1 (20±9 mmHg) and Group 2 (17±8 mmHg, p=0.001). This result was confirmed at 6-months follow-up (p=0.012). Rate of small valve size (≤23 mm) implanted was similar among groups (Group 1: 78%, Group 2: 60%, Group 3: 62%, p=0.123). Similar 1-year all-cause mortality was observed among groups (9%, 13%, 0%, respectively, p=0.135).

Conclusions

In patients with failed surgical aortic prosthesis, ViV-TAVI is an effective option and is associated with sustained improved hemodynamics in all patients. Anyway, the choice of prosthetic valve type and implantation technique are relevant on residual transprosthetic gradients and should be taken into account for a better long-term outcome.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of left and right ventricular strain in heart failure with reduced and preserved ejection fraction: a meta-analysis

Background

The association of speckle tracking echocardiography measures of left ventricular (LV) and right ventricular (RV) strain with clinical outcome in heart failure with reduced and preserved ejection fraction (HFrEF and HFpEF) has been extensively investigated. In fact, while the contribute of LV ejection fraction (LVEF) for prognosis is controversial, myocardial strain has proven to be a strong and independent prognostic predictor in many HF studies.

Purpose

The aim of this meta-analysis was to assess the prognostic value of LV global longitudinal strain (GLS) and free wall RV longitudinal strain (fwRVLS) by 2-dimensional speckle tracking echocardiography in patients with HFrEF, HF with mildly-reduced ejection fraction (HFmrEF) and HFpEF.

Methods

A systematic literature search of medical databases including Pubmed, Scopus, Ovid Online, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Scopus was performed using PRISMA principles. All relevant studies in English language reporting the predictive value of LV GLS and/or fwRVLS for mortality and/or cardiovascular events in HFrEF, HFmrEF and HFpEF, with follow up &gt;6 months, were identified. Case reports/series and abstract congresses were excluded (Fig. 1). All-cause mortality and a composite endpoint of cardiovascular death, re-hospitalization for HF, cardiac transplantation, ventricular assist device implantation were analyzed. Hazard ratios (HR) were extracted from univariate and multivariate random-effects models reporting on the association of LV GLS and fwRVLS and outcome and described as pooled estimates with 95% confidence intervals (CI).

Results

Fifty studies (n=18276 patients) satisfied the inclusion criteria (35 studies in chronic HF, 15 studies in acute HF). Most studies (n=36) included patients with HFrEF, while 14 studies included patients with HFmrEF (n=3) and with HFpEF (n=11); thus HFmrEF and HFpEF were grouped together for the analysis. Overall, 48 studies included LV GLS (median value = −9% [from −17% to −11%], 17 studies included fwRVLS (median value = −18% [from −24% to −14%]). Over a median follow up of 32 [from 7 to 67] months follow up, 5618 (31%) had a cardiovascular event or died. LV GLS and fwRVLS were independently associated with all-cause mortality and the composite outcome, regardless of LVEF (Fig. 2), both in HFrEF (HR 1.26; 95% CI [1.15; 1.37]; p&lt;0.01 for LV GLS and HR 1.06; 95% CI [1.03; 1.09]; p&lt;0.01 for fwRVLS) and in HFpEF (HR 1.07; 95% CI [1.03; 1.12]; p&lt;0.01 for LV GLS and HR 1.08; 95% CI [0.96; 1.21]; p&lt;0.01 for fwRVLS).

Conclusions

These meta-analysis data demonstrate that LV and RV strain are associated with mortality and cardiovascular events in patients with HF, HFmrEF and HFpEF and may provide important additive prognostic information. These findings emphasize the potential usefulness of LV GLS and fwRVLS in clinical practice to improve the risk stratification and management of patients with HF regardless of LVEF.

Funding Acknowledgement

Type of funding sources: None.

Improving assessment of different flow state of aortic stenosis: implication for prognosis in patients undergoing transcatheter aortic valve replacement

Background

Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (EF), and both situations represent the most challenging subset of patients with AS to manage and generally have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Few and controversial data exist on the outcomes of these patients compared to normal-flow high-gradient (NF-HG) AS following transcatheter aortic valve replacement (TAVR).

Purpose

This study aims to better characterize patients with different transvalvular flow-gradient patterns undergoing TAVR and to examine the prognostic value of these flow state.

Methods

Overall, 1208 patients with severe symptomatic AS undergoing TAVR were categorized according to flow-gradient patterns as follow: 976 patients NF-HG (DPmean &gt;40 mmHg), 107 paradoxical LF-LG (pLF-LG: DP mean &lt;40 mmHg, EF &gt;50%, and SVi &lt;35 mL/m2), and 125 classical LF-LG (DP mean &lt;40 mmHg, EF &lt;50%, SVi &lt;35 mL/m2).

Results

TAVR was feasible in all AS subtypes. When compared with NF-HG and pLF-LG, LF-LG had a worse symptomatic status (NYHA III–IV 86% vs 62% and 67%, respectively, p&lt;0.001), a higher prevalence of eccentric hypertrophy (Figure 1, left), a higher level of LV global afterload reflected by a higher valvuloarterial impedance and a higher pulmonary pressure (Table). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group. While intraoperative (p=0.935) and 30-day mortality (p=0.911) did not differ significantly among the 3 groups, LF-LG had a lower overall 5-year survival (LF-LG 50%, pLF-LG 65%, NF-HG 84%, p&lt;0.001) (Figure 1, right). LF-LG AS was associated with a hazard ratio for 5-year mortality of 2.416 (95% CI: 1.658–3.520, p&lt;0.001).

Conclusions

TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rate than patients with NF-HG, whereas survival in LF-LG patients was 2-fold higher. Therefore, being able to identify patients less likely to improve after TAVR may help to guide treatment decision.

Funding Acknowledgement

Type of funding sources: None.

Comparison between Automatic and Semiautomatic System for the 3D Echocardiographic Multiparametric Evaluation of RV Function and Dimension

Background: The right ventricle (RV) plays a pivotal role in cardiovascular diseases and 3-dimensional echocardiography (3DE) has gained acceptance for the evaluation of RV volumes and function. Recently, a new artificial intelligence (AI)–based automated 3DE software for RV evaluation has been proposed and validated against cardiac magnetic resonance. The aims of this study were three-fold: (i) feasibility of the AI-based 3DE RV quantification, (ii) comparison with the semi-automatic 3DE method and (iii) assessment of 2-dimensional echocardiography (2DE) and strain measurements obtained automatically. Methods: A total of 203 subject (122 normal and 81 patients) underwent a 2DE and both the semi-automatic and automatic 3DE methods for Doppler standard, RV volumes and ejection fraction (RVEF) measurements. Results: The automatic 3DE method was highly feasible, faster than 2DE and semi-automatic 3DE and data obtained were comparable with traditional measurements. Both in normal subjects and patients, the RVEF was similar to the two 3DE methods and 2DE and strain measurements obtained by the automated system correlated very well with the standard 2DE and strain ones. Conclusions: results showed that rapid analysis and excellent reproducibility of AI-based 3DE RV analysis supported the routine adoption of this automated method in the daily clinical workflow.

P-469 Micro-vapor fast freezing of human spermatozoa: development of a new method to use low number of cryopreserved spermatozoa

Study question

Can Vapor Fast Freezing conducted in 10µl tips (microVFF/tips) efficiently preserve sperm viability and motility in banking samples with very low sperm concentration?

Summary answer

MicroVFF resulted able to efficiently preserve sperm viability and motility in patients with severe oligozoospermia or criptozoospermia

What is known already

Sperm cryopreservation is usually performed by conventional slow or fast freezing using carriers containing large semen volume, such as 500ul High Security Straws (500µl HSS). These carriers however are not suitable for patients with very low sperm concentration and many devices have been tested to freeze small volumes or even singularly isolated sperms (i.e.SpermVD®, Cryoloop, Cell Sleeper). Recently, our group showed that micro-VFF better preserve sperm viability and motility or DNA integrity with respect to a VFF conducted with 500µl HSS, in normozoospermic samples.

Study design, size, duration

The study was designed for 20 oligospermic or criptozoospermic subjects afferent to Semen Cryopreservation and Andrology Laboratory of Careggi Hospital for semen analysis, but during 24 months up to 34 patients were recruited for the trial. 13 samples were subsequently thawed and, due to the low sperm number, only motility and viability was compared between the two methods.

Participants/materials, setting, methods

34 semen samples with low sperm concentration (0.06-7.7mil/ml) were cryopreserved with either microVFF/tips or the conventional method (VFF/ 500µl HSS). Thawing was conducted by keeping sample at room temparature and immediately observed by light microscopy at 20x and 40x. Total motility was scored as rapid/slow/non-progressive motility (a+b+c). Viability was evaluated by eosin test. For each method, the recovery of motility and viability was calculated as: post-thaw percentage/pre-thaw percentage

Main results and the role of chance

The microVFF method showed a better recovery of motility than the conventional method: 0.38 (±0.21)% vs 0.21 (±0.14)% (n = 13, p &lt; 0.05). A similar statistically significant difference was observed for the mean recovery of viability: 0.43 (±0.20) vs 0.29 (±0.13) (n = 13, p &lt; 0.5). for micro-freezing and conventional method, respectively. As frozen samples are used in the ART setting, microVFF/tips also shows the technical advantage to discharge directly the sample in fresh clean medium bridge in the ICSI plate, where swimming spermatozoa are washed from cryoprotectant compounds. Skipping conventional centrifugation/washing step after thawing highly protect from sperm motility/viability loss, as recently demonstrated by our group.

Limitations, reasons for caution

Results need to be confirmed in a larger number of patients. Although we previously showed that microVFF/tips also better preserve sperm DNA integrity than conventional method, in this study no other evaluations were possible due to the low number of spermatozoa/sample

Wider implications of the findings

Present results appear to be promising to enlarge the population who can be offered semen cryopreservation in our laboratory, including Klinefelter patients, severe oligo- and criptozoospermic menand patients undergoing testicular biopsy.

Trial registration number

not applicable

P-068 Oxidative stress and DNA fragmentation of spermatozoa in patients with cancer

Study question

Does cancer increase sperm DNA fragmentation (sDF) level by increasing oxidative stress in human spermatozoa?

Summary answer

Cancer increases both sDF and oxidative stress, but further studies are necessary to understand whether higher levels of ROS are responsible for sperm DNA damage.

What is known already

In recent years, it has been emerging that not only oncological therapies but also cancer itself can induce abnormal spermatogenesis. In addition, several Authors reported that occurrence of malignancy provokes also increases of sperm DNA damage, although such finding was not confirmed by others and the possible mechanisms responsible for such damage are presently unknown

Study design, size, duration

This was a prospective observational study conducted from 2018 to today, conducted in 102 patients affected by cancer and in 66 control subjects.

Participants/materials, setting, methods

We recruited 102 patients affected by cancer and 66 male partners of infertile couples as control subjects, in the Andrology Clinic of University of Florence. Control subjects were normozoospermic with absence of leukocytospermia, semen viscosity, smoking habit and recent antibiotic therapies. In the recruited men, we evaluated standard semen parameters, sperm DNA Fragmentation with SCD (Sperm Chromatin Dispersion) Test and oxidative stress as percentage of viable spermatozoa with MitoSOX™ Red labeling on total viable spermatozoa.

Main results and the role of chance

We found poorer standard semen parameters (sperm motility, concentration and number) in cancer patients (both testicular and hematological ones) with respect to control group, whereas no differences were observed between the two types of cancer. Testicular, but not hematological patients, were younger than control subjects. No difference was seen in the other tested characteristics (sperm morphology, abstinence, semen volume and pH, BMI). Regarding sDF, we found higher median values [IQR] in cancer patients (total: 22.25[17.00-25.95], n = 68; hematological: 23.00[20.13-26.38], n = 28; testicular: 21.13[16.13-25.73], n = 40) vs control subjects (12.50[8.25-14.75], n = 53); p &lt; 0.05, test U di Mann-Whitney. In addition, the amount of sperm oxidative stress was dramatically higher in patients with cancer (total:38.92[24.90-58.87], n = 79; hematological: 38.85[24.98-50.77], n = 34; testicular: 38.92[20.59-63.59], n = 45) vs control subjects (11.50[8.38-17.20], n = 62); p &lt; 0.05, test U di Mann-Whitney. We also studied the occurrence of a correlation between levels of sDF and oxidative stress. We found a sharp correlation when both cancer patients and control subjects were analysed (Spearman coefficient = 0.62, p &lt; 0.001, n = 103), but such correlation was completely lost when only cancer patients were considered (Spearman coefficient = 0.10, p &gt; 0.05, n = 50). This finding suggests that mechanisms different from ROS attack to DNA could explain the increase of sDF levels in cancer patients.

Limitations, reasons for caution

The study did not investigate, because of scarce availability of semen samples from cancer patients, other possible mechanisms (i.e apoptosis, defects in sperm chromatin maturation, failure in DNA system repair) which could cause the observed increase of sperm DNA damage in such patients.

Wider implications of the findings

Cancer patients show high levels of both sDF and oxidative stress. This finding rises concern, as cancer patients cryopreserve semen for using it with Assisted Reproductive Tecnhologies and both parameters represent a threat for natural and assisted reproduction. In addition, emerging evidence suggest that oxidative stress may alter sperm epigenome.

Trial registration number

not applicable

Unexpected Huge Prevalence of Intracardiac Extension of Wilms Tumor—A Single Center Experience from a Ugandan Hospital

Wilms tumor (WT) is the most common primary renal malignancy in young children. WT vascular extension to the inferior vena cava (IVC) occurs in 4–10% of cases and can reach the right atrium (RA) in 1%. Data on WT clinical presentation and outcome in developing countries are limited. The aim of the present study is to describe the prevalence of intracardiac extension in a consecutive population of WT patients observed in a large non-profit Ugandan hospital. A total of 16 patients with a histological diagnosis of 29 WT were screened in a 6-month period. Patient n°2, a 3 y/o child, presented with a 3-week history of abdominal distension, difficulty in breathing, and swelling of the lower limbs. A cardiovascular system exam showed rhythmic heart sounds, a heart rate of 110 beats per minute, and a pansystolic murmur on the tricuspid area; the abdomen was grossly distended with a palpable mass in the right flank, hepatomegaly, and splenomegaly. An abdomen ultrasound showed an intra-abdominal tumor, involving the right kidney and the liver and extended to the IVC. An ultrasound guided biopsy showed a picture consistent with WT. Cardiac echo showed a huge, mobile, cardiac mass attached to the right side of the interatrial septum, involving the tricuspid valve annulus, causing a “functional” tricuspid stenosis. The patient died of cardiogenic shock 7 days after admission. Patient n°3, a 3 y/o child, presented with analogue symptoms and the same diagnosis. The cardiac echo showed a round mass in the RA. Thirteen more patients were screened with cardiac echo, showing a normal heart picture. In our limited series, we found WT cardiac extension in three patients over 16 (19%). Cardiac echo performed routinely can lead to a better staging, prognostic, and therapeutic assessment. In our setting, the intra-cardiac extension could be more frequent than previously reported and might have prognostic implications.

P295 EXERCISE OXYGEN KINETIC IN HYPERTROPHIC CARDIOMYOPATHY: RESULTS FROM A MULTICENTER CARDIOPULMONARY EXERCISE TESTING STUDY

Aims

Reduced cardiac output (CO) has been considered crucial in symptoms’ genesis in hypertrophic cardiomyopathy (HCM). We evaluated the cardiopulmonary exercise testing (CPET) response in HCM focusing on parameters strongly associated with stroke volume (SV) and cardiac output (CO), such as oxygen uptake (VO2) and O2–pulse, considering both their absolute values and temporal behavior during physical exercise.

Methods and Results

We enrolled 312 non–end stage HCM patients, divided according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva maneuver (72% with LVOTO&lt;30; 10% between 30 and 49 and 18% ≥ 50mmHg). Peak VO2 (percent of predicted), O2–pulse and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety–six (31%) HCM patients presented an abnormal O2–pulse temporal behavior, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106±45 vs. 130±49W), VO2 (74±17 vs. 80±20%) and O2–pulse (12 [9–14] vs. 14 [11–17]ml/beat), with higher VE/VCO2 slope (28 [25–31] vs. 27 [24–31]) (p &lt; 0.005 for all). Only 2 patients had an abnormal VO2/work slope.

Conclusion

None of CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal O2–pulse exercise behavior, which is strongly related to inadequate SV during exercise, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, helping identifying more advanced disease irrespectively of LVOTO. Adding O2–pulse kinetics evaluation to standard CPET could lead to a potential incremental benefit in terms of HCM prognostic stratification and, then, therapeutic management.

P330 A CASE OF SEVERE AORTIC STENOSIS IN A YOUNG PATIENT WITH BICUSPID AORTIC VALVE, FAMILIAL HYPERCHOLESTEROLEMIA AND CALCIFICATION AT THE SINOTUBULAR JUNCTION

Background

Familial hypercholesterolemia (FH) is a disorder characterized by elevated LDL–C and premature vascular calcifications. Aortic stenosis (AS) is the most frequent complication of bicuspid aortic valve (BAV), often requiring aortic valve replacement. Cardiac surgery in patients with severely calcified ascending aorta is challenging.

Case Presentation

A 28 year old male from Albania presented to the ED for dyspnea and low–threshold angina. The patient had family history for CAD and a sister with known FH treated with PCSK9–i. He had BAV, known hypercholesterolemia (max cholesterol 660 mg/dL), treated since 2015 with rosuvastatin plus ezetimibe, with reported irregular intake. He was treated with PCI and bioresorbable vascular scaffold on LAD coronary artery. He underwent surgical removal of limb xanthomas. At admission, the patient was asymptomatic at rest. Cardiac auscultatory findings included an ejection murmur in the aortic area. He presented upper and inferior eyelid xanthelasmas, bilateral calcaneal tendon thickening, elbows and knee xanthoma removal scars. Blood tests were unremarkable, except for lipid profile (LDL–C 443 mg/dL, HDL 36 mg/dL, TG 73 mg/dL). The echocardiography showed BAV, severe AS (Vmax 4,2 m/s, MPG 41 mmHg, AVA 0.46 cm2/m2), EF 60%. A coronary angiography excluded significant stenosis in the epicardial coronary vessels. An aortic CT scan showed sinotubular junction with preserved diameters and severe multiple parietal calcifications, ascending aorta with diffuse atheromatous disease. The patient underwent mechanical aortic valve replacement, ascending aorta thromboendarterectomy, non–coronary sinus enlargement patch, double CABG (SVG–OM, SVG–LAD) due to diffuse hypokinesia of the left ventricle after the interruption of extracorporeal circulation. At a 3–month outpatient re–evaluation, due to the unsatisfactory response to the regular intake of rosuvastatin plus ezetimibe (TC 309 mg/dL, TG 52 mg/dL, HDL 34 mg/dL, LDL–C 264 mg/dL), a PCSK9–i was prescribed. Genetic studies for FH are ongoing.

Discussion

This case underlines the importance of aortic evaluation before aortic valve replacement, even in young FH patients, in which severe aortic calcification can influence surgical approach.

Conclusion

We described the multidisciplinary management of a severe symptomatic AS in a young male with FH and sinotubular junction parietal calcifications, which represented a challenging substrate for valve replacement.

Bioprosthetic aortic valve replacement in patients aged 50 years old and younger: Structural valve deterioration at long-term follow-up. Retrospective study

Background

Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR).

Methods

We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment.

Results

The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival.

Conclusions

In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

Safety, Efficacy and Long-Term Outcomes of Patients Treated with the Occlutech Paravalvular Leak Device for Significant Paravalvular Regurgitation

Between December 2014 and March 2021, 144 patients with aortic (Ao) or mitral (Mi) paravalvular leaks (PVLs) were enrolled at 21 sites in 10 countries. Safety data were available for 137 patients, who were included in the safety analysis fraction (SAF), 93 patients with Mi PVLs and 44 patients with Ao PVLs. The full analysis set (FAS) comprised 112 patients with available stratum (aortic/mitral leak) as well as baseline (BL), 180-day or later assessments (2 years). Procedural success (implantation of the device with a proper closure of the PVL, defined as reduction in paravalvular regurgitation of ≥one grade as assessed by echocardiography post implantation) was achieved in 91.3% of FAS patients with Mi PVLs and in 90.0% of those with Ao PVLs. The proportion of patients suffering from significant or severe heart failure (HF), classified as New York Heart Association (NYHA) class III/IV, decreased from 80% at baseline to 14.1% at 2-year follow-up (FAS). The proportion of FAS patients needing hemolysis-related blood transfusion decreased from 35.5% to 3.8% and from 8.1% to 0% in Mi patients and Ao patients, respectively. In total, 35 serious adverse events (SAEs) were reported in 27 patients (19.7%) of the SAF population. The SAEs considered possibly or probably related to the device included device embolization (three patients), residual leak (two patients) and vascular complication (one patient). During follow-up, 12/137 (8.8%) patients died, but none of the deaths was considered to be device-related. Patients implanted with the Occlutech Paravalvular Leak Device (PLD) showed long-lasting improvements in clinical parameters, including NYHA class and a reduced dependency on hemolysis-related blood transfusions.

Exercise oxygen pulse kinetics in patients with hypertrophic cardiomyopathy

OBJECTIVES

Reduced cardiac output (CO) has been considered crucial in symptoms' genesis in hypertrophic cardiomyopathy (HCM). Absolute value and temporal behaviour of O₂-pulse (oxygen uptake/heart rate (VO₂/HR)), and the VO₂/work relationship during exercise reflect closely stroke volume (SV) and CO changes, respectively. We hypothesise that adding O₂-pulse absolute value and kinetics, and VO₂/work relationship to standard cardiopulmonary exercise testing (CPET) could help identify more exercise-limited patients with HCM.

METHODS

CPETs were performed in 3 HCM dedicated clinical units. We retrospectively enrolled non-end-stage consecutive patients with HCM, grouped according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva manoeuvre (72% of patients with LVOTO <30; 10% between 30 and 49 and 18% ≥50 mm Hg). We evaluated the CPET response in HCM focusing on parameters strongly associated with SV and CO, such as O₂-pulse and VO₂, respectively, considering their absolute values and temporal behaviour during exercise.

RESULTS

We included 312 patients (70% males, age 49±18 years). Peak VO₂ (percentage of predicted), O₂-pulse and ventilation to carbon dioxide production (VE/VCO₂) slope did not change across LVOTO groups. Ninety-six (31%) patients with HCM presented an abnormal O₂-pulse temporal behaviour, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106±45 vs 130±49 W), VO₂ (21.3±6.6 vs 24.1±7.7 mL/min/kg; 74%±17% vs 80%±20%) and O₂-pulse (12 (9-14) vs 14 (11-17) mL/beat), with higher VE/VCO₂ slope (28 (25-31) vs 27 (24-31)) (p<0.005 for all). Only 2 patients had an abnormal VO₂/work slope.

CONCLUSION

None of the frequently used CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal temporal behaviour of O₂-pulse during exercise, which is strongly related to inadequate SV increase, correlates with reduced functional capacity (peak and anaerobic threshold VO₂ and workload) and increased VE/VCO₂ slope, identifying more advanced disease irrespectively of LVOTO.

ROLE OF CARDIOPULMONARY EXERCISE TEST IN THE PREDICTION OF HEMODYNAMIC IMPAIRMENT IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION

Periodic repetition of right heart catheterization (RHC) in pulmonary arterial hypertension (PAH) can be challenging. We evaluated the correlation between RHC and cardiopulmonary exercise test (CPET) aiming at CPET use as a potential noninvasive tool for hemodynamic burden evaluation. One hundred and forty‐four retrospective PAH patients who had performed CPET and RHC within 2 months were enrolled. The following analyses were performed: (a) CPET parameters in hemodynamic variables tertiles; (b) position of hemodynamic parameters in the peak end‐tidal carbon dioxide pressure (P_ETCO₂) versus ventilation/carbon dioxide output (VE/VCO₂) slope scatterplot, which is a specific hallmark of exercise respiratory abnormalities in PAH; (c) association between CPET and a hemodynamic burden score developed including mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), cardiac index, and right atrial pressure. VE/VCO₂ slope and peak P_ETCO₂ significantly varied in mPAP and PVR tertiles, while peak oxygen uptake (peak VO₂) and O₂ pulse varied in the tertiles of all hemodynamic parameters. P_ETCO₂ versus VE/VCO₂ slope showed a strong hyperbolic relationship (R² = 0.7627). Patients with peak P_ETCO₂ > median (26 mmHg) and VE/VCO₂ slope < median (44) presented lower mPAP and PVR (p < 0.005) than patients with peak P_ETCO₂ < median and VE/VCO₂ slope > median. Multivariate analysis individuated peak VO₂ (p = 0.0158) and peak P_ETCO₂ (p = 0.0089) as hemodynamic score independent predictors; the formula 11.584 − 0.0925 × peak VO₂ − 0.0811 × peak P_ETCO₂ best predicts the hemodynamic score value from CPET data. A significant correlation was found between estimated and calculated scores (p < 0.0001), with a precise match for patients with mild‐to‐moderate hemodynamic burden (76% of cases). The results of the present study suggest that CPET could allow to estimate the hemodynamic burden in PAH patients.

The Role of Multimodality Imaging in Left-Sided Prosthetic Valve Dysfunction

Prosthetic valve (PV) dysfunction (PVD) is a complication of mechanical or biological PV. Etiologic mechanisms associated with PVD include fibrotic pannus ingrowth, thrombosis, structural valve degeneration, and endocarditis resulting in different grades of obstruction and/or regurgitation. PVD can be life threatening and often challenging to diagnose due to the similarities between the clinical presentations of different causes. Nevertheless, identifying the cause of PVD is critical to treatment administration (thrombolysis, surgery, or percutaneous procedure). In this report, we review the role of multimodality imaging in the diagnosis of PVD. Specifically, this review discusses the characteristics of advanced imaging modalities underlying the importance of an integrated approach including 2D/3D transthoracic and transesophageal echocardiography, fluoroscopy, and computed tomography. In this scenario, it is critical to understand the strengths and weaknesses of each modality according to the suspected cause of PVD. In conclusion, for patients with suspected or known PVD, this stepwise imaging approach may lead to a simplified, more rapid, accurate and specific workflow and management.

229 Long-term clinical and echocardiographic outcome following TAVR in patients with severe aortic stenosis and different transvalvular flow state

Aims

Haemodynamic classifications of severe aortic stenosis (AS) have important prognostic implications, with low flow state (defined on the basis of a stroke volume index, SVi&lt;35 mL/m2) known to be a predictor of worse prognosis. As transcatheter aortic valve replacement (TAVR) has become widely used for patients with severe AS, issues were raised concerning its efficacy in patients with different haemodynamic classifications combining transvalvular flow state and pressure gradients. In fact, data on TAVR outcomes in patients with low gradient (LG) AS are limited and in some cases controversial. The aim of this study was to evaluate the efficacy and long-term clinical and echocardiographic outcome of TAVR in patients with different transvalvular flow-gradient patterns.

Methods

In this single centre study, 1078 patients (mean age 81±7 years) with severe symptomatic AS (AVA&lt;1 cm2) undergoing TAVR were categorized according to flow-gradient patterns as follow: 867 patients (80%) with normal flow-high gradient (NF-HG: mean transaortic gradient DP mean&gt;40 mmHg), 94 (9%) with paradoxical low flow LG (pLF-LG: DP mean&lt;40 mmHg, ejection fraction EF &gt; 50%, and SVi&lt;35 mL/m2), and 117 (11%) classical LF-LG (DP mean&lt;40 mmHg, EF &lt; 50%, SVi&lt;35 mL/m2).

Results

TAVR was feasible in all AS subtypes with similar rate of unsuccessful procedure (1.3% NF-HG, 1.1% pLF-LG, 0% LF-LG P=470). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group (Figure A). Overall, intraoperative (P=957) and 30-day mortality (P=817) did not differ significantly among the 3 groups. Longer follow-up showed that, compared to NF-HG patients, pLF-LG had similar all-cause mortality rate [HR 1.35(0.95–1.90), P=0.094] up to 5 years and LF-LG had a significant higher mortality rate [HR 1.89(1.43–2.49), P&lt;0.001],(Figure B). Moreover, LF-LG patients had higher rehospitalization for heart failure (NF-HG: 3%, pLF-LG: 6%, LF-LG 10%, P=0.001).

Conclusions

We provided evidence that TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. A careful haemodynamic classifications of severe AS is of utmost importance for identifying patients who benefits the most from TAVR procedure.

53 Exercise oxygen kinetic in hypertrophic cardiomyopathy: results from a multicentre cardiopulmonary exercise testing study

Aims

Reduced cardiac output (CO) has been considered crucial in symptoms’ genesis in hypertrophic cardiomyopathy (HCM). We evaluated the cardiopulmonary exercise testing (CPET) response in HCM focusing on parameters strongly associated with stroke volume (SV) and cardiac output (CO), such as oxygen uptake (VO2) and O2-pulse, considering both their absolute values and temporal behaviour during physical exercise.

Methods and results

We enrolled 312 non-end stage HCM patients, divided according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva manoeuver (72% with LVOTO &lt; 30; 10% between 30 and 49; and 18% ≥50 mmHg). Peak VO2 (percent of predicted), O2-pulse, and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety-six (31%) HCM patients presented an abnormal O2-pulse temporal behaviour, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106 ± 45 vs. 130 ± 49 W), VO2 (74 ± 17% vs. 80 ± 20%) and O2-pulse (12 [9–14] vs. 14 [11–17]ml/beat), with higher VE/VCO2 slope (28 [25–31] vs. 27 [24–31]) (P &lt; 0.005 for all). Only two patients had an abnormal VO2/work slope.

Conclusions

None of CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal O2-pulse exercise behaviour, which is strongly related to inadequate SV during exercise, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, helping identifying more advanced disease irrespectively of LVOTO. Adding O2-pulse kinetics evaluation to standard CPET could lead to a potential incremental benefit in terms of HCM prognostic stratification and, then, therapeutic management.

Feasibility and Accuracy of the Automated Software for Dynamic Quantification of Left Ventricular and Atrial Volumes and Function in a Large Unselected Population

We aimed to evaluate the feasibility and accuracy of machine learning-based automated dynamic quantification of left ventricular (LV) and left atrial (LA) volumes in an unselected population. We enrolled 600 unselected patients (12% in atrial fibrillation) clinically referred for transthoracic echocardiography (2DTTE), who also underwent 3D echocardiography (3DE) imaging. LV ejection fraction (EF), LV, and LA volumes were obtained from 2D images; 3D images were analyzed using dynamic heart model (DHM) software (Philips) resulting in LV and LA volume–time curves. A subgroup of 140 patients also underwent cardiac magnetic resonance (CMR) imaging. Average time of analysis, feasibility, and image quality were recorded, and results were compared between 2DTTE, DHM, and CMR. The use of DHM was feasible in 522/600 cases (87%). When feasible, the boundary position was considered accurate in 335/522 patients (64%), while major (n = 38) or minor (n = 149) border corrections were needed. The overall time required for DHM datasets was approximately 40 seconds. As expected, DHM LV volumes were larger than 2D ones (end-diastolic volume: 173 ± 64 vs. 142 ± 58 mL, respectively), while no differences were found for LV EF and LA volumes (EF: 55% ± 12 vs. 56% ± 14; LA volume 89 ± 36 vs. 89 ± 38 mL, respectively). The comparison between DHM and CMR values showed a high correlation for LV volumes (r = 0.70 and r = 0.82, p < 0.001 for end-diastolic and end-systolic volume, respectively) and an excellent correlation for EF (r = 0.82, p < 0.001) and LA volumes. The DHM software is feasible, accurate, and quick in a large series of unselected patients, including those with suboptimal 2D images or in atrial fibrillation.

Rest and exercise oxygen uptake and cardiac output changes 6 months after successful transcatheter mitral valve repair

Aims

Changes in peak exercise oxygen uptake (VO₂) and cardiac output (CO) 6 months after successful percutaneous edge‐to‐edge mitral valve repair (pMVR) in severe primary (PMR) and functional mitral regurgitation (FMR) patients are unknown.

The aim of the study was to assess the efficacy of pMVR at rest by echocardiography, VO₂ and CO (inert gas rebreathing) measurement and during cardiopulmonary exercise test with CO measurement.

Methods and results

We evaluated 145 and 115 patients at rest and 98 and 66 during exercise before and after pMVR, respectively.

After successful pMVR, significant reductions in MR and NYHA class were observed in FMR and PMR patients. Cardiac ultrasound showed reverse remodelling (left ventricular end‐diastolic volume from 158 ± 63 mL to 147 ± 64, P < 0.001; ejection fraction from 51 ± 15 to 48 ± 14, P < 0.001; pulmonary artery systolic pressure (PASP) from 43 ± 13 to 38 ± 8 mmHg, P < 0.001) in the entire population. These changes were significant in PMR (n = 62) and a trend in FMR (n = 53), except for PASP, which decreased in both groups. At rest, CO and stroke volume (SV) increased in FMR with a concomitant reduction in arteriovenous O₂ content difference [ΔC(a‐v)O₂]. Peak exercise, CO and SV increased significantly in both groups (CO from 5.5 ± 1.4 L/min to 6.3 ± 1.5 and from 6.2 ± 2.4 to 6.7 ± 2.0, SV from 57 ± 19 mL to 66 ± 20 and from 62 ± 20 to 69 ± 20, in FMR and PMR, respectively), whereas peak VO₂ was unchanged and ΔC(a‐v)O₂ decreased.

Conclusions

These data confirm pMVR‐induced clinical improvement and reverse ventricular remodelling at a 6‐month analysis and show, in spite of an increase in CO, an unchanged exercise performance, which is achieved through a ‘more physiological’ blood flow distribution and O₂ extraction behaviour. Direct rest and exercise CO should be measured to assess pMVR efficacy.

Catheter-based Closure of a Post-infective Aortic Paravalvular Pseudoaneurysm Fistula With Severe Regurgitation After Two Valve Replacement Surgeries: A Case Report

Backgsround: Infective endocarditis (IE) of prosthetic valves is a dire complication of cardiac valve replacement surgery and is associated with high rates of morbidity and mortality. Case Summary: A 72-year-old woman with multiple comorbidities underwent surgical replacement of the aortic valve with a mechanical prosthetic valve after recurrent IE. After 10 years, IE recurred and the mechanical valve was surgically replaced with a bioprosthetic valve. Ten years later, severe heart failure developed due to severe paravalvular leak (PVL) caused by an aortic annulus abscess complicated by a paravalvular pseudoaneurysm fistula (PPF). The patient was deemed at prohibitive surgical risk and a catheter-based PVL closure procedure was planned. However, the interventional procedure was delayed several months due to the Covid-19 pandemic with progressive heart failure worsening. Despite an acute satisfactory result of the PPF transcatheter closure and a significant clinical improvement, the patient died 10 months later due to multiorgan failure. It is likely that this was due, at least in part, to the long treatment delay caused by the unprecedented strain on the healthcare system. Discussion: In patients at high surgical risk, early diagnosis and prompt interventional treatment of severe PVL are crucial for improving expectancy and quality of life. However, the recent outbreak of COVID-19 caused deferral of elective and semi-elective structural heart disease procedures (SHD) as in our case. Thus, a proactive and vigilant stance on managing SHD should be a priority even in the context of the COVID-19 pandemic.

Detection of Mechanical Prosthetic Valve Dysfunction

The long-term outcome of mechanical aortic and mitral prosthetic valve (A-PV, M-PV) dysfunction (PVD) remains a serious complication associated with high morbidity and mortality. We sought to evaluate the incremental diagnostic value of combined transthoracic echocardiography (TTE) and fluoroscopy (F) in patients with suspected PVD. A total of 354 patients (178 A-PV, 176 M-PV) were imaged by TTE and F within 5 days of hospital admission. PVD was confirmed by transesophageal echocardiography, computed tomography, effective thrombolysis, or surgical inspection. PVD was confirmed in 101 patients (57%) with M-PV and 99 (55%) with A-PV. Regardless of the mechanism of PVD, TTE shows good sensitivity and specificity, with accuracy of 80% for M-PV and 91% for A-PV. F shows high specificity, but low sensitivity with accuracy of 68% for M-PV and 78% for A-PV. The integration of TTE + F significantly improved accuracy both for M-PV (83%) and A-PV (96%). At ROC analysis, the combined model of TTE + F showed the highest area under the curve for the detection of PVD compared with TTE and F alone (p < 0.001). In conclusion, in patients with a clinical suspicion of PVD, the combined model of TTE + F offers incremental value over TTE or F alone. This multimodality imaging approach overcomes limitations of TTE or F alone and provides prompt identification of patients who may require further imaging assessment and/or closer follow up.

Tricuspid annular dilation in patients undergoing early mitral valve surgery: is it an old story?

Patients with mitral valve prolapse (MVP), undergoing early surgery for severe regurgitation, are usually characterized by a low degree of right chambers' remodeling. In this selected population, the mechanisms leading to tricuspid annular (TA) dilatation (TAD) are not well understood. In this setting, we aimed to evaluate, using three-dimensional echocardiography (3DE), how right chambers affect TA size and might contribute to functional tricuspid regurgitation (FTR) progression. We studied 159 patients treated with early isolated surgery for MVP, characterized by: sinus rhythm; normal biventricular function; normal or elevated pulmonary artery pressure; tricuspid regurgitation (TR) ≤ mild; no concomitant cardiac disease. All patients reached a 3-year echocardiographic follow-up. Based on two-dimensional echocardiography, patients were divided in Group 1 (N = 68, 43%, TAD, TA ≥ 21 mm/m²) and Group 2 (N = 91, 57%, no TAD, TA < 21 mm/m²). By 3DE, Group 1 showed larger TA size, right atrial (RA) volume and right ventricular (RV) conical remodeling compared to Group 2 (p < 0.05). The multivariate analysis revealed that RA volume, RV basal diameter and function were independently correlated to TA size (p < 0.05). At the 3-year follow-up there was a low incidence of FTR, with a trend towards FTR progression in Group 1 (p = 0.07). In patients undergoing early surgery for MVP, TAD seems to result from distinctive early-onset geometrical changes of the right chambers, preceding TR, RV dilatation and pulmonary hypertension at rest. An integrated approach, including right chambers' assessment by 3DE, might help to better recognized patients at higher risk for TAD and, potentially for FTR.

Predicting Long-Term Mortality in TAVI Patients Using Machine Learning Techniques

Background: Whereas transcatheter aortic valve implantation (TAVI) has become the gold standard for aortic valve stenosis treatment in high-risk patients, it has recently been extended to include intermediate risk patients. However, the mortality rate at 5 years is still elevated. The aim of the present study was to develop a novel machine learning (ML) approach able to identify the best predictors of 5-year mortality after TAVI among several clinical and echocardiographic variables, which may improve the long-term prognosis. Methods: We retrospectively enrolled 471 patients undergoing TAVI. More than 80 pre-TAVI variables were collected and analyzed through different feature selection processes, which allowed for the identification of several variables with the highest predictive value of mortality. Different ML models were compared. Results: Multilayer perceptron resulted in the best performance in predicting mortality at 5 years after TAVI, with an area under the curve, positive predictive value, and sensitivity of 0.79, 0.73, and 0.71, respectively. Conclusions: We presented an ML approach for the assessment of risk factors for long-term mortality after TAVI to improve clinical prognosis. Fourteen potential predictors were identified with the organic mitral regurgitation (myxomatous or calcific degeneration of the leaflets and/or annulus) which showed the highest impact on 5 years mortality.

Proper Selection Does Make the Difference: A Propensity-Matched Analysis of Percutaneous and Surgical Cut-Down Transfemoral TAVR

Background. Transcatheter aortic valve replacement (TAVR) is an established technique to treat severe symptomatic aortic stenosis patients with a wide range of surgical risk. Currently, the common femoral artery is the first choice as the main access route for the procedure. The objective of this observational study is to report our experience on percutaneous and surgical cut-down transfemoral TAVRs comparing the two approaches. Methods. From January 2014 to January 2019, five hundred eleven consecutive patients underwent TAVR for severe symptomatic aortic stenosis. We analyzed only elective transfemoral procedures. After propensity score-matching based on age, sex, EuroSCORE II, mean aortic gradient, and left ventricular ejection fraction, we obtained two homogeneous populations: surgical cut-down (n = 119) and percutaneous (n = 225), which were labeled Group 1 and Group 2, respectively. Results. The main findings were that there were no significant procedural outcome differences between the two groups, but Group 2 patients had a shorter length of hospital stay and were more frequently discharged home. At follow-up, Group 1 patients had lower survival rates. Conclusions. An accurate preoperative assessment of the femoral access is mandatory to achieve satisfactory outcomes with transfemoral TAVRs. Nevertheless, the percutaneous approach allows shorter in-hospital stay and the need for rehabilitation, thus potentially decreasing the costs of the procedure.

Prosthesis-patient mismatch after aortic valve in valve procedure: incidence, predictors and clinical outcomes

Funding Acknowledgements

Type of funding sources: None.

Background. Transcatheter aortic valve-in-valve (TAVI ViV) implantation is an appealing treatment option for patients with degenerated bioprostheses. However, elevated residual gradients after TAVI ViV procedure are very common. These are an unwanted effects of prosthesis-patient mismatch (PPM). Currently, the actual incidenceof PPM, its predictors and its clinical outcomes have not been completely investigated.

Purpose. The aims of this study was to investigate the incidence, predictors and clinical outcome of PPM and therefore of elevated gradients after TAVI ViV.

Methods. 75 patients (age 78 ± 9 years, 36 male), who underwent TAVI-ViV due to failed aortic biological valve (60 stented, 15 stentless), were enrolled. Mechanism of bioprosthetic valve failure was stenosis (34 cases, 45%), regurgitation (24 cases, 32%) or combination (17 cases, 23%). Elevated residual gradients were defined as a mean DP&gt; 20 mmHg. PPM was identified by the indexed effective orifice area (EOAi) measured by echocardiography (moderate PPM if 0.65 &lt; EOAi &lt; 0.85 cm²/m²; severe PPM if EOAi &lt; 0.6 cm²/m²).

Results. ViV TAVI was feasible in all patients, 33 patients (44%) were implanted with a balloon-expandable valve and 42 (56%) with a self-expandable valve. Post-procedural post-ballooning was performed in 16 out of 42 patients (38%) receiving a self-expandable valve. Post-operative mean DP&gt; 20 mmHg was found in 35 patients (48%). Moderate PPM was found in 24 cases (33%) and severe PPM in 15 (20%). A logistic regression analyses identified small size of surgical prosthesis (size &lt; 23 mm) [OR: 6.061(2.127-17.267), p = 0.001] and failed stented valve [OR: 20.727(2.522-170.364), p = 0.005] as independent predictors for the occurrence PPM. Interestingly PPM did not affect early and 1 years mortality (1 years mortality 1.3 %), while mortality was higher in pts with stentless prostheses (9%)

Conclusions. PPM is a frequent finding after ViV procedures. Despite elevated residual gradients, TAVI ViV resolved prosthetic dysfunction and PPM did not affect mortality.  Therefore, this procedure represents a promising new option for patients with failed biological prosthetic valves.

Feasibility and accuracy of the automated software for dynamic quantification of left ventricular and atrial volumes and function in a large unselected population

Funding Acknowledgements

Type of funding sources: None.

Objective. Preliminary studies showed the accuracy of machine learning based automated dynamic quantification of left ventricular (LV) and left atrial (LA) volumes. We aimed to evaluate the feasibility and accuracy of machine learning based automated dynamic quantification of LV and LA volumes in an unselected population.

Methods. We enrolled 600 unselected patients (12% in atrial fibrillation) clinically referred for transthoracic echocardiography (2DTTE), who also underwent 3D echocardiography (3DE) imaging. LV ejection fraction (EF), LV and LA volumes were obtained from 2D images; 3D images were analysed using Dynamic Heart Model (DHM) software (Philips) resulting in LV and LA volume-time curves. A subgroup of 140 patients underwent also cardiac magnetic resonance (CMR) imaging. Average time of analysis, feasibility, and image quality were recorded and results were compared between 2DTTE, DHM and CMR.

Results. The use of DHM was feasible in 522/600 cases (87%). When feasible, the boundary position was considered accurate in 335/522 patients (64%), while major (n = 38) or minor (n = 149) borders corrections were needed. The overall time required for DHM datasets was approximately 40 seconds, resulting in physiologically appearing LV and LA volume–time curves in all cases. As expected, DHM LV volumes were larger than 2D ones (end-diastolic volume: 173 ± 64 vs 142 ± 58 mL, respectively), while no differences were found for LV EF and LA volumes (EF: 55%±12 vs 56%±14; LA volume 89 ± 36 vs 89 ± 38 mL, respectively). The comparison between DHM and CMR values showed a high correlation for LV volumes (r = 0.70 and r = 0.82, p &lt; 0.001 for end-diastolic and end-systolic volume, respectively) and an excellent correlation for EF (r= 0.82, p &lt; 0.001) and LA volumes.

Conclusions. The DHM software is feasible, accurate and quick in a large series of unselected patients, including those with suboptimal 2D images or in atrial fibrillation.

Table 1 DHM quality Adjustment Feasibility Good Suboptimal Minor Major Total of patients (n, %) 522/600 (87%) 327/522 (62%) 195/522 (28%) 149/522 (29%) 38/522 (6%) Normal subjects (n, %) 39/40 (97%) 23/39 (57%) 16/39 (40%) 9/39 (21%) 1/39 (3%) Atrial Fibrillation (n, %) 59/73 (81%)* 28/59 (47%) 31/59 (53%) 15/59 (25%) 6/59 (10%) Valvular disease (n, %) 271/312 (87%) 120/271 (%) 151/271 (%) 65/271 (24%) 16/271 (6%) Coronary artery disease (n, %) 47/58 (81%)* 26/47 (46%) 21/47 (37%) 16/47 (34%) 5/47 (11%) Miscellaneous (n, %) 24/25 (96%) 18/24 (75%) 6/24 (25%) 5/24 (21%) 3/24 (12%) Feasibility of DHM, image quality and need to adjustments in global population and in each subgroup. Abstract Figure 1

Role of the tricuspid annulus in functional tricuspid regurgitation development after early isolated mitral valve surgery: is it an old story?

Funding Acknowledgements

Type of funding sources: None.

Background. Functional Tricuspid Regurgitation (FTR) has been described as a common condition after isolated mitral valve (MV) surgery, affecting patients’ prognosis. Thus, in cases without significant tricuspid regurgitation (TR) but tricuspid annular (TA) dilatation, TV annuloplasty is currently recommended. Studies suggesting the currently used cut-off for definition of TA dilatation were based on 2D echocardiography (2DE) and included patients treated with MV surgery with heterogeneous MV disease, degree of cardiac remodeling and heart rhythm. As the management of severe MR has moved towards an earlier surgical treatment, few data are available about the incidence of FTR in the population undergoing early isolated MV surgery without TR, but 2DE satisfying criteria for TA dilatation.  

Aims. To test, in patients treated with early isolated MV surgery for MV prolapse (MVP), without TR and either normal or dilated TA (i) if the currently used 2D TA cut-off is predictive of FTR and cardiac events development (ii) how right chambers’ remodeling assessed by 3D echocardiography (3DE) affects TA dimension.

Methods. We studied 159 patients (age 61 ± 11) treated with early isolated MV surgery between 2010 and 2017. Eligible patients were those with 3DE images; normal left and right ventricular (LV and RV) function; sinus rhythm; normal or elevated right ventricular systolic pulmonary artery pressure (sPAP); normal or dilated TA by 2DE; absent TR. The decision to not perform TV annuloplasty in patients with TA dilatation was based on the surgical inspection. All patients underwent a complete 2DE, 3DE analysis was performed using custom software, including LV, RV, left atrial (LA) and right atrial (RA) assessment. 3D TA dimension were obtained using MPR. Clinical and 2DE follow-up was performed at 36 ± 6 months after surgery, major adverse cardiac events (MACEs, including cardiac hospitalization, cardiac death, arrhythmias) and FTR were recorded.

Results. Based on 2DE TA dimensions, patients were divided in group 1 (N = 68, 43%, TA≥21 mm/m²) and group 2 (N= 91, 57%, normal TA). Patients in group 1 showed larger RA volume, RV basal diameter and TA area (p &lt; 0.05) by 3DE compared to group 2 (Table). At the multivariate analysis, only the 3D RA volume, RV basal diameter and RV function were independently correlated to the TA area (p &lt; 0.05). At the follow-up, no differences were noted between groups in FTR development and MACEs at the Kaplan-Meier analysis (Fig.). At the COX analysis, 2DE TA dilatation failed to result a predictor of cardiovascular events (model’s X2, p &gt; 0.05).

Conclusions. In patients undergoing early MV surgery, the currently defined TA dilatation by 2DE may not necessarily evolve in FTR, and a larger cut-off may be needed. In this population, the evaluation of right chambers’ dimension and function may better define the probability to develop FTR.

Abstract Figure. Fig

Novelties in 3D Transthoracic Echocardiography

Cardiovascular imaging is developing at a rapid pace and the newer modalities, in particular three-dimensional echocardiography, allow better analysis of heart structures. Identifying valve lesions and grading their severity represents crucial information and nowadays is strengthened by the introduction of new software, such as transillumination, which provide detailed morphology descriptions. Chambers quantification has never been so rapid and accurate: machine learning algorithms generate automated volume measurements, including left ventricular systolic and diastolic function, which is extremely important for clinical decisions. This review provides an overview of the latest innovations in the echocardiography field, and is helpful by providing a better insight into heart diseases.

Is 3D analysis of longitudinal strain useful to predict long-term cardiac events in patients undergoing early mitral valve surgery?

Background

In patients with mitral valve prolapse (MVP) and significant mitral regurgitation (MR), the presence of reduced 3D left ventricular (LV) global longitudinal strain (GLS) has already been described. However, precise data about this finding in predicting long-term cardiac events are lacking, especially in patients after MV surgery. Particularly, few data are available about the role of 3D GLS in events prediction in patients diagnosed with Barlow or Fibro-Elastic-Deficiency (FED) disease.

Aim

To determinate whether 3D LV GLS may identify a subgroup of patients with MVP and severe MR at higher risk for cardiac events after MV surgery.

Methods

We studied 143 patients diagnosed with MVP with normal LV function, who underwent isolated MV surgery between 2011 and 2017 for severe MR. A comprehensive 2D transthoracic echocardiography (TTE) analysis was performed, degree of MR was obtained using the PISA method (Proximal Isovelocity Surface Area), degree of tricuspid regurgitation was visually estimated. 3D analysis using custom software provided measurement of left atrial (LA) and right atrial (RA) dimension, right ventricular (RV) dimension and function and LV size and function including global longitudinal strain (GLS). Cardiac events (including cardiac death, arrhythmia, hospitalization for heart failure, embolic events or arrhythmia) were recorded during a follow-up of 4.6±2 years.

Results

Study patients were diagnosed with Barlow or FED in 92 (65%) and 51 (35%) of cases, respectively. The baseline 3D analysis showed left chambers dilatation with normal LV function and normal GLS, normal right chambers and systolic pulmonary artery pressure (sPAP). Based on 3D GLS, patients were divided in Group 1 (N=84, 59%, normal GLS ≥−21%) and Group 2 (N=59, 41%, reduced GLS ≤−20%). No differences were noted at baseline between groups (Table 1). At the follow-up, 43 events were recorded, including 1 death, 12 hospitalizations (3 for heart failure, 3 for embolic events and 6 for atrial fibrillation – AF) and 30 minor arrhythmic events, mostly premature ventricular complex (PVCs) and AF. The Kaplan Meier analysis showed no differences in cardiac events between groups (Figure 1, A). Among patients with Barlow, a significant difference in events was detected between patients with reduced and normal GLS at the Kaplan Meier analysis (Figure 1, B). This finding was not found in FED patients.

Conclusions

Patients undergoing MV surgery for MVP with initial LV remodeling and normal function, seem to be characterized by a low rate of major cardiac events. Interestingly, only in the Barlow population, a reduced 3D LV GLS strain may detect cases at higher risk of minor cardiac events, mostly minor arrhythmia.

Funding Acknowledgement

Type of funding source: None

T1 mapping and cardiac magnetic resonance feature tracking in mitral valve prolapse

OBJECTIVES

T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. We sought to demonstrate that T1-map and CMR-FT may identify the presence of subclinical myocardial structural changes in patients with mitral valve prolapse (MVP).

METHODS

Consecutive MVP patients with moderate-to-severe mitral regurgitation and comparative matched healthy subjects were prospectively enrolled and underwent CMR-FT analysis to calculate 2D global and segmental circumferential (CS) and radial strain (RS) and T1-map to determine global and segmental native T1 (nT1) values.

RESULTS

Seventy-three MVP patients (mean age, 57 ± 13 years old; male, 76%; regurgitant volume, 57 ± 21 mL) and 42 matched control subjects (mean age, 56 ± 18 years; male, 74%) were included. MVP patients showed a lower global CS (- 16.3 ± 3.4% vs. - 17.8 ± 1.9%, p = 0.020) and longer global nT1 (1124.9 ± 97.7 ms vs. 1007.4 ± 26.1 ms, p < 0.001) as compared to controls. Moreover, MVP patients showed lower RS and CS in basal (21.6 ± 12.3% vs. 27.6 ± 8.9%, p = 0.008, and - 13.0 ± 6.7% vs. - 14.9 ± 4.1%, p = 0.013) and mid-inferolateral (20.6 ± 10.7% vs. 28.4 ± 8.7%, p < 0.001, and - 12.8 ± 6.3% vs. - 16.5 ± 4.0%, p < 0.001) walls as compared to other myocardial segments. Similarly, MVP patients showed longer nT1 values in basal (1080 ± 68 ms vs. 1043 ± 43 ms, p < 0.001) and mid-inferolateral (1080 ± 77 ms vs. 1034 ± 37 ms, p < 0.001) walls as compared to other myocardial segments. Of note, nT1 values were significantly correlated with CS (r, 0.36; p < 0.001) and RS (r, 0.37; p < 0.001) but not with regurgitant volume.

CONCLUSIONS

T1-map and CMR-FT identify subclinical left ventricle tissue changes in patients with MVP. Further studies are required to correlate these subclinical tissue changes with the outcome.

KEY POINTS

• T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. • In MVP patients, we demonstrated a longer global nT1 with associated reduced global circumferential (CS) and radial strain (RS) as compared to control subjects. • Among MVP patients, the mid-basal left ventricle inferolateral wall showed longer nT1 with reduced CS and RS as compared to other myocardial segments. Further studies are required to correlate these subclinical tissue changes with the outcome.