ABSTRACT Background Mitral transcatheter edge‐to‐edge repair (TEER) can achieve substantial mitral regurgitation (MR) reduction in appropriately selected patients, yet outcomes after technically successful intervention remain heterogeneous. This variability has prompted interest in echocardiographic markers of limited treatment benefit. However, adverse prognosis after TEER and absence of benefit attributable to TEER are fundamentally different concepts, and most available imaging studies evaluate the former rather than the latter. Methods This state‐of‐the‐art review summarizes evidence on echocardiographic assessment of prognosis and treatment response across the mitral TEER pathway, integrating baseline multichamber phenotyping, procedural and immediate hemodynamic assessment, longitudinal imaging, and evidence from randomized trials of TEER in secondary MR. Results Baseline left ventricular remodeling and myocardial dysfunction, left atrial disease, pulmonary hypertension, right ventricular dysfunction and right ventricular–pulmonary arterial uncoupling, and tricuspid regurgitation identify greater cardiovascular disease burden and residual risk after TEER. Procedural assessment extends beyond residual MR to include transmitral pressure gradient, forward flow, and left atrial hemodynamics, whereas serial imaging characterizes subsequent ventricular, atrial, pulmonary, and right‐heart trajectories. Persistent structural or hemodynamic abnormalities and absence of reverse remodeling should not be equated with irreversible disease or therapeutic futility. Randomized subgroup analyses in secondary MR have not consistently demonstrated significant treatment‐effect modification by several adverse echocardiographic phenotypes; however, these analyses were not adequately powered to exclude clinically meaningful interactions. Moreover, COAPT excluded patients with extreme ventricular remodeling, markedly elevated pulmonary pressures, or advanced RV dysfunction, limiting generalizability to these populations. Differences among COAPT, MITRA‐FR, and RESHAPE‐HF2 further caution against defining a universal echocardiographic treatment‐response phenotype. Conclusions Echocardiography is essential for defining MR mechanism and severity, characterizing multichamber cardiovascular disease, evaluating procedural results, and refining longitudinal risk assessment. However, current evidence does not establish a validated echocardiographic threshold or phenotype that reliably predicts absence of treatment benefit. Randomized subgroup findings require cautious interpretation because of limited statistical power and the exclusion of patients with the most advanced ventricular and pulmonary vascular disease. Future adequately powered comparative studies should evaluate heterogeneity of treatment effect across MR etiologies using standardized multichamber imaging and patient‐centered outcomes.
ABSTRACT Objective To evaluate the independent and incremental value of a standardized first‐trimester binary cardiac assessment for screening severe congenital heart disease (CHD) in fetuses with increased nuchal translucency (NT). Method This single‐center retrospective diagnostic accuracy study included 223 singleton fetuses with NT ≥ 3.0 mm at 11–13 + 6 weeks of gestation who underwent prenatal screening at our hospital between January 2019 and December 2023. First‐trimester binary cardiac assessment was performed through blinded review of archived ultrasound images. Clinical and screening variables, including NT thickness and pregnancy‐associated plasma protein A (PAPP‐A), were collected. Missing serum marker data were addressed using multiple imputation. Logistic regression and receiver operating characteristic (ROC) curve analyses were used to assess the predictive and diagnostic performance of the cardiac assessment alone and in combination with conventional screening indicators. The DeLong test was used to compare the baseline model (NT + PAPP‐A) with the incremental model (NT + PAPP‐A + cardiac assessment). Results A positive first‐trimester cardiac assessment was independently associated with severe CHD (adjusted OR = 4.02, 95% CI: 1.09–14.87). In the primary imputed analysis, the baseline model (NT + PAPP‐A) had an AUC of 0.840 (95% CI: 0.772–0.912), and the incremental model adding cardiac assessment had an AUC of 0.879 (95% CI: 0.812–0.945); however, the DeLong test did not show a statistically significant difference ( p = 0.243). The cardiac assessment showed particularly high sensitivity for left‐sided obstructive cardiac malformations (90.0%). Conclusion A standardized first‐trimester cardiac assessment is independently associated with severe CHD in fetuses with thickened NT. Adding it to NT thickness and maternal PAPP‐A did not significantly improve model discrimination in this retrospective cohort, although the AUC increased numerically. Prospective multicenter studies are needed to determine whether this combined strategy provides incremental value.
ABSTRACT Purpose Sodium‐glucose cotransporter‐2 inhibitors promote cardiac reverse remodeling in heart failure (HF), yet data integrating two‐dimensional and three‐dimensional echocardiography (2DE and 3DE, respectively) in optimally treated HFrEF populations are limited. This study aimed to evaluate heart chambers size and function by 2D/3DE after dapagliflozin initiation, and to explore whether baseline estimated glomerular filtration rate (eGFR) or myocardial fibrosis on cardiac magnetic resonance (CMR) influence reverse remodeling. Methods Seventy‐five patients with LVEF ≤40% on guideline‐directed therapy were prospectively enrolled. Echocardiographic and clinical data were collected at baseline and 6‐month follow‐up (6MFU) after introduction of dapagliflozin 10 mg daily. Sub‐analyses were performed according to eGFR (<45 vs. ≥45 mL/min/1.73 m 2 ) and extent of late gadolinium enhancement (LGE) on CMR. Results After 6MFU, left ventricular (LV) end‐diastolic and end‐systolic volumes reduced, and LVEF increased as assessed by both 2DE (respectively: 88[72–122] vs. 92[79–122]mL/m 2 , 58[42–80] vs. 57[48–88]mL/m 2 , 36.6±8.8 vs. 34.5±7.7%; p < 0.001) and 3DE (respectively: 100[79–140] vs. 108[90–136]mL/m 2 , 64[46–82] vs. 69[55–93]mL/m 2 , 37.4±8.7 vs. 34.4±7.9%; p < 0.001). No significant association between eGFR and the magnitude of LV reverse remodeling was detected, while CMR analyses suggested a possible inverse correlation between LGE burden and improvement in 2D LVEF. LV diastolic function improved (grade≥2 diastolic dysfunction: 4.7% vs. 18.7%; p = 0.015), along with systolic pulmonary artery pressure (25[23–29] vs. 27[24–29]mmHg; p = 0.037). Conclusion In optimally treated HFrEF patients, LV size and systolic and diastolic function significantly improved during the 6MFU following dapagliflozin initiation. No significant differences in the magnitude of LV reverse remodeling were detected according to eGFR or LGE burden. Trial registration number NCT05770167. Key Learning Points What is already know Sodium−glucose cotransporter‐2 inhibitors improve clinical outcomes in heart failure across a wide spectrum of left ventricular ejection fraction, with evidence of cardiac reverse remodeling. Dapagliflozin has been shown to reduce left ventricular and left atrial volumes, improve biventricular systolic function, and lower filling pressures, independent of diabetes status and baseline renal function. What this study adds In clinically stable HFrEF patients on fully optimized guideline‐directed medical therapy, significant left ventricular reverse remodeling and improvement in systolic and diastolic function within 6 months after introduction of dapagliflozin was observed, as consistently demonstrated by both 2D and 3D echocardiography. A proportion of patients with baseline LVEF ≤35% crossed the 35% threshold at 6‐month follow‐up. This observation is hypothesis‐generating and may warrant further investigation regarding the potential implications of reverse remodeling for subsequent device‐therapy assessment. Exploratory analyses did not detect a statistically significant association between baseline renal function and the magnitude of cardiac reverse remodeling. In the CMR subgroup, preliminary data suggest that the extent of LGE burden might inversely correlate with improvement in 2D LVEF.
ABSTRACT Purpose To investigate the detection rate of congenital heart disease (CHD) on fetal echocardiogram after a normal and complete detailed fetal ultrasound among pregnancies conceived by in vitro fertilization (IVF). Methods This retrospective cohort study examined singleton IVF pregnancies that underwent a detailed fetal anatomic survey without any identified abnormalities, followed by fetal echocardiogram. The primary outcome was the rate of CHD diagnosis after normal and complete anatomic ultrasound. Patients with multifetal gestation, pre‐gestational diabetes, a known family history of CHD, fetal abnormalities on anatomy ultrasound, or patients who had an incomplete initial anatomy ultrasound were excluded. Prenatal CHD was confirmed with neonatal imaging and infants were followed after birth. Results 300 pregnancies were included, and of these 266 had a normal and complete anatomy ultrasound. 1.5% ( n = 4) of pregnancies had minor CHD identified on fetal echocardiography which was not identified on the anatomy ultrasound. None of the infants required cardiac‐related interventions in the first year of life. Conclusion No major CHD was identified at fetal echocardiography after a normal and complete anatomic survey. Our results support the American Institute of Ultrasound in Medicine guidelines that state a dedicated fetal echocardiogram may be considered, but is not recommended, for singleton IVF pregnancies.
