Aims:Multiple and mixed valvular heart disease (MMVD) are frequent situations in clinical practice. Despite a high prevalence, comprehensive insights into their clinical presentation, management strategies, impact of multimodality imaging, and outcomes are not well established, due to a lack of dedicated studies. Methods and results:The 'EACVI-MMVD Study' will be a large prospective, multicentre, observational cohort study led by the Heart Imagers of Tomorrow of the European Association of Cardiovascular Imaging (EACVI). It will assess the proportion, management, and prognosis of MMVD over a 1-year period of follow-up. All consecutive patients diagnosed with MMVD using transthoracic echocardiography will be recruited over a 6-month recruitment period in 88 centres from 24 different countries. Baseline evaluation will be determined by physicians and encompass the whole spectrum of multimodality imaging including transthoracic and transoesophageal echocardiography, stress echocardiography, computed tomography, and cardiovascular magnetic resonance. Centres will have the opportunity to send cardiovascular imaging data for core laboratory analysis and to extend recruitment throughout a 5-year follow-up period. Conclusion:The EACVI-MMVD study will be the largest international multicentre study evaluating the prevalence of MMVD in clinical routine and determining the impact of multimodality cardiovascular imaging in MMVD patients.Clinical Trial Registration: NCT06235385 URL: https://classic.clinicaltrials.gov/ct2/show/NCT06235385.

Abstract Background Post-operative left ventricular (LV) dysfunction remains a common adverse consequence in patients with primary mitral regurgitation (MR) undergoing mitral valve (MV) surgery. Currently, cardiac magnetic resonance imaging (CMR) is a very useful imaging modality that complements echocardiography (Echo) in providing accurate grading of MR severity in these patients. Yet it remains unclear whether the consideration of CMR-assessed LV volumes and function would offer advantages over conventional echocardiographic LV measurements in identifying patients at risk of LV systolic dysfunction after MV surgery. Purpose We sought to compare the relationship between CMR- or Echo-assessed preoperative LV volumetric and function measurements and the occurrence of post-operative LV systolic dysfunction in patients with chronic significant primary MR undergoing MV surgery. Methods The study population consisted of 214 patients (median age: 59 years, 20% women) with chronic significant primary MR due to MV prolapse or flail who underwent echocardiography and CMR in 2 tertiary centers, between 2005 and 2022, before MV repair surgery. The endpoint was the occurrence of post-operative LV systolic dysfunction (defined as LV ejection fraction [EF] < 50%) at echocardiographic follow-up when available. ROC curves were used to evaluate relations between preoperative Echo or CMR characteristics and post-operative LV dysfunction. Side-by-side comparisons of AUCs were done using DeLong’s tests. Results At echocardiographic follow-up, 40 patients (19%) had post-operative LV dysfunction, with a median follow-up time of 8.6 months (interquartile range: 6.7 – 12.5 months) after MV surgery. Compared with those with normal LV function, patients with post-operative LV dysfunction exhibited higher absolute and indexed (ind) LV end-systolic diameters (ESD) and volumes (ESV) (all p<0.043, Figure 1). These patients also showed lower preoperative CMR-assessed LVEF (p=0.004), while Echo-LVEF did not show a significant relationship (p=0.071). Additionally, no relationship was found between MR quantitative parameters (regurgitant orifice area, volume, or fraction) and post-operative LV function (all p>0.247). The AUCs of the imaging preoperative characteristics tested (LVESD, indLVESD, Echo-indLVESV, CMR-indLVESV, Echo-LVEF, CMR-LVEF) numerically ranged from 0.59 (0.50-0.69), p=0.034 (Echo-LVEF) to 0.69 (0.60-0.77), p<0.001 (Echo-indLVESD, Figure 2). No significant differences were found in the side-by-side comparisons of the AUCs (all p>0.118). Conclusion In this series of patients with chronic significant primary MR who underwent MV surgery, conventional preoperative Echo and CMR LV measurements had similar diagnostic value in detecting post-operative LV systolic dysfunction. Our results indicate that both echocardiography and CMR are valuable imaging tools for identifying primary MR patients at risk of post-operative LV dysfunction. Figure 1 Figure 2

Valvular regurgitation is common in developed countries with an increasing prevalence due to the aging of the population and more accurate diagnostic imaging methods. Echocardiography is the gold standard method for the assessment of the severity of valvular heart regurgitation. Nonetheless, cardiovascular magnetic resonance (CMR) has emerged as an additional tool for assessing mainly the severity of aortic and mitral valve regurgitation in the setting of indeterminate findings by echocardiography. Moreover, CMR is a valuable imaging modality to assess ventricular volume and flow, which are useful in the calculation of regurgitant volume and regurgitant fraction of mitral valve regurgitation, aortic valve regurgitation, tricuspid valve regurgitation, and pulmonary valve regurgitation. Notwithstanding this, reference values and optimal thresholds to determine the severity and prognosis of valvular heart regurgitation have been studied lesser by CMR than by echocardiography. Hence, further larger studies are warranted to validate the potential prognostic relevance of the severity of valvular heart regurgitation determined by CMR. The present review describes, analyzes, and discusses the use of CMR to determine the severity of valvular heart regurgitation in clinical practice.

Background: The tricuspid valve is a complex threedimensional (3D) structure. Echocardiography (2D/3D) is the gold standard for evaluating valve function and anatomy. The aim of our study was to compare in vivo with 3D echocardiographic tricuspid valve measurements in patients treated for mitral valve disease. Methods: Among the 139 patients treated for mitral valve disease, 37 had an intraoperative evaluation by 3D trans-esophageal echocardiography. After exposure of the valve, we took several pictures to obtain annular and leaflet measurements. We traced the echocardiographic annular measurements (area, perimeter, septal anterior, and latero-lateral diameters) at six different moments of the cardiac cycle: early, mid, and late, systole and diastole; leaflet lengths and areas were measured only during end-systole and diastole. From the intraoperative pictures, we obtained annular and leaflet measurements and compared them to echocardiographic findings using Pearson’s correlation test. Results: Significant correlations were found between 3D echocardiography and in vivo measurements in terms of valve areas and perimeter (p < 0.01; r = 0.77 and p < 0.01; r=0.61, respectively) while diameters correlated moderately. Correlations of leaflet measurements were poor (R: 0.51–0.61). Multivariate linear regression analysis identified annulus areas and tenting height (p = 0.03 and 0.04, respectively) as significant predictors of tricuspid regurgitation. Conclusion: Our study demonstrated that annulus area and perimeter correlate better than diameters for measuring the tricuspid annulus and have significant influence on functional tricuspid regurgitation. Leaflet analysis remains limited. Further studies will identify their impact on follow-up recurrence of functional tricuspid regurgitation.

BACKGROUND: Although increased left ventricular (LV) volumes and reduced ejection fraction (EF) are associated with adverse outcomes in heart failure (HF), there are limited data regarding the prognostic value of right ventricular (RV) systolic dysfunction (RVSD) in ischemic cardiomyopathy. The purpose of this study was to evaluate the impact of RV function assessment by cardiac magnetic resonance (CMR) before surgical revascularization on survival in patients with coronary artery disease (CAD) and low EF. METHODS: We prospectively evaluated survival of 107 consecutive patients (94 males, age 66 ± 10 years) with CAD and LV dysfunction (EF: 25 ± 7%) undergoing CMR prior complete surgical revascularization. RESULTS: Mean RV function parameters were respectively: RVEDVi 84±28mL/m2, RVESVi 46±25mL/m2 and RVEF 45±16%. RVSD, defined by RV EF ≤35%, was present in 32 (30%) pts. Perioperative mortality at 30 days (n=6 CV death) was significantly higher in patients with RVSD (13% vs. 3%, p=0.043). During the median follow-up of 4.2 years, 42 pts died (worsening HF n=10, sudden death n=12, other CV death n=8, non CV death n=11), 1 pt underwent heart transplantation. The primary end point of cardiovascular death or cardiac transplantation was reached by 14 of 32 pts with RVSD and 17 of 75 pts without RVSD (44% versus 23%, p=0.028). In univariate analysis, age (1.05, 95% CI 1.008-1.09, p= 0.017), eGFR (0.98, 95% CI 0.97-0.99, p=0.017), LVEF (0.94, 95% CI 0.90-0.99, p=0.031) and RVSD (2.51, 95% CI 1.21-5.12, p=0.011) were predictors of the primary end-point. In a stepwise multivariable analysis adjusting for age, eGFR, and LVEF, RVSD remained a significant independent predictor of the primary end-point (HR 3.57; 95% CI, 1.69-7.52; p =0.001). CONCLUSIONS: RVSD is a strong independent predictor of cardiovascular mortality in patients with ischemic cardiomyopathy undergoing coronary bypass surgery. Evaluation of RV function should thus be performed in all HF patients prior surgery.

BACKGROUND:During acute myocardial ischemia, myocardial postsystolic shortening (PSS) is considered as a sign of viability. In chronic left ventricular (LV) ischemic dysfunction, the value of PSS is less well established. In this study, PSS was compared with transmural extent of necrosis and contractile reserve in patients with chronic LV ischemic dysfunction.METHODS:A total of 25 patients (20 men, mean age: 63 +/- 8 years) with LV dysfunction (mean ejection fraction: 32 +/- 10%, range: 14%-47%) and stable coronary artery disease underwent rest color Doppler myocardial imaging, low-dose dobutamine echocardiography, and late enhancement gadolinium-magnetic resonance imaging. Strain (epsilon) curves were computed in 16 segments from color Doppler myocardial imaging sequences and were compared with transmural extent of necrosis and with contractile reserve. End-systolic epsilon was defined as epsilon value at aortic valve closure, peak epsilon (epsilon-peak) as maximal epsilon value during cardiac cycle, and time to epsilon-peak as time interval between aortic valve closure and epsilon-peak. PSS was considered when epsilon-peak occurred after aortic valve closure.RESULTS:Of 348 analyzable segments, 212 (61%) were graded as abnormal. In dysfunctional segments, PSS was more prevalent in transmural than in nontransmural infarcted segments (96% vs 50%, P < .001) and time to epsilon-peak was correlated to transmural extent of necrosis (r = 0.69, P < .0001). In nontransmurally infarcted segments, prevalence of PSS was similar in segments with or without contractile reserve (37% vs 45%, respectively).CONCLUSION:In chronic LV dysfunction, PSS is not a specific marker of viability. These results suggest strongly that delayed myocardial shortening may be associated to scarred segments.