INTRODUCTION:Tricuspid regurgitation is frequent, and its related systemic venous congestion is associated with mortality. Diuretics are the main therapy but what shapes their effect is not fully known. AIM AND METHODS:In this single-center cross-sectional study, we aimed to assess the association of right heart metrics of size and function in relation to diuretic dose. In consecutive patients with measurable tricuspid regurgitation regurgitant volume (RVol) by echocardiography, a high diuretic dose (HDD) was considered a furosemide dose (or equivalent) of greater than 40 mg. Parameters of right atrial (RA) and right ventricular (RV) size and function, tricuspid regurgitation degree and congestion signs were compared between groups with or without HDD. RESULTS:Of 120 patients (37% men; age 74 ± 13 years), 31.7% had HDD. HDD was prevalent in 16% of patients with mild tricuspid regurgitation, 25% with moderate tricuspid regurgitation and 49% with severe tricuspid regurgitation ( P  = 0.011). In multivariate analysis including RV and RA parameters of size and function, only the RA strain was independently associated with diuretic therapy ( B -0.111, P  < 0.0001) and HDD ( B -0.101, P  = 0.007). There was a progressive decline in RA strain with increasing diuretic dose ( PANOVA  < 0.0001). The RA strain was lower in HDD patients independently of chronic kidney disease ( P for interaction 0.798) and tricuspid regurgitation severity ( P for interaction 0.712). Most patients with congestive signs showed a lower RA strain (all P  < 0.05). CONCLUSION:Reduced RA function in tricuspid regurgitation patients with venous congestion is independently associated with a higher dose of diuretic therapy.

Abstract Background tricuspid regurgitation (TR) is frequent, and its related systemic venous congestion is associated with mortality. Purpose This study aims to evaluate the role of right atrial (RA) function, measured using the strain technique, on the medium- to long-term clinical effects of tricuspid regurgitation (TR). Our primary objective was to analyze the impact of RA function, measured at baseline, on a composite endpoint consisting of death and/or hospitalization for predominantly right-sided heart failure. The secondary endpoints are hospitalizations, worsening of renal function, and an increase in diuretic dosage (DD). Methods We performed a single center, prospective, observational study regarding adult patients with tricuspid regurgitation and measurable effective regurgitant orifice area (EROA) and a state of hemodynamic stability that underwent a complete echocardiography and full cardiologic evaluation in our Institution, from January 2020 to February 2023. Those patients with acute HF, poor quality imaging, previous repair or prosthetic replacement of the tricuspid valve, and severe renal or hepatic insufficiency were excluded. Patients were assessed clinically at each follow up. Results 134 patients were included (females 62%, mean age 73 ± 13 years old). Median follow up was 23,5 months (12 - 34 months). TR was functional in 87% of cases and was more than moderate in 52% of cases. Mean RA strain was 18,7 ± 11,2%, and divided patients in low strain (LS) and high strain (HS). HS was associated with lower increase and frequently a decrease in DD (-5,5 ± 44,7 mg vs 20,8 ± 63,2 mg, p = 0,009) but no echocardiographic variable independently predicted an increase in DD. Patients with worsening renal function had significantly lower RA (16.7 ± 10.6% vs 20.7 ± 10.9%, p 0.042). LS independently predicted a worsening renal function (OR 3,07; 95% CI 1,026-9,2). RA strain was significantly lower in hospitalized patients (13.1 ± 8 vs 20.3 ± 11.4, p<0.001). Cox regression analysis showed a LS to be an independent predictor of the composite endpoint (adjusted HR 3.1, 95% CI 1.101 – 8.74) correcting for other clinical and echocardiographic variables. ROC curve analysis showed an RA strain cut-off of 18.5% to have a sensitivity of 79% and specificity of 56% in predicting the combined endpoint. Conclusions RA strain is associated with DD and LS patients have higher DD at follow up. RA strain is an independent predictor of worsening renal function. RA function measured by strain is an independent predictor of the composite endpoint of death and/or hospitalization.

Abstract Introduction breast cancer is the most common cancer among women, and in those undergoing chemotherapy, a potential adverse event is cardiotoxicity. Various clinical scores and echocardiographic parameters have been proposed, but predicting left ventricular dysfunction remains challenging. Purpose this study aims to identify baseline pre-chemotherapy echocardiographic parameters that can predict cardiotoxicity. Methods consecutive patients diagnosed with non-metastatic breast cancer and treated with chemotherapy (including anthracycline, anti-HER2, taxanes or hormonal therapy) were prospectively enrolled and followed for one year with clinical and echocardiographic assessments at baseline and every three months. The diagnosis of cancer therapy-related cardiac dysfunction (CTRCD) was based on the 2022 ESC Guidelines. The case series was therefore divided based on the occurrence of mild CTRCD or not. For descriptive purpose we used mean and confidence intervals; median and interquartile ranges when appropriated. We used Student's T-test or Mann-Whitney U for within-group differences, paired T-test or Wilcoxon-Signed-Rank Test for repeated controls. CTRCD onset over time was evaluated using the Kaplan-Meier method. ROC analysis was used to identify cut-off values able to define at risk patients. Statistical significance was setted at p < 0.05. Results we examined 138 patients with an average age of 53.52 years. 58 patients developed mild CTRCD, (18 within the first trimester, 26 between 3-6 months, 8 between 6-9 months, and 6 between 9-12 months). (Picture 1). Parameters like left ventricle global longitudinal strain (GLS), left ventricle eiection fraction (LVEF), early peak atrial longitudinal strain (PALS), peak atrial contraction (PACS) and left atrial volume were evaluated. These parameters showed significant deterioration over time in the overall population; PACS and PALS changed early at 3 months, but nothing was significantly correlated with mild CTRCD diagnosis. A significant difference between the two groups was observed only for PALS at 6 months and PACS at 12 months. At the ROC analysis only GLS showed clinical utility in predicting mild CTRCD with an AUC of 0.83 (Picture 2), and the best cut-off value was -21 (sensitivity 0.724, specificity 0.850, positive predictive value 0.778, negative predictive value 0.810). Conclusions echocardiographic parameters worsened over time in chemotherapy patients. Atrial strain showed significant differences between groups. Basal atrial parameters did not predict CTRCD in our study, but literature supports the relevance of left atrial strain for predicting CTRCD. A baseline GLS value of ≤ -21 may indicate a higher likelihood of mild cardiotoxicity, probably because chemotherapy effect could cause more easily a reduction > 15% in GLS without reduction in LVEF when the baseline GLS is more negative. These findings require confirmation from larger studies.

Tricuspid regurgitation (TR) is related to survival, and right atrial (RA) size and function may play a role. This study aimed to assess the impact of RA function measured by strain (RA strain [RAS]) on outcome and end-organ congestion. We enrolled 134 patients (mean age 73 ± 13 years, 62% women) with any TR grade or etiology and a complete echocardiogram, clinical follow-up, and renal function assessment. The primary end point was a combination of overall mortality and right-sided heart failure hospitalization, and the secondary end point was worsening renal function (WRF). After a median follow-up of 23.5 months (interquartile range 12 to 34 months), the combined end point was reached by 31% of patients. Patients with RAS ≤18% showed lower event-free survival (log-rank p <0.001). In the multivariable analysis, RAS ≤18% (HR 3.1, 95% CI 1.1 to 8.8) and pulmonary artery systolic pressure (PASP) (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1 to 1.05) were independent predictors of the primary end point. Patients with RAS ≤18% and PASP >45 mm Hg had the worst outcome (HR 4.3, 95% CI 2 to 9.5). RAS ≤18% (odds ratio 3.22, 95% CI 1.11 to 9.33) and PASP >45 mm Hg (OR 3.2, 95% CI 1.15 to 8.88) were independent predictors of WRF, adjusting for TR severity, left and right ventricular function, age, gender, diabetes, diuretics, atrial fibrillation. The addition of RAS ≤18% had incremental power over PASP and echocardiographic variables of TR severity and right or left ventricular function to predict WRF (p = 0.026). In conclusion, RA function measured by RAS independently predicts mortality and hospitalizations in patients with TR and independently and incrementally predicts WRF over time.

Trastuzumab is widely used in HER2 breast cancer. However, it may cause left ventricular (LV) dysfunction. A decrease in LV global longitudinal strain (GLS) has been previously demonstrated to be a good predictor of subsequent cancer therapy related dysfunction (CTRCD). Left atrial morphological remodeling during Trastuzumab therapy has also been shown. The aim of this study is exploring the relationship between early changes in left atrial function and the development of Trastuzumab-induced cardiotoxicity. Consecutive patients with diagnosis of HER2+non-metastatic breast cancer treated with Trastuzumab were prospectively enrolled. A clinical, conventional, and advanced echocardiographic assessment was performed at baseline and every three months, until a one-year follow-up was reached. One-hundred-sixteen patients completed the 12 months follow-up, 10 (9%) cases of CTRCD were observed, all after the sixth month. GLS and LVEF significantly decreased in the CTRCD group at 6 months of follow-up, with an earlier (3 months) significant worsening in left atrial morpho-functional parameters. Systolic blood pressure, early peak atrial longitudinal strain (PALS), peak atrial contraction (PACS) and left atrial volume (LAVI) changes resulted independent predictors of CTRCD at multivariable logistic regression analysis. Moreover, early changes in PALS and PACS resulted good predictors of CTRCD development (AUC 0.85; p = 0.008, p < 0.001 and 0.77; p = 0.008, respectively). This prospective study emphasizes that the decline in PALS and PACS among trastuzumab-treated patients could possibly increase the accuracy in identifying future CTRCD in non-metastatic HER2 breast cancer cases, adding predictive value to conventional echocardiographic assessment.

Background and aims: Epidemiology of tricuspid regurgitation (TR) is poorly known and its burden in the community is challenging to define. We aimed to evaluate the prevalence of TR in a geographically defined area and its outcome, in particular overall survival and hospitalization, considering different clinical contexts. Methods: We retrospectively analyzed consecutive outpatients referred between 2006 and 2013 for echocardi-ography and clinical evaluation. Patients with at least moderate TR were included and five different clinical settings were defined: concomitant significant left-sided valvular heart disease (LVHD-TR), heart failure (HF-TR), previous open-heart valvular surgery (postop-TR), pulmonary hypertension (PHTN-TR) and isolated TR (iso-lated-TR). Primary endpoint was a composite outcome of all-cause mortality or first hospitalization for HF.Results: Of 6797 consecutive patients with a clinical visit and echocardiograms performed in routine practice in a geographically defined community, moderate or severe TR was found in 4.8% of patients (327) . During median follow-up of 6.1 years, TR severity was a determinant of event-free survival. Analyzed for each clinical subset, eight-year event-free survival was 87 +/- 7% for postop-TR subgroup, 75 +/- 7% for isolated-TR, 67 +/- 6% for PHTN-TR, 58 +/- 6% for LHVD-TR and 52 +/- 11% for HF-TR.Conclusion: Moderate or more TR is a notable finding in the community and has impact on event-free survival in all clinical settings, with the worst outcomes when associated with relevant left-sided valvular heart disease and HF.

Riportiamo un raro caso di anomalia valvolare congenita. Una donna asintomatica di 17 anni è stata indirizzata al nostro laboratorio di ecocardiografia per una valutazione di idoneità allo sport agonistico (pattinaggio artistico). La paziente non presentava altre anomalie cardiache congenite né anamnesi familiare di malattie cardiovascolari. L’ecocardiografia transtoracica e la risonanza magnetica cardiaca hanno rivelato una malformazione quadricuspide della valvola aortica con un lieve rigurgito aortico.

ObjectivesWe hypothesised that low flow low gradient aortic stenosis (LFLGAS) is associated with more severe coronary microvascular dysfunction (CMD) compared with normal-flow high-gradient aortic stenosis (NFHGAS) and that CMD is related to reduced cardiac performance.MethodsInvasive CMD assessment was performed in 41 consecutive patients with isolated severe aortic stenosis with unobstructed coronary arteries undergoing transcatheter aortic valve implantation (TAVI). The index of microcirculatory resistance (IMR), resistive reserve ratio (RRR) and coronary flow reserve (CFR) were measured in the left anterior descending artery before and after TAVI. Speckle tracking echocardiography was performed to assess cardiac function at baseline and repeated at 6 months.ResultsIMR was significantly higher in patients with LFLGAS compared with patients with NFHGAS (24.1 (14.6 to 39.1) vs 12.8 (8.6 to 19.2), p=0.002), while RRR was significantly lower (1.4 (1.1 to 2.1) vs 2.6 (1.5 to 3.3), p=0.020). No significant differences were observed in CFR between the two groups. High IMR was associated with low stroke volume index, low cardiac output and reduced peak atrial longitudinal strain (PALS). TAVI determined no significant variation in microvascular function (IMR: 16.0 (10.4 to 26.1) vs 16.6 (10.2 to 25.6), p=0.403) and in PALS (15.9 (9.9 to 26.5) vs 20.1 (12.3 to 26.7), p=0.222). Conversely, left ventricular (LV) global longitudinal strain increased after TAVI (−13.2 (8.4 to 16.6) vs −15.1 (9.4 to 17.8), p=0.047). In LFLGAS, LV systolic function recovered after TAVI in patients with preserved microvascular function but not in patients with CMD.ConclusionsCMD is more severe in patients with LFLGAS compared with NFHGAS and is associated with low-flow state, left atrial dysfunction and reduced cardiac performance.

Tricuspid regurgitation (TR) is a frequent valvular pathology and when significant, may cause systemic venous congestion (SC). The right atrium (RA) is an intermediate structure between the tricuspid valve and the venous system and its role in SC is not yet defined. A total of 116 patients with a measurable TR effective regurgitant orifice area (EROA) and regurgitant volume (RVol) were selected from 2020 to 2022. SC was estimated by echocardiography using inferior vena cava diameter and estimated right atrial pressure (eRAP) and by clinical congestive features. TR grade was mild in 23 patients (20%), moderate in 53 patients (46%), and severe in 40 patients (34%). There was a significant decrease in RA function measured by strain with increasing TR severity (p <0.001). There was a marked difference in RA strain between the groups with eRAP >10 and ≤10 mm Hg (25 ± 11% vs 11 ± 7%, p <0.0001). Variables independently associated with inferior vena cava diameter were RA strain (β -0.532, p <0.001), RA volume indexed (β 0.249, p = 0.002), RVol (β 0.229, p = 0.005) and EROA (β 0.185, p = 0.016), and independently associated with eRAP >10 mm Hg were EROA (odds ratio [OR] 1.024, 95% confidence interval [CI] 1.002 to 1.046), RVol (OR 1.039, 95% CI 1.007 to 1.072) and RA strain (OR 0.863, 95% CI 0.794 to 0.940). The addition of RA strain to models containing EROA or RVol significantly improved the power of the model. RA strain was independently associated with the presence of 3 or more congestive features. In conclusion, echocardiographic and clinical signs of SC are frequent in higher degrees of TR, and RA function seems to play a key role in modulating the downstream effect of TR.

Left ventricular global longitudinal strain (GLS) has an important role in the diagnosis of cancer therapy-related cardiac dysfunction (CTRCD). Little is known about the role of atrial function in diagnosing CTRCD. The aim of our study was to assess the impact of anti-cancer drugs on atrial function measured by speckle-tracking echocardiography in breast cancer women. A prospective multicenter study was conducted enrolling 169 breast cancer women treated with anthracyclines. A cardiological evaluation including an electrocardiogram and echocardiogram with an analysis of GLS, left atrial (LA) strain, and LA stiffness (LASi) was performed at baseline (T0), 3 (T1), and 6 months (T2) after starting chemotherapy. The patients were divided into two groups: patients with asymptomatic mild cardiotoxicity at T1 (with a relative reduction in GLS > 15%; Group 1) and those without (Group 2). We did not find a significant change in left ventricular ejection fraction (LVEF) at T1 and T2; we found a significant change in GLS (p-value < 0.0001) in the peak atrial longitudinal strain (PALS) and in LASi (p-value < 0.0001). Impairment of atrial function was greater in Group 1 compared to Group 2. A PALS variation > 20.8% identified patients who were most likely to develop asymptomatic mild cardiotoxicity [AUC 0.62; CI (0.51–0.73) p = 0.06, sensitivity 45%, specificity 69.5%]. Conclusions: PALS and LASi significantly change during chemotherapy in association with GLS. Atrial strain is an additional parameter that could be measured together with GLS to detect cardiotoxicity early.

Abstract Background Trastuzumab (TZ) is widely used for his key role in HER2 positive breast cancer. However, the most concerning cardiovascular complication is cardiotoxicity. Many studies have highlighted the importance of screening for subclinical myocardial dysfunction using left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). However, there are only few studies investigating a possible atrial damage. Purpose Aim of this study was to analyze the modification peak atrial systolic longitudinal strain (PALS) in patients undergoing therapy with TZ in a follow-up period of 12 months. The fluctuation of left atrial function parameters under chemotherapy was evaluated focusing the attention on those patients who developed cancer therapy–related cardiac dysfunction (CTRCD). Methods 116 women affected by breast cancer treated with TZ were enrolled. Each patient underwent a complete echocardiography at baseline and every 3 months. Exclusion criteria were poor quality imaging and lack of a complete follow up with consequent missing data. CTRCD was defined as a decrease in the left ventricular ejection fraction of >10 percentage points to a value <53% at any time of follow-up. 2D-Speckle tracking analysis was performed at baseline and at each examination using Tomtec software to analyze both atrial and left ventricular function. Trends of GLS, and PALS during 12 months-follow up periods were analyzed. Additionally, we explored if diabetes and renal impairment were associated with more prevalent atrial subclinical disfunction as demonstrated in previous studies. Results A total of 10 patients (9%) developed cancer therapy–related cardiac dysfunction. A significant reduction in GLS compared to the baseline was observed during the whole follow-up (p=0.05), starting in the first six months of treatment (-21 ± 2% vs -17 ± 2%, p= 0.021). Interestingly, PALS showed a similar trend with a significant decrease during the whole 12 months-follow up (p=0.012), starting in the first 3 months (45 ± 9% vs 35 ± 8%, p=0.001). 6 patients presented a diagnosis of diabetes at baseline, and presented lower PALS compared to the non-diabetic counterpart (38± 10% vs 49 ± 12% p=0.03). 2 patients presented a significant renal impairment (eGFR ≤30 ml/min). Similarly, these patients presented a lower PALS at baseline (32 ± 7% and 48 ± 7%; p=0.055). Conclusions In patients treated with Trastuzumab the development of left atrial impairment is frequent and PALS modifications seem to precede GLS variations in patients with CTRCD, suggesting a possible cardiotoxic effect of such therapy on both atrial and left ventricular myocardium and physiology.

Abstract Background Tricuspid regurgitation (TR) is a relatively common echocardiographic finding and its proportional influence on prognosis and quality of life has been well described. A bidirectional relationship connects TR severity and its volume overload with right ventricular (RV) dilation and dysfunction. Purpose to assess the impact of RV size and function on TR severity. Material and Methods 116 stable patients with TR were enrolled at the time of echocardiography (43 men, 37%; mean age 74±13 years). TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RV size was assessed by RV End Diastolic Area (EDA) and RV function by RV Free Wall Longitudinal Strain (FWLS). Results TR was quantified mild in 23 patients, moderate in 53 and severe in 40 patients, with higher predominance of functional rather than organic etiology (101 vs 15 patients); median EROA was 31 mm2 and median RVol was 30 mL. Mean RV-FWLS was -25.9±7%, -21.4±7.4% and -18.4±6.4% respectively in mild, moderate and severe TR with a statistically significant difference between the groups (p=0.001). Mean RV-EDA was 19±7.7 cm2 in mild TR, 21.7±8.5 cm2 and 26.2±7 cm2 in moderate and severe TR respectively (p=0.002). In univariate analysis both RV-FWLS and RV-EDA were predictor of TR grade estimated by TR-EROA (p=0.012 and p<0.0001 respectively). In linear multivariable analysis only RV-EDA was an independent predictor of TR-EROA (p=0.001). A ROC curve analysis confirmed the better ability of RV-EDA to identify severe TR (sTR) compared to RV-FWLS (AUC=0.738 vs AUC=0.669). Conclusions RV remodeling in terms of chamber dilation seems to better predict a higher TR severity compared to RV dysfunction.

Abstract Background Trastuzumab (TZ) is widely used for his key role in HER2 positive breast cancer. However, the most concerning cardiovascular complication is cardiotoxicity. Many studies have highlighted the importance of screening for subclinical myocardial dysfunction using left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). However, there are only few studies investigating a possible atrial damage. Purpose Aim of this study is to analyze the modification of GLS and peak atrial systolic longitudinal strain (PALS) in patients undergoing therapy with TZ in a follow-up period of 12 months. The eventual fluctuation of left atrial function under chemotherapy was evaluated and the correlation between subclinical atrial disfunction and early left ventricular impairment was investigated. Methods 105 women affected by breast cancer treated with TZ were enrolled. Each patient underwent a complete echocardiography at baseline and every 3 months. 37 patients (35%) were excluded from the left atrial function analysis while LV function evaluation was performed in 83 patients (21%). Exclusion criteria were poor quality imaging and lack of a complete follow up with consequent missing data. 2D-Speckle tracking analysis was performed at baseline and at each examination using Tomtec software in order to analyze both atrial and left ventricular function. Subclinical LV disfunction was defined as a GLS reduction of ≥15% compared to the baseline value. Left atrial impairment was arbitrary defined as a PALS reduction of ≥25% compared to the initial value. Finally, trends of GLS and PALS during 12 months-follow up periods were analyzed. Additionally, we explored if diabetes and renal impairment were associated with more prevalent atrial subclinical disfunction as demonstrated in previous studies. Results A total of 49% patients developed subclinical LV dysfunction. Similarly, 48% patients showed a left atrial impairment. Interestingly a significant (p=0.0001) reduction in GLS was observed during the follow-up, particularly in the first six months of treatment. PALS showed a similar trend with a significant decrease during the whole 12 months-follow up (p=0.0001) and mostly in the first 6 months. 6 patients presented a diagnosis of diabetes at baseline, and presented lower PALS compared to the non-diabetic counterpart (37.6±9.9% vs 48.7±12.2%, p=0.03). 2 patients presented a significant renal impairment (eGFR ≤30 ml/min). Similarly, these patients presented a lower PALS at baseline (32±7 and 48±7; p=0.05). Conclusions In patients treated with Trastuzumab development of left atrial impairment is frequent and PALS modifications follow a similar pattern to GLS variations during the treatment, suggesting a possible cardiotoxic effect of such therapy on both atrial and left ventricular myocardium and physiology. Funding Acknowledgement Type of funding sources: None.

Abstract Background tricuspid regurgitation (TR) of either organic or functional etiology can lead to systemic venous congestion particularly in its more severe forms. Little is known about the role of the right atrium (RA) which acts as an intermediate player between TR and systemic veins. Purpose to assess the influence of right atrial size and function on venous congestion in TR patients. Methods 101 stable patients with at least mild to moderate TR were enrolled at the time of echocardiography (age 74±13 years, 37% male). Systemic congestion was assessed by inferior vena cava (IVC) diameter and right atrial pressure (RAP) estimated according to inferior vena cava diameter and collapsibility. TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RA and right ventricular (RV) function were assessed respectively by peak atrial longitudinal strain (PALS) and free wall longitudinal strain (FWLS) while indexed RA volume (RAVi) by Simpson's disk summation method. Results TR was quantified mild or moderate in 52 patients and more than moderate in 49 patients (mean EROA 37±31 mm2; mean RVol 34±23 ml). Mean indexed RA volume was 58±31 ml/m2; mean RA strain was 18±11% and mean RV strain (free wall) was -21 ± 7%. Mean IVC diameter was 20±6 mm; estimated RAP was ≤5 mmHg in 32 patients, 6-10 mmHg in 26, 11-15 mmHg in 26 and greater than 15 mmHg in 17 patients. In univariate analysis both IVC diameter and RAP correlated significantly with EROA, RVol, RAVi and RA strain (p<0.0001 for all); only RAP correlated with RV strain. In linear multivariate analysis only RAVi and RA strain were independent predictors of IVC diameter (p=0.01 and <0.0001, respectively), and only RVol and RA strain were independent predictors of RAP (p=0.001 and 0.002, respectively). We found a RA strain cut-off of -15% to have a sensitivity of 82% and specificity of 70% to identify a RAP greater than 15 mmHg (area under the curve-AUC 0.842). Conclusions RA size and function together with the TR-related volume overload were independent predictors of venous congestion. Among these variables, only RA strain predicted both parameters of venous congestion.

Abstract Background Little is known about coronary microvascular function of patients with low-flow low-gradient aortic stenosis (LFLGAS). We hypothesized that LFLGAS is associated with more severe coronary microvascular dysfunction (CMD) compared with normal-flow high-gradient aortic stenosis (NFHGAS) and that CMD is related to reduced cardiac efficiency. Purpose To perform a prospective invasive assessment of CMD in patients with LFLGAS undergoing TAVI and to compare it with patients with NFHGAS. Moreover, we aimed to assess the possible acute impact of TAVI on coronary microvascular function and the interactions between CMD and of cardiac performance at speckle tracking echocardiography (STE). Methods Invasive thermodilution-based assessment was systematically performed in 41 consecutive patients with isolated severe AS with angiographic unobstructed coronary arteries undergoing TAVI. The index of microcirculatory resistance (IMR), resistive reserve ratio (RRR) and coronary flow reserve (CFR) were derived to assess coronary microcirculatory function before and after TAVI. Advanced echocardiographic imaging, including STE, was performed to assess cardiac function. Results IMR was significantly higher in patients with LFLGAS compared with patients with NFHGAS (24.1 [14.6–39.1] vs 12.8 [8.6–19.2] p=0.002). Similarly, RRR was significantly lower in LFLGAS compared with NFHGAS (1.4 [1.1–2.1] vs 2.6 [1.5–3.3] p=0.020). No significant differences were observed in CFR between the two groups. High IMR was associated with low stroke volume index (rho=−0.427, p=0.005), low cardiac output (rho=−0.517, p=0.001), reduced peak atrial longitudinal strain (PALS) (rho=−0.610, p≤0.001) and presence of atrial fibrillation (54.6% vs 21.1%, p=0.036). Conversely, IMR was only modestly associated with the mean pressure aortic valve gradient (rho=−0.304, p=0.054). Notably, the mean gradient was significantly associated with IMR in the NFHGAS group (rho=0.632, p=0.003) but not in the LFLGAS (rho=−0.222, p=0.333). Similarly, high IMR was associated with the AVA in the NFHGAS group (rho=−0.50, p=0.025) but not in patients with LFLGAS (rho=0.157, p=0.497). Paradoxical LFLGAS emerged as a phenotype associated with CMD, poor left ventricular longitudinal systolic function and left atrial dysfunction. TAVI determined no significant variation in microvascular function (IMR: 16.0 [10.4–26.1] vs 16.6 [10.2–25.6], p=0.403) and in PALS (15.9 [9.9–26.5] vs 20.1 [12.3–26.7], p=0.222). Conversely, left ventricular global longitudinal strain increased overall after TAVI (−13.2 [8.4–16.6] vs −15.1 [9.4–17.8], p=0.047). Conclusions LFLGAS is associated with impaired coronary microvascular function compared with NFHGAS. Combined invasive assessment of microvascular function and advanced non-invasive imaging contributed to define different AS phenotypes. CMD was associated with low-flow state, left atrial dysfunction and reduced cardiac efficiency in patients with AS. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott Vascular

Abstract Funding Acknowledgements Type of funding sources: None. Background Trastuzumab (TZ) is a key therapy for HER-2 positive breast cancer that may have different side effects on the cardiovascular system. One of the most concerning complications is cancer therapy-related cardiac dysfunction (CTRCD). In literature there are conflicting data about the efficacy of heart failure drugs like ACE-inhibitors, ARBs and beta-blockers to prevent such an event. Purpose Aim of this study is to describe our experience on cardioprotective drugs in preventing TZ-related CTRCD. Methods 105 consecutive women affected by HER-2 positive breast cancer treated with TZ referring to our echo-lab were enrolled in our single center prospective study. 3 patients were excluded due to an early TZ suspension not related to cardiovascular complications. Thus 102 patients (97,1%) were eligible for analyses. 86 of these (84,3%) were also treated with Anthracyclines. All patients underwent consecutive transthoracic echocardiography (TTE) before starting TZ and then every 3 months up to 12 months. 2D-Speckle tracking analysis was performed at baseline and at each examination using Tomtec software. A complete clinical evaluation was also performed at each follow up. LV systolic dysfunction was defined as an absolute reduction of LVEF >10% from baseline to LVEF < 53% or a relative reduction of GLS >15% from baseline and a reduction of LVEF >10% from baseline. Results Overall, before starting TZ, 12 patients were taking ACE-inhibitors or ARBs (11,8%) and 5 patients beta-blockers (4,9%). CTRCD occurred in 11 patients (10,8%), among these 9 (81,8%) weren’t taking any heart failure drugs and 5 (45,5%) didn’t present any cardiovascular risk factor. We observed no significant association among cardiovascular risk factors. Use of potential cardioprotective drugs before TZ administration seems to reduce the risk of development of myocardial dysfunction (relative risk 1,67; 95% confidence interval [CI], 0,41 to 6,82; P > 0.05). No clear association was found between any cardiovascular risk factors and CTRCD (relative risk 0,81; 95% confidence interval [CI], 0,26 to 2,47; P > 0.05). Conclusions In HER-2 positive breast cancer patients treated with TZ an early treatment with ACE-inhibitors or ARBs and/or beta-blockers is associated to the prevention of CTRCD. CTRCD seems not to be related to the presence of cardiovascular risk factors. Abstract Figure. Baseline patient characteristics

Abstract Background Contrast echocardiography is mainly performed for the assessment of global left ventricular (LV) function, left ventricular ejection fraction (LVEF) and stroke volume (SV) thanks to improved visualization of endocardial LV borders. Neverless in some patients estimation of ventricular volumes could be difficult also with contrast and assessment of LVEF can be really hard. The aim of the study was to find alternative methods for LV function evaluation independent from volume assessment. Methods Patients who underwent a contrast echocardiography between October 2015 and September 2022 were enrolled in the study. A complete transthoracic echocardiography was performed and Sonovue contrast was then injected. End-diastolic and end-systolic LV volume in apex 4 and 2 chamber views, were measured prior and after injecting contrast. Left ventricular outflow tract diameter (LVOTd) was measured and LVOT velocity time integral was traced in order to calculate LVOT VTI Stroke Volume (product of LVOT cross sectional area to the LVOT VTI). LVOT VTI SV obtained during traditional echocardiography was then compared to LV SV calculated as the difference between end-diastolic and end-systolic volume traced after contrast. After intravenous bolus injection of Sonovue pulmonary transit time (PTT) was recorded as contrast agent's transit time from right to left ventricle in apex 4 chamber view (seconds). PTT was then compared to measures of LV function: LVEF with and without Sonovue and LV SV with contrast. Results 149 patients were enrolled in the study, 86 had history of CAD, 31 presented dilatative cardiomyopathy, 5 hypertrophic cardiomyopathy (HMC), 113 had arterial hypertension, and 37 diabetes. Medium BMI was 28. The main indications for contrast echocardiography were measurement of EF and exclusion of thrombi in LV apex. LVOT VTI SV was calculated in 126 patients. In the same patients LVEF Stroke Volume was calculated. A strong correlation (P value < 0.0001) between LVOT VTI SV and LV SV was found (Figure 1). PPT was calculated in 74 patient and in the same patients LVEF with and without contrast (Figure 2) and LV SV were calculated. A strong correlation (P-value <0.048, p-value<0.006 and p-value < 0.046 respectively) was found. Conclusion This study demonstrates that, besides extremely poor acoustic windows, bedside echocardiography, with and without contrast, can be used to estimate LV function using volume-independent methods like PTT and LVOT VTI SV.

Abstract Background right-ventricular (RV)-pulmonary arterial (PA) uncoupling expressed by Tricuspid Annular Plane Systolic Excursion (TAPSE)/Pulmonary Artery Systolic Pressure (PAPs) ratio is associated with poor outcomes in patients with heart failure (HF). TAPSE/PAPs ratio has been poorly investigated in patients with tricuspid regurgitation (TR) with related volume overload and progressive right chambers remodeling. Purpose to assess the effectiveness of other estimation methods of RV-PA coupling in different TR severity groups compared to the classic TAPSE/PAPs ratio. Material and Methods 116 stable patients with TR were enrolled at the time of echocardiography (43 men, 37%; mean age 74±13 years). TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RV function was assessed by RV Free Wall Longitudinal Strain (FWLS). PAPs was obtained using the following formula: 4*(peak tricuspid regurgitation velocity)2 + right atrial pressure (RAP); meanPAP was estimated using TR continuous wave signal mean gradient (PAPmIT) and pulmonary artery regurgitation peak gradient (PAPmIP), adding RAP for both. RV-PA coupling was evaluated by TAPSE/PAPs ratio, TAPSE/PAPmIT and TAPSE/PAPmIP ratios. Result TR was quantified mild in 23 patients, moderate in 49, severe and torrential in 29 and 15 patients respectively. Mean RV-FWLS was -26.4±6.9% in mild, -21.8±7.4% in moderate, -18±7% and -18.3±4.2% in severe and torrential TR respectively (p<0.0001). Mean TAPSE/PAPs ratio was 0.6±0.23 mm/mmHg, 0.44±0.19, 0.38±0.19 and 0.37±0.12 mm/mmHg in mild, moderate, severe and torrential TR respectively, with a statistically significant difference between the 4 groups (p<0.0001). Mean TAPSE/PAPmIP ratio was 1.08±0.5 mm/mmHg in mild TR, 0.68±0.34 in moderate, 0.67±0.5 in severe TR and 0.47±0.13 mm/mmHg in torrential TR with a statistically significant difference between distinct TR grades (p=0.004). Mean TAPSE/PAPmIT in mild TR was 0.92±0.5 mm/mmHg, 0.63±0.29 in moderate, 0.53±0.29 and 0.51±0.16 mm/mmHg in severe and torrential TR respectively with a statistically significant difference between the groups (p<0.0001). Finally, an analysis of covariance with RV-FWLS as potential confounder was performed: only the adjusted means of TAPSE/PAPmIP and TAPSE/PAPmIT ratios preserved a statistically significant difference between distinct TR groups (p=0.01 and p=0.019 respectively). Conclusion TAPSE/PAPmIP and TAPSE/PAPmIT ratios seem to preserve a stronger relation with increasing TR grade and worsening of RV disfunction, suggesting it as a more powerful index in this subset of patients. The progression of TR grade leading to a right chamber remodeling could influence the reliability of RV-PA uncoupling expressed by standard TAPSE/PAPs ratio.