Abstract 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.

Abstract 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> 20 mmHg. PPM was identified by the indexed effective orifice area (EOAi) measured by echocardiography (moderate PPM if 0.65 < EOAi < 0.85 cm²/m²; severe PPM if EOAi < 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> 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 < 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.

Abstract Discordance between studies drives debate regarding the "ideal" (early surgery vs watchful waiting) management of asymptomatic severe mitral regurgitation (MR) in valve prolapse (MVP). Independently on disagreement between studies, strategies are mainly oriented towards early surgery in centers that can achieve <1% mortality rates and >95% repair rates. Data on a detailed evaluation of outcomes in terms of left ventricular ejection fraction (LV EF) in the early repair strategy are lacking. Aims of this study in a large population undergoing early MVP repair are: a) to assess LV function comparing EF and volumes in the follow-up (FU) at 6 month (6ms) and 3 year (3ys) b) to verify whether pre-op volumes and EF may predict functional results c) to compare these findings to the surgical procedure (simple or complex) and to the residual MR. Between 2008 and 2018, 1000 cases underwent early MV repair in our Center. We retrospectively selected 300 pts with pre-op 2D and 3DTTE, 6 ms and 3ys 2DTTE FU. Results: 286 pts (200 males; 61 ± 12 ys; 222 Barlow, 78 fibroelastic deficiency at 3DTTE examination) had MV surgery (96% reparability; 14 MV replacement after a first attempt of repair). 87 had complex MVP and in 56 the surgical procedure was complex. MR at 6ms <1+ (262 pts) predicted stability of MR at 3ys, while in the 38 cases with MR >1+, MR increased at 3ys (2,6±.6+). Complexity of pre-op 3D morphology predicted complexity of MV repair and identified pts with higher risk of MR recurrence. Table summarizes functional results showing that early restoration of MR, causes significant morphological and haemodynamic improvements at 6 ms without significant additional changes at 3ys. Pre-op systolic LV volume and EF significantly correlated with LV remodelling. In conclusions a) early MV repair is associated with favourable LV remodelling and stable systolic function at FU; b) 2DTTE predicts in an early surgical strategy favourable LV remodelling c) pre-operative 3DTTE morphology (simple vs complex MVP) predicts repair procedure (simple vs complex) that in the large majority (91%) is associated with freedom from MR recurrence. Table Pre-op 6-month FU 3-years FU Left ventricular end diastolic volume (ml) 140 ± 41 104 ± 30 * 103 ± 35 Left ventricular end systolic volume (ml) 49 ± 19 45 ± 19* 43 ± 22 Left ventricular ejection fraction (%) 65 ± 7 58 ± 8* 59 ± 7§ Mitral regurgitation (+) 3.9 ± 0.2 0.6±.6* 0.9±.9§ Left atrial volume (ml) 123 ± 48 91 ± 35* 87 ± 45 *= p < 0.01 6 ms vs pre-op; §=p < 0.01 3ys vs 6 ms

Purpose.We previously re-validated noninvasive estimation of pulmonary wedge pressure (PWP) measuring the CW pulmonary valve regurgitation end-diastolic pressure gradient (PWPecho).Using the latter as surrogate of PWP, we sought to test accuracy of left ventricular (LV) filling pressures estimation by the EAE guidelines algorithm (EAEalg) in a large non-selected population.Methods.We studied 1019 patients in sinus rhythm with GE Vivid7/9 systems (age: 10-93 y.; EF%: 13-83%, normal, n= 827 and reduced ,50%, n= 192), in whom PWPecho could be measured (feasibility 75%), with normal pulmonary vascular resistances (WU, 2).The EAEalg combined E/e' (average), left atrial volume (LAV), E/A, Edec, pulmonary venous systolic fraction (SF), and echo-derived pulmonary systolic pressure (PSPe) to obtain 3 groups: normal, high PWP and not classifiable.These were compared to the PWPecho estimate.Results: Feasibility was high for all variables (E/E' 90%, LAV 93%, E/A 95%, Edec 90%, SF 91%, PSPe 92%), and for the EAEAlg (94%).Using the EAEAlg, 17% (n=137) of patients with normal in contrast to 10% (n=19) of patients with EF,50% were not classifiable, in the former secondary to the combination of a E/E'= 9-13 range, and LAV≥ 34ml/m2.In the remaining (classified, 84%) patients, utility of EAEalg even when limited to patients with EF,50% was still hampered by a low positive predictive value (PPV) (Table ).Further, when only E/e' was tested in the same patients at ROC analysis (cutoff= 15; AUC=0.72,CI:0.6-0.8),accuracy was still impaired by a low PPV (53%), albeit a fair negative predictive value (NPV) (79%).Correlation between PWPecho and E/e' was modest even in patients with EF,50% (r=0.4,p,0.001), and at multiple regression analysis, E/ e' was independently determined by age and mitral regurgitation in all patients, and by LV end-diastolic volume in EF,50% (r= 0.7, p,0.001) and by LV mass index in EF.50% (r= 0.64, p,.001).Conclusions.Noninvasive estimation of PWP by EAE guidelines is limited by a low PPV in both patients with and without reduced LV EF.In this setting, utility of the E/e' is limited, it being influenced by patient age, preload and LV mass.

Purpose: Echocardiographic 2D speckle tracking left ventricular (LV) global longitudinal strain (GLS, %) has been proposed as an index of LV systolic function and a possible substitute of biplane ejection fraction (EFb, %), given its semi-automatic calculation modality. Peak systolic GLS (GLPS) is calculated online, but maximum GLS (GLMS, which includes post-ejection strain) offline. Aim of this study was to analyse determinants of and differences between GLPS and GLMS in identifying EFb< 50% in unselected patients. Methods: We studied 300 consecutive patients with (203) and without (97) heart diseases undergoing echocardiography (ranges, age: 14-93 y., HR: 40-130 bpm, systolic arterial pressure: 90-180 mmHg, EFb: 15-78%), using a GE Vivid7 system and offline analysis on Echopac v12. GLPS and GLMS were derived by LV wall tracking in the 3 apical views. Low normal cutoffs for GLPS and GLMS were set respectively at -17% and -18% (based on lower 5% percentile of 60 previously screened normal subjects). Results: GLPS and GLMS correlated highly (r=0.92, p<0.001). At multiple regression analysis, LV end-diastolic volume index, relaxation (tissue Doppler Ea) and stroke index (LV outflow pulsed Doppler) similarly determined GLPS (r=0.87, p<0.001) and GLMS (r=0.88, p<0.001); the former was also influenced by LV myocardial performance index (contractility), filling pressure (tissue Doppler E/Ea) and mass index. Relaxation did not influence EFb. For both GLPS and GLMS, feasibility and accuracy were high and negative (NPV) was superior to positive (PPV) predictive value in identifying EFb <50% (Table). Compared to patients with normal EFb and GLPS, those with reduced GLPS but normal EFb were characterized by concentric LV hypertrophy (p<0.001) and prolonged relaxation (p=0.002). View this table: Identification of EFb (feasibility = 100% Conclusions: Both GLPS and GLMS are highly feasible and accurate in identifying reduced EFb in unselected patients. Given similar physiopathologic determinants, the online modality of the former makes it a preferred modality to evaluate global LV systolic function, with the added value of identifying patients with normal EFb and diastolic (prolonged relaxation) dysfunction.

Purpose: Echocardiograhic 2D speckle tracking strain (STS) analysis is used to evaluate left ventricular (LV) dyssynchrony in patients eligible for cardiac resynchronization therapy. However there is no agreement on which strain type (Long, longitudinal; Rad, radial; Circ, circumferential) performs best, and normal values for dyssynchrony (post-systolic time delay, PSTD), for each wall segment within each strain, are lacking. We evaluated physiologic PSTD in a group of normal subjects. Methods: We screened 70 subjects (age 45±18 y., range 16-85) with normal history, ECG, standard echocardiogram, blood pressure, laboratory data and stress echocardiography using GE Vivid7 or Vivid9 machines with offline analysis on Echopac v12. Maximum peak (%) and time to peak (TTP, ms) 2D speckle tracking longitudinal strain was calculated from the 3 apical views, and radial and circumferential maximum values from LV short axis views at the mitral, papillary and apical levels, using a LV 18 wall segments model. PSTD was measured as the difference between TTP strain (%) and time to end-ejection (from pulsed Doppler LV outflow), taking as reference the beginning of isovolumic contraction (= first positive/negative deflection on the pulsed tissue Doppler mitral annulus velocity tracing). Results: Mean global maximum Long strain was -21.7±1.9%, and mean Circ strain at base, papillary and apex were respectively -17.5±4.1%, -18.2±3.7% and -25.6±4.6%. The Table shows the mean maximum PSTDs for the 3 strains (means from 18 individual segments): all calculated SDs were below the 76 ms cutoff used for LV dyssynchrony, but all the upper 95% CI of the PSTDs were above the 130 ms cutoff used for LV dyssynchrony. The highest delays were found for the Circ strain of the basal and papillary lateral and posterior segments. Age did not influence significantly PSTDs. Maximum strain post-systolic time delays Conclusions: Longitudinal strain shows the lowest and circumferential the highest variability of PSTDs. Although the SD cutoffs appear adequate in order to separate physiologic from pathologic PSTDs, there is overlap when the absolute PSTDs values are used.

INTRODUCTION:Frailty syndrome has not been explored in depth in elderly HIV-infected patients.METHODS:As of December 2009, a total of 60 patients (out of 160 patients > 60 years) were screened and 20 patients were transferred to our newly created Geriatrics-HIV program. We divided this group of already ''frail patients'' in three different subgroups; the mildly, moderately and the very frail groups based on the number of domains failed during the initial geriatrics screening.RESULTS:The percentages of mildly, moderately, and severely frail elderly patients in our cohort were 20% 50% and 30% respectively. The most common comorbidities found were HTN (60%), and history of AIDS-related opportunistic infections (40%). Smoking was highly prevalent in all groups. The average number of medications used per patient was 8.1 with 65% of patients being compliant with their regimens.DISCUSSION:We found that cognitive impairment, presence of comorbidities, high number of medications used, and past history of any opportunistic infection are factors prevalent in severely frail patients infected with HIV in our cohort. The significance of these factors in development and progression of frailty syndrome in HIV-positive patients needs to be elucidated.