Interventional echocardiographers (IE) have a crucial role in growing structural heart interventional procedures. Previous studies showed a 5 times higher exposure of IE than that of the invasive cardiologist. No dedicated and adapted radiation protection device currently exists for IE. It is from this observation that the interventional cardiology team of the Nantes University Hospital, together with the company "LemerPax", have designed a radiation protection cabin (EchoSafe) dedicated to the protection of the IE in the operative room. The objective of this study is to evaluate the radioprotective performances of this cabin in real life. We included during 6 months all procedures that required transesophageal echocardiography. These procedures were divided into two groups (the first on which the usual protection device were used, i.e. a leaded glass door – the second on which the "Echosafe" device was used). We matched the procedures to obtain a total amount of irradiation estimated by the DAP (dose area product) close between the two groups. Irradiation measurements of the IE were performed with 10 TLD (thermoluminescent detectors) distributed over the whole body. We included a total of 64 procedures: 24 procedures in the control group, and 40 in the "echosafe" group. The cumulative DAP for each group was 75,206.9 Cgy/cm2 in the control group, and 70,042 mGy.cm2 in the echosafe group. Patient characteristics were identical between the two groups. The results show that in the "echosafe" group, irradiation was below the dose limit for the left lens, shoulders, thorax, and neck, a 49% reduction in irradiation of the right lens, 76% of the right wrist, 12% of the left wrist, 49% of the pubis, and 36% of the right ankle. The "echosafe" device offers a clear reduction in the irradiation of the IE during structural heart intervention. Irradiation measurment of the sonographer (Fig. 1).

Primary mitral regurgitation (MR) is the second cause of valvular surgery in Europe. Early surgery seems to improve long term prognosis, raising the need of prognostic markers. Evaluate the prognostic value of %VO2max, assessed by cardiopulmonary echocardiography exercise test (CPEET), in terms of free-of-cardiovascular-event survival. The patients underwent CPEET for primary MR between march 2012 and march 2019. Clinical follow-up of a composite cardiovascular event (cardiovascular death, heart failure progression ≥ 1 NYHA stage or unplanned hospitalization for heart failure, de novo atrial fibrillation, systemic embolic event, symptomatic ventricular tachycardia). 180 patients were analysed, with a median follow-up of 33 months. Free-of-events survival at 48 months was significantly associated with % VO2max < 80% predicted (38.5% vs. 62.3%, P < 0.0001), with circulatory power < 3500 (29.8% vs. 61.7%, P < 0.0001), with half time recovery of VO2 > 180s (42.3% vs. 58.1%, P = 0.001) and with maximal effort sPAP > 60 mmHg (42.2% vs. 67.8% P = 0.006) in univariate analysis. In multivariate analysis the impairment of %VO2max < 80% predicted, was an independent predictor of free-of-event survival [HR = 0.96 (0.94;0.98), P < 0.0001]. An impairment of functional capacity, assessed by a cardiopulmonary-echocardiography-exercise-test with a %VO2max < 80% of the predicted value, independently predicts cardiovascular events in primary MR. This parameter should be considered as an equivalent of symptoms and for this reason indicate an early surgical repair of the mitral valve. CPEET is a feasible and worthwhile exam, and should be considered in the evaluation of asymptomatic patients with severe MR.

Abstract Background Mitral valve prolapse (MVP) is a frequent pathology that can be complicated by mitral regurgitation, heart failure, rhythm disorders, arterial embolism and death. The aim of this study was to evaluate the prognostic interest of ventricular volumes, right ventricular ejection fraction (RVEF) and late gadolinium enhancement (LGE) assessed by cardiac magnetic resonance (CMR) imaging on cardiovascular morbi-mortality in a cohort of patients with MVP Methods We examined the prognostic value of CMR imaging in 237 patients with MVP (no to severe mitral regurgitation) included between 2010 and 2019. All patients underwent a comprehensive echocardiography. The main endpoint was a composite endpoint of cardiovascular death, heart failure, new onset atrial fibrillation, arterial embolism. Results Among the 237 patients (63% male), 97 (41%) had LGE (75 myocardial wall, 10 papillary muscle tip and 12 both locations). Factors associated with LGE in multivariable analysis were age (OR 1.02, P = 0.037), left ventricular (LV) mass (OR 1.01, P = 0.008) and pulmonary artery systolic pressure (PAPS, OR 1.02, P = 0.069). Follow-up was censored at the time of surgery or percutaneous repair. In univariate analysis NYHA class, LV mass, left atrial volume, PAPS, LV end-diastolic and end-systolic volumes, chordal rupture and MR degree were associated with outcome. RVEF and biventricular dysfunction (LV EF < 60% and RV EF < 40%) were also associated with impaired event-free survival (36.0 ± 17.0% vs 65.4± 5.8%, P = 0.019). Finally, LGE was associated with a decreased event-free survival (55.6 ± 9.9% vs 70.7± 6.9%, P = 0.002). In multivariablee analysis, moderate to severe mitral regurgitation (HR : 2.14 [1.44-3.19], P < 0.0001) and the presence of LGE were predictors of impaired event-free survival (HR : 2.12 [1.08-4.16], P = 0.003). Conclusion CMR imaging provides additional prognostic information to echocardiography in the study of MVP. Myocardial fibrosis of the left ventricle and right ventricular function as assessed by CMR imaging are predictors of cardiovascular morbidity and mortality in MVP.

Abstract Funding Acknowledgements PHRCI mitral 2012 Background Filamin-A mitral valve prolapse/dystrophy (FLNA-MVP) phenotype associates moderate MVP and a paradoxical restricted motion in diastole. Purpose We aimed to assess the association of MVP with restricted motion in diastole in MVP patients (restricted MVP). Methods We prospectively enrolled 433 MVP probands (57 ± 16 years). Patients underwent a clinical examination and a comprehensive echocardiographic analysis of mitral valve apparatus. Results Among the 433 probands, 27 (6.2%, 95% CI 3.9-8.5) had both a MVP and a doming aspect in diastole. Patients with restricted MVP exhibited shorter posterior chordae tendinaes (24.8 ± 6.3 vs 27.2 ± 5.9 mm, P = 0.037), and a shorter distance between papillary muscle (PM) tips and mitral annulus (anterior PM: P = 0.0001; posterior PM: P = 0.009). Anterior mitral valve leaflet was lengthened (15.5 ± 2.4 vs 14.3 ± 2.6 mm/m², P = 0.018), but leaflet thickness, leaflet prolapse, and mitral valve annulus did not differ between the 2 groups. Bicuspid aortic valve was more frequent in patients with restricted phenotype (14.8 vs 2.9%, P < 0.05). Familial recurrence of restricted MVP was identified even in the absence of Filamin-A mutation. Conclusion Restricted MVP is a quite frequent finding in MVP patients and is associated with PM tips location closer to mitral annulus. Restricted MVP can be regarded as a third type of MVP beside myxomatous Barlow disease and fibro-elastic deficiency MVP.

Un’embolia cerebrale di origine cardiaca è responsabile del 25-30% degli infarti cerebrali. Questa proporzione aumenta con l’età e, dopo i 90 anni, oltre il 50% degli infarti è di origine cardioembolica, principalmente a causa di una fibrillazione atriale. L’origine cardiaca dell’embolia cerebrale è importante da determinare, perché impone un trattamento specifico, che spesso si basa su un’efficace anticoagulazione. Questa identificazione è, talvolta, semplice, ma può anche richiedere indagini complesse o prolungate per evidenziare un disturbo del ritmo parossistico o un trombo intracardiaco. L’origine è difficile da affermare, se esistono diverse potenziali fonti di infarto. La fibrillazione atriale non valvolare è la cardiopatia emboligena più frequente, ma costituisce una malattia eterogenea. La comparsa degli anticoagulanti orali diretti ha notevolmente semplificato la gestione terapeutica della fibrillazione e ha permesso di ridurre il rischio di complicanze emorragiche, in particolare cerebrali. Il ruolo di alcune anomalie morfologiche cardiache resta incerto (prolasso della valvola mitrale, escrescenza di Lambl, ecc.), mentre ora è dimostrata l’imputabilità di altre anomalie, come nel caso del forame ovale pervio, dopo la pubblicazione contemporanea di tre studi interventistici nel 2017. Alcune cardiopatie richiedono un trattamento specifico per eliminare definitivamente la fonte di embolia (forame ovale pervio, tumore, endocardite, ecc.) o richiedono sempre il ricorso alle antivitamine K, come nel caso delle valvole meccaniche. La prognosi dell’infarto cerebrale di origine cardioembolica è generalmente peggiore perché gli emboli sono più voluminosi e il volume dell’infarto è maggiore, portando a una maggiore mortalità precoce e tardiva. In urgenza, la gestione è quella di qualsiasi infarto cerebrale acuto e può includere le tecniche di ricanalizzazione, come la trombolisi endovenosa in assenza di controindicazioni e/o la trombectomia meccanica.

Mitral valve prolapse (MVP) is a common condition in the general population, which can be associated to non-specific ECG abnormalities described initially as ST segment depression, T waves flattening or inversion, especially in the inferior leads. Lately, this type of ECG abnormalities has been reported in patients with MVP and ventricular arrhythmias (VA) or sudden death (SD). However, the prevalence of ECG abnormalities has never been studied in a large series of patients, and the link between ECG abnormalities, VA and SD to echocardiography examination has never been prospectively assessed. To study the prevalence of ECG abnormalities including ventricular arrhythmias in MVP patients and their link with echocardiographic characteristics. All patients (n=731, MVP = 486, Controls = 245) were prospectively enrolled and underwent a comprehensive echocardiography and ECG. In MVP patients 81 had minimal systolic displacement (MSD), 92 isolated MVP, 108 mild-moderate MR, and 196 severe MR. A comprehensive qualitative and quantitative analysis of ECG obtained from rest ECG, 24-hours ECG recording or exercise stress tests, was carried out. Mean follow-up was 4.4 years. The mains ECG abnormalities were an inversion of T wave in the inferior leads found in 12 MVP vs 1 control (2.5 vs 0.4%, P=0.047) or a QRS notch (5.1 vs 2.9%, P=0.13). In bileaflet MVP T wave inversion was more frequent as compared with other MVP patients (3.8 vs 0.8%, P=0.039). In addition there was a progressive prolongation of PR interval, QRS duration and increase QT dispersion associated with worsening of MR and heart chambers remodeling. None of ECG findings were significantly linked with the presence of MVP only. Out of 731 individuals, 27 (3.7%) had an history of VA or SD. In a multivariate analysis, bileaflet prolapse and mitral annulus disjunction were associated with VA or SD, whereas none of ECG criterion was associated with. In this large prospective series of MVP patients, prevalence of inferior leads ECG abnormalities is very low. Prolongation of atrio-ventricular and ventricular conduction, as well increased QT dispersion is associated with worsening of MR and LV remodeling. Bileaflet prolapse and mitral annulus disjunction are associated with VA or SD. Type of funding source: None

Abstract Background Structural valve degeneration (SVD) remains a major complication of aortic bioprostheses. Purpose We aimed to assess the mode of SVD leading to bioprosthetic aortic valve failure (BVF) in a large series of patients. Methods Between 2010 and 2017, we prospectively enrolled 261 consecutive patients with BVF related to SVD. All patients underwent a clinical work-up. Explanted bioprostheses were analysed for assessing the mechanism of SVD. Results The delay from surgery to SVD diagnosis was 8.5±3.3 (1.7 to 21.4) years, 10 years after exclusion of a specific type of bioprosthesis. Of the 261 SVD patients, 150 (57%) had mainly a stenotic type, and 111 (43%) a regurgitant type. In regurgitant SVD bioprosthesis was more frequently porcine (19 vs 7%, P=0.002), prosthesis diameter was larger (23.2±2.5 vs 21.6±1.9 mm; P<0.0001), severe mismatch was less frequent (6 vs 17%, P=0.005), cardiovascular risk factors and especially diabetes, obesity and hypertension were less frequent, patients were more often in NYHA class 3–4 (64 vs 49%; p=0.015), Nt-pro BNP was significantly higher (P<0.0001), and diuretic treatment was more frequent (73 vs 61%, P=0.04). Bioprostheses were explanted during redo surgery in 112 (43%) patients. Of these 112 bioprostheses, moderate to severe calcifications were present in 94 (83.9%) and was the main cause of either stenotic (n=64, 57.1%) or regurgitant SVD. A cusp tear (n=46) accounted for 41.1% of the explanted SVD. A perforation, a recent thrombus or a delamination process were occasionally identified. Structural degeneration developed with minimal calcification in 18 (16.1%) bioprostheses. Conclusion Structural valve degeneration remains a matter of concern in current practice with a mean delay of 8 to 10 years after surgery. Beside classical SVD with extensive calcification process other types of SVD can be observed with minimal calcification.

Aims The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE). Methods and results Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, F-18-fluorodeoxyglucose positron emission tomography/computed tomography (F-18-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). F-18-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated. Conclusion Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.

Abstract Background Filamin-A mitral valve prolapse/dystrophy (FLNA-MVP) phenotype associates MVP and a paradoxical restricted motion in diastole. Purpose We aim to assess the association of mitral valve prolapse to restricted motion in diastole in MVP patients (restricted MVP). Methods We prospectively enrolled 475 MVP probands (64±13 years) and controls relatives. Patients underwent a clinical examination and a comprehensive echocardiographic analysis of mitral valve apparatus. Results Among 475 consecutive probands, 48 (10.1%, 95% CI 7.7–13.3) had both a MVP and a doming aspect in diastole. Patients with restricted MVP exhibited shorted chordae tendinaes, and a shorter distance between papillary muscle tip and mitral annulus. Compared with controls, mitral valve leaflets were lenghtened, thickened and mitral valve annulus was enlarged. The prevalence of polyvalvular disease and bicuspid aortic valve was not increased in restricted MVP patients compared with conventional MVP. Familial form of restricted MVP was identified even in the absence of Filamin-A mutation. Conclusion Restricted MVP is a quite frequent finding in MVP patients and is associated with unique features of the MV apparatus. Restricted MVP can be regarded as a third type of MVP beside myxomatous Barlow disease and fibro-elastic deficiency MVP. Acknowledgement/Funding PHRC I Mitral, Fédération Française de Cardiologie, Fondation Coeur et recherche

Aims The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) European Endocarditis (EURO-ENDO) registry aims to study the care and outcomes of patients diagnosed with infective endocarditis (IE) and compare findings with recommendations from the 2015 ESC Clinical Practice Guidelines for the management of IE and data from the 2001 Euro Heart Survey. Methods and results Patients (n = 3116) aged over 18 years with a diagnosis of IE based on the ESC 2015 IE diagnostic criteria were prospectively identified between 1 January 2016 and 31 March 2018. Individual patient data were collected across 156 centres and 40 countries. The primary endpoint is all-cause mortality in hospital and at 1 year. Secondary endpoints are 1-year morbidity (all-cause hospitalization, any cardiac surgery, and IE relapse), the clinical, epidemiological, microbiological, and therapeutic characteristics of patients, the number and timing of non-invasive imaging techniques, and adherence to recommendations as stated in the 2015 ESC Clinical Practice Guidelines for the management of IE. Conclusion EURO-ENDO is an international registry of care and outcomes of patients hospitalized with IE which will provide insights into the contemporary profile and management of patients with this challenging disease.

Structural valve degeneration (SVD) of bioprostheses is a common and serious complication in patients undergoing aortic valve replacement. SVD pathophysiology remains unclear.18F-sodium fluoride (NaF) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) have respectively shown that an active metabolic phenomenon of calcification rather than an inflammatory process contribute to native aortic valve stenosis. We studied the respective value of NaF and FDG PET to explore the potential mechanisms involved in SVD. SVD patients underwent NaF PET to explore potential active calcification process, FDG PET to explore potential inflammatory process and thoracic CT. Tracer uptake was quantitatively measured by the bioprosthesis tissue-to-background ratio of standardized uptake values (TBR). Echocardiographic parameters, bioprosthesis calcium scoring on CT, and qualitative pattern of NaF and FDG activity on bioprostheses were analyzed. Twenty-one patients were included. Calcium score was higher in patients with significant NaF visual uptake versus patients without (1065 ± 505 vs. 462 ± 320, P = 0.015). The median NaF TBR (3.49, [2.33–5.04]) was significantly higher than FDG (1.34, [1.20–1.47]). Patients with NaF TBR greater than the median value had a higher calcium score (1059 ± 550 vs. 566 ± 363, P = 0.05), and showed a tendency to have more severe hemodynamic stenosis. Picture shows an example of patient with SVD (A); CT (B) established localizations of calcium deposits; NaF PET/CT (C) show intense uptake adjacent to calcifications; FDG PET/CT (D) show no uptake (Fig. 1). These results suggest a link between SVD severity and active calcification activity and opens new perspectives on the assessment of SVD pathophysiology through NaF PET quantification of ongoing mineral burden.

Abnormalities of the valvular and subvalvular apparatus in mitral valve prolapse (MVP) may influence left ventricular (LV) mechanics. To evaluate LV mechanics and ventriculo-valvular interaction in patients with isolated MVP. A single-center study prospectively recruiting adult patients with isolated MVP or minimal systolic displacement (MSD) as well as control population. Potential factors for impaired left ventricular function, including all heart disease, as well as arterial hypertension, diabetes and obesity, were excluded. A complete two-dimensional echocardiography was performed, with analysis of the regional and global longitudinal strain (GLS) and specific mitral valve measurements. The results were compared between the 3 groups and the determinants of the myocardial deformation were sought. 122 patients with an isolated MVP, 91 with a MSD and 229 controls were included. There was no significant difference in terms of volume or overall hypertrophic remodeling. In the MVP group, there was a significant increase of the GLS (controls −20.1 ± 2.5% vs. MVP −21.3 ± 2.2%, P < 0.05, MSD −20.7 ± 2.3%), LVEF (controls 62.3 ± 5.4% vs. MVP 63.9 ± 5.6%, P < 0.05, MSD 63.4 ± 5.5%) and systolic ejection volume (controls: 40.7 ± 7.6 versus MVP 42.8 ± 7.8 ml/m2, MSD 41.7 ± 7.6 ml/m2). In MVP population, there was a regional increase of longitudinal strain in the lateral and posterior walls. GLS values were correlated with the extent of prolapse (area under the valve: β = 0.24, P < 0.0001) (Fig. 1). In the absence of other confounding factors, such as mitral insufficiency, structural and functional abnormalities specific to MVP influence left ventricular mechanics, particularly longitudinal strain values.

Structural valve degeneration (SVD) remains the main complication of aortic bioprosthesis. The study aimed to evaluate SVD mode, outcome and effect of treatment. Patients with presumed aortic SVD by echocardiography in our institution between January 2010 and December 2016 were included. All-cause mortality, cardiovascular morbidity, and effect of treatment were assessed. After exclusion of 4 patients with others causes of increased gradients, 220 patients were analyzed (78 ± 9 years, 52% men). Regurgitant SVD (n = 94, 43%) occurred later than stenotic (n = 126, 57%) SVD (9.2 ± 3.7 vs. 7.9 ± 3.0 years; P = 0.003). Patients with a regurgitant SVD were more symptomatic, had a larger bioprosthesis, and were more often referred to invasive management. Exclusive medical care (Med) was retained in 67 patients, redo-surgery in 89 and VinV in 64. Macroscopic examination of explanted bioprostheses (n = 71) demonstrated severe calcifications in 56.3%, mainly in stenotic SVD (71 vs. 42%, P = 0.02), and leaflet tear in 28%. Overall survival at 35 months was significantly associated with the type of management (VinV: 85.3 ± 4.9%, redo-surgery 86.7 ± 3.8%, Med 60.1 ± 7.7%, P < 0.0001). In multivariable analysis, predictive factors of overall survival were bioprosthesis type, Nt proBNP level (HR = 1.52 [95% CI: 1.17–1.97], P = 0.002), transvalvular maximal velocity, and invasive management (Redo-surgery: HR = 0.35 [95% CI: 0.15–0.81], P = 0.014; VinV: HR = 0.32 [95% CI: 0.13–0.77], P = 0.011) as compared to Med. Structural valve degeneration remains a matter of concern. Regurgitant SVD occurs later than stenotic SVD which is characterized by a more severe calcification process. Redo-surgery and VinV are associated with a better outcome, independently of failure mode, and should be considered in most SVD patients. Although VinV was proposed to older and higher-risk patients, its effect on overall survival was comparable to redo-surgery in multivariable analysis.

Aortic valve sclerosis-stenosis (AVS) is regarded a consequence of cardiovascular risk and genetic factors. Severe AVS is a significant cause of morbidity and mortality in 5% of individuals over 65 years of age. Despite previous attempts, little is known about genetics of AVS. We aimed to study genetic and non-genetic determinants of AVS in a large family with little cardiovascular risk factors. We identified a 5 generations large family of AVS. We proposed a screening to all relatives with clinical, biological and echocardiography assessment. Aortic valve (AV) calcium score was evaluated by CT scan. Biological assessment comprised especially DNA extraction for Next Generation Sequencing. The family comprises >100 relatives. To date 34 members (53.1 ± 14.7 years, 17 males) have been screened, 15 are affected (59.6 ± 10.8 years) and 19 non-affected (46.3 ± 13.6, P < 0.01). The youngest patient is a 36 years old woman with AV sclerosis. Echocardiographic examination revealed a unique inheritable phenotype of sclerosis or calcified progressive stenosis with a fusiform aorta in 7 patients. All AV were tricuspid, with a sclerosis in 12 (35.3%) or stenosis in 3 (8.8%). Aortic insufficiency (n = 6, 17.6%) was greater in affected members (P < 0.01). Ascending aorta was larger (38.8 ± 4.4 vs. 34.8 ± 8.7 mm, P = 0.05) and AV calcium was score greater (88.4 ± 199 vs. 0 UH) in affected members. High rate genotyping of 20 individuals allowed us to identify a common IBD (Identity By Descendance) region for all affected members on chromosome 5(rs4129875 to rs31619). Whole genome analysis was carried out in 4 cousins allowing the identification of 18 rare functional variants shared by at least 3 out of 4 sequenced individuals. Preliminary phenotypic and genetic approach of a large family of AVS reports a homogeneous and unique clinical portrait with early onset tricuspid AVS and fusiform aorta. While specific gene remains to be identified, IBD found a chromosome 5 region associated with AVS (Fig. 1).

Pathophysiology and mechanisms in valve disease 1123variable logistic regression model including EF, age and MVP, lower EF (Adjusted OR 0.86 (95% CI, 0.77-0.97,p=0.01)) and lower age (Adjusted OR 0.94 (95% CI, 0.89-0.98,p=0.006) remained independent markers for severe arrhythmic events.MVP in MAD with severe arrhythmic events Conclusions: Patients with MAD frequently presented with arrhythmic symptoms, and 12% had experienced severe arrhythmic events.MVP was found in only half of the patients with MAD and was not associated with arrhythmic events, indicating MAD itself as an arrhythmogenic entity.In patients with MAD, lower age and EF were markers of severe arrhythmic events.

Organic mitral regurgitation (MR) is a frequent heart valve disease which influences ventricular functions and impacts cardiovascular outcome. Right Ventricular Free Wall Longitudinal Strain (RVLS) is a good prognosticator in heart failure. Hence, we aimed to study its predictive value in organic MR. Two hundred fifty-eight patients (59 ± 15 years, 154 males) with mild to severe organic MR were prospectively enrolled with a complete echocardiography including RV free wall and LV global longitudinal strain assessment. Out of 181 patients with moderate to severe MR, 101 had normal LV and RV function (NoDysf), 40 patients (22%) had an isolated LV dysfunction (≤ −20%, LVdysf), 17 (9%) had an isolated RV dysfunction (≤ −21%, RVdysf), 23 (13%) had a biventricular dysfunction (BiVdysf). Biventricular dysfunction was strongly associated with worse structural (tricuspid annulus diameter: 22.2 ± 3.5 mm/m2 vs. 19.2 ± 3.5 mm/m2, P = 0.0003) and functional RV remodeling (RV fractional shortening: 27.6 ± 9.6% vs. 38.3 ± 11.4%, P < 0.0001, TAPSE: 19.4 ± 5.3 mm vs. 25 ± 4.6 mm, P < 0.0001, tricuspid annular S wave velocity: 12.6 ± 2.9 cm/s vs. 15.5 ± 3.1 cm/s, P = 0.0001) compared with NoDysf. Pulmonary pressure (51.4 ± 20.4 mmHg vs. 39.11 ± 4 mmHg, P = 0.0002) and resistances (Abbas formula: 0.36 ± 0.15 vs. 0.22 ± 0.08, P < 0.0001) were increased in BiVdysf. Forty-nine patients (19%) experienced a cardiovascular events during the follow up period (21.6 ± 14.4 months). At 40 months follow-up, survival free of event was impaired in patients with BiVdysf compared with other groups (Nodysf: 73.2 ± 6%, RVDysf: 70.2 ± 13%, LVDysf: 66 ± 10% and BiVDysf: 41 ± 19%, P = 0.011). In organic MR, we identified by echocardiographic strain modality a sub-group of patients (BiVDysf), which portends a higher cardiovascular risk. The adjunction of RV longitudinal strain assessment in the clinical work-up of these patients could improve the evaluation of cardiovascular risk and may be helpful in the clinical-decision making process.

Organic mitral regurgitation (MR) is a frequent heart valve disease which influences ventricular functions and impacts cardiovascular outcome. Right Ventricular Free Wall Longitudinal Strain (RVLS) is a good prognosticator in heart failure. Hence, we aimed to study its determinants in organic MR. One hundred ninety-two patients (60 ± 15 years, 125 males) with mild to severe chronic organic MR were prospectively enrolled and underwent a comprehensive echocardiography with RVLS assessment. RV ejection fraction (EF) was also measured by cardiac magnetic resonance (CMR) imaging (n = 128) or radionuclide angiography (n = 6) in 134 patients (70%) Patients were stratified into 2 groups according to RVLS ≤ −26% (normal function) or > −26% (RV dysfunction). Patients with RV dysfunction exhibited a more severe condition with greater MR (SOR MR: 0.46 ± 0.25 cm2 versus 0.38 ± 0.22 cm2, P = 0.023), were more symptomatic (NYHA 2.0 ± 0.9 versus 1.5 ± 0.6, P < 0.0001), had a lower left ventricular global longitudinal strain (LVGLS) (−19.6 ± 3.9% versus −21.5 ± 2.8%, P = 0.0001) and a lower RV EF by CMR/radionuclide Imaging (45.8 ± 10% versus 50.2 ± 7%, P = 0.0037). RVLS correlated with TAPSE (r = −0.40, P < 0.0001), RV Fractional shortening (r = −0.38, P < 0.0001), TEI index (r = 0.3, P < 0.0001) and tricuspid annular systolic velocity (r = −0.27, P < 0.0001). In addition, RVLS correlated only weakly (r = −0.40, P < 0.0001) with RV EF. In multivariate analysis, pathophysiological determinants of RVLS were rhythm (β = −0.26, P < 0.0001), pulmonary vascular resistance (Abbas formula, β = 0.26, P < 0.0001), LVGLS (β = 0.19, P = 0.01) and LV end-systolic volume (β = 0.15, P = 0.028). RVLS correlates with classical echocardiographic parameters of RV function. RVLS is influenced by pulmonary vasculature resistance (ventriculo-arterial coupling) and LV function (RV to LV interdependence), in agreement with previous findings. As a simple parameter, RVLS could be added to the routine assessment of RV function in organic MR.

Reverse cardiac remodelling is a major goal of aortic valve replacement (AVR). Global longitudinal strain (GLS) currently allows a more sensitive evaluation of systolic function than left ventricle ejection fraction (LVEF). The European Translink FP7 project prospectively included patients with aortic stenosis scheduled for surgical or percutaneous AVR. The present substudy included patients enrolled in Nantes University Hospital. Patients were separated in two groups according to baseline left ventricle (LV) GLS value (normal ≤ or altered > −16%). Changes in LV GLS and cardiac morphology were evaluated 6 months after AVR. Two hundred patients (64% men, mean age 74 ± 9 years) were included and the follow up at 6 months was completed in 127. LVEF at baseline was 62 ± 10% and GLS −16.1 ± 3.7%. Patients with impaired GLS at baseline ( n = 85, 43%) were more often diabetics and obese, and had higher NT-proBNP levels. Cardiac cavities remodelling was more pronounced, LVEF was moderately decreased (57.1 ± 10.9% vs. 65.9 ± 7.3%; P < 0.001), and valvulo-arterial impedance was higher. These patients experienced a significant improvement in GLS at 6 months (−15.3 ± 3.8% vs. −12.9 ± 2.3%; P < 0.001), in contrast with patients with normal GLS at baseline (-18.7 ± 1.6% vs. −18.1 ± 2.6%; P = 0.07). Baseline LVEF and septal E/Ea were significantly associated with GLS value at 6 months in multivariate analysis. There was no significant change in left atrium size but a decrease in E/Ea at 6 months. Despite a significant decrease in pulmonary artery pressure, there was a significant alteration of right ventricle strain at 6 months (−20.7 ± 4.7% vs. −23.2 ± 5.8%; P < 0.001), in correlation with tricuspid annulus dilatation ( Fig. 1 ). Left ventricle presented a significant reverse remodelling after surgical or percutaneous AVR, especially in patients with altered GLS before procedure. This favourable LV remodelling contrast with unfavourable right cavities remodelling.