IntroductionRight ventricular (RV) dysfunction and pulmonary hypertension (PH) have been previously associated with unfavorable outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI), but little is known about the effect of right ventricle (RV) to pulmonary artery (PA) coupling. Our study aimed to evaluate the determinant factors and the prognostic value of RV-PA coupling in patients undergoing TAVI.MethodsOne hundred sixty consecutive patients with severe AS were prospectively enrolled, between September 2018 and May 2020. They underwent a comprehensive echocardiogram before and 30 days after TAVI, including speckle tracking echocardiography (STE) for myocardial deformation analysis of the left ventricle (LV), left atrium (LA), and RV function. Complete data on myocardial deformation was available in 132 patients (76.6 ± 7.5 years, 52.5% men) who formed the final study population. The ratio of RV free wall longitudinal strain (RV-FWLS) to PA systolic pressure (PASP) was used as an estimate of RV-PA coupling. Patients were analyzed according to baseline RV-FWLS/PASP cut-off point, determined through time-dependent ROC curve analysis, as follows: normal RV-PA coupling group (RV-FWLS/PASP ≥0.63, n = 65) and impaired RV-PA coupling group (RV-FWLS/PASP < 0.63, n = 67).ResultsA significant improvement of RV-PA coupling was observed early after TAVI (0.75 ± 0.3 vs. 0.64 ± 0.3 before TAVI, p < 0.001), mainly due to PASP decrease (p < 0.001). LA global longitudinal strain (LA-GLS) is an independent predictor of RV-PA coupling impairment before and after TAVI (OR = 0.837, p < 0.001, OR = 0.848, p < 0.001, respectively), while RV diameter is an independent predictor of persistent RV-PA coupling impairment after TAVI (OR = 1.174, p = 0.002). Impaired RV-PA coupling was associated with a worse survival rate (66.3% vs. 94.9%, p-value < 0.001) and emerged as an independent predictor of mortality (HR = 5.97, CI = 1.44–24.8, p = 0.014) and of the composite endpoint of death and rehospitalization (HR = 4.14, CI = 1.37–12.5, p = 0.012).ConclusionOur results confirm that relief of aortic valve obstruction has beneficial effects on the baseline RV-PA coupling, and they occur early after TAVI. Despite significant improvement in LV, LA, and RV function after TAVI, RV-PA coupling remains impaired in some patients, it is mainly related to persistent pulmonary hypertension and is associated with adverse outcomes.

Sciendo provides publishing services and solutions to academic and professional organizations and individual authors. We publish journals, books, conference proceedings and a variety of other publications.

Blood rheology is an important determinant of blood flow but is probably one of the most neglected areas in clinical literature and practice. Blood viscosity changes according to shear rates and depends on cellular and plasma factors. RBCs' aggregability and deformability are the main determinants of local flow characteristics in areas with lower and higher shear rates, but plasma viscosity is the main regulatory factor of flow resistance in the microcirculation. In individuals with altered blood rheology, the mechanical stress to vascular walls induces endothelial injury and vascular remodelling, and promotes atherosclerosis. Increased values of whole blood viscosity and plasma viscosity are correlated with cardiovascular risk factors and adverse cardiovascular events. The long-term effects of physical exercise can produce a hemorheological fitness that protects against cardiovascular diseases.

OBJECTIVE:Plasma viscosity is one of the critical factors that regulate microcirculatory flow but has received scant research attention. The main objective of this study was to evaluate plasma viscosity in cardiac surgery with respect to perioperative trajectory, main determinants, and impact on outcome.METHODS:Prospective, single center, observational study, including 50 adult patients undergoing cardiac surgery with cardiopulmonary bypass between February 1, 2020 and May 31, 2021. Clinical perioperative characteristics, short term outcome, standard blood analysis, plasma viscosity, total proteins, and fibrinogen concentrations were recorded at 10 distinct time points during the first perioperative week.RESULTS:The longitudinal analysis showed that plasma viscosity is strongly influenced by proteins and measurement time points. Plasma viscosity showed a coefficient of variation of 11.3 ± 1.08 for EDTA and 12.1 ± 2.1 for citrate, similarly to total proteins and hemoglobin, but significantly lower than fibrinogen (p < .001). Plasma viscosity had lower percentage changes compared to hemoglobin (RANOVA, p < .001), fibrinogen (RANOVA, p < .001), and total proteins (RANOVA, p < .001). The main determinant of plasma viscosity was protein concentrations. No association with outcome was found, but the study may have been underpowered to detect it.CONCLUSION:Plasma viscosity had a low coefficient of variation and low perioperative changes, suggesting tight regulation. Studies linking plasma viscosity with outcome would require large patient cohorts.

Abstract Background Left main percutaneous coronary intervention (PCI) has been established as an effective and safe treatment option for left main coronary artery disease. There are data suggesting that different stent platforms can impact the outcomes after left main PCI. The aim of current study was to compare the four-year outcomes of patients with left main stenosis treated by PCI with a balloon-expandable stent or a self-apposing stent. Methods and Results A total of 146 patients with left main stenosis treated by PCI were included, of which 84 (57.5%) had balloon-expandable stents (Group A) and 62 (42.5%) had self-apposing stents (Group B). Baseline SYNTAX scores were higher in Group A than in Group B. Proximal optimization technique was used more often in Group A (45.2% in Group B vs 81.4% in Group A, p<0.001). The same observations were made for kissing balloon postdilation (30.6% Group B vs 62.7% in Group A, p<0.001). Procedural success with TIMI 3 flow was achieved in similar proportions in both groups. Mortality rate and MACE rates at 4-year follow-up were higher in Group B compared to Group A but have not reached statistical significance in univariable or multivariable analysis. Implantation of a self-apposing stent has been an independent predictor for target lesion revascularization rate (TLR) in multivariable analysis (HR 0.06, CI − 1.11–11.7, =0.03). Conclusions In our study, TLR rate was significantly higher in patients with left main lesion treated by PCI with self-apposing stents.

Acute mesenteric ischemia is a life-threatening disease that can be managed by surgery or endovascular therapy. Endovascular therapy shows great efficacy and good clinical outcomes even in technically demanding interventions, and it can become an alternative to surgery. After the revascularisation of mesenteric arteries, we should take into account the risk of reperfusion injury with systemic inflammatory response syndrome and worse clinical outcomes. We present a case of acute embolic mesenteric ischemia associated with acute left external iliac artery occlusion due to poorly anticoagulated atrial fibrillation, treated by a complex multiple stent-based angioplasty.

BackgroundPatients with hypertrophic cardiomyopathy (HCM) have an increased prevalence of atrial fibrillation (AF) compared to the general population, and left atrium (LA) remodeling is strongly correlated with the risk of AF. This prospective, monocentric study aimed to assess the role of LA electrocardiographic and echocardiographic (structural and functional) parameters in predicting the risk for incident AF in patients with HCM.Methods and ResultsThe study population consisted of 126 HCM patients in sinus rhythm (52.6 ± 16.2 years, 54 men), 118 of them without documented AF. During a median follow-up of 56 (7–124) months, 39 (30.9%) developed a new episode of AF. Multivariable analysis showed that LA booster pump function (assessed by ASr, HR = 4.24, CI = 1.84–9.75, and p = 0.038) and electrical dispersion (assessed by P wave dispersion – Pd, HR = 1.044, CI = 1.029–1.058, and p = 0.001), and not structural parameters (LA diameter, LA volume) were independent predictors of incident AF. Seventy-two patients had a LA diameter < 45 mm, and 16 of them (22.2%) had an AF episode during follow-up. In this subgroup, only Pd emerged as an independent predictor for incident AF (HR = 1.105, CI = 1.059–1.154, and p = 0.002), with good accuracy (AUC = 0.89).ConclusionLeft atrium booster pump function (ASr) and electrical dispersion (Pd) are related to the risk of incident AF in HCM patients. These parameters can provide further stratification of the risk for AF in this setting, including in patients considered at lower risk for AF based on the conventional assessment of LA size.

Objective Pulmonary arterial hypertension (PAH) can lead to left main coronary artery compression (LMCo), but data on the impact, screening and treatment are limited. A meta-analysis of LMCo cases could fill the knowledge gaps in this topic. Methods Electronic databases were searched for all LMCo/PAH studies, abstracts and case reports including pulmonary artery (PA) size. Restricted maximum likelihood meta-analysis was used to evaluate LMCo-associated factors. Specificity, sensitivity and accuracy of PA size thresholds for diagnosis of LMCo were calculated. Treatment options and outcomes were summarized. Results A total of five case–control cohorts and 64 case reports/series (196 LMCo and 438 controls) were included. LMCo cases had higher PA diameter (Hedge’s g 1.46 [1.09; 1.82]), PA/aorta ratio (Hedge’s g 1.1 [0.64; 1.55]) and probability of CHD (log odds-ratio 1.22 [0.54; 1.9]) compared to non-LMCo, but not PA pressure or vascular resistance. A 40 mm cut-off for the PA diameter had balanced sensitivity (80.5%), specificity (79%) and accuracy (79.7%) for LMCo diagnosis, while a value of 44 mm had higher accuracy (81.7%), higher specificity (91.5%) but lower sensitivity (71.9%). Pooled mortality after non-conservative treatment ( n = 150, predominantly stenting) was 2.7% at up to 22 months of mean follow-up, with 83% survivors having no angina at follow-up. Conclusion PA diameter, PA/aorta ratio and CHD are associated with LMCo, while hemodynamic parameters are not. Data from this study support that a PA diameter cut-off between 40 and 44 mm can offer optimal accuracy for LMCo screening. Preferred treatment was coronary stenting, associated with low mid-term mortality and symptom relief. Graphical abstract Diagnosis and management of left main coronary artery compression (LMCo) in patients with pulmonary arterial hypertension (PAH).

Sciendo provides publishing services and solutions to academic and professional organizations and individual authors. We publish journals, books, conference proceedings and a variety of other publications.

Sciendo provides publishing services and solutions to academic and professional organizations and individual authors. We publish journals, books, conference proceedings and a variety of other publications.

Abstract Coarctation of the aorta (CoA) is a relatively frequent congenital defect. Its natural evolution is marked by serious complications including aortic dissection, heart failure, coronary artery disease, infective endocarditis, or cerebral haemorrhages. Correction of CoA before complications arise is associated with a favourable long-term outcome. Timely diagnosis of CoA is therefore of utmost importance in the prognosis of these patients. Non-invasive imaging techniques, ranging from chest radiography to echocardiography, Cardiac Computed Tomography (CCT), and Cardiac Magnetic Resonance (CMR) have evolved to the extent where they can not only suggest but also precisely characterize the lesion and guide further management. We present a series of 3 case reports, highlighting the diagnostic approach and treatment for this pathology.

Sciendo provides publishing services and solutions to academic and professional organizations and individual authors. We publish journals, books, conference proceedings and a variety of other publications.

Background. Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease (ULMCAD) have become a feasible and efficient alternative to coronary artery bypass surgery, especially in patients with acute coronary syndrome (ACS). There are limited data regarding early and late outcomes after ULMCAD PCI in patients with ACS and stable angina.The aim of this study was to compare early and four-year clinical outcomes in patients with ULMCAD PCI presenting as ACS or stable angina in a high-volume PCI center.Methods. We conducted a single center retrospective observational study, which included 146 patients with ULMCAD undergoing PCI between 2014 and 2018. Patients were divided in two groups: Group A included patients with stable angina (n = 70, 47.9%) and Group B patients with ACS (n = 76, 52.1%).Results. 30-day mortality was 8.22% overall, lower in Group A (1.43% vs 14.47%, p = 0.02). Mortality and major adverse cardiac events (MACE) rates at 4 years were significantly lower in Group A (9.64% vs 33.25%, p = 0.001, and 24.06% vs 40.11%, p = 0.012, respectively). Target lesion revascularization (TLR) at 4 year did not differ between groups (15% in Group A vs 12.76% in Group B, p = 0.5).Conclusions. In our study patients with ULMCAD and ACS undergoing PCI had higher early and long-term mortality and MACE rates compared to patients with stable angina, with similar TLR rate at 4-year follow-up.

Myxomatous mitral valve disease (MVD) is a common disorder in which the entire mitral valve apparatus seems to be involved. Mitral valve repair is nowadays the method of choice for the correction of mitral regurgitation but the optimal shape and flexibility of the annuloplasty ring remain controversial. Considering that myxomatous MVD covers a wide spectrum from limited fi bro-elastic deficiency to extensive Barlow disease, we presume that the mitral annulus morphological and functional changes are likely different in different types of myxomatous MVD. We analyze the 3-dimensional geometry and the dynamics of the mitral annulus in 110 patients with significant mitral regurgitation due to different types of myxomatous mitral valve disease and 40 normal subjects using 3D transesophageal echocardiography. The mitral annulus differs in patients with limited MVD, extensive MVD and in normal controls in terms of size, shape, and dynamics. Patients with limited MVD have larger, flatter, dysfunctional and more mobile mitral annulus compared to normal, while patients with extensive MVD have even larger, flatter and more dysfunctional mitral annulus, with reduced mobility. The non-planar dynamics has different patterns during systole, according to the extension of MV disease. Our data may be important for the appropriate choose of annuloplasty mitral annulus in mitral valve repair, the current trend being to choose the ring according to the underlying pathology.

Abstract Funding Acknowledgements Type of funding sources: None. Background Although earlier publications suggested a more benign clinical course for patients (pts) with apical hypertrophic cardiomyopathy (ApHCM), recent studies report increased morbidity and mortality, comparable to the prognosis of other HCM variants. Moreover, information regarding cardiac remodelling and its relationship with symptoms in pts with ApHCM is scarce. The aim of our study was to assess left ventricular (LV), right ventricular (RV) and left atrial (LA) remodelling in pts with ApHCM in comparison with non-apical variants of HCM (nonApHCM), and the impact of cardiac remodelling on heart failure symptoms. Methods One hundred fifty-one consecutive pts with HCM (52 ± 16 yrs, 47% men) in sinus rhythm and with preserved LV ejection fraction (16 pts with ApHCM and 135 pts with nonApHCM), were prospectively enrolled. Comprehensive echocardiography was performed in all, including the measurement of maximal LV wall thickness (LVWT), RV free wall thickness (RVWT) and maximal LA volume indexed to body surface area (LAVi). Global LV strain (ɛ), RVɛ, LAɛ and end-diastolic LA strain rate (ASr) were measured using speckle-tracking echocardiography (STE). The ratio of E to average e’ was used to estimate LV filling pressure. The degree of mitral regurgitation (1/2/3) has also been assessed. Heart failure symptoms were defined according to the New York Heart Association (NYHA) classification. Results Forty-eight pts in nonApHCM group had intraventricular obstruction. There were no significant differences between pts with and without ApHCM regarding: age (58 ± 20 vs 52 ± 16 yrs), gender distribution, RVWT, LVɛ (-14.9 ± 2.7 vs -13.9 ± 3.5 %), RVɛ (-19.6 ± 3.6 vs -10.0 ± 5.0%), LAɛ (19.2 ± 5.8 vs 16.4 ± 7.1%)(p > 0.05 for all). Pts with ApHCM had lower values for LVWT (17.2 ± 1.9 vs 21.4 ± 5.2 mm, p = 0.002), E/e’ (12.0 ± 5.8 vs 17.6 ± 8.5, p = 0.02) and LAVi (48 ± 16 vs 61 ± 25, p = 0.03) compared to pts with nonApHCM. Pts with ApHCM had slightly better LA contractile function as assessed by ASr (-1.23 ± 0.50 vs -0.97 ± 0.49 sec-1, p = 0.05). Mitral regurgitation was more often severe in nonApHCM pts (56/42/31 vs 10/4/0, p < 0.001). There was no significant difference between the percentage of symptomatic pts (NYHA class ≥2) in ApHCM vs nonApHCM group (p = 0.3). In the ApHCM group, symptomatic pts had significantly lower ASr compared to asymptomatic pts (-0.98 ± 0.35 vs -1.61 ± 0.46 sec-1, p = 0.01). Conclusions Despite of lower LVWT values, less severe MR and no obstruction, pts with apical HCM have similar prevalence of heart failure symptoms, and similar LV, RV and LA dysfunction compared to pts with non-apical HCM. Symptomatic pts with apical HCM have worse LA contractile function compared to asymptomatic pts.

Type of funding sources: None. Background. Transcatheter aortic valve replacement (TAVR) prostheses have better hemodynamics compared to surgical prostheses, with lower incidence of prosthesis-patient mismatch (PPM). Nonetheless, this complication is neither rare nor benign in the expanding population of TAVR patients (pts). Data regarding the effect of TAVR PPM on cardiac function is scarce. Our aim was to determine the short-term impact of PPM on left atrium (LA) function in patients undergoing transfemoral TAVR. Methods. One hundred forty-three consecutive pts (76.3 ± 7.5 yrs, 74 men) considered to be at high risk for SAVR were enrolled and examined before and 30 days after TAVR. All pts underwent a comprehensive echocardiogram, including speckle tracking echocardiography (STE) for LA and left ventricular (LV) strain analysis. Longitudinal LA strain parameters were assessed from the apical 4-chamber view. Peak values of global longitudinal LA strain (LAε) and LA systolic strain rate (SSr, reservoir function) and early diastolic strain rate (ESr, conduit function) were measured in all. Contractile LA function (late diastolic strain rate, ASr) was assessed in patients in sinus rhythm (106 pts). Results. Fifty-five pts (38%) had PPM (defined as an indexed effective orifice area, EOA ≤0.85 cm2/m2). Most of these pts (71%) had moderate PPM (indexed EOA between 0.65 and 0.85 cm2/m2). No significant differences in age (76.4 ± 8.1 vs 76.3 ± 7.2 yrs, p = 0.9), gender (p = 0.2), body surface area (p = 0.8), body mass index (p = 0.2) and the presence of cardiovascular risk factors (p > 0.2 for all) were observed between pts with and without PPM. The severity of post-TAVR aortic regurgitation was mild in 92 pts (64%) and moderate in 12 pts (8%) without any significant difference between pts with and without PPM. The post-TAVR prevalence of ³moderate mitral regurgitation was not different between the two groups (p = 0.40). After TAVR, there were no significant differences in terms of indexed LV mass, volumes, ejection fraction (p > 0.5 for all). LV global longitudinal strain was also similar between groups (-13.7 ± 4.3 vs -14 ± 3.6%, p = 0.7). Although LA volumes were similar between patients with and without PPM (47.8 ± 12.4 vs 49.3 ± 20.3 ml/m2, p = 0.6), in the mismatch-group we found a significantly reduced systolic global LA strain (12.7 ± 6.2 vs 15.9 ± 7.9%, p = 0.009) and impaired LA contractile function (ASr: -1.0 ± 0.4 vs -1.2 ± 0.5, p = 0.03). Parameters of LV diastolic function were also worse in the mismatch-group, with an E/e’sep ratio of 22 ± 10 vs 17 ± 7, p = 0.01. Conclusions. In our study group TAVR was associated with an incidence of PPM of 38%. The short-term follow-up of these patients revealed a significantly impaired LA function and increased LV filling pressure in patients with PPM compared to those without PPM. To our knowledge, this is the first report about the effect of PPM on the LA global and contractile function.

Abstract Despite being at the extreme spectrum of congenital heart disease-associated pulmonary hypertension, patients with Eisenmenger syndrome have better outcomes compared to other types of pulmonary arterial hypertension, especially in the case of post-tricuspid shunts. This survival advantage seems to be at least partly due to significant resilience of the right ventricle and a relative resistance to failure. This paper aims to review the concept of right ventricular adaptive remodeling in Eisenmenger syndrome, its impact on prognosis and the role of multimodality imaging in the right ventricle's assessment in this setting.

Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.

Abstract Background Left atrial (LA) volume is an important cardiovascular prognostic marker. However, data regarding the prognostic value of LA volume in severe AS patients (pts) after surgical aortic valve replacement (AVR) are scarce. Moreover, the predictive role of LA function in AS pts after AVR has not yet been studied. Our study aimed to assess the relationship of LA volume index (LAVi) and function with outcome, in terms of mortality, in severe AS pts who underwent surgical AVR. Methods A total of 360 consecutive pts with isolated severe AS (aortic valve area index ≤ 0.6 cm2/m2) referred to our echocardiography laboratory were prospectively screened. Two hundred and seventeen pts with preserved left ventricular (LV) ejection fraction (≥50%) and in sinus rhythm were enrolled. All patients underwent a baseline comprehensive echocardiogram, including speckle tracking analysis of both LV and LA strain. Symptomatic pts (142 pts, 65%) that were subject to AVR were followed for a median period of 4 years (IQR 3-6 years). The endpoint was all-cause mortality after AVR. The last update of the survival status was obtained in January 2019. Outcome data were available in 116 severe AS pts that underwent AVR (mean age 63 ± 10 yrs, 56% men), who formed the final study population. Results Seventeen (14%) pts died during follow-up. No significant differences were found between nonsurvivors and survivors after AVR in terms of age and cardiovascular risk factors. Nonsurvivors had higher BNP plasma values (p=.04) at baseline compared with surviving pts. Survivors and nonsurvivors alike exhibited similar preoperative AS severity and LV systolic function parameters (ejection fraction and global longitudinal strain). Moreover, there were no significant differences between the two groups regarding baseline valvuloarterial impedance, average E/e’ ratio, and LA longitudinal deformation parameters. Nonsurvivors had a tendency toward higher LV mass index (p=.08). Nonsurvivors had higher preoperative LA volume index (LAVi)(50 ± 12 vs. 44 ± 10 ml/m2, p=.003). In a multivariable Cox regression analysis adjusted for age, LAVi emerged as the only independent predictor for death in our population study (HR 1.06, 95% CI 1.01-1.11, p=.02). A cut-off value for LAVi derived from ROC curve analysis was used to construct Kaplan-Meier survival curves. A value of 43 ml/m2 for LAVi predicted all-cause mortality after AVR in severe AS pts with 71% sensitivity and 54% specificity. Conclusions In our study, preoperative LAVi predicted death in severe AS pts after surgical AVR. LAVi assessment may improve preoperative risk stratification in patients with severe AS, however further larger prospective studies are needed. Abstract P301 Figure.