A primer kardiális malignitások nagyon ritka elváltozások. A kardiális tumorokról általánosságban elmondható, hogy obstrukció, embolizáció és aritmia generálásán keresztül tudnak változatos panaszokat okozni. A National Cancer Database 2004–2016-ig mindössze 826 primer kardiális malignitást rögzített, amelyeknek nagyjából 88,5%-a volt szarkóma. A primer kardiális szarkómák közül a differenciálatlan, illetve az angioszarkóma szövettani típus a leggyakoribb. A szarkómák fent említett extrém ritka előfordulási gyakorisága ellenére bizonyos echokardiográfiás jellemzők alapján gondolnunk kell rájuk mint lehetséges diagnózisra. Ilyenek pl. a széles alapon való rögzülés, inhomogén szerkezet, hyper- és hypoechogen részeket egyaránt tartalmazó területek. Ha felmerül a primer kardiális szarkóma lehetősége, mielőbb szívsebészeti és onkológiai irányba kell referálni a beteget, tekintettel a rendkívül gyors és agresszív tumornövekedésre. Javasolt a legkevésbé invazív műtéti technika kiválasztása, gondolva a tumor recidívahajlamából adódó lehetséges reoperációkra. A műtét után elengedhetetlen a szoros echokardiográfiás követés. Jelen kazuisztika egy 57 éves nőbeteg esetét mutatja be a szarkóma diagnosztizálásától a reoperáció és a másodvonalas onkológiai terápiáig, kiemelve az echokardiográfia szerepét.

Background/Objectives: Conduction system pacing (CSP) is a potential alternative to biventricular pacing (BVP) in heart failure with reduced ejection fraction (HFrEF) and left bundle branch block (LBBB) or non-LBBB. Available data also suggest that unlike BVP, CSP may improve clinical outcome in patients with right bundle branch block (RBBB), although its effects on cardiac mechanics and energetics are ill-defined. Herein, we report on echocardiographic and clinical outcomes of CSP in this patient cohort. Methods: CSP either with His bundle pacing or LBB area pacing was attempted as a primary strategy in patients with RBBB, QRS duration ≥ 130 ms, LVEF < 35% and NYHA II-IV symptoms after optimized medical therapy for 6 months. Data on functional status, NT-proBNP and echocardiographic parameters were collected at baseline and 6 months after CSP. Results: CSP performed in 16 patients reduced QRS duration from 155.3 ± 12.8 ms to 130 ± 16.5 ms (p < 0.001), increased LVEF from 27 ± 7% to 33 ± 9% (p = 0.01), improved LV global longitudinal strain from -7 ± 3% to -10 ± 4% (p = 0.004) and improved LV peak strain dispersion from 126 ± 28 ms to 96 ± 23 ms (p = 0.004). Global myocardial work index increased from 582 ± 277 mmHg% to 840 ± 306 mmHg% (p = 0.003), as did global constructive work (900 ± 374 mmHg% to 1203 ± 393 mmHg%; p = 0.006) and global work efficiency (from 71 ± 7% to 77 ± 8%; p = 0.004). NYHA class (12.5% with NYHA II, 87.5% with NYHA III before vs. 25% with NYHA I, 50% with NYHA II and 25% with NYHA III at 6 months; p = 0.002) and 6 min walk distance (from 354 ± 88 m to 411 ± 95 m; p = 0.003) improved, while NT-proBNP decreased (from 4093 ± 7215 ng/L to 2087 ± 2872 ng/L, p = 0.003). Conclusions: CSP improved functional capacity and echocardiographic parameters related to cardiac functions and myocardial work in HFrEF patients with RBBB. Nevertheless, these results await further confirmation by large-scale, multi-center randomized trials.

Anatomical characteristics of the left atrium and the pulmonary veins (PVs) may be relevant to the success rate of cryoballoon (CB)-ablation for atrial fibrillation (AF). Cardiac computed tomography (CCT) is considered as the gold standard for preablation imaging. Recently, three-dimensional transesophageal echocardiography (3DTOE) has been proposed for preprocedural assessment of cardiac structures relevant to CB-ablation. The accuracy of 3DTOE has not been validated by other imaging modalities. We prospectively evaluated the feasibility and the accuracy of 3DTOE imaging for the assessment of left atrial and PV structures prior to pulmonary vein isolation (PVI). In addition, CCT was used to validate the measurements obtained with 3DTOE. PV anatomy of 67 patients (59.7 Novel 3DTOE method for the assessment of PV parameters relevant to CB ablation. The first direct comparison of pre-ablation measurements with 3DTOE and CCT imaging. 3DTOE measurements of RSPV, LLR and the LSPV’s minor axis diameter were validated by CCT.

Background A direct comparison of three-dimensional transesophageal echocardiography (3DTEE) and cardiac computed tomography imaging has demonstrated good inter-technique agreement for the following pulmonary vein (PV) parameters: the ostium area of the right superior PV (RSPV) and its major (a) and minor axis (b) diameters, the left lateral ridge and the minor axis (b) diameter of the left superior PV. Herein, under investigation, was the predictive value of these parameters for arrhythmia recurrence (AR) after PV isolation with the 28 mm second generation cryoballoon (CBG2). Methods One hundred eleven patients (67 men, mean age 58.06 ± 10.58 years) undergoing 3DTEE before PV isolation with the CBG2 for paroxysmal atrial fibrillation were followed. “Point by point” redo intervention was offered in case of AR and reconnected PVs were defined. Results During a mean follow-up of 617 ± 258.86 days, 65 (58.9%) patients remained free of AR. Longer RSPV b was found to be the only significant predictor for AR (hazard ratio [HR] 1.059; 95% confidence interval [CI] 1.000–1.121; p = 0.048). RSPV b ≥ 28 mm resulted in a threefold (HR 3.010; 95% CI 1.270–7.134, p = 0.012) increase in the risk of AR. The association of RSPV b with AR was independent of the biophysical parameters of cryoapplications. In 25 “redo” patients, reconnections were found 1.75 times more likely in the RSPV than in the other 3 PVs altogether. Conclusions Right superior PV b measured with 3DTEE might be a significant predictor of AR after PV isolation with the CBG2. In case of RSPV b exceeding 28 mm, alternative PV isolation techniques or use of a larger balloon might be considered.

The vast majority of studies focusing on the effects of endurance exercise on hematological parameters and leukocyte gene expression were performed in adult men, so our aim was to investigate these changes in young females. Four young (age 15.3 ± 1.3 yr) elite female athletes completed an exercise session, in which they accomplished the cycling and running disciplines of a junior triathlon race. Blood samples were taken immediately before the exercise, right after the exercise, and then 1, 2, and 7 days later. Analysis of cell counts and routine biochemical parameters were complemented by RNA sequencing (RNA-seq) to whole blood samples. The applied exercise load did not trigger remarkable changes in either cardiovascular or biochemical parameters; however, it caused a significant increase in the percentage of neutrophils and a significant reduction in the ratio of lymphocytes immediately after exercise. Furthermore, endurance exercise induced a characteristic gene expression pattern change in the blood transcriptome. Gene set enrichment analysis (GSEA) using the Reactome database revealed that the expression of genes involved in immune processes and neutrophil granulocyte activation was upregulated, whereas the expression of genes important in translation and rRNA metabolism was downregulated. Comparison of a set of immune cell gene signatures (ImSig) and our transcriptomic data identified 15 overlapping genes related to T-cell functions and involved in podosome formation and adhesion to the vessel wall. Our results suggest that RNA-seq to whole blood together with ImSig analysis are useful tools for the investigation of systemic responses to endurance exercise.

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hungarian Government Research Fund, Szív- és érkutatási kiválóságközpont (IRONHEART) Background In approximately 30-40% of cases, the left ventricular systolic function does not improve following cardiac resynchronization therapy (CRT; non-responders). Currently, the role of right ventricular (RV) systolic function is yet not well established. Our aim was to assess the RV systolic function with 3D echocardiography in CRT patients. Methods We involved 24 patients (12–12 CRT responder and non-responder) who received CRT in our department, and whose 1-year follow-up data were available. We considered the patients "responder" when the left ventricular ejection fraction (LV EF) improved with at least 10% after CRT implantation. We characterized several 3D and 2D parameters of RV using a dedicated RV analysis software, such as RV ejection fraction (EF), body surface area-indexed end-diastolic (EDVi) and end-systolic (ESVi) volumes, free-wall longitudinal (RV GLS) and radial strains. Results After the follow-up, LV EF was 43 ± 8% in responders and 26 ± 7% in non-respoders (p < 0.0001). RV EF was significantly higher (EF: 44 ± 9%; p = 0.003) in responders compared to non-reponders (EF: 32 ± 9%). There was no significant difference in RV EDVi: 65 ml/m² (IQR: 54-74) in responders and 53 ml/m2 (IQR: 42-67) in non-responders (p = 0.22). RV ESVi was also comparable between CRT responders (37 ml/m² - IQR: 28-39) and non-responders (36 ml/m² - IQR: 28-46), (p = 0.85). RV GLS was significantly higher in CRT responders (-13 ± 3% vs. -10 ± 4% in non-responders; p = 0.02) in parallel with the change of the RV EF, while the RV radial strains did not differ between the two groups (2.5 ± 1.7% in responders vs. 2 ± 1% in non-responders; p = 0.47). Conclusions The lower RV EF based on mainly the longitudinal function of RV indicates non-respondence to CRT, however, it is not associated with RV dilation, i.e. adverse remodelling. These results suggest mechanical abnormality of RV function in the background of impaired EF.

Abstract Background Cardiac resynchronisation therapy (CRT) fails to improve echocardiographic parameters and outcome in 20–40% of heart failure (HF) patients with reduced ejection fraction (EF) referred to as CRT non-responders (CRT-NR). The aim of this study was to compare the outcomes of CRT-NR patients who received a CRT defibrillator (CRT-D) device with patients after primary implantable cardioverter-defibrillator (ICD) implantation for impaired left ventricular (LV) function. Methods CRT-NR status was defined as no or less than 10% improvement in LV EF 12 months post implantation. CRT-NR patients and those after primary ICD implantation for LV EF<35% were identified in our database between 2010 and 2019. CRT-NR patients were further categorized as progressors (decrease in LV EF ≥5%) or non-progressors (LV EF change between +9 to −5%). Primary endpoint was all-cause mortality or the need for heart transplantation during follow-up. Statistical significance was assessed by Log-rank test of Kaplan-Meier survival analysis. Results 151 CRT-NR patients and 219 patients after primary ICD implantation were identified with a mean ± SEM follow-up of 43.7±2.5 and 47.3±2.2 months, respectively. Baseline (preoperative) LV EFs were higher (p<0.05) for the overall CRT-NR group (EF = 27.4±0.4%) than for the ICD group (EF = 25.2±0.3%) Further, both CRT-NR subgroups of progressors (n=49; EF = 28.6±0.7%) and non-progressors (n=102; EF = 26.9±0.5%) had also significantly higher baseline LV EF as compared to ICD patients (p<0.05). No statistical significance was found between the two CRT-NR subgroups. Event free median survival for the overall CRT-NR group (55.6 months) was significantly worse than for the ICD group (79.6; p<0.05). This difference was driven by progressor patients who had a significantly worse event free survival (37.8 months, p<0.05) than ICD patients, while vent free survival in non-progressors (60.8 months) was comparable to ICD patients (p=0.18). Conclusion Progressor subgroup of CRT-NR have worse outcome as compared to non-progressors and also to those after primary prevention ICD implantation. The poor prognosis of these patients should have implications for timely decision regarding all therapeutic measures currently available for the management of heart failure. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Project no. TKP2021-EGA-18 has been implemented with the support provided from the National Research, Developement and Innovation Fund of Hungary, financed under the TKP2021-EGA funding scheme

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hungarian Government Research Fund, Szív- és érkutatási kiválóságközpont (IRONHEART) Aims Atrial sizes are considered markers of ventricular filling pressures. The studies focused on left atrial (LA) maximum volume (LAV max), however during diastole the left ventricular (LV) diastolic pressure affects the LA minimum volume (LAV min) instead. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three-dimensional echocardiography (3DE) in predicting elevated LV filling pressure. Methods Eighty-eight consecutive patients with and without left-sided heart disease were prospectively examined with transthoracic 3DE who underwent right heart catheterization because of clinical indication. Elevated LV filling pressure was determined as the pulmonary artery wedge pressure was higher than 15 mm Hg. The atrial volumes were measured offline with dedicated commercial software. Results Thirty-eight patients (24 males, age 62 ± 8 y) had left-sided heart disease (group A) and 50 (20 males, age 62 ± 15 y) had pulmonary hypertension because of lung disease (Group B). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in group A than in group B (LAVi max: 64 ± 31 ml/m² vs. 40 ± 22 ml/m², p = 0.001; LAVi min: 51 ± 22 ml/m² vs. 25 ± 21 ml/m², p < 0.0001). The LA minimum volume correlated with the pulmonary artery wedge pressure [r = 0.6 (p < 0.0001) for LAV min vs. r = 0.47 (p < 0.0001) for LAV max]. In the receiver operating characteristic (ROC) curves of parameters predicting the elevated LV filling pressure, the areas under the curve (AUC) for LAVi min and LAVi max were 0.86 (95% CI, 0.79-0.94), 0.79 (95% CI, 0.70-0.89), respectively. The ROC analysis indicated a possible cutoff value of 28 ml/m² for LAVi min to elevated LV filling pressure (AUC = 0.86; sensitivity = 87%, specificity = 74%). Conclusion The left atrial minimum volume measured by transthoracic 3DE is a useful parameter for predicting elevated left ventricular filling pressure.

INTRODUCTION:Increased muscle sympathetic nerve activity (MSNA) indicates an adverse outcome in heart failure. Decreased baroreflex modulation of MSNA is a well-known feature of the disease. The determinability of cardiovagal baroreflex sensitivity (BRS) in heart failure is low, however, the determinability of sympathetic BRS is not known.METHODS:We have assessed the spontaneous, MSNA burst incidence-based baroreflex index (BRSsymp) in 33 stable heart failure patients and in 10 healthy controls using the traditional r ≥ .5 cutoff for acceptable individual diastolic pressure-burst incidence slopes, and also a more stringent r ≥ .7 cutoff. We have also assessed the influence of 6/min breathing.RESULTS:The determinability of BRSsymp in heart failure patients was 64% during spontaneous breathing with r ≥ .5 cutoff, and 39% using the r ≥ .7 cutoff. The determinability of these indices further decreased during 6/min breathing, dropping to 29% with the r ≥ .7 cutoff. In contrast, the determinability of the cardiovagal BRS indices increased significantly with 6/min breathing (from 24% to 66%; p < .001). Patients who still had determinable BRSsymp at the r ≥ .7 cutoff had a significantly lower baseline burst incidence than those with an undeterminable index (70 ± 14 vs. 89 ± 10 burst/100 cycles; p < .002). Neither the 6/min breathing, nor the r ≥ .7 cutoff limit influenced the high availability of BRSsymp in healthy subjects.CONCLUSION:The determinability of BRSsymp in heart failure patients is limited, especially with the 0.7 limit for correlation. Undeterminable BRSsymp in patients is associated with higher sympathetic activity. 6/min breathing improves the determinability of cardiovagal BRS indices, but not that of BRSsymp.

Potential pitfalls of fractional flow reserve (FFR) measurements are well-known drawbacks of invasive physiology measurement, e.g., significant drift of the distal pressure trace may lead to the misclassification of stenoses. Thus, a simultaneous waveform analysis of the pressure traces may be of help in the quality control of these measurements by online detection of such artefacts as the drift or the wedging of the catheter. In the current study, we analysed the intracoronary pressure waveform with a dedicated program. In 130 patients, 232 FFR measurements were performed and derivative pressure curves were calculated. Local amplitude around the dicrotic notch was calculated from the distal intracoronary pressure traces (δdPn/dt). A unidimensional arterial network model of blood flow was employed to simulate the intracoronary pressure traces at different flow rates. There was a strong correlation between δdPn/dt values measured during hyperaemia and FFR (r = 0.88). Diagnostic performance of distal δdPn/dt ≤ 3.52 for the prediction of FFR ≤ 0.80 was 91%. The correlation between the pressure gradient and the corresponding δdPn/dt values obtained from all measurements independently of the physiological phase was also significant (r = 0.80). During simulation, the effect of flow rate on δdPn/dt further supported the close correlation between the pressure ratios and δdPn/dt. Discordance between the FFR and the δdPn/dt can be used as an indicator of possible technical problems of FFR measurements. Hence, an online calculation of the δdPn/dt may be helpful in avoiding some pitfalls of FFR evaluation.

Abstract Aim While sympathetic overactivity in heart failure (HF) with reduced ejection fraction (HFrEF; EF < 40%) is well‐documented, it is ill‐defined in patients with mildly reduced EF (HFmrEF; EF 40–49%). Furthermore, the significance of ischaemic versus non‐ischaemic aetiology in sympathetic activation is also unclear and has yet to be studied in HF. Our goal was to compare muscle sympathetic nerve activity (MSNA) in HFmrEF and HFrEF patients and in healthy subjects, as well as to elucidate the influence of the underlying disease. Methods and results Twenty‐three HFrEF (age 58 ± 10 years), 33 HFmrEF patients (age 61 ± 10 years), including 11 subjects with non‐ischaemic cardiomyopathy in each HF groups and 10 healthy controls (age 55 ± 10 years), were studied. MSNA—detected by peroneal microneurography, continuous arterial pressure, and ECG—was recorded. MSNA frequency (burst/min) and incidence (burst/100 cycles) were calculated. Association with the patients' characteristics were assessed, and aetiology‐based comparisons were performed. Burst frequency demonstrated a significant stepwise increase in both HFmrEF (41 ± 11 burst/min) and HFrEF (58 ± 17 burst/min, P < 0.001) patients as compared with controls (27 ± 9; P < 0.001 for both HF groups). Similarly, burst incidences were 66 ± 17, 82 ± 15, and 36 ± 10 burst/100 cycles in HFmrEF, HFrEF patients, and in healthy controls, respectively (P < 0.001 for all). Burst frequencies in HF patients showed significant correlation with NT‐proBNP levels, and significant inverse correlations with the subjects' mean RR intervals, stroke volumes, pulse pressures, and EF. Conclusions Muscle sympathetic nerve activity parameters indicated significant sympathetic activation in both HFmrEF and HFrEF patients as compared with healthy controls with no difference in relation to ischaemic versus non‐ischaemic aetiology.

BACKGROUND:Measurements of fractional flow reserve (FFR) and/or coronary flow reserve (CFR) are widely used for hemodynamic characterization of coronary lesions. The frequent combination of the epicardial and microvascular disease may indicate a need for complex hemodynamic evaluation of coronary lesions. This study aims at validating the calculation of CFR based on a simple hemodynamic model to detailed computational fluid dynamics (CFD) analysis. METHODS:Three-dimensional (3D) morphological data and pressure values from FFR measurements were used to calculate the target vessel. Nine patients with one intermediate stenosis each, measured by pressure wire, were included in this study. RESULTS:A correlation was found between the determined CFR from simple equations and from a steady flow simulation (r = 0.984, p < 10-5). There was a significant correlation between the CFR values calculated by transient and steady flow simulations (r = 0.94, p < 10-3). CONCLUSIONS:Feasibility was demonstrated of a simple hemodynamic calculation of CFR based on 3D-angiography and intracoronary pressure measurements. A simultaneous determination of both the FFR and CFR values provides the capability to diagnose microvascular dysfunction: the CFR/FFR ratio characterizes the microvascular reserve.

Abstract Aims The current guidelines on pulmonary hypertension (PH) recommend the use of invasive examination for differentiating between left‐sided heart disease‐related (post‐capillary) and pre‐capillary PH. However, atrial sizes are considered markers of ventricular filling pressures. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three‐dimensional echocardiography (3DE) in differentiating between pre‐capillary and post‐capillary PH. Methods and results Seventy‐five consecutive patients with PH were prospectively examined with transthoracic 3DE. After less than 24 h, the patients underwent right heart catheterization and 3DE and were classified as pre‐capillary or post‐capillary PH according to the recommendations of the ESC guidelines. The atrial volumes were measured offline with dedicated commercial software. Thirty‐eight patients (13 men, age 65 ± 18 year) had pre‐capillary PH, and 37 (23 men, age 62 ± year) had post‐capillary PH. The mean pulmonary artery pressures were similar in patients with pre‐capillary and post‐capillary PH (38 [IQR 26, 54] mmHg vs. 41 [IQR 33, 48] mmHg, respectively, P = 0.49). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in the post‐capillary PH patient group than in the pre‐capillary PH patient group (LAVi max: 64 ± 32 mL/m2 vs. 41 ± 25 mL/m2, P = 0.001; LAVi min: 50 ± 22 mL/m2 vs. 26 ± 24 mL/m2, P < 0.0001). The indexed right atrial minimum volume (RAVi min) was also higher in patients with post‐capillary PH (51 ± 27 mL/m2 vs. 38 ± 26 mL/m2; P = 0.02). Both the left atrial (LA) and right atrial (RA) volumes, especially the LA minimum volume, correlated with the pulmonary artery wedge pressure (PAWP) (r = 0.62 (P < 0.0001) for LAV min vs. r = 0.49 (P < 0.0001) for LAV max; r = 0.32 (P = 0.005) for RAV min vs. r = 0.24 (P = 0.04) for RAV max). Multivariate logistic regression analysis showed that LAVi min was an independent predictor of post‐capillary PH. In the receiver operating characteristic (ROC) curves of parameters predicting the post‐capillary PH, the areas under the curve (AUC) for LAVi min, LAVi max, and RAVi min were 0.86 (95% CI, 0.76–0.95), 0.78 (95% CI, 0.67–0.89), and 0.66 (0.53–0.78), respectively. Concerning the performance of the atrial volume ratio for differentiating post‐capillary PH, the AUC of the atrial volume ratio was significantly lower [AUC: 0.66 (95% CI, 0.53–0.78)]. The ROC analysis indicated a possible cutoff value of 27.7 mL/m2 for LAVi min to predict post‐capillary PH (AUC = 0.86; sensitivity = 86%, specificity = 76%). Conclusions The BSA‐indexed left atrial minimum volume measured by transthoracic 3DE is a useful parameter for differentiating pre‐capillary from post‐capillary pulmonary hypertension.

In order to make optimal decisions on the treatment of atherosclerotic coronary heart disease (CHD), appropriate evaluation is necessary, including both the anatomical and physiological assessment of the coronary arteries. According to current guidelines, a fractional flow reserve (FFR)–based clinical decision is recommended, but coronary flow reserve (CFR) measurements and microvascular evaluation should also be considered in special cases for a detailed exploration of the coronary disease state. We aimed to generate an extended physiological evaluation during routine FFR measurement and define a new pathological flow–related prognostic factor. Fluid dynamic equations were applied to calculate CFR on the basis of the three-dimensional (3D) reconstruction of the invasively acquired coronary angiogram and the measured intracoronary pressure data. A new, potentially robust prognostic parameter of a coronary lesion called the “flow separation index” (FSi), which is thought to detect the pathological flow amount through a stenosis was introduced in a vessel-specific flow range. Correlations between FSi and the clinically established physiological indices (CFR and FFR) were determined. The FSi was calculated in 19 vessels of 16 patients, including data from the pre- and post-stent revascularization treatment of 3 patients. There was no significant correlation between the FSi and the CFR (r = −0.23, p = 0.34); however, there was significant negative correlation between the FSi and the FFR (r = −0.66, p = 0.002). An even stronger correlation was found between the FSi and the ratio of the resting pressure ratio and the FFR (r = 0.92, p < 0.0001). The diagnostic power of the FSi for predicting the FFR value of <0.80, as a gold standard prognostic factor, was tested by receiver operating characteristic analysis. FSi > 0.022 proved to be the cutoff value of the prediction of a pathologically low FFR with a 0.856 area under the curve (95% confidence interval: 0.620 to 0.972). The present flow–pressure–velocity display provides a comprehensive summary of patient-specific pathophysiology in CHD. The consequences of epicardial stenoses can be evaluated together with their complex relations to microvascular conditions. Based on these values, clinical decision-making concerning both pharmacological therapy and percutaneous or surgical revascularization may be more precisely guided.

Abstract Background In approximately 30-40% of cases, the left ventricular systolic function does not improve following cardiac resynchronization therapy (CRT; non-responders). Currently, the role of right ventricular (RV) systolic function is not yet completely clear in the background. Our aim was to assess the RV systolic function with 3D echocardiography in CRT patients. Methods We selected 19 patients who received CRT in our department between May and June 2017, and whose 1-year follow-up data were available. We characterized several 2D parameters of RV systolic function, such as RV free wall strain (RV GLSFW), annular s’ wave velocity (TDI s), tricuspid annulus plane systolic excursion (TAPSE), RV fractional area change (RV FAC). A number of 3D parameters were also assessed, such as RV ejection fraction (EF), end-diastolic (EDV) and end-systolic (ESV) volumes, using a dedicated RV analysis software. Moreover, we measured the LV EF and considered the patients "responder", when the LV EF improved with at least 10% after CRT implantation. Results From 19 patients, 12 was identified as responders (R) and 7 as non-responders (NR). No significant difference was seen in the mean age of patients in the two groups (NR: 68 ± 6 year; R: 67 ± 9 year, p = 0.76), however, the proportion of male individuals was higher in the NR group (8/12 vs. 1/7). The RV EF was higher in the R group (41 ± 8% vs.29 ± 10%; p = 0.012), while the EDV or ESV did not differ between the two groups. The RV GLSFW (–21.2 ± 7% vs.–13.9 ± 7%, p = 0.045) and the TAPSE (16.8 ± 5 mm vs.11.4 ± 3 mm, P = 0.03) values were significantly different between the two groups. Based on logistic regression analysis, the RV EF was an independent predictor of non-respondence. Conclusions The lower RV EF indicates non-respondence to CRT, however, it is not associated with RV dilation, i.e.adverse remodelling. These results suggest mechanical abnormality of RV function in the background of impaired EF.

The dimensions of the pulmonary veins are important parameters when planning pulmonary vein isolation (PVI), especially with the cryoballoon ablation technique. Acknowledging the dimensions and anatomical variations of the pulmonary veins (PVs) may improve the outcome of the intervention. Conventional 2D transoesophageal echocardiography can only provide limited data about the dimensions of the PVs; however, 3D echocardiography can further evaluate relevant diameters and areas of the PVs, as well as their spatial relationship to surrounding structures. In previous literature data, parameters influencing the success rate of PVI have already been identified. These are the left lateral ridge, the intervenous ridge, the ostial area of the PVs and the ovality index of the ostium. Proper imaging of the PVs by 3D echocardiography is a technically challenging method. One crucial step is the collection of images. Three individual transducer positions are necessary to visualize the important structures; these are the left lateral ridge, the ostium of the PVs and the intervenous ridge of the left and right PVs. Next, 3D images are acquired and saved as digital loops. These datasets are cropped, which result in the en face views displaying spatial relationships. This step can also be employed to determine the anatomical variations of the PVs. Finally, multiplanar reconstructions are created to measure each individual parameter of the PVs. Optimal quality and orientation of the acquired images are paramount for the appropriate assessment of PV anatomy. In the present work, we examined the 3D visibility of the PVs and the suitability of the above method in 80 patients. The aim was to provide a detailed outline of the essential steps and potential pitfalls of PV visualization and assessment with 3D echocardiography.

Abstract Background Right ventricular (RV) pacing may worsen left ventricular (LV) systolic function causing heart failure, but the exact mechanism of the LV dysfunction is unknown. The purpose of this study was to examine the right ventricle by three-dimensional echocardiography in patients with LV dysfunction accompanied by long-term RV pacing. Methods We analysed consecutive patients receiving permanent pacemaker (PPM) due to atrioventricular block from 2015 January to 2017 March (n = 335). During the mean follow-up period (27 months) 4 patients were selected with at least 5% decrease in the LV ejection fraction measured by two-dimensional echocardiography (B group). Control (K) group contains 4 age-, sex-, concomitant disease matched patients without the sign of LV dysfunction from the same time interval. Right ventricle function was assessed by 3D echocardiography. Results In both groups, there were 3 men, and the mean age was similar (B: 68 ± 6 y vs. K: 66 ± 10 y; p = 0.65). Right ventricular ejection fraction (EF) was significantly higher in controls compared to patients (K: 49 ± 7.8% vs. B: 36 ± 3.1%; p = 0.02), while the right ventricular volumes [end-systolic (K: 79 ± 47 ml vs. B: 71 ± 7 ml; p = 0.77), end-diastolic (K: 151 ± 73 ml vs. B: 111 ± 11 ml; p = 0.36) and stroke volumes (K: 58 ± 44 ml vs. B: 40 ± 6 ml; p = 0.5)] did not differ significantly. We did not find any important differences between the groups regarding the permanent right ventricle pace rate (K: 93 ± 5.6% vs. B: 84 ± 19.5%; p = 0.5), systolic pulmonary pressure (K: 34 ± 6 mmHg vs. B: 35 ± 18 mmHg; p = 0.92), or the severity of tricuspid regurgitation. Conclusion The left ventricular dysfunction after permanent right ventricular pacing results in right ventricular systolic dysfunction. The decrease of RV ejection fraction is not associated with RV enlargement or increase of pulmonary pressure.

The effect of hydrostatic pressure on physiological intracoronary measurements is usually ignored in the daily clinical practice. Our aim was to investigate this effect on Pd/Pa (distal/aortic pressure) and FFR (fractional flow reserve). 41 FFR measurements between 0.7 and 0.9 were selected. The difference in the height of the orifice and that of the sensor was defined in mm on the basis of 3D coronary reconstruction. Resting Pd/Pa and FFR were adjusted by subtracting the hydrostatic pressure gradient from the distal pressure. Height measurements were also performed from 2D lateral projections for each coronary segment (n = 305). In case of the LAD, each segment was located higher (proximal: − 13.69 ± 5.4; mid: − 46.13 ± 6.1; distal: − 56.80 ± 7.7 mm), whereas for the CX, each segment was lower (proximal: 14.98 ± 8.3; distal: 28.04 ± 6.3 mm) compared to the orifice. In case of the RCA, the distances from the orifice were much less (proximal: − 6.39 ± 2.9; mid: − 6.86 ± 7.0; distal: 17.95 ± 6.6 mm). The effect of these distances on pressure ratios at 100 Hgmm aortic pressure was between − 0.044 and 0.023. The correction for height differences changed the interpretation of the measurement (negative/positive result) in 5 (12%) and 11 (27%) cases for the FFR (cut-off value at 0.80) and the resting Pd/Pa (cut-off value at 0.92), respectively. The clinical implementation of hydrostatic pressure calculation should be considered during intracoronary pressure measurements. A correction for this parameter may become crucial in case of a borderline significant coronary artery stenosis, especially in distal coronary artery segments.

Image-based fractional flow reserve (FFR) calculations reported good agreement with FFR measured invasively. The purpose of this study was to perform a retrospective analysis of the cases of a previous study on less invasive FFR calculation (simple FFR: FFRsim) as a simple calculation from hyperemic contrast flow data and three-dimensional coronary parameters. We aimed to analyze the relations between the pressure wire-based FFR (FFRmeas) and fixed FFRsim: calculated from the fixed hyperemic velocity, rest FFRsim: calculated using the non-hyperemic frame count data to extrapolate the hyperemic velocity (based on the database used in the FAVOR1 study) hyp FFRsim: the hyperemic velocity derived from the frame count assessment during vasodilation.To calculate the frame count reserve (CFRFC) the resting frame count was divided by the hyperemic frame count; this value was then used to determine the CFRFC/FFRmeas ratio as an indicator of microvascular function in the corresponding myocardial area of the measured coronary vessel. A total of 50 lesions with intermediate stenosis were investigated. Correlation between rest FFRsim (from the resting frame count extrapolated to the hyperemic velocity) and FFRmeas was lower than the correlation between hyp FFRsim and FFRmeas (r=0.761 vs. 0.824). Based on ROC curve analysis for predicting the abnormal FFR of ≤0.80 the AUC were significantly higher for the hyperemia-based parameter than those calculated from resting frame counts. Significantly higher AUC were detected by the hyp FFRsim than by the rest FFRsim: 0.936 (95% CI: 0.828 to 0.985) vs. 0.862 (CI: 0.734 to 0.943); p=0.011. Linear regression analyses between the FFRsim (either by fixed FFRsim or by rest FFRsim or by hyp FFRsim methods) and the FFRmeas showed higher intercepts and less steep of the slopes in the subgroups with presence of microvascular disease defined as CFRFC/FFRmeas <2 than in those without microvascular disease (CFRFC/FFRmeas >2); the difference reached significant level (p=0.019) when calculated by rest FFRsim. Hyperemic challenge either by adenosine or regadenoson is required for exact image-based FFR calculation especially in cases of suspicion for microvascular coronary disease. Type of funding source: None

Levelezési cím:lis vazodilatációban meghatározható frakcionális áramlási rezerv (FFR) által vezérelt revaszkularizáció.Azonban jelen--bé invazív képalapú (image based) FFR-számítással kezdi.Amit bizonyos értéktartomány (0,75-0,85) esetén nyugalmi és vazodilatációs invazív nyomáshányados együttes mérését is ajánljuk.-Recently, two large scale outcome trial have proved that non-hyperemic pressure ratio has similar ability for the gui-