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

BACKGROUND:In primary mitral regurgitation (MR) atrial dysfunction is believed to be the result of atrial interstitial fibrotic replacement, and left atrial (LA) strain has been suggested as a non-invasive tool to identify a maladaptive atrial remodelling beyond LA enlargement. We aim to investigate the association between LA function and the extent of interstitial fibrosis within the atrial wall in patients undergoing surgery, and their relation with MR characteristics and clinical profiles. METHODS:49 consecutive patients (61 ± 10 years, men 75%) with severe primary MR due to prolapse or flail were enrolled the day before surgery and a complete echocardiographic examination with LA strain analysis was performed. During surgery, a single-site full-thickness sample of the LA free wall was obtained from each patient. RESULTS:Areas of interstitial fibrosis were detected in all atrial specimens (median degree 6.5% [4.75-9.25]). No correlation was found between fibrosis degree and echocardiographic parameters like LA strain, LA volume, quantitative parameters of MR degree, regurgitant jet direction, estimated pulmonary artery pressure (sPAP), or clinical parameters like NYHA class or NTproBNP. However, lower LA reservoir and contractile strain values were associated with higher sPAP (p = 0.002 and p = 0.01, respectively), NTproBNP values (p < 0.0001) and symptoms severity (p < 0.05). CONCLUSIONS:In this selected cohort with severe primary MR and relatively low single-site histological LA fibrosis, LA strain was associated with markers of haemodynamic burden but not with biopsy-derived fibrosis percentage.

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

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

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

Transcatheter aortic valve-in-valve implantation (TAVI-VIV) in degenerated surgical aortic bioprosthesis is a treatment option in patients with high surgery risk. Some surgical bioprosthesis have a high-risk of coronary artery occlusion (CAO), which is one of the most dreadful complications of TAVI-VIV procedures. Two main techniques such as Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) and Shortcut (Pi-Cardia, Rehovot, Israel) are used to split the bioprosthetic leaflet to prevent CAO. In this Viewpoint we discuss the role of transesofageal echocardiography and intracardiac ultrasound in guiding and detecting complications during leaflet splitting. We also propose a classification of different scenarios regarding leaflet splitting success and coronary ostia position in relation to target bioprosthetic leaflet.

Coronary angiography (CA) is poorly correlated with non-invasive myocardial stress imaging (NSI) and myocardial ischemia is often observed in patients with unobstructed coronary arteries. Moreover, the diagnostic performance of combined epicardial and microcirculatory angiography-derived physiological assessment and its correlation with NSI remains unknown. A total of 917 coronary vessels in 319 patients who underwent both CA and NSI were included in this multicenter observational retrospective analysis. Quantitative flow ratio (QFR) and angiography-derived index of microcirculatory resistance (IMRangio) analyses were performed to estimate coronary epicardial and microcirculatory function respectively. NSI demonstrated evidence of myocardial ischemia in 76% of the cases. IMRangio (36 [22 to 50] vs 29 [21 to 41], p <0.001) was significantly higher and QFR (0.92 [0.78 to 0.99] vs 0.97 [0.91 to 0.99], p <0.001) was significantly lower in vessels subtending ischemic territories. Overall, the diagnostic accuracy of QFR was moderate (area under the curve of receiver operating characteristic [AUC(ROC)] 0.632 [95% confidence interval [CI] 0.589 to 0.674], p <0.0001) but it was higher in patients with normal microcirculatory function (AUC(RO)C = 0.726 [95% CI 0.669 to 0.784], p <0.0001, p Value for AUC(ROC) comparison = 0.009). Combined QFR/IMRangio assessment provided incremental diagnostic performance compared with the evaluation of epicardial or microcirculatory districts in isolation (p Value for AUC comparison <0.0001) and it was able to identify the predominant mechanism of myocardial ischemia in 77% of the patients with positive NSI. Our study suggests the value of a combined angiography-derived assessment of epicardial and microvascular function for the definition of the predominant mechanism of myocardial ischemia in patients with suspected coronary artery disease.

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

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

Background: By the framework of proportionate/disproportionate secondary mitral regurgitation (sMR), disproportionate sMR is characterized by a low left ventricular stroke volume (SV) and an out of proportion regurgitant fraction (RF) for the same effective regurgitant orifice area (EROA). The degree of aortic stiffness is a determinant of the ventricular forward SV. We aim to analyze the importance of aortic stiffness in influencing the discrepancy between measures of mitral valve lesion severity (EROA) and sMR hemodynamic burden (regurgitant volume [RV] and RF).Methods: We enrolled stable patients with heart failure with reduced ejection fraction (HFrEF) and at least mild sMR. Mitral EROA, RV, RF and aortic pulse wave velocity (PWV) were measured by echocardiography. We defined three groups based on the degree of actual RF deviation from RF estimated by the linear regression equation of RF on EROA (concordant, low-discordant [residuals lower-than -5%] and high-discordant RF [residuals higher-than 5%]). Results: 117 patients were analyzed (68 +/- 13 years; female 30%; LVEF 33 +/- 8%; EROA 16 +/- 12mm2; RV 24 +/- 15 ml; RF 27 +/- 13%; PWV 6.6 +/- 3.2 m/s). LVEF, end-diastolic-volume and EROA didn't differ among groups. PWV and RV were higher in patients with high-discordant RF (p <= 0.01), whereas total left ventricular-SV and left ventricular outflow tract-SV (LVOT-SV) were lower (p <= 0.0004). PWV was associated with LVOT-SV (r=-0.3;p = 0.0008) and RV (r = 0.3;p = 0.0009). High-discordant RF was predicted by PWV (p = 0.001) independently of LVOT-SV and RV.Conclusion: In this HFrEF cohort with sMR, higher PWV was associated with higher-than-expected RF for a given EROA. Aortic stiffness might play a role in the discrepancy between mitral valve lesion severity and sMR hemodynamic burden.

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

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

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

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

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

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

Abstract 1. Introduction Caseous Calcification of the Mitral Annulus (CCMA) is a rare condition characterized by a liquefaction degeneration that usually involves posterior mitral ring and it is considered a variant of mitral annulus calcification. Its prevalence is very low, but it is possible that it is often underdiagnosed or misdiagnosed. This condition is related with increased age, female sex, chronic kidney disease and calcium metabolism disorders. The lesion can be detected using imaging techniques and its management is conservative in most cases. 2. Case Study A 72-year-old man hospitalized for bilateral pneumonia complicated with ARDS has come to our attention. The patient had a history of stage IV renal failure, type 2 diabetes mellitus and calcific degenerative aortic valve disease. During its stay in the Intensive Care Unit a routine Transthoracic Echocardiogram showed a vegetation suspected for infective endocarditis that involved the posterior mitral leaflet. However, the clinical presentation did not support endocarditis diagnosis as no microorganisms were isolated at multiple blood cultures and other Duke Criteria were negative. Given the limited acoustic viewing of transthoracic echocardiogram it was necessary to perform a Transesophageal Echocardiogram (TEE) for a better characterization of the valve lesion. TEE showed the presence of a round lesion, about 2×2 cm in size, with smooth borders, located over the mitral annulus with extension up to the posterior mitral leaflet and with a partially mobile portion. The lesion had a corpuscular appearance inside with less echogenicity and without evidence of flow. No significant functional alterations of the mitral valve were detected (anterograde transmitral flow Mean Gradient 4-5 mmHg; Mild regurgitation). We therefore concluded for Caseous Calcification of the Mitral Annulus as the most likely diagnosis and decided for a conservative management. A new TEE was performed as a control after one week showing no significant changes on the valve lesion. 3. Conclusions It is important for echocardiographers to be familiar with CCMA and to know how to distinguish it from other valve lesions such as infective vegetation, abscesses or tumors. An integration with other cardiac imaging techniques, patient past medical history and clinical-laboratory data can help the physician in the correct characterization of valve lesions and subsequent most appropriate therapeutic approach for the patient.

Abstract Introduction The prognostic role of RV function assessment in severe AS has been demonstrated in previous studies. However, the role of 2D speckle tracking RV evaluation in the context of severe AS has not been completely clarified. Methods We retrospectively evaluated consecutive patients with severe AS referred to TAVI at our institution. Exclusion criteria were severe aortic regurgitation, severe mitral stenosis and poor acoustic window for a correct 2D speckle tracking right chamber evaluation. The echocardiographic exams were analyzed off-line with a semi-automatic software (Tomtec Arena, Autostrain ®) to assess RVFW strain and LV GLS. Additionally, a conventional echocardiographic evaluation was made in both right and left chambers (LVEF, FAC, LVEF). Prevalence of conventional RV disfunction was defined as a TAPSE<17 mm or FAC<35%. RVFW impairment cuf-off was defined below 20%. Multivariate regression models were elaborate to assess the major determinants of RV function. Moreover, logistic regression analysis has been made to analyze if RV function could predict high-risk clinical features in the context of severe AS. Results Our cohort was composed of 110 consecutive patients. Mean RVFW was 21±7%, TAPSE 21±4 mm, FAC 44±11% and mean RV area 10±4 cmq/mq. The prevalence of RV disfunction defined by standard echocardiography was 26% (29 patients), instead, RVFW was impaired (below 20%) in 53 patients (40%). At multivariate regression analysis, the main RVFW determinants were MR, AS severity, LVMI, GLS and E/e’ (R2 0.68, p<0.001 including AVA; R2 0.53, p<0.001 including mean gradient). At logistic regression analysis RVFW strain was associated with previous HF hospitalization admission independently from TAPSE (CI 95% 1.03–1.22, p=0.008). Furthermore in a second model, RVFW strain was a significant predictor of advanced NYHA class independently from FAC (CI 95%, 1.01–1.18, p=0.0036). Conclusion The major determinants of RV function in patients with severe AS were MR and LV function. A pressure overload driven by the MR-LV dysfunction combination on right sided heart could impact profoundly negatively on RV function. RVFW strain in this study resulted a more sensitive parameter that conventional RV assessment in highlighting more symptomatic severe-AS patients.

Abstract Introduction Echocardiographic evaluation of severe aortic stenosis (SAS) is is important to guide the therapeutic approach but often challenging. Recent studies have demonstrated that the ratio of acceleration time/ejection time (AT/ET) is a simple and reproducible echocardiographic parameter that integrates aortic stenosis severity evaluation and adds information on patient's prognosis. Aim The aim of the study is to investigate the role of the ratio of acceleration time (AT) and ejection time (ET) and its major determinants in severe aortic stenosis . Methods Consecutive echocardiograms of patients with severe AS referred to our center were analyzed offline using Tomtec Arena (Tomtec, Untershlei heim, Germany). AT was measured from the start of the CW Doppler aortic wave, to the peak of the aortic jet. ET was calculated from the same starting point, to the end of the CW Doppler aortic wave. Results A total of 135 patients with severe aortic stenosis formed the study cohort: patients with AT/ET below the median value of 0.35 (vs. higher) presented lower LVEDV (60 vs. 71 ml/mq; p 0.014), left ventricle mass index (116 vs 130 g/m2; p 0.035) and higher LVEF (58 vs 50%; p 0.001), GLS (- 14 vs - 12%; p 0.025), FAC (46 vs 41%; p 0.01), SBP (141 vs 131 mmHg; p 0.003). At multivariable analysis the major AT/ET determinants were systolic arterial pressure and bi-ventricular performance parameters. The following nested regression were created: the first inclusive of systolic arterial pressure (PAS), fractional area change (FAC), left ventricular mass indexed (LVMI), global longitudinal strain (GLS) (R2=0.48 p<0.001), the second inclusive of PAS, FAC, LVMI, GLS, AVA (R2=0.57, p<0.001), the third inclusive of PAS, FAC, LVMI, LVEF, AVA (R2=0.64, p<0.001). Conclusion Our study demonstrated that AT/ET ratio relates quite well with LV performance in the context of SAS. An high ACT/ET ratio tends to be associated with a poor bi-ventricular performance and LV negative remodeling. It is possible that this simple parameter in the next future could help in staging the disease among SAS patients.

Abstract Introduction Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly, although infrequent in the general population (prevalence estimates as 0.2-3%). It begins at the junction of the left subclavian and internal jugular veins, passes through the left side of the mediastinum adjacent to the aortic arch, and mostly drains into the right atrium via the coronary sinus (CS). For the majority of cases it is asymptomatic and it is mostly detected incidentally. More rarely it can be associated with other congenital abnormalities, such as aortic bicuspid valve, aortic coartation or atrial septal defects. Besides, in less than 10% of the cases the left superior vena cava drains in the left atrium, leading to a right-to-left shunt. Lastly, it can lead to arrhythmic problems. Case presentation A 85-year-old man was admitted to the emergency department for syncope. Previous medical history was unknown and there was no clinical documentation available. The electrocardiogram showed an atrial fibrillation and some pacemaker-induced beats. An echocardiogram was performed, which showed dilation and dysfunction of the right chambers and a dilated CS. Moreover, the same exam revealed the two pacemaker leads passing through the CS and ending their course into the right atrium and ventricle. The chest X-ray displayed the pacemaker leads passing to the left side of the aorta. Furthermore, a computed tomography angiography was performed in the suspicion of a pulmonary embolism. The exam showed small vascular filling defects in arteries of the right inferior lung lobe, but also the presence of two superior vena cavas, with the left one draining into the CS. The pacemaker leads passed from the left subclavian vein through the left superior vena cava reaching the right chambers. Therefore, the diagnosis of PLSVC was confirmed. Discussion and Conclusions Despite the benign natural history of this diagnosis, it is important to know the existence of this condition. PLSVC can be suspected when a dilated CS is detected on a transthoracic echocardiogram, with a parasternal long axis view. The best projections to visualize the dilatation of CS are also the apical four-chamber and the subcostal view. Besides, the direct detection of left superior vena cava can be obtained with a suprasternal view. The presence of the right superior vena cava should also be confirmed with a subcostal or suprasternal view. The differential diagnosis for a dilatation of the CS includes anomalous pulmonary venous return with a pulmonary vein draining in the CS, the “unroofed coronary sinus”, a tricuspid regurgitation with a jet directed towards the CS, elevated right-chamber filling pressures. The diagnosis of PLSVC can be confirmed with a saline contrast echocardiography (“bubble-test”) or with other radiological investigations (computed tomography or magnetic resonance). It should be reported in radiological reports even when it is an incidental finding because of its clinical relevance: it is essential to know its presence in advance in invasive procedures, such as pacemaker implantation, ablative procedures, cardiac surgery, because it could affect the proper approaches and could lead to complications. Moreover, in a minority of cases, it can be associated with other congenital abnormalities or with arrhythmic problems.