OBJECTIVE:The aim of this study was to investigate whether using radial access for coronary chronic total occlusion recanalization is effective and safe. METHOD:We enrolled 308 patients with chronic total coronary occlusion in our prospective study, between 2016 and 2019, in two cardiovascular centers. We included all transradial chronic total coronary occlusion percutan coronary interventions performed and all transfemoral cases were excluded from the study. A successful procedure was defined as recanalization of the target artery to <50% stenosis with successful stenting. We have investigated the procedural success rate, major adverse cardiac and cerebral events ratio, vascular complication rate, and the procedure related factors. RESULTS:During the 3-year period, we enrolled 272 cases with complex transradial chronic total occlusion percutan coronary intervention. The average age was 73 ± 9 years, and 74% were men. The procedural success was 83.4%, while the technical success was 64.7%. The 1-year rate of major adverse cardiac and cerebral events ratio was 15.6%. The rate vascular access complications was 2.57%. Procedural complications were observed in 4.78%. In 1.8% of cases, it was necessary to convert from transradial to transfemoral access during the procedure due to technical reasons. The rate of vascular access complications was 2.57%. The average contrast consumption was 178.1 ml (176-211), the average procedure time 52.3 min (51.3-66.2), the radiation 2140 mGy (2110-2998). CONCLUSION:Transradial access for chronic total occlusion recanalization is safe and effective and it is also associated with acceptable amount of access site complication rate. Orv Hetil. 2026; 167(1): 16-22.

Background: Transradial access has become a preferred strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) because of lower access site complication rates and increasing feasibility for complex CTO techniques using large-bore slender or sheathless systems. However, long-term outcomes after successful transradial CTO recanalization and their predictors remain incompletely defined. We aimed to identify long-term clinical and procedural predictors of major adverse cerebrovascular and cardiac events (MACCEs) after successful transradial CTO PCI. Methods: We performed a prospective dual-center cohort study including 227 consecutive patients who underwent successful transradial CTO PCI at two high-volume catheterization laboratories with dedicated CTO programs. A total of 405 CTO PCI procedures were screened; all femoral access cases were excluded and only transradial cases were eligible. Baseline clinical characteristics, left ventricular ejection fraction (LVEF), lesion complexity including J-CTO score, coronary disease extent, and procedural variables were prospectively collected and/or verified from institutional databases. The primary endpoint was MACCEs, defined as a composite of all-cause death, non-fatal myocardial infarction, target vessel revascularization, and stroke/transient ischemic attack. Event rates were estimated using Kaplan-Meier methods. Predictors were explored using Cox proportional hazards regression with clinically relevant covariates and procedural characteristics entered into multivariable models. Results: Among 227 patients with successful transradial CTO recanalization and complete 5-year follow-up among survivors, cumulative MACCEs and all-cause mortality were 44.0% and 21.5%, respectively. In multivariable Cox analysis, prior myocardial infarction, right coronary artery target vessel, and a higher number of implanted stents were independently associated with increased MACCE risk, whereas previous PCI and preserved LVEF (≥40%) were associated with lower MACCE risk. For all-cause mortality, preserved LVEF was independently protective, while right coronary artery target vessel intervention was associated with increased mortality risk; severe chronic kidney disease showed a significant univariable association and remained a strong signal after multivariable adjustment. Conclusions: After successful transradial CTO PCI, long-term MACCEs appear to be driven primarily by baseline comorbidity and coronary disease burden. No deaths were related to access site bleeding, and vascular access was not associated with fatal complications. These findings contribute to personalized cardiovascular medicine by identifying readily available clinical, anatomical, and procedural factors that enable individualized long-term risk stratification following successful transradial CTO recanalization. Integrating these predictors into post-procedural assessment may support tailored secondary prevention, follow-up strategies, and patient management according to individual risk profiles.

Célkitűzés: Tudományos munkánk célja volt megvizsgálni a transradialis behatolás biztonságosságát és hatékonyságát krónikus teljes coronariaocclusio rekanalizációjában. Módszer: 2016 és 2019 között két cardiovascularis centrumban összesen 308 krónikus teljes coronariaocclusiós beteget vontunk be prospektív vizsgálatunkba. A transfemoralis behatolásból végzett eseteket kizártuk, így 272, transradialis behatolásból végzett krónikus teljes coronariaelzáródás miatt coronaria intervención átesett beteg adatait dolgoztuk fel. Procedurálisan sikeresnek tekintettük a beavatkozást, ha <50%-os reziduális szűkület maradt vissza a beavatkozás végén. Vizsgáltuk a beavatkozás sikerességét, a major cardialis és cerebralis események előfordulásának gyakoriságát, a vascularis komplikációk arányát, a procedurális faktorokat. Eredmények: A 3 éves vizsgálati periódusban 272, komplex krónikus teljes coronariaocclusiós eset percutan coronariaintervencióját végeztük el transradialis behatolásból. A betegek átlagéletkora 73 ± 9 év volt, és 74%-uk volt férfi. A procedurális siker 83,4%, míg a technikai siker aránya 64,7% volt. A major cardialis és cerebralis események 1 éves előfordulása 15,6%, a vascularis szövődmények előfordulása 2,57% volt. Procedurális komplikációt 4,78%-ban észleltünk. Az esetek 1,8%-ában volt szükség technikai okok miatt transradialisról transfemoralisra váltani a beavatkozás alatt. Az átlagos kontrasztanyag-felhasználás 178 ml (176–211), az átlagos procedurális idő 52,3 min (51,3–66,2) és a sugárdózis 2140,5 (2110–2998) mGy volt. Következtetés: Eredményeink alapján elmondható, hogy a transradialis behatolásból végzett krónikus teljes coronariaelzáródás percutan intervenciója biztonságos és sikeres beavatkozás, amely elfogadható arányú szövődményrátával társul. Orv Hetil. 2026; 167(1): 16–22.

Frailty and heart failure (HF) both have become increasingly prevalent and each adversely affects prognosis. Data regarding the potential frailty-modifying effect of cardiac resynchronization therapy (CRT) upgrade remain scarce. This study aimed to evaluate the impact of frailty on clinical outcomes in the Budapest-CRT Upgrade trial population. Patients with heart failure and reduced ejection fraction (HFrEF), an implanted pacemaker or implantable cardioverter-defibrillator (ICD) and ≥ 20

Abstract In patients with aortic stenosis (AS) evaluating left ventricular (LV) systolic function is challenging due to the influence of increased afterload on traditional measures. Myocardial work (MW) analysis, a novel echocardiographic method, adjusts myocardial deformation to instantaneous LV pressure, providing a more accurate reflection of LV contractile state. Notably, prolonged LV pressure overload induces significant backward effects beyond the LV; the classification of this extravalvular cardiac damage effectively represents the cardiopulmonary system's involvement in AS. Both MW analysis and cardiac damage staging may possess significant prognostic value in the clinically complex cohort of transcatheter aortic valve replacement (TAVR) candidates. Thus, our objective was to evaluate the prognostic value of MW analysis and cardiac damage staging in TAVR patients. We enrolled 314 patients (79±6 years, 40% female) prior to TAVR. Echocardiographic assessments were conducted one day before the procedure. LV ejection fraction (EF) was calculated, global longitudinal strain (GLS) was measured using speckle-tracking echocardiography. LV pressure was estimated from systolic blood pressure and transaortic mean gradient, and global constructive work (GCW) was quantified using dedicated software. Based on echocardiographic data, we determined the extent of cardiac damage associated with AS, categorizing patients into Stage 0 (no cardiac damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (pulmonary artery vasculature or tricuspid valve damage), or Stage 4 (right ventricular damage). The primary endpoint was all-cause mortality, reached by 69 patients during a median follow-up period of 25 months. Preprocedural EF was 47±13 %, GLS was -12.3±4.2 %, GCW was 2043±769 mmHg%. 14 (5%) patients were classified as Stage 0, 61 (20%) as Stage 1, 133 (43%) as Stage 2, 22 (7%) as Stage 3, and 74 (24%) as Stage 4. GCW showed a decline through AS Stages (from Stage 0-4: 2963±652 vs. 2154±621 vs. 2174±706 vs. 2044±827 vs. 1553±757 mmHg%; p<0.001). Using univariate Cox analysis GCW (HR 0.968 [95% CI 0.938-0.998] per 100 unit change; p=0.034) and AS Staging (HR 1.236 [95% CI 1.016-1.505]; p=0.034) were associated with all-cause mortality, while EF (HR 0.982 [95% CI 0.964-1.001]; p=NS) and GLS (HR 1.047 [95% CI 0.989-1.108]; p=NS) were not. In multivariate Cox regression models, both GCW (HR 0.958 [95% CI 0.923-0.994] per 100 unit change; p=0.022) and AS cardiac damage staging (HR 1.281 [95% CI 1.040-1.577]; p=0.020) were significant independent predictors of all-cause mortality. In TAVR patients, preoperative GCW values continuously decreased across all AS Stages. GCW and AS Staging showed strong association with all-cause mortality in our cohort, while EF and GLS did not. Furthermore, GCW and AS Staging had higher prognostic value than any other echocardiographic measure, highlighing their role in preprocedural assessment before TAVR.

Extravascular implantable cardioverter-defibrillator is a recently developed substernal system to prevent sudden cardiac death. Extravascular devices, such as subcutaneous and substernal implantable cardioverter-defibrillators, were designed to avoid the possible complications of conventional transvenous leads. However, their combination with a left ventricular assist device (LVAD) is often challenging. Electromagnetic interference generated by the LVAD may affect previously implanted cardioverter-defibrillators, particularly subcutaneous extravascular devices. To our knowledge, this is the first reported experience of the concomitant use of an extravascular implantable cardioverter-defibrillator with a durable LVAD.

Abstract Background With increasing life expectancy and aging of the population, aortic valve stenosis (AS) is now the most prevalent valvular disease in developed nations. Left ventricular (LV) functional assessment is challenging in this pressure-overloaded disease state, however, myocardial work analysis may overcome this issue by proving load-adjusted measures of LV function. Notably, long-standing severe AS results in progressive damage of the heart, starting from left ventricular (LV) remodeling to significant backward effects eventually leading to manifest right ventricular dysfunction. Myocardial work parameters, being less load-dependent markers of LV function may follow the extent of cardiac damage. However, the relationship of cardiac damage staging and myocardial work measures is scarcely investigated. Purpose Accordingly, we aimed to examine the relationship of myocardial work indices and AS staging in a transcatheter aortic valve replacement (TAVR) candidate AS cohort. Methods 296 patients (79±7 years, 41% female) with severe AS were enrolled. Medical history was obtained and we performed detailed echocardiography prior to TAVR. Aortic valve area (AVA) was calculated using the continuity equation. LVEDVi was measured using the biplane Simpson method. Based on the echocardiographic data, we determined the extent of cardiac damage caused by AS, patients were classified as Stage 0 (no cardiac damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (pulmonary artery vasculature or tricuspid valve damage), or Stage 4 (right ventricular damage). We determined the LV ejection fraction (EF) and via speckle-tracking echocardiography global longitudinal strain (GLS) was also measured. Then, utilizing left ventricular volume curves derived from systolic blood pressure and mean transaortic gradient, we calculated global myocardial work index (GWI). Results 14 (5%) patients were classified as Stage 0, 61 (21%) as Stage 1, 132 (45%) as Stage 2, 16 (5%) as Stage 3, and 73 (25%) as Stage 4. EF (from Stage 0-4: 61±6 vs. 48±12 vs. 48±11 vs. 45±14 vs. 40±15%, p≤0.01) and GLS (-16.9±3.4 vs.-13.2±3.3 vs. -12.6±3.8 vs. -11.8±4.8 vs. -9.8±4.4%, p≤0.01) only differed in Stages 3 and 4, while GWI values formed a more defined spectrum through the Stages (2481±543 vs. 1726±588 vs. 1717±686 vs. 1581±867 vs. 1185±692 mmHg%, p≤0.001). Using multivariate regression analysis, examining relevant clinical and echocardiographic parameters, age (β=0.15, p=0.02), cardiac damage stage (β=-0.19, p≤0.01), AVA (β=0.21, p≤0.01), LVEDVi (β=-0.33, p≤0.001) and having a pacemaker (β=-0.15, p=0.01) were independent predictors of GWI (R²= 0.41, p≤0.0001). Conculsions LV GWI show distinct changes throughout the spectrum of cardiac damage associated with severe AS. Beyond age, AVA, LVEDVi and having a pacemaker, cardiac damage stage is also an independent determinant of GWI in this population.

AIMS:Low-gradient (LG) aortic stenosis (AS) poses a diagnostic challenge. Aortic valve calcium score (AVCS) assessment has emerged as a complementary diagnostic method when echocardiography provides discordant results. However, the diagnostic and prognostic values of AVCS in LGAS have not been thoroughly studied. Our aims in this study were to investigate the prognostic importance of AVCS in LGAS and to assess whether symptomatic patients with LGAS and low AVCS may benefit from aortic valve intervention (AVI). METHODS AND RESULTS:A total of 327 symptomatic patients (78.5 ± 7.3 years, 51% women) with severe AS defined by the aortic valve area who underwent computed tomography for transcatheter aortic valve intervention (TAVI) planning were enrolled. AVCS was measured. AVCS < 2000AU in men and < 1200 AU in women was considered a low AVCS. A total of 243 patients had high gradient (HG) and 84 had LGAS. A low AVCS was present in 25 (10%) patients with HG and 34 (40%) with LGAS. Over a median follow-up period of 4.9 years, 194 deaths occurred. In multivariate analysis, AVCS was a significant independent predictor of all-cause mortality among patients with HGAS [adjusted hazard ratio (aHR): 2.317; CI: 1.104-4.861; P = 0.026] but not among those with LGAS (aHR: 0.848; CI: 0.434-1.658; P = 0.630). After propensity score matching between patients who underwent AVI and those who were medically treated, AVI (94% TAVI) was a significant and independent predictor of survival among LGAS patients with a low AVCS even after adjustment for clinical variables (aHR: 0.102, CI: 0.028-0.369; P < 0.001). CONCLUSION:The prevalence of a low AVCS is much higher in patients with LGAS than in those with HGAS. In patients with symptomatic severe LGAS, a low AVCS does not entail a better prognosis. AVI is equally beneficial in LGAS patients with a high or low AVCS, similarly to those with HGAS.

Abstract It is well known that left ventricular (LV) performance is substantially influenced by the corresponding loading conditions and LV synchrony. Notably, data are scarce about the interaction of these factors: previous studies suggest that patients with left bundle branch block (LBBB) has increased afterload sensitivity. This phenomenon may have special importance in certain clinical situations, such as aortic stenosis (AS) patients with concomitant right ventricular pacing (RVP). Accordingly, our aim was to investigate the effects of RVP on LV function in patients with severe AS before and after transcatheter aortic valve replacement (TAVR). Patients with a previously implanted pacemaker and significant AS undergoing TAVR in our Institute were screened. Only subjects with intrinsic non-LBBB QRS were enrolled (n=31). Detailed echocardiographic protocol suitable for speckle-tracking and myocardial work analysis was obtained. Myocardial work measures were calculated by estimating LV pressure as the sum of the systolic blood pressure and the mean aortic gradient. The patients underwent two sets of echocardiographic examinations: one with their narrow QRS rhythm and one with RVP. Those patients (n=19), who did not develop LBBB or complete AV-block also underwent a post-TAVI protocol. We measured LV ejection fraction (EF), global longitudinal strain (GLS) and also global work index (GWI) and global wasted work (GWW). Preoperatively, RVP resulted in significantly lower LV EF (55±9 vs. 49±10%, p≤0.001), GLS (-14.2±3.6 vs. -11.9±3.5%, p≤0.001) and GWI (1830±502 vs. 1322±546 mmHg%, p≤0.001) compared to narrow QRS rhythm, while GWW was markedly higher (222±129 vs. 344±146 mmHg%, p≤0.001). After TAVR, LV EF was comparable (55±9 vs. 52±8%, p=0.11), while GLS (-13.8±.3.8 vs. -11.4±3.8%, p≤0.001) and GWI (1360±403 vs. 1018±385 mmHg%, p≤0.01) was lower in RVP. Notably, the relative change in GWI in response to RVP was significantly lower after TAVR (-31±21 vs. -22±20%, p≤0.05). In patients with severe AS, LV dyssynchrony associated with RVP results in markedly lower LV functional measures. TAVR alleviates LV pressure overload, and the detrimental effect of RVP may dampen with the afterload reduction. Significant AS and RVP may have a highly unfavorable interaction raising the need for early interventions in this population.

Aortic stenosis has become the most prevalent valvular disease with increasing life expectancy and the ageing of the population, representing a significant clinical burden for health care providers. Its treatment has been revolutionized by transcatheter aortic valve replacement (TAVR) as a safe and minimally invasive option for elderly patients. Left ventricular (LV) functional measurement is of particular importance before TAVR, however, increased afterload significantly influences the conventional echocardiographic parameters. Non-invasive myocardial work examines myocardial deformation in the context of instantaneous LV pressure, thus, it might be a more reliable measure of LV function. Accordingly, we aimed to study non-invasive myocardial work and its relationship with functional outcome following TAVR. We enrolled 90 TAVR candidates (80 [75–84] years; 44

Abstract Introduction The BUDAPEST CRT Upgrade trial has established the strong clinical benefit of upgrading heart failure patients with a reduced left ventricular (LV) ejection fraction (HFrEF) and a high right ventricular pacing (RVP) burden to cardiac resynchronization therapy with defibrillator (CRT-D). Importantly, however, the CRT upgrade response is not homogeneous regarding LV reverse remodeling and associated clinical outcomes. The presence of mechanical dyssynchrony (MD) assessed by echocardiography has been linked to more CRT benefits; still, its change in response to CRT and added prognostic value in HFrEF patients with high RVP are scarcely investigated. Purpose Accordingly, we aimed to assess the prevalence, clinical characteristics, CRT response rate, and prognostic value of RVP-induced MD in the BUDAPEST CRT Upgrade cohort. Methods The multicentre, randomized, controlled trial enrolled 360 HFrEF patients with a pacemaker or implantable cardioverter defibrillator (ICD) and significant RVP (≥ 20%) who were randomly assigned to receive CRT-D upgrade or ICD in a 3:2 ratio. Protocol echocardiography was performed at baseline and at 12-month follow-up visits and was evaluated at a central core lab. Beyond LV end-diastolic (EDV) and end-systolic volumes (ESV), longitudinal strain-derived septal deformation patterns by speckle tracking were assessed to determine the presence of RVP-induced MD. The endpoints were volumetric non-response (defined by a relative decrease in LV ESV <15%) and the composite of volumetric non-response or HF hospitalization. Results The echocardiographic assessment was feasible in 325 patients at baseline; 133 (41%) patients presented with MD. Females were more likely to present with MD (female vs. male, 65% vs. 38%, p=0.003). MD patients had higher LV EDV (MD vs. no-MD, 248±78 vs. 219±78 mL, p=0.001) and LV ESV (190±67 vs. 165±64 mL, p<0.001) at baseline. In the CRT-D group, 126 (75%) patients were volumetric responders, and 41 (25%) were non-responders at 12 months. CRT patients with baseline MD were less likely to experience volumetric non-response (OR 0.35 [95% CI 0.15-0.82], p=0.015) or the composite endpoint (OR 0.37 [95% CI 0.17-0.77], p=0.008). Out of 57 CRT patients with baseline MD who had follow-up assessment available, 52 (91%) patients had a favorable change: the MD pattern disappeared. Patients with MD resolution at 12 months were less likely to experience volumetric non-response or the composite endpoint (OR 0.39 [95% CI 0.17-0.93], p=0.034; OR 0.38 [95% CI 0.16-0.86], p=0.021, respectively). CRT patients with resolved MD were less likely of ischemic etiology and had 100% posterior or lateral LV lead location. Conclusions The presence of RVP-induced MD and its resolution is associated with better clinical response in HFrEF patients undergoing CRT-D upgrade. MD assessment can refine patient selection algorithms of CRT.Figure 1

BACKGROUND The COVID-19 pandemic adversely affected health care systems. Patients in need of transcatheter aortic valve replacement (TAVR) are especially susceptible to treatment delays. OBJECTIVES This study sought to evaluate the impact of the COVID-19 pandemic on global TAVR activity. METHODS This international registry reported monthly TAVR case volume in participating institutions prior to and during the COVID-19 pandemic (January 2018 to December 2021). Hospital -level information on public vs private, urban vs rural, and TAVR volume was collected, as was country -level information on socioeconomic status, COVID-19 incidence, and governmental public health responses. RESULTS We included 130 centers from 61 countries, including 65,980 TAVR procedures. The first and second pandemic waves were associated with a significant reduction of 15% (P < 0.001) and 7% (P < 0.001) in monthly TAVR case volume, respectively, compared with the prepandemic period. The third pandemic wave was not associated with reduced TAVR activity. A greater reduction in TAVR activity was observed in Africa (-52%; P = 0.001), Central -South America (-33%; P < 0.001), and Asia (-29%; P < 0.001). Private hospitals (P = 0.005), urban areas (P = 0.011), low -volume centers (P = 0.002), countries with lower development (P < 0.001) and economic status (P < 0.001), higher COVID-19 incidence (P < 0.001), and more stringent public health restrictions (P < 0.001) experienced a greater reduction in TAVR activity. CONCLUSIONS TAVR procedural volume declined substantially during the first and second waves of the COVID-19 pandemic, especially in Africa, Central -South America, and Asia. National socioeconomic status, COVID-1 9 incidence, and public health responses were associated with treatment delays. This information should inform public health policy in case of future global health crises. (J Am Coll Cardiol Intv 2024;17:374-387) (c) 2024 by the American College of Cardiology Foundation.

AIMS:Patients with obesity have an overall higher cardiovascular risk, at the same time obesity could be associated with a better outcome in a certain subgroup of patients, a phenomenon known as the obesity paradox. Data are scarce in candidates for cardiac resynchronization therapy (CRT). We aimed to investigate the association between body mass index (BMI) and all-cause mortality in patients eligible for CRT. METHODS:Altogether 1,585 patients underwent cardiac resynchronization therapy between 2000-2020 and were categorized based on their BMI, 459 (29%) patients with normal weight (BMI < 25 kg/m2), 641 (40%) patients with overweight (BMI 25- < 30 kg/m2) and 485 (31%) with obesity (BMI ≥ 30 kg/m2). The primary endpoint was all-cause mortality, heart transplantation, and left ventricular assist device implantation. We assessed periprocedural complications and 6-month echocardiographic response. RESULTS:Normal-weight patients were older compared to patients with overweight or obesity (70 years vs. 69 years vs. 68 years; P ‹0.001), respectively. Sex distribution, ischaemic aetiology, and CRT-D implantation rates were similar in the three patient groups. Diabetes mellitus (BMI < 25 kg/m2 26% vs. BMI 25- < 30 kg/m2 37% vs. BMI ≥ 30 kg/m2 48%; P ‹0.001) and hypertension (BMI < 25 kg/m2 71% vs. BMI 25- < 30 kg/m2 74% vs. BMI ≥ 30 kg/m2 82%; P ‹0.001) were more frequent in patients with overweight and obesity. During the mean follow-up time of 5.1 years, 973 (61%) reached the primary endpoint, 66% in the BMI < 25 kg/m2 group, 61% in the BMI 25- < 30 kg/m2 group and 58% in the BMI ≥ 30 kg/m2 group (log-rank P‹0.05). Patients with obesity showed mortality benefit over normal-weight patients (HR 0.78; 95%CI 0.66-0.92; P = 0.003). The obesity paradox was present in patients free from diabetes, atrial fibrillation, and ischemic events. Periprocedural complication rates did not differ in the three groups (BMI < 25 kg/m2 25% vs. BMI 25- < 30 kg/m2 28% vs. BMI ≥ 30 kg/m2 26%; P = 0.48). Left ventricular ejection fraction improved significantly in all patient groups (BMI < 25 kg/m2 median ∆ -LVEF 7% vs. BMI 25- < 30 kg/m2 median ∆ -LVEF 7.5% vs. BMI ≥ 30 kg/m2 median ∆ -LVEF 6%; P < 0.0001) with a similar proportion of developing reverse remodeling (BMI < 25 kg/m2 58% vs. BMI 25- < 30 kg/m2 61% vs. BMI ≥ 30 kg/m2 57%; P = 0.48); P = 0.75). CONCLUSIONS:The obesity paradox was present in our HF cohort at long-term, patients underwent CRT implantation with obesity and free of comorbidities showed mortality benefit compared to normal weight patients. Patients with obesity showed similar echocardiographic response and safety outcomes compared to normal weight patients.

Introduction: Low gradient (LG) aortic stenosis (AS) remains a diagnostic challenge. Computed tomography (CT) aortic valve calcium scoring (AVCS) provides a good discrimination of patients with severe high gradient (HG) and moderate AS, however data on its diagnostic value among patients with low gradient severe AS are scarce.Our aims were: 1, to assess the diagnostic sensitivity of the recommended AVCS thresholds in our patient population with severe AS, particularly in those with low LGAS; 2, to identify any factors associated with below cut-off AVCS values despite severe AS; 3, to evaluate the prognosis of severe AS patients with low and high AVCS values.

Abstract Introduction Right ventricular (RV) pacing (RVP) impairs left ventricular (LV) function. Nevertheless, the interaction between arterial afterload and RVP-associated LV dysfunction has not been investigated yet. Purpose We sought to examine the effect of afterload on RVP-evoked LV hemodynamic changes in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) as well as in a small animal model of sustained LV pressure overload (PO). Methods Thirty-five patients with AS and a previously implanted pacemaker underwent detailed echocardiographic examination immediately before TAVI and also on the second postoperative day. The ultrasound measurements were carried out during intrinsic, narrow QRS rhythm and during frequency-matched RVP as well. Global myocardial work index (GMWI) was calculated to assess LV contractility. In parallel, LV pressure-volume analysis was performed in Wistar rats with transverse aortic constriction (TAC) or sham operation (Sham) during intrinsic narrow QRS rhythm (termed as TAC-Vsense and Sham-Vsense) as well as during RVP (termed as TAC-Vpace and Sham-Vpace). RVP was achieved in rats by an octopolar electrophysiology catheter placed in the RV. Results RVP decreased LV contractility in AS patients before and after TAVI as well. Nevertheless, the extent of RVP-evoked LV dysfunction was alleviated following pressure unloading (ΔGMWI: -37±7 vs. -25±8%, before TAVI vs. after TAVI, P<0.05). Similarly, although RVP was associated with reduced LV contractility in both the TAC (the slope of the maximum rate of LV pressure rise-end-diastolic volume relation [dPdtmax-EDV]: 92±8 vs. 53±6mmHg/s/µl, TAC-Vsense vs. TAC-Vpace; P<0.05) and Sham groups (dPdtmax-EDV: 74±5 vs. 60±9 mmHg/s/µl, Sham-Vsense vs. Sham-Vpace; P<0.05), the negative inotropic effect of RVP was found to be stronger in the TAC compared to the Sham group (ΔdPdtmax-EDV: -42±4 vs. -19±6%; TAC vs. Sham, P<0.01). Furthermore, reduction of the maximal rate of LV pressure decrease (ΔdPdtmin: -20±3 vs. -5±5%, TAC vs. Sham, P<0.01) and prolongation of the active relaxation time constant (Δτ: 22±3 vs. 6±3%, TAC vs. Sham, P<0.01) also occurred to a greater extent in case of sustained LV PO, indicating augmented diastolic dysfunction. Conclusion Our translational results indicate that RVP-induced LV dysfunction might be afterload dependent.

Background: Vascular access site complications (VASCs) after endovascular interventions requiring a large-bore access are frequent and known to be associated with increased morbidity and mortality. Although balloon-expandable covered stents (BECSs) are increasingly used in such indications, their performance in this rather hostile territory is currently unknown. We aimed to evaluate the safety and efficacy of BECSs in common femoral artery (CFA) VASCs management. Methods: This is a national multicenter retrospective study of all patients who underwent BECS implantation of the CFA due to a VASCs after an endovascular procedure between January 2020 and May 2023 in major tertiary referral centers in Hungary. Operative data were collected and follow-up ultrasound examinations were performed. Our study is registered on ClinicalTrials.gov (NCT05220540) and followed the STROBE guidelines. Results: Of the 23 patients enrolled (13 females, mean age: 74.2 ± 8.6), technical success was achieved in 21 (91.3%) cases, with one perioperative death. After an average follow-up of 18.0 ± 11.4 months, another nine (39.1%) deaths occurred, and one was VASCs-associated. BECS occlusion was detected in one (4.3%) patient, being the only reintervention (4.3%) where revascularization was also achieved. Conclusions: Although BECS implantation for CFA VASCs is feasible with a relatively high technical success rate, the mortality rate is non-negligible. Until adequately evaluated, BECS implantation in such indications is to be used with caution, ideally only within the framework of a trial.

Frailty is a complex clinical syndrome associated with aging and comorbidities, which correlates with unfavorable outcomes. However, in heart failure patients, frailty is very common, data is scarce about those, who are eligible for Cardiac Resynchronization Therapy (CRT) implantation. We investigated the incidence of frailty and the association of Frailty Index (FI) with the outcome. Thirty baseline clinical parameters were used by the Rockwood cumulative deficit method to determine patients' FI in our single-center cohort. Based on previous studies, patients with FI ≤ 0.210 were considered as non-frail, those with FI 0.10–0.210 were classified in Frail-1, with FI > 0.10 in Frail-2 groups, respectively. Echocardiographic response after 12 months and all-cause mortality were investigated by frailty groups. Among 1004 included patients, 75 (7%) were considered Non-frail, 271 (27%) grouped in Frail-1, and 658 (66%) in Frail-2 with a median FI of 0.36 (0.28–0.43). Patients in Frail-2 group were older, with more comorbidities compared with non-frail patients or those in Group Frail-1. During the median follow-up time of 4.8 years, 29 (39%) patients died in the Non-frail, 140 (52%) in Frail-1, and 471 (72%) in the Frail-2 groups (log-rank p < 0.001). Group Frail-2 showed an unfavorable outcome compared to the non-frail (HR 2.49, 95%CI 1.92–3.22; p < 0.001) and the Frail-1 group (1.83, 95%CI 1.55–2.16; p < 0.001). In our HFrEF patients eligible for CRT implantation, patients were exceedingly vulnerable with a high prevalence of frailty. The calculated frailty index was associated with outcome and proved to be prevalent in individual risk stratification.