BACKGROUND:Tricuspid regurgitation (TR) is a progressive and underdiagnosed condition associated with poor prognosis. Although the TRI-SCORE is a validated risk model for patients undergoing tricuspid valve surgery, it does not incorporate echocardiographic measures of right ventricular (RV) function or RV-pulmonary artery coupling, which are increasingly recognised as major prognostic determinants. OBJECTIVES:To evaluate whether integration of simple, widely available echocardiographic indices-tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP), TAPSE/RV end-diastolic area (RVAD) and TAPSE/RV end-systolic area (RVAS)-improves the prognostic performance of the TRI-SCORE in patients with moderate-to-severe TR. METHODS:We retrospectively included 93 patients with severe TR, including functional, mixed and primary/Cardiac Implantable Electronic Device (CIED)-related aetiologies treated with medical therapy, surgery or transcatheter edge-to-edge repair. The primary endpoint was all-cause mortality; the secondary endpoint was a composite of mortality or heart failure hospitalisation. Multivariable Cox regression models were used to assess the incremental predictive value of each TAPSE-derived ratio beyond the TRI-SCORE. Optimal thresholds were derived using spline regression and maximally selected rank statistics. RESULTS:Lower TAPSE/PASP, TAPSE/RVAD and TAPSE/RVAS values were independently associated with worse outcomes. Each parameter significantly enhanced risk discrimination when added to the TRI-SCORE (C-index improved from 0.614 to 0.710 for TAPSE/PASP, 0.685 for TAPSE/RVAD and 0.696 for TAPSE/RVAS; all p<0.001). Prognostically relevant cut-offs were identified at 0.44, 0.80 and 1.3, respectively. CONCLUSIONS:Simple echocardiographic indices of RV function provide substantial incremental prognostic value when combined with the TRI-SCORE and may improve risk stratification and timing of intervention in isolated TR.

BACKGROUND:Although physiological assessment has been used in decision-making for revascularization, its role in predicting the future risk of acute coronary syndrome (ACS) remains underexplored. OBJECTIVES:This study aims to investigate the independent and combined prognostic significance of hemodynamic disease severity and distribution in identifying ACS culprit vessels, in conjunction with lumen and plaque characteristics. METHODS:The EMERALD-II study is an international, multicenter, internal case-control study enrolling 351 patients with ACS who underwent coronary computed tomography angiography (CTA) 1 month to 3 years before the event. Culprit and nonculprit vessels were identified by matching invasive coronary angiography with coronary CTA findings. High-risk plaque (HRP) characteristics, including minimum lumen area <4 mm2, plaque burden ≥70%, low-attenuation plaque, positive remodeling, spotty calcification, and napkin-ring sign, were assessed by a core laboratory, with HRP defined as ≥3 HRP characteristics. From coronary CTA, the authors derived both the hemodynamic severity of the disease (fractional flow reserve derived from computed tomography [FFRCT]) and its spatial distribution (diffuse vs focal), as assessed by the pullback pressure gradient derived from coronary CTA (PPGCT). Vessels were categorized into 4 hemodynamic disease patterns: nonischemic (FFRCT >0.80), hemodynamic diffuse (FFRCT ≤0.80 and PPGCT ≤0.50), mixed (FFRCT ≤0.80 and 0.50 < PPGCT ≤0.60), and focal disease (FFRCT ≤0.80 and PPGCT >0.60). RESULTS:Among 873 vessels, the mean FFRCT was 0.74 ± 0.17 and the mean PPGCT was 0.54 ± 0.14. Both lower FFRCT and higher PPGCT were independently associated with higher ACS risk (OR per 0.1 increase in FFRCT: 0.71 [95% CI: 0.65-0.77]; P < 0.001; OR per 0.1 increase in PPG: 1.22 [95% CI: 1.09-1.37]; P < 0.001). Among the 4 subgroups of hemodynamic disease pattern, hemodynamic focal disease showed the highest risk of ACS (relative risk [RR]: 2.02 [95% CI: 1.74-2.36]; P < 0.001), myocardial infarction (RR: 1.75 [95% CI: 1.43-2.14]; P < 0.001), and unstable angina (RR: 2.54 [95% CI: 2.00-3.22]; P < 0.001). It remained a predictor for ACS in nonobstructive lesions (OR: 3.56 [95% CI: 1.43-8.84]), obstructive lesions (OR: 3.16 [95% CI: 1.96-5.07]), non-HRP (OR: 6.69 [95% CI: 3.59-12.5]), and HRP (OR: 2.98 [95% CI: 1.83-4.87]). Although the maximal lesion-level ΔFFRCT (differences in FFRCT across the lesion) demonstrated superior model performance compared with models incorporating FFRCT and PPGCT, higher PPGCT was additionally associated with increased ACS risk, particularly among vessels with maximal ΔFFRCT ≥0.10. CONCLUSIONS:Hemodynamic disease distribution, as measured by PPGCT, complements FFRCT in predicting ACS risk. The integration of hemodynamic disease patterns provides additional prognostic value beyond lumen and plaque characteristics, with hemodynamic focal disease emerging as an independent predictor and a potential therapeutic target for ACS prevention. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II]; NCT03591328).

BackgroundThe Tri-Score is a surgical risk model developed to predict outcomes after isolated tricuspid valve surgery. Its prognostic value across contemporary treatment strategies, including transcatheter interventions and medical therapy, remains uncertain.MethodsIn this retrospective multicenter cohort study, 104 patients treated between 2010 and 2024 for isolated ≥moderate tricuspid regurgitation (TR) were included. Patients were managed with medical therapy (n=31), surgery (n=40), or transcatheter edge-to-edge repair (T-TEER; n=33). The primary endpoint was all-cause mortality during follow-up, and the secondary endpoint was a composite of all-cause mortality or heart failure hospitalization. Outcomes were analyzed according to baseline Tri-Score categories: low (0–3), intermediate (4–5), and high (≥6). Multivariable Cox regression adjusted for treatment strategy, age, and sex.ResultsMean age was 74.8±12.9 years, and 62% were female. Median follow-up was 45 months (IQR 27–63). TR reduction to

BACKGROUND:Risk assessment of coronary side branch (SB) lesions remains challenging because stenosis-based assessment alone often fails to identify clinically relevant lesions. OBJECTIVES:To characterize SB lesions associated with acute coronary syndrome (ACS), evaluate the performance of conventional main vessel (MV)-derived high-risk plaque criteria in SB lesions, and identify independent SB predictors of ACS. METHODS:We analyzed 2451 coronary lesions (2011 MV, 440 SB) from the EMERALD-II study, in which coronary CT angiography was performed 1-36 months before ACS using an AI-assisted quantitative analysis platform. Lesion characteristics included stenosis severity, plaque burden, adverse plaque characteristics (APCs), and the change in CT-derived fractional flow reserve across the lesion (ΔFFRCT). Diagnostic performance of conventional high-risk plaque criteria was compared between MV and SB lesions. RESULTS:Culprit lesions showed greater stenosis severity, plaque burden, APC count, and ΔFFRCT than non-culprit lesions in both vessels. However, these interrelationships were weaker in SB lesions. Among lesions meeting high-risk criteria, SB lesions were less often ACS culprits than MV lesions: ≥50% stenosis, 11.1% vs. 38.5%; plaque burden ≥70%, 8.6% vs. 23.8%; ≥2 APCs, 18.2% vs. 34.4%; and ΔFFRCT ≥0.10, 19.4% vs. 49.4%. Positive predictive values and F1-scores were consistently lower for SB lesions. APC count and ΔFFRCT were independent predictors of ACS in SB lesions. CONCLUSIONS:SB lesions had a substantially lower likelihood of subsequent ACS culprit status than equivalent MV lesions. These findings from AI-assisted CCTA analysis highlight the limitations of applying MV-derived thresholds to SB lesions and support the need for SB-specific risk assessment.

BackgroundThe TRI-SCORE is a disease-specific risk model developed to predict outcomes after isolated tricuspid valve surgery. Although its prognostic value has been demonstrated across contemporary treatment strategies, independent external validation in multicenter cohorts across a broader clinical and etiological spectrum remains limited. We evaluated the prognostic performance of the TRI-SCORE in patients with isolated ≥ moderate tricuspid regurgitation (TR) treated with medical therapy, surgery, or transcatheter tricuspid edge-to-edge repair (T-TEER).MethodsIn this retrospective multicenter study, 104 patients with isolated ≥ moderate TR treated between 2010 and 2024 were included. Patients underwent medical therapy (n = 31), isolated tricuspid valve surgery (n = 40), or T-TEER (n = 33). The primary endpoint was all-cause mortality, and the secondary endpoint was a composite of all-cause mortality or heart failure hospitalization. Multivariable Cox proportional hazards models included TRI-SCORE and selected clinically relevant covariates.ResultsThe median age was 77.0 years (IQR, 69.8–83.0), 62% of patients were women, and the median follow-up was 45 months (IQR, 27–63). During follow-up, all-cause mortality occurred in 37 (36%), and the composite endpoint in 40 (38%). One-year all-cause mortality increased across TRI-SCORE categories (7%, 13%, and 33% in the low-, intermediate-, and high-risk groups, respectively; P = 0.03). Baseline TRI-SCORE independently predicted all-cause mortality (HR 1.23; 95% CI 1.08–1.40) and the composite endpoint (HR 1.34; 95% CI 1.17–1.52). At 1 year, TR was reduced to < moderate severity in 60% of medically treated patients, 91% of surgically treated patients, and 68% of T-TEER-treated patients. Although surgery was associated with a lower risk of the composite endpoint (HR 0.39; 95% CI 0.17–0.89), Kaplan–Meier analysis showed no significant survival difference among treatment groups.ConclusionsIn this multicenter real-world cohort of patients with isolated ≥ moderate TR, the TRI-SCORE provided independent prognostic information across medical therapy, surgery, and T-TEER. These findings provide external validation of the TRI-SCORE in a multicenter cohort representing a broader clinical and etiological spectrum than previously evaluated, supporting its use for baseline risk stratification across contemporary management strategies. Treatment comparisons should be interpreted cautiously because of the observational study design.

This paper describes the role of cardiovascular magnetic resonance (CMR) imaging in assessing patients with mitral valve disease. Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases. It often progresses without significant symptoms, leading to left ventricular overload, dysfunction, frequent decompensated heart failure episodes, and excess mortality. Cardiovascular magnetic resonance assessment is recommended for MR when routine ultrasound imaging information is insufficient or discordant. A well-planned CMR can provide an in-depth assessment of the mitral valve apparatus, leaflet morphology, and papillary muscles. In addition, it can precisely inform the impact of MR on left atrial and ventricular remodelling. The review aims to highlight established and emerging techniques for morphological assessment, flow assessment (including regurgitation and stenosis), myocardial assessment, and haemodynamic assessment of mitral valve disease by CMR. It also proposes a simplified clinical flow chart for CMR assessment of the mitral valve.

Background: Discrepancies between stenosis severity assessed at coronary computed tomography angiography (CCTA) and ischemia might depend on vessel type. Coronary plaque features are associated with ischemia. Thus, we evaluated the vessel-specific correlation of CCTA-derived diameter stenosis (DS) and invasive fractional flow reserve (FFR) and explored whether integrating morphological plaque features stratified by vessel might increase the predictive yield in identifying vessel-specific ischemia. Methods: Observational cohort study including patients undergoing CCTA for suspected coronary artery disease, with at least one vessel with DS >= 50 % at CCTA, undergoing invasive coronary angiography and FFR. Plaque analysis was performed using validated semi-automated software. Coronary vessels were stratified in left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA). Per vessel independent predictors of ischemia among CCTA-derived anatomical and morphologic plaque features were tested at univariable and multivariable logistic regression analysis. The best cut-off to predict ischemia was determined by Youden's index. Ischemia was defined by FFR <= 0.80. Results: The study population consisted of 192 patients, of whom 224 vessels (61 % LAD, 19 % LCX, 20 % RCA) had lesions with DS >= 50 % interrogated by FFR. Despite similar DS, the rate of FFR <= 0.80 was higher in the LAD compared to LCX and RCA (67.2 % vs 43.2 % and 44.2 %, respectively, p = 0.018). A significant correlation between DS and FFR was observed only in LAD (p = 0.003). At multivariable analysis stratified by vessel, the vessel-specific independent predictors of positive FFR were percent atheroma volume (threshold>17 %) for LAD, non-calcified plaque volume (threshold >130 mm(3)) for LCX, and lumen volume (threshold <844 mm(3)) for RCA. Integrating DS and vessel-specific morphological plaque features significantly increased the predictive yield for ischemia compared to DS alone (AUC ranging from 0.51 to 0.63 to 0.76-0.80). Conclusions: Integrating DS and vessel-specific morphological plaque features significantly increased the predictive yield for vessel-specific ischemia compared to DS alone, potentially improving patients' referral to the catheterization laboratory.

Abstract Introduction Echocardiography-derived septal strain patterns stages are associated with a stepwise increase in survival for each increment in strain stage among patients treated with cardiac resynchronization therapy (CRT). However, it is unknown whether the strain stages could also predict survival in conservatively-treated (i.e. not CRT-implanted) patients. Purpose This study aims to investigate the interplay between septal strain patterns and long-term survival in both CRT- and conservatively-treated patients. Methods In this multicentre study, CRT-eligible patients from six European centres underwent speckle-tracking strain analysis on echocardiography. CRT-treated patients (CRT) were enrolled prospectively and assessed prior to device implantation. Conservatively-treated patients (CON) were assessed retrospectively. Dyssynchrony was graded through analysis of septal strain curves, categorizing patients into five distinct patterns, denoted as strain Stage-0 (no dyssynchrony) through strain Stage-4 (severe dyssynchrony) (Fig. A). The study endpoint was all-cause mortality. Results A total of 267 CRT patients (69% males, 89% left bundle branch block (LBBB) and QRS 166±20 ms) and 167 CON patients (69% males, 87% LBBB, QRS 155±25 ms) were included. Median follow-up time was 49 (40-57) months. CON patients within the highest strain stages had the worst outcome, whereas CRT-treated patients within the highest strain stages had the best survival (Fig. B). A stepwise increase in survival difference was observed between CRT and CON patients for each increment in strain stage (Fig. B-F). Hazard ratios (HR) were: Stage-0: 1.42 (95% CI: 0.59-3.44, p=0.436) / Stage-1: 2.63 (95% CI: 1.19-5.82, p=0.017) / Stage-2: 3.93 (95% CI: 1.20-12.83, p=0.024) / Stage-3: 5.74 (95% CI: 1.72-19.19, p=0.005) and Stage-4: 16.49 (95% CI: 4.84-56.21, p<0.001). Conclusions The strain stages demonstrated a strong survival benefit for CRT-treated compared to conservatively-treated, but CRT-eligible patients. Patients with more severe dyssynchrony (highest strain stages) have most benefit from CRT implantation. These findings underscore the potential value of the strain stages in refining risk stratification and patient selection of CRT.

BACKGROUND:Extravalvular cardiac damage (EVCD) and extracellular volume (ECV) are key determinants of poor outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). We aimed to assess the association of ECV derived by means of cardiac computed tomography (CT) with EVCD before and after TAVI, its impact on left ventricular reverse remodelling, and functional improvements at 3-month follow-up in patients with severe AS undergoing TAVI. METHODS:This was a prospective study of 73 consecutive patients undergoing TAVI, with CT-derived ECV assessment and baseline and follow-up echocardiographic evaluation of EVCD. After identifying the best ECV cutoff for predicting EVCD progression and advanced EVCD (stages 3-4) at follow-up according to the Youden index, patients were divided into low (n = 39) and high (n = 34) ECV groups. Predictors of EVCD progression, advanced EVCD, and functional improvements at follow-up were identified by means of logistic regression analysis. RESULTS:At 3-month follow-up, 34.2% of patients showed EVCD progression. ECV ≥ 32% accurately predicted EVCD progression and stages 3-4 (area under the receiver operating characteristic curve 0.66, P < 0.001). At follow-up, patients with high ECV were more frequently in stages 3-4 (P = 0.011) and had a 50% progression rate (P = 0.012). Conversely, patients with low ECV exhibited greater LV reverse remodelling (P = 0.004) and improvement in New York Heart Association (NYHA) functional class at both 3-month (P = 0.020) and 6-month (P = 0.001) follow-ups compared with patients with high ECV. High ECV emerged as an independent predictor of EVCD progression (odds ratio [OR] 4.34, 95% CI 1.36-13.78, P = 0.013), stages 3-4 (OR 5.71, 95% CI 1.77-18.42, P = 0.004) and lack of improvement in NYHA functional class (OR 3.22, 95% CI 1.14-9.09, P = 0.027) at 3-month follow-up. CONCLUSIONS:Elevated CT-derived ECV was associated with EVCD progression and reduced functional improvement after TAVI.

Background Left bundle branch block (LBBB) causes left atrial (LA) dyssynchrony. It is unknown if LA dyssynchrony impacts long-term prognosis. Objectives The purpose of this study was to determine mechanisms of LA dyssynchrony in LBBB and if LA dyssynchrony impacts long-term prognosis. Methods In a prospective multicenter study of 168 heart failure patients with LBBB, echocardiographic strain imaging was done before and after 6 months with cardiac resynchronization therapy (CRT). Outcome was assessed after 6 years. Dyssynchrony was measured relative to septum as delay in left ventricular (LV) lateral wall shortening and LA lateral wall stretch. Response to CRT was defined as at least 15% reduction in LV end-systolic volume. Results Before CRT, there was marked LA dyssynchrony of 105 ± 76 ms, which decreased to 37 ± 68 ms in CRT-responders (P < 0.001), whereas nonresponders showed only a modest reduction in LA dyssynchrony (P < 0.05). There was strong association between LA and LV dyssynchrony (r = 0.70), consistent with direct LV-LA mechanical interaction. CRT caused modest increase in LA reservoir strain (P < 0.01) and marked increase of LV filling time (P < 0.001) in responders. Mortality after 6 years was 21% (35 deaths). LA dyssynchrony did not independently predict mortality. However, the combination of preserved LA reservoir strain (≥18%) and resolved LA dyssynchrony (≤53 ms) after 6 months with CRT was associated with excellent long term-prognosis: HR: 0.11 (95% CI: 0.03-0.42) vs preserved reservoir strain and persistent LA dyssynchrony. Conclusions LA dyssynchrony in LBBB was attributed to direct LV-LA mechanical interactions. CRT improved diastolic function by increasing LV filling time. Patients with preserved LA reservoir strain and resolution of LA dyssynchrony by CRT had excellent long-term prognosis. (Contractile Reserve in Dyssynchrony: A Novel Principle to Identify Candidates for Cardiac Resynchronization Therapy [CRID-CRT]; NCT02525185)

Mitral regurgitation (MR) is a common valvular disease associated with poor prognosis. Percutaneous mitral valve repair (PMVR) combined with guideline-directed medical therapy has shown prognostic benefits, yet a substantial proportion of patients experience major adverse cardiovascular events (MACE), including death and heart failure hospitalization, within the first year. Identifying short-term nonresponders remains a clinical priority. This study evaluated the prognostic value of advanced right ventricular (RV) function parameters in predicting MACE following PMVR using the MitraClip system. A total of 60 consecutive patients with symptomatic severe MR undergoing PMVR were analyzed. Echocardiographic assessments were performed at baseline, postprocedure before discharge, and at 6-month follow-up. Parameters included tricuspid annular plane systolic excursion (TAPSE) normalized to pulmonary artery systolic pressure (TAPSE/PASP), right ventricular end-diastolic area (TAPSE/RVAD), and end-systolic area (TAPSE/RVAS), along with RV myocardial work indices. During the first year, 35% of patients experienced MACE. At baseline, those who developed MACE had significantly higher creatinine, troponin T, NT-proBNP levels, larger right heart dimensions, and lower TAPSE (all p <0.05), while other clinical, imaging, and procedural characteristics were similar. In multivariate analysis, TAPSE/PASP, TAPSE/RVAS, and TAPSE/RVAD were independent predictors of MACE (all p <0.05), with AUC values ranging from 0.80 to 0.85, indicating strong predictive capacity. Throughout follow-up, these indices remained significantly lower in patients with MACE, while RV myocardial work parameters had lower predictive accuracy (AUC<0.60). In conclusion, a comprehensive RV assessment, particularly TAPSE-based indices, can help identify patients at higher risk of adverse outcomes after PMVR, whereas RV myocardial work indices appear less reliable.

Background Acute coronary syndrome (ACS) arises from a complex interplay among luminal narrowing, plaque morphology, and hemodynamic environment. Objectives The authors aimed to compare the effectiveness of anatomy- and physiology-based ACS risk assessment. Methods In this international, multicenter, internal case-control study, 351 ACS patients who underwent coronary computed tomography angiography (CCTA) 1 month to 3 years before the event were analyzed. Lesions were classified as culprit or nonculprit based on invasive coronary angiography at the time of ACS. Core lab CCTA analyses assessed lesion-specific characteristics: stenosis severity, adverse plaque characteristics (APC) (low-attenuation plaque, positive remodeling, spotty calcification, napkin-ring sign), plaque burden at minimum lumen area, and changes in CCTA-derived fractional flow reserve (ΔFFRCT). Diagnostic performance in identifying culprit lesions was compared. Results Among 2,451 lesions, 363 (14.8%) became ACS culprits, with a median interval of 375 [95.0-644.5] days. All anatomical and simulated physiological characteristics were independently associated with culprit lesions (all P < 0.001). In identifying ACS culprit lesions, plaque burden ≥70% showed the highest sensitivity of 90.6% (87.2%-93.2%) and ΔFFRCT ≥0.10 had the highest specificity of 88.3% (86.9%-89.6%) %. Predictability was similar between ΔFFRCT and the combined degree of stenosis, the number of APCs, and plaque burden (area under the curve 0.805 [0.782-0.829] vs 0.802 [0.777-0.826]; P = 0.748), with additive discrimination towards each other. Conclusions Luminal narrowing, plaque quality and quantity, and local hemodynamics were independent predictors of ACS, offering specificity in physiology and sensitivity in anatomy. A comprehensive assessment of them further refined the risk prediction for future ACS. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II]; NCT03591328)

Cardiac conduction disease often necessitates permanent pacemaker implantation. While right ventricular pacing (RVP) effectively treats bradycardia, it may lead to adverse cardiac remodeling and heart failure. Left bundle branch area pacing (LBBAP) has emerged as an alternative, potentially preserving myocardial function. Non-invasive myocardial work (MW) assessment provides valuable insights into left ventricular systolic function, energetics, and efficiency. This study systematically reviewed and analyzed MW parameters, comparing LBBAP to RVP and His bundle pacing (HBP). A meta-analysis of 241 patients across five studies examined four MW parameters-Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), and Global Work Efficiency (GWE)-at baseline, post-implantation, and last follow-up (median: 180 days, IQR: 7-360 days). At baseline, MW parameters were similar between LBBAP and RVP. Post-implantation, LBBAP preserved MW more effectively, showing significantly higher GWI than RVP (2250.0 ± 400.0 vs. 1600.0 ± 300.0 mmHg%, p = 0.027), a difference that remained significant at follow-up (p = 0.035). GWE was also significantly higher at follow-up (p = 0.011), while GCW and GWW showed no significant differences. MW parameters did not differ significantly between LBBAP and HBP (all p-values >0.05). These findings suggest that LBBAP provides superior MW preservation compared to RVP, with significant benefits in GWI and GWE, while demonstrating comparable performance to HBP.

Evidence suggests that even mild-to-moderate paravalvular regurgitation (PVR) following transcatheter aortic valve implantation (TAVI) is associated with adverse outcomes. We directly compared the diagnostic performance and predictive value of invasive (hemodynamic) versus noninvasive (echocardiographic) assessments of PVR. Additionally, we explored the effectiveness of a comprehensive integrated approach that combines both methodologies to accurately identify and predict the clinical consequences of PVR. This retrospective, single-center, observational study included 126 patients with PVR after TAVI. PVR severity was assessed through both invasive (Aortic Regurgitation Index - ARI - and ARIratio) and noninvasive metrics. Additionally, an integrated PVR staging system was developed, incorporating both methodologies and classifying patients into mild, moderate or severe categories. The prognostic significance of this integrated staging approach was also evaluated, particularly concerning major adverse cardiovascular events (MACE) at the latest clinical follow-up. Our findings revealed a poor agreement between hemodynamic assessments and noninvasive evaluation (Cohen's Kappa = 0.24) particularly in cases graded invasively as mild and subsequently reclassified via echocardiographic metrics. The integrated PVR staging demonstrated superior diagnostic accuracy compared to the invasive method (AUC 0.805 vs 0.660 respectively, De Long p = 0.020) while showing comparable accuracy to noninvasive staging (AUC 0.750 p = 0.357). However, invasive assessment was more effective in predicting early MACE, whereas noninvasive method provided a better accuracy in evaluating late events. Moreover, patients with severe PVR identified through the integrated assessment had significantly lower event-free survival (log-rank chi-square 31.97, p <0.001). In conclusion, invasive assessment of PVR effectively identifies patients at risk for early MACE, particularly those with moderate or severe PVR. However, echocardiography significantly enhances risk stratification in all other cases. Therefore, an integrated approach combining both invasive and noninvasive modalities may represent the most appropriate strategy for identifying patients at increased risk of adverse outcomes following TAVI.

A substantial number of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) experience adverse events after TAVI, with health care expenditure. We aimed to investigate cardiac remodeling and long-term outcomes in diabetic patients with severe AS, left ventricular ejection fraction (LVEF) < 50

Abstract Introduction Long-term response to cardiac resynchronization therapy (CRT) is primarily assessed by 2D echocardiography. The combination of 3D echocardiography and left ventricular (LV) pressure curve estimation allows for pressure-volume (PV) analysis and LV work efficiency (LVWE) estimation which may be superior to today’s methods. Aim To investigate if PV-analysis by 3D echocardiography is superior to 2D volumes at predicting long-term survival in CRT. Methods In a recent prospective multicenter study, non-invasive PV-analysis (n=106) and 2D volume analysis by biplane Simpson’s method (n=195) were performed, before and 6 months after CRT. The LV pressure curve was estimated by aligning a reference pressure curve with mitral and aortic valve events obtained from echocardiography. The amplitude of the curve was adjusted to brachial systolic cuff pressure and combined with 3D volumes for PV-analysis. As shown in figure 1, LVWE was calculated as the ratio of estimated stroke work (red area) to total mechanical energy (red + blue areas). The cutoff value for change in LV end-systolic volume (ESV) was set at 15% and at >35% for LVWE using Receiver Operator Curve analysis. Volumetric non-responders were subdivided into response based on LVWE. Results After 6±2 years follow-up, 47 (23%) patients had died. Relative change in 3D and 2D LV ESV showed similar ability to predict long-term all-cause mortality (log rank p<0.001 for both) (Figure 2). However, LVWE identified patients with a positive effect of CRT who were volumetric non-responders. These patients had similar outcomes as volumetric responders (HR 1.91, 95% CI: 0.54-6.81) (Figure 3). LVWE also identified non-responders with particularly adverse outcomes (HR 3.46, 95% CI: 1.32-9.10 vs volumetric non-response and LVWE >35%). Conclusions PV-analysis by 3D-echoardiography identifies a new group of patients who respond to CRT without a 15% reduction in ESV who have similar outcomes to volumetric responders. In our data, 3D echocardiography was superior to 2D volumes at predicting long-term all-cause mortality after CRT. LV work efficiency before and after CRT LV work efficiency and survival

BACKGROUND:The relevant time frame for predicting future acute coronary syndrome (ACS) based on coronary lesion characteristics remains uncertain. OBJECTIVES:The aim of this study was to investigate the association of lesion characteristics with test-to-event time and their prognostic impact on ACS. METHODS:The EMERALD II (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II) study analyzed 351 patients who underwent coronary computed tomography angiography (CTA) and experienced ACS between 1 month and 3 years of follow-up. Lesions identified on coronary CTA were classified as culprit (n = 363) or nonculprit (n = 2,088) on the basis of invasive coronary angiography findings at the time of ACS. Core laboratory coronary CTA analyses assessed 4 domains: degree of stenosis, plaque burden, number of adverse plaque characteristics (APC) (low-attenuation plaque, positive remodeling, spotty calcification, and napkin-ring sign), and changes in coronary CTA-derived fractional flow reserve across the lesion (ΔFFRCT). Patients were categorized into short (<1 year), mid (1-2 years), and long (2-3 years) test-to-event time groups. RESULTS:Patient characteristics, including cardiovascular risk factors, did not differ across short, mid, and long test-to-event groups (P > 0.05 for all), and the proportion of ACS culprit lesions was similar (P = 0.552). Among culprit lesions, shorter test-to-event time was associated with higher luminal stenosis, plaque burden, and ΔFFRCT (P for trend < 0.001 for all). The predictability for ACS culprit lesions based on the combined 4 characteristics tended to decrease over time and significantly reduced beyond 2 years (AUC: 0.851 vs 0.741; P = 0.006). In predicting ACS risk within test-to-event time <2 years using obstructive lesions (stenosis ≥ 50%), APC ≥2, plaque burden ≥70%, and ΔFFRCT ≥0.10, the risk was elevated compared to the average proportion of lesions becoming ACS culprit (12.1%) in the following subsets: lesions with 4 characteristics (proportion of lesions becoming ACS culprit: 49.3%; P < 0.001), lesions with 3 characteristics (obstructive lesions with plaque burden ≥70% and either ΔFFRCT ≥0.10 [proportion of lesions becoming ACS culprit: 33.0%; P < 0.001] or APC ≥2 [proportion of lesions becoming ACS culprit: 31.2%; P < 0.001]), and lesions with 2 characteristics (plaque burden ≥70% and ΔFFRCT ≥0.10; proportion of lesions becoming ACS culprit: 21.5%; P = 0.016). CONCLUSIONS:Increased luminal stenosis, plaque burden, and ΔFFRCT were associated with shorter test-to-ACS event time. The prognostic impact of lumen, plaque, and local hemodynamic characteristics was most relevant to ACS risk within a 2-year period, with higher risk observed when specific combinations of them were present. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II] Study; NCT03591328).