Significant tricuspid regurgitation (TR) is increasingly recognized as a major determinant of morbidity and mortality, yet the clinical impact of significant TR has long been underestimated. Assessment of right ventricular (RV) systolic function is central to understanding and managing TR and represents the principal determinant of symptoms, therapeutic response, and long-term outcomes. The unique sensitivity of the RV to alterations in preload and afterload leads to maladaptive remodeling, making accurate functional assessment essential for risk stratification and for optimizing the timing and type of intervention, especially given the expanding range of available surgical and transcatheter treatment options. Echocardiography remains the primary imaging modality, providing qualitative and quantitative evaluations of RV function through parameters such as tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), and tissue Doppler systolic velocity (S′). Advances in speckle-tracking echocardiography for RV free-wall longitudinal strain and in three-dimensional imaging have improved accuracy; however, all echocardiographic measures remain limited by the complex geometry of the RV. When feasible and available, cardiac magnetic resonance (CMR) imaging serves as the reference standard for precise assessment of RV volumetric and functional parameters. Impaired RV systolic function, both before and after intervention, irrespective of the imaging parameter used for the assessment, consistently predicts adverse outcomes in patients with severe TR, including heart failure progression, reduced exercise tolerance, and decreased survival. Therefore, early recognition and quantification of RV dysfunction are crucial to enable timely therapy, as interventions before the development of advanced RV impairment provide symptomatic and survival benefits. This review summarizes the pathophysiology, quantitative thresholds, and prognostic significance of RV function assessment, emphasizing the pivotal role this evaluation plays in the contemporary management of significant TR.

Aims:Multiple and mixed valvular heart disease (MMVD) are frequent situations in clinical practice. Despite a high prevalence, comprehensive insights into their clinical presentation, management strategies, impact of multimodality imaging, and outcomes are not well established, due to a lack of dedicated studies. Methods and results:The 'EACVI-MMVD Study' will be a large prospective, multicentre, observational cohort study led by the Heart Imagers of Tomorrow of the European Association of Cardiovascular Imaging (EACVI). It will assess the proportion, management, and prognosis of MMVD over a 1-year period of follow-up. All consecutive patients diagnosed with MMVD using transthoracic echocardiography will be recruited over a 6-month recruitment period in 88 centres from 24 different countries. Baseline evaluation will be determined by physicians and encompass the whole spectrum of multimodality imaging including transthoracic and transoesophageal echocardiography, stress echocardiography, computed tomography, and cardiovascular magnetic resonance. Centres will have the opportunity to send cardiovascular imaging data for core laboratory analysis and to extend recruitment throughout a 5-year follow-up period. Conclusion:The EACVI-MMVD study will be the largest international multicentre study evaluating the prevalence of MMVD in clinical routine and determining the impact of multimodality cardiovascular imaging in MMVD patients.Clinical Trial Registration: NCT06235385 URL: https://classic.clinicaltrials.gov/ct2/show/NCT06235385.

Rapport du cas Patient de 63 ans, ayant subi un remplacement valvulaire aortique dans un contexte de sténose aortique, ainsi qu'un monopontage coronaire. Deux semaines après, il présente une bactériémie à Enterococcus faecalis, attribuée à une pyélonéphrite traitée par Amoxicilline. Deux mois plus tard, récidive de bactériémie à Enterococcus faecalis et mise en évidence d'un pseudo-anévrisme du trigone mitro-aortique. Il est initialement traité médicalement, avant de bénéficier de l'intervention dite « Hémi-Commando ». Discussion Le trigone mitro-aortique est une zone fibreuse, située entre la cuspide non coronaire et la cuspide coronaire gauche de la valve aortique et le feuillet antérieur de la valve mitrale [1]. Cette zone est peu vascularisée et donc très sensible aux infections et aux traumatismes [2]. L’érosion de l'anneau aortique conduit à la formation d'un abcès sous-valvulaire secondairement détergé ce qui mène in fine à la destruction du trigone. Conclusions Le pseudo-anévrisme est une complication rare de la chirurgie valvulaire aortique et des endocardites. Au vu du risque de rupture, la chirurgie précoce est recommandée.

With this document, the European Association of Cardiovascular Imaging provides an Expert Consensus on the role of multi-modality imaging (MMI) in the management of patients with multiple valvular heart disease (MVD). Emphasis is given to the use of MMI to unravel the diagnostic challenges that characterize these patients and to improve risk stratification. Complementing the last European Society of Cardiology and European Association of Cardio-Thoracic Surgery guidelines on valvular heart disease, this Expert Consensus document also outlines how MMI assessment should form an integral part of the multi-disciplinary heart team discussion for patients with MVD to help with complex decision-making regarding the choice and timing of treatment.

Journal Article Accepted manuscript Unveiling type B aortic dissection in Loeys-Dietz syndrome by transthoracic echocardiography: back to to the root Get access Michael Rietze, MD, Michael Rietze, MD Cardiology Department, CHU Saint-Pierre, Brussels, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar Bram Beun, MD, Bram Beun, MD Internal Medicine Department CHU Saint-Pierre, Brussels, Université Libre de Bruxelles (ULB), Brussels, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar Ivan Dimov, MD, Ivan Dimov, MD Cardiology Department, CHU Saint-Pierre, Brussels, Belgium https://orcid.org/0000-0002-9624-9315 Search for other works by this author on: Oxford Academic PubMed Google Scholar Aurelia David-Cojocariu, MD, Aurelia David-Cojocariu, MD Cardiology Department, CHU Saint-Pierre, Brussels, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar Philippe Unger, MD, PhD Philippe Unger, MD, PhD Cardiology Department, CHU Saint-Pierre, Brussels, Belgium Corresponding author: Philippe Unger, MD, Cardiology Department, CHU Saint-Pierre, 322, Rue Haute, B-1000 Brussels, Belgium, Tel: +322 535.33.50, Email: [email protected] https://orcid.org/0000-0001-6154-1546 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal - Cardiovascular Imaging, jeaf020, https://doi.org/10.1093/ehjci/jeaf020 Published: 17 January 2025 Article history Received: 13 January 2025 Accepted: 13 January 2025 Published: 17 January 2025

Background:Behçet's syndrome (BS) is a rare, chronic multisystem inflammatory disorder that can lead to severe cardiovascular complications. Among these, aortic pseudoaneurysms are infrequent and associated with high mortality due to their risk of rupture. The diagnosis of BS remains challenging due to its variable clinical presentation and the absence of specific biomarkers, particularly when the initial presentation is atypical. Case summary:We present the case of a 32-year-old former professional football player who presented with severe aortic regurgitation with heart failure due to a pseudoaneurysm of the ascending aorta. Initial suspicion of infective endocarditis and aortic dissection was excluded after a clinical, microbiological, and imaging assessment. Emergent Bentall procedure was successfully performed. Subsequently, typical clinical features, including recurrent oral ulcers, pseudofolliculitis, and superficial venous thrombophlebitis, led to the diagnosis of BS. The patient received systemic immunosuppressive therapy combining corticosteroids and infliximab. At 8-month follow-up, echocardiography demonstrated normalization of left ventricular function and no recurrence or new vascular involvement. Discussion:The case highlights the importance of considering BS in the differential diagnosis of young patients presenting with acute aortic disease. Aortic involvement in BS, although rare, can lead to severe complications. To the best of our knowledge, this is the first reported case of a pseudoaneurysm of the aortic root as the initial manifestation of BS. Rapid surgical intervention followed by appropriate medical therapy led to a favourable outcome. Recognizing BS as a potential cause of acute presentations of ascending aortic disease may ensure early and effective management.

Purpose: Thromboembolism (TE) arises in 20% to 50% of patients with infective endocarditis (IE), significantly contributing to mortality. While the pathogenesis of IE includes the formation of vegetations with platelet-fibrin clots, antithrombotic therapy (AT) has not consistently shown to prevent TE. Moreover, because of the increased risk of cerebral hemorrhage, guidelines advise against using AT in the management of IE. However, many patients with IE already receive AT at admission due to pre-existing cardiovascular conditions. This retrospective, multicentric study aims to provide insights into the in-hospital mortality and complications of patients with IE under various regimens of pre-existing AT, compared to IE controls without AT. Methods: A total of 363 patients with IE were included at 2 tertiary hospitals in Belgium. The following groups were compared: 129 patients with IE without AT (group 1), 104 patients with IE with an antiplatelet treatment (group 2), 100 patients with IE under anticoagulant therapy (group 3), and 30 patients with IE treated with combined antiplatelet and anticoagulant agents at admission (group 4). Results: This study found no significant differences in in-hospital mortality ( P = .091), TE ( P = .413), or hemorrhagic stroke ( P = .274) between groups. There was a nonsignificant trend toward reduced vegetation size ( P = .112) in the anticoagulant-treated IE groups 3 and 4. There were significantly more viridans streptococci infections in the younger control group 1 ( P = .012). Conclusion: This analysis challenges the conventional caution against AT use in IE, suggesting that pre-existing AT does not significantly influence mortality or complications in patients with IE.

CASE REPORT:We report the case of a 63-year-old patient who underwent aortic valve replacement with a biological valve for a bicuspid aortic stenosis, and LIMA-IVA single-bypass surgery. Two weeks later, he presented with Enterococcus faecillis bacteremia, attributed to left pyelonephritis and successfully treated with Amoxicillin. Two months after his surgery, he had a new bacteremia due to Enterococcus faecalis and we discovered a pseudo-aneurysm of the mitro-aortic trigone. Our patient is treated medically at first, before benefiting from the "Hemi-Commando" procedure. DISCUSSION:The mitro-aortic trigone is a fibrous area, located between the left half of the noncoronary cusp and the left coronary cusp of the aortic valve and the anterior leaflet of the mitral valve [1]. This area, important in the maintenance of mitral and aortic functions, [ii] is poorly vascularized and therefore very susceptible to infections and trauma [2]. Erosion of the aortic ring leads to the formation of a subvalvular abcess, secondarily detergated en then leads to the destruction of the trigone. CONCLUSIONS:Pseudoaneurysm is a rare complication of aortic valve surgery and endocarditis. Given the risk of rupture, early surgery is recommended.

Mixed valvular diseases (MVDs) are common but have received little attention in the literature, especially regarding the mitral valve (MV) and the right-sided cardiac valves. Whereas echocardiography plays a pivotal diagnostic role, the diagnosis is made difficult due to haemodynamic interactions that may invalidate common indices of severity used in isolated stenosis or regurgitation. The diagnostic strategy should aim at initially separately assessing stenosis and regurgitation, taking into account the diagnostic pitfalls, with complementary use of multimodality imaging in cases of persisting diagnostic uncertainties. Unlike aortic stenosis, the calcium score cannot be used as a surrogate for haemodynamic severity of mixed MV disease. Severe stenosis and/or severe regurgitation are indicative of severe MVD, and management should follow recommendations on the predominant lesion. However, some patients with the combination of moderate stenosis and moderate regurgitation have a poor prognosis when left untreated. Concordant data suggest that, in patients with mixed aortic or MV disease, transvalvular velocities and pressure gradients are more powerful prognostic indicators than valve area or the severity of regurgitation. It is essential to consider the global repercussions that indicate poor outcomes in patients with MVD. However, whereas symptoms and/or ventricular dysfunction are considered as clear indication for intervention, imaging cut-offs have not been validated for balanced moderate regurgitation and stenosis. Although emerging evidence tends to support earlier management, further prospective studies are required, and pending the results of these studies, asymptomatic patients with MVD should be closely monitored.

BackgroundRecent data suggest that the true incidence of atrial fibrillation (AF) after patent foramen ovale (PFO) closure has probably been underestimated, and may differ according to the type of closing device used.ObjectivesOn the basis of continuous rhythm monitoring with an implantable device, this study aims to assess the incidence of supraventricular arrhythmia following PFO closure with the Occlutech PFO device.MethodsThis is a multicentric analysis of consecutive PFO closure patients treated with an Occlutech device between 01/01/2019 and 20/03/2024, with an implantable loop recorder (IRL) (or a pacemaker or implantable cardioverter defibrillator) implanted for at least 3 months preceding the procedure, and with available follow-up for at least 1month post procedure. Primary endpoint was the incidence of patients with new onset supraventricular arrhythmia (AF, atrial flutter or any supraventricular tachycardia) lasting >30 s, post PFO closure.ResultsA total of 59 patients met the inclusion criteria. Patients were monitored (95% with ILR) during 284 days (IQR 241.5–374) before, and for 422 days (IQR 237–776) post PFO closure. Supraventricular arrhythmia post PFO closure was reported in 18 patients (31%), with median time-interval until arrhythmia occurrence of 16.5 days (IQR 13–21). A total of 88 supraventricular arrhythmia events (96.6% AF) were documented during follow-up. In 94.4% of patients with supraventricular arrhythmia, new-onset arrhythmia occurred in the first 45 days after PFO closure. Six patients (33.3%) with supraventricular arrhythmia post PFO closure, presented AF episodes beyond 60 days after PFO closure.ConclusionsIn this multicenter retrospective analysis of patients undergoing percutaneous PFO closure with the Occlutech PFO device, implantable continuous rhythm monitoring devices were able to diagnose new-onset supraventricular arrhythmia (97% AF) after PFO closure in 31% of patients. While 94% of new-onset supraventricular arrhythmia events occurred in the first 45 days post-procedure, one-third of patients with arrhythmia post PFO closure presented AF episodes beyond 60 days post procedure.

Multiple and mixed valvular heart disease (MMVD) is defined as the combination of stenotic or regurgitant lesions occurring on ≥2 cardiac valves (ie, multiple valvular heart disease [VHD]) or the combination of stenotic and regurgitant lesions on the same valve (ie, mixed VHD). This condition is frequent in clinical routine, with a notable shift in epidemiology over recent years, marked by a decline in rheumatic heart disease and an increase in degenerative causes. Even if echocardiography stands as the cornerstone for diagnosing VHD, practicians need to remain cautious because some echocardiographic parameters might be invalid in the context of MMVD. Considering echocardiography's pitfalls, MMVD needs to be assessed using multiparametric perspective, including cardiovascular magnetic resonance, cardiac computed tomography, biomarkers, and the assessment of comorbidities. Multimodality imaging seems to be a promising approach to assess patient's prognosis, by providing a precise analysis of cardiac remodeling and an accurate evaluation of MMVD severity. Due to the heterogeneity of this clinical scenario, studies are typically conducted in single centers with a limited number of patients. Therefore, there is a lack of dedicated guidelines regarding the severity assessment and the clinical decision-making for these MMVD patients. The aim of this review is to provide a state-of-the-art using the available evidence on the management of MMVD considering the interactions between different valve lesions, the diagnostic pitfalls, and the strategies that should be considered including the role of multimodality imaging in the presence of MMVD.

With this document, the European Association of Cardiovascular Imaging (EACVI) provides an Expert Consensus on the role of multi-modality imaging (MMI) in the management of patients with multiple valvular heart disease (MVD). Emphasis is given to the use of MMI to unravel the diagnostic challenges that characterize these patients and to improve risk stratification. Complementing the last European Society of Cardiology and European Association of Cardio-Thoracic Surgery guidelines on valvular heart disease, this Expert Consensus document also outlines how MMI assessment should form an integral part of the multi-disciplinary heart team discussion for patients with MVD to help with complex decision-making regarding the choice and timing of treatment.

"Mechanical valve obstructive thrombosis in an asymptomatic patient: a gap in current recommendations." Acta Cardiologica, ahead-of-print(ahead-of-print), pp. 1–2Keywords: Mechanical heart valvemitral valvethrombosisguidelines Disclosure statementNo potential conflict of interest was reported by the author(s).

(1) Background: infective endocarditis (IE) is a significant health concern associated with important morbidity and mortality. Only limited, often monocentric, retrospective data on IE in Belgium are available. This prospective study sought to assess the clinical characteristics and outcomes of Belgian IE patients in the ESC EORP European endocarditis (EURO-ENDO) registry; (2) Methods: 132 IE patients were identified based on the ESC 2015 criteria and included in six tertiary hospitals in Belgium; (3) Results: The average Belgian IE patient was male and 62.8 ± 14.9 years old. The native valve was most affected (56.8%), but prosthetic/repaired valves (34.1%) and intracardiac device-related (5.3%) IE are increasing. The most frequently identified microorganisms were S. aureus (37.2%), enterococci (15.5%), and S. viridans (15.5%). The most frequent complications were acute renal failure (36.2%) and embolic events (23.6%). Cardiac surgery was effectively performed when indicated in 71.7% of the cases. In-hospital mortality occurred in 15.7% of patients. Predictors of mortality in the multivariate analysis were S. aureus (HR = 2.99 [1.07–8.33], p = 0.036) and unperformed cardiac surgery when indicated (HR = 19.54 [1.91–200.17], p = 0.012). (4) Conclusion: This prospective EURO-ENDO ancillary analysis provides valuable contemporary insights into the profile, treatment, and clinical outcomes of IE patients in Belgium.

BackgroundConflicting prognostic results have been reported in patients with discordant high-gradient aortic stenosis ([DHG-AS] the combination of a mean pressure gradient ≥40 mm Hg and an aortic valve area [AVA] >1 cm2). Moreover, existing studies only included selected patients without concomitant aortic regurgitation.ObjectivesThe authors assessed the prevalence and survival of patients presenting with DHG-AS in an unselected group of consecutive patients presenting to the echocardiography laboratory of a tertiary referral center.MethodsA total of 3,547 adult patients with AVA ≤1.5 cm2 and peak aortic jet velocity ≥2.5 m/s or mean gradient ≥25 mm Hg who presented between 2005 and 2015 were included. Baseline clinical and echocardiographic data, and, when available, aortic valve calcium (AVC) score were collected in an institutional database, with subsequent retrospective analysis. The primary endpoint was all-cause mortality during follow-up.ResultsDHG-AS was observed in 163 patients (11.6% of patients with a high gradient). After adjustment for potential confounders, overall mortality rate of patients with DHG-AS was similar to that of patients with concordant severe aortic stenosis (HR: 0.98 [95% CI: 0.66-1.44]; P = 0.91), and patients with discordant low-gradient aortic stenosis (HR: 0.85 [95% CI: 0.58-1.26]; P = 0.42), and higher than concordant moderate aortic stenosis (HR: 0.54 [95% CI: 0.36-0.81]; P = 0.003). After adjustment for aortic velocities, aortic regurgitation had no significant impact on survival. AVC was higher than in patients with concordant moderate aortic stenosis and discordant low-gradient aortic stenosis, and not significantly different from that of concordant severe aortic stenosis.ConclusionsDHG-AS is not uncommon. Whereas AVA >1.0 cm2 is often seen as moderate aortic stenosis, a high-pressure gradient conveys a poor prognosis, whatever the AVA and the severity of concomitant aortic regurgitation.