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Background: High-intensity physical activity has traditionally been discouraged in patients with hypertrophic cardiomyopathy due to concerns about triggering sudden cardiac death. However, current guidelines adopt a more liberal stance, and evidence on risk factors for exercise-related sudden cardiac death remains limited. This study investigated the clinical, morphological and genetic factors associated with high-intensity physical activity-related sudden cardiac death in hypertrophic cardiomyopathy., Methods: This retrospective study included 75 patients with documented sudden cardiac death events from a cohort of 2619 patients with hypertrophic cardiomyopathy evaluated between 2005 and 2023. Physical activity levels at the time of the sudden cardiac death event were classified as high-intensity (≥6 metabolic equivalents) or low-intensity to moderate-intensity. Clinical and imaging characteristics, cardiopulmonary exercise test findings and genetic data were compared between the groups., Results: Among the 75 patients, 15 (20%) experienced sudden cardiac death events during high-intensity activity. These patients were younger than those with events during low-intensity or moderate-intensity activity (median age: 25 (IQR 16-43) years vs 56 (48-64) years, p<0.001). High-intensity activity-related events were associated with higher European Society of Cardiology sudden cardiac death risk scores (median 4.9 vs 2.4, p=0.023) and fewer ventricular arrhythmias during exercise testing. However, there were no differences in the degree of left ventricular hypertrophy, left ventricular outflow tract obstruction, left ventricular systolic or diastolic function or genetic findings between groups. In multivariable analysis, younger age was the only independent risk factor of high-intensity activity-related sudden cardiac death events. Recurrent events in patients who survived initial high-intensity activity-related sudden cardiac death were triggered by subsequent high-intensity activity., Conclusions: High-intensity physical activity-related sudden cardiac death in hypertrophic cardiomyopathy is associated with younger age; however, in this small cohort, no associations were found with traditional risk factors, including left ventricular hypertrophy or obstructive physiology., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Introduction and Objectives: Significant secondary tricuspid regurgitation (STR) is associated with poor prognosis, but its heterogeneity makes predicting patient outcomes challenging. Our objective was to identify STR prognostic phenogroups., Methods: We analyzed 758 patients with moderate-to-severe STR: 558 (74 ± 14 years, 55% women) in the derivation cohort and 200 (73 ± 12 years, 60% women) in the external validation cohort. The primary endpoint was a composite of heart failure hospitalization and all-cause mortality., Results: We identified 3 phenogroups. The low-risk phenogroup (2-year event-free survival 80%, 95%CI, 74%-87%) had moderate STR, preserved right ventricular (RV) size and function, and a moderately dilated but normally functioning right atrium. The intermediate-risk phenogroup (HR, 2.20; 95%CI, 1.44-3.37; P < .001) included older patients with severe STR, and a mildly dilated but uncoupled RV. The high-risk phenogroup (HR, 4.67; 95%CI, 3.20-6.82; P < .001) included younger patients with massive-to-torrential tricuspid regurgitation, as well as severely dilated and dysfunctional RV and right atrium. Multivariable analysis confirmed the clustering as independently associated with the composite endpoint (HR, 1.40; 95%CI, 1.13-1.70; P = .002). A supervised machine learning model, developed to assist clinicians in assigning patients to the 3 phenogroups, demonstrated excellent performance both in the derivation cohort (accuracy = 0.91, precision = 0.91, recall = 0.91, and F1 score = 0.91) and in the validation cohort (accuracy = 0.80, precision = 0.78, recall = 0.78, and F1 score = 0.77)., Conclusions: The unsupervised cluster analysis identified 3 risk phenogroups, which could assist clinicians in developing more personalized treatment and follow-up strategies for STR patients., (Copyright © 2025. Published by Elsevier España, S.L.U.)

Heart failure (HF) is a major cause of mortality and morbidity in South Korea, imposing substantial physical, emotional, and financial burdens on patients and society. Despite the high burden of symptom and complex care needs of HF patients, palliative care and hospice services remain underutilized in South Korea due to cultural, institutional, and knowledge-related barriers. This position statement from the Korean Society of Heart Failure emphasizes the need for integrating palliative and hospice care into HF management to improve quality of life and support holistic care for patients and their families. By clarifying the role of palliative care in HF and proposing practical referral criteria, this position statement aims to bridge the gap between HF and palliative care services in South Korea, ultimately improving patient-centered outcomes and aligning treatment with the goals and values of HF patients., Competing Interests: Conflict of Interest: Jin Joo Park serves as an Editor-in-Chief of the International Journal of Heart Failure, but has no role in the decision to publish this article. Except for that, no potential conflict of interest relevant to this article was reported., (Copyright © 2025. Korean Society of Heart Failure.)

Aims: This study compared echocardiography (echo) and cardiac computed tomography (CT) in measuring the Wilkins score and evaluated the potential added benefit of CT in predicting immediate percutaneous mitral valvuloplasty (PMV) outcomes in rheumatic mitral stenosis (MS) patients deemed eligible for PMV by echo., Methods and Results: From a multicentre registry of 3,140 patients with at least moderate MS, we included 96 patients (age 56.4±11.5 years, 81% female) eligible for PMV based on echo Wilkins score (≤9) who underwent PMV and had measurable CT and echo images. We compared Wilkins scores from both modalities and analyzed their relationship with unsuccessful procedural outcomes, defined as suboptimal post-procedural mitral valve area (<1.5 cm2) or newly developed mitral regurgitation grade ≥III. The mean CT score was higher than the echo score (8.0±2.4 vs. 7.3±1.2 point, p =0.005). Procedural success was achieved in 65 (67.7 %) patients. Unsuccessful results occurred in 31 patients, primarily in intermediate echo score (7-9 points) group. Among patients with intermediate echo scores, 90% had high CT scores (≥9), which were associated with significantly higher rates of unsuccessful PMV compared to lower CT scores (61.1% vs 18.9%, p<0.001)., Conclusions: CT-derived Wilkins scores were higher than echo-derived scores, with the most significant discrepancy in the intermediate echo score group. CT identified a subgroup of patients at higher risk for unsuccessful PMV among those with intermediate echo-based feasibility. Patients with intermediate echo-based PMV feasibility may benefit from CT-based reclassification, potentially improving patient selection and procedural outcomes., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Aims: Patients with moderate aortic stenosis (AS) show a poor prognosis if they have high-risk features. We investigated herein the incremental prognostic value of left ventricular (LV) and left atrial (LA) strain in patients with moderate AS., Methods and Results: In a cohort of 923 patients with moderate AS (median age 74 years, men 55%, aortic valve area 1.18 [interquartile range (IQR) 1.08-1.30] cm2, mean pressure gradient 25 [IQR 23-30] mmHg), the LV global longitudinal strain (LV-GLS) and LA reservoir strain (LARS) were measured using speckle-tracking echocardiography. Absolute values of myocardial strain were used. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization. During a median of 5.9 years, the primary endpoint occurred in 186 patients (20.2%). The median LV-GLS and LARS were 17.7% (IQR 14.8-19.7%) and 24.5% (IQR 18.7-29.3%), respectively. LV-GLS [adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.87-0.97] and LARS (adjusted HR 0.97, 95% CI 0.95-0.99) were significant predictors of the primary outcome, independent of clinical and echocardiographic variables, including LV ejection fraction. Notably, the prognostic value of LV-GLS was stronger than that of LARS, remaining significant after further adjustment for LARS. LV-GLS < 17% and LARS < 22% were identified as optimal cut-offs for the primary outcome. Patients with both reduced LV-GLS and LARS had the worst outcomes (log-rank P < 0.001). LV-GLS < 17% and LARS < 22% had incremental prognostic values on top of other clinical and echocardiographic variables., Conclusion: In moderate AS, reduced LV-GLS and LARS have incremental prognostic values and can refine risk stratification to identify high-risk patients., Competing Interests: Conflict of interest: None., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Hypertrophic cardiomyopathy (HCM) needs careful differentiation from other cardiomyopathies. Current guidelines recommend genetic testing, but genetic data on differential diagnoses and their relation with clinical outcomes in HCM are still lacking. This study aimed to investigate the prevalence of genetic variants and the proportion of other cardiomyopathies in patients with suspected HCM in Korea and compare the outcomes of HCM according to the presence of sarcomere gene mutation., Methods: We enrolled 1,554 patients with suspected HCM having left ventricular hypertrophy on transthoracic echocardiography between April 2012 and February 2023. Patients who declined genetic testing or who had pure apical HCM without a familial history were excluded. Genetic testing was performed using a next-generation sequencing panel or whole-exome sequencing for cardiomyopathies. We performed cardiovascular magnetic resonance if the diagnosis was inconclusive. Genotype-positive HCM was defined as sarcomere gene mutations of pathogenic or likely pathogenic variants. Adverse clinical outcomes were defined as a composite of all-cause death, resuscitated cardiac arrest, heart failure-related admission, appropriate implantable cardioverter defibrillator shocks, and stroke., Results: Of 492 patients (mean age 49.6 ± 14.7 years, 29.4% women) who underwent genetic testing, 214 (43.5%) had disease-causing gene mutations. After combining gene tests, multi-imaging modality, and clinical information, 447 (90.9%) had HCM, and 27 (5.5%) had Fabry disease. Among the HCM patients, 182 (40.7%) were genotype-positive, and 265 (59.3%) were genotype-negative. Kaplan-Meier curve analysis showed that genotype-positive HCM patients experienced more composite outcomes (log-rank, P < 0.001). In multivariable Cox analysis, non-sustained ventricular tachycardia (NSVT) (hazard ratio [HR], 1.91; 95% confidence interval [CI], 1.17-3.12; P = 0.010), left ventricular ejection fraction (LVEF) < 50% (HR, 5.50; 95% CI, 2.68-11.27; P < 0.001), LA reservoir strain (HR, 0.96; 95% CI, 0.93-0.99; P = 0.037), and positive sarcomere gene mutation (HR, 1.70; 95% CI, 1.04-2.78; P = 0.034) were significantly association with composite outcomes. Sarcomere gene mutation had incremental value for predicting adverse outcomes added on NSVT and LVEF < 50%., Conclusion: Genetic testing is helpful in diagnosing HCM, and sarcomere gene mutations in HCM are significantly associated with clinical outcomes., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2024 The Korean Academy of Medical Sciences.)

Background: In patients with tricuspid regurgitation (TR), delayed surgical intervention is associated with poor outcomes, particularly in advanced stages. This study aimed to assess whether earlier tricuspid valve (TV) surgery provides a survival benefit in patients with moderate to severe TR who are considered at low to intermediate risk of adverse clinical or surgical outcomes., Methods: This retrospective cohort study included 10 016 patients diagnosed with moderate to severe TR between 2008 and 2020. Patients were stratified using the the Tricuspid Regurgitation Impact on Outcomes (TRIO) Score (for general health risk) and TRI-SCORE (for perioperative risk). We focused on patients deemed at low or intermediate risk by these scores, comparing the all-cause mortality of those who underwent TV surgery to those managed medically., Results: Among 8874 patients categorised as low or intermediate risk, 871 (9.8%) underwent TV surgery. Patients in the surgical group were younger and had a higher prevalence of RV enlargement and RV dysfunction compared to those in the medical treatment group. During a mean follow-up of 5.2 years, surgical patients had a lower risk of death (HR 0.38, 95% CI 0.29 to 0.50) compared with medically managed patients after adjusting for confounders. This association persisted in patients who underwent isolated TV surgery. However, the potential for residual confounding in this non-randomised analysis should be considered., Conclusions: TV surgery was associated with higher survival rates in patients with moderate to severe TR and low to intermediate prognostic risk. However, the observational nature of the study means that uncontrolled confounding cannot be excluded. These findings warrant further investigation in randomised studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Determining elevated left atrial (LA) pressure is crucial in patients with atrial fibrillation (AF), yet non-invasive estimation using echocardiography remains unclear. This study aimed to identify useful echocardiographic indices for identifying elevated LA pressure in patients with AF., Methods and Results: Patients with paroxysmal or persistent AF referred for catheter ablation at two tertiary hospitals were prospectively enrolled. Mean LA pressure was measured immediately after transseptal puncture. Elevated mean LA pressure was defined as ≥15 mmHg. Transthoracic echocardiography was performed to acquire the guideline-recommended parameters. A total of 176 patients were included, and 63 (36%) patients had a mean LA pressure ≥15 mmHg. Patients with elevated LA pressure had more frequent hypertension, larger LA, higher septal E/e', and worse LA strain than the remaining patients. The correlations between mean LA pressure and each echocardiographic parameter were weak. Septal E/e' ratio showed the best correlation with mean LA pressure (r = 0.351, P < 0.001), and septal E/e' ratio ≥11 was the best parameter (area under the curve = 0.7, sensitivity = 65%, specificity = 73%, accuracy = 70%) to identify elevated mean LA pressure. A hierarchical algorithm consisting of septal E/e' ratio, LA reservoir strain, and LA volume index improved identification of patients with elevated mean LA pressure (sensitivity = 61%, specificity = 91%, accuracy = 80%)., Conclusion: In patients with AF, the septal E/e' ratio was the best single parameter for identifying elevated mean LA pressure. A hierarchical algorithm combining the septal E/e' ratio, LA reservoir strain, and LA volume index helps identify elevated LA pressure in patients with AF., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Percutaneous mitral valvuloplasty (PMV) is a standard treatment for severe rheumatic mitral stenosis (RMS). However, the prognostic significance of the change in mitral valve area (∆MVA) during PMV is not fully understood., Methods and results: This study analyzed data from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, which included 3,140 patients with severe RMS. We focused on patients with severe RMS undergoing their first PMV. Changes in echocardiographic parameters, including MVA quantified before and after PMV, and composite outcomes, including mitral valve reintervention, heart failure admission, stroke, and all-cause death, were evaluated. An optimal result was defined as a postprocedural MVA ≥1.5 cm 2 without mitral regurgitation greater than Grade II. Of the 308 patients included in the study, those with optimal results and ∆MVA >0.5 cm² had a better prognosis (log-rank P<0.001). Patients who achieved optimal results but with ∆MVA ≤0.5 cm² had a greater risk of composite outcomes than those with optimal outcomes and ∆MVA >0.5 cm² (nested Cox regression analysis, hazard ratio 2.27; 95% confidence interval 1.09-4.73; P=0.028)., Conclusions: Achieving an increase in ∆MVA of >0.5 cm 2 was found to be correlated with improved outcomes. This suggests that, in addition to achieving traditional optimal results, targeting an increase in ∆MVA of >0.5 cm 2 could be a beneficial objective in PMV treatment for RMS.

Background: This study was designed to determine the current status of diagnosis and treatment of valvular heart disease (VHD) in Korea., Methods: A nationwide registry study was conducted in 45 hospitals in Korea involving adult patients with at least moderate VHD as determined by echocardiography carried out between September and October of 2019. Of a total of 4,094 patients with at least moderate VHD, 1,482 had severe VHD (age, 71.3 ± 13.5 years; 49.1% male). Echocardiographic data used for the diagnosis of each case of VHD were analyzed. Experts from each center determined the diagnosis and treatment strategy for VHD based on current guidelines and institutional policy. The clinical outcome was in-hospital mortality., Results: Each valve underwent surgical or transcatheter intervention in 19.3% cases of severe mitral stenosis, 31.4% cases of severe primary mitral regurgitation (MR), 7.5% cases of severe secondary MR, 43.7% cases of severe aortic stenosis, 27.5% cases of severe aortic regurgitation, and 7.2% cases of severe tricuspid regurgitation. The overall in-hospital mortality rate for patients with severe VHD was 5.4%, and for secondary severe MR and severe tricuspid regurgitation, the rates were 9.0% and 7.5%, respectively, indicating a poor prognosis. In-hospital mortality occurred in 73 of the 1,244 patients (5.9%) who received conservative treatment and in 18 of the 455 patients (4.0%) who received a surgical or transcatheter intervention, which was significantly lower in the intervention group (P = 0.037)., Conclusions: This study provides important information about the current status of VHD diagnosis and treatment through a nationwide registry in Korea and helps to define future changes., Competing Interests: Declarations. Ethics approval and consent to participate: The study protocol was approved by the Institutional Review Board of Chonnam National University Hospital (No. CNUH-2021–203) and the participating centers, each of which waived the requirement for written informed consent because of the study’s retrospective nature and the anonymized approach to data analysis. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests., (© 2024. The Author(s).)

Competing Interests: Conflicts of Interest None.

Surgical occlusion of the left atrial appendage (LAA) during cardiac surgery in patients with atrial fibrillation (AF) is known to reduce thromboembolism. However, data on the clinical significance of LAA occlusion (LAAO) in patients with mitral regurgitation (MR) are lacking. A total of 237 AF patients with chronic severe MR who underwent mitral valve (MV) surgery were retrospectively analyzed. Patients were divided into two groups according to concomitant LAAO or LAA preservation. The primary outcome was a composite of all-cause death and thromboembolic events (ischemic stroke or systemic embolism). The LAA was surgically occluded in 98 (41%) patients and preserved in 139 (59%) patients. During the follow-up period (median, 37 months), 29 primary outcomes occurred. In the Kaplan-Meyer analysis, the LAA preservation group showed a greater cumulative incidence of the primary outcome (P = 0.002) and thromboembolic events (P = 0.003) than the LAAO group. In the univariate Cox regression analysis, coronary artery disease, CHA 2 DS 2 -VASc score, a cauliflower-shaped LAA, Maze, and no LAAO were significantly associated with the primary outcome. In the multivariate Cox regression analysis, concomitant LAAO was significantly linked to the primary outcome (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.10-0.91, P = 0.033) and thromboembolic events (HR: 0.19, 95% CI: 0.04-0.87, P = 0.032). These benefits from LAAO were consistent, even after propensity score-matched analysis. For patients undergoing surgery for chronic MR who also have AF, concomitant surgical LAAO is associated with favorable clinical outcome., (© 2024. The Author(s).)

Background and Objectives: Lipid lowering therapy is essential to reduce the risk of major cardiovascular events; however, limited evidence exists regarding the use of statin with ezetimibe as primary prevention strategy for middle-aged adults. We aimed to investigate the impact of single pill combination therapy on clinical outcomes in relatively healthy middle-aged patients when compared with statin monotherapy., Methods: Using the Korean National Health Insurance Service database, a propensity score match analysis was performed for baseline characteristics of 92,156 patients categorized into combination therapy (n=46,078) and statin monotherapy (n=46,078) groups. Primary outcome was composite outcomes, including death, coronary artery disease, and ischemic stroke. And secondary outcome was all-cause death. The mean follow-up duration was 2.9±0.3 years., Results: The 3-year composite outcomes of all-cause death, coronary artery disease, and ischemic stroke demonstrated no significant difference between the 2 groups (10.3% vs. 10.1%; hazard ratio [HR], 1.022; 95% confidence interval [CI], 0.980-1.064; p=0.309). Meanwhile, the 3-year all-cause death rate was lower in the combination therapy group than in the statin monotherapy group (0.2% vs. 0.4%; p<0.001), with a significant HR of 0.595 (95% CI, 0.460-0.769; p<0.001). Single pill combination therapy exhibited consistently lower mortality rates across various subgroups., Conclusions: Compared to the statin monotherapy, the combination therapy for primary prevention showed no difference in composite outcomes but may reduce mortality risk in relatively healthy middle-aged patients. However, since the study was observational, further randomized clinical trials are needed to confirm these findings., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2024. The Korean Society of Cardiology.)

Competing Interests: Conflict of interest: None declared.

Cardio-oncology is a critical field due to the escalating significance of cardiovascular toxicity as a side effect of anticancer treatments. Cancer therapy-related cardiac dysfunction (CTRCD) is a prevalent condition associated with cardiovascular toxicity, necessitating effective strategies for prediction, monitoring, management, and tracking. This comprehensive review examines the definition and risk stratification of CTRCD, explores monitoring approaches during anticancer therapy, and highlights specific cardiovascular toxicities linked to various cancer treatments. These include anthracyclines, HER2-targeted agents, vascular endothelial growth factor inhibitors, immune checkpoint inhibitors, chimeric antigen receptor T-cell therapies, and tumor-infiltrating lymphocytes therapies. Incorporating the Korean data, this review offers insights into the regional nuances in managing CTRCD. Using systematic follow-up incorporating cardiovascular imaging and biomarkers, a better understanding and management of CTRCD can be achieved, optimizing the cardiovascular health of both cancer patients and survivors., (© 2024. The Author(s).)

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea., (© 2024. The Author(s).)

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the diagnosis and management of valvular heart diseases with referring to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee sought to reflect national data on the topic of valvular heart diseases published to date through a systematic literature search based on validity and relevance. In the part II of this article, we intend to present recommendations for diagnosis and treatment of mitral valve disease and tricuspid valve disease., (© 2024. The Author(s).)

This study aimed to investigate the relationship between complex aortic plaque (CAP) and short-term as well as long-term outcomes following cardioembolic stroke. CAP is a known risk factor for occurrence and recurrence of ischemic stroke. However, the association of CAP on cardioembolic stroke remains unclear. This was retrospective study using prospective cohort of consecutive patients with cardioembolic stroke who underwent transesophageal echocardiography. The functional outcome was evaluated using the modified Rankin Scale score at 3 months, and long-term outcomes were assessed by recurrence of ischemic stroke and occurrence of major adverse cardiovascular events (MACE). Among 759 patients with cardioembolic stroke, 91 (12.0%) had CAP. Early ischemic stroke recurrence within 3 months was associated with CAP (p = 0.025), whereas CAP was not associated with functional outcome at 3 months (odd ratio  1.01, 95% confidence interval [CI]  0.57-1.84, p = 0.973). During a median follow-up of 3.02 years, CAP was significantly associated with ischemic stroke recurrence (hazard ratio = 2.68, 95% CI 1.48-4.88, p = 0.001) and MACE occurrence (hazard ratio = 1.61, 95% CI 1.03-2.51, p = 0.039). In conclusion, CAP was associated with early ischemic stroke recurrence and poor long-term outcomes in patients with cardioembolic stroke. It might be helpful to consider transesophageal echocardiography for patients with cardioembolic stroke to identify CAP., (© 2024. The Author(s).)

Objectives: Malignant pericardial effusion (MPE) in patients with cancer is associated with poor prognosis. This study aimed to compare clinical outcomes in patients with cancer who underwent pericardiocentesis versus pericardial window formation., Methods: In the present study, 765 consecutive patients with cancer (mean age 58.4 years, 395 men) who underwent pericardial drainage between 2003 and 2022 were retrospectively analysed. All-cause death and MPE recurrence were compared based on the drainage method (pericardiocentesis vs pericardial window formation) and time period (period 1: 2003-2012; period 2: 2013-2022)., Results: Pericardiocentesis was performed in 639 (83.5%) patients and pericardial window formation in 126 (16.5%). There was no difference in age, sex distribution, proportion of metastatic or relapsed cancer, and chemotherapy status between the pericardiocentesis and pericardial window formation groups. Difference was not found in all-cause death between the two groups (log-rank p=0.226) regardless of the period. The pericardial window formation group was associated with lower MPE recurrence than the pericardiocentesis group (6.3% vs 18.0%, log-rank p=0.001). This advantage of pericardial window formation was more significant in period 2 (18.1% vs 1.3%, log-rank p=0.005). In multivariate analysis, pericardial window formation was associated with lower MPE recurrence (HR: 0.31, 95% CI: 0.15 to 0.63, p=0.001); younger age, metastatic or relapsed cancer, and positive malignant cells in pericardial fluid were associated with increased recurrence., Conclusion: In patients undergoing pericardial drainage for MPE, pericardial window formation showed mortality outcomes comparable with pericardiocentesis and was associated with lower incidence of MPE recurrence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The rapid economic development of South Korea provides a unique model to study changes in the clinical characteristics, treatment approaches, and clinical outcomes of patients with rheumatic mitral stenosis (MS) relative to socioeconomic growth., Methods: From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, 2,337 patients diagnosed with moderate or severe rheumatic MS between January 2001 and December 2020 were analyzed. Patients were grouped into consecutive 5-year intervals based on their year of diagnosis. Clinical characteristics, echocardiographic data, and clinical outcomes were assessed., Results: Over 20 years, the severity of mitral stenosis increased from 79.1% to 90.2%; similarly, the average age at diagnosis increased from 54.3 to 63.0 years (all P < 0.001). Comorbidities such as hypertension and atrial fibrillation increased (6.3% to 29.5% and 41.4% to 46.9%, respectively; all P for trend < 0.05). The rate of mitral intervention within five years after diagnosis increased from 31.2% to 47.4% ( P for trend < 0.001). However, clinical outcomes of rheumatic mitral stenosis deteriorated over time in the composite outcomes (log-rank test, P < 0.001). Conversely, the incidence of stroke remained stable (60.6-73.7%; P < 0.001), which might be attributed to the increased use of anticoagulation therapy., Conclusion: This study observed an increase in patient age, comorbidities, and valve disease severity as the country transitioned from a developing to developed status. Despite a rise in mitral valve interventions, clinical outcomes deteriorated over 20 years, highlighting the need for modified treatment approaches to improve patient outcomes., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2024 The Korean Academy of Medical Sciences.)

Background: Current heart failure (HF) guidelines recommend a multidisciplinary approach, discharge education, and self-management for HF. However, the recommendations are challenging to implement in real-world clinical settings., Objective: We developed a mobile health (mHealth) platform for HF self-care to evaluate whether a smartphone app-based intervention with Bluetooth-connected monitoring devices and a feedback system can help improve HF symptoms., Methods: In this prospective, randomized, multicenter study, we enrolled patients 20 years of age and older, hospitalized for acute HF, and who could use a smartphone from 7 tertiary hospitals in South Korea. In the intervention group (n=39), the apps were automatically paired with Bluetooth-connected monitoring devices. The patients could enter information on vital signs, HF symptoms, diet, medications, and exercise regimen into the app daily and receive feedback or alerts on their input. In the control group (n=38), patients could only enter their blood pressure, heart rate, and weight using conventional, non-Bluetooth devices and could not receive any feedback or alerts from the app. The primary end point was the change in dyspnea symptom scores from baseline to 4 weeks, assessed using a questionnaire., Results: At 4 weeks, the change in dyspnea symptom score from baseline was significantly greater in the intervention group than in the control group (mean -1.3, SD 2.1 vs mean -0.3, SD 2.3; P=.048). A significant reduction was found in body water composition from baseline to the final measurement in the intervention group (baseline level mean 7.4, SD 2.5 vs final level mean 6.6, SD 2.5; P=.003). App adherence, which was assessed based on log-in or the percentage of days when symptoms were first observed, was higher in the intervention group than in the control group. Composite end points, including death, rehospitalization, and urgent HF visits, were not significantly different between the 2 groups., Conclusions: The mobile-based health platform with Bluetooth-connected monitoring devices and a feedback system demonstrated improvement in dyspnea symptoms in patients with HF. This study provides evidence and rationale for implementing mobile app-based self-care strategies and feedback for patients with HF., Trial Registration: ClinicalTrials.gov NCT05668000; https://clinicaltrials.gov/study/NCT05668000., (©Minjae Yoon, Seonhwa Lee, Jah Yeon Choi, Mi-Hyang Jung, Jong-Chan Youn, Chi Young Shim, Jin-Oh Choi, Eung Ju Kim, Hyungseop Kim, Byung-Su Yoo, Yeon Joo Son, Dong-Ju Choi. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 29.04.2024.)

Background: TRI-SCORE was recently developed in Europe as a risk model for predicting in-hospital death after isolated tricuspid valve surgery. We aimed to validate TRI-SCORE in an Asian population and investigate its value for predicting long-term outcomes., Methods and Results: The TRI-SCORE was calculated for 202 patients (65±11 years, 61% women, 81% functional tricuspid regurgitation) who underwent isolated tricuspid valve surgery for severe tricuspid regurgitation at 2 Korean centers and was based on 8 parameters: age, New York Heart Association class, right-sided heart failure signs, furosemide daily dose, glomerular filtration rate, bilirubin, left ventricular ejection fraction, and moderate/severe right ventricular dysfunction. The primary outcome was all-cause death during follow-up; the secondary outcome was in-hospital death. During a median follow-up duration of 50 (interquartile range, 21-82) months after isolated tricuspid valve surgery, 23 (11.4%) patients experienced the primary outcome, and 7 (3.5%) patients experienced the secondary outcome. Observed all-cause death and in-hospital death increased by up to 50% in those with higher scores. Patients with the primary outcome had a higher TRI-SCORE (4.5±2.4 versus 2.9±2.1; P =0.001) than those without. The TRI-SCORE showed a significant association with the primary outcome (concordance index, 0.77, cutoff value, 4) and in-hospital death (area under the curve, 0.84; cutoff value, 3). Using the Kaplan-Meier analysis, patients with a high TRI-SCORE exhibited a poor outcome for all-cause death at follow-up (log-rank P <0.001) and in-hospital death (log-rank P =0.004)., Conclusions: TRI-SCORE was validated in an Asian population and helped predict long-term outcomes after isolated tricuspid valve surgery.

Background and Objectives: Evidence regarding the efficacy and safety of intracardiac echocardiography (ICE) for guidance during transcatheter aortic valve replacement (TAVR) is limited. This study aimed to compare the clinical efficacy and safety of ICE versus transesophageal echocardiography (TEE) for guiding TAVR., Methods: This prospective cohort study included patients who underwent TAVR from August 18, 2015, to June 31, 2021. Eligible patients were stratified by echocardiographic modality (ICE or TEE) and anesthesia mode (monitored anesthesia care [MAC] or general anesthesia [GA]). Primary outcome was the 1-year composite of all-cause mortality, rehospitalization for cardiovascular cause, or stroke, according to the Valve Academic Research Consortium-3 (VARC-3) definition. Propensity score matching was performed, and study outcomes were analyzed for the matched cohorts., Results: Of the 359 eligible patients, 120 patients were matched for the ICE-MAC and TEE-GA groups, respectively. The incidence of primary outcome was similar between matched groups (18.3% vs. 20.0%; adjusted hazard ratio, 0.94; 95% confidence interval [CI], 0.53-1.68; p=0.843). ICE-MAC and TEE-GA also had similar incidences of moderate-to-severe paravalvular regurgitation (PVR) (4.2% vs. 5.0%; adjusted odds ratio, 0.83; 95% CI, 0.23-2.82; p=0.758), new permanent pacemaker implantation, and VARC-3 types 2-4 bleeding., Conclusions: ICE was comparable to TEE for guidance during TAVR for the composite clinical efficacy outcome, with similar incidences of moderate-to-severe PVR, new permanent pacemaker implantation, and major bleeding. These results suggest that ICE could be a safe and effective alternative echocardiographic modality to TEE for guiding TAVR., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2024. The Korean Society of Cardiology.)

Background: This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm 2 )., Methods: From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm 2 < MVA ≤ 1.5 cm 2 and MVA ≤ 1.0 cm 2 , respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention., Results: Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012)., Conclusions: PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Aortic valve replacement (AVR) is considered a class I indication for symptomatic severe aortic stenosis (AS). However, there is little evidence regarding the potential benefits of early AVR in symptomatic patients diagnosed with normal-flow, low-gradient (NFLG) severe AS., Methods: Two-hundred eighty-one patients diagnosed with symptomatic NFLG severe AS (stroke volume index ≥35 mL/m², mean transaortic pressure gradient <40 mmHg, peak transaortic velocity <4 m/s, and aortic valve area <1.0 cm²) between January 2010 and December 2020 were included in this retrospective study. After performing 1:1 propensity score matching, 121 patients aged 75.1±9.8 years (including 63 women) who underwent early AVR within 3 months after index echocardiography, were compared with 121 patients who received conservative care. The primary outcome was a composite of all-cause death and heart failure (HF) hospitalization., Results: During a median follow-up of 21.9 months, 48 primary outcomes (18 in the early AVR group and 30 in the conservative care group) occurred. The early AVR group demonstrated a significantly lower incidence of primary outcomes (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.29-0.93; p=0.028); specifically, there was no significant difference in all-cause death (HR, 0.51; 95% CI, 0.23-1.16; p=0.110), although the early AVR group showed a significantly lower incidence of hospitalization for HF (HR, 0.43; 95% CI, 0.19-0.95, p=0.037). Subgroup analyses supported the main findings., Conclusions: An early AVR strategy may be beneficial in reducing the risk of a composite outcome of death or hospitalization for HF in symptomatic patients with NFLG severe AS. Future randomized studies are required to validate and confirm our findings., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2023. The Korean Society of Cardiology.)

Aims: Mechanical function of the left atrium (LA) and the left ventricle (LV) has been demonstrated to be a prognostic factor in patients with hypertrophic cardiomyopathy (HCM). We explore whether myocardial mechanical function can be improved by septal reduction therapy in symptomatic obstructive HCM., Methods and Results: Among 65 patients who underwent septal myectomy for symptomatic obstructive HCM from 2006 to 2022, 44 were analysed after excluding those who underwent simultaneous valve repair or replacement or maze operation. LA and LV functional variables including LA strain and LV global longitudinal strain were evaluated by two-dimensional and speckle-tracking echocardiography and compared before and 1 year after surgery. After septal myectomy, LA volume index (58.1 ± 18.3 vs. 45.3 ± 14.6 mL/m 2 , P = 0.001) decreased significantly. As LV end-systolic dimension increased after surgery, the LV ejection fraction decreased (73.8 ± 6.7 vs. 62.9 ± 8.3%, P < 0.001). LA strain (24.4 ± 9.3 vs. 30.5 ± 13.6%, P = 0.004) improved after septal myectomy, but LV global longitudinal strain deteriorated (-12.6 ± 3.6 vs. -11.6 ± 4.3%, P = 0.033), mainly related to worsening non-septal longitudinal strain (-14.4 ± 4.3 vs. -10.9 ± 8.4%, P = 0.005)., Conclusions: As haemodynamic loads due to LV outflow tract obstruction was relieved through surgical septal reduction therapy in patients with symptomatic obstructive HCM, there was a significant reduction in LA volume and restoration of LA mechanical dysfunction. However, LV mechanical dysfunction deteriorated even after surgical septal reduction therapy., (© 2023 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background Mitral annular calcification (MAC) is a chronic degenerative process that may progress. This study aimed to investigate associating factors and clinical implications of MAC progression. Methods and Results Among 560 patients with MAC identified by transthoracic echocardiography between January 2012 and June 2016, 138 patients (mean±SD age 72.7±10.2 years, 73 women) with mild or moderate MAC who received follow-up examination within 18 to 36 months were retrospectively analyzed. Progressive MAC was defined as hemodynamic or structural profiles that had worsened by more than 1 grade. Hemodynamic features were assessed by the transmitral mean diastolic pressure gradient (MDPG), and structural features were assessed by the MAC angle in the parasternal short-axis view. The clinical outcome was defined as a composite of all-cause mortality, hospitalization for heart failure, and occurrence of ischemic stroke. Forty-three patients (31.2%) showed progressive MAC. Patients with progressive MAC had higher systolic blood pressure, pulse pressure, MAC angle, and MDPG than those with stable MAC. Patients with progressive MAC had smaller left ventricular (LV) end-systolic dimensions and higher LV ejection fractions compared with those with stable MAC. In multivariate analysis, pulse pressure, LV ejection fraction, MAC angle, and MDPG at baseline were significantly associated with MAC progression. During a median of 39.2 months' follow-up, patients with progressive MAC showed poorer clinical outcomes than those with stable MAC (log-rank P =0.015). Conclusions MAC progression is not rare and is associated with structural substrate and hemodynamic loads that result in mechanical stress. Patients with progressive MAC have poor outcomes.

Background Real-world evidence for the selection of gatekeeping studies in patients with suspected coronary syndromes is limited. Methods and Results We identified 27 036 patients who underwent coronary computed tomography angiography (CCTA), single-photon emission computed tomography, and the treadmill test for suspected coronary syndromes from the Korean National Health Insurance Service-National Sample Cohort between 2006 and 2014. The primary end point was a composite of cardiac death and myocardial infarction, and the secondary end point was a composite of the primary end point and revascularization. During a median follow-up of 5.4 years, the risk of both primary and secondary end points was significantly higher in the single-photon emission computed tomography group (hazard ratio [HR], 1.81 [95% CI, 1.34-2.45]; and HR, 1.42 [95% CI, 1.22-1.66]), but significantly lower in the treadmill test group (HR, 0.53 [95% CI, 0.42-0.67]; and HR, 0.69 [95% CI, 0.62-0.76]) compared with the CCTA group. After balancing baseline risk factors, there was no significant difference in the primary end point in those with single-photon emission computed tomography (HR, 1.11 [95% CI, 0.78-1.57]; P =0.58) or treadmill test (HR, 0.84 [95% CI, 0.65-1.08]; P =0.18) groups, compared with the CCTA group. The event rate of the secondary end point was significantly lower in the treadmill test group than in the CCTA group (HR, 0.87 [95% CI, 0.78-0.96]; P =0.008). Conclusions Compared with functional testing, initial CCTA was not associated with a lower rate of cardiac death or myocardial infarction when used as an initial diagnostic test for patients with suspected coronary syndromes.

Competing Interests: Conflict of interest: None declared.

Aims: Quantitative assessment of tricuspid regurgitation (TR) is challenging, and the prognostic implications of cardiac magnetic resonance (CMR)-quantified measures of TR remain unclear in patients with heart failure with reduced ejection fraction (HFrEF). This study investigated the prognostic value of functional TR quantified by CMR in patients with HFrEF., Methods and Results: A total of 262 patients with HFrEF who underwent CMR were analysed. Patients who had primary TR, who had acute HF, or for whom cardiac surgery was planned were excluded. TR volume and fraction were indirectly calculated via subtracting methods. The primary outcome was defined as a composite of all-cause death and hospitalization for HF. Renal outcome was defined as a composite of a decrease in estimated glomerular filtration rate ≥50% or progression to end-stage renal disease. During the follow-up period (median 921 days), 62 primary outcomes and 48 renal outcomes occurred. When divided into two or three groups based on TR fraction in Kaplan-Meier analysis, patients with higher TR fractions showed worse primary outcomes and renal outcomes than those with lower TR fractions. In Cox regression analysis, a 10% increase in TR fraction was significantly associated with primary outcome [hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.29-1.73, P < 0.001] and renal outcome (HR 1.31, 95% CI 1.12-1.55, P = 0.001). TR fraction exhibited a strong positive linear relationship with primary outcomes and renal outcomes in restricted cubic spline curves., Conclusion: CMR-quantified measures of TR were independently associated with adverse clinical outcomes in patients with HFrEF., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Because of the short half-life of non-vitamin K antagonist oral anticoagulants (NOACs), consistent drug adherence is crucial to maintain the effect of anticoagulants for stroke prevention in atrial fibrillation (AF). Considering the low adherence to NOACs in practice, we developed a mobile health platform that provides an alert for drug intake, visual confirmation of drug administration, and a list of medication intake history. This study aims to evaluate whether this smartphone app-based intervention will increase drug adherence compared with usual care in patients with AF requiring NOACs in a large population., Methods: This prospective, randomized, open-label, multicenter trial (RIVOX-AF study) will include a total of 1,042 patients (521 patients in the intervention group and 521 patients in the control group) from 13 tertiary hospitals in South Korea. Patients with AF aged ≥19 years with one or more comorbidities, including heart failure, myocardial infarction, stable angina, hypertension, or diabetes mellitus, will be included in this study. Participants will be randomly assigned to either the intervention group (MEDI-app) or the conventional treatment group in a 1:1 ratio using a web-based randomization service. The intervention group will use a smartphone app that includes an alarm for drug intake, visual confirmation of drug administration through a camera check, and presentation of a list of medication intake history. The primary endpoint is adherence to rivaroxaban by pill count measurements at 12 and 24 weeks. The key secondary endpoints are clinical composite endpoints, including systemic embolic events, stroke, major bleeding requiring transfusion or hospitalization, or death during the 24 weeks of follow-up., Discussion: This randomized controlled trial will investigate the feasibility and efficacy of smartphone apps and mobile health platforms in improving adherence to NOACs., Trial Registration: The study design has been registered in ClinicalTrial.gov (NCT05557123)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Yoon, Park, Hur, Hao, Shim, Yoo, Cho, Lee, Kim, Kim, Lee and Choi.)

The management and follow-up of moderate aortic stenosis (AS) lacks consensus as the progression patterns are not well understood. This study aimed to identify the hemodynamic progression of AS, and associated risk factors and outcomes. We included patients with moderate AS with at least three transthoracic echocardiography (TTE) studies performed between 2010 and 2021. Latent class trajectory modeling was used to classify AS groups with distinctive hemodynamic trajectories, which were determined by serial systolic mean pressure gradient (MPG) measurements. Outcomes were defined as all-cause mortality and aortic valve replacement (AVR). A total of 686 patients with 3093 TTE studies were included in the analysis. Latent class model identified two distinct AS trajectory groups based on their MPG: a slow progression group (44.6%) and a rapid progression group (55.4%). Initial MPG was significantly higher in the rapid progression group (28.2 ± 5.6 mmHg vs. 22.9 ± 2.8 mmHg, P < 0.001). The prevalence of atrial fibrillation was higher in the slow progression group; there was no significant between-group difference in the prevalence of other comorbidities. The rapid progression group had a significantly higher AVR rate (HR 3.4 [2.4-4.8], P < 0.001); there was no between-group difference in mortality (HR 0.7 [0.5-1.0]; P = 0.079). Leveraging longitudinal echocardiographic data, we identified two distinct groups of patients with moderate AS: slow and rapid progression. A higher initial MPG (≥ 24 mmHg) was associated with more rapid progression of AS and higher rates of AVR, thus indicating the predictive value of MPG in management of the disease., (© 2023. The Author(s).)

We investigated myocardial performance concerning obstructive sleep apnea (OSA) severity and the benefits of continuous positive airway pressure (CPAP) therapy. In this randomized sham-controlled trial, 52 patients (mean age, 49 years; 92%, males; mean AHI, 59) with severe OSA were randomly assigned to receive either CPAP or sham treatment for 3 months. The severity of OSA was determined using the apnea/hypopnea index (AHI), oxygen desaturation index (ODI), percentage of sleep time below 90% oxygen saturation (T90), and average O 2 saturation during sleep (mean SpO 2 ). We compared the changes in myocardial work after 3 months of CPAP (n = 26) versus the sham group (n = 26) at rest and during an exercise stress test. Unlike AHI or ODI, indices of hypoxemia including T90 and mean SpO 2 were significantly correlated with global constructive work, as defined by work of left ventricle (LV) that contributes to LV ejection during systole (T90, β = 0.393, p = 0.012; mean SpO 2 , β = 0.331, p = 0.048), and global wasted work (GWW), as defined by work of LV that does not contribute to LV ejection (T90, β = 0.363, p = 0.015; mean SpO 2 , β =  - 0.370, p = 0.019). After 3 months, GWW decreased (80.0 ± 49.2 to 60.8 ± 26.3, p = 0.009) and global work efficiency increased (94.0 ± 4.5 to 95.7 ± 2.0, p = 0.008) in the CPAP group compared to those in the sham group. At the 3-month follow-up exercise stress echocardiography, worsening of GWW during exercise was significantly decreased in the CPAP group compared to that in the sham group (p = 0.045 at 50 W). Hypoxemia indices were closely associated with myocardial performance in patients with severe OSA. CPAP treatment for 3 months improved left ventricular myocardial performance by decreasing wasted work and increasing work efficacy compared to the sham treatment., (© 2023. The Author(s).)

Background: We aimed to investigate left ventricular (LV) global longitudinal strain (GLS) in end-stage renal disease patients and its change after kidney transplantation (KT)., Methods: We retrospectively reviewed patients who underwent KT between 2007 and 2018 at two tertiary centers. We analyzed 488 patients (median age, 53 years; 58% male) who had obtained echocardiography both before and within 3 years after KT. Conventional echocardiography and LV GLS assessed by two-dimensional speckle-tracking echocardiography were comprehensively analyzed. Patients were classified into three groups according to the absolute value of pre-KT LV GLS (|LV GLS|). We compared longitudinal changes of cardiac structure and function according to pre-KT |LV GLS|., Results: Correlation between pre-KT LV EF and |LV GLS| were statistically significant, but the constant was not high (r = 0.292, p < 0.001). |LV GLS| was widely distributed at corresponding LV EF, especially when the LV EF was > 50%. Patients with severely impaired pre-KT |LV GLS| had significantly larger LV dimension, LV mass index, left atrial volume index, and E/e' and lower LV EF, compared to mildly and moderately reduced pre-KT |LV GLS|. After KT, the LV EF, LV mass index, and |LV GLS| were significantly improved in three groups. Patients with severely impaired pre-KT |LV GLS| showed the most prominent improvement of LV EF and |LV GLS| after KT, compared to other groups., Conclusions: Improvements in LV structure and function after KT were observed in patients throughout the full spectrum of pre-KT |LV GLS|., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2023 Korean Society of Echocardiography.)

Background Hypertrophic cardiomyopathy (HCM) is a genetic disorder affecting not only the myocardium but also the mitral valve (MV) and its apparatus. This study aimed to investigate the prognostic implication of MV disease and its progression in East Asian patients with HCM. Methods and Results We assessed MV structure and function on the indexed echocardiogram of 1185 patients with HCM (mean±SD age, 60±14 years; men, 67%) in a longitudinal HCM registry, and 667 patients who performed follow-up echocardiogram after 3 to 5 years were also analyzed. Progression of mitral regurgitation (MR) was defined as the increase of at least 1 grade. Clinical outcomes were defined as a composite of cardiovascular death, heart failure hospitalization, MV surgery or septal myectomy, and heart transplantation. Most of the entire cohort was nonobstructive type (n=1081 [91.2%]). A total of 278 patients (23.5%) showed at least mild MR on indexed echocardiogram. MR, systolic anterior motion, and mitral annular calcification were more prevalent in patients with obstructive HCM. During 7.0±4.0 years of follow-up, presence of MR was independently associated with poor clinical outcomes (hazard ratio [HR], 1.60 [95% CI, 1.07-2.40]; P =0.023). On follow-up echocardiogram, 67 (10.0%) patients showed MR progression, and it was independently associated with poor prognosis (HR, 2.46 [95% CI, 1.29-4.71]; P =0.007). Conclusions In East Asian patients with HCM whose major type is nonobstructive, MV disease is common. MR, systolic anterior motion, and mitral annular calcification are more prevalent in patients with obstructive HCM. The presence and progression of MR are associated with a poor prognosis in patients with HCM.

Aims: We aimed to evaluate the efficacy of the measured effective orifice area (EOA)/reference EOA ratio in discriminating mechanical prosthetic aortic valve (PAV) obstruction., Methods and Results: This is a retrospective study of 193 mechanical PAV patients with an elevated mean transprosthetic pressure gradient (PG) over 20 mmHg or peak velocity over 3 m/s. Of those, 143 patients were objectively proven PAV obstruction with cardiac computed tomography or surgical inspection. The EOA was measured using the continuity equation, and the reference EOA values were obtained from previous guidelines. The measured/reference EOA ratio was significantly lower in the obstruction group (0.63 ± 0.18 vs. 0.86 ± 0.17; P < 0.001). The EOA ratio added incremental value for discriminating obstruction from the conventional parameters recommended in the guidelines. Receiver operating characteristic curve analysis revealed that the measured/reference EOA ratio discriminated PAV obstruction from those without obstruction [area under the curve (AUC), 0.840; 95% confidence interval, 0.783-0.898; P < 0.001]. A cutoff of 0.71 had 73.4% sensitivity and 82.0% specificity. The novel diagnostic algorithm adding the EOA ratio had similar accuracy to previous guideline algorithms, including reference EOA, and conventional Doppler parameters (AUC, 0.763 vs. 0.731; P = 0.309). In patients with a large PAV (≥23 mm), the novel algorithm had higher accuracy than the previous algorithm (AUC, 0.788 vs. 0.642; P = 0.019)., Conclusion: The ratio of measured/reference EOA adds incremental value over conventional Doppler parameters and might be helpful for distinguishing PAV obstruction., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The function of left atrium (LA) is difficult to assess because of its ventricle-dependent, dynamic movement. The aim of this study was to assess LA function using velocity vector imaging (VVI) and compare LA function in patients with hypertrophic cardiomyopathy (HCMP) and left ventricular hypertrophy (LVH) with normal controls., Methods: Fourteen patients with HCMP (72% male, mean age of 52.6 ± 9.8), 15 hypertensive patients with LVH (88% male, mean age of 54.0 ± 15.3), and 10 age-matched controls (83% male, mean age of 50.0 ± 4.6) were prospectively studied. Echocardiographic images of the LA were analyzed with VVI, and strain rate (SR) was compared among the 3 groups., Results: The e' velocity (7.7 ± 1.1; 5.1 ± 0.8; 4.5 ± 1.3 cm/sec, p = 0.013), E/e' (6.8 ± 1.6; 12.4 ± 3.3; 14.7 ± 4.2, p = 0.035), and late diastolic SR at mid LA (-1.65 ± 0.51; -0.97 ± 0.55; -0.82 ± 0.32, p = 0.002) were significantly different among the groups (normal; LVH; HCMP, respectively). The e' velocity, E/e', and late diastolic SR at mid LA were significantly different between normal and LVH (p = 0.001; 0.022; 0.018), whereas LA size was similar between normal and LVH (p = 0.592). The mean late diastolic peak SR of mid LA was significantly correlated with indices of diastolic function (E/e', e', and LA size)., Conclusions: The SR is a useful tool for detailed evaluation of LA function, especially early dysfunction of LA in groups with normal LA size., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2023 Korean Society of Echocardiography.)

Objective: Early warfarin anticoagulation is recommended in patients undergoing surgical bioprosthetic valve implantation or valve repair. It is unclear whether non-vitamin K antagonist oral anticoagulants can be a full alternative to warfarin. This study aimed to compare efficacy and safety of edoxaban with warfarin in patients early after surgical bioprosthetic valve implantation or valve repair., Methods: The Explore the Efficacy and Safety of Edoxaban in Patients after Heart Valve Repair or Bioprosthetic Valve Replacement study was a prospective, randomized (1:1), open-label, clinical trial conducted from December 2017 to September 2019. Patients were randomly assigned to receive edoxaban (60 mg or 30 mg once daily) or warfarin for the first 3 months after surgical bioprosthetic valve implantation or valve repair. The primary efficacy outcome was a composite of death, clinical thromboembolic events, or asymptomatic intracardiac thrombosis. The primary safety outcome was the occurrence of major bleeding., Results: Of 220 participants, 218 (109 per group) were included in the modified intention-to-treat analysis. The primary efficacy outcome occurred in 4 patients (3.7%) taking warfarin and none taking edoxaban (risk difference, -0.0367; 95% confidence interval, -0.0720 to -0.0014; P < .001 for noninferiority). The primary safety outcome occurred in 1 patient (0.9%) taking warfarin and 3 patients (2.8%) taking edoxaban (risk difference, 0.0183; 95% confidence interval, -0.0172 to 0.0539; P = .013 for noninferiority)., Conclusions: Edoxaban is noninferior to warfarin for preventing thromboembolism and is potentially comparable for risk of major bleeding during the first 3 months after surgical bioprosthetic valve implantation or valve repair., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: This study aimed to elucidate the relationship between premature ventricular complexes (PVCs) and right ventricular (RV) dysfunction, and the effects of radiofrequency catheter ablation (RFCA) on RV function., Methods: A total of 110 patients (age, 50.8 ± 14.4 years; 30 men) without structural heart disease who had undergone RFCA for RV outflow tract (RVOT) PVCs were retrospectively included. RV function was assessed using fractional area change (FAC) and global longitudinal strain (GLS) before and after RFCA. Clinical data were compared between the RV dysfunction (n = 63) and preserved RV function (n = 47) groups. The relationship between PVC burden and RV function was analyzed. Change in RV function before and after RFCA was compared between patients with successful and failed RFCA., Results: PVC burden was significantly higher in the RV dysfunction group than in the preserved RV function group (p < .001). FAC and GLS were significantly worse in proportion to PVC burden (p < .001 and p < .001, respectively). The risk factor associated with RV dysfunction was PVC burden [odds ratio (95% confidence interval), 1.092 (1.052-1.134); p < .001]. Improvement in FAC (13.0 ± 8.7% and -2.5 ± 5.6%, respectively; p < .001) and GLS (-6.8 ± 5.7% and 2.1 ± 4.2%, respectively; p < .001) was significant in the patients with successful RFCA, compared to the patients in whom RFCA failed., Conclusions: Frequent RVOT PVCs are associated with RV dysfunction. RV dysfunction is reversible by successful RFCA., (© 2022 Wiley Periodicals LLC.)

Background: Valvular heart disease (VHD) is a common cause of cardiovascular morbidity and mortality worldwide; however, its epidemiological profile in Korea requires elucidation., Methods: In this nationwide retrospective cohort study from the Korean valve survey, which collected clinical and echocardiographic data on VHD from 45 medical centers, we identified 4,089 patients with VHD between September and October 2019., Results: The aortic valve was the most commonly affected valve (n = 1,956 [47.8%]), followed by the mitral valve (n = 1,598 [39.1%]) and tricuspid valve (n = 1,172 [28.6%]). There were 1,188 cases of aortic stenosis (AS) and 926 cases of aortic regurgitation. The most common etiology of AS was degenerative disease (78.9%). The proportion of AS increased with age and accounted for the largest proportion of VHD in patients aged 80-89 years. There were 1,384 cases of mitral regurgitation (MR) and 244 cases of mitral stenosis (MS). The most common etiologies for primary and secondary MR were degenerative disease (44.3%) and non-ischemic heart disease (63.0%), respectively, whereas rheumatic disease (74.6%) was the predominant cause of MS. There were 1,172 tricuspid regurgitation (TR) cases, of which 46.9% were isolated and 53.1% were associated with other valvular diseases, most commonly with MR. The most common type of TR was secondary (90.2%), while primary accounted for 6.1%., Conclusions: This report demonstrates the current epidemiological status of VHD in Korea. The results of this study can be used as fundamental data for developing Korean guidelines for VHD., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2023 Korean Society of Echocardiography.)

Background: In this study, we investigate the utility of geometric orifice area (GOA) on cardiac computed tomography (CT) and differences from effective orifice area (EOA) on Doppler echocardiography in patients with bicuspid aortic stenosis (AS)., Methods: A total of 163 patients (age 64 ± 10 years, 56.4% men) with symptomatic bicuspid AS who were referred for surgery and underwent both cardiac CT and echocardiography within 3 months were studied. To calculate the aortic valve area, GOA CT was measured by multiplanar CT planimetry, and EOA Echo was calculated by the continuity equation with Doppler echocardiography. The relationships between GOA CT and EOA Echo and patient symptom scale, biomarkers, and left ventricular (LV) functional variables were analyzed., Results: There was a significant but modest correlation between EOA Echo and GOA CT ( r = 0.604, p < 0.001). Both EOA Echo and GOA CT revealed significant correlations with mean pressure gradient and peak transaortic velocity, and the coefficients were higher in EOA Echo than in GOA CT . EOA Echo of 1.05 cm 2 and GOA CT of 1.25 cm 2 corresponds to hemodynamic cutoff values for diagnosing severe AS. EOA Echo was well correlated with the patient symptom scale and log NT-pro BNP, but GOA CT was not. In addition, EOA Echo had a higher correlation coefficient with estimated LV filling pressure and LV global longitudinal strain than GOA CT ., Conclusion: GOA CT can be used to evaluate the severity of bicuspid AS. The threshold for GOA CT for diagnosing severe AS should be higher than that for EOA Echo . However, EOA Echo is still the method of choice because EOA Echo showed better correlations with clinical and functional variables than GOA CT ., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kim, Lee, Seo, Suh, Cho, Hong, Ha, Kim and Shim.)

Background: There are insufficient data regarding the risk factors associated with valve dysfunction of bioprosthetic valves in the mitral position This study aimed to investigate the factors associated with bioprosthetic mitral valve (MV) dysfunction (MVD)., Methods: A total of 245 patients (age 67.2±11.2 years, 74.9% women) who were followed up for more than 5 years after surgical bioprosthetic MV replacement were analysed in the setting of retrospective study design. MVD was defined as an increased mean gradient of >5 mm Hg with limited leaflet motion and/or newly developed MV regurgitation of at least moderate severity on follow-up echocardiography. The clinical outcome was defined as a composite of cardiovascular mortality, redo MV surgery or intervention and heart failure-related hospitalisations., Results: During a median of 96.0 months (IQR 67.0-125.0 months), bioprosthetic MVD occurred in 66 (27.6%) patients. Factors associated with bioprosthetic MVD detected by multivariate regression analysis were age at surgery (HR 0.98, 95% CI 0.96 to 0.99, p<0.001), chronic kidney disease (HR 3.27, 95% CI 1.74 to 6.12, p<0.001), elevated mean diastolic pressure gradient >5.5 mm Hg across the bioprosthetic MV early after operation (HR 2.02, 95% CI 1.08 to 3.78, p=0.028) and average haemoglobin level after surgery (HR 0.80, 95% CI 0.67 to 0.96, p=0.015). Patients with bioprosthetic MVD showed significantly poorer clinical outcomes than those without bioprosthetic MVD (log-rank p<0.001)., Conclusions: Young age at operation, chronic kidney disease, elevated pressure gradient across the bioprosthetic MV early after surgery and postsurgical anaemia are associated with bioprosthetic MVD. Bioprosthetic MVD is associated with poor clinical outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Neutralising antibodies (NAbs) have been shown to be correlative of immune protection against SARS-CoV-2. We report the protocol for a national longitudinal study to assess and compare the level of NAbs generated in response to COVID-19 vaccines in Brunei Darussalam in adults 2-6 weeks post primary series (BBIBP-CorV, AZD1222, or mRNA-1273 vaccines) and their subsequent follow-up after administration of a third (booster-1) dose (BBIBP-CorV, mRNA-1273, or BNT162b2)., Methods and Analysis: Participant data will be extracted and processed from the national electronic health record system (Bru-HIMS) and the national mobile health application (BruHealth) into a research data platform. Eligible adults who have received their primary or booster vaccine will be invited using a stratified random sampling strategy based on age, gender and vaccine type (baseline target population, n=3000; 2-6 weeks post last dose). Blood serum will be isolated, and NAb levels assessed using the cPass surrogate virus neutralisation test. Baseline participants will then be screened for eligibility for subsequent longitudinal analysis. Those who have received a third dose will be followed up at 1, 3, 6, 9 and up to 12 months. NAb levels will be evaluated across the participant population according to vaccine platform/booster type, time since the last dose and correlated with demographic data. The study period is from December 2021 to January 2023 and aims to evaluate how NAb levels wane following a third vaccine dose across different vaccine platforms and determine the impact and rate of breakthrough infections., Ethics and Dissemination: This study has been approved by the Medical and Ethical Research Committee of Ministry of Health, Brunei Darussalam. Individual NAb test results will be shared with each participant by text message. The findings from this study will help policy-makers in Brunei develop future vaccination strategies and establish regulations across multiple agencies., Competing Interests: Competing interests: CWT and LFW received a patent for the development of the cPass SARS-CoV-2 Neutralization Antibody Detection Kit used in the study. CYS, YW, SYC and YW are employed by EVYD Technology, who is the provider for the BruHealth and EVYDResearch platforms., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Conflict of interest: None declared.

Background: Functional tricuspid regurgitation (TR) usually decreases after atrial septal defect (ASD) closure; however, it may persist and cause heart failure that requires treatment. We aimed to investigate clinical and echocardiographic factors predicting persistent TR after ASD closure., Methods: Among 348 adults who underwent isolated ASD closure between January 2010 and September 2020, 91 (26.1%) patients with significant TR (at least moderate degree) before ASD closure were included. Persistent TR was defined as significant TR on echocardiography at 6 months to 1 year after ASD correction. We comprehensively analyzed the echocardiogram before ASD closure, including speckle-tracking imaging. Right ventricular (RV)-pulmonary arterial (PA) (RV-PA) coupling was assessed by the ratio of RV global longitudinal strain (RV GLS) and tricuspid annular S' velocity to PA systolic pressure (PASP)., Results: Persistent TR was observed in 22 (24.2%) patients. Patients with persistent TR were significantly older and had larger TR jet areas and lower RV-PA coupling parameters than those without persistent TR. On multivariable regression, persistent TR was independently associated with age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.01-1.14, p = 0.030) and |RV GLS|/PASP (OR 0.001, 95% CI 0.00-0.017, p = 0.012). ROC curves analysis showed that |RV GLS|/PASP's best cut-off for persistent TR was 0.46 (cut-off 0.46, the area under the curve 0.789, p < 0.001)., Conclusion: Persistent TR after ASD closure is not rare. Old age and RV-PA uncoupling could be associated with persistent TR after ASD closure. In older patients with abnormal RV-PA coupling, careful evaluation and concomitant or subsequent TR intervention may be considered., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lee, Shin, Kim, Seo, Cho, Lee, Kim, Hong, Ha and Shim.)