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Although cardiac computed tomography angiography (CCTA) assessment of right ventricular dysfunction (RVD) is feasible, the incremental prognostic value remains uncertain in patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. This study sought to determine the incremental clinical utility of RVD identification by CCTA while accounting for clinical and echocardiographic parameters.Patients who underwent multiphasic ECG-gated functional CCTA using dual-source system for routine TAVR planning were evaluated. Biphasic contrast protocol injection allowed for biventricular contrast enhancement. CCTA-based RVD was defined as right ventricular ejection fraction (RVEF) ​ ​50%. The association of CCTA-RVD with all-cause mortality and the composite outcome of death or heart failure hospitalization after TAVR was evaluated and examined for its incremental utility beyond clinical risk assessment and echocardiographic parameters.A total of 502 patients were included (median [IQR] age, 82 [77 to 87] years; 56% men) with a median follow-up of 22 [16 to 32] months. Importantly, 126 (25%) patients were identified as having RVD by CCTA that was not identified by echocardiography. CCTA-defined RVD predicted death and the composite outcome in both univariate analyses (HR for mortality, 2.15; 95% CI, 1.44-3.22; p ​ ​0.001; HR for composite outcome, 2.11; 95% CI, 1.48-3.01; p ​ ​0.001) and in multivariate models that included clinical risk factors and echocardiographic findings (HR for mortality, 1.74; 95% CI, 1.11-2.74; p ​= ​0.02; HR for composite outcome, 1.63; 95% CI, 1.09-2.44; p ​= ​0.02).Functional CCTA assessment pre-TAVR correctly identified 25% of patients with RVD that was not evident on 2D echocardiography. The presence of RVD on CCTA independently associates with clinical outcomes post-TAVR.

Transcatheter tricuspid valve interventions (TTVIs) are rapidly growing as a less invasive treatment of high surgical risk patients with advanced TR. A comprehensive anatomic and functional assessment of the tricuspid valve and right-sided chambers is essential for candidate selection and procedural planning. Advanced imaging with cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) can provide accurate anatomic and functional assessment of the tricuspid valve, its apparatus, and the right-sided chambers. In this review, we provide an updated overview of the emerging role of CCT and CMR for TR patient evaluation, TTVI planning, and follow-up.

Evaluation of prosthesis-patient mismatch (P-PM) after transcatheter aortic valve replacement (TAVR) by transthoracic echocardiography (TTE) has provided conflicting results regarding its impact on outcomes. Whether post-TAVR computed tomography angiography (CTA) evaluation of P-PM can improve our understanding is unknown. We aimed to evaluate the inter-modality (TTE vs. CTA) agreement, inter-valve platform (balloon-expanding valve [BEV] vs. self-expandable valve [SEV]) differences in P-PM severity, and outcomes related to P-PM after TAVR.We analyzed patients with both CTA and TTE before and after TAVR. Indexed effective orifice area was calculated using two methods: TTE-derived left ventricular outflow tract (LVOT) area from measured diameter and post-TAVR CTA-measured area. Body size specific cut-offs for P-PM severity were used: for body mass index (BMI) ​ ​30 ​kg/mA total of 447 patients were included (median age, 83 years; 54% male). The prevalence of P-PM (moderate or severe) was lower with CTA vs. TTE (3.5% vs. 19.5%, p ​ ​0.001). The prevalence of P-PM measured by TTE was more common in BEV compared to SEV (p ​= ​0.002), while CTA assessment showed no difference in P-PM incidence and severity between TAVR platforms (p ​= ​0.40). In multivariable analysis, CTA-defined but not TTE-defined P-PM was associated with mortality after TAVR (HR:3.97; 95%CI,1.55-10.2; p ​= ​0.004). Both CTA-defined and TTE-defined P-PM were associated with the composite of death and heart failure rehospitalization.Although post-TAVR CTA substantially downgraded the prevalence of P-PM compared to TTE, it identified a subset of patients with clinically relevant P-PM which associated with outcomes.

Functional mitral regurgitation (FMR) is a common and complex valve disease, in which severity and risk stratification is still a conundrum. Although risk increases with FMR severity, it is modulated by subjacent left ventricular (LV) disease. The extent of LV remodeling and dysfunction is traditionally evaluated by echocardiography, but a growing body of evidence shows that myocardial fibrosis (MF) assessment by cardiac magnetic resonance (CMR) may complement risk stratification and inform treatment decisions. This review summarizes the current knowledge on the comprehensive evaluation that CMR can provide for patients with FMR, in particular for the assessment of MF and its potential impact in clinical decision-making.

Funding Acknowledgements Type of funding sources: None. Background Percutaneous leaflet repair with the MitraClip device (Abbott Vascular, Menlo Park, CA) is safe and effective in patients with severe functional mitral regurgitation (FMR). Residual or recurrent MR may occur in up to 40% of patients and is associated with persistent symptoms and impaired survival. The anatomical characteristics associated with residual or recurrent MR after MitraClip are not well defined by computed tomography angiography (CTA) in FMR population. Methods A retrospective analysis of patients with significant FMR, who underwent retrospective-gated CTA at Minneapolis Heart Institute between July 2015 to January 2020, identified those who underwent percutaneous leaflet repair with MitraClip. Anatomical and functional parameters were assessed by pre-procedure CTA and compared between those with and without residual (≥2) MR. Results A total of 25 patients were included (median[Q1, Q3]; age, 80[75, 85]; 44% men) and classified into ventricular FMR (V-FMR, n = 12) and atrial FMR (A-FMR, n = 13) according to anatomical and functional characteristics by CTA. 50% of V-FMR and 38% of A-FMR had residual/worsening MR. Among V-FMR patients with residual/worsening MR, shorter coaptation length was observed (2.2[2, 2.3] mm vs. 3.5[3, 4], p = 0.006) (Figure). No differences in anatomical or functional characteristics were seen in A-FMR patients. Conclusion Longer coaptation length in V-FMR is predictive of successful MitraClip procedure, whereas mitral annulus size and cardiac volumes are not. Total (N = 12) No residual/no worsening MR (N = 6) Residual/worsening MR (N = 6) P value Septal-lateral diameter, mm 31.9 (30.5, 37.9) 32.2 (30.1, 39.8) 31.9 (29.5, 35) 0.749 Annulus area, cm² 11.2 (10.4, 13.6) 11.3 (10.1, 14.6) 11.1 (9.6, 12.6) 0.631 Tenting area, cm² 1.6 (1.3, 2.1) 1.6 (1.2, 2.2) 1.7 (1.2, 2.3) 0.873 Tenting height, mm 8.5 (6.5, 9.7) 8.5 (6.6, 9.3) 8.3 (6.3, 10.1) 0.749 Coaptation length, mm 2.6 (2.1, 3.5) 3.5 (3.0, 4.0) 2.2 (2.0, 2.3) 0.006 Total (N = 13) No residual/no worsening MR (N = 8) Residual/worsening MR (N = 5) P value Septal-lateral diameter, mm 32.3 (29.5, 39.0) 32.0 (29.2, 39.9) 34.3 (30.8, 39.02) 0.464 Annulus area, cm² 10.3 (9.2, 14.7) 10.2 (9.0, 14.6) 12.4 (9.4, 14.7) 0.661 Tenting area, cm² 1.2 (0.8, 1.8) 1.1 (0.7, 2.2) 1.3 (0.7, 1.8) 0.884 Tenting height, mm 5.5 (4.1, 6.9) 6.3 (4.1, 8.7) 4.6 (3.7, 5.8) 0.213 Coaptation length, mm 2.3 (1.5, 2.8) 2.5 (1.4, 3.5) 1.9 (1.5, 2.6) 0.464 Comparison of baseline CT parameters between no residual/ no worsening MR and residual/ worsening MR Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Background Computed tomography angiography (CTA) is key imaging modality for procedure planning for transcatheter aortic valve replacement (TAVR). Functional assessment by CTA with LV global longitudinal strain (LVGLS) has recently shown to be feasible. However, there is limited data on its prognostic value in patients with severe aortic stenosis (AS) who treated with TAVR. Purpose To evaluate the association of baseline CTA-LVGLS with post-TAVR outcome. Methods Patients who underwent contrast multiphasic gated CTA for TAVR planning were studied. LVGLS was measured using dedicated feature-tracking software (Medis®). Cox regression analysis evaluated the association of baseline LVGLS with a composite outcome of all-cause death and heart failure hospitalization after TAVR. Results A total of 431 patients were included (median [IQR] age, 83 [77,87]years; 44% female); the society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score, 3.3 [2.3,5.1]%; CTA-LVGLS, -18.0 [-21.6,-14.2]%; LV ejection fraction was preserved at 60 [55,65]%. After a median follow-up of 19 [13,27] months, 99 composite outcomes occurred after TAVR. On multivariable Cox regression analysis, LVGLS was associated with the risk of composite outcome even after adjustment for baseline characteristics (Figure A). Patients with reduced LVGLS (above the median >-18.0%) had higher risk of the composite outcome than those with preserved GLS (p = 0.003; Figure B). Conclusion Baseline CTA-LVGLS was associated with the risk of death or heart failure hospitalization over the clinical and echocardiographic characteristics in severe AS patients undergoing TAVR. Abstract Figure.

Background: It has recently been demonstrated that high-energy diagnostic transthoracic ultrasound and intravenous microbubbles dissolve thrombi (sonothrombolysis) and increase angiographic recanalization rates in patients with ST-segment–elevation myocardial infarction. We aimed to study the effect of sonothrombolysis on the myocardial dynamics and infarct size obtained by real-time myocardial perfusion echocardiography and their value in preventing left ventricular remodeling. Methods: One hundred patients with ST-segment–elevation myocardial infarction were randomized to therapy (50 patients treated with sonothrombolysis and percutaneous coronary intervention) or control (50 patients treated with percutaneous coronary intervention only). Left ventricular volumes, ejection fraction, risk area (before treatment), myocardial perfusion defect over time (infarct size), and global longitudinal strain were determined by quantitative real-time myocardial perfusion echocardiography and speckle tracking echocardiography imaging. Results: Risk area was similar in the control and therapy groups (19.2±10.1% versus 20.7±8.9%; P =0.56) before treatment. The therapy group presented a behavior significantly different than control group over time ( P P =0.015). The left ventricular global longitudinal strain was higher in the therapy than control immediately after percutaneous coronary intervention (14.1±4.1% versus 12.0±3.3%; P =0.012), and this difference was maintained until 6 months (17.1±3.5% versus 13.6±3.6%; P P =0.026). Conclusions: Sonothrombolysis reduces microvascular obstruction and improves myocardial dynamics in patients with ST-segment–elevation myocardial infarction and is an independent predictor of left ventricular remodeling over time.

Preclinical studies have demonstrated that high mechanical index (MI) impulses from a diagnostic ultrasound transducer during an intravenous microbubble infusion (sonothrombolysis) can restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI).This study tested the clinical effectiveness of sonothrombolysis in patients with STEMI.Patients with their first STEMI were prospectively randomized to either diagnostic ultrasound-guided high MI impulses during an intravenous Definity (Lantheus Medical Imaging, North Billerica, Massachusetts) infusion before, and following, emergent percutaneous coronary intervention (PCI), or to a control group that received PCI only (n = 50 in each group). A reference first STEMI group (n = 203) who arrived outside the randomization window was also analyzed. Angiographic recanalization before PCI, ST-segment resolution, infarct size by magnetic resonance imaging, and systolic function (LVEF) at 6 months were compared.ST-segment resolution occurred in 16 (32%) high MI PCI versus 2 (4%) PCI-only patients before PCI, and angiographic recanalization was 48% in high MI/PCI versus 20% in PCI only and 21% in the reference group (p 0.001). Infarct size was reduced (29 ± 22 g high MI/PCI vs. 40 ± 20 g PCI only; p = 0.026). LVEF was not different between groups before treatment (44 ± 11% vs. 43 ± 10%), but increased immediately after PCI in the high MI/PCI group (p = 0.03), and remained higher at 6 months (p = 0.015). Need for implantable defibrillator (LVEF ≤30%) was reduced in the high MI/PCI group (5% vs. 18% PCI only; p = 0.045).Sonothrombolysis added to PCI improves recanalization rates and reduces infarct size, resulting in sustained improvements in systolic function after STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).

Brazilian registries have shown a gap between evidence-based therapies and real treatments. We aim to compare the use of the pharmacoinvasive strategy and mortality in patients with ST elevation myocardial infarction (STEMI) transferred pre- and post-chest pain protocol with access to telemedicine (CPPT) in a private hospital network.A CPPT was implemented in 22 private emergency departments in 2012. Emergency physicians and nurses of all facilities were trained to disseminate the information to comply with a chest pain protocol focusing on reperfusion therapy (pharmacoinvasive strategy) for STEMI. To conduct clinical discussions using telemedicine, a cardiologist from a reference hospital in cardiology (RHC) was available 24 h/day, 7 days/week. Using the database of all consecutive admissions, we compared the data of patients with STEMI transferred to the RHC in 2011 (pre-CPPT) and 2013-2014 (post-CPPT).We included 376 patients (113 pre-CPPT and 263 post-CPPT) with STEMI. All patients admitted in the RHC were transferred from the 22 emergency departments. Comparing pre-CPPT and post-CPPT, we did not find differences regarding age, gender, hypertension, dyslipidemia, diabetes, smoking, previous myocardial infarction, or Killip classification. However, the use of CPPT was associated with a greater use of pharmacoinvasive strategy (55.8% versus 38%; p = 0.002) and a trend toward lower in-hospital mortality (3% versus 8%; p = 0.06).The implementation of a CPPT was associated with a significant increase in the use of pharmacoinvasive strategy in patients with STEMI and a trend toward reduced in-hospital mortality in a private hospital network.

We have recently demonstrated that the association of microbubble infusion and high mechanical index (MI) ultrasound is a safe and effective method of preventing microvascular obstruction in patients with ST elevation myocardial infarction (STEMI). However, the potential influence of tissue

LVD was present in 45.3% of patients and was more frequent in male than in female (32.9% vs. 67.1%, p

Background Advances in tissue characterization with late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) have highlighted the importance of myocardial fibrosis (MF) in hypertrophic cardiomyopathy (HCM) by confirming that its presence and extent predicts adverse outcomes. Despite of the identification of several genes related to HCM, few studies have investigated the association between genotype and MF. In this study, we sought to investigate the relationship between two most common gene mutations in HCM and the extension of MF by LGE.