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Left ventricular assist devices (LVADs) are gaining increasing importance as therapeutic strategy in advanced heart failure (HF), not only as bridge to recovery or to transplant but also as destination therapy. Even though long-term LVADs are considered a precious resource to expand the treatment options and improve clinical outcome of these patients, these are limited by peri-operative and post-operative complications, such as device-related infections, haemocompatibility-related events, device mis-positioning, and right ventricular failure. For this reason, a precise pre-operative, peri-operative, and post-operative evaluation of these patients is crucial for the selection of LVAD candidates and the management LVAD recipients. The use of different imaging modalities offers important information to complete the study of patients with LVADs in each phase of their assessment, with peculiar advantages/disadvantages, ideal application, and reference parameters for each modality. This clinical consensus statement sought to guide the use of multimodality imaging for the evaluation of patients with advanced HF undergoing LVAD implantation., Competing Interests: Conflict of interest: E.D.: research and teaching facilities from General Electric Healthcare and Abbott structural. M.Ci.: investigator-initiated research grants to institution: Novartis and Abbott; advisory role, speaker honoraria, and travel grants: Abbott, Abiomed, and GE Healthcare. All other authors have no conflict of interest to declare related to this paper., (© 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: Advanced heart failure (AdHF) is characterized by variable degrees of left ventricular (LV) dysfunction, myocardial fibrosis, and raised filling pressures which lead to left atrial (LA) dilatation and cavity dysfunction. This study investigated the relationship between LA peak atrial longitudinal strain (PALS), assessed by speckle-tracking echocardiography (STE), and invasive measures of LV filling pressures and fibrosis in a group of AdHF patients undergoing heart transplantation (HTX)., Methods and Results: We consecutively enrolled patients with AdHF who underwent HTX at our Department. Demographic and basic echocardiographic data were registered, then invasive intracardiac pressures were obtained from right heart catheterization, and STE was also performed. After HTX, biopsy specimens from explanted hearts were collected to quantify the degree of LV myocardial fibrosis. Sixty-four patients were included in the study (mean age 62.5 ± 11 years, 42% female). The mean LV ejection fraction (LVEF) was 26.7 ± 6.1%, global PALS was 9.65 ± 4.5%, and mean pulmonary capillary wedge pressure (PCWP) was 18.8 ± 4.8 mmHg. Seventy-three % of patients proved to have severe LV fibrosis. Global PALS was inversely correlated with PCWP (R = -0.83; P < 0.0001) and with LV fibrosis severity (R = -0.78; P < 0.0001) but did not correlate with LVEF (R = 0.15; P = 0.2). Among echocardiographic indices of LV filling pressures, global PALS proved the strongest [area under the curve 0.955 (95% confidence interval 0.87-0.99)] predictor of raised (>18 mmHg) PCWP., Conclusion: In patients with AdHF, reduced global PALS strongly correlated with the invasively assessed LV filling pressure and degree of LV fibrosis. Such relationship could be used as non-invasive indicator for optimum patient stratification for therapeutic strategies., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Mitral valve prolapse (MVP) is usually regarded as a benign condition though the proportion of patients with a life-threatening arrhythmic MVP form remains undefined. Recently, an experts' consensus statement on arrhythmic MVP has proposed approaches for risk stratification across the spectrum of clinical manifestation. However, sudden cardiac death may be the first presentation, making clinicians focused to early unmasking this subset of asymptomatic patients. Growing evidence on the role of cardiac imaging in the in-deep stratification pathway has emerged in the last decade. Pathology findings have suggested the fibrosis of papillary muscles and inferobasal left ventricular wall as the malignant hallmark. Cardiac magnetic resonance, while of limited availability, allows the identification of this arrhythmogenic substrate. Therefore, speckle-tracking echocardiography may be a gateway to prompt referring patients to further advanced imaging investigation. Our review aims to summarize the phenotypic features linked to the arrhythmic risk and to propose an image-based algorithm intended to help stratifying asymptomatic MVP patients., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: The aim of this study was to investigate the long-term outcome of takotsubo syndrome (TTS) patients with and without hypertension (HT) and to evaluate the effectiveness of treatment with beta-blockers (BBs) and/or renin-angiotensin-aldosterone system inhibitors (RAASi)., Methods and Results: The study population includes a register-based, multicentre cohort of consecutive patients with TTS, divided into two groups according to the history of HT. Further stratification was performed for BB/RAASi prescription at discharge. The primary outcome was the composite of all-cause death and TTS recurrence at the longest available follow-up. The propensity score weighting technique was used to account for potential confounding. In the overall population (903 patients, mean age 70 ± 11 years), HT was reported in 66% of cases. At a median 2-year follow-up, there was no difference in the risk of the primary composite outcome between patients with and without HT. The adjusted Cox regression analysis showed a significantly lower risk for the primary outcome [adjusted hazard ratio (aHR): 0.69; 95% confidence interval (CI): 0.49-0.99] in patients who received BB vs. those who did not. Renin-angiotensin-aldosterone system inhibitors treatment was not associated with the primary study outcome. The lower risk for the primary outcome with BB treatment was confirmed in patients with HT (aHR: 0.37; 95% CI: 0.24-0.56) but not in patients without (aHR: 1.83; 95% CI: 0.92-3.64; Pinteraction < 0.001)., Conclusion: In this TTS study, HT did not affect the long-term risk of adverse events but increased the probability of benefit from BB treatment after discharge. Owing to the favourable outcome impact of BB prescription in TTS patients with HT, a tailored pharmacological therapy should be considered in this cohort., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Right heart failure (RHF) after left ventricular assist device (LVAD) implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial work (MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of right ventricular myocardial work to predict RHF and long-term mortality after LVAD implant., Methods and Results: Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in six patients (26%). A lower right ventricular global work efficiency [RVGWE, OR 0.86, 95% confidence intervals (CI) 0.76-0.97, P = 0.014] was associated with the occurrence of early RHF. Among MW indices, the performance for early RHF prediction was greatest for RVGWE [area under the curve (AUC) 0.92] and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long-term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, P = 0.033)., Conclusion: RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Speckle-tracking echocardiography (STE) strain imaging has been a major advancement in myocardial function quantification. We aimed to explore current worldwide clinical application of STE., Methods and Results: Access, feasibility, access, and clinical implementation of STE were investigated with a worldwide open-access online survey of the European Association of Cardiovascular Imaging. Participants (429 respondents and 77 countries) from tertiary centres (46%), private clinics, or public hospitals (54%) using different vendors for data acquisition and analysis were represented. Despite almost universal access (98%) to STE, only 39% of the participants performed and reported STE results frequently (>50%). Incomplete training and time constraints were the main reasons for not using STE more regularly. STE was mainly used to assess the LV (99%) and less frequently the right ventricular (57%) and the left atrial (46%) function. Cardiotoxicity (88%) and cardiac amyloidosis (87%) were the most frequent reasons for the clinical use of LV STE. Left atrial STE was used most frequently for the diagnosis of diastolic dysfunction and right ventricular STE for the assessment of right ventricle (RV) function in pulmonary hypertension (51%). Frequency of STE use, adherence to optimal techniques, and clinical appropriateness of STE differed according to training experience and across vendors. Key suggestions outlined by respondents to increase the clinical use of STE included improved reproducibility (48%) and standardization of strain values across vendors (42%)., Conclusion: Although STE is now readily available, it is underutilized in the majority of centres. Structured training, improved reproducibility, and inter-vendor standardization may increase its uptake., Competing Interests: Conflict of interest: L.E.S.: none, S.S.J.: none, M.C.: participated data safety monitoring or advisory board for Novo Nordisk and Astra Zeneca, received equipment, or other services from Novartis, B.C.: participated on a data safety monitoring board or advisory board for AMGEN and BMS, V.D.: received speaker fees from Edwards Lifesciences, GE Healthcare, Medtronic, Novartis, and Philips and consulting fees from Edwards Lifesciences and Novo Nordisk, E.D.: none, T.E.: none, R.F.C.: none, R.M.: none, T.P.: none, B.A.P.: received honoraria and receipt of equipment from GE Healthcare, and Hitaci-Aloka, J.S.H.: none, M.S.: received honoraria from GE Electric. Canon Medical, and M.D.: none. EACVI received an unrestricted education grant from General Electric. General Electric was completely blinded to the data collected and was not involved in analysis or drafting the manuscript., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: The prognostic impact of flow trajectories according to stroke volume index (SVi) and transvalvular flow rate (FR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) remains poorly assessed. We evaluated and compared SVi and FR prior and after TAVR for severe AS., Methods and Results: Patients were categorized according to SVi (<35 mL/m2) and FR (<200 mL/s). The association of pre- and post-TAVR SVi and FR with all-cause mortality up to 3 years was assessed with multivariable Cox regression models. Among 980 patients with pre-TAVR flow assessment, SVi was reduced in 41.3% and FR in 48.1%. Baseline flow status was not an independent mortality predictor [SVi: hazard ratio (HR) 1.22, 95% confidence interval (CI) 0.85-1.82, FR: HR 0.78, 95% CI 0.48-1.27]. Among 731 patients undergoing early (5 days, interquartile range 2-29) post-TAVR flow assessment, SVi recovered in 40.1% and FR in 49.0% patients with baseline low flow. Reduced FR following TAVR was an independent predictor of mortality (HR 1.67, 95% CI 1.02-2.74), whereas SVi was not (HR 0.97, 95% CI 0.53-1.78). Three-year estimated mortality in patients with recovered FR was lower than that in patients with reduced FR (13.3 vs. 37.7% vs, P = 0.003) and similar to that in patients with normal baseline FR (P = 0.317)., Conclusion: Baseline flow status was not an independent predictor of mid-term mortality among all-comers with severe AS undergoing TAVR. Flow recovery early after TAVR was frequent. Post-TAVR FR, but not SVi, was independently associated with mid-term all-cause mortality. By impacting flow status, AV replacement modifies the association of flow status with outcomes., Competing Interests: Conflict of interest: M.M. received consultant fees from Abbott, Boston Scientific, Kardia, and Medtronic. The other authors have no conflicts of interest to declare., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The athlete's heart is a well-known phenomenon in adults practising competitive sports. Unfortunately, to date, most of the studies on training-induced cardiac remodelling have been conducted in adults and the current recommendations refer mainly to adult individuals. However, an appropriate interpretation of resting ECG and imaging in children practising sports is crucial, given the possibility of early detect life-threatening conditions and managing therapy and eligibility to sports competitions in the rapidly growing paediatric athlete population. While several articles have been published on this topic in adult athletes, a practical guide for the clinical evaluation of paediatric athletes is still missing. In this critical review, we provided a comprehensive description of the current evidence on training-induced remodelling in paediatric athletes with a practical approach for clinicians on how to interpret the resting 12-lead ECG and cardiac imaging in the paediatric athlete. Indeed, given that training may mimic potential cardiovascular disorders, clinicians evaluating children practising sports should pay attention to the risk of missing a diagnosis of a life-threatening condition. However, this risk should be balanced with the risk of overdiagnosis and unwarranted disqualification from sports practice, when interpreting an ECG as pathological while, on the contrary, it may represent a physiological expression of athlete's heart. Accordingly, we proposed an algorithm for the evaluation of normal, borderline, and abnormal ECG findings that can be useful for the readers for their daily clinical practice., 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.)

Aims: Cardiac amyloidosis (CA) affects the four heart chambers, which can all be evaluated through speckle-tracking echocardiography (STE)., Methods and Results: We evaluated 423 consecutive patients screened for CA over 5 years at two referral centres. CA was diagnosed in 261 patients (62%) with either amyloid transthyretin (ATTR; n = 144, 34%) or amyloid light-chain (AL; n = 117, 28%) CA. Strain parameters of all chambers were altered in CA patients, particularly those with ATTR-CA. Nonetheless, only peak left atrial longitudinal strain (LA-PALS) displayed an independent association with the diagnosis of CA or ATTR-CA beyond standard echocardiographic variables and cardiac biomarkers (Model 1), or with the diagnosis of ATTR-CA beyond the validated IWT score in patients with unexplained left ventricular (LV) hypertrophy. Patients with the most severe impairment of LA strain were those most likely to have CA or ATTR-CA. Specifically, LA-PALS and/or LA-peak atrial contraction strain (PACS) in the first quartile (i.e. LA-PALS <6.65% and/or LA-PACS <3.62%) had a 3.60-fold higher risk of CA, and a 3.68-fold higher risk of ATTR-CA beyond Model 1. Among patients with unexplained LV hypertrophy, those with LA-PALS or LA-PACS in the first quartile had an 8.76-fold higher risk for CA beyond Model 1, and a 2.04-fold higher risk of ATTR-CA beyond the IWT score., Conclusions: Among STE measures of the four chambers, PALS and PACS are the most informative ones to diagnose CA and ATTR-CA. Patients screened for CA and having LA-PALS and/or LA-PACS in the first quartile have a high likelihood of CA and ATTR-CA., Competing Interests: Conflict of interest: none declared., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

In the last decade, speckle tracking echocardiography (STE) has acquired a fundamental role in the evaluation of the systolic function of the left ventricle, with several advantages over the Doppler method, including angle independence, greater reproducibility, and rapidity of image acquisition. Speckle tracking finds application in various pathologies, ranging from ischaemic heart disease, to cardiomyopathies, to heart failure, both with reduced and preserved ejection fraction (EF), in which the EF is not a reliable prognostic marker and the estimate of left ventricular function by means of 'strain' is of crucial utility. In addition, the strain of the left atrium finds application in many clinical contexts as an early index of diastolic dysfunction and left ventricular filling pressures. Finally, the strain of the right ventricle is of particular prognostic importance in the evaluation of heart failure, particularly in its advanced form, becoming an indispensable index in the evaluation of patients who are candidates for advanced therapeutic strategies. This document aims to describe the various fields of clinical application of STE, with particular emphasis on its diagnostic and prognostic role, so much that it is now integrated into the algorithms for managing multiple pathologies in daily clinical practice., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the use of different cardiac imaging modalities for the evaluation of the right heart., Methods and Results: Delegates from 250 EACVI registered centres were invited to participate in a survey which was also advertised on the EACVI bulletin and on social media. One hundred and thirty-eight respondents from 46 countries across the world responded to the survey. Most respondents worked in tertiary centres (79%) and echocardiography was reported as the commonest imaging modality used to assess the right ventricle (RV). The majority of survey participants (78%) included RV size and function in &gt;90% of their echocardiographic reports. The RV basal diameter obtained from the apical four-chamber view and the tricuspid annular plane systolic excursion were the commonest parameters used for the echocardiographic assessment of RV size and function as reported by 82 and 97% respondents, respectively. Survey participants reported arrhythmogenic cardiomyopathy as the commonest condition (88%) where cardiac magentic resonance (CMR) imaging was used for right heart assessment. Only 52% respondents included RV volumetric and ejection fraction assessments routinely in their CMR reports, while 30% of respondents included these parameters only when RV pathology was suspected. Finally, 73% of the respondents reported pulmonary hypertension as the commonest condition where right heart catheterization was performed., Conclusion: Echocardiography remains the most frequently used imaging modality for the evaluation of the right heart, while the use of other imaging techniques, most notably CMR, is increasing., 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.)

In recent years, the role of pre-participation evaluation (PPE) in the prevention of sudden cardiac death in competitive athletes has become evident. Most physicians routinely supplement assessment by resting electrocardiogram with imaging techniques, such as echocardiography. The primary goal of imaging in the clinical assessment of competitive athletes is to exclude cardiovascular conditions associated with adverse outcomes. Cardiac computed tomography is emerging as an important technique for stratifying cardiovascular risk and assessing coronary artery disease (CAD), particularly in master athletes. Conversely, in young athletes, this technique has the best non-invasive coronary artery resolution and provides valuable details on coronary artery anatomy. Recent technical developments have brought about a dramatic reduction in radiation exposure, a major drawback of this diagnostic method; nowadays cardiac computed tomography may be performed at a dose of barely one millisievert. The present review provides a practical guide for the use of cardiac computed tomography in the PPE of competitive athletes, with a specific focus on its value for detecting congenital coronary anomalies and CAD in young and master athletes, respectively., Competing Interests: Conflict of interest: None declared., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please e-mail: journals.permissions@oup.com.)

The right atrium (RA) is the cardiac chamber that has been least well studied. Due to recent advances in interventional cardiology, the need for greater understanding of the RA anatomy and physiology has garnered significant attention. In this article, we review how a comprehensive assessment of RA dimensions and function using either echocardiography, cardiac computed tomography, and magnetic resonance imaging may be used as a first step towards a better understanding of RA pathophysiology. The recently published normative data on RA size and function will likely shed light on RA atrial remodelling in atrial fibrillation (AF), which is a complex phenomenon that occurs in both atria but has only been studied in depth in the left atrium. Changes in RA structure and function have prognostic implications in pulmonary hypertension (PH), where the increased right ventricular (RV) afterload first induces RV remodelling, predominantly characterized by hypertrophy. As PH progresses, RV dysfunction and dilatation may begin and eventually lead to RV failure. Thereafter, RV overload and increased RV stiffness may lead to a proportional increase in RA pressure. This manuscript provides an in-depth review of RA anatomy, function, and haemodynamics with particular emphasis on the changes in structure and function that occur in AF, tricuspid regurgitation, and PH., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Aims: In patients with heart failure (HF), chronically raised left ventricular (LV) filling pressures lead to progressive left atrial (LA) dysfunction and fibrosis. We aimed to assess the correlation of LA reservoir strain (peak atrial longitudinal strain, PALS) by speckle tracking echocardiography (STE) and LA fibrosis assessed by myocardial biopsy in patients undergoing heart transplantation (HTx)., Methods and Results: Forty-eight patients with advanced HF [mean age 51.2 ± 8.1 years, 29% females; LV ejection fraction ≤25% and New York Heart Association (NYHA) class III-IV] referred for HTx were enrolled and underwent pre-operative echocardiographic evaluation, right heart catheterization, and cardiopulmonary exercise testing. Exclusion criteria were non-sinus rhythm, mechanical ventilation, severe mitral/tricuspid regurgitation, or other valvular disease and poor acoustic window. After HTx, LA bioptic samples were collected and analysed to determine the extent of myocardial fibrosis (%). LA fibrosis showed correlation with PALS (R = -0.88, P < 0.0001), VO2max (R = -0.68, P < 0.0001), NYHA class (R = 0.66, P < 0.0001), LA stiffness (R = 0.58, P = 0.0002), and E/e' (R = 0.44, P = 0.005), while poorly correlated with E/A ratio (R = 0.23, P = 0.21). PALS had a good correlation with NYHA class (R = -0.64, P < 0.0001), PAoP (R = -0.61, P = 0.03) and VO2max (R = 0.57, P = 0.0001). Multivariate regression analysis identified PALS (beta = -0.91, P < 0.001) and LA Volume (beta = -0.19, P = 0.03) as predictors of LA Fibrosis, while E/e' was not a significant predictor (beta = 0.15, P = 0.08)., Conclusion: Emerging as a possible index of myocardial fibrosis in patients with advanced HF, PALS could help to optimize the management and the selection of those patients with irreversible LA structural damage for advanced therapeutic strategies., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and is associated with relevant morbidity and mortality. However, an evidence-based treatment is still absent. The heterogeneous definitions, differences in aetiology/pathophysiology, and diagnostic challenges of HFpEF made it difficult to define its epidemiological landmarks so far. Several large registries and observational studies have recently disclosed an increasing incidence/prevalence, as well as its prognostic significance. An accurate definition of HFpEF epidemiological boundaries and phenotypes is mandatory to develop novel effective and rational therapeutic approaches., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

The interpretation of 12-lead resting electrocardiogram (ECG) in patients with a definitive diagnosis or with the suspicion of a cardiomyopathy represents a cornerstone for the diagnostic work up and management of patients. Although low electrocardiographic QRS voltages (LQRSV) detected by 12-lead resting ECG have historically been acknowledged by physicians, in view of recent evidence on the demonstration of myocardial scar by cardiac magnetic resonance and its relevance as a cause of sudden cardiac death even in young individuals, a new interest has been raised about the utility of LQRSV in the clinical practice. Beyond their diagnostic value, LQRSV have also demonstrated a prognostic role in different cardiomyopathies. The present review summarizes the diagnostic and prognostic value of LQRSV in cardiomyopathies, reporting the new evidence, primarily based on advanced imaging studies, supporting the clinical utility of this parameter., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with hypertrophic cardiomyopathy (HCM)., Methods and Results: A total of 213 centres from 38 different countries (87% European) responded to the survey. One hundred twenty-one (57%) centres followed HCM patients in a general cardiology outpatient clinic and 85 (40%) centres in a specialized HCM/cardiomyopathy clinic. While echocardiography was the primary imaging modality, cardiovascular magnetic resonance (CMR) has become an important complementary tool. Cardiac anatomy, left ventricular (LV) systolic, and diastolic function were assessed according to current European guidelines and recommendations. To evaluate LV obstruction, 49% of the centres performed bedside provocation manoeuvres in every patient and 55% of the centres used exercise stress echocardiography. The majority of centres used the 5-year risk assessment of sudden cardiac death (SCD) calculated with the HCM Risk-SCD score. However, 34% of the centres also used extensive non-infarct late gadolinium enhancement on CMR and 27% the presence of LV apical aneurysm to help select patients for primary prevention implantable cardioverter-defibrillator therapy. Ninety-nine percent of the responding centres performed regular imaging follow-up of HCM patients., Conclusion: Most centres followed European guidelines and recommendations for the diagnosis and management of patients with HCM. The importance of bedside provocation manoeuvres and exercise stress echocardiography to diagnose LV outflow obstruction requires emphasis. Additional risk markers for SCD are used in many centres and might indicate the need for an update of current European recommendations., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: The European Association of Cardiovascular Imaging Scientific Initiatives Committee conducted a global survey to evaluate the impact of the 2019 coronavirus disease (COVID-19) pandemic on the mental well-being of cardiac imaging specialists., Methods and Results: In a prospective international survey performed between 23 July 2021 and 31 August 2021, we assessed the mental well-being of cardiac imaging specialists ∼18 months into the COVID-19 pandemic. One-hundred-and-twenty-five cardiac imaging specialists from 34 countries responded to the survey. More than half described feeling anxious during the pandemic, 34% felt melancholic, 27% felt fearful, and 23% respondents felt lonely. A quarter of respondents had increased their alcohol intake and more than half reported difficulties in sleeping. Two-thirds of respondents described worsening features of burnout during the past 18 months, 44% considered quitting their job. One in twenty respondents had experienced suicidal ideation during the pandemic. Despite these important issues, the majority of participants (57%) reported having no access to any formal mental health support at work., Conclusion: The survey has highlighted important issues regarding the mental well-being of cardiac imaging specialists during the COVID-19 pandemic. This is a major issue in our sub-specialty, which requires urgent action and prioritization so that we can improve the mental health of cardiovascular imaging specialists., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Aims: Endurance sports practice has significantly increased over the last decades, with a growing proportion of participants older than 40 years. Although the benefits of moderate regular exercise are well known, concerns exist regarding the potential negative effects induced by extreme endurance sport. The aim of this study was to analyse the acute effects of an ultramarathon race on the electrocardiogram (ECG), biventricular function, and ventricular arrhythmias in a population of master athletes., Methods and Results: Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and at the end of the race. The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, R-wave amplitude in V1 and QTc duration were higher after the race (P < 0.001). Exercise-induced isolated premature ventricular beats were observed in 7% of athletes; none showed non-sustained ventricular tachycardia before or during the race. Left ventricular ejection fraction, global longitudinal strain (GLS), and twisting did not significantly differ before and after the race. After the race, no significant differences were found in right ventricular inflow and outflow tract dimensions, fractional area change, s', and free wall GLS., Conclusion: In master endurance athletes running an ultra-marathon, exercise-induced ventricular dysfunction, or relevant ventricular arrhythmias was not detected. These results did not confirm the hypothesis of a detrimental acute effect of strenuous exercise on the heart., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: Heart failure with preserved ejection fraction (HFpEF) is a growing public health problem. Impairment in left ventricular (LV) diastolic function has been proposed as a key pathophysiologic determinant. However, the role of concomitant systolic dysfunction despite preserved LV ejection fraction (LVEF) has not been well characterized. To analyse LV myocardial deformation, diastolic function, and contractile reserve (CR) in patients with HFpEF at rest and while during exercise, as well as their correlation with functional capacity., Methods and Results: Standard echo, lung ultrasound, LV 2D speckle-tracking strain, and myocardial work efficiency (MWE) were performed at rest and during exercise in 230 patients with HFpEF (female sex 61.2%; 71.3 ± 5.3 years) in 150 age- and sex-comparable healthy controls. LV mass index and LAVI were significantly increased in HFpEF. Conversely, global longitudinal strain (GLS) and MWE were consequently reduced in HFpEF patients. During effort, HFpEF showed reduced exercise time, capacity, and VO2 peak. Increase in LVEF and LV GLS was significantly lower in HFpEF patients, while LV E/e' ratio, pulmonary pressures, and B-lines by lung ultrasound rose. A multivariable analysis outlined that LV MWE at rest was closely related to maximal Watts reached (beta coefficient: 0.43; P < 0.001), peak VO2 (beta: 0.50; P < 0.001), LV E/e' (beta: 0.52, P < 0.001), and number of B-lines during effort (beta: -0.36; P < 0.01)., Conclusions: The lower resting values of LV GLS and MWE in HFpEF patients suggest an early subclinical myocardial damage, which seems to be closely associated with lower exercise capacity, greater pulmonary congestion, and blunted LV contractile reserve during effort., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: The aim of this study is to analyse how current recommendations on left ventricular (LV) diastolic function assessment have been adopted. Identifying potential discrepancies between recommendations and everyday clinical practice would enable us to better understand and address the remaining challenges in this controversial and complex field., Methods and Results: A total of 93 centres, mainly from tertiary care settings, responded to the survey. More than three-quarters (77%) of centres follow the 2016 ASE/EACVI recommendations for LV diastolic function evaluation in patients with preserved ejection fraction based upon e', E/e', tricuspid regurgitation velocity, and left atrial (LA) volume. These recommendations were generally preferred to the previous 2009 version. Many centres also consider strain assessments in the LV (48%) and left atrium (53%) as well as diastolic stress echocardiography (33%) to be useful as additional assessments of LV diastolic function. Echocardiographic assessments of LV diastolic function were used frequently to guide therapy in 72% of centres., Conclusion: There is widespread adoption of current recommendation on the evaluation of LV diastolic function and these are frequently used to guide patient management. Many centres now also consider LV and LA strain assessments useful in the clinical assessment of diastolic function. These may be considered in future recommendations., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

In clinical decision making, myocardial viability is defined as myocardium in acute or chronic coronary artery disease and other conditions with contractile dysfunction but maintained metabolic and electrical function, having the potential to improve dysfunction upon revascularization or other therapy. Several pathophysiological conditions may coexist to explain this phenomenon. Cardiac imaging may allow identification of myocardial viability through different principles, with the purpose of prediction of therapeutic response and selection for treatment. This expert consensus document reviews current insight into the underlying pathophysiology and available methods for assessing viability. In particular the document reviews contemporary viability imaging techniques, including stress echocardiography, single photon emission computed tomography, positron emission tomography, cardiovascular magnetic resonance, and computed tomography and provides clinical recommendations for how to standardize these methods in terms of acquisition and interpretation. Finally, it presents clinical scenarios where viability assessment is clinically useful., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Cardiovascular diseases represent a major health problem, being one of the leading causes of morbidity and mortality worldwide. Therefore, in this scenario, cardiovascular prevention plays an essential role although it is difficult to establish when promoting and implementing preventive strategies. However, there is growing evidence that prevention should start even before birth, during pregnancy, aiming to avoid the onset of cardiovascular risk factors, since events that occur early in life have a great impact on the cardiovascular risk profile of an adult. The two pillars of this early preventive strategy are nutrition and physical exercise, together with prevention of cardio-metabolic diseases during pregnancy. This review attempts to gather the growing evidence of the benefits of antenatal, perinatal and primordial prevention, discussing also the possibility to reverse or to mitigate the cardiovascular profile developed in the initial stages of life. This could pave the way for future research, investigating the optimal time and duration of these preventing measures, their duration and maintenance in adulthood, and the most effective interventions according to the different age and guiding in the next years, the best clinical practice and the political strategies to cope with cardiovascular disease., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

The coronavirus disease of 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has been rapidly escalating, becoming a relevant threat to global health. Being a recent virus outbreak, there are still no available therapeutic regimens that have been approved in large randomised trials and so patients are currently being treated with multiple drugs. This raises concerns regarding drug interaction and their implication in arrhythmic burden. In fact, two of the actually used drugs against SARS-CoV2, such as chloroquine and the combination lopinavir/ritonavir, might determine a QT (the time from the start of the Q wave to the end of the T wave) interval prolongation and they show several interactions with antiarrhythmic drugs and antipsychotic medications, making them prone to an increased risk of developing arrhythmias. This brief review focuses the attention on the most relevant drug interactions involving the currently used COVID-19 medications and their possible association with cardiac rhythm disorders, taking into account also pre-existing condition and precipitating factors that might additionally increase this risk. Furthermore, based on the available evidence and based on the knowledge of drug interaction, we propose a quick and simple algorithm that might help both cardiologists and non-cardiologists in the management of the arrhythmic risk before and during the treatment with the specific drugs used against SARS-CoV2., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread in nearly 200 countries in less than 4 months since its first identification; accordingly, the coronavirus disease 2019 (COVID 2019) has affirmed itself as a clinical challenge. The prevalence of pre-existing cardiovascular diseases in patients with COVID19 is high and this dreadful combination dictates poor prognosis along with the higher risk of intensive care mortality. In the setting of chronic heart failure, SARS-CoV-2 can be responsible for myocardial injury and acute decompensation through various mechanisms. Given the clinical and epidemiological complexity of COVID-19, patiens with heart failure may require particular care since the viral infection has been identified, considering an adequate re-evaluation of medical therapy and a careful monitoring during ventilation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the current practice for the assessment and management of patients with suspected patent foramen ovale (PFO) and cryptogenic stroke., Methods and Results: In total, 79 imaging centres from 34 countries across the world responded to the survey, which comprised 17 questions. Most non-invasive investigations for PFO were widely available in the responding centres, with the exception of transcranial colour Doppler which was only available in 70% of sites, and most commonly performed by neurologists. Standard transthoracic echocardiography, with or without bubbles, was considered the first-level test for suspected PFO in the majority of the centres, whereas transoesophageal echocardiography was an excellent second-level modality. Most centres would rule out atrial fibrillation (AF) as a source of embolism in all patients with cryptogenic stroke (63%), with the remainder reserving investigation for patients with multiple AF risk factors (33%). Cardiac magnetic resonance was the preferred tool for identifying other unusual aetiologies, like cardiac masses or thrombi. After PFO closure, there was variation in the use of antiplatelet therapy: a quarter recommended treatment for life, while only 12% recommended 5 years as stipulated in the guidelines (12%). Antibiotic prophylaxis prior to dental or endoscopic procedures was not recommended in 41% of centres, contrary to what the guidelines recommended., Conclusion: Our survey revealed a variable adherence to the current recommendations for the diagnosis and management of patients with cryptogenic stroke and PFO. Efforts should focus on optimizing and standardizing diagnostic tests and treatment of this condition., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with suspected and confirmed chronic coronary syndromes., Methods and Results: One-hundred and ten imaging centres from 37 countries across the world responded to the survey. Most non-invasive investigations for coronary artery disease were widely available, except cardiovascular magnetic resonance (available 40% centres). Coronary computed tomography angiography (CCTA) and nuclear scans were reported by a multi-disciplinary team in only a quarter of centres. In the initial assessment of patients presenting with chest pain, only 32% of respondents indicated that they rely on pre-test probability for selecting the optimal imaging test while 31% proceed directly to CCTA. In patients with established coronary artery disease and recurrent chest pain, respondents opted for stress echocardiography (27%) and nuclear stress perfusion scans (26%). In asymptomatic patients with coronary artery disease and an obstructive (>70%) right coronary artery stenosis, 58% of respondents were happy to pursue medical therapy without further testing or intervention. This proportion fell to 29% with left anterior descending artery stenosis and 1% with left main stem obstruction. In asymptomatic patients with evidence of moderate-to-severe myocardial ischaemia (15%), only 18% of respondents would continue medical therapy without further investigation., Conclusion: Despite guidelines recommendations pre-test probability is used to assess patients with suspected coronary artery in a minority of centres, one-third of centres moving directly to CCTA. Clinicians remain reticent to pursue a strategy of optimal medical therapy without further investigation or intervention in patients with controlled symptoms but obstructive coronary artery stenoses or myocardial ischaemia., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aortic stenosis (AS) is the most prevalent valvular disease in developed countries, with a prevalence that is set to expand further with an ageing population. The most recent guidelines on valvular heart disease published by the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery, aim to standardize the diagnosis and management of valvular heart diseases. The imaging criteria of the current guidelines are mostly based on EACVI Recommendations, with an appropriate diagnostic workflow being of major importance, to ensure streamlined and efficient patient assessment and accurate diagnoses and decisions regarding the timing of surgery. The EACVI Scientific Initiatives Committee, therefore, created a survey on the imaging assessment of patient with AS to investigate the diagnostic patient pathways used in different centres across Europe. In particular, we conducted this survey to better understand the use and access of advanced imaging techniques in AS including 3D transthoracic echocardiography and 3D transoesophageal echocardiography, cardiac computed tomography, and cardiovascular magnetic resonance., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: To evaluate standard reporting of cardiac chambers size and function by transthoracic echocardiography (TTE), the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of three-dimensional echocardiography (3DE) and speckle tracking-derived myocardial deformation imaging (STE) was explored., Methods and Results: A total of 96 European Echocardiography Laboratories from 22 different countries responded to the survey, which consisted of 20 questions. For most of the standard parameters of cardiac chamber size and function, answers from the centres were homogeneous and demonstrated good adherence to current recommendations. In particular, all centres assessed left ventricular (LV) and left atrial (LA) size combining diameter measurements with volumes obtained using the bi-plane Simpson's method. More variability was observed in the measurements of the right heart chambers and thoracic aorta. Interestingly, >90% of centres had access to 3DE and STE; however, the large majority of centres reserved the use of these techniques for selected cases, particularly for the measure of 3D LV volumes and ejection fraction and global longitudinal strain in patients being considered for cardiac device implantation, surgical intervention (valvular heart disease) or screened for cardiotoxicity. Only 10% of centres used 3DE for right ventricular and LA volumes. Also, <30% of the centres used LA strain imaging., Conclusion: In Europe, a good adherence to current recommendations was observed for most of the standard parameters of cardiac chambers quantification by TTE. Advanced echocardiography modalities, such as 3DE and STE, are widely available but used only in selected cases., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Objective: The purpose of this study was to assess the relationship between cephalometric parameters and apnoea-hypopnoea index (AHI) controlling for the effect of gender, age, and body mass index (BMI) on a large sample of patients with obstructive sleep apnoea (OSA)., Methods: This retrospective cohort study was conducted on the lateral cephalograms of 253 Caucasian adult OSA patients. Cephalometric analyses were performed using 14 parameters for skeletal and soft tissue morphology, including antero-posterior and vertical jaw relationships, hyoid bone position, soft palate length and thickness, airway space, and tongue length and height. A hierarchical regression was run to examine the amount of variability in AHI that cephalometric variables explained after controlling for patients' general characteristics (gender, age, and BMI)., Results: After controlling for gender, age, and BMI, the increase in AHI variance accounted for by cephalometric parameters was equal to 0.103. Among the cephalometric variables, only MP-H and PNS-P were statistically significant (P < 0.05)., Limitations: Given the retrospective nature of the study, it is difficult to assess whether other confounding variables not considered in the present study could have influenced the relationship between cephalometric parameters and AHI., Conclusions: This study revealed the existence of a relationship between OSA severity and some cephalometric parameters. Indeed soft palate length and vertical position of the hyoid bone were significant predictors of AHI in adult Caucasian OSA patients., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

One of the missions of the European Association of Cardiovascular Imaging (EACVI) is 'to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging'. The future of imaging involves multimodality so each imager should have the incentive and the possibility to improve its knowledge in other cardiovascular techniques. This article presents the results of a 20 questions survey carried out in cardiovascular imaging (CVI) centres across Europe. The aim of the survey was to assess the situation of experience and training of CVI in Europe, the availability and organization of modalities in each centre and to ask for vision about potential improvements in CVI at national and European level., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)