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Response to cardiac resynchronization therapy (CRT) is reduced in patients with high left ventricular (LV) scar burden, in particular when scar is located in the LV lateral wall or septum. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can identity scar, but is not feasible in all patients. This study investigates if myocardial metabolism by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and contractile function by echocardiographic strain are alternatives to LGE-CMR. In a prospective multicenter study, 132 CRT candidates (91% with left bundle branch block) were studied by speckle tracking strain echocardiography, and 53 of these by FDG-PET. Regional myocardial FDG metabolism and peak systolic strain were compared to LGE-CMR as reference method. Reduced FDG metabolism (<70% relative) precisely identified transmural scars (≥50% of myocardial volume) in the LV lateral wall, with area under the curve (AUC) 0.96 (95% confidence interval (CI) 0.90–1.00). Reduced contractile function by strain identified transmural scars in the LV lateral wall with only moderate accuracy (AUC = 0.77, CI 0.71–0.84). However, absolute peak systolic strain >10% could rule out transmural scar with high sensitivity (80%) and high negative predictive value (96%). Neither FDG-PET nor strain identified septal scars (for both, AUC < 0.80). In CRT candidates, FDG-PET is an excellent alternative to LGE-CMR to identify scar in the LV lateral wall. Furthermore, preserved strain in the LV lateral wall has good accuracy to rule out transmural scar. None of the modalities can identify septal scar. The present study is part of the clinical study "Contractile Reserve in Dyssynchrony: A Novel Principle to Identify Candidates for Cardiac Resynchronization Therapy (CRID–CRT)", which was registered at clinicaltrials.gov (identifier NCT02525185). The ability of peak systolic strain by echocardiography and glucose metabolism by FDG-PET to identify transmural LV lateral and septal scar in CRT candidates compared to LGE-CMR, illustrated in three representative patients. LGE-CMR (left images) allows for direct scar identification independent of wall motion, and was used as reference standard for scar. Peak systolic strain by echocardiography (middle images) was generally inconclusive of scar, but absolute strain >10% in the LV lateral wall implies that transmural scar in this region is unlikely. Glucose metabolism by FDG-PET (right images) accurately identified transmural LV lateral wall scar, but was unable to distinguish transmural septal scar from septal hypo-metabolism due to left bundle branch block in itself. FDG-PET = 18F-fluorodeoxyglucose Positron Emission Tomography; LV = left ventricular; CRT = cardiac resynchronization therapy; LGE = late gadolinium enhancement; CMR = cardiac magnetic resonance. [Display omitted] • FDG-PET is a good alternative to CMR to identify transmural left ventricular lateral wall scars in patients referred for CRT. • Strain by echocardiography is only moderately accurate, but relatively preserved strain (>10%) in the lateral wall strain means that transmural scar in this region is unlikely. • Contrary to preserved strain, reduced strain in the lateral wall is inconclusive with regard to scar. • Neither FDG-PET nor echocardiographic strain identifies septal scar. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) is an implant-based therapy applied to patients with a specific heart failure (HF) profile. The identification of patients that may benefit from CRT is a challenging task and the application of current guidelines still induce a non-responder rate of about 30%. Several studies have shown that the assessment of left ventricular (LV) mechanics by speckle tracking echocardiography can provide useful information for CRT patient selection. A comprehensive evaluation of LV mechanics is normally performed using three different echocardioraphic views: 4, 3 or 2-chamber views. The aim of this study is to estimate the relative importance of strain-based features extracted from these three views, for the estimation of CRT response. Several features were extracted from the longitudinal strain curves of 130 patients and different methods of feature selection (out-of-bag random forest, wrapping and filtering) have been applied. Results show that more than 50% of the 20 most important features are calculated from the 4-chamber view. Although features from the 2- and 3-chamber views are less represented in the most important features, some of the former have been identified to provide complementary information. A thorough analysis and interpretation of the most informative features is also provided, as a first step towards the construction of a machine-learning chain for an improved selection of CRT candidates. [ABSTRACT FROM AUTHOR]

Aims: Functional mitral regurgitation (FMR) is associated with poor outcome in systolic heart failure (HF) patients. Percutaneous edge‐to‐edge mitral valve repair (PMVR) in Mitra‐Fr study failed to prove any beneficial effect over optimal medical treatment (OMT) but win in COAPT study. Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF patients with severe secondary MR. Method and results: Thirty‐seven patients with severe FMR undergoing PMVR were included and compared (according to indices of LV myocardial function and the relationship between LV‐size and the degree of regurgitation) to nineteen patients with FMR treated by OMT. Both groups were clinically comparable. At 6‐month follow‐up, cardiac index such as LV global constructive work (GCW) improved significantly in both groups (1.86 vs 2.13 L/min/m2, P = .02, 1.73 vs 2.28 L/min/m2P = .002 and 977 vs 1101 mm Hg.%, P = .003, 967 vs 1110 mm Hg.%, P = .002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end‐systolic volume index, LV ejection fraction, and global longitudinal strain were not different. Receiver operating characteristics in PMVR with LVEF ≤ 35% subgroup analysis demonstrated that global work index (GWI) had the best ability to identify patients with worse evolution (AUC = 0.882; P = .009), confirmed by univariable logistic regression, particularly for patients with GWI < 482 mm Hg.%. Conclusion: Echocardiographic characteristics at 6‐month follow‐up are not different when compare PMVR and OMT for HF patients with severe FMR. A low global work index might be a tool for discouraging the implantation of clips for this indication. [ABSTRACT FROM AUTHOR]

Background: Myocardial work (MW) estimation by pressure‐strain loops (PSL) allows the non‐invasive assessment of myocardial performance. Aim of this study is to provide the reference values for global myocardial work index (WI), constructive work (CW), wasted work (WW), and work efficiency (WE) in a group of healthy volunteers accounting for age and gender. Methods and results: 2D standard and speckle‐tracking echocardiography were performed in 115 healthy volunteers (median age 36.3 [18–69] years, males: 67%). PSLs were used to assess MW. Mean ± standard deviation or median and inter‐quartile range, 5° and 95° percentile values for global myocardial WI, CW, WW, and WE in the whole population were 1926 ± 247 mm Hg, (1534–2356); 2224 ± 229 mm Hg, (1894–2647); 90 (61–123) mm Hg%, (38–195); and 96 (94–97)%, (91–98), respectively. Global WI (2031 ± 247 vs 1874 ± 232 mm Hg%, P = .001) and global CW (2289 ± 261 vs 2194 ± 207 mm Hg%, P = .04) were higher in women than in men. Age did not affect MW parameters. The segmental analysis showed that myocardial WI, CW, and WE were lower in the left ventricular basal segments than in the apex. The apex‐to‐base gradient was inverted for WW (all P < .0001). Conclusions: The assessment of MW is feasible in normal subjects. The presented referral ranges of global myocardial WI, CW, WW, and WE were not affected by age. An apex‐to‐base gradient was observed for all MW parameters. Nevertheless, the wide variability of MW parameters prevents for the moment the application of this technique in the routine clinical setting. [ABSTRACT FROM AUTHOR]

Background: The estimation of myocardial work by pressure strain loops (PSLs) is a totally new non‐invasive approach to assess myocardial performance, and its role in patients with hypertrophic cardiomyopathy is unknown. The aims of the present study are therefore: (a) to compare myocardial work in patients with non‐obstructive hypertrophic cardiomyopathy (HCM) and in a subset of age‐matched healthy controls and (b) to assess the correlation between myocardial work and left ventricular (LV) fibrosis. Design: Eighty‐two patients with non‐obstructive HCM (58 ± 14 years) and 20 age‐matched healthy subjects (58 ± 7 years, P = 0.99) underwent standard and speckle‐tracking echocardiography to assess myocardial dimensions and deformation parameters. PSLs analysis was used to estimate global myocardial constructive work (GCW) and wasted work (GWW). LV fibrosis was estimated at cardiac magnetic resonance (CMR) by qualitative assessment of late gadolinium enhancement (LGE), and significant fibrosis was defined as LGE in ≥2 LV segments. Results: Global constructive work (1599 ± 423 vs 2248 ± 249 mm Hg%, P < 0.0001) was significantly reduced in HCM compared to the control group. No difference was observed in GWW (141 ± 125 vs 101 ± 88 mm Hg%, P = 0.18) and LV ejection fraction (LVEF) (63 ± 13 vs 66 ± 4% P = 0.17) between the two groups. In HCM, GCW was the only predictor of LV fibrosis at multivariable analysis (OR 1.01, 95% CI: 0.99–1.08, P = 0.04). A cutoff value of 1623 mm Hg% (AUC 0.80, 95% CI: 0.66–0.93, P < 0.0001) was able to predict myocardial fibrosis with a good sensitivity and fair specificity (82% and 67%, respectively). Conclusions: Global constructive work is significantly reduced in HCM despite normal LVEF and is associated with the LV fibrosis as assessed by LGE. [ABSTRACT FROM AUTHOR]

Functional tricuspid regurgitation (FTR) is an independent risk factor for morbidity and mortality. New pathophysiological concepts but also new therapeutic options are justifying new knowledges for characterizing FTRs and their prognoses. Aim: To study echocardiographic criteria associated with prognosis in FTR-patients using a clustering method in two cohorts. Two hundred forty-one patients with at least severe (≥grade 3) TR were enrolled: 92 in the retrospective cohort (mean age 77.9 ± 13 years) and 149 in the prospective validation cohort. Hierarchical clustering analysis was conducted. Four parameters explained the clustering categorization according to a multinomial regression (right ventricular (RV) end-diastolic mid-cavity diameter, RV free-wall strain, right atrial (RA) volume index, RA strain; p = 0.0039). Three clusters were identified in the retrospective cohort: Cluster 1 had better right ventricular, left ventricular, and right atrial function than Cluster 2 (reduced RV and RA strain despite similar sizes). Cluster 3 included patients with severely dilated heart chambers associated to RV and RA dysfunctions. When applying the model in the validation (external) cohort, the rate of the primary endpoint (hospitalization for heart failure and/or death from any cause) was lowest in Cluster 1 (30.8% versus 48% and 58.8% in Clusters 2 and 3, respectively; p < 0.05). In FTR patients, different profiles of RV and RA remodeling are associated with different outcomes. Therefore, the diagnostic work-up in this clinical setting should include RV and RA characteristics. Under noninterventional management, the phenotype corresponding to preserved RV size and preserved RA and RV functions appears to have a better prognosis. [Display omitted] • In patients with a Functional Tricuspid Regurgitation, different profiles of RV and RA remodeling are associated with different outcomes. • Not only the right ventricular size or function are important, both should be consider. • Do not forget the right atrium. [ABSTRACT FROM AUTHOR]

Abstract Aims The current algorithm in transthoracic echocardiography (TTE) proposed in the 2016 ASE/EACVI recommendation for the estimation of left ventricular filling pressure (LVFP) is quite complex and time-consuming. B-lines, in lung ultrasonography (LUS), could constitute an interesting tool for LVFP evaluation in clinical practice, although data regarding their association with invasive haemodynamics are lacking. The purpose of this study was to explore the diagnostic accuracy of B-lines in identifying elevated left ventricular end-diastolic pressure (LVEDP). Method and results 81 adults with significant dyspnoea (NYHA ≥ 2) were prospectively analyzed by LUS in four areas in each hemithorax and a complete TTE within four hours prior to coronary angiography. Twenty-eight patients had elevated LVEDP. Clinical variables yielded a C-index of 79% to identify elevated LVEDP. The number of total B-lines was higher in the elevated LVEDP group (1.0vs17.0, p < 0.0001) and significantly increased the diagnostic accuracy (C-index increase = 10.5%, p = 0.002) and net reclassification index (NRI = 145.4, 113.0–177.9, p < 0.0001) on top of clinical variables. Conclusion This study demonstrates the substantial diagnostic capacity of B-lines to identify elevated LVEDP, which appears superior to that of classical echocardiographic strategies. This tool should be considered in a multi-parametric approach in patients with heart failure. Highlights • ASE/EACVI recommendation for the estimation of left ventricular filling pressure is quite complex and time consuming. • B-lines, in lung ultrasound, could constitute an interesting tool for LVFP evaluation in clinical practice, but data regarding their association with invasive hemodynamics are lacking. • Clinical variables had a C-index of 79% to identify elevated LVEDP. • Total B-lines number was higher in the elevated LVEDP group (1.0vs17.0, p < 0.0001) and significantly increased diagnostic accuracy (C-index increase = 15.5%, p = 0.004) and a net reclassification index (NRI = 142.0, 108.5–175.6, p < 0.0001) on top of clinical variables. • In contrast, the 2016 ASE/EACVI recommendations did not significantly increase neither the reclassification nor the diagnostic accuracy. There is an important diagnostic capacity of B-lines to identify elevated filling pressure and that is probably something to consider in our clinical routine. [ABSTRACT FROM AUTHOR]

Background: Almost all attempts to improve patient selection for cardiac resynchronization therapy (CRT) using echo-derived indices have failed so far. We sought to assess: the performance of homemade software for the automatic quantification of integral 3D regional longitudinal strain curves exploring left ventricular (LV) mechanics and the potential value of this tool to predict CRT response.Methods: Forty-eight heart failure patients in sinus rhythm, referred for CRT-implantation (mean age: 65 years; LV-ejection fraction: 26%; QRS-duration: 160 milliseconds) were prospectively explored. Thirty-four patients (71%) had positive responses, defined as an LV end-systolic volume decrease ≥15% at 6-months. 3D-longitudinal strain curves were exported for analysis using custom-made algorithms. The integrals of the longitudinal strain signals (I L,peak) were automatically measured and calculated for all 17 LV-segments.Results: The standard deviation of longitudinal strain peak (SDI L,peak ) for all 17 LV-segments was greater in CRT responders than non-responders (1.18% s-1 [0.96; 1.35] versus 0.83% s-1 [0.55; 0.99], p = 0.007). The optimal cut-off value of SDI L,peak to predict response was 1.037%.s-1. In the 18-patients without septal flash, SDI L,peak was significantly higher in the CRT-responders.Conclusions: This new automatic software for analyzing 3D longitudinal strain curves is avoiding previous limitations of imaging techniques for assessing dyssynchrony and then its value will have to be tested in a large group of patients. [ABSTRACT FROM AUTHOR]