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Echocardiography is the cornerstone in the diagnosis of any valvular heart disease. The accurate diagnosis of aortic stenosis, the left ventricle function and the other heart valves evaluation are currently done by ultrasound alone. Prosthetic valve choice and dimensions prior to implantation can be done solely by proper use of echocardiography. The emergence of new methods to cure aortic stenosis such as trans-catheter aortic valve replacement (TAVR) emphasized the diagnostic value of cardiac ultrasound. The usefulness of echocardiography in TAVR can be divided in the baseline assessment (common to patients treated by conventional surgery), intra-procedural guidance of valve deployment and post-procedural follow-up. In the baseline diagnostic work-up echocardiography should allow proper assessment of low-gradient severe aortic stenosis and especially of "low-flow, low-gradient" aortic stenosis, as far the benefit of any valve intervention in these cases may be overshadowed by persistent ventricular dysfunction. "Classic" TAVR is performed with a trans-esophageal echocardiography probe in place, but recently intracardiac echocardiography (ICE) was advocated to reduce the need for general anesthesia. "Minimalist TAVR approach" recommends no echo-guidance and valve implantation by angiography alone. Post-TAVR echo assessment should allow prompt recognition of early complications and the severity of para-valvular leaks. Long term follow-up by echocardiography assesses prosthetic valve function, left ventricular functional recovery and the impact of the procedure on associated conditions (mitral regurgitation, pulmonary hypertension or tricuspid regurgitation). This article emphasizes the role of the cardiologist with ultrasound skills in the assessment of patients addressed to TAVR. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy (HCM) is a common genetic cardiac disease characterized by a diverse clinical presentation and natural history. Many affected individuals have mild or no symptoms and remain undiagnosed, others develop severe heart failure, and some die suddenly, often at a young age and in the absence of previous symptoms. Left ventricular outflow tract obstruction is the most frequent cause of heart failure. Abolition of outflow obstruction and alleviation of symptoms in drug-refractory patients requires invasive intervention. In the 1960s, surgical septal myectomy emerged as the primary strategy to relieve the obstruction. Since the 1990s, alcohol septal ablation has become a frequent alternative to myectomy, because it reduces the obstruction without requiring open-heart surgery. However, in recent years, the enthusiasm for septal ablation has decreased because of its arrhythmogenicity and incomplete abolition of obstruction. On the other hand, during the last 15 years, surgical myectomy has undergone important technical evolution and has become one of the safest open-heart procedures, with an operative mortality of <1% when performed by experienced surgeons at specialized centers. The operation substantially improves quality of life, prolongs survival and is considered by the international HCM guidelines the gold standard for invasive treatment of outflow obstruction. [ABSTRACT FROM AUTHOR]

Aims - Baseline mechanical intraventricular dyssynchrony showed only a weak correlation with response to CRT in HF patients with wide QRS. We aimed to evaluate the effects of RV pacing on baseline intraventricular dyssynchrony in patients submitted to CRT. Methods - In 40 consecutive HF patients (LBBB, sinus rhythm, normal PR interval, 22 ischemic etiology, 65.5±10.7 years, 21 women, NYHA class 3.3 ± 0.5, LV ejection fraction 20.1±4.1%), speckle tracking radial strain was performed during sinus rhythm (ODO mode) and during RV pacing (DDD with optimum AV interval) one week after biventricular device implantation. RV lead was placed on interventricular septum (RVS, n=30) and RV apex (RVA, n=10). Patients had significant baseline intraventricular dyssynchrony, (i.e. =130 ms time difference in peak septal wall to infero-lateral wall strain). Maximum LV delay area (MDA) was defined as the segment with the latest systolic peak from the 6 regional color-coded time-strain curves. Midventricular global radial strain (mGRS) was determined averaging the segmental radial strain values. Results - Overall, RV pacing did not significantly increased intraventricular dyssynchrony (350±98 ms vs. 322±90 ms during SR, p=0.08). However, RVA pacing significantly increased LV dyssynchrony (367±58 ms vs. 312±60 ms during SR, p<0.001). mGRS was significantly reduced during RV pacing (13.3±8.5% vs. 18.3±7.4% during SR, p<0.001). The location of MDA shifted during RV pacing in 31 out of 40 patients (77%). Conclusions - In HF patients with wide QRS submitted to CRT, RV pacing alters the pattern of intraventricular dyssynchrony and impairs LV strain. [ABSTRACT FROM AUTHOR]

Purpose - We present the case of a 56 year-old patient with severe aortic stenosis (AoS), severe heart failure (left ventricular ejection fraction of 20%), in NYHA class III with permanent atrial fi brillation and type 2 diabetes mellitus, but no associated coronary artery disease. The local Heart Team decided to treat the patient by trans-catheter aortic valve replacement (TAVR). Consequently full imagistic assessment found that transfemoral approach was not possible, because of low femoro-iliac diameter on both sides and heavy calcifi cation. Transapical approach was considered. Methods - The patient was brought intubated to the cathlab under general anesthesia. Extracoporeal circulation was performed by cannulation of both right and left femoral vessels to partially sustain LV function during TAVR. Apical access was obtained by left minithoracotomy. A 29 mm Sapien XT valve was mounted without predilatation in the aortic orifi ce, expanded and postdilated once because of signifi cant paravalvular leak. Results - The prosthetic valve was successfully implanted with minimal residual paravalvular leak. The patient was detubated early and discharged 7 days after TAVR. At one year follow-up he remains in NYHA class II, with persistent LV dysfunction and an EF of 25%. Conclusion - Transapical TAVR is a treatment option for patients with advanced aortic stenosis, severe LV dysfunction and no femoral access route. [ABSTRACT FROM AUTHOR]