Search

While the combination of a small aortic valve area (AVA) and low mean gradient is frequently labeled 'low-flow low-gradient aortic stenosis (AS)', there are two potential causes for this finding: underestimation of mean gradient and underestimation of AVA.In order to investigate the prevalence and causes of discordant echocardiographic findings in symptomatic patients with AS and normal left ventricular (LV) function, we evaluated 72 symptomatic patients with AS and normal LV function by comparing Doppler, invasive, computed tomography (CT) LV outflow tract (LVOT) area, and calcium score (CaSc).Thirty-six patients had discordant echocardiographic findings (mean gradient40 mmHg, AV area ≤ 1 cm²). Of those, 19 had discordant invasive measurements (true discordant [TD]) and 17 concordant (false discordant [FD]): In 12 of the FD the mean gradient was30 mmHg; technical pitfalls were found in 10 patients (no reliable right parasternal Doppler in 6). LVOT area by echocardiography or CT could not differentiate between concordants and discordants nor between TD and FD (p = NS). CaSc was similar in concordants and FD (p = 0.3), and it was higher in true concordants than in TD (p = 0.005). CaSc positive predictive value for the correct diagnosis of severe AS was 95% for concordants and 93% for discordants.Discordant echocardiographic findings are commonly found in patients with symptomatic AS. Underestimation of the true mean gradient due to technical difficulties is an important cause of these discrepant findings. LVOT area by echocardiography or CT cannot differentiate between TD and FD. In the absence of a reliable and compete multi-window Doppler evaluation, patients should undergo CaSc assessment.

OBJECTIVES Repair of severe mitral valve and mitral regurgitation (MR) in patients with degenerative bileaflet pathology can be challenging. Initial results with a ring-only repair (ROR) approach have shown promising results, but long-term outcomes in larger series are lacking. We report on outcomes of ROR in severe MR secondary to bileaflet prolapse, including Barlow’s disease. METHODS Eighty patients with degenerative multi-segment bileaflet disease underwent ROR for severe MR with a predominantly central regurgitant jet indicating balanced bileaflet prolapse. The main outcome measure of this study was long-term recurrent MR probability. Secondary outcomes were late mortality, reoperation and in-hospital complications. RESULTS The mean age was 53 ± 15 years and 54% were males. The mean ejection fraction was 59.2 ± 6.6, 24% and 40% had atrial fibrillation. Barlow’s disease was found in 77% of the patients. Minimally invasive surgery was performed in 15 patients (19%). There were no perioperative mortalities or cerebrovascular events in the entire cohort. Post-repair mild outflow tract obstruction (systolic anterior motion) was observed in 4 patients (5%) after ROR. In a mean follow-up of 60 ± 48 months, there was 1 case of death. At follow-up, there was 1 (1%) reoperation due to recurrent MR, and 4 patients who had recurrent moderate or more MR. The 10-year freedom from recurrent MR was 97%. None had severe MR at the latest follow-up. CONCLUSIONS In patients with severe MR and a central regurgitant jet secondary to balanced multi-segment bileaflet mitral valve prolapse, ROR is a simple and efficient approach providing excellent long-term results without a substantial risk of systolic anterior motion.

OBJECTIVES Left ventricular outflow tract obstruction causes symptoms of heart failure in most patients with hypertrophic cardiomyopathy. Resection of the secondary mitral valve (MV) chordae has recently been shown to move the MV apparatus posteriorly, thereby eradicating the outflow gradient. The aim of this study was to evaluate whether secondary chordal resection concomitant to septal myectomy improves outcomes. METHODS Between 2005 and 2020, a total of 165 patients underwent septal myectomy without MV repair or replacement in our Medical Center. Secondary MV chordal resection was performed in 60 patients, and their outcomes were compared with those of the remaining 105 patients who did not undergo chordal resection (controls). Mean age was 61 ± 13 and 58 ± 16 years, respectively (P = 0.205). RESULTS There were no in-hospital deaths throughout the entire cohort. Of those patients who underwent secondary chordal resection, New York Heart Association functional class decreased from 3 (interquartile range 2–3) preoperatively to 1 (interquartile range 1–2) postoperatively (P CONCLUSIONS In this observational study, we report that secondary chordal resection concomitant to septal myectomy for left ventricular outflow tract obstruction is safe, relieves heart failure symptoms and reduces left ventricular outflow tract gradient in appropriately selected patients.

Distinct anatomical features predispose bicuspid AS patients to conduction disturbances after TAVR. This study sought to evaluate whether the incidence of permanent pacemaker implantation (PPMI) and left bundle branch block (LBBB) in patients with bicuspid aortic stenosis (AS) following transcatheter aortic valve replacement (TAVR) is related to an anatomical association between bicuspid AS and short membranous septal (MS) length.Sixty-seven consecutive patients with bicuspid AS from a Bicuspid AS TAVR multicenter registry and 67 propensity-matched patients with tricuspid AS underwent computed tomography before TAVR.MS length was significantly shorter in bicuspid AS compared with tricuspid AS (6.2 ± 2.5 mm vs. 8.4 ± 2.7 mm, respectively; p 0.001). In patients with bicuspid AS, MS length and aortic valve calcification were the most powerful pre-procedural independent predictors of PPMI or LBBB (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 1.15 to 1.55, p = 0.003 and OR: 1.92, 95% CI: 1.1 to 3.34, p = 0.022, respectively). When taking into account pre- and post-procedural parameters, aortic valve calcification and the difference between MS length and implantation depth were the most powerful independent predictors of PPMI or LBBB in patients with bicuspid AS (OR: 1.82, 95%: 1.1 to 3.1, p = 0.027; OR: 1.25, 95% CI: 1.10 to 1.38, p = 0.003).MS length, which was significantly shorter in bicuspid AS compared with tricuspid AS, aortic valve calcification, and device implantation deeper than MS length predict PPMI or LBBB in bicuspid AS after TAVR.

Multimodality imaging in cardiology : a statement on behalf of the Task Force on Multimodality Imaging of the European Association of Cardiovascular Imaging

International audience; The European Society of Cardiology (ESC) guidelines for management of atrial fibrillation (AF) recommend the use of CHA(2)DS(2)VASc risk score for assessment of thromboembolic (TE) risk, whereas the stratification of bleeding risk should be obtained by HAS-Bleed to balance the most appropriate anticoagulation (OAC) therapy. However, men with CHA(2)DS(2)VASc score=1 and women with CHA(2)DS(2)VASc=2, who are at intermediate TE risk, represent a grey zone where guidelines do not provide a definite OAC indication. Accordingly, implementation of risk stratification with echocardiography could be extremely useful. Both prospective and cross-sectional studies on transthoracic echocardiography (TTE) prediction of TE events and studies utilizing transoesophageal echocardiographic parameters as surrogate markers of TE events makes sustainable the hypothesis that echocardiography could improve TE prediction in non-valvular AF. Moreover, considering the close association of AF and stroke, all echo-Doppler parameters that have shown to predict AF onset and recurrence could be useful also to predict TE events in this clinical setting. Accordingly, EACVI AFib Echo Europe Registry has been designed as an observational, cross-sectional study, with the aim of evaluating: (i) left atrial (LA) size and function together with left ventricular geometry, systolic and diastolic functions in paroxysmal, persistent, and permanent AF; (ii) relationships of structural/ functional parameters with clinical TE and bleeding risk profile. By the AFib Echo Europe Registry, we expect to collect data on echocardiographic phenotype of patients with AF. The large data set accumulated will be useful to test the level of agreement of different echocardiographic measurements with the available risk scores.

Background The combination of a small aortic valve area valve area (AVA) and a low mean gradient (MG) severity pose a serious clinical challenge in the diagnosis of severe aortic stenosis (AS). While this discordance is frequently labeled “low-flow low-gradient AS”, there are two additional potential causes: underestimation of MG and underestimation of AVA. Purpose To investigate prevalence and root causes of discordant echocardiographic findings in symptomatic patients with AS and normal LV function by comparing Doppler data, invasive hemodynamic data, CT LV outflow tract size and calcium score. Methods and results We studied 67 severely symptomatic patients with AS and an LVEF>50%. Thirty patients (45%) had discordant echocardiographic findings (MG35 mmHg; in 5 it was >30 mmHg and only in 2 between 25 and 29 mmHg. In 6 of the 14 patients with underestimated MG, no right parasternal Doppler examination had been performed, LVOT VTI tracings were clearly suboptimal in 3 patients and 1 case was deemed inadequate due to poor imaging quality. LVOT area by echocardiography or by CT could not differentiate between Concordants and Discordants (p=0.3 and p=0.8 respectively) or between True and False Discordants (p=0.5 and p=0.6 respectively). While calcium score was similar in Concordants (2711±1159 AU) and False Discordants (2692±1136AU, p=0.96), it tended to be higher in Concordants (2711±1159 AU), when compared to True Discordants (1906±1284 AU, p=0.07). In patients with concordant echocardiographic findings calcium score levels of >3000 AU in men and >1600 AU in female had a positive predictive value (PPV) of 90% for the correct diagnosis of severe aortic stenosis. In patients with discordant findings the PPV was 80%. Conclusions 1) The majority of severely symptomatic AS patients with normal LV systolic function an echocardiographic AVA≤1.0 cm2 and a MG>30mmHg considered for TAVR have severe AS by calcium score. 2) In this patient population, discordant echocardiographic findings are in about half of the cases due to technical factors (“pseudo-discordance”) rather than due to true low flow low-gradient stenosis. 3) Pseudo-discordance is mainly due to mild-moderate underestimation of gradients, caused by a lack of reliable right parasternal tracings, rather than due to underestimation of valve area due to the echocardiographic circularity assumption in the presence of an elliptical LVOT. 4) The diagnosis of true low-flow AS cannot be established without a clear Doppler tracing from the right parasternal window. 5) Absent an adequate right parasternal window, patients should undergo CT assessment of calcium score.

Background Degenerative mitral valve disease involving anterior leaflet pathology is considered less favorable regarding durability of surgical repair than isolated posterior leaflet disease. We aimed to compare the outcomes of patients undergoing mitral valve repair for anterior, posterior, and bileaflet pathologies, and to investigate predictors for repair failure. Methods Of the 760 consecutive patients with degenerative leaflet disease who underwent mitral valve repair, 485 (64%) had posterior, 223 (29%) had bileaflet, and 52 (7%) had anterior leaflet pathology. Mean age was 58 ± 12, 54 ± 14, and 58 ± 17 years, respectively (P = .001). Mean follow-up was 67 ± 47 months. Results There was no in-hospital or 30-day mortality. Freedom from reoperation was 97%, 95%, and 92%, respectively, and there were 25 (5%), 9 (4%), and 1 (2%) late deaths in the posterior, bileaflet, and anterior groups, respectively (not significant). Late echocardiography revealed that 94%, 97%, and 96% of patients (posterior, bileaflet, and anterior groups respectively) were free from moderate-severe or severe mitral regurgitation (P = .375). Postoperative residual mild mitral regurgitation emerged as the strongest predictor for recurrent mitral regurgitation (grade 3/4) at follow-up (hazard ratio = 2.36; 95% confidence interval, 1.30-4.29; P = .005). Unlike patients with excess mitral tissue, among patients with fibroelastic deficiency or those who underwent major leaflet resection, the use of larger ring annuloplasty was associated with recurrent mitral regurgitation (hazard ratio = 1.31/ring size increment; P Conclusions Mitral valve repair can be achieved with excellent early and intermediate results across all valve pathologies. Further studies are required to determine the potential long-term impact of the underlying pathology on the rate of recurrent mitral regurgitation.

Very little data exist on the impact of sex on aortic and arterial anatomy as relevant for transcatheter aortic valve implantation (TAVI).To investigate whether patients with severe aortic stenosis (AS) referred for TAVI display sex-specific differences in aortic root and ilio-femoral artery size.In 506 patients referred for pre-procedural CT evaluation before TAVI we performed a detailed assessment of aortic root anatomy: size of the annulus and the sinus of Valsalva (SoV), diameter of the sino-tubular junction (STJ), and distance of the coronary artery ostia to the aortic annulus plane; we also determined the dimensions of aorta, subclavian, and ilio-femoral arteries.Women had significantly smaller aortic root dimensions (annulus mean diameter: 22.9 ± 2.2 mm vs. 25.7 ± 2.7 mm, SoV mean diameter: 31.8 ± 4.2 mm vs. 36.3 ± 3.8 mm, STJ mean diameter: 26.3 ± 3.4 mm vs. 29.8 ± 4.2 mm) and lower left and right coronary artery ostia take-off (12.3 ± 2.4 vs. 14.1 ± 2.9 mm; 14.8 ± 2.6 vs. 17.1 ± 3.2 mm, respectively) than men (P 0.001 for all), even after adjustment for their smaller body surface area (BSA) and height. Dimensions of the ascending aorta, subclavian and ilio-femoral arteries were also significantly smaller in women, but not when adjusted for BSA.Women with severe AS had smaller aortic root dimensions even after correcting for their smaller body size and height, reflecting a sex-specific difference. In contrast, sex-related differences in aortic, subclavian, and ilio-femoral dimensions were fully explained by the smaller BSA of women.

International audience; Aims: Assessment of left ventricular (LV) volumes and ejection fraction (LVEF) with cardiac imaging is important in the selection of patients for cardiac resynchronization therapy (CRT). Several observational studies have explored the role of imaging-derived LV dyssynchrony parameters to predict the response to CRT, but have yielded inconsistent results, precluding the inclusion of imaging-derived LV dyssynchrony parameters in current guidelines for selection of patients for CRT. Methods: The EuroCRT is a large European multicentre prospective observational study led by the European Association of Cardiovascular Imaging. We aim to explore if combing the value of cardiac magnetic resonance (CMR) and echocardiography could be beneficial for selecting heart failure patients for CRT in terms of improvement in long-term survival, clinical symptoms, LV function, and volumes. Speckle tracking echocardiography will be used to assess LV dyssynchrony and wasted cardiac work whereas myocardial scar will be assessed with late gadolinium contrast enhanced CMR. All data will be measured in core laboratories. The study will be conducted in European centres with known expertise in both CRT and multimodality cardiac imaging.

Secondary mitral valve regurgitation (MR) remains a challenging problem in the diagnostic workup and treatment of patients with heart failure. Although secondary MR is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading, current therapy is mainly focused on resting conditions. An exercise-induced increase in secondary MR, however, is associated with impaired exercise capacity and increased mortality. In an era where a multitude of percutaneous solutions are emerging for the treatment of patients with heart failure, it becomes important to address the dynamic component of secondary MR during exercise as well. A critical reappraisal of the underlying disease mechanisms, in particular the dynamic component during exercise, is of timely importance. This review summarizes the pathophysiological mechanisms involved in the dynamic deterioration of secondary MR during exercise, its functional and prognostic impact, and the way current treatment options affect the dynamic lesion and exercise hemodynamics in general.

The present study was designed to assess the role of jugular venous distension (JVD) as a predictor of short- and long-term mortality in a "real-life" setting. The independent association between the presence of admission JVD and the 30-day, 1- and 10-year mortality was assessed among 2,212 patients hospitalized with acute heart failure (HF) who were enrolled in the Heart Failure Survey in Israel (2003). Independent predictors of JVD finding in study patients included: the presence of significant hyponatremia (odds ratio [OR] 1.48; p = 0.03), reduced left ventricular ejection fraction ([LVEF] OR 1.24; p = 0.03), anemia (OR 1.3; p = 0.01), New York Heart Association III to IV (OR 1.34; p0.01) and age75 years (OR 1.32; p = 0.01). The presence of JVD versus its absence at the time of HF hospitalization was associated with increased 30-day mortality (7.2% vs 4.9%, respectively; p = 0.02), 1-year (33% vs 28%, respectively; p0.001), and greater 10-year mortality (91.8% vs 87.2%, respectively; p0.001). Consistently, interaction term analysis demonstrated that the presence of JVD at the time of the index HF hospitalization was independently associated with a significant increased risk for 10-year mortality, with a more pronounced effect among younger patients, patients with reduced LVEF, preserved renal function, and chronic HF. In conclusion, in patients admitted with HF, JVD is associated with specific risk factors and is independently associated with increased risk of both short- and long-term mortality. These findings can be used for improved risk assessment and management of this high-risk population.

Purpose Carbohydrate antigen 125 (CA125), a marker for ovarian cancer, is thought to be associated with the clinical severity of heart failure (HF) and fluid congestion. Mesothelial cells in the pericardium, pleura, peritoneum and M¨ullerian epithelium produce CA125 presumably in response to mechanical (congestion) stress. With the growing use of left ventricular assist device (LVAD) for advanced HF, assessment of right ventricular (RV) function and hemodynamics is of major interest. We aimed to assess CA125 as a predictor of right heart function and hemodynamics. Methods All 164 patients hospitalized for advanced HF in 2015-2019 were prospectively assessed for CA125 and B-type natriuretic peptide (BNP) levels combined with echocardiography and right heart study. Patients were stratified into 4 groups: high BNP-high CA125 (HB-HC), high BNP-low CA125 (HB-LC), low BNP-high CA125 (LB-HC), and low BNP-low CA125 (LB-LC). Results High CA125 (>35 IU/ml) significantly predicted high BNP (>400 pg/ml) (95% CI 1.01-1.02, p 10mmHg (95% CI 1.06-1.13, p 10mmHg, whereas CA125 continued to be independently associated with a 9% higher OR for RA>10mmHg, per unit of change (95% CI 1.05-1.15, p Conclusion CA125 independently predicts RA pressure and RV function in advanced HF patients. CA125 is a promising marker for risk stratification of patients being evaluated for LVAD implantation.

International audience

Coronary artery size is increased in patients with left ventricular hypertrophy (LVH), thus accommodating higher flow rates necessary to perfuse an increased muscle mass; yet despite an absolute increase in myocardial blood flow, flow per unit mass is reduced, rendering the myocardium susceptible to

Aims The Medtronic Engager™ aortic valve bioprosthesis is a self-expanding valve with support arms facilitating anatomically correct positioning and axial fixation. Valve leaflets, made of bovine pericardium, are mounted on a Nitinol frame. Here, we report the first in man study with this new implant (Trial Identifier [NCT00677638][1]). Methods and results Thirty patients (mean age 83.4 ± 3.8 years; 83% female) with tricuspid aortic valve stenosis were included in the study. Mean logistic EuroSCORE was 23.4 ± 11.9. Mean aortic annulus diameter was 21.8 ± 1.4 mm. For this study, the Engager was available in only one size (23 mm), to fit aortic annuli of 19–23 mm. Standard transapical valve implantation was performed using predilation of the aortic valve and rapid ventricular pacing during ballon valvuloplasty and most valve deployments. Accurate valve placement was achieved in 29/30 cases (97%). Post-implant peak-to-peak gradient was 13.3 ± 9.3 mmHg. In 80% of the patients, no more than grade I paravalvular leakage was observed, in 13% grades I–II and in 3% grade II. Three patients (10%) required permanent pacemaker implantation for higher-degree or complete atrioventricular block. Four dissections (13%) occurred during positioning of the valve and were treated surgically in three cases. Thirty-day and in-hospital mortality were 20% and 23%, respectively, and 6-month survival was 56.7%. No structural failure occurred for up to 1 year. Conclusion This series established the feasibility of implanting a novel self-expanding transapical aortic valve prosthesis predictably into an anatomically correct position. Observed complications led to complete redesign of the delivery system for upcoming clinical studies with the goal of establishing safety and performance. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00677638&atom=%2Fehj%2F32%2F7%2F878.atom

The most effective therapy demands the most complete understanding of the mechanism. Noninvasive imaging has provided key early observations of left ventricular outflow tract (LVOT) narrowing and flow acceleration in hypertrophic cardiomyopathy (HCM) (1,2), resulting from developmental abnormalities (3). On the basis of these observations, the original lift (Venturi) theory for LVOT obstruction by systolic anterior motion (SAM) of the mitral valve in HCM implicated upper septal hypertrophy as the sole culprit, but was therefore unable to explain residual SAM after upper septal reduction or SAM without septal hypertrophy (4–12). Those observations were subsequently explained by a more complete understanding of the interaction of mitral valve structural abnormalities with altered flow, which positions slack leaflet portions into the path of flow diverted by a bulging septum to affect the posterior leaflet surface and generate form-drag forces pushing the leaflet anteriorly; these are compounded by Venturi lift forces later in systole as the LVOT narrows and flow accelerates above the valve (13–23). An important element in understanding the role of mitral valve abnormalities in causing SAM was the observation of Sherrid et al. (24,25) that the distal leaflet (13) is pre-positioned in the outflow tract, such that even low flow rates can move the distal leaflet anteriorly and superiorly to occlude the outflow tract. Why does this pre-positioning occur (Figure 1)? Certainly, anterior papillary muscle (PM) positioning anteriorly and leaflet elongation may predispose to it; but, because motion of structures is driven by flow-induced forces, this leaflet orientation suggests the influence of as yet unknown flow vectors oriented to push the leaflet anteriorly. Because Doppler color flow mapping can only provide velocity components parallel to the beam, until now, actual flow vectors relative to cardiac structures, which could provide greater pathophysiologic information, could be estimated but not precisely determined (26–28). FIGURE 1 Comparison of Positioning and Movement of the Distal Mitral Leaflet From End Diastole to Early Systole in Normal Control and HCM Patients As in the case of noninvasive measurement of pressure gradients from Doppler velocities, Doppler technology has yielded its richest clinical rewards when combined with fluid mechanics, the conservation principles of classical mechanics applied to fluids within ingeniously-selected control volumes. In this issue of the Journal, Ro et al. (29) have now applied a novel technology that provides vector maps of intracardiac flows from Doppler velocity components. The vectors are derived using the stream function of flow by applying conservation laws to measured Doppler velocity components within volumes of interest containing noncompressible blood. The investigators applied this technology to answer our original question of leaflet pre-positioning in HCM: the majority of patients with obstruction have swirling flow vortices (26) that affect the posterior leaflet surfaces from below, moving them anteriorly. These vortices are generated by late-diastolic mitral inflow within the confined upper ventricular cavity, and pre-position the distal leaflets into the oncoming systolic wave, creating what can be termed diastolic anterior motion (DAM) as a precursor to SAM. In the remainder of patients, septal geometry redirects even the earliest, low-velocity systolic flows beneath the posterior leaflet, producing drag or pushing forces that drive SAM. The study confirms that SAM results from anatomically-predisposed leaflets that protrude into these late diastolic/early systolic flows. Once SAM has begun, additional vectors directed posteriorly into the cul-de-sac beneath the posterior leaflet provide insight into its progression, and might conceivably help explain its resolution through a competing “negative or reverse Venturi” (14). Venturi forces act perpendicular to the axis of high-velocity jets. Such forces may act not only on the outflow side of the leaflets in an anterior direction (reinforcing SAM-septal contact), but also on their posterior surface in an opposing direction, initiating detachment of the leaflet from the septum, and thus promoting resolution of SAM. Clinical implications of these findings include a better understanding of how abnormal valvular structures interact with flows determined by abnormal ventricular geometry, for example, to cause residual SAM with potential for dynamic obstruction in patients following septal reduction. These findings highlight the importance of septal reduction over a sufficient axial length to minimize anteriorly-directed vortex flows and flow redirected to affect the posterior leaflet surface to reduce residual SAM. These results further support the potential of leaflet modification and papillary muscle reorientation to reduce the anatomic substrate for SAM (30–39). It will, therefore, be of great interest to learn how these flows change in patients with septal reduction, and how those changes correlate with residual SAM, obstruction, and mitral regurgitation (20). An intriguing future direction would combine 3-dimensional assessment of cardiac structure with computational flow modeling to answer the even more basic question of how these structures create abnormal vortices in the first place, and how we might ultimately “sculpt” LV geometry to ensure the most physiologic outflow without obstruction (26). Thus, this study uses a new technology to answer a longstanding question, indicating how SAM has a late-diastolic impetus, generated by diastolic anterior motion—DAM leading to SAM—which may be modified therapeutically. On a more general note, these observations emphasize that, due to the cyclic nature of cardiac action, phenomena occurring during one cardiac phase can best be understood by also considering the impact of the preceding one.

Cardiac rehabilitation programs are greatly underutilized.This study was a multicenter interventional controlled cohort study.From cardiothoracic departments of five medical centers, 520 coronary artery bypass graft (CABG) patients (386 men) were enrolled in the control arm and 504 CABG patients (394 men) in the intervention arm of our study. A 1-hour seminar to medical staff on the benefits of cardiac rehabilitation followed the control phase and preceded the intervention phase. Patients in the intervention arm received written and oral explanations on cardiac rehabilitation benefits and eligibility, and a follow-up telephone call 2 weeks after hospital discharge. Patients in both study arms were interviewed in the hospital prior to CABG surgery and in their homes a year later.Rates of participation in cardiac rehabilitation were 16.5% (86/520) for the control arm and 31.0% (156/504) for the intervention arm (p 0.001). Factors strongly associated with participation in cardiac rehabilitation were: belonging to the intervention arm (OR: 2.06 95% CI: 1.46-2.90, p 0.0001), male sex, average or above average income, sports related physical activity before surgery, younger age and BMI 30 kg/m(2). Particularly high increases in participation rates following the implementation were observed among subpopulations of 10 years or less education and those reporting below average income. "Lack of knowledge" regarding cardiac rehabilitation was the reason most commonly stated for not participating in a cardiac rehabilitation program.Participation in cardiac rehabilitation almost doubled following a low cost intervention with significant effects on subpopulations that have been underrepresented in cardiac rehabilitation programs.

Purpose Although echocardiography is not recommended as a modality for rejection monitoring, serial echocardiography is routinely performed in patients following heart transplantation (HT). We sought to investigate the intra-patient fluctuations of structural and hemodynamic echocardiographic indexes and explore whether variability (relative changes), rather than absolute values, is associated with HT outcomes. Methods Between 2004-2017 we reviewed 723 echocardiographic examinations of 107 HT patients, at 0-3 months after HT. The following indexes were studied: interventricular septal (IVS) and posterior wall (PW) thickness, ejection fraction (EF), mitral valve deceleration time (DT), peak velocity flow in early (E) and late diastole (A) and their ratio (E/A), lateral and septal annular velocity (e’), and systolic pulmonary pressure (SPAP). Coefficients of variation (CV) were calculated for each parameter as the percent ratio of its standard deviation and its mean value. Endpoints, assessed from 3 months post HT, included any-treated rejection (ATR), all-cause mortality and cardiac allograft vasculopathy. Results CV was highest for E/A ratio (25±17%) and lowest for EF (6±4%). ATR was significantly associated with a higher CV of EF, DT, E, E/A, SPAP, e’ (p Conclusion High intra-patient (study-to-study) variability in echocardiographic indexes of left ventricular wall thickness, left ventricular filling and pulmonary artery pressure is associated with a higher rate of clinically significant rejections and mortality. The degree of variation of these parameters, rather than their absolute value, might be more useful during serial follow-up to identify patients at risk for unfavorable outcomes.

Recent data suggest that exercise training (ET) confers significant symptomatic and functional improvements in patients with diastolic dysfunction, and thus may be beneficial in patients with hypertrophic cardiomyopathy (HCM). However, there are no data regarding the safety or efficacy of ET in HCM patients.A prospective non-randomized intervention design was used.We enrolled 20 patients with symptomatic HCM, significantly limited in everyday activity, into a supervised cardiac rehabilitation exercise program.Patients were 62 ± 13 years old, in New York Heart Association (NYHA) functional class II (35%) or III (65%), had a mean interventricular septum dimension of 17 ± 5 mm and left ventricular ejection fraction (LVEF) of 53 ± 15%. Left ventricular outflow gradient was present at rest in nine patients (mean 51 ± 24 mm Hg) and six patients had an implantable defibrillator. Exercise prescription was based on heart rate reserve (HRR) determined from a symptom-limited graded exercise stress test. Exercise intensity was gradually increased from 50% to 85% of the HRR over the training period. Patients completed an average of 41 ± 8 hours of aerobic ET. No adverse events or sustained ventricular arrhythmias occurred during the training program. Functional capacity, assessed by a graded exercise test, improved from 4.7 ± 2.2 to 7.2 ± 2.8 metabolic equivalents (METs) (p = 0.01). NYHA functional class improved from baseline by ≥ 1 grade in 10 patients (50%) and none experiencing deterioration during follow-up.The present study suggests that patients with HCM who remain symptomatic despite medical therapy may achieve considerable functional improvement through a supervised ET program.

ObjectivesThe aim of this study was to test the hypothesis that mitral valve (MV) enlargement occurring in chronic aortic regurgitation (AR) prevents functional mitral regurgitation (FMR).BackgroundChronic AR causes left ventricular (LV) dilation, creating the potential for FMR. However, FMR is typically absent during compensated AR despite substantial LV enlargement. Increased mitral leaflet area has been identified in AR, but it is unknown whether increased MV size can represent a compensatory mechanism capable of preventing FMR.MethodsDatabase review of 816 patients with at least moderate AR evaluated the prevalence of FMR. A total of 90 patients were enrolled prospectively for 3-dimensional echocardiography (30 AR, 30 FMR, and 30 controls) to assess MV geometry including total leaflet area.ResultsFMR was present in 5.6% of AR patients by database review. Prospectively, only 1 AR patient had more than mild FMR despite increased LV end-diastolic volume (82 ± 22, 86 ± 23, and 51 ± 12 cm3/m2, respectively, for AR, FMR vs. control patients; p < 0.01) and similar sphericity index, annular area, and tethering distances compared with FMR. Total MV area was largest in AR (31.3% greater than normal), increasing significantly more than in FMR. The ratio of valve size to closure area was maintained in AR, whereas decreases in this ratio and LV ejection fraction independently predicted FMR.ConclusionsFMR prevalence is low in chronic AR. MV leaflet area is significantly increased compared with control and FMR patients, preserving a normal relationship to the area needed for closure in the dilated LV. Understanding the mechanisms underlying this adaptation could lead to new therapeutic interventions to prevent FMR.

International audience; Aims The present Euro-Filling report aimed at comparing the diagnostic accuracy of the 2009 and 2016 echocardiographic grading algorithms for predicting invasively measured left ventricular filling pressure (LVFP). Method and results A total of 159 patients who underwent simultaneous evaluation of echo estimates of LVFP and invasive measurements of LV end-diastolic pressure (LVEDP) were enrolled at nine EACVI centres. Thirty-nine (25%) patients had a reduced LV ejection fraction (< 50%), 77 (64%) were in NYHA >= II, and 85 (53%) had coronary artery disease. Sixty-four (40%) patients had elevated LVEDP (>= 15 mmHg). Taken individually, all echocardiographic Doppler estimates of LVFP (E/A, E/e', left atrial volume, tricuspid regurgitation jet velocity) were marginally correlated with LVEDP. By using the 2016 recommendations, 65% of patients with normal non-invasive estimate of LVFP had normal LVEDP, while 79% of those with elevated non-invasive LVFP had elevated invasive LVEDP. By using 2009 recommendations, 68% of the patients with normal non-invasive LVFP had normal LVEDP, while 55% of those with elevated non-invasive LVFP had elevated LVEDP. The 2016 recommendations (sensitivity 75%, specificity 74%, positive predictive value 39%, negative predictive value 93%, AUC 0.78) identified slightly better patients with elevated invasive LVEDP (>= 15 mmHg) as compared with the 2009 recommendations (sensitivity 43%, specificity 75%, positive predictive value 49%, negative predictive value 71%, AUC 0.68). Conclusion The present Euro-Filling study demonstrates that the new 2016 recommendations for assessing LVFP noninvasively are fairly reliable and clinically useful, as well as superior to the 2009 recommendations in estimating invasive LVEDP.

Background and Purpose— Despite overwhelming evidence for the benefits of anticoagulation in patients with brain ischemia and atrial fibrillation, vast underuse has been reported. Methods— Use of anticoagulation for secondary stroke prevention was assessed in the National Acute Stroke Israeli Survey registry (NASIS) of hospitalized patients with atrial fibrillation and acute brain ischemia. Logistic regression analysis was performed to evaluate the effects of clinical covariates on anticoagulation therapy at discharge, and anticoagulation use over time was assessed in subgroups of patients with identified barriers to anticoagulation utilization. Results— There were 1254 survivors of acute brain ischemia with atrial fibrillation (mean age 77.2±10.6 years; 57.7% female). Between 2004 and 2013, the proportion of patients discharged on anticoagulation increased from 55% to 76.2%, and among those without perceived contraindications from 70% to 96% ( P P Conclusions— In survivors of acute brain ischemia with atrial fibrillation, we observed a substantial increase in anticoagulation utilization within less than a decade. This change was mainly driven by greater utilization of anticoagulation in subgroups with traditional clinical barriers to anticoagulation use, indicating a shift in physicians’ perceptions of the risk–benefit ratio of anticoagulation.

Objectives The purpose of this study was to assess deformation dynamics and in vivo mechanical properties of the aortic annulus throughout the cardiac cycle. Background Understanding dynamic aspects of functional aortic valve anatomy is important for beating-heart transcatheter aortic valve implantation. Methods Thirty-five patients with aortic stenosis and 11 normal subjects underwent 256-slice computed tomography. The aortic annulus plane was reconstructed in 10% increments over the cardiac cycle. For each phase, minimum diameter, ellipticity index, cross-sectional area (CSA), and perimeter (Perim) were measured. In a subset of 10 patients, Young's elastic module was calculated from the stress-strain relationship of the annulus. Results In both subjects with normal and with calcified aortic valves, minimum diameter increased in systole (12.3 ± 7.3% and 9.8 ± 3.4%, respectively; p Conclusions The aortic annulus, generally elliptic, assumes a more round shape in systole, thus increasing CSA without substantial change in perimeter. Perimeter changes are negligible in patients with calcified valves, because tissue properties allow very little expansion. Aortic annulus perimeter appears therefore ideally suited for accurate sizing in transcatheter aortic valve implantation.

A structurally normal mitral valve when abnormally tethered in a dilated ventricle will start to leak once the available closing force becomes insufficient to achieve effective systolic leaflet coaptation [(1)][1]. Conversely, diastolic tethering may restrict leaflet mobility and thus limit

We hypothesized that attachment of elastic coil to the left ventricular (LV) wall, capable of exerting outward forces may allow the transfer of energy from systole to diastole and improve diastolic function.An extra-ventricular-device, composed of a series of elastic elements interposed between spiral screws attached to the epimyocardium of the LV free-wall was developed. The hemodynamic and mechanical effects of the device were tested using a computerized model, an in vitro model utilizing a computerized-controlled fluid pump, eight healthy sheep and 10 mini-pigs induced with diastolic dysfunction by renal wrapping. The computerized and in vitro models predicted a reduction of the LV diastolic pressure curve and partial normalization of the pressure-volume loop. The sheep study demonstrated preservation of animal's wellbeing including maintaining cardiac mechanical function with stable energy transfer from systole to diastole throughout the 6 months follow-up. The mini-pigs study showed an increase in the early diastolic to systolic strain-rate ratio in the mid-endocardial level (23 ± 10%, P = 0.008) and an increase in early apical reverse rotation rate of 50% (P = 0.016 compared to control).This study presents a novel concept of using a mechanical device to transfer energy from systole to diastole, potentially enhancing diastolic function.

Background A number of reports controversially describe the influence of cholesterol level and lipid-lowering treatment (LLT) on the progression of coronary calcium (CC). We tested the hypothesis that long-term changes in serum cholesterol (CL) would affect the progression of CC. Methods The study population comprised 510 patients with stable angina pectoris, mean age of 63±9years. At baseline 372 patients received statin and/or fibrate (LLT group) while 138 patients did not (No-LLT at baseline group). Spiral CT every 24months was used to track the progression of CC over a median 5.6year follow-up. Results CL decreased during follow-up in both groups, but more pronouncedly in patients with LLT. The changes in total calcium score (TCS) were similar in both groups ( p =0.3). Changes in CL during follow-up were not associated with CC: TCS increased by 501±63 from baseline in the 1st (upper) quartile, and by 350±44, 403±41 and 480±56 in the 2nd, 3rd, and 4th quartiles of CL longitudinal changes ( p =0.2), respectively. Baseline TCS and its changes were not correlated with baseline CL and its changes. New calcified lesions were diagnosed in 132 (28.2%) out of the 467 patients available for this analysis, without significant difference between groups ( p =0.4). Multivariate analysis demonstrated that only baseline TCS ( p p =0.007) and age ( p =0.006) were independent predictors for the TCS changes. Conclusions Longitudinal CL changes do not seem to have a measurable effect on the rate of progression of CC.

Although the benefit of antithrombotic therapy for stroke prevention in atrial fibrillation (AF) is well recognized, its potential effect on stroke severity and outcome is less well established. Our objective was to examine the effect of preadmission antithrombotic therapy on stroke severity and outcome in patients with AF within a large comprehensive nationwide stroke survey. The data from consecutive patients with AF admitted with acute ischemic stroke or transient ischemic attack during a 2-month period were collected. The patients were categorized into 4 groups according to the use of preadmission antithrombotic therapy: no antithrombotic therapy, antiplatelet therapy, warfarin with an admission international normalized ratio (INR)2 and INR ofor = 2. Of 1,938 patients presenting with acute brain ischemia, 329 (17%) had AF. The age-adjusted rate of more severe stroke (baseline National Institutes of Health stroke scale score5) stratified by antithrombotic therapy use was 70% for no antithrombotic therapy use, 55% for antiplatelet therapy use, 59% for warfarin with an INR2, and 38% for warfarin with an INR ofor = 2 (p = 0.01). Compared to warfarin therapy with an admission INR ofor = 2, the adjusted odds ratio for more severe strokes was 4.0 (95% confidence interval [CI] 1.7 to 10.0) for no antithrombotic therapy, 2.2 (95% CI 1.0 to 9.4) for antiplatelet therapy, and 2.7 (95% CI 1.1 to 6.7) for warfarin therapy with an INR of2. Similarly, graded associations of antithrombotic medication were observed with severe disability (modified Rankin Scale score3) or death at discharge, with corresponding adjusted odds ratios of 4.1 (95% CI 1.8 to 9.9), 2.1 (95% CI 1.0 to 4.6), and 1.5 (95% CI 0.6 to 3.5), and 1-year mortality, with corresponding adjusted ORs of 2.4 (95% CI 0.9 to 6.7), 1.9 (95% CI 0.8 to 5.0), and 2.2 (95% CI 0.8 to 6.2). In conclusion, in addition to its established benefit for stroke prevention, effective anticoagulation therapy is associated with decreased stroke severity and better functional outcome and survival in patients with AF presenting with acute brain ischemia.

Development of insulin resistance (IR) and the progressive failure of the pancreatic beta-cell function (BCF) may be important in the pathogenesis of type 2 diabetes. Influence of peroxisome proliferator-activated receptors ligand bezafibrate on BCF and IR in patients with diabetes is unknown. The present study was aimed to investigate the long-term effect of bezafibrate on these parameters in diabetic patients enrolled in the Bezafibrate Infarction Prevention (BIP) Study.Metabolic and inflammatory parameters were analyzed from stored frozen plasma samples obtained from 351 diabetic patients (168 treated by bezafibrate and 183 by placebo) who completed a 2-year of randomized, double-blind, placebo-controlled study period. The homeostatic indexes of BCF (HOMA-BCF) and IR (HOMA-IR) were calculated according to the homeostasis model of assessment.Both groups displayed similar baseline characteristics. During follow-up, in the placebo group there was 28% rise of HOMA-IR (p0.001). In contrast, HOMA-IR in patients in the bezafibrate group did not change (p=0.99). The intergroup differences in HOMA-IR percentage changes were in favor of bezafibrate (p=0.01). HOMA-BCF values have significantly decreased by 13.9% (p=0.04) in patients of placebo group, whereas in patients of bezafibrate group HOMA-BCF was stable during follow-up and its alterations (-2.9%) were non-significant (p=0.59).Diabetic patients from the placebo group demonstrated a progressive declining of BCF and an increasing of IR over 2 years of follow-up. These longitudinal changes were attenuated when patients used bezafibrate.

Background Calcium is often deposited in the aorta, but the associations and clinical implications of calcification of the aorta have not yet been elucidated. Methods In a prospective cohort of 455 hypertensive patients with at least 1 additional risk factor for atherosclerosis that underwent dual slice spiral computed tomography of the chest for assessment of arterial calcification (mean age 65.7±5.8, range 52–80 years, 48% female), we assessed for calcifications of the ascending and descending aorta and their association with the risk of subsequent ischemic cerebrovascular events during 3-year follow-up. Results Calcification of the ascending or descending aorta was present in 342 (75%) patients (60% calcification of the ascending aorta and 56% of the descending aorta). The main associations of calcification of the thoracic aorta were increasing age and the presence of coronary calcification, mitral annulus calcification, and aortic valve calcification. In a logistic regression model the main predictors of ischemic cerebrovascular events ( n =27) during follow-up were the presence of severe calcification (thickness of ≥5 mm) of the descending aorta (OR 4.9, 95%CI 1.8 to 13.5) and cigarette smoking (OR 2.8, 95%CI 1.1 to 6.7). Conclusions Calcification of the thoracic aorta is highly prevalent among women and men with hypertension, is age-related, and correlates with calcification of the coronary arteries and heart valves. Only severe calcification of the descending aorta is associated with subsequent ischemic cerebrovascular events, suggesting that calcification of the thoracic aorta is a marker of the burden of vascular disease.

Over the past years it has been recognized that insulin resistance (IR) is an independent risk factor for the development of diabetes, whereas its association with cardiovascular events remains controversial. The aim of our study was to explore the association between IR per se and cardiovascular events among patients with preexisting coronary artery disease.The mean follow-up period of this prospective study was 6.2 years. Metabolic and inflammatory parameters were analyzed from stored frozen plasma samples obtained at baseline from 2938 patients aged 45 to 74 years. The homeostatic index of IR (HOMA-IR) was calculated according to the homeostasis model assessment.New major cardiovascular events (fatal and nonfatal myocardial infarction and sudden death) were recorded in 108 (11.1%) patients from the lowest IR tertile, in 147 (14.7%) from the intermediate tertile, and in 166 (17.2%) from the highest tertile (P = .0002). The linear trend for total and cardiac death across the tertiles of HOMA-IR was significant as well (P = .02 and P = .009, respectively). The highest age-adjusted rates for major cardiovascular events and new diabetes were found among patients within the top tertile of HOMA-IR (57% and 130% higher rates, respectively, tertile 3 vs tertile 1, P.0001 for both). Multivariable analysis identified HOMA-IR (tertile 3 vs tertile 1) as an independent predictor of increased risk of major cardiovascular events and new diabetes with hazard ratios (95% CI) of 1.4 (1.1-1.8) and 1.5 (1.1-2.0), respectively.Insulin resistance per se is an independent risk factor for cardiovascular events and new diabetes in patients with preexisting coronary artery disease.

International audience; Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but−even in adult life−remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.

PURPOSE OF REVIEW The present article reviews the recent advances in the echocardiographic assessment of left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM). In particular, it highlights the role of novel imaging techniques in promoting our understanding of the pathophysiology of obstruction and discusses the prognostic value of information obtained from exercise echocardiography and the emerging role of image-guidance technologies for interventional relief of obstruction. RECENT FINDINGS The advent of novel echocardiography technologies, such as vector flow mapping, continues to expand our understanding of the exact mechanism of systolic anterior motion leading to dynamic LVOT obstruction by providing new insights into the interaction between pathologic mitral geometry and the left ventricular flow field. New studies provide evidence for the prognostic value of exercise echocardiography in the assessment of patients with HCM. Myocardial contrast perfusion imaging can delineate the anatomy of septal perforator arteries and identify the downstream septal perfusion bed, which is critical for safely guiding the procedure of alcohol septal ablation. SUMMARY Echocardiography represents a versatile, continuously evolving, and easily repeatable technique, allowing truly dynamic imaging studies, and is therefore most appropriate to evaluate a dynamic disease condition such as LVOT obstruction in HCM. It provides profound insights into the pathophysiology of LVOT obstruction, information on its clinical impact, and guidance for its relief by interventional strategies.

Objectives To describe the incidence of atrial fibrillation induced by dobutamine stress echocardiography and characterize patients at risk of developing atrial fibrillation, by constructing a simple validated risk score index. Design An observational study using prospectively collected data. Methods 3800 consecutive patients in sinus rhythm undergoing dobutamine stress echocardiography were randomly divided to a case (2/3) and test group (1/3). Associations of predetermined demographic, clinical, electrocardiographic and echocardiographic variables were calculated in patients with and without atrial fibrillation induced by dobutamine stress echocardiography in the case group. Logistic regression analysis determined significant independent risk predictors, a scoring index was constructed and validated on the test group. Results There was a 2% incidence of dobutamine stress echocardiography-induced atrial fibrillation in the study population. Risk predictors of atrial fibrillation included: a history of atrial fibrillation (2 points), increased left atrial diameter, right bundle branch block, decreased rest heart rate and hypertension (1 point each). The case subgroup low-risk patients (score 0–2) had a 1% risk, moderate-risk patients (score 3) a 2.7% and high-risk patients (score 4–6) a 14.5% risk of developing atrial fibrillation during dobutamine stress echocardiography. The rates in the test subgroup were 1%, 3.8% and 15.3%, respectively. Conclusion Atrial fibrillation during dobutamine stress echocardiography is not common, the risk of developing atrial fibrillation during dobutamine stress echocardiography can be predicted by using a simple risk score system comprised of clinical, electrocardiographic and rest echocardiographic variables, which may be of help when planning a dobutamine stress echocardiography test in selected cases.

It was hypothesized that restricted diastolic leaflet motion is implicated not only in the mechanism of systolic mitral regurgitation (MR) but also in the mechanism of diastolic MR observed in patients with severe heart failure. Cardiac resynchronization therapy (CRT) can oppose increased mitral leaflet tethering by increasing transmitral pressure, thereby providing an opportunity to explore this hypothesis. A total of 26 consecutive candidates for CRT with diastolic MR were compared with 26 candidates without diastolic MR. Maximal diastolic mitral leaflet opening and inflow direction and measures of mitral valve apparatus (i.e., mitral annular diameters, calculated mitral annular area, and tethering distance) were assessed from the apical 4-chamber view before and during CRT. There were no significant differences in New York Heart Association functional class, ejection fraction, QRS duration, PR interval, systolic MR grade, or 2-dimensional geometry of the mitral valve apparatus between the groups. Patients with diastolic MR had more restricted maximal diastolic leaflet openings (54 degrees +/- 17 degrees vs 71 degrees +/- 11 degrees , p = 0.003) and substantially smaller inflow angles (66 degrees +/- 7 degrees vs 79 degrees +/- 9 degrees , p = 0.0003) compared with patients without diastolic MR. After the institution of CRT, diastolic MR was eliminated in all patients, although there were no significant changes in any of the parameters of mitral valve apparatus. In conclusion, abnormal mitral valve tethering is a constitutive element of the mechanism of diastolic MR in patients with left ventricular dysfunction. Its acute resolution after CRT does not seem to be caused by changes in mitral valve geometry but rather by an increase in transmitral closing forces.

Congestive heart failure is associated with cognitive impairment, particularly of attentional skills. We assessed, in a hypothesis-generating study, the effect of an exercise training program on cognitive functions among patients with severe congestive heart failure.Patients with severe congestive heart failure (n=20; New York Heart Association functional class III; left ventricular ejection fractionor =35%) were evaluated before and following a standardized and supervised exercise training program (x2/week for 18 weeks; exercise group), while 5 additional patients did not undergo an exercise training program (control group). A battery of cognitive tests was used to assess cognitive functions. Physical performance was assessed by the 6-min walk test and the modified Bruce exercise test, cardiac index and systemic vascular resistance using thoracic electrical bioimpedance, and cerebral vasomotor reactivity to hypercapnia by means of the breath-holding index using transcranial Doppler.Time of completion of the trail making A (105+/-116 to 75+/-52; p=0.02) and B (169+/-100 to 119+/-65; p=0.002) tests, and of the Stroop part A (40+/-13 to 37+/-13; p=0.04) was shorter in patients completing the exercise training program, but not in control patients, while the other neuropsychological measures remained unchanged in both groups. Cerebral vasomotor reactivity to hypercapnia remained diminished (breath-holding index 0.64+/-0.27 vs. 0.68+/-0.37) despite significant improvements in exercise capacity (6-min walk test 308+/-87 to 423+/-91 m, p0.001; modified Bruce exercise test 5.6+/-3.8 to 9.8+/-3.4 min, p0.001).Patients with severe congestive heart failure undergoing an exercise training program improve in some measures of cognitive functions that are limited to general attention and psychomotor speed. Based on these preliminary findings, further evaluations are designed within the framework of a larger controlled clinical trial.

One thousand fifty-one consecutive patients who had acute myocardial infarction were classified into 3 risk groups by 4 echocardiographic risk assessments: left ventricular ejection fraction, left ventricular filling pattern, estimated systolic pulmonary artery pressure, and mitral regurgitation, with 30-day mortality rates of 13.7%, 3.8%, and 1%, respectively (p0.001). Independent echocardiographic and clinical predictors of 30-day mortality included age (10 years, hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.91 to 1.89), female gender (HR 2.12, 95% CI 0.94 to 4.74), Killip's classor =II on admission (HR 3.09, 95% CI 1.38 to 7.11), group 2 (moderate) risk (HR 2.89, 95% CI 1.07 to 8.56), and group 1 (high) risk (HR 8.16, 95% CI 2.95 to 25.23).

Background Mitral annulus calcification (MAC) may be a form of atherosclerosis. The goal of the present work was to investigate whether helical CT can determine the presence of MAC and to clarify its possible association with coronary artery disease (CAD) in elderly patients. Design and Methods Three hundred and twenty-nine consecutive elderly patients (165 men and 164 women, age range 60–79 years) underwent double helical CT of the heart to determine MAC and coronary calcifications (CC) according to a previously described protocol. Results MAC was documented in 60 patients (25 men, 35 women; mean age 69±4.5 years, range 60–78 years). The non-MAC group (control) included 269 patients (140 men, 129 women; mean age 67±4.6 years, range 60–79 years). Age was the only risk factor which had significant association with MAC ( p =0.01). A significant difference was found between MAC and control group for mean total CC score and advanced CC (total CC>300) (323±565 vs. 184±429, p =0.033 and 30% vs. 16%, p =0.017, respectively). A significant difference was also found between groups for the prevalent proven CAD (30% vs. 16%, p =0.008). Stepwise logistic regression analysis identified age [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.7–6.4, p p =0.001), and MAC (OR 2.4, 95% CI 1.2–5.0, p =0.016) as the independent variables significantly associated with CAD. The independent variables significantly associated with advanced CC (TCS>300) were MAC (OR 2.6, 95% CI 1.3–5.2, p =0.005), gender (male) (OR 2.3, 95% CI 1.2–4.2, p =0.012) and age (OR 1.9, 95% CI 1.0–3.7, p =0.052). Conclusions Our study demonstrated the usefulness of helical computed tomography in the detection of mitral annular calcification as an additional marker of prevalent CAD. However, the diagnostic significance of the MAC detection is relatively minor and should not be considered as a direct proof for coronary atherosclerosis.

This study examined left ventricular (LV) filling properties and exercise hemodynamics noninvasively before and after an exercise training program in patients with chronic heart failure (HF). Although exercise training did not improve LV filling properties in patients with advanced HF, LV filling properties determined the hemodynamic benefit attainable from exercise in this patient group.

Background Protruding aortic arch thrombus is associated clinically with life-threatening emboli. Definitive treatment for aortic arch thrombus removal has demanded complicated vascular surgical procedures, with high morbidity and mortality. Methods and results Transesophageal echocardiography (TEE) enabled diagnosis of a protruding thrombus at the aortic arch in 5 patients, and a simultaneous lesion in the descending aorta in 1 patient. Four patients had visceral emboli, coinciding with peripheral emboli in 2 patients, and the fifth patient had peripheral and cerebral emboli. One patient had had ischemic stroke and femoral emboli a few months previously. Mean patient age was 51 years. None had clinical evidence of coronary or peripheral atherosclerotic occlusive disease. Risk factors included hypertension (n = 2), smoking (n = 4), and preexisting thrombophilia (n = 4). Five patients underwent TEE-guided aortic balloon thrombectomy from the arch with a 34-mm occluding balloon catheter. One patient also underwent balloon thrombectomy from the descending aorta with a 14F Foley catheter. Access into the aorta was obtained through the iliac artery (n = 4) during laparotomy because of visceral ischemia or through the transfemoral approach (n = 2). Previous procedures included superior mesenteric embolectomy (n = 3), segmental bowel resection (n = 1), splenectomy (n = 1), and peripheral arterial embolectomy n=3). Real-time intraoperative TEE enabled visualization of the protruding thrombus and assisted with maneuvering of the balloon catheter. At completion peripheral thrombectomy thrombus material was retrieved in 4 patients. Postoperatively there were no clinically proved new procedure-related visceral emboli, and all patients received anticoagulant therapy thereafter. Follow-up TEE within 2 weeks and up to 7 years revealed no recurrent aortic arch thrombus. Conclusions TEE-guided aortic balloon thrombectomy used in 6 procedures was effectively completed without visceral or peripheral ischemic complications. It enabled removal of the life-threatening source of emboli from the proximal aorta, thereby averting the need of major aortic surgery.

Coronary calcium (CC) is invariably associated with coronary atherosclerosis and can be diagnosed noninvasively by fast spiral computed tomography (dual slice mode) (CT). Calcium is often deposited in the aorta as well, but the pathogenesis, correlates and clinical implications of calcification of the aorta are not yet elucidated. A possible association between the presence of CC and thoracic aorta calcification, as detected by spiral CT, has not been investigated yet. The goal of the present work was to examine by spiral CT whether an association exists between the presence of CC and thoracic aorta calcification in patients with high risk for atherosclerotic development. Four hundred and five patients with at least two risk factors for atherosclerosis were included (212 men and 193 women, age ranged 52-79 years). All underwent chest CT for CC and aortic calcification scoring. Calcifications' thickness ofor =5 mm was considered advanced. CC was documented in 294 patients (170 men, 124 women; mean age 66 +/- 6 years, range 55-78 years). The non-CC group (control) included 111 patients (42 men, 69 women; mean age 64 +/- 6 years, range 52-79 years). Significant differences were found between CC group and control for the presence of ascending aorta calcification (69% versus 36%, P0.001), and advanced calcification ofor =5mm (17% versus 4%, P0.001). Significant differences were also found between groups regarding the presence of descending aorta calcification (60% versus 38%, P0.001), and number of consecutive slices with calcification (18.8 +/- 12.4 versus 10.7 +/- 8.7, P0.01). We identified age (in decades) (OR 1.9, 95% CI 1. 2-3.0, P0.001), gender (female) (OR 0.4, 95% CI 0.2-0.6, P0.001), and thoracic aorta calcification (OR 2.9, 95% CI 1.7-5.0, P0.001) as the independent variables significantly associated with CC. Only age [odds ratio (OR) 3.05, 95% confidence interval (CI) 1.86-5.01, P0.001] and CC (OR 2.53, 95% CI 1.26-5.08, P = 0.006) were identified as independent variables for the prediction of thoracic aorta calcification.Our study demonstrated a strong association of CC and calcification of the thoracic aorta on spiral CT.

ObjectivesThe aim of this study was to evaluate the significance of increased left atrial (LA) volume determined within the first 48 h of admission as a long-term predictor of outcome in patients with acute myocardial infarction (MI).BackgroundThe LA volume reflects left ventricular (LV) diastolic properties. Whereas other LV Doppler diastolic characteristics are influenced by acute changes in LV function, LA volume is stable and reflects diastolic properties before MI.MethodsClinical and echocardiographic parameters were prospectively collected in 395 consecutive patients with acute MI. Patients with LA volume index (LAVI) >32 ml/m2(normal + 2 standard deviations) were compared with those with LAVI ≤32 ml/m2. Independent clinical and echocardiographic prognostic risk factors for five years' mortality were determined by the Cox proportional hazard model.ResultsLeft atrial volume index >32 ml/m2was found in 63 patients (19%) who had a higher incidence of congestive heart failure on admission (24% vs. 12%, p < 0.01), a higher incidence of mitral regurgitation, increased LV dimensions, and reduced LV ejection fraction when compared with patients with LAVI ≤32 ml/m2. Their five-year mortality rate was 34.5% versus 14.2% (p < 0.001). Significant independent risk predictors of five years' mortality were age (10 years) (odds ratio [OR] 1.45; 95% confidence interval [CI]1.14 to 1.86), Killip class ≥2 on admission (OR 2.30; 95% CI 1.29 to 4.09), LAVI >32 ml/m2(OR 2.22; 95% CI 1.25 to 3.96), diabetes (OR 1.94; 95% CI 1.15 to 3.28), and LV restrictive filling pattern (OR 1.89; 95% CI 1.09 to 3.31).ConclusionsIn patients with acute MI, increased LA volume, determined within the first 48 h of admission, is an independent predictor of five-year mortality with incremental prognostic information to clinical and echocardiographic data.

Background— Recent studies have shown that type 2 diabetes is preventable by both lifestyle interventions and medications that influence primary glucose metabolism. Whether pharmacological interventions that influence primary lipid metabolism can also delay development of type 2 diabetes is unknown. The goal of this study was to evaluate the effect of the peroxisome proliferator–activated receptor ligand bezafibrate on the progression of impaired fasting glucose phase to type 2 diabetes in patients with coronary artery disease over a 6.2-year follow-up period. Methods and Results— The study sample comprised 303 nondiabetic patients 42 to 74 years of age with a fasting blood glucose level of 110 to 125 mg/dL (6.1 to 6.9 mmol/L). The patients received either 400 mg bezafibrate retard (156 patients) or placebo (147 patients) once a day. No patients were using statins, and use of ACE inhibitors, which also reduce diabetes incidence, was relatively low. During follow-up, development of new-onset diabetes was recorded in 146 patients: in 80 (54.4%) from the placebo group and 66 (42.3%) from the bezafibrate group ( P =0.04). The mean time until onset of new diabetes was significantly delayed in patients on bezafibrate compared with patients on placebo: 4.6±2.3 versus 3.8±2.6 years ( P =0.004). Multivariate analysis identified bezafibrate treatment as an independent predictor of reduced risk of new diabetes development (hazard ratio, 0.70; 95% CI, 0.49 to 0.99). Other significant variables associated with future overt type 2 diabetes in patients with impaired fasting glucose were total cholesterol level (hazard ratio, 1.22; 95% CI 1.0 to 1.51) and body mass index (hazard ratio, 1.10; 95% CI, 1.05 to 1.16). Conclusions— Bezafibrate reduces the incidence and delays the onset of type 2 diabetes in patients with impaired fasting glucose. Whether the combination of bezafibrate with other recommended drugs for secondary prevention (statins and ACE inhibitors) would be as efficacious as suggested by our results remains to be determined.