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AIMS: Functional ischaemic mitral regurgitation (IMR) is common in patients with ischaemic left ventricular dysfunction undergoing coronary artery bypass surgery. Although the presence of IMR negatively affects prognosis, the additional benefit of valve repair is debated, particularly with mild IMR at rest. Exercise echocardiography may help identify a subset of patients at higher risk of cardiovascular events by revealing the dynamic component of IMR. METHODS: A large prospective, multicentre, non-randomized registry is designed to evaluate the effects of surgery on IMR at rest and on its dynamic component at exercise (z). SIMRAM will enrol approximately 550 patients with IMR in up to 17 centres with clinical and exercise follow-up for 1 year. Three sets of outcomes will be prospectively assessed and several hypotheses will be tested including determinants of adverse outcome and progressive left ventricular remodeling, efficacy of treatment and role of ischaemia on the dynamic consequences of IMR. Enrolment began in November 2006 and is expected to end by early 2008. [ABSTRACT FROM AUTHOR]

Background: Acute mitral regurgitation may cause pulmonary edema, but the pathogenetic role of chronic ischemic mitral regurgitation, a dynamic condition, has not yet been characterized. Methods: We prospectively studied 28 patients (mean [+/-SD] age, 65+/-11 years) with acute pulmonary edema and left ventricular systolic dysfunction and 46 patients without a history of acute pulmonary edema. The two groups were matched for all baseline characteristics. Patients underwent quantitative Doppler echocardiography during exercise. Exercise-induced changes in the left ventricular volume, the ejection fraction, the mitral regurgitant volume, the effective regurgitant orifice area, and the transtricuspid pressure gradient were compared in patients with and without acute pulmonary edema. Results: The two groups had similar clinical and baseline echocardiographic characteristics. They also had similar exercise-induced changes in heart rate, systolic blood pressure, and left ventricular volumes. In the univariate analysis, patients with recent pulmonary edema had a much higher increase than did the patients without pulmonary edema in mitral regurgitant volume (26+/-14 ml vs. 5+/-14 ml, P<0.001), the effective regurgitant orifice area (16+/-10 mm2 vs. 2+/-9 mm2, P<0.001), and the transtricuspid pressure gradient (29+/-10 mm Hg vs. 13+/-11 mm Hg, P<0.001). In the multivariate analysis, exercise-induced changes in the effective regurgitant orifice area (P<0.001), in the transtricuspid pressure gradient (P=0.001), and in the left ventricular ejection fraction (P=0.02) were independently associated with a history of recent pulmonary edema. Conclusions: In patients with left ventricular systolic dysfunction, acute pulmonary edema is associated with the dynamic changes in ischemic mitral regurgitation and the resulting increase in pulmonary vascular pressure. [ABSTRACT FROM AUTHOR]

New insights into the pathophysiology and natural history of patients with aortic stenosis, coupled with advances in diagnostic imaging and the dramatic evolution of transcatheter aortic valve replacement, are fueling intense interest in the management of asymptomatic patients with severe aortic stenosis. An intervention that is less invasive than surgery could conceivably justify pre-emptive transcatheter aortic valve replacement in subsets of patients, rather than waiting for the emergence of early symptoms to trigger valve intervention. Clinical experience has shown that symptoms can be challenging to ascertain in many sedentary, deconditioned, and/or elderly patients. Evolving data based on imaging and biomarker evidence of adverse ventricular remodeling, hypertrophy, inflammation, or fibrosis may radically transform existing clinical decision paradigms. Clinical trials currently enrolling asymptomatic patients have the potential to change practice patterns and lower the threshold for intervention., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Hypoalbuminemia is common in heart failure (HF), especially in elderly patients. It is associated with an increased risk of death. The present study sought to examine the prognostic significance of serum albumin level in the prediction of hospital mortality in patients admitted for acute non-ischemic HF., Methods and Results: We examined the association between albumin and hospital mortality in a cohort of 546 patients admitted for acute non-ischemic HF. None of the patients had infectious disease, severe arrhythmias (atrial fibrillation, ventricular tachycardia, ventricular fibrillation), required invasive ventilation, or presented with acute coronary syndrome or primary valvular disease. Thirty-six patients (7%) died during the hospital stay. These patients were significantly older (78 ± 9 vs. 72 ± 12 years; P  = 0.006), had higher heart rate ( P  < 0.0001), increased creatinine level ( P  = 0.01), lower systolic and diastolic blood pressures ( P  < 0.05), elevated leucocyte count ( P  = 0.001), and lower albumin levels (31.3 ± 5.6 g/L vs. 36.9 ± 4.1 g/L; P  < 0.001). With multivariable analysis, age ( P  = 0.01), heart rate ( P  < 0.0003), diastolic blood pressure ( P  < 0.01), leukocyte count ( P  = 0.009), and serum albumin level ( P  < 0.0001) emerged as independent predictors of hospital mortality. Hypoalbuminemia (<34 g/L) yielded the best sensitivity (78.8%) and specificity (75%) for predicting hospital death., Conclusions: Serum albumin level measured at admission can serve as a simple prognostic factor in acute non-ischemic HF. Hypoalbuminemia is associated with increased risk of hospital mortality, especially in elderly patients.

Introduction: Aortic stenosis (AS) is the most common cause of valvular heart disease. Imaging plays a major role in the diagnosis and evaluation of AS severity., Areas Covered: The present review focuses on new emerging concepts in AS by stressing the substantial value of imaging into the understanding of the complex pathophysiology and management of AS. Expert commentary: Though, standard 2D echocardiography is often diagnostic multi-modality imaging can be required in patients with doubtful results or to refine the evaluation of AS.

Aortic stenosis is the most frequent valvular heart disease. In aortic stenosis, therapeutic decision essentially depends on symptomatic status, stenosis severity, and status of left ventricular systolic function. Surgical aortic valve replacement or transcatheter aortic valve implantation is the sole effective therapy in symptomatic patients with severe aortic stenosis, whereas the management of asymptomatic patients remains controversial and is mainly based on individual risk stratification. Imaging is fundamental for the initial diagnostic work-up, follow-up, and selection of the optimal timing and type of intervention. The present review provides specific recommendations for utilization of multimodality imaging to optimize risk stratification and therapeutic decision-making processes in aortic stenosis., (© 2016 American Heart Association, Inc.)

In patients with heart failure, exercise echocardiography can help in risk stratification and decision making. The prognostic significance of exercise pulmonary hypertension (PH) in patients with secondary mitral regurgitation (MR) remains unknown. The aim of the present study was to assess the prognostic value of exercise PH in patients with secondary MR and narrow QRS intervals. From 2005 to 2012, 159 consecutive patients with secondary MR, narrow QRS intervals, left ventricular dysfunction (mean ejection fraction 36 ± 7%), and measurable systolic pulmonary arterial pressure (SPAP) during exercise echocardiography were included. Resting and exercise PH were defined as SPAP >50 and >60 mm Hg, respectively. Exercise PH was more frequent than resting PH (40% vs 13%, p <0.0001). On multivariate logistic regression, the independent determinants of exercise PH were resting SPAP (p <0.0001), exercise MR severity (p <0.0001), and e'-wave velocity (p = 0.004). The incidence of cardiac events during follow-up was significantly higher in patients with exercise PH compared with those without exercise PH (4 years: 40 ± 7% vs 20 ± 5%, p <0.0001). Patients with exercise PH exhibited higher rates of cardiac events and death than those with resting PH. In a multivariate Cox proportional hazards model, exercise PH was independently associated with the occurrence of cardiac events (p <0.0001). In conclusion, in patients with secondary MR, exercise PH is determined mainly by resting SPAP, left ventricular diastolic burden, and exercise MR severity. Exercise PH is a powerful predictor of poor outcomes, with a 5.3-fold increased risk for cardiac-related death during follow-up. These results highlight the added value of exercise echocardiography in secondary MR., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Elevated resting heart rate is associated with worse outcomes in chronic heart failure (HF) but little is known about its prognostic impact in acute setting. The main aim of the present study was to examine the relationship between resting heart rate obtained 24-36h after admission for acute non-arrhythmic HF and in-hospital mortality., Methods and Results: We examined the association of heart rate with in-hospital mortality in a cohort of 712 patients admitted for acute HF. None of the patients had significant arrhythmias, required invasive ventilation, or presented with acute coronary syndrome or primary valvular disease. Forty patients (5.6%) died during the hospital stay. Those patients were significantly older (78±9 vs. 72±12years; p=0.0021), had higher heart rate (92±22 vs. 78±18bpm; p<0.0001), NT pro-BNP (p=0.0005), creatinine (p=0.023), were often diabetics (p=0.026) and had lower systolic and diastolic blood pressures (p<0.05). There was a significant graded relationship between the increase in mortality rate and tertile of heart rate (p<0.01). With multivariable analysis, age (p=0.037), heart rate (p<0.0001), diastolic blood pressure (p<0.001), prior ischemic heart disease (p=0.02) and creatinine (p=0.019) emerged as independent predictors of in-hospital mortality. After adjusting for predictors of poor prognosis, patients in the highest heart rate tertile had worst outcomes when compared with those in the lowest heart rate group (p=0.007)., Conclusions: Higher heart rate 24-36h after admission for acute non-arrhythmic HF is associated with increased risk of in-hospital mortality. Early targeting of elevated heart rate might represent a complementary therapeutic challenge., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

The role of exercise testing and stress imaging in the management of patients with valvular heart disease (VHD) is reviewed in this article. The American College of Cardiology/American Heart Association and the European Society of Cardiology/European Association of Cardiothoracic Surgery have recently put emphasis on the role of exercise testing to clarify symptom status and the use of stress imaging to assess the dynamic component of valvular abnormalities and unmask subclinical myocardial dysfunction that could be missed at rest. Recent studies have demonstrated the incremental prognostic value of exercise echocardiography for asymptomatic patients with severe aortic stenosis, moderate-severe mitral stenosis, and severe primary mitral regurgitation. In patients with low-flow, low-gradient aortic stenosis, dobutamine stress echocardiography is recommended to differentiate true severe from pseudosevere aortic stenosis. Data on the prognostic value of stress echocardiography in aortic regurgitation and functional mitral regurgitation are less robust. Data are sparse on the use of stress imaging in right-sided VHD, however recent studies using stress cardiovascular magnetic resonance imaging offer some prognostic information. Although the strongest recommendations for surgical treatment continue to be based on symptom status and resting left ventricular repercussions, stress imaging can be useful to optimize risk stratification and timing of surgery in VHD. Randomized clinical trials are required to confirm that clinical decision-making based on stress imaging can lead to improved outcomes., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Aims: The appropriate timing for surgery in severe asymptomatic primary mitral regurgitation (MR) remains controversial. It has been shown that late gadolinium enhancement on cardiovascular magnetic resonance (LGE CMR), which may identify myocardial fibrosis, is associated with a worse outcome in various cardiomyopathies. We sought to investigate the prevalence and significance of delayed enhancement in primary MR., Methods: We prospectively included 41 patients with at least moderate primary MR and without overt signs of left ventricular (LV) dysfunction. Patients with evidence of coronary artery disease, arrhythmias or significant concomitant valvular disease were excluded. All patients were scheduled for transthoracic echocardiography and LGE CMR., Results: A total of 39 patients had interpretable LGE CMR images. Among them, 12 (31%) had late contrast uptake of the LV wall. LGE CMR showed an infarct pattern in three patients, a pattern of mid-wall fibrosis in seven patients and two patients had a combined pattern. Patients with delayed enhancement on CMR had significant higher LV diameters (LV end-systolic diameter 39 ± 4 vs. 34 ± 5 mm, P = 0·002; LV end-diastolic diameter 57 ± 5 vs. 50 ± 5 mm, P = 0·001). There was a trend towards a higher indexed left atrial volume (55 ± 21 vs. 44 ± 13 mL/m², P = 0·06). By contrast, there was no significant association between myocardial contrast uptake and age, LV ejection fraction and MR severity., Conclusion: Left ventricular remodelling seems to be associated with the presence of delayed enhancement on CMR in primary MR. Further data are needed to determine whether LGE CMR can predict a less favourable outcome or could improve risk stratification in asymptomatic primary MR., (© 2014 Stichting European Society for Clinical Investigation Journal Foundation.)

Background: In aortic stenosis (AS), the combination of risk factors can progressively lead to an increased arterial rigidity, which can be evaluated by the carotid artery and aortic stiffness (β index). The aim of this study was to investigate the relationship between carotid and aortic β index, left ventricular (LV) function, plasma brain natriuretic peptide (BNP) level, and symptoms in patients with AS., Methods: Comprehensive echocardiography including Doppler tissue imaging of the mitral annulus was performed in 53 patients with AS (aortic valve area < 1.2 cm(2)) and preserved LV ejection fractions (≥ 50%). Carotid β index was automatically derived from ultrasound wall tracking of the right carotid artery. The mitral E/e' ratio was used to estimate LV filling pressures., Results: Carotid β index was higher in women than in men and was significantly correlated with age (P < .0001), diastolic arterial pressure (P = .046), pulse pressure (P = .006), and systemic arterial compliance (P = .001). Interestingly, carotid β index was significantly correlated with E/e' ratio (P < .0001) and plasma BNP level (P = .011). In multivariate regression analysis, carotid β index was an independent predictor of E/e' ratio (P < .0001) and of BNP level (P = .02). Moreover, carotid β index was significantly higher in symptomatic patients (P = .009). Aortic β index was significantly correlated with carotid β index (P < .0001), E/e' ratio (P = .004), and BNP (P < .001) and was significantly higher in symptomatic patients (P = .037)., Conclusions: In patients with moderate to severe AS and preserved LV ejection fractions, the presence of increased carotid artery and aortic stiffness, assessed using carotid and aortic β index, is independently associated with elevated LV filling pressures, BNP level, and symptoms., (Copyright © 2014 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

The management and the clinical decision making in asymptomatic patients with aortic stenosis are challenging. An "aggressive" management, including early aortic valve replacement, is debated in these patients. However, the optimal timing for surgery remains controversial due to the lack of prospective data on the determinants of aortic stenosis progression, multicenter studies on risk stratification, and randomized studies on patient management. Exercise stress testing with or without imaging is strictly contraindicated in symptomatic patients with severe aortic stenosis. Exercise stress test is now recommended by current guidelines in asymptomatic patients and may provide incremental prognostic value. Indeed, the development of symptoms during exercise or an abnormal blood pressure response are associated with poor outcome and should be considered as an indication for surgery, as suggested by the most recently updated European Society of Cardiology 2012 guidelines. Exercise stress echocardiography may also improve the risk stratification and identify asymptomatic patients at higher risk of a cardiac event. When the test is combined with imaging, echocardiography during exercise should be recommended rather than post-exercise echocardiography. During exercise, an increase >18 to 20 mm Hg in mean pressure gradient, absence of improvement in left ventricular ejection fraction (i.e., absence of contractile reserve), and/or a systolic pulmonary arterial pressure >60 mm Hg (i.e., exercise pulmonary hypertension) are suggestive signs of advanced stages of the disease and impaired prognosis. Hence, exercise stress test may identify resting asymptomatic patients who develop exercise abnormalities and in whom surgery is recommended according to current guidelines. Exercise stress echocardiography may further unmask a subset of asymptomatic patients (i.e., without exercise stress test abnormalities) who are at high risk of reduced cardiac event free survival. In these patients, early surgery could be beneficial, whereas regular follow-up seems more appropriate in patients without echocardiographic abnormalities during exercise., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Two-dimensional transthoracic echocardiography (2DTTE) remains the first-line diagnostic imaging tool to assess primary mitral regurgitation although cardiovascular magnetic resonance (CMR) has proven to establish left ventricular function more accurately and might evaluate mitral regurgitation severity more reliably. We sought to compare routine evaluation of left ventricular function and mitral regurgitation severity by 2DTTE with assessment by CMR in moderate to severe primary mitral regurgitation without overt left ventricular dysfunction., Methods: We prospectively included 38 patients (79% of male, age 57 ± 14 years) with at least moderate primary mitral regurgitation, a left ventricular ejection fraction ≥60% and a left ventricular end-systolic diameter ≤45 mm. Patients with evidence of coronary artery disease, arrhythmias or significant concomitant valvular disease were excluded. All patients were scheduled for 2DTTE and CMR., Results: Left ventricular end-diastolic and end-systolic volumes were significantly underestimated by 2DTTE in comparison with CMR, although there was a strong correlation (Pearson r = 0.81, p < 0.00001 and r = 0.7, p < 0.00001, respectively). Measurement of the regurgitant orifice was similar between 2DTTE PISA method and planimetry by CMR (47 ± 24 vs. 42 ± 16 mm2, p = 0.12) with a strong correlation between both imaging techniques (Pearson r = 0.76, p < 0.0001). By contrast, assessment of the regurgitant volume by 2DTTE and by phase contrast velocity mapping by CMR showed poor agreement., Conclusions: In moderate to severe primary mitral regurgitation without overt left ventricular dysfunction, 2DTTE significantly underestimates left ventricular remodelling in comparison to CMR. Measurement of the regurgitant orifice with planimetry by CMR shows good agreement with the PISA method by 2DTTE and thus may be a valuable alternative to assess mitral regurgitation severity.

Purpose of Review: The emerging role of exercise and especially exercise echocardiography in aortic stenosis has been recently emphasized. In this clinical setting, stress testing can help identify patients who are falsely asymptomatic, unmask those who will rapidly become symptomatic and appraise the true haemodynamic consequences of aortic stenosis., Recent Findings: Both exercise stress test and exercise stress echocardiography are strictly contraindicated in symptomatic patients. In contrast, exercise testing is recommended by current guidelines in asymptomatic patients with aortic stenosis. During exercise, either the development of symptoms or an abnormal blood pressure response is associated with a poor outcome and should be considered as an indication for surgery. Exercise echocardiography permits stratification and identification of asymptomatic patients at a higher risk of a cardiac event: exercise-induced increase of more than 18-20  mmHg in mean pressure gradient, absence of left ventricular contractile reserve and/or exercise pulmonary hypertension are suggestive features of an advanced disease process., Summary: Exercise echocardiography has the advantage of its wide availability, low cost and versatility. In asymptomatic severe aortic stenosis, exercise echocardiography can help unmask patients at a more advanced stage of the disease and could aid in identifying those who may benefit from an early elective aortic valve surgery.

The part II of the best of the European Heart Journal - Cardiovascular Imaging in 2012 specifically focuses on studies of valvular heart diseases, heart failure, cardiomyopathies, and congenital heart diseases.

Background: With an increasing prevalence of patients with valvular heart disease (VHD), a dedicated management approach is needed. The challenges encountered are manifold and include appropriate diagnosis and quantification of valve lesion, organization of adequate follow-up, and making the right management decisions, in particular with regard to the timing and choice of interventions. Data from the Euro Heart Survey have shown a substantial discrepancy between guidelines and clinical practice in the field of VHD and many patients are denied surgery despite having clear indications. The concept of heart valve clinics (HVCs) is increasingly recognized as the way to proceed. At the same time, very few centres have developed such expertise, indicating that specific recommendations for the initial development and subsequent operating requirements of an HVC are needed., Aims: The aim of this position paper is to provide insights into the rationale, organization, structure, and expertise needed to establish and operate an HVC. Although the main goal is to improve the clinical management of patients with VHD, the impact of HVCs on education is of particular importance: larger patient volumes foster the required expertise among more senior physicians but are also fundamental for training new cardiologists, medical students, and nurses. Additional benefits arise from research opportunities resulting from such an organized structure and the delivery of standardized care protocols., Conclusion: The growing volume of patients with VHD, their changing characteristics, and the growing technological opportunities of refined diagnosis and treatment in addition to the potential dismal prognosis if overlooked mandate specialized evaluation and care by dedicated physicians working in a specialized environment that is called the HVC.

Primary mitral regurgitation is generally an insidious disease with late onset of symptoms. Current European and American guidelines recommend surgery in severe primary mitral regurgitation when symptoms, overt left ventricular dysfunction, pulmonary hypertension or atrial fibrillation, occur. However, recent large studies reported an improved outcome in asymptomatic patients with severe mitral regurgitation referred for early mitral valve repair despite the risk of operative mortality or mitral valve replacement. Moreover, primary mitral regurgitation appears to have an important dynamic character in up to one-third of patients. This article provides an overview of the incremental evidence of the ability of exercise echocardiography to assess the functional repercussions of mitral regurgitation and the identification of high-risk patients who might benefit from early referral for surgery.

Acromegaly is a disease characterized by chronic growth hormone hypersecretion. Cardiovascular complications represent the main cause of death. We present here a rare case of dilated cardiomyopathy whose diagnosis revealed an acromegaly. This will provide the opportunity to review an uncommon disease and its recently reassessed prevalence.

Inadvertent insertion of a defibrillation lead in the left ventricle is a rare complication generally underdiagnosed after device implantation. Management is not strictly codified due to the small number of observed cases. We report the case of a 78 year-old man in whom the diagnosis has been performed lately during an echocardiography.

Aims: In aortic stenosis (AS), both reduced systemic arterial compliance and increased valvular load have been shown to contribute to impaired left ventricular (LV) function. However, the relationship between LV function and aortic stiffness has not yet been investigated. We aimed to assess the relationship between aortic stiffness and LV global longitudinal strain (GLS), LV filling pressures (E/E') and B-type natriuretic peptide (BNP) in AS., Methods and Results: A comprehensive echocardiogram was performed in 48 consecutive patients with severe AS (<0.6 cm(2)/m(2)) and preserved LV ejection fraction (≥50%). Aortic stiffness index (beta) was calculated based on aortic diameters measured by echocardiography and blood pressure. Systemic arterial compliance (SAC) and valvulo-arterial impedance (Z(va)) were also determined. Aortic beta index was significantly correlated with Z(va) (r = 0.30, P= 0.03) and SAC (r = -0.29, P = 0.04). GLS (r = 0.45, P = 0.001), E/E' (r = 0.48, P = 0.001) and BNP levels (r = 0.45, P = 0.001) were significantly related to aortic beta index. No significant correlation was found between GLS or E/E' and SAC or Z(va). In multivariate regression analysis, aortic beta index remained correlated with GLS, E/E', and BNP levels., Conclusions: In patients with severe AS and preserved LV ejection fraction, independently of the valvular load, an increase in aortic rigidity, as assessed by aortic beta index, is independently correlated with reduced LV longitudinal function, increased LV filling pressures, and BNP levels.

Objective: Exercise systolic pulmonary arterial pressure (SPAP) predicts the occurrence of symptoms in patients with degenerative mitral regurgitation (MR). However, this measurement is not always available. The purpose of this study was to identify resting echocardiographic predictors of exercise SPAP and whether predicted exercise SPAP may predict symptom-free survival., Methods: We prospectively enrolled 89 consecutive asymptomatic patients with moderate or greater degenerative MR in whom exercise SPAP was measurable. Left ventricular (LV) systolic and diastolic function were assessed by comprehensive transthoracic echocardiography. Tissue Doppler imaging was used to measure Ea- (early diastolic) and Sa- (systolic) wave velocities and time-to-peak (TP) Sa velocity. Multiple linear regression was built to identify resting predictors of exercise SPAP., Results: Patients with exercise pulmonary hypertension (PHT) (n = 45, 51%) were significantly older and more frequently male, and had shorter TP-Sa velocity and higher E/Ea ratio and LV end-diastolic volume than those without exercise PHT. Exercise SPAP was best correlated with resting LV end-diastolic volume (r = 0.55), TP-Sa (r = 0.72), and E/Ea ratio (r = 0.52). Multiple linear regression analysis allowed us to build the following predictive equation with good precision (r(2) = 0.80): By using this formula, predicted exercise SPAP was well correlated with observed exercise SPAP (r = 0.89). Predicted exercise PHT was associated with significant reduced symptom-free survival in both univariate (P = .04) and multivariate (P = .045) analyses., Conclusion: In asymptomatic patients with degenerative MR, exercise PHT can be accurately predicted using resting comprehensive echocardiography., (Copyright © 2011 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Aims: The present study sought to determine the relationship between left atrial (LA) volume (structural changes) and LA function as assessed by strain rate imaging in patients with aortic stenosis (AS)., Methods and Results: The study consisted of a total of 64 consecutive patients with severe AS (<1 cm&sup2;) and 20 healthy control subjects. The phasic LA volumes and function (tissue Doppler-derived strain) were assessed in all patients. As compared with healthy controls, all strain-derived parameters of LA function were reduced in patients with AS. Conversely, only indexed LA passive volume (increased) (7.6 ± 3.8 vs. 10.5 ± 5.1 ml/m&sup2;, P= 0.02) and LA active fraction (decreased) (43 ± 6.7 vs. 31 ± 13.3%, P< 0.001) (volume-based parameters) were significantly different between AS and controls. In AS, LA volume-derived function parameters were poorly correlated with LA strain parameters. In fact, by multivariable analysis, no LA phasic strain parameters emerged as independently associated with LA phasic volume parameters., Conclusions: In AS, changes in LA function did not parallel changes in LA size. Furthermore, the increase in LA volume does not necessarily reflect the presence of intrinsic LA dysfunction.

Symptom development represents one of the most important indications for surgical intervention in patients with significant valvular heart disease. Exercise testing has an established role in the assessment of exercise capacity and symptomatic status in patients with severe valvular heart disease who claim to be asymptomatic. In these patients, clinical decision can be influenced by the results of exercise testing. In addition to the assessment of symptomatic response to exercise, stress echocardiography can provide valuable information on exercise-induced changes in valve hemodynamics, ventricular function and pulmonary artery pressure. Abnormal left ventricular response to exercise, increase in pulmonary pressure or change in the hemodynamic severity of the valvular disease adds to the prognostic value of elicited symptoms. In this article we discuss the validated indications, proven prognostic values and potential influence on clinical decisions of stress echocardiography in left valvular heart diseases.

Documented ventricular tachyarrhythmias or related symptoms need meticulous cardiac investigations. The mechanism of ventricular arrhythmia must be defined. The prognosis is related to underlying cardiac electrical or structural disorders. In the absence of cardiovascular abnormalities, the prognosis is good. No disqualification to competitive activity is required in most cases. Assessment of the risk of sudden death remains a continuing challenge in athletes. This article reviews the diagnostic and therapeutic approaches of ventricular arrhythmias encountered in trained athletes.

Tachycardia-mediated cardiomyopathy is a form of dilated cardiomyopathy and heart failure induced by a persistent/chronic supraventricular or ventricular tachyarythmia. The incidence and the patho-physiology remain unspecified. Sometimes related to a previous cardiomyopathy, the diagnosis is always retrospective, but important because of the clinical and the significant haemodynamic improvement following the control of heart rate.

Ischaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodelling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces (papillary muscles displacement leading to a more apical position of the leaflets and their coaptation point) and reduced closing forces (reduced contractility, dyssynchrony of the papillary muscles, intra-left ventricular dyssynchrony). Although mitral regurgitation has an unloading effect and reduces impedance, the volume overload begets further left ventricular dilatation, increases ventricular wall stress leading to worsened performance. Ischaemic mitral regurgitation is characteristically dynamic: its severity may vary with haemodynamic conditions. Both the severity of ischaemic mitral regurgitation and its dynamic component worsen prognosis. There are numerous possible treatment modalities, but the management of the individual patient remains difficult. Medical therapy is mandatory; revascularization procedures are frequently not sufficient to reduce mitral regurgitation; the role of combined surgical therapy by mitral valve repair is not yet defined in the absence of large randomized trial. Some patients are good candidates for cardiac resynchronization therapy that may reduce the amount of regurgitation. New therapeutic targets are under investigation.

The congenital long QT syndrome (LQTS) is a hereditary cardiac disease characterized by a prolongation of the QT interval > 440 ms at rest ECG associated with a high risk of ventricular arrhythmias (torsade de pointe). Clinical manifestations are syncope and sudden cardiac death. The implicated genes encode cardiac ion channel subunits or proteins involved in modulating ionic currents. The diagnosis of LQTS can be complex in borderline cases. Etiology, pathogenesis, diagnosis and treatment are discussed.

The aim of this study was to determine the impact of aortic stenosis (AS) on the different components of left atrial (LA) function. The study consisted of a total of 52 consecutive patients with severe AS (aortic valve area < 1 cm(2)) and 20 normal subjects matched for gender, heart rate, body surface area, and baseline systolic blood pressure. Phasic LA longitudinal function was assessed using tissue Doppler imaging. LA peak systolic (reservoir function), early diastolic (conduit function), and late diastolic (active function) strain rates were measured. During late diastole, LA peak strain (active function) was also measured. Mitral annular systolic, early diastolic (Ea), and late diastolic (Aa) velocities were also measured. Compared with controls, all strain values were significantly reduced in patients with AS. By multivariate regression analysis, mitral E-wave deceleration time (p = 0.033) and E/Ea ratio (p = 0.02, R(2) = 0.43) emerged as independently associated with LA peak systolic strain rate. Ea was the sole determinant of LA early diastolic strain rate (p < 0.0001, R(2) = 0.42), whereas LA late diastolic strain rate was independently related to aortic valve area (p = 0.031) and Aa (p = 0.022, R(2) = 0.51). In conclusion, in patients with severe AS, the 3 components of LA function are reduced. LA reservoir dysfunction is related to left ventricular filling pressures, whereas LA conduit dysfunction depends on left ventricular relaxation. Active LA dysfunction is related to the severity of AS and late left ventricular diastolic function., (Copyright © 2010 Elsevier Inc. All rights reserved.)

This article is a review on the role of stress echocardiography in valvular heart diseases, describing what the validated indications are, how to perform the test and the utility of performing this examination. Most valve diseases are characteristically dynamic and this dynamic component is best appreciated by exercise Doppler echocardiography. Dobutamine stress echocardiography is also useful in patients with severe aortic stenosis and left ventricular dysfunction. The main advantage of stress echocardiography is to concomitantly allow the evaluation of symptoms, exercise capacity and the hemodynamic consequences of valve diseases, especially in patients with severe valve diseases who deny symptoms or present equivocal symptoms. It also provides important prognostic information and may help to optimize surgical timing in difficult cases. Whether these data should be integrated in the management of patients needs further validation.

The management of patients with hypertrophic cardiomyopathy has largely evolved over the past two decades. One important finding is that medical treatment appears under used. Invasive procedure are reserved to patients with obstructive hypertrophic cardiomyopathy who remain symptomatic despite optimal medical treatment. Indications for implantable cardiac defibrillator are still debated. A global and multidisciplinary approach of the patient and of his family is mandatory.

Objectives: We sought to quantify exercise-induced changes in patients with degenerative mitral regurgitation (MR), to examine the relationship between exercise-induced changes in MR and in systolic pulmonary artery pressure (PAP), and to identify their potential impact on symptom-free survival., Background: MR severity can change during exercise in patients with functional MR. Quantified changes in MR severity during exercise remain undetermined in patients with degenerative MR., Methods: Resting and bicycle exercise Doppler-echocardiography were performed in 61 asymptomatic patients (age 62+/-14 years) with moderate to severe degenerative MR (i.e., mitral valve prolapse or flail). Mitral regurgitation was quantified at rest and exercise with effective regurgitant orifice (ERO) area and regurgitant volume calculated with the proximal isovelocity surface area (EROP) and the quantitative Doppler (EROD) methods., Results: At rest, EROP and EROD were well-correlated (r=0.87, p<0.0001), but EROD was larger than EROP (54+/-21 mm2 vs. 42+/-24 mm2, p<0.0001). During exercise, mean ERO and regurgitant volume markedly increased in 32% of patients by >or=10 mm2 and >or=15 ml, respectively. There was good correlation between exercise EROP and EROD (r=0.84, p<0.0001). Changes in systolic PAP were correlated with changes in ERO and regurgitant volume (r=0.59, p=0.02 and r=0.60, p=0.02). Patients with a marked increase in regurgitant volume during exercise had lower symptom-free survival than those in whom MR decreased or remained unchanged (p=0.0015)., Conclusions: Degenerative MR might be dynamic and increases during exercise in one-third of patients. Marked changes in MR severity are associated with exercise-induced changes in systolic PAP and reduced symptom-free survival., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Current guidelines recommend mitral valve surgery for asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular systolic function when exercise pulmonary hypertension (PHT) is present. However, the determinants of exercise PHT have not been evaluated. The aim of this study was to identify the echocardiographic predictors of exercise PHT and the impact on symptoms., Methods and Results: Comprehensive resting and exercise transthoracic echocardiography was performed in 78 consecutive patients (age, 61+/-13 years; 56% men) with at least moderate degenerative mitral regurgitation (effective regurgitant orifice area =43+/-20 mm(2); regurgitant volume =71+/-27 mL). Exercise PHT was defined as a systolic pulmonary arterial pressure (SPAP) >60 mm Hg. Exercise PHT was present in 46% patients. In multivariable analysis, exercise effective regurgitant orifice was an independent determinant of exercise SPAP (P<0.0001) and exercise PHT (P=0.002). Resting PHT and exercise PHT were associated with markedly reduced 2-year symptom-free survival (36+/-14% versus 59+/-7%, P=0.04; 35+/-8% versus 75+/-7%, P<0.0001). After adjustment, although the impact of resting PHT was no longer significant, exercise PHT was identified as an independent predictor of the occurrence of symptoms (hazard ratio=3.4; P=0.002). Receiver-operating characteristics curves revealed that exercise PHT (SPAP >56 mm Hg) was more accurate than resting PHT (SPAP >36 mm Hg) in predicting the occurrence of symptoms during follow-up (P=0.032)., Conclusions: Exercise PHT is frequent in patients with asymptomatic degenerative mitral regurgitation. Exercise mitral regurgitation severity is a strong independent predictor of both exercise SPAP and exercise PHT. Exercise PHT is associated with markedly low 2-year symptom-free survival, emphasizing the use of exercise echocardiography. An exercise SPAP >56 mm Hg accurately predicts the occurrence of symptoms.

Valvular heart diseases are of increasing importance among the general adult population. When compared with other heart diseases, there are few trials in the field of valvular heart disease and randomized clinical trials are particularly scarce. Two sets of guidelines exist: one in the USA and the other in Europe. However, they are not always consistent due to the lack of randomized data and it appears that, frequently, there is a gap between the existing guidelines and their effective application.

Chronic heart failure is a growing public health problem with a bad prognosis. Despite the seriousness of this syndrome and the well defined therapeutic approach, adherence to guidelines remains poor. After briefly recalling the main points of these guidelines, we present statistical data regarding therapeutic care of these patients. We then present factors influencing prescription or non prescription of heart failure drugs and emphasize the importance of a team management programme and patients pathways.

Adherence to the rules for antithrombotic ment in atrial fibrillation patients significantly reduces the risk of stroke. We review the criteria for the use of anti-vitamin K as well as its daily management in patients with atrial fibrillation.

The management of asymptomatic patients with severe aortic stenosis is challenging. Unfortunately, evaluation of symptoms such as dyspnoea remains subjective. The use of exercise echocardiography may help to predict major events in patients with asymptomatic severe aortic stenosis. This article explains how to perform the test and discusses which echocardiographic measurements should be obtained, focusing on the diagnostic and prognostic value of these measurements. An increase in mean transaortic pressure gradient >or= 18 mmHg predicts a worse prognosis in patients with severe aortic stenosis. The absence of left ventricular contractile reserve also has an important prognostic impact. Evaluation of filling pressures and looking for a worsening or a new mitral regurgitation are also part of the exam. Further studies are required to determine whether surgery should be recommended in the presence of an abnormal exercise echocardiogram in severe asymptomatic aortic stenosis., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)