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Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR).We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment.The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival.In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

ObjectiveMitral annular disjunction (MAD) is an abnormality linked to mitral valve prolapse (MVP), possibly associated with malignant ventricular arrhythmias. We assessed the agreement among different imaging techniques for MAD identification and measurement.Methods131 patients with MVP and significant mitral regurgitation undergoing transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were retrospectively enrolled. Transoesophageal echocardiography (TOE) was available in 106 patients. MAD was evaluated in standard long-axis views (four-chamber, two-chamber, three-chamber) by each technique.ResultsConsidering any-length MAD, MAD prevalence was 17.3%, 25.5%, 42.0% by TTE, TOE and CMR, respectively (pConclusionsAn integrated imaging approach could be necessary for a comprehensive assessment of patients with MVP and symptoms suggestive for arrhythmias. If echocardiography is fundamental for the anatomic and haemodynamic characterisation of the MV disease, CMR may better identify small length MAD as well as myocardial fibrosis.

Mitral regurgitation (MR) is frequently associated with severe aortic stenosis, but its influence on outcomes after transcatheter aortic valve implantation (TAVI) remains controversial. This study sought to assess the baseline etiology and degree of MR in TAVI population, identify the predictors of MR changes and investigate the clinical and prognostic impact of baseline MR at mid and long-term follow-up.We enrolled 572 consecutive patients who underwent TAVI. MR degree and etiology were evaluated by echocardiography at baseline and 1-year follow-up. Clinical outcomes were obtained up to 3-year follow-up.At baseline, 168 patients (29%) had moderate-to-severe MR (MR ≥ 2). Organic MR was more frequently associated with MR ≥ 2 (MR 2: 20%, MR ≥ 2: 43%, p 0.001). Relevant MR had improved more in functional MR (79%) compared to organic MR (50%, p = 0.001). At the multivariate analysis, the coexistence of coronary artery disease (p = 0.026), absence of atrial fibrillation (p = 0.038) and functional etiology (p = 0.025) were predictors of MR improvement after TAVI. Patients with baseline MR ≥ 2 had a higher mortality rate than those with MR 2 at 1-year and 3-year follow-up. Moreover, a landmark analysis starting from 1-year to 3-year follow-up, demonstrated that organic MR was associated with an increased risk of mortality throughout 3-year follow-up compared with functional MR, irrespective of MR severity.Baseline MR ≥ 2 in TAVI patients was associated with early and late mortality rate. At 1-year, significant improvement in MR severity was observed mainly in patients with functional MR ≥ 2. Organic MR ≥ 2 had a negative impact on 3-year, but not 1-year, mortality rate.

Prosthetic valve (PV) dysfunction (PVD) is a complication of mechanical or biological PV. Etiologic mechanisms associated with PVD include fibrotic pannus ingrowth, thrombosis, structural valve degeneration, and endocarditis resulting in different grades of obstruction and/or regurgitation. PVD can be life threatening and often challenging to diagnose due to the similarities between the clinical presentations of different causes. Nevertheless, identifying the cause of PVD is critical to treatment administration (thrombolysis, surgery, or percutaneous procedure). In this report, we review the role of multimodality imaging in the diagnosis of PVD. Specifically, this review discusses the characteristics of advanced imaging modalities underlying the importance of an integrated approach including 2D/3D transthoracic and transesophageal echocardiography, fluoroscopy, and computed tomography. In this scenario, it is critical to understand the strengths and weaknesses of each modality according to the suspected cause of PVD. In conclusion, for patients with suspected or known PVD, this stepwise imaging approach may lead to a simplified, more rapid, accurate and specific workflow and management.

Aims Haemodynamic classifications of severe aortic stenosis (AS) have important prognostic implications, with low flow state (defined on the basis of a stroke volume index, SVi Methods In this single centre study, 1078 patients (mean age 81±7 years) with severe symptomatic AS (AVA40 mmHg), 94 (9%) with paradoxical low flow LG (pLF-LG: DP mean 50%, and SVi Results TAVR was feasible in all AS subtypes with similar rate of unsuccessful procedure (1.3% NF-HG, 1.1% pLF-LG, 0% LF-LG P=470). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group (Figure A). Overall, intraoperative (P=957) and 30-day mortality (P=817) did not differ significantly among the 3 groups. Longer follow-up showed that, compared to NF-HG patients, pLF-LG had similar all-cause mortality rate [HR 1.35(0.95–1.90), P=0.094] up to 5 years and LF-LG had a significant higher mortality rate [HR 1.89(1.43–2.49), P Conclusions We provided evidence that TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. A careful haemodynamic classifications of severe AS is of utmost importance for identifying patients who benefits the most from TAVR procedure.

MitraClip (MC) is the most common percutaneous treatment for severe mitral regurgitation (MR). An accurate two-dimensional and three-dimensional echocardiographic (3DTEE) imaging is mandatory for the optimal procedural result. Recently transillumination 3DTEE rendering (3DTr) has been introduced integrating a virtual light source into the dataset and with the addition of glass effect (3DGl) allows to adjust tissue transparency improving depth perception and anatomical structure delineation in comparison with the standard 3DTEE (3DSt). The aim of this retrospective study in 30 patients undergoing MC, was to compare 3DSt, 3DTr, and 3DGl in mitral valve (MV) evaluation and procedural result assessment. 3DTEE acquisitions obtained before and after MC were processed with 3DSt, 3DTr, and 3DGl rendering. Each reconstruction was scored for quality and for ability to recognize MV anatomy, MR origin, clip position, dimension and grasping. Imaging quality was judged good or optimal in 52%, 76%, and 96% in 3DSt, 3DTr, and 3DGl reconstructions respectively. In 26/30 patients a diagnostic incremental value was found with 3DTr vs. 3DSt and in 15/26 with 3DGl vs. 3DTr and 3DSt. Only 3DGl with perpendicular cropping of the clip allowed to visualize and measure the grasped portion of each mitral leaflets. 3DTEE imaging during MC may be improved by 3DTr and 3DGl providing a better evaluation of MV, of leaflet grasping and of residual MR jets after MC.

Background: The right ventricle (RV) plays a pivotal role in cardiovascular diseases and 3-dimensional echocardiography (3DE) has gained acceptance for the evaluation of RV volumes and function. Recently, a new artificial intelligence (AI)–based automated 3DE software for RV evaluation has been proposed and validated against cardiac magnetic resonance. The aims of this study were three-fold: (i) feasibility of the AI-based 3DE RV quantification, (ii) comparison with the semi-automatic 3DE method and (iii) assessment of 2-dimensional echocardiography (2DE) and strain measurements obtained automatically. Methods: A total of 203 subject (122 normal and 81 patients) underwent a 2DE and both the semi-automatic and automatic 3DE methods for Doppler standard, RV volumes and ejection fraction (RVEF) measurements. Results: The automatic 3DE method was highly feasible, faster than 2DE and semi-automatic 3DE and data obtained were comparable with traditional measurements. Both in normal subjects and patients, the RVEF was similar to the two 3DE methods and 2DE and strain measurements obtained by the automated system correlated very well with the standard 2DE and strain ones. Conclusions: results showed that rapid analysis and excellent reproducibility of AI-based 3DE RV analysis supported the routine adoption of this automated method in the daily clinical workflow.

Background: Whereas transcatheter aortic valve implantation (TAVI) has become the gold standard for aortic valve stenosis treatment in high-risk patients, it has recently been extended to include intermediate risk patients. However, the mortality rate at 5 years is still elevated. The aim of the present study was to develop a novel machine learning (ML) approach able to identify the best predictors of 5-year mortality after TAVI among several clinical and echocardiographic variables, which may improve the long-term prognosis. Methods: We retrospectively enrolled 471 patients undergoing TAVI. More than 80 pre-TAVI variables were collected and analyzed through different feature selection processes, which allowed for the identification of several variables with the highest predictive value of mortality. Different ML models were compared. Results: Multilayer perceptron resulted in the best performance in predicting mortality at 5 years after TAVI, with an area under the curve, positive predictive value, and sensitivity of 0.79, 0.73, and 0.71, respectively. Conclusions: We presented an ML approach for the assessment of risk factors for long-term mortality after TAVI to improve clinical prognosis. Fourteen potential predictors were identified with the organic mitral regurgitation (myxomatous or calcific degeneration of the leaflets and/or annulus) which showed the highest impact on 5 years mortality.

The long-term outcome of mechanical aortic and mitral prosthetic valve (A-PV, M-PV) dysfunction (PVD) remains a serious complication associated with high morbidity and mortality. We sought to evaluate the incremental diagnostic value of combined transthoracic echocardiography (TTE) and fluoroscopy (F) in patients with suspected PVD. A total of 354 patients (178 A-PV, 176 M-PV) were imaged by TTE and F within 5 days of hospital admission. PVD was confirmed by transesophageal echocardiography, computed tomography, effective thrombolysis, or surgical inspection. PVD was confirmed in 101 patients (57%) with M-PV and 99 (55%) with A-PV. Regardless of the mechanism of PVD, TTE shows good sensitivity and specificity, with accuracy of 80% for M-PV and 91% for A-PV. F shows high specificity, but low sensitivity with accuracy of 68% for M-PV and 78% for A-PV. The integration of TTE + F significantly improved accuracy both for M-PV (83%) and A-PV (96%). At ROC analysis, the combined model of TTE + F showed the highest area under the curve for the detection of PVD compared with TTE and F alone (p0.001). In conclusion, in patients with a clinical suspicion of PVD, the combined model of TTE + F offers incremental value over TTE or F alone. This multimodality imaging approach overcomes limitations of TTE or F alone and provides prompt identification of patients who may require further imaging assessment and/or closer follow up.

Cardiovascular imaging is developing at a rapid pace and the newer modalities, in particular three-dimensional echocardiography, allow better analysis of heart structures. Identifying valve lesions and grading their severity represents crucial information and nowadays is strengthened by the introduction of new software, such as transillumination, which provide detailed morphology descriptions. Chambers quantification has never been so rapid and accurate: machine learning algorithms generate automated volume measurements, including left ventricular systolic and diastolic function, which is extremely important for clinical decisions. This review provides an overview of the latest innovations in the echocardiography field, and is helpful by providing a better insight into heart diseases.

Three-dimensional echocardiographic (3DE) of right ventricle (RV) has been validated in many clinical settings. However, the necessity of complicated and off-line dedicated software has reduced its diffusion. A new simplified "on board" 3DE software (OB) has been developed to obtain RV volumes and ejection fraction (EF) together with several conventional parameters automatically derived from 3DE: tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), longitudinal strain (LS). Aims of this study were to evaluate feasibility and accuracy of OB RV analysis. A complete 2DE and 3DE with OB 3DRV evaluation was obtained in 35 normal subjects and 105 patients with different pathologies. Results were compared with the conventional off-line software (OFL) and with the 2D-derived corresponding values. A subgroup of 22 patients underwent also cardiac CMR. OB 3DRV was feasible in 133/140 cases (95%) in a mean time of 97.5 ± 33 s lower than OFL analysis (129 ± 52 s plus dataset loading 80 ± 24 s). Imaging quality was good in 84%. OB and OFL 3DE RV volumes and EF were similar. 3DE derived FSA and LS (but not TAPSE) were similar to 2DE values and correlated with tissue Doppler systolic peak velocity, dP/dt, systolic pulmonary pressure and myocardial performance index. OB RV volumes and EF well correlated with CMR. (bias + SD: - 21.5 ± 20 mL for EDV; - 8.2 ± 12.4 mL for ESV; - 1 ± 5.9% for EF). OB 3DE method is feasible, simple, time saving. It easily provides 3DE RV volumes and multiple functional parameters. Off-line operator border adjustment may improve accuracy of 3DE TAPSE.

Graphical abstract, Highlights • PH can sometimes be a challenging diagnosis. • Echocardiography can assess RV overload and evaluate sudden changing in PASP. • Although rare, scurvy should be part of an expanded differential diagnosis of PH.

Background: Mitral valve regurgitation (MR) is the most common valvular heart disease and current variables associated with MR recurrence are still controversial. We aim to develop a machine learning-based prognostic model to predict causes of mitral valve (MV) repair failure and MR recurrence. Methods: 1000 patients who underwent MV repair at our institution between 2008 and 2018 were enrolled. Patients were followed longitudinally for up to three years. Clinical and echocardiographic data were included in the analysis. Endpoints were MV repair surgical failure with consequent MV replacement or moderate/severe MR (&gt, 2+) recurrence at one-month and moderate/severe MR recurrence after three years. Results: 817 patients (DS1) had an echocardiographic examination at one-month while 295 (DS2) also had one at three years. Data were randomly divided into training (DS1: n = 654, DS2: n = 206) and validation (DS1: n = 164, DS2 n = 89) cohorts. For intra-operative or early MV repair failure assessment, the best area under the curve (AUC) was 0.75 and the complexity of mitral valve prolapse was the main predictor. In predicting moderate/severe recurrent MR at three years, the best AUC was 0.92 and residual MR at six months was the most important predictor. Conclusions: Machine learning algorithms may improve prognosis after MV repair procedure, thus improving indications for correct candidate selection for MV surgical repair.

The Authors' reply We thank Dr Garbi and colleagues1 for their interest in our recently published study.2 The authors underline that mitral annular disjunction (MAD) cannot be considered a risk factor for sudden cardiac death in mitral valve prolapse (MVP), as it is a widespread anatomical variation of the mitral valve annulus (MVA), also described in histological specimens of hearts without MVP. We agree that the link between MAD and malignant MVP is still speculative, as several factors may be responsible for ventricular arrhythmias, including genetic, structural, mechanical …

MitraClip is a validated treatment for significant mitral regurgitation (MR) in high-risk patients. Aims of the study were to evaluate immediate changes in mitral valve (MV) geometry induced by MitraClip and correlations between baseline geometry and cardiac remodeling. Eighty patients who underwent MitraClip for primary (48%) or secondary (52%) MR were enrolled. Intraoperative transesophageal echocardiographic 3D images were acquired immediately before and after the procedure for MV annulus (MVA) morphology analysis. Transthoracic 3D echocardiography was performed preoperatively and at 6 months follow-up (6MFU). Patients were classified on the basis of MR reduction (ΔMR) at 6MFU as Optimal (ΔMR ≥ 2) or Suboptimal (ΔMR2). An optimal result was reached in 60 (75%) patients, whereas 20 subjects showed a ΔMR2 at 6MFU. The Optimal showed significantly smaller baseline MVA (antero-posterior diameter 4.05 ± 0.59 vs 4.43 ± 0.68 cm; anterolateral-posteromedial diameter 4.38 ± 0.56 vs 4.70 ± 0.73 cm; MVA circumference 14.1 ± 1.7 vs 15.1 ± 2.3 cm; and 3D area 14.8 ± 3.9 vs 17.4 ± 5.3 cm

The right ventricle plays an important role in the morbidity and mortality of patients presenting with symptoms and signs of cardiopulmonary disease. This cardiac chamber has a unique crescent shape, which adds complexity to the quantification of its size and function. Until recently, little uniformity in echocardiographic imaging of the right heart existed because of a lack of familiarity with various techniques, and the enormous attention directed towards left heart quantification. Three-dimensional (3D) echocardiography, a major technological breakthrough in the field of cardiovascular imaging, provides several advantages over two-dimensional (2D) imaging in the quantitative evaluations of right ventricle because of its independence from any geometrical assumption. In this review, we focus on the contribution of this new modality to the evaluation of right ventricle.

Aims Scarce data are available on the long-term structural and functional changes of prosthetic valves after transcatheter aortic valve implantation (TAVI). The objective was to evaluate with echocardiography the long-term structural and functional changes of prosthetic valves after TAVI. Methods and results Structural valve deterioration (SVD) was defined as leaflet thickening ≥3mm, presence of calcification and abnormal leaflet motion. Five-year echocardiographic follow-up was available in 96 out of 318 patients who underwent TAVI with a balloon-expandable device between April 2008 and December 2011. At 1-year follow-up, no patient showed SVD. At 5-year follow-up, SVD were observed in 29 (30%) patients who showed also a significant reduction of aortic valve area (AVA) together with an increase of mean and peak aortic pressure gradients at the latest echocardiography evaluation. Moreover, rate of central aortic valve regurgitation ≥2 was higher in SVD patients as compared to those without SVD, while there was no difference in terms of paravalvular regurgitation. Despite SVD, one patient only reached the criteria for severe stenosis and no reintervention was needed at 5-year follow-up. Variables independently associated with SVD were female sex, small body surface area, use of a 23 mm valve, and small AVA at pre-discharge echocardiogram. Conclusion At 5-year follow-up, 30% of patients who underwent TAVI with a balloon-expandable valve showed initial SVD. However, SVD was not associated with severe stenosis in most of the patients and had no significant impact on and clinical outcome.

Aims Proper measurement of the aortic annulus (AoA) is crucial for the success of transcatheter aortic valve implantation (TAVI). Transthoracic echocardiography (TTE) is the first step to assess AoA diameter, but a two-dimensional TTE (2DTTE) measurement is no longer accepted as the sole determinant of prosthetic size. The aims of the study were to evaluate feasibility and accuracy of three-dimensional TTE (3DTTE) estimation of AoA dimensions in comparison with multidetector computer tomography (MDCT). Methods and results We enrolled 100 consecutive patients referred for TAVI. Feasibility of AoA evaluation was 91% for 3DTTE and in 90% for MDCT. In 81 of 100 patients, AoA maximum diameter (max-D), minimum diameter (min-D), and area were measured and compared using 2DTTE, 3DTTE, and MDCT. Image quality of 3DTTE was sufficient in 47, good in 46 and optimal in 7%. High correlations ( P < 0.001) were found between MDCT and 3DTTE (max-D: r = 0.89; min-D r = 0.86; area: r = 0.93), and between MDCT and 2DTTE (min-D: r = 0.81; area 0.78). The 3DTTE measurements were found to be highly reproducible on intra- and interobserver variability analyses. Regarding the choice of prosthesis size, agreement between 3DTTE and MDCT was very good ( k = 0.84, P < 0.001) while it was poor between 2DTTE and MDCT ( k = 0.36, P < 0.001). Conclusions 3DTTE may be a valid imaging alternative in patients unsuitable for MDCT during the preoperative evaluation for TAVI. Evaluation of AoA through 3DTTE is feasible, and measurements closely approximate those of MDCT thus improving TTE accuracy in identifying the correct prosthesis size.

Objectives The authors sought to investigate the accuracy of transthoracic echocardiography (TTE)-derived parameters in the identification of bileaflet aortic prosthesis dysfunction, compared with fluoroscopy (FL). Background Identification of bileaflet aortic prosthesis dysfunction is challenging, because high mean pressure gradient (MPG >20 mm Hg) is not proof of prosthetic obstruction (AVPO), and may be due to prosthesis–patient mismatch (PPM). Conversely, high gradients may not be manifest in AVPO and low cardiac output. Methods TTE and FL were prospectively performed in 100 nonconsecutive patients with bileaflet aortic prosthesis. TTE included the estimation of MPG, indexed effective orifice area (EOAi), Doppler velocity index (DVI), intraprosthetic regurgitation, acceleration time (AT), ejection time (ET), AT/ET, and the difference (dA) between the expected prosthetic orifice area and EOA. FL allowed the calculation of opening and closing angles, and the discrimination of AVPO from normal (NL) and PPM. Results On the basis of FL examination and MPG and EOAi at TTE, patients were classified as NL (42%), PPM (32%), and AVPO (26%). High MPG (>20 mm Hg) was present in 65% of the patients, with higher values in PPM (36 ± 8 mm Hg) and AVPO (43 ± 16 mm Hg) than in NL (16 ± 6 mm Hg). DVI was reduced in PPM (0.30 ± 0.05) and AVPO (0.25 ± 0.04) compared with NL (0.42 ± 0.09). In AVPO, dA (0.59 ± 0.32 cm2), AT (108 ± 20 ms), and AT/ET (0.35 ± 0.05) significantly differed from NL (dA = −0.12 ± 0.43 cm2, AT = 74 ± 15 ms, AT/ET = 0.25 ± 0.05) and PPM (dA = 0.15 ± 0.24 cm2, AT = 78 ± 13 ms, AT/ET = 0.26 ± 0.04). Moderate or severe intraprosthetic regurgitation was observed only in AVPO. All considered TTE-derived parameters were found related to obstruction, and dA (accuracy = 87%), AT (94%), and AT/ET (89%) showed the highest accuracy in discriminating normofunctioning prostheses from AVPO. Conclusions In the presence of high MPG, TTE parameters play a key role in aortic prosthesis examination. Especially time indices and dA add to the functional assessment of prosthetic aortic valves. However, the TTE discrimination between AVPO and PPM may be suboptimal, and fluoroscopy is a complementary and essential diagnostic step.

Aims Despite expected improvement in left ventricular (LV) systolic and diastolic function after transcatheter aortic valve implantation (TAVI), the complex relationship between pre-existent LV systolic and diastolic function and changes in LV haemodynamics and clinical symptoms have been scarcely investigated. This study investigated the presence of pre-operative LV diastolic dysfunction and its improvement over time after TAVI alongside improvement in New York Heart Association (NYHA) class in high-risk patients with severe aortic stenosis. Methods and results The study population ( n = 358) was divided into two groups according to baseline LV ejection fraction (LVEF): LVEF < 50% ( n = 96) and LVEF ≥ 50% ( n = 262). We compared clinical and echocardiographic parameters between groups before TAVI, at 6 and 12 months follow-up. Grade III LV diastolic dysfunction was more frequent in patients with LVEF < 50% compared with patients with LVEF ≥ 50% (50.0 vs. 16.3%, P < 0.001). Systolic and diastolic echocardiographic parameters improved after TAVI together with improvement in NYHA class both in patients with LVEF < 50% (diastolic dysfunction grade ≥2: baseline 100% of patients; 12 months 58.8%, P < 0.001; NYHA III/IV: baseline, 93.8%; 12 months, 9.7%, P < 0.001) and with LVEF ≥ 50% (diastolic dysfunction grade ≥2: baseline, 87.1%; 12 months, 61.2%; NYHA III/IV: baseline, 74.5%; 12 months, 2.6%, P < 0.001). All-cause mortality was comparable between groups. Conclusion TAVI exerts favourable effects on LV systolic and diastolic function with a remarkable improvement in LV diastolic function associated with improvement in NYHA functional class at follow-up. Prognosis at 1 year after TAVI was not influenced by baseline LV diastolic dysfunction both in patients with and without LV systolic dysfunction.

A recent histological study of resected scallop-P2 in mitral valve (MV) prolapse, showed that chordae tendinae may be missing or hidden in superimposed fibrous tissue of the leaflets, contributing to their thickening. This may have relevant clinical implication because detailed analysis of MV leaflets has a central role in the evaluation of patients undergoing repair. The aim of this study was to analyze MV leaflets focusing on thickness of prolapsing segments and the presence of chordal rupture (CR). We enrolled 246 patients (age 63 ± 13 years, 72 men) with isolated P2 prolapse and also 50 age-matched patients with normal MV anatomy as control group. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were retrospectively analyzed to quantify the length and the proximal and distal thickness of both anterior (A2) and posterior (P2) MV scallops. Measurements were performed at end diastole in the standard TTE and TEE views. TTE and TEE measurements were feasible in all cases. Echocardiographically 176 patients had CR (group A), 45 had no rupture (group B), and 25 had an uncertain diagnosis (group C). All pathological groups showed thickening and elongation of involved leaflets versus normal, whereas no differences in leaflets characteristics were found among MV groups. Most patients undergoing MV repair had CR with thickening of the prolapsed segment. These findings are in agreement with recent histological studies showing superimposed fibrous tissue on MV leaflets partially including ruptured chordae. This may also explain that in cases without ruptured chordae, thickness of the leaflets is markedly increased (hidden chordae?). In conclusion, detailed analysis of MV apparatus may further improve knowledge of these patients and may influence surgical timing.

Background A controversial aspect of carotid artery stenting (CAS) is the placement of a stent with or without predilation. The study was designed to test the hypothesis that direct stenting (DS) was not inferior to CAS with predilation. Methods Elective CAS with filter protection was performed in 205 consecutive, unselected patients with carotid artery stenosis (>50% if symptomatic and ≥75% if asymptomatic by Doppler assessment) who were randomly assigned to CAS with predilation ( n =100) or direct stenting (DS, n =105). Filter and stent selection were left to the operator's discretion. The study end-point was the angiographic success, defined as ≤30% angiographic residual stenosis after CAS without abnormal angiographic findings in cerebral circulation and without cross-over to predilation in the DS group. Results At baseline, patient clinical characteristics and stenosis anatomic features did not differ between groups. Angiographic success was 99% and 97%, p =0.33, in predilation and DS, respectively. No cross-over to predilation occurred in the DS group. Procedural time was shorter in DS as compared to predilation (24.3±7% versus 19.9±6%, p =0.001) and visible debris were more frequently captured in predilation as compared to DS (50% versus 36%, p =0.003). No peri-procedural and 30-day death or major stroke occurred in both groups. Minor stroke and TIA rates were similar in either group (2% versus 0% and 8% versus 5.7%, p =ns, respectively). Conclusion In an unselected, consecutive series of patients submitted to CAS, DS is a feasible technique and is not inferior to CAS with predilation.

Unfavorable complex anatomy or congenital anomalies of supra-aortic vessel take-off may increase carotid artery stenting (CAS) procedural difficulties and complications through the femoral route. We assessed the feasibility, safety, and efficacy of CAS through the right brachial approach in patients in whom left internal carotid artery stenosis and bovine aortic arch configuration were identified with computed tomography (CT) angiography. Bovine configuration of the aortic arch and left carotid artery stenosis were easily identified by CT angiography and successfully treated through the right brachial approach technique.

According to current recommendations, patients could benefit from tricuspid valve (TV) annuloplasty at the time mitral valve (MV) surgery if tricuspid regurgitation is severe or if tricuspid annulus (TA) dilatation is present. Therefore, an accurate pre-operative echocardiographic study is mandatory for left but also for right cardiac structures. Aims of this study are to assess right atrial (RA), right ventricular (RV) and TA geometry and function in patients undergoing MV repair without or with TV annuloplasty. We studied 103 patients undergoing MV surgery without (G1: 54 cases) or with (G2: 49 cases) concomitant TV annuloplasty and 40 healthy subjects (NL) as controls. RA, RV and TA were evaluated by three-dimensional (3D) transthoracic echocardiography. Comparing the pathological to the NL group, TA parameters and 3D right chamber volumes were significantly larger. RA and RV ejection fraction and TA% reduction were lower in pathological versus NL, and in G2 versus G1. In pathological patients, TA area positively correlated to systolic pulmonary pressure and negatively with RV and RA ejection fraction. Patients undergoing MV surgery and TV annuloplasty had an increased TA dimensions and a more advanced remodeling of right heart chambers probably reflecting an advanced stage of the disease.

Transcatheter aortic valve implantation (TAVI) has extended the treatment options for severe, symptomatic aortic valve stenosis (AS). Risk factors for AS have been shown to be similar to atherosclerosis. Consequently, coronary artery disease (CAD), peripheral vascular and carotid artery diseases are often found concurrently with diagnostic, procedural and prognostic implications. This study sought to describe comprehensive vascular assessment in terms of prevalence, severity and correlations in TAVI candidates. A total of 323 patients (81 ± 6 years) undergoing TAVI were enrolled. Vascular pathologies were evaluated by invasive coronary angiography, computer-tomography (abdominal aorta, renal, iliac and femoral arteries), echo-color Doppler ultrasound (carotid artery), and transoesophageal echocardiography (thoracic aorta). CAD was found in 173 (54%) patients, of which 65 (38%) had 1-vessel, 45 (26%) 2-vessel and 59 (34%) 3-vessel disease. Carotid artery disease was present in 33.6% patients, of which 23.6% unilateral and 10.0% bilateral. Iliac, femoral and renal stenosis were found in 29.2%, 22.0%, and 4.7%, respectively. Cardiovascular risk factor and gender correlated with CAD. CAD patients presented more frequently with significant stenosis (luminal narrowing ≥ 50%) of at least one other district. Multi-districts significant stenosis stratified patients on long-term survival and the coexistence of 3-districts involvement with CAD negatively impacts on mortality. Multimodality imaging assessment shows that coronary, carotid, and peripheral artery disease are often found concurrently in patients undergoing TAVI. Several risk factors and gender correlate with the presence and severity of CAD and peripheral pathologies. Long-term mortality is increased in patients with a more compromised vascular situation.

A 52-year-old man was referred for evaluation of palpitation. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva, and normal anatomy of the aortic valve with no regurgitation. Three-dimensional computed tomography confirmed the aneurysm with a diameter of 21 × 13.7 mm arising from the right coronary sinus of Valsalva under the right coronary artery. Surgical repair was performed without changing the normal anatomy of the aortic valve, preserving the right coronary ostium. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with normal functioning of the aortic valve.

Factors correlating to mitral annulus calcification (MAC) include risk factors predisposing to atherosclerosis. In patients with mitral valve (MV) prolapse (MVP), other anatomic or mechanical factors have been supposed to facilitate MAC. The aims of this study were, in patients with MVP undergoing MV repair, (1) to describe the prevalence and characteristics of MAC, (2) to correlate MAC with clinical risk factors, coronary involvement, and aortic valve disease, and (3) to describe prevalence, site, and extension of MAC in fibroelastic deficiency (FED) versus Barlow's disease (BD) and correlate MAC to surgical outcomes (repair vs replacement). In 410 consecutive patients with MVP suitable for surgical MV repair, detailed clinical and echocardiographic data were collected to characterize MAC in BD and FED. MAC was found in 99 patients (24%). Age, female gender, coronary artery disease, and cardiovascular risk factors were correlated with MAC. MAC was equally distributed in FED and BD groups despite patients with FED being older with more cardiovascular risk factors. The most common localization of MAC was annular involvement adjacent to P2 (75%), P1 (31%), and P3 (35%). The presence of MAC affected surgical outcomes in both groups (8% patients with MAC underwent replacement after a first attempt of repair vs 3% without MAC). MAC is a common finding in patients undergoing MV repair, and several clinical characteristics correlate with MAC either in FED or BD. In conclusion, despite very high percentage of repairability, MAC influences surgical outcomes and very detailed echo evaluation is advocated.

The authors sought to investigate the accuracy of transthoracic echocardiography (TTE)-derived parameters in the identification of bileaflet aortic prosthesis dysfunction, compared with fluoroscopy (FL).Identification of bileaflet aortic prosthesis dysfunction is challenging, because high mean pressure gradient (MPG20 mm Hg) is not proof of prosthetic obstruction (AVPO), and may be due to prosthesis-patient mismatch (PPM). Conversely, high gradients may not be manifest in AVPO and low cardiac output.TTE and FL were prospectively performed in 100 nonconsecutive patients with bileaflet aortic prosthesis. TTE included the estimation of MPG, indexed effective orifice area (EOAi), Doppler velocity index (DVI), intraprosthetic regurgitation, acceleration time (AT), ejection time (ET), AT/ET, and the difference (dA) between the expected prosthetic orifice area and EOA. FL allowed the calculation of opening and closing angles, and the discrimination of AVPO from normal (NL) and PPM.On the basis of FL examination and MPG and EOAi at TTE, patients were classified as NL (42%), PPM (32%), and AVPO (26%). High MPG (20 mm Hg) was present in 65% of the patients, with higher values in PPM (36 ± 8 mm Hg) and AVPO (43 ± 16 mm Hg) than in NL (16 ± 6 mm Hg). DVI was reduced in PPM (0.30 ± 0.05) and AVPO (0.25 ± 0.04) compared with NL (0.42 ± 0.09). In AVPO, dA (0.59 ± 0.32 cm(2)), AT (108 ± 20 ms), and AT/ET (0.35 ± 0.05) significantly differed from NL (dA = -0.12 ± 0.43 cm(2), AT = 74 ± 15 ms, AT/ET = 0.25 ± 0.05) and PPM (dA = 0.15 ± 0.24 cm(2), AT = 78 ± 13 ms, AT/ET = 0.26 ± 0.04). Moderate or severe intraprosthetic regurgitation was observed only in AVPO. All considered TTE-derived parameters were found related to obstruction, and dA (accuracy = 87%), AT (94%), and AT/ET (89%) showed the highest accuracy in discriminating normofunctioning prostheses from AVPO.In the presence of high MPG, TTE parameters play a key role in aortic prosthesis examination. Especially time indices and dA add to the functional assessment of prosthetic aortic valves. However, the TTE discrimination between AVPO and PPM may be suboptimal, and fluoroscopy is a complementary and essential diagnostic step.

Context: Evidence is accumulating in favor of erectile dysfunction (ED) as a vascular disorder in the vast majority of patients. Endothelial dysfunction is the initial step of the atherosclerotic process involving many vascular districts, including penile and coronary circulation. Objective: To make a holistic and comprehensive approach to the proposed triad of endothelial dysfunction-cardiovascular disease (CVD)-ED and its clinical implications. Evidence acquisition: A MedLine search of the dates January 1980 to July 2008 was performed that included original and review manuscripts articles with focus on anatomic, physiologic, epidemiologic, and clinical outcomes. Evidence synthesis: There is room to consider ED as a marker of early subclinical coronary artery disease (CAD). Moreover, ED is an independent predictor of future cardiovascular (CV) events. Noninvasive tests assessing the endothelium integrity are the flow-mediated dilation of the brachial artery and the circulating endothelial activated cells. Conclusions: The onset of sexual dysfunction should be considered as a marker of subclinical systemic vascular disease and has been found to predict subsequent CV events. It is, therefore, crucial to identify asymptomatic patients with ED who may be at risk of occult CAD. Their early recognition may lead to treatment of risk factors and conditions associated with endothelial dysfunction, hopefully reducing the rate of major CV events. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. Context: Evidence is accumulating in favor of erectile dysfunction (ED) as a vascular disorder in the vast majority of patients. Endothelial dysfunction is the initial step of the atherosclerotic process involving many vascular districts, including penile and coronary circulation. Objective: To make a holistic and comprehensive approach to the proposed triad of endothelial dysfunction-cardiovascular disease (CVD)-ED and its clinical implications. Evidence acquisition: A MedLine search of the dates January 1980 to July 2008 was performed that included original and review manuscripts articles with focus on anatomic, physiologic, epidemiologic, and clinical outcomes. Evidence synthesis: There is room to consider ED as a marker of early subclinical coronary artery disease (CAD). Moreover, ED is an independent predictor of future cardiovascular (CV) events. Noninvasive tests assessing the endothelium integrity are the flow-mediated dilation of the brachial artery and the circulating endothelial activated cells. Conclusions: The onset of sexual dysfunction should be considered as a marker of subclinical systemic vascular disease and has been found to predict subsequent CV events. It is, therefore, crucial to identify asymptomatic patients with ED who may be at risk of occult CAD. Their early recognition may lead to treatment of risk factors and conditions associated with endothelial dysfunction, hopefully reducing the rate of major CV events. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.