Background: Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS) but sometimes occult at rest and elicited by stress. Aim: This study sought to assess LA volume and function at rest and during stress across the spectrum of AF. Methods: In a prospective, multicenter, observational study design, we enrolled 3042 patients [age = 64 ± 12; 63.8% male] with known or suspected CCS: 2749 were in sinus rhythm (SR, Group 1); 191 in SR with a history of paroxysmal AF (Group 2); and 102 were in permanent AF (Group 3). All patients underwent stress echocardiography (SE). We measured left atrial volume index (LAVI) in all patients and LA Strain reservoir phase (LASr) in a subset of 486 patients. Results: LAVI increased from Group 1 to 3, both at rest (Group 1 = 27.6 ± 12.2, Group 2 = 31.6 ± 12.9, Group 3 = 43.3 ± 19.7 mL/m², p < 0.001) and at peak stress (Group 1 = 26.2 ± 12.0, Group 2 = 31.2 ± 12.2, Group 3 = 43.9 ± 19.4 mL/m², p < 0.001). LASr progressively decreased from Group 1 to 3, both at rest (Group 1 = 26.0 ± 8.5%, Group 2 = 23.2 ± 11.2%, Group 3 = 8.5 ± 6.5%, p < 0.001) and at peak stress (Group 1 = 26.9 ± 10.1, Group 2 = 23.8 ± 11.0 Group 3 = 10.7 ± 8.1%, p < 0.001). Stress B-lines (≥2) were more frequent in AF (Group 1 = 29.7% vs. Group 2 = 35.5% vs. Group 3 = 57.4%, p < 0.001). Inducible ischemia was less frequent in SR (Group 1 = 16.1% vs. Group 2 = 24.7% vs. Group 3 = 24.5%, p = 0.001). Conclusions: In CCS, rest and stress LA dilation and reservoir dysfunction are often present in paroxysmal and, more so, in permanent AF and are associated with more frequent inducible ischemia and pulmonary congestion during stress.

Background/Objectives: Severe aortic stenosis (AS) is the most frequent valvular heart disease. Models for stratifying cardiac damage associated with aortic stenosis have been developed to predict outcomes following valve replacement. However, evidence regarding morphological and functional evolution, as well as potential changes in the degree of cardiac damage, is limited. We aim to provide information on the evolution of cardiac morphology and the function of patients undergoing transcatheter aortic valve replacement (TAVR) who have been classified using a cardiac damage staging system. Methods: In total, 496 patients were included in the analysis, and were classified into four stages based on the extent of cardiac damage as follows: Stage 0, no cardiac damage: left ventricle global longitudinal strain (LV-GLS) < −17%; right ventricular–arterial coupling (RVAc) ≥ 0.35), and absence of significant mitral regurgitation (MR). Stage 1, left-sided subclinical damage: LV-GLS ≥ −17%. Stage 2, left-sided damage: significant MR. Stage 3, right-sided damage: RVAc < 0.35. Results: The mean age was 82.1 ± 5.9 years, and 53.0% were female. In total, 24.5% of patients met the criteria for Stage 0, and Stage 1 included 42.8% of patients, Stage 2 included 16.5%, and Stage 3 comprised 16.2% of patients. Mortality was 8.4% for stage 0, 17.4% for stage 1, 25.6% for stage 2, and 28.6% for stage 3 patients (p = 0.004). Diabetes mellitus (DM) (p = 0.047) and chronic kidney disease (CKD) (p = 0.024) were the only clinical predictors of no change or worsening in the stage of cardiac damage. Regarding echocardiographic variables, concomitant tricuspid, and mitral regurgitation, ≥ 2 were both significantly associated with no change or worsening, also (p < 0.001). Conclusions: Cardiac damage that is secondary to severe aortic stenosis has morphological and functional repercussions that, even after valve replacement, persist and might worsen the prognosis.

Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm², a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm² with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as “classical” low-flow low-gradient (LFLG) AS or normal LVEF “paradoxical” LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.

Background: Echocardiography is essential for diagnosing and guiding therapy in aortic stenosis (AS). Cardiac damage staging systems may better characterize myocardial and extracardiac involvement. We aim to evaluate the presence and progression of cardiac damage across the clinical course of AS. Methods: A single-center retrospective cohort study was conducted, which included consecutive patients who ultimately underwent TAVR and had retrievable serial echocardiograms at moderate AS, first severe AS, and pre-TAVR symptomatic severe AS (2017–2021). A total of 179 patients were evaluated (mean age 82.7 [5.9] years at moderate AS; 46% male, p = 0.27). Cardiac damage was classified according to two established staging systems. Results: The median time from moderate to severe AS was 32 months (IQR 18–48). Most echocardiographic parameters deteriorated primarily at symptom onset, whereas moderate AS and first severe (asymptomatic) AS showed broadly similar profiles. However, left ventricular global longitudinal strain (LV GLS) was already impaired at the first severe stage, and right ventricular–arterial coupling (RVAc, TAPSE/sPAP) progressively worsened as AS advanced to the severe stage, independently of symptom status (LV GLS −18.1%, n = 163; −17.1%, n = 143; and −14.9%, n = 143; RVAc 1.0, n = 131; 0.8, n = 130; and 0.7, n = 130), respectively; overall p < 0.05. Both staging systems demonstrated increasing cardiac damage with AS progression. Conclusions: Cardiac damage may occur early in AS. The marked deterioration at symptom onset underscores the importance of systematic myocardial assessment and supports prospective studies to evaluate whether integrating LV GLS and RVAc as sensitive early markers of disease progression improves risk stratification.

Background/Objectives: In patients with severe aortic stenosis (AS), extra valvular cardiac damage is associated with outcomes following intervention. We aimed to analyze differences in AS-related cardiac damage between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) patients in a contemporary cohort of patients with severe AS. Methods: Patients who underwent SAVR or TAVR in a tertiary care center from 2017 to 2022 were included in this retrospective analysis. Clinical and echocardiographic parameters before surgery were compared, and patients were classified according to two available cardiac damage staging systems. Additionally, all-cause mortality 1-year post-intervention was assessed according to these stages. Results: Eight hundred and seventy-four patients were included (524 underwent TAVR and 350 underwent SAVR). TAVR patients were significantly older (81.9 ± 6.1 vs. 69.5 ± 9.5 years; p < 0.001), more commonly female (52.4% vs. 37.7%; p < 0.001), and had higher surgical risk (EuroSCORE II 6.2 ± 7.0 vs. 2.7 ±3.3; p < 0.001). Compared with SAVR, patients treated with TAVR had significantly more advanced (right-sided) cardiac damage, both with Généreux (37.8% vs. 23.1%; p < 0.001) and Gutiérrez-Ortiz (16.5% vs. 9.0%; p = 0.007) staging systems. Moreover, regardless of the type of intervention or the staging system used, mortality was significantly higher in patients with right-sided damage. Conclusions: In a contemporary cohort of severe symptomatic AS patients, those treated with TAVR had significantly more extensive cardiac damage compared with those who underwent SAVR. This finding raises the question of when to intervene in patients chosen for TAVR. Earlier intervention, before advanced cardiac damage ensues, might help to improve outcomes.

Background: Several cardiac damage staging systems for aortic stenosis (AS) have been proposed, but their usefulness in patients undergoing surgical aortic valve replacement (SAVR) remains unknown. Objectives: We aim to externally validate two staging systems in patients who underwent SAVR. Methods: Single-centre prospective cohort of patients treated with SAVR (2017–2022). Based on baseline echocardiographic parameters, patients were classified into the different stages of two published staging systems (Généreux et al. and Gutiérrez et al.), and the discriminatory yield of these systems for 1-year mortality was evaluated. Results: In total, 350 patients were analysed (mean age 69 (9.4) years, 37.8% were female). The median EuroSCORE II was 1.7 (1.1–3.1), and 1-year mortality occurred in 17 (4.8%) patients. The staging system developed by Gutiérrez et al. had an area under the ROC curve (AUC) of 0.687 (95% CI: 0.571–0.803) and was superior to Généreux et al.’s system (AUC of 0.554; 95% CI: 0.439–0.669; p = 0.008). Applying Gutiérrez et al.’s system, 1-year mortality rates progressively increased with higher damage staging: 1.9% (2/103) for Stage 0; 5.1% (5/175) for Stage 1; 12.5% (5/40) for Stage 2; and 15.6% (5/32) for Stage 3 (which represents right-sided damage measured by right ventricular–arterial coupling (RVAc); p= 0.038). No significant differences in outcomes between stages were found when using the staging proposed by Généreux et al. (p = 0.218). Conclusions: In a surgical cohort of patients with AS, a cardiac staging system that included RVAc showed greater discriminatory power for 1-year mortality. Assessing the interrelation between right ventricular function and afterload could help in better risk stratification in this context.