Background: Transcatheter mitral valve repair (TMVR) is an effective therapy for high-risk patients with severe mitral regurgitation (MR) but heart failure (HF) readmissions and death remain substantial on mid-term follow-up. Recently, right ventricular (RV) to pulmonary arterial (PA) coupling has emerged as a relevant prognostic predictor in HF. In this study, we aimed to assess the prognostic value of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP) ratio as a non-invasive measure of RV-to-PA coupling in patients undergoing TMVR with MitraClip (Abbott, CA, USA). Methods: Multicentre registry including 228 consecutive patients that underwent successful TMVR with MitraClip. The sample was divided in two groups according to TAPSE/PASP median value: 0.35. The primary combined endpoint encompassed HF readmissions and all-cause mortality. Results: Mean age was 72.5 ± 11.5 years and 154 (67.5%) patients were male. HF readmissions and all-cause mortality were more frequent in patients with TAPSE/PASP ≤ 0.35: Log-Rank 8.844, p = 0.003. On Cox regression, TAPSE/PASP emerged as a prognostic predictor of the primary combined endpoint, together with STS-Score. TAPSE/PASP was a better prognostic predictor than either TAPSE or PASP separately. Conclusions: TAPSE/PASP ratio appears as a novel prognostic predictor in patients undergoing MitraClip implantation that might improve risk stratification and candidate selection.

To evaluate the interobserver reliability of echocardiographic findings of right ventricle (RV) dysfunction for prognosticating normotensive patients with pulmonary embolism (PE). A central panel of cardiologists evaluated echocardiographic studies of 75 patients included in the PROTECT study for the following signs: RV diameter, RV/left ventricular (LV) diameter ratio, hypokinesis of the RV free wall, and tricuspid plane systolic excursion (TAPSE). Investigators used intraclass correlation to assess agreement between the measurements of the central panel and each of the local cardiologists. Investigators used the single weighted kappa statistic to test for agreement between readers of interpretation of RV enlargement and RV hypokinesis. The two observers had fair agreement (k = 0.45) for RV enlargement assessed by the RV diameter, and good agreement (k = 0.65) for RV enlargement assessed by the RV/LV diameter ratio. The interobserver reliability of the assessment whether hypokinesis of the RV free wall is present was good (к = 0.70), and whether RV dysfunction (assessed by TAPSE measurement) is present was very good (k = 0.86). The intraclass correlation for the RV/LV diameter ratio was fair (0.55; 95% confidence interval [CI], 0.37-0.69), for the RV diameter was good (0.70; 95% CI, 0.56-0.80), and for the TAPSE measurement was very good (0.85; 95% CI, 0.77-0.90). On Bland-Altman analysis, the mean differences for RV diameter, RV/LV diameter ratio and TAPSE measurement were 2.33 (±5.38), 0.06 (±0.23) and 0.08 (±2.20), respectively. TAPSE measurement is the least user dependent and most reproducible echocardiographic finding of RV dysfunction in normotensive patients with PE.

Left ventricle trabeculae (LVT) are frequently seen in different cardiac diseases. Normal reference values of LVT in different cardiac conditions are not known. The aim of the study was to quantify with cardiac magnetic resonance (CMR), LVT mass (LVTM) and LVTM percentage (LVTM%) in different heart diseases and to evaluate their influence on left ventricular morphological and functional parameters. Fifty-nine patients (14 controls, 17 ischemic cardiomyopathy, 15 nonischemic dilated cardiomyopathy, 7 valvular heart disease and 6 with left ventricle hypertrophy) were enrolled. Cine-MR images were acquired with steady-state free-precession sequence in a short-axis view. LVTM was calculated as the difference between LVM excluding/including trabecuale from the blood cavity. LVTM% was calculated as the percentage of the whole left ventricle mass excluding trabeculae from the blood cavity. Mean age was 47.60 +/- 22.03 years; male 62.7%. Mean LVTM was of 33.38 +/- 16.1 g with mean LVTM% of 19.22 +/- 6.5%. Significant differences between groups for both parameters with P values of 0.02 were obtained. Nonischemic dilated cardiomyopathy showed the highest degree of LVTM (44.73 +/- 16.0 g) and LVTM% (23.26 +/- 6%). Significant differences were noted in left ventricular morphological and functional parameters with inclusion/exclusion of LVT in the myocardial mass. Reference values and differences of LVTM and LVTM% in various cardiac conditions are given for the first time. Quantification of these parameters with CMR may be clinically useful in the differential diagnosis between left ventricular noncompaction and other cardiac diseases. Exclusion of LVT from myocardium alters left ventricular morphological and functional parameters, which have significant clinical importance.

Background: The search for reliable cardiac functional parameters is crucial in patients with mitral regurgitation (MR). In the Italian arm of the European Registry of MR, we compared the ability of global longitudinal strain (GLS) and left ventricular (LV) ejection fraction (LVEF) to detect cardiac damage in MR. Methods: Five hundred four consecutive patients with MR underwent a complete echo-Doppler exam. A total of 431, 53 and 20 patients had degenerative, secondary and mixed MR, respectively. The main echocardiographic parameters, including LV and left atrial (LA) size measurements, pulmonary artery systolic pressure (PASP) and GLS were compared between patients with mild MR (n = 392) vs. moderate to severe MR (n = 112). Results: LVEF and GLS were related one another in the pooled population, and separately in patients with mild and moderate/severe MR (all p < 0.0001). However, a certain number of patients were above the upper or below the lower limits of the 95% confidence interval (CI) of the normal relation in the pooled population and in patients with mild MR. Only 2 patients were below the 95% CI in moderate to severe MR. After adjusting for confounders by separate multivariate models, LVEF and GLS were independently associated with LV and left atrial size in the pooled population and in mild and moderate/severe MR. GLS, but not LVEF, was also independently associated with PASP in patients with mild and moderate to severe MR. Conclusions: Both LVEF and GLS are independently associated with LV and LA size, but only GLS is related to pulmonary arterial pressure. GLS is a powerful hallmark of cardiac damage in MR.

Prosthesis deterioration rate, years after a previous surgical valve replacement, is rising. Usually, the standard management is reoperation, but for very high risk patients an alternative has arisen: the valve-in-valve approach. We present an 84-year-old Caucasian woman with a mitral bioprosthesis (Mosaic II, number 29) since 1994. Over the last few months the patient displayed worsening heart failure symptoms, until her current admission in NYHA III–IV functional class, because of a severely degenerated mitral prosthesis (severe regurgitation, severe pulmonary hypertension). The transapical access, conventionally used for transcatheter aortic valve implantation (Edwards SAPIEN THV 23) was chosen, guided by transoesophageal echocardiography (TOE) with a new three-dimensional (3D) probe. After the procedure, the mitral regurgitation completely disappeared, an appropriate valve opening was achieved (valve area >2 cm2) and the patient was discharged 6 days later, remaining well in the outpatient follow-up. Only a restricted number of patients have been submitted to mitral transcatheter valve-in-valve implantation and to the best of our knowledge this is the first accurate description of the 3D TOE part, focusing on the surgeon requirements.