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ObjectivesThis study was conducted in order to evaluate the accuracy of a compressed sensing (CS) real-time single-breath-hold cine sequence for the assessment of left and right ventricular functional parameters in daily practice.MethodsCardiac magnetic resonance (CMR) cine images were acquired from 100 consecutive patients using both the reference segmented multi-breath-hold steady-state free precession (SSFP) acquisition and a prototype single-breath-hold real-time CS sequence, providing the same slice number, position, and thickness. For both sequences, the left (LV) and right ventricular (RV) ejection fractions (EF) and end-diastolic volumes (EDV) were assessed as well as LV mass (LVM). The visualization of wall-motion disorders (WMD) and signal void related to mitral or tricuspid regurgitation was also analyzed.ResultsThe CS sequence mean scan time was 23 ± 6 versus 510 ± 109 s for the multi-breath-hold SSFP sequence (p < 0.001). There was an excellent correlation between the two sequences regarding mean LVEF (r = 0.995), LVEDV (r = 0.997), LVM (r = 0.981), RVEF (r = 0.979), and RVEDV (r = 0.983). Moreover, inter- and intraobserver agreements were very strong with intraclass correlations of 0.96 and 0.99, respectively. On CS images, mitral or tricuspid regurgitation visualization was good (AUC = 0.85 and 0.81, respectively; ROC curve analysis) and wall-motion disorder visualization was excellent (AUC ≥ 0.97).ConclusionCS real-time single-breath-hold cine imaging reduces CMR scan duration by almost 20 times in daily practice while providing reliable measurements of both left and right ventricles. There was no clinically relevant information loss regarding valve regurgitation and wall-motion disorder depiction.Key Points• Compressed sensing single-breath-hold real-time cine imaging is a reliable sequence in daily practice.• Fast CS real-time imaging reduces CMR scan time and improves patient workflow.• There is no clinically relevant information loss with CS regarding heart valve regurgitation or wall-motion disorders.

Abstract Background and Aims Although the classification of secondary tricuspid regurgitation (STR) by atrial or ventricular aetiology (A-STR or V-STR) carries prognostic importance, the confounding effects of New York Heart Association (NYHA) class have not yet been elucidated. We aimed to correlate STR and NYHA classification with patient outcomes. Methods We studied 281 patients with severe STR who presented to 16 French hospitals between 2017 and 2019. Patients were separated into A-STR and V-STR categories using echocardiographic criteria (A-STR = tricuspid tenting height ≤10 mm, right mid-ventricular diameter ≤38 mm, and LVEF ≥ 50%). We tracked time to cardiovascular disease-related hospitalization or death, whichever came first. Results Of the patients 91/281 (32.7%) had A-STR, 164/281 (58.4%) had mixed/V-STR, and 25/281 (8.9%) could not be classified. Baseline age, labs, comorbidities and NYHA category (Class I–II = mildly symptomatic, Class III–IV = very symptomatic) did not differ between groups (P > 0.05). Although there were no differences in event-free survival among groups (70.7% vs. 65.9%, P = 0.59), this was confounded by NYHA class (P = 0.0104). Thus, among mildly symptomatic patients, estimated 5 year event-free survival was 76.4% in the A-STR group and 53.2% in the mixed/V-STR group (P < 0.05). Among very symptomatic patients, there was no difference in estimated event-free survival (39.4% vs. 17.2%, P > 0.05). Conclusions Though A-STR carries a more favourable prognosis in mildly symptomatic patients, this distinction is irrelevant in patients with advanced disease. Thus, the value of tricuspid valve intervention may become ‘too little, too late’ if A-STR is not promptly addressed. Atrial TR as more favourable prognosis except in advanced patients.

Abstract Aims In the Tri.FR trial, tricuspid transcatheter edge-to-edge repair (T-TEER) reduced severity of tricuspid regurgitation (TR) and improved the composite clinical score, driven by patient-reported outcomes. The purpose of this study was to describe the longitudinal impact of T-TEER on different dimensions and items of quality of life compared with guideline-directed medical treatment (OMT) alone. Methods and results Patients were randomized to T-TEER +OMT (n = 152) or OMT alone (n = 148). Health status was assessed at baseline, 6 weeks, 6 months, and 1 year using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Minnesota Living with Heart Failure (MLHF) Questionnaire. Mixed effects linear regression analysed changes over time. Patients receiving T-TEER + OMT experienced a significant increase in KCCQ overall summary score (KCCQ-OS) at all time points: +17.0 points (95% confidence interval [CI] 13.1–21.5) at 6 weeks, +15.9 points (95% CI 11.2–20.6) at 6 months, and +18.7 points (95% CI 13.8–23.6) at 1 year. The mean between-group difference in KCCQ-OS was +10.3 points (95% CI 5.6–15.0) in favour of T-TEER + OMT, evident at 6 weeks and sustained for 1 year. Similarly, MLHF total scores improved significantly in the T-TEER group (mean between-group difference −8.61 points, 95% CI –12.6 to −4.6), including physical (−3.9, 95% CI –5.9 to −1.9) and emotional (−2.2, 95% CI –3.4 to −1.0) subscales. Conclusions Compared with OMT alone, T-TEER resulted in substantial, multidimensional, and sustained improvements in patient-reported quality of life. These findings reinforce the value of T-TEER in managing severe symptomatic TR. This study is one of the first randomised trials to demonstrate that transcatheter tricuspid valve repair (T-TEER) yields substantial and sustained improvements in quality of life across multiple domains, beyond clinical and echocardiographic outcomes. Using both the Kansas City Cardiomyopathy Questionnaire and the Minnesota Living with Heart Failure questionnaire, the Tri.FR trial robustly quantifies patient-perceived benefits-particularly in physical and emotional well-being-following T-TEER. The findings position T-TEER as a pivotal, patient-centred strategy for managing severe symptomatic tricuspid regurgitation, especially in elderly, high-risk patients with heart failure with preserved ejection fraction.

The impact of transcatheter aortic valve replacement (TAVR) leaflet design on long-term device performance is still unknown. This study sought to compare the clinical and hemodynamic outcomes of intra- (IA) versus supra-annular (SA) TAVR designs up-to 10-years following implantation. Consecutive patients with at least 5-years follow-up following TAVR for severe symptomatic aortic stenosis from June 2007 to December 2016 were included. Bioprosthetic valve failure (BVF) and hemodynamic valve deterioration (HVD) were defined according to VARC-3 updated definitions and estimated using cumulative incidence function to account for the competing risk of death. A total of 604 patients (82 years; 53% female) were analyzed and divided into IA (482) and SA (122) groups. Overall survival rates at 10-years were similar (IA 15%, 95%CI: 10-22; SA 11%, 95%CI: 6-20; = 0.21). Compared to the SA TAVR, mean transaortic gradients were significantly higher and increased over time in the IA group. IA TAVRs showed higher 10-year cumulative incidences of BVF (IA 8% vs. SA 1%, = 0.02) and severe HVD (IA 5% vs. SA 1%, = 0.05). The occurrence of BVF and HVD in the IA group occurred primarily in the smallest TAVR devices (20-23-mm). After excluding these sizes, the cumulative incidences of BVF (IA 5% vs. SA 1%, = 0.40) and severe HVD (IA 2% vs. SA 1%, = 0.11) were similar. In this study, TAVR leaflet design had no impact on survival at 10-years. IA devices showed higher transaortic gradients and cumulative incidences of HVD and BVF predominantly occurring in the smallest valve sizes.

Although staging of the extent of aortic stenosis (AS)-related cardiac damages is usually performed via echocardiography, this technique has considerable limitations in assessing pulmonary artery and right chamber pressures. The present hypothesis-generating study sought to explore the efficacy of a staging system of cardiac damage based on echocardiographic and invasive [right heart catheterization (RHC)] hemodynamic parameters in patients undergoing transcatheter aortic valve implantation (TAVI). We studied 90 symptomatic patients with severe AS in whom echocardiographic and invasive evaluation by RHC was obtained prior to TAVI. Cardiac damage stages were defined as follows: no cardiac damage (stage 0), left ventricular (LV) damage (stage 1), left atrial or mitral valve damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), and right ventricular (RV) dysfunction or low-flow state (stage 4). With the integrative approach using RHC, pulmonary hypertension (PH) was defined as an mPAP ≥25 mmHg and the low-flow state corresponded to a cardiac index of <1.8 L/min/m and a right atrial pressure of >10 mmHg. During follow-up (median: 2.9 years), 43 patients (47.8%) died. The integrative cardiac damage staging was associated with a significant increase in all-cause and cardiovascular mortality per each increase of cardiac damage stage, whereas the outcome was similar according to the echocardiographic staging. A staging system of cardiac lesion based on echocardiographic and invasive hemodynamic parameters in patients with severe AS undergoing TAVI predicts mortality. Patients with pre-existing PH, ≥ moderate tricuspid regurgitation and/or RV dysfunction, and a low-flow state had a markedly increased risk of death. Further larger studies are needed to validate our findings.

Various definitions of very severe (VS) tricuspid regurgitation (TR) have been proposed based on the effective regurgitant orifice area (EROA) or tricuspid coaptation gap (TCG). Because of the inherent limitations associated with the EROA, we hypothesized that the TCG would be more suitable for defining VSTR and predicting outcomes. In this French multicentre retrospective study, we included 606 patients with ≥moderate-to-severe isolated functional TR (without structural valve disease or an overt cardiac cause) according to the recommendations of the European Association of Cardiovascular Imaging. Patients were further stratified into VSTR according to the EROA (≥60 mm ) and then according to the TCG (≥10 mm). The primary endpoint was all-cause mortality and the secondary endpoint was cardiovascular mortality. The relationship between the EROA and TCG was poor ( = 0.22), especially when the size of the defect was large. Four-year survival was comparable between patients with an EROA <60 mm vs. ≥60 mm (68 ± 3% vs. 64 ± 5%,  = 0.89). A TCG ≥10 mm was associated with lower four-year survival than a TCG <10 mm (53 ± 7% vs. 69 ± 3%,  < 0.001). After adjustment for covariates, including comorbidity, symptoms, dose of diuretics, and right ventricular dilatation and dysfunction, a TCG ≥10 mm remained independently associated with higher all-cause mortality (adjusted HR[95% CI] = 1.47[1.13-2.21],  = 0.019) and cardiovascular mortality (adjusted HR[95% CI] = 2.12[1.33-3.25],  = 0.001), whereas an EROA ≥60 mm was not associated with all-cause or cardiovascular mortality (adjusted HR[95% CI]: 1.16[0.81-1.64],  = 0.416, and adjusted HR[95% CI]: 1.07[0.68-1.68],  = 0.784, respectively). The correlation between the TCG and EROA is weak and decreases with increasing defect size. A TCG ≥10 mm is associated with increased all-cause and cardiovascular mortality and should be used to define VSTR in isolated significant functional TR.

On-pump cardiac surgery provokes a predictable perioperative myocardial ischaemia–reperfusion injury which is associated with poor clinical outcomes. We determined the occurrence of time-of-the-day variation in perioperative myocardial injury in patients undergoing aortic valve replacement and its molecular mechanisms. We studied the incidence of major adverse cardiac events in a prospective observational single-centre cohort study of patients with severe aortic stenosis and preserved left ventricular ejection fraction (>50%) who were referred to our cardiovascular surgery department at Lille University Hospital (Lille, France) for aortic valve replacement and underwent surgery in the morning or afternoon. Patients were matched into pairs by propensity score. We also did a randomised study, in which we evaluated perioperative myocardial injury and myocardial samples of patients randomly assigned (1:1) via permuted block randomisation (block size of eight) to undergo isolated aortic valve replacement surgery either in the morning or afternoon. We also evaluated human and rodent myocardium in ex-vivo hypoxia–reoxygenation models and did a transcriptomic analysis in myocardial samples from the randomised patients to identify the signalling pathway(s) involved. The primary objective of the study was to assess whether myocardial tolerance of ischaemia–reperfusion differed depending on the timing of aortic valve replacement surgery (morning vs afternoon), as measured by the occurrence of major adverse cardiovascular events (cardiovascular death, myocardial infarction, and admission to hospital for acute heart failure). The randomised study is registered with ClinicalTrials.gov, number NCT02812901. In the cohort study (n=596 patients in matched pairs who underwent either morning surgery [n=298] or afternoon surgery [n=298]), during the 500 days following aortic valve replacement, the incidence of major adverse cardiac events was lower in the afternoon surgery group than in the morning group: hazard ratio 0·50 (95% CI 0·32–0·77; p=0·0021). In the randomised study, 88 patients were randomly assigned to undergo surgery in the morning (n=44) or afternoon (n=44); perioperative myocardial injury assessed with the geometric mean of perioperative cardiac troponin T release was significantly lower in the afternoon group than in the morning group (estimated ratio of geometric means for afternoon to morning of 0·79 [95% CI 0·68–0·93; p=0·0045]). Ex-vivo analysis of human myocardium revealed an intrinsic morning–afternoon variation in hypoxia–reoxygenation tolerance, concomitant with transcriptional alterations in circadian gene expression with the nuclear receptor Rev-Erbα being highest in the morning. In a mouse Langendorff model of hypoxia–reoxygenation myocardial injury, Rev-Erbα gene deletion or antagonist treatment reduced injury at the time of sleep-to-wake transition, through an increase in the expression of the ischaemia–reperfusion injury modulator CDKN1a/p21. Perioperative myocardial injury is transcriptionally orchestrated by the circadian clock in patients undergoing aortic valve replacement, and Rev-Erbα antagonism seems to be a pharmacological strategy for cardioprotection. Afternoon surgery might provide perioperative myocardial protection and lead to improved patient outcomes compared with morning surgery. Fondation de France, Fédération Française de Cardiologie, EU-FP7-Eurhythdia, Agence Nationale pour la Recherche ANR-10-LABX-46, and CPER-Centre Transdisciplinaire de Recherche sur la Longévité.

Background Left ventricular end‐systolic diameter (LVESD) and ejection fraction (LVEF) are the parameters to look for when discussing repair in asymptomatic patients with a primary mitral regurgitation (PMR). Loading conditions are altering LV‐function quantification. LV‐myocardial work (LVMW) is a method based on pressure‐strain loops. Hypothesis We sought to evaluate the additive value of the LVMW for predicting clinical events in patients with PMR. Methods 103 patients (66% men, median age 57 years) with asymptomatic severe PMR were explored at rest and during an exercise stress echocardiography. LV myocardial global work index (GWI), constructive work (GCW), wasted work (GWW), and work efficiency (GWE) were measured with speckle‐tracking echocardiography at rest and low workload. The indication for surgery was based on the heart teams' decision. The median follow‐up was 670 days. Results Clinical events occurred for 50 patients (48.5%) with a median of event‐free survival distribution of 289 days. Systolic pulmonary artery pressure (sPAP) at rest was 32.61 ± 8.56 mmHg and did not predict the risk of event like LVEF and LVESD. Changes in, GLS (hazard ratio [HR] 0.55; 95% confidence interval (Cl): 0.36–0.83; p = .005), GWI (HR 1.01; 95% Cl: 1.00–1.02; p = .002) and GCW (HR 1.85; 95% Cl: 1.28–2.68; p = .001) in addition to Left Atrial Volume Index (HR 1.73; 95% CI: 1.28 – 2.33; p < 0,001) were independent predictors of events. Conclusion Changes in myocardial work indices related to low‐dose exercise are relevant to best predict PMR patient prognosis It might help to better select patient's candidate for “early‐surgery.” Selecting asymptomatic patients with a primary mitral regurgitation that are at risk, remains a clinical issue. Echocardiography and the advances in the use of the speckle‐tracking tools could help The present work demonstrates that global longitudinal and its use for the calculation of myocardial work indices is a tool of interest. It is demonstrated here that myocardial work could be the best tool we have for assessing the consequences of the mitral regurgitation on the left ventricle.

ObjectiveTo evaluate whether the epicardial adipose tissue (EAT) phenotype is associated with the electrophysiological properties of adjacent atrial myocardium in patients with atrial fibrillation (AF).MethodsBetween January and May 2017, 30 consecutive patients referred for a first AF catheter ablation were prospectively included. For each patient, a pre-procedural computed tomography scan was performed to assess total and left atrial (LA) EAT amount and radiodensity. A detailed point-by-point voltage mapping using an electroanatomic mapping system was realized to assess the presence of LA low-voltage zone (LVZ).ResultsTen patients (33.3%) presented at least one LVZ. Older age (65 ± 7 vs. 58 ± 10 years, p = 0.05) was the only clinical parameter associated with LVZ. Despite no greater LA-EAT thickness by CT scan (3.0 [2.6–3.5] mm vs. 2.8 [2.2–3.1] mm, p = 0.354), patients with LA-LVZ presented significantly lower LA-EAT radiodensity than patients with no LA-LVZ (− 101.8 ± 12.5 HU vs. − 90.4 ± 6.3 HU, p = 0.004). No difference between total-EAT volume (131 ± 61 cm3 vs.107 ± 58 cm3, p = 0.361) and total-EAT radiodensity (− 106.8 ± 4.3 HU vs. − 102.4 ± 6.9 HU, p = 0.119) was found.ConclusionLow LA-EAT radiodensity is associated with the presence of LVZ in patients with medical history of AF.Key Points• Cardiovascular risk factors are associated with low adipose tissue computed tomography attenuation.• Epicardial adipose tissue (EAT) has emerged as an important factor in the pathogenesis of metabolic-related cardiac diseases such as atrial fibrillation.• We showed that low left atrial EAT attenuation is associated with the presence of low-voltage zone, a surrogate for atrial fibrosis, within the adjacent myocardium.

Severe aortic stenosis (AS) has been associated with bleeding. However, there is a lack of prospective assessment of bleeding events and their clinical significance in a large population of outpatients with variable degree of AS severity. To assess the incidence, source, determinants, and prognostic impact of major bleeding in patients with variable degree of AS severity. Between May 2016 and December 2017, consecutive outpatients were included. Major bleeding was defined as type ≥3 bleed using the Bleeding Academic Research Consortium definition. Cumulative incidence was calculated with death as the competing event. Data was censored at time of aortic valve replacement. Among 2,830 patients, 46 major bleeding events occurred (0.7%/year) during a median follow-up of 2.1 years (interquartile range: 1.4-2.7). Most frequent sites of bleeding were gastrointestinal (50%) and intracranial (30.4%). Major bleeding was significantly associated with all-cause mortality (hazard ratio: 5.93 (95% confidence interval 3.64-9.65); P < .001). AS severity was associated with major bleedings (P = .041). By multivariable analysis, severe AS was an independent determinant of major bleeding (hazard ratio vs mild AS: 3.59 [95% confidence interval 1.56-8.29]; P = .003). The increased risk of bleeding associated with severe AS was significantly exacerbated in patients using oral anticoagulation. In AS patients, major bleeding is rare but a strong independent predictor of death. AS severity is a determinant of bleeding events. Severe AS and oral anticoagulation should be identified as an association at very high risk of major bleeding. [Display omitted]