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Correspondence to Dr Francisco Gual-Capllonch, Cardiology, Son Espases University Hospital, Palma, 07120, Spain; fgualc@gmail.com Lemarchand et al1 address an everyday question in the echocardiography laboratories about the reliability of systolic pulmonary artery pressure (sPAP) estimation in cases of severe tricuspid regurgitation (TR). Fourth, an inverse relationship between the tricuspid orifice and the peak flow velocity of TR-V has been described, with the lowest velocities in cases of valvectomy.6 Although increased RA pressures may contribute to this finding, it also suggests that velocity may depend on geometrical factors.7 To assess whether these factors actually alter the non-invasive sPAP measurement or it is only affected by RA pressure underestimation, invasive RA pressure plus non-invasive RV–RA gradient should have been compared with invasive sPAP. For the time being, however, we consider that sPAP cannot be estimated in cases of TR-V with low velocity and triangular shape on continuous Doppler and a laminar flow on pulsed Doppler.6 Finally, we completely agree with the authors in the role of ‘V-wave cut-off’ sign for the classification of TR, which is less subject to interobserver variability and prognostically relevant.1 In our opinion, this sign should be incorporated to distinguish between severe TR and TR-V.8 Ethics statements Patient consent for publication Not required.

Background Prosthetic valve dysfunction due to entrapment of the subvalvular apparatus is a rare condition, particularly when occurring as a delayed postoperative complication. Spontaneous papillary muscle rupture in the absence of an ischemic event is also uncommon. The simultaneous presence of both conditions renders this case of intermittent symptomatic mitral regurgitation exceptional. Case presentation We present the case of a 72-year-old woman with a history of rheumatic heart disease and a mechanical mitral valve prosthesis. Although the initial postoperative course was uneventful, she developed rapidly progressive heart failure symptoms two years after surgery, secondary to newly onset severe mitral regurgitation. Transesophageal echocardiography was crucial in elucidating the underlying mechanism, revealing a ventricular mass intermittently interfering with the proper closure of the mechanical prosthesis. The main differential diagnoses regarding the origin of the mass included: remnants of the subvalvular apparatus, vegetation, thrombotic material and pannus formation. Given the clinical deterioration, surgical intervention was considered necessary despite the lack of precise knowledge regarding the nature of mass. Surgical exploration confirmed the rupture of the subvalvular apparatus involving the anterolateral papillary muscle as the underlying cause of the prosthetic dysfunction. Excision of the ruptured chordae tendineae and residual papillary muscle was performed with a favorable outcome and no complications. Conclusions This case illustrates a rare cause of late prosthetic mitral valve dysfunction: the entrapment of the subvalvular apparatus due to spontaneous rupture of the papillary muscle. Transesophageal echocardiography proved highly valuable in understanding the mechanism of dysfunction; however, surgical exploration ultimately established the definitive diagnosis and facilitated the correction of the issue.

Background Despite its proven prognostic value in different contexts, the precise implications of left atrial strain (LAS) assessment throughout different phases of the atrial cycle remain uncertain. A direct correlation between left atrial reservoir strain (LARS) and left ventricular global longitudinal strain (GLS) has been consistently demonstrated in several studies involving patients with various heart diseases. The objective of our study is to identify factors directly associated with LARS, left atrial conduction strain (LACS) and left atrial booster strain (LABS) in patients without cardiovascular (CV) disease. Methods Transthoracic echocardiographic examinations in patients without CV disease were prospectively selected in two tertiary hospitals echocardiography labs for clinical purposes. LAS, maximal and minimal left atrial (LA) volumes and left atrial ejection fraction (LAEF) were measured using the two-dimensional strain analysis package provided by the EchoPAC Plugging workstation (AFI LA). Results A total of 196 cases were included, median age of 54 (45–62) with 85 (43%) being men. The mean left ventricular ejection fraction (LVEF) was 61% ± 5, and the median GLS was − 18% (-17 to -20). Median indexed maximum volume of left atrium (LAVI) was 27 ml/m 2 (22–31), and LAEF was 64% (58–70). The mean LARS biplane was 35,1% ± 8. Notably, LARS was greater in the 2-chamber view (36,1% ± 10) compared to the 4-chamber view (34,1% ± 8 p  < 0,05). The multivariate analysis of LARS revealed that sex, GLS, LAEF and e’ mean are independently correlated with LARS. Multivariate analysis of LACS showed independent correlations between LACS and age, GLS, LAEF, E/A ratio and e’ mean . Conversely, the multivariate analysis of LABS demonstrated significant correlations among A wave, e’ mean , and left atrial stiffness index (LASI). Conclusions In patients without CV disease, GLS emerges as a crucial determinant of LARS and LACS. LAEF and e’ mean are directly and independently related to both LARS and LACS. LARS (univariate) and LACS (multivariate) exhibited a decline with older age in individuals without CV disease.

Although pulmonary embolism (PE) is a frequent complication in COVID-19, its consequences remain unknown. We performed pulmonary function tests, echocardiography and computed tomography pulmonary angiography and identified blood biomarkers in a cohort of consecutive hospitalized COVID-19 patients with pneumonia to describe and compare medium-term outcomes according to the presence of PE, as well as to explore their potential predictors. A total of 141 patients (56 with PE) were followed up during a median of 6 months. Post-COVID-19 radiological lung abnormalities (PCRLA) and impaired diffusing capacity for carbon monoxide (DLCOc) were found in 55.2% and 67.6% cases, respectively. A total of 7.3% had PE, and 6.7% presented an intermediate–high probability of pulmonary hypertension. No significant difference was found between PE and non-PE patients. Univariate analysis showed that age > 65, some clinical severity factors, surfactant protein-D, baseline C-reactive protein, and both peak red cell distribution width and Interleukin (IL)-10 were associated with DLCOc < 80%. A score for PCRLA prediction including age > 65, minimum lymphocyte count, and IL-1β concentration on admission was constructed with excellent overall performance. In conclusion, reduced DLCOc and PCRLA were common in COVID-19 patients after hospital discharge, but PE did not increase the risk. A PCRLA predictive score was developed, which needs further validation.

Introduction Sacubitril/valsartan (S–V) has been shown to reduce clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This benefit has been mostly attributed to an improvement in systolic function. Aim This study aimed to evaluate longitudinal changes in several echocardiographic parameters of diastolic function in a cohort of patients with HFrEF receiving S–V. Methods Echocardiographic parameters of consecutive patients receiving S–V, such as diastolic dysfunction (DD) grade and other individual diastolic and systolic function parameters, were prospectively collected at baseline and at 6-month follow-up. New York Heart Association (NYHA) functional class was also recorded. Results 65 patients (73.9% males; 61.5 ± 13 years) with HFrEF in NYHA class II–IV were evaluated. There was a significant reduction in DD grade after treatment with maximal tolerated doses ( p  < 0.001). Patients with advanced DD showed the most significant improvements: 75% and 60% of patients with initial grade 3 and 2, respectively, had better grade after 6 months of S–V. Moreover, there was a reduction in E/e′ ratio ( p  = 0.004), left atrial longitudinal strain ( p  = 0.002), and an improvement of left ventricle ejection fraction ( p  < 0.001) and NYHA functional class ( p  = 0.001). Among those subjects who improved their functional class, a higher percentage improved their DD grade (39.3%, p  = 0.025) in comparison with those not improving their NYHA class (25%, p  = 0.434). Conclusions In addition to an improvement in systolic function parameters, patients with HFrEF receiving S–V improved their diastolic function. This echocardiographic improvement is particularly relevant in those patients with better NYHA class at 6-month follow-up.

Hepatitis A is an acute disease of the liver caused by the hepatitis A virus (HAV). Chronic liver disease, other viral hepatitis coinfections, and age over 50 years are the main host factors associated with an increased risk of complications. We investigated the evolution of hepatitis A hospitalizations and in-hospital deaths during 2000-2021 in Spain according to demographic characteristics, presence of other sexually transmitted infections, and vaccination strategy (universal or risk-group vaccination). Using data from the Spanish National Health System's Minimum Basic Data Set, we calculated age-standardized cumulative hospitalization incidence and 95% confidence interval (CI), factors associated with hospital stay, and hospitalization deaths. Adjusted OR (aOR) values were calculated using a multivariate logistic regression model. The Spanish cumulative hospitalization incidence for hepatitis A over the 22-year period was 8.84 per 1 000 000 globally and 12.54 and 5.26 per 1 000 000 for men and women, respectively (RR = 2.38; 95% CI: 2.28-2.50). Median length of stay was 4 days (range 0-85). Factors associated with hospitalization >7 days were age groups 40-59 and ≥60 years (aOR 1.58; 95% CI: 1.37-1.82 and aOR 5.09; 95% CI: 4.01-6.47, respectively), cirrhosis (aOR 6.11; 95% CI: 2.59-14.43), and presence of HIV and HBV (aOR 1.65; 95% CI: 1.15-2.38 and 2.01; 95% CI: 1.03-3.63, respectively). In-hospital deaths were associated with age ≥ 60 years (aOR 35.23; 95% CI: 11.12-111.58), hospitalization >7 days (aOR 4.37; 95% CI: 1.80-10.58), cirrhosis (aOR 8.84; 95% CI: 2.37-32.99), and HCV infection (aOR 8.66; 95% CI: 1.57-47.87). The cumulative hospitalization incidence was lower in regions implementing universal vaccination (RR 0.79; 95% CI: 0.75-0.84). Results of studies based on characteristics of hospitalized hepatitis A cases taking into account the existing prevention policies can be useful to have a better knowledge about its evolving epidemiology and to improve the prevention and control of the disease.

Liver cirrhosis is a major cause of death worldwide. Cirrhosis develops after a long asymptomatic period of fibrosis progression, with the diagnosis frequently occurring late, when major complications or cancer develop. Few reliable tools exist for timely identification of individuals at risk of cirrhosis to allow for early intervention. We aimed to develop a novel score to identify individuals at risk for future liver-related outcomes. We derived the LiverRisk score from an international prospective cohort of individuals from six countries without known liver disease from the general population, who underwent liver fibrosis assessment by transient elastography. The score included age, sex, and six standard laboratory variables. We created four groups: minimal risk, low risk, medium risk, and high risk according to selected cutoff values of the LiverRisk score (6, 10, and 15). The model's discriminatory accuracy and calibration were externally validated in two prospective cohorts from the general population. Moreover, we ascertained the prognostic value of the score in the prediction of liver-related outcomes in participants without known liver disease with median follow-up of 12 years (UK Biobank cohort). We included 14 726 participants: 6357 (43·2%) in the derivation cohort, 4370 (29·7%) in the first external validation cohort, and 3999 (27·2%) in the second external validation cohort. The score accurately predicted liver stiffness in the development and external validation cohorts, and was superior to conventional serum biomarkers of fibrosis, as measured by area under the receiver-operating characteristics curve (AUC; 0·83 [95% CI [0·78–0·89]) versus the fibrosis-4 index (FIB-4; 0·68 [0·61–0·75] at 10 kPa). The score was effective in identifying individuals at risk of liver-related mortality, liver-related hospitalisation, and liver cancer, thereby allowing stratification to different risk groups for liver-related outcomes. The hazard ratio for liver-related mortality in the high-risk group was 471 (95% CI 347–641) compared with the minimal risk group, and the overall AUC of the score in predicting 10-year liver-related mortality was 0·90 (0·88–0·91) versus 0.84 (0·82–0·86) for FIB-4. The LiverRisk score, based on simple parameters, predicted liver fibrosis and future development of liver-related outcomes in the general population. The score might allow for stratification of individuals according to liver risk and thus guide preventive care. European Commission under the H20/20 programme; Fondo de Investigación Sanitaria de Salud; Instituto de Salud Carlos III; Spanish Ministry of Economy, Industry, and Competitiveness; the European Regional Development Fund; and the German Ministry of Education and Research (BMBF).

Background: The main consequences of chronic hepatitis B virus (HBV) infections are cirrhosis and hepatocellular carcinoma (HCC), both associated with frequent hospitalization. The aim of this study was to analyze the impact of universal HBV vaccination in Spain on chronic HBV-related hospital discharges from 2005 to 2021. Methods: Using data from the Minimum Basic Data Set of the Spanish National Health System, we calculated the hospital discharge rate ratio (HDRR) and 95% confidence interval (CI) values for chronic HBV-related discharges between 2005 and 2021. For comparative purposes, we calculated the HDRR and 95% confidence interval (CI) values for the early (2005–2013) and later (2014–2021) periods and the vaccinated compared with unvaccinated cohorts for the 20–39 age group. Results: The hospital discharge rate per 1,000,000 people was 3.08 in 2005 and 4.50 in 2021 for HCC, and 4.81 in 2005 and 1.92 in 2021 for cirrhosis. Comparing the early and later periods, values were higher for HCC (HDRR 1.13; 95% CI: 1.06–1.20) and lower for cirrhosis (HDRR 0.56; 95% CI: 0.51–0.60). The rate for the 20–39 age group was lower for the vaccinated compared with the unvaccinated cohorts overall (HDRR 0.53; 95% CI: 0.45–0.62), for HCC (HDRR 0.66; 95% CI: 0.53–0.82), and for cirrhosis (HDRR 0.41; 95% CI: 0.33–0.53). Conclusions: This study describes the important impact, after 25 years, of universal HBV vaccination in Spain: cirrhosis hospital discharge rate was reduced, and the vaccinated cohorts, compared with the unvaccinated cohorts in the 20–39 age group, had a lower hospital discharge rate of both HCC and cirrhosis.