Left ventricular fibrosis and CMR tissue characterization of papillary muscles in mitral valve prolapse patients.

PURPOSE: Mitral valve prolapse (MVP) is associated with left ventricle (LV) fibrosis, including the papillary muscles (PM), which is in turn linked to malignant arrhythmias. This study aims to evaluate comprehensive tissue characterization of the PM by cardiovascular magnetic resonance (CMR) imaging and its association with LV fibrosis observed by intraoperative biopsies. METHODS: MVP patients with indication for surgery due to severe mitral regurgitation (n = 19) underwent a preoperative CMR with characterization of the PM: dark-appearance on cine, T1 mapping, conventional bright blood (BB) and dark blood (DB) late gadolinium enhancement (LGE). CMR T1 mapping was performed on 21 healthy volunteers as controls. LV inferobasal myocardial biopsies were obtained in MVP patients and compared to CMR findings. RESULTS: MVP patients (54 ± 10 years old, 14 male) had a dark-appearance of the PM with higher native T1 and extracellular volume (ECV) values compared with healthy volunteers (1096 ± 78ms vs. 994 ± 54ms and 33.9 ± 5.6% vs. 25.9 ± 3.1%, respectively, p < 0.001). Seventeen MVP patients (89.5%) had fibrosis by biopsy. BB-LGE + in LV and PM was identified in 5 (26.3%) patients, while DB-LGE + was observed in LV in 9 (47.4%) and in PM in 15 (78.9%) patients. DB-LGE + in PM was the only technique that showed no difference with detection of LV fibrosis by biopsy. Posteromedial PM was more frequently affected than the anterolateral (73.7% vs. 36.8%, p = 0.039) and correlated with biopsy-proven LV fibrosis (Rho 0.529, p = 0.029). CONCLUSIONS: CMR imaging in MVP patients referred for surgery shows a dark-appearance of the PM with higher T1 and ECV values compared with healthy volunteers. The presence of a positive DB-LGE at the posteromedial PM by CMR may serve as a better predictor of biopsy-proven LV inferobasal fibrosis than conventional CMR techniques.

Left Ventricular Fibrosis and CMR Tissue Characterization of Papillary Muscles in Mitral Valve Prolapse Patients.

Purpose: Mitral valve prolapse (MVP) is associated with left ventricle (LV) fibrosis, including the papillary muscles (PM), which is in turn linked to malignant arrhythmias. This study aims to evaluate comprehensive tissue characterization of the PM by cardiovascular magnetic resonance (CMR) imaging and its association with LV fibrosis observed by intraoperative biopsies. Methods: MVP patients with indication for surgery due to severe mitral regurgitation (n=19) underwent a preoperative CMR with characterization of the PM: dark-appearance on cine, T1 mapping, conventional bright blood (BB) and dark blood (DB) late gadolinium enhancement (LGE). CMR T1 mapping was performed on 21 healthy volunteers as controls. LV inferobasal myocardial biopsies were obtained in MVP patients and compared to CMR findings. Results: MVP patients (54±10 years old, 14 male) had a dark-appearance of the PM with higher native T1 and extracellular volume (ECV) values compared with healthy volunteers (1096±78ms vs 994±54ms and 33.9±5.6% vs 25.9±3.1%, respectively, p<0.001). Seventeen MVP patients (89.5%) had fibrosis by biopsy. BB-LGE+ in LV and PM was identified in 5 (26.3%) patients, while DB-LGE+ was observed in LV in 9 (47.4%) and in PM in 15 (78.9%) patients. DB-LGE+ in PM was the only technique that showed no difference with detection of LV fibrosis by biopsy. Posteromedial PM was more frequently affected than the anterolateral (73.7% vs 36.8%, p=0.039) and correlated with biopsy-proven LV fibrosis (Rho 0.529, p=0.029). Conclusions: CMR imaging in MVP patients referred for surgery shows a dark-appearance of the PM with higher T1 and ECV values compared with healthy volunteers. The presence of a positive DB-LGE at the posteromedial PM by CMR may serve as a better predictor of biopsy-proven LV inferobasal fibrosis than conventional CMR techniques.

Cardiovascular magnetic resonance pulmonary perfusion for functional assessment of pulmonary vein stenosis.

BACKGROUND: Cardiovascular magnetic resonance (CMR) imaging allows to combine pulmonary perfusion measurements and pulmonary venous angiography during a single-session examination with both imaging modules representing the basis for accurate diagnosis and therapeutic stratification of pulmonary vein (PV) stenosis. The present study investigated the clinical utility of dynamic pulmonary perfusion imaging integrated into a comprehensive CMR protocol for the evaluation of patients with suspected PV stenosis. METHODS: 162 patients with clinically suspected PV stenosis after catheter ablation of atrial fibrillation underwent a combined single-session CMR examination (cardiac cine imaging, dynamic pulmonary perfusion, and three-dimensional PV angiography). CMR angiography was used for visual grading of PV stenoses; dynamic pulmonary perfusion imaging was evaluated per lung lobe visually and quantitatively. RESULTS: All PV stenosis ≥90% showed a visible perfusion deficit of the corresponding lung lobe (60/60, 100%) while all PVs with luminal narrowing <50% exhibited normal pulmonary perfusion (680/680, 100%). However, every third 70-89% stenosis showed a normal pulmonary perfusion (10/31, 32%) while every fourth 50-69% PV stenosis was associated with hypoperfusion of the corresponding lung lobe (9/39, 23%). For quantitative pulmonary perfusion measurements, ROC analysis demonstrated high discriminatory power regarding PV stenosis detection with the highest AUC values for time-to-peak enhancement (cut-off value, 8.5 s). CONCLUSIONS: The combination of CMR angiography and CMR pulmonary perfusion allowed for assessment of the anatomical degree of PV stenosis and its hemodynamic impact on the pulmonary parenchymal level. Thus, the proposed comprehensive CMR protocol provided an efficient diagnostic work-up of patients with suspected PV stenosis.

Mitral Valve Prolapse Induces Regionalized Myocardial Fibrosis.

Background Mitral valve prolapse (MVP) is one of the most common forms of cardiac valve disease and affects 2% to 3% of the population. Previous imaging reports have indicated that myocardial fibrosis is common in MVP and described its association with sudden cardiac death. These data combined with evidence for postrepair ventricular dysfunction in surgical patients with MVP support a link between fibrosis and MVP. Methods and Results We performed histopathologic analysis of left ventricular (LV) biopsies from peripapillary regions, inferobasal LV wall and apex on surgical patients with MVP, as well as in a mouse model of human MVP (Dzip1S14R/+). Tension-dependent molecular pathways were subsequently assessed using both computational modeling and cyclical stretch of primary human cardiac fibroblasts in vitro. Histopathology of LV biopsies revealed regionalized fibrosis in the peripapillary myocardium that correlated with increased macrophages and myofibroblasts. The MVP mouse model exhibited similar regional increases in collagen deposition that progress over time. As observed in the patient biopsies, increased macrophages and myofibroblasts were observed in fibrotic areas within the murine heart. Computational modeling revealed tension-dependent profibrotic cellular and molecular responses consistent with fibrosis locations related to valve-induced stress. These simulations also identified mechanosensing primary cilia as involved in profibrotic pathways, which was validated in vitro and in human biopsies. Finally, in vitro stretching of primary human cardiac fibroblasts showed that stretch directly activates profibrotic pathways and increases extracellular matrix protein production. Conclusions The presence of prominent regional LV fibrosis in patients and mice with MVP supports a relationship between MVP and progressive damaging effects on LV structure before overt alterations in cardiac function. The regionalized molecular and cellular changes suggest a reactive response of the papillary and inferobasal myocardium to increased chordal tension from a prolapsing valve. These studies raise the question whether surgical intervention on patients with MVP should occur earlier than indicated by current guidelines to prevent advanced LV fibrosis and potentially reduce residual risk of LV dysfunction and sudden cardiac death.

Quantification of regurgitation in mitral valve prolapse with four-dimensional flow cardiovascular magnetic resonance.

BACKGROUND: Four-dimensional cardiovascular magnetic resonance (CMR) flow assessment (4D flow) allows to derive volumetric quantitative parameters in mitral regurgitation (MR) using retrospective valve tracking. However, prior studies have been conducted in functional MR or in patients with congenital heart disease, thus, data regarding the usefulness of 4D flow CMR in case of a valve pathology like mitral valve prolapse (MVP) are scarce. This study aimed to evaluate the clinical utility of cine-guided valve segmentation of 4D flow CMR in assessment of MR in MVP when compared to standardized routine CMR and transthoracic echocardiography (TTE). METHODS: Six healthy subjects and 54 patients (55 ± 16 years; 47 men) with MVP were studied. TTE severity grading used a multiparametric approach resulting in mild/mild-moderate (n = 12), moderate-severe (n = 12), and severe MR (n = 30). Regurgitant volume (RVol) and regurgitant fraction (RF) were also derived using standard volumetric CMR and 4D flow CMR datasets with direct measurement of regurgitant flow (4DFdirect) and indirect calculation using the formula: mitral valve forward flow - left ventricular outflow tract stroke volume (4DFindirect). RESULTS: There was moderate to strong correlation between methods (r = 0.59-0.84, p < 0.001), but TTE proximal isovelocity surface area (PISA) method showed higher RVol as compared with CMR techniques (PISA vs. CMR, mean difference of 15.8 ml [95% CI 9.9-21.6]; PISA vs. 4DFindirect, 17.2 ml [8.4-25.9]; PISA vs. 4DFdirect, 27.9 ml [19.1-36.8]; p < 0.001). Only indirect CMR methods (CMR vs. 4DFindirect) showed moderate to substantial agreement (Lin's coefficient 0.92-0.97) without significant bias (mean bias 1.05 ± 26 ml [- 50 to 52], p = 0.757). Intra- and inter-observer reliability were good to excellent for all methods (ICC 0.87-0.99), but with numerically lower coefficient of variation for indirect CMR methods (2.5 to 12%). CONCLUSIONS: In the assessment of patients with MR and MVP, cine-guided valve segmentation 4D flow CMR is feasible and comparable to standard CMR, but with lower RVol when TTE is used as reference. 4DFindirect quantification has higher intra- and inter-technique agreement than 4DFdirect quantification and might be used as an adjunctive technique for cross-checking MR quantification in MVP.

Quantification of regurgitation in mitral valve prolapse with automated real time echocardiographic 3D proximal isovelocity surface area: multimodality consistency and role of eccentricity index.

Three-dimensional transthoracic echocardiography (3D-TTE) provides a semi-automated proximal isovelocity surface area method (3D-PISA) to obtain quantitative parameters. Data assessing regurgitation severity in mitral valve prolapse (MVP) are scarce, so we assessed the 3D-PISA method compared with 2D-PISA and cardiovascular magnetic resonance (CMR) and the role of an eccentricity index. We evaluated the 3D-PISA method for assessing MR in 54 patients with MVP (57 ± 14 years; 42 men; 12 mild/mild-moderate; 12 moderate-severe; and 30 severe MR). Role of an asymmetric (i.e. eccentricity index ≥ 1.25) flow convergence region (FCR) and inter-modality consistency were then assessed. 3D-PISA derived regurgitant volume (RVol) showed a good correlation with 2D-PISA and CMR derived parameters (r = 0.86 and r = 0.81, respectively). The small mean differences with 2D-PISA derived RVol did not reach statistical significance in overall population (5.7 ± 23 ml, 95% CI - 0.6 to 12; p = 0.08) but differed in those with asymmetric 3D-FCR (n = 21; 2D-PISA: 72 ± 36 ml vs. 3D-PISA: 93 ± 47 ml; p = 0.001). RVol mean values were higher using PISA methods (CMR 57 ± 33 ml; 2D-PISA 73 ± 39 ml; and 3D-PISA 79 ± 45 ml) and an overestimation was observed when CMR was used as reference (2D-PISA vs. CMR: mean difference: 15.8 ml [95% CI 10-22, p < 0.001]; and 3D-PISA vs. CMR: 21.5 ml [95% CI 14-29, p < 0.001]). Intra- and inter-observer reliability was excellent (ICC 0.91-0.99), but with numerically lower coefficient of variation for 3D-PISA (8%-10% vs. 2D-PISA: 12%-16%). 3D-PISA method for assessing regurgitation in MVP may enable analogous evaluation compared to standard 2D-PISA, but with overestimation in case of asymmetric FCR or when CMR is used as reference method.

Grading of aortic regurgitation by cardiovascular magnetic resonance and pulsed Doppler of the left subclavian artery: harmonizing grading scales between imaging modalities.

Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) are current standard for assessing aortic regurgitation (AR). Regurgitant fraction (RF) can also be estimated by Doppler examination of the left subclavian artery (LSA-Doppler). However, a comparison of AR grading scales using these methods and a TTE multiparametric approach as reference is lacking. We evaluated the severity of AR in 73 patients (58 ± 15 years; 57 men), with a wide spectrum of AR of the native valve. Using a recommended TTE multiparametric approach the AR was divided in none/trace (n = 12), mild (n = 23), moderate (n = 12), and severe (n = 26). RF was evaluated by LSA-Doppler (ratio between diastolic and systolic velocity-time integrals) and by CMR phase-contrast imaging (performed in the aorta 1 cm above the aortic valve); the grading scales were then calculated. There were a good correlation between all methods, but mean RF values were greater with TTE compared with LSA-Doppler and CMR (39 ± 16% vs. 35 ± 18% vs. 32 ± 20%, respectively; p < 0.037). Mean differences in RF values between methods were significant in the groups with mild and moderate AR. Grading scales that best defined the TTE derived AR severity using CMR were: mild, < 21%; moderate, 22 to 41%; and severe, > 42%; and using LSA-Doppler: mild, < 29%; moderate, 30 to 44%; and severe, > 45%. RF values for AR grading using TTE, LSA-Doppler and CMR correlate well but differ in groups with mild and moderate AR when using a recognized multiparametric echocardiographic approach. Clinical prospective studies should validate these proposed modality adjusted grading scales.

Multi-biomarker mortality prediction in patients with aortic stenosis undergoing valve replacement.

OBJECTIVES: The prognostic value of biomarkers in aortic stenosis (AS) remains understudied. We investigated whether a combination of biomarkers related to cardiovascular stress, inflammation, and damage is associated with mortality in patients with severe AS undergoing surgical aortic valve replacement (SAVR). METHODS: From a prospective registry of patients with severe AS referred for SAVR, 499 participants (mean age, 68 ± 8.5 years; 292 male) with available preoperative echocardiograms and biomarker data were included. Preoperative concentrations of NT-pro-B-type natriuretic peptide, high-sensitivity cardiac troponin T, and C-reactive protein were dichotomized as high or low, according to calculated cut-off values. RESULTS: The mean follow-up time was 775 ± 410 days; 25 patients died. Only patients with elevated levels of all three biomarkers (n = 55) showed increased mortality [hazard ratio (HR), 7.26; 95% confidence interval (CI), 2.52-20.93; p < 0.001; reference group, no elevated biomarkers, n = 159]. Patients with elevated levels of the three biomarkers had higher 3-year all-cause mortality (24% vs. 4.5%); this remained true after multivariable adjustment (HR, 4.08; 95% CI, 1.87-8.87; p < 0.001). Patients with EuroSCOREs (logES) >3.0% tended to exhibit a higher risk of all-cause mortality (HR, 2.19; 95% CI, 0.98-4.87; p = 0.055); the mortality rate was 12-fold higher when logES >3 was combined with the three elevated biomarkers. This combination also showed a net reclassification improvement of 33% and significant likelihood-ratio test results. CONCLUSIONS: A multiple biomarker approach might be useful for predicting postoperative mid-term mortality in patients with severe AS undergoing SAVR. Further large-scale prospective validation should be performed.

Prevalence of permanent pacemaker implantation after conventional aortic valve replacement-a propensity-matched analysis in patients with a bicuspid or tricuspid aortic valve: a benchmark for transcatheter aortic valve replacement.

OBJECTIVES: Elective treatment of aortic valve disease by transcatheter aortic valve replacement (TAVR) is becoming increasingly popular, even in patients with low risk and intermediate risk. Even patients with a bicuspid aortic valve (BAV) are increasingly considered eligible for TAVR. Permanent pacemaker implantation (PMI) is a known-frequently understated-complication of TAVR affecting 9-15% of TAVR patients with a potentially significant impact on longevity and quality of life. BAV patients are affected by the highest PMI rates, although they are frequently younger compared to their tricuspid peers. The aim of the study is to report benchmark data-from a high-volume centre (with a competitive TAVR programme) on PMI after isolated surgical aortic valve replacement (SAVR) in patients with BAV and tricuspid aortic valve (TAV). METHODS: We performed a retrospective single-centre analysis on 4154 patients receiving isolated SAVRs (w/o concomitant procedures), between 2000 and 2019, of whom 1108 had BAV (27%). PMI rate and early- and long-term outcomes were analysed. For better comparability of these demographically unequal cohorts, 1:1 nearest neighbour matching was performed. RESULTS: At the time of SAVR, BAV patients were on average 10 years younger than their TAV peers (59.7 ± 12 vs 69.3 ± 9; P < 0.001) and had less comorbidities; all relevant characteristics were equally balanced after statistical matching. Overall PMI rate was significantly higher in BAV patients (5.4% vs 3.8%; P = 0.03). BAV required PMI exclusively (100%) and TAV required predominately (96%) for persistent postoperative high-degree atrioventricular block. After matching, the PMI rate was similar (5.1% vs 4.4%, P = 0.5). In-hospital mortality in the matched cohort was 1% in both groups. Long-term survival was more favourable in BAV patients (94% vs 90% in TAV at 5 years; 89% vs 82% in TAV at 9 years; P = 0.013). CONCLUSIONS: With SAVR, the overall incidence of PMI among BAV patients seems significantly higher; however, after propensity matching, no difference in PMI rates between BAV and TAV is evident. The PMI rate was remarkably lower among BAV patients after SAVR compared to the reported incidence after TAVR.

Left atrial size and total atrial emptying fraction in atrial fibrillation progression.

BACKGROUND: Left atrial (LA) size and low-voltage areas (LVA) mirror atrial fibrillation (AF) progression. Whether these factors are important for the impairment of total atrial emptying fraction is understudied. OBJECTIVE: The aim of the present analysis was to investigate the association between LA volume and total atrial emptying fraction with AF progression phenotypes: persistent AF and LVA. METHODS: Patients undergoing first AF ablation were included in the analysis. LVA were determined using high-density maps and defined as <0.5 mV. All patients underwent cardiovascular magnetic resonance imaging before the intervention. Cardiovascular magnetic resonance data (LA volume, LA emptying fraction [LA-EF], and right atrial emptying fraction [RA-EF]) were measured in all patients. RESULTS: The study population included 211 patients (65 ± 11 years; 124 (59%) men; 122 (58%) persistent AF; 54 (26%) LVA). There were 4 disease progression groups: paroxysmal AF without LVA, paroxysmal AF with LVA, persistent AF without LVA, and persistent AF with LVA. While LA volume increased according to the AF progression phenotype (98 ± 27, 145 ± 34, 134 ± 41, 141 ± 39 mL, respectively; P < .001), total LA-EF (51% ± 17%, 32% ± 17%, 33% ± 17%, 22% ± 11%; P < .001) and RA-EF (47% ± 13%, 36% ± 17%, 30% ± 16%, 23% ± 12%; P < .001) decreased. In multivariable analysis, age (odds ratio [OR] 1.084; 95% confidence interval [CI] 1.028-1.142; P = .003), persistent AF (OR 3.478; 95% CI 1.117-10.830; P = .031), and total LA-EF (OR 0.933; 95% CI 0.899-0.968; P < .001) showed a significant association for LVA. Using receiver operating characteristic curve analysis, LA-EF (area under the curve 0.778; 95% CI 0.711-0.846; P < .001) and RA-EF (area under the curve 0.726; 95% CI 0.650-0.802; P < .001) were significantly associated with the absence of LVA. CONCLUSION: LVA and persistent AF are associated with worse total atrial emptying fraction.

Reversibility of severe mitral valve regurgitation after left ventricular assist device implantation: single-centre observations from a real-life population of patients.

OBJECTIVES: This study evaluates the impact of untreated preoperative severe mitral valve regurgitation (MR) on outcomes after left ventricular assist device (LVAD) implantation. METHODS: Of the 234 patients who received LVAD therapy in our centre during a 6-year period, we selected those who had echocardiographic images of good quality and excluded those who underwent mitral valve replacement prior to or mitral valve repair during LVAD placement. The 128 patients selected were divided into 2 groups: Group A with severe MR (n = 65) and Group B with none to moderate MR (n = 63, 28 with moderate MR). We evaluated transthoracic echocardiography preoperatively [15 (7-28) days before LVAD implantation; median (interquartile range)] and postoperatively up to the last available follow-up [501 (283-848) days after LVAD]. We collected mortality, complications and clinical status indicators of the patient cohort. RESULTS: We observed a significant decrease in the severity of MR after LVAD implantation (severe MR 51% pre- vs 6% post-LVAD implantation, P < 0.001). There was no difference between groups in terms of right heart failure, rate of urgent heart transplantation, pump thrombosis or ventricular arrhythmias. There was no difference in 1-year survival and 3-year survival (87.7% vs 88.4% and 71.8% vs 66.6% for Groups A and B, respectively, P = 0.97). CONCLUSIONS: Preoperative severe MR resolves in the majority of patients early on after LVAD implantation and is not associated with worse clinical outcomes or intermediate-term survival.

Quantification of Aortic Valve Regurgitation by Pulsed Doppler Examination of the Left Subclavian Artery Velocity Contour: A Validation Study with Cardiovascular Magnetic Resonance Imaging.

BACKGROUND: Reflux of the aortic regurgitation (AR) causes an increased diastolic reverse flow in the aorta and its branching vessels. We aimed to evaluate the feasibility and accuracy of Doppler measurements in the left subclavian artery (LSA) for quantification of AR in a cardiovascular magnetic resonance imaging (CMR) validation study. METHODS: Systolic and diastolic flow profiles of the LSA (subclavicular approach) were evaluated prospectively by use of pulsed wave Doppler in 59 patients (55.5 ± 15 years; 44 men), 47 with a wide spectrum of AR and 12 as control group. Using CMR phase-contrast sequences (performed 1 cm above the aortic valve), the AR was divided into three groups: mild, regurgitant fraction (RF) < 20% (n = 17); moderate, RF 20%-40% (n = 10); and severe, RF > 40% (n = 20). The LSA Doppler-derived RF was calculated as the ratio between diastolic and systolic velocity-time integrals (VTI). RESULTS: Quality LSA Doppler signal could be obtained in all cases. Patients with CMR severe AR had higher values of LSA Doppler-derived RF (51% ± 9% vs 36% ± 11% vs 16% ± 8%; P < .0001). LSA Doppler showed a good correlation with CMR, with a sensitivity of 95%, specificity of 89%, and diagnostic accuracy for severe AR of 91.5%. Finally, Bland-Altman plots showed agreement in the group with moderate to severe AR (mean bias = -2.2% ± 8%, 95% CI, -17.7 to 13.3; P = .145) but differed in mild AR. CONCLUSIONS: Measurements of the RF for quantification of AR using LSA Doppler are comparable to those of CMR, highlighting the potential role of LSA Doppler as an adjunctive technique to assess the severity of AR.

Tumor Or Thrombus? The Role Of Cardiac Magnetic Resonance Imaging In Differentiating Left Atrial Mass In a Transplanted Heart: A Case Report.

An unknown mass in the left atrium can be challenging to differentiate, especially after previous heart transplant. A precise diagnosis is clinically crucial because of the therapeutic implications. CMR is a useful, non-invasive tool to distinguish intra-cardiac lesions, thereby enabling clinicians to initiate adequate therapy.

Advanced symptoms are associated with myocardial damage in patients with severe aortic stenosis.

BACKGROUND: Once aortic stenosis (AS) is severe, patients develop symptoms at different stages. Indeed, symptom status may correlate poorly with the grade of valve narrowing. Multiple pathophysiological mechanisms, other than valvular load, may explain the link between AS and symptom severity. We aimed to describe the relationship between the severity of symptoms and the characteristics of a cohort of patients with severe AS already referred for aortic valve replacement (AVR). METHODS: We analyzed 118 consecutive patients (70±9 years, 55% men) with severe AS referred for AVR. We identified 84 patients with New York Heart Association (NYHA) I-II, and 34 with NYHA III-IV symptoms. Clinical and echocardiographic parameters were compared between these two groups. Left ventricular ejection fraction (LVEF), global longitudinal peak systolic strain (GLPS), NT-pro-B-type natriuretic peptide (BNP), and high-sensitive troponin T (hs-TNT) were determined at the time of admission. RESULTS: AS severity was similar between groups. Compared with the NYHA I-II group, patients in NYHA III-IV group were older and more likely to have comorbidities, worse intracardiac hemodynamics and more LV damage. Variables independently associated with NYHA III-IV symptomatology were the absence of sinus rhythm, higher E/e' ratio, and increased hs-TNT. GLPS showed a good correlation not only with hs-TNT as a marker of myocardial damage, but also with markers of increased afterload imposed on LV, being not directly related with advanced symptoms. CONCLUSIONS: Advanced symptoms in patients with severe AS referred for AVR are associated with worse intracardiac hemodynamics, absence of sinus rhythm, and more myocardial damage. It supports the concept of transition from adaptive LV remodeling to myocyte death as an important determinant of symptoms of heart failure.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa as a complication after minimally invasive mitral valve repair.

Pseudoaneurysm of the mitral-aortic intervalvular body is a rare condition, which has been reported as a result of endocarditis, chest trauma or cardiac surgery. We describe here the first case after minimally invasive mitral valve repair. Such a complication may be overlooked in the early postoperative echocardiographic study and may lead to fistula formation, compression of adjacent structures, infection, or rupture. Both computed tomography and echocardiography provide a detailed anatomy of the pseudoaneurysm and its communication with the left ventricular outflow tract.