An unusual case of painless type A aortic dissection.

The pathogenesis of acute aortic dissection (AAD) is not fully elucidated yet, but it was recently shown that inflammation contributes to the occurrence and development of both Stanford type A and type B AAD. We describe a rare case of a painless type A aortic dissection that occurred in an 85-year-old male, with moderate calcified aortic stenosis and a moderately dilated ascending aorta in 6-month clinical and echocardiographic follow-up. A chronic calculous cholecystitis with neutrophilic leukocytosis and severely increased C reactive protein was diagnosed in the last 3 months. In this patient, a chronic systemic inflammatory state might have contributed to generate the intimal entry tear in the aortic root. In particular, a neutrophil mobilization might have played a causative role in aortic rupture.

Incremental diagnostic role of left atrial strain analysis in thrombotic risk assessment of nonvalvular atrial fibrillation patients planned for electrical cardioversion.

During the COVID-19 pandemic, transesophageal echocardiography (TEE) for left atrial appendage thrombosis (LAAT) detection should be limited to situations of absolute necessity. We sought to identify the main conventional and functional echocardiographic parameters associated with LAAT on TEE in non-valvular atrial fibrillation (NVAF) patients planned for electrical cardioversion (ECV). This retrospective study included 125 consecutive NVAF patients (71.5±7.8 yrs, 75 males), who underwent TEE at our Institution between April 2016 and January 2020, to exclude LAAT before scheduled ECV. All patients underwent a transthoracic echocardiography (TTE) implemented with speckle tracking echocardiography (STE) analysis of left atrial (LA) strain and strain rate (SR) parameters. 28% of patients were diagnosed with LAAT, while 72% without LAAT. Compared to controls, patients with LAAT had significantly higher CHA2DS2-Vasc Score and average E/e' ratio, and significantly lower left ventricular ejection fraction (LVEF). Moreover, LA-peak positive global atrial strain (GSA+) and LA-SR parameters were significantly reduced in patients with LAAT. Multivariate logistic regression revealed that, differently from CHA2DS2-Vasc Score, LVEF (OR 0.88, 95%CI 0.81-0.97, p = 0.01), average E/e' ratio (OR 2.36, 95%CI 1.41-3.98, p = 0.001), and LA-GSA+ (OR 0.57, 95%CI 0.36-0-90, p = 0.01) were independently associated with LAAT. LA-GSA+ (optimal cut-off ≤ 9.1%, AUC 0.95) showed the highest diagnostic performance. Finally, a strong linear correlation of LA peak-to-peak SR with both LA appendage filling (r = 0.86) and emptying (r = 0.83) velocities was demonstrated. TTE implemented with STE analysis of LA mechanics improves thrombotic risk assessment of NVAF patients.

Reduced Myocardial Strain Parameters in Subjects With Pectus Excavatum: Impaired Myocardial Function or Methodological Limitations Due to Chest Deformity?

Pectus excavatum (PE) may cause symptoms and alter cardiopulmonary function. Left ventricular (LV) and right ventricular (RV) function have been reported to be impaired in PE subjects. However, this issue has not been systematically investigated with respect to the degree of chest wall abnormality. We aimed to evaluate the influence of severity of chest shape abnormality on myocardial strain parameters in PE subjects. We studied 30 healthy subjects (55.8 ± 14.0 year/old, 18 males) with PE, assessed by the ratio of chest transverse diameter over the distance between sternum and spine (modified Haller index, MHI, >2.5), and 30 controls (MHI ≤2.5) matched by age, sex, and cardiovascular risk factors. Participants underwent 2-dimensional (2D) transthoracic echocardiography implemented with 2D-speckle tracking echocardiography. Right-heart and left-heart chamber dimensions, and stroke volume, were significantly reduced in PE subjects (all P< 0.0001). While LV ejection fraction, E/A, and E/e', did not significantly differ between the 2 groups, all LV and RV strain and strain rate parameters were severely reduced in subjects with PE (P < 0.0001). Importantly, in PE subjects, but not in controls, LV global longitudinal strain, LV global circumferential strain, LV global radial strain, and RV free wall systolic strain, were all linearly correlated to MHI (all P < 0.0001). In healthy subjects with PE, abnormal chest anatomy progressively impairs myocardial strain. However, this impairment is not due to subclinical myocardial dysfunction; it might reflect intraventricular dyssynchrony due to compressive phenomena, or technical limitations of strain methodology, due to chest wall abnormality.

Prognostic Relevance of Left Ventricular Thrombus Motility: Assessment by Pulsed Wave Tissue Doppler Imaging.

Pulsed wave tissue Doppler imaging (PW-TDI) easily detects motion of cardiac structures. Hence, PW-TDI could be of value for assessing potentially cardioembolic masses. We sought to evaluate the prognostic value of left ventricular (LV) thrombus mobility assessed by PW-TDI. In 83 consecutive patients with echocardiographically detected LV thrombi, PW-TDI echocardiographic study was performed. At 1-year follow-up, the composite of major adverse cardiovascular events (MACE) defined as all-cause mortality plus hospitalizations for stroke/systemic embolism was evaluated. Seventy-two patients (77.1 ± 13.1 year/old, 32 males) were studied. All thrombi were located at the LV apex. At 1-year follow-up, 17 cardioembolic events occurred. By univariable Cox analysis, variables associated with MACE were heart rate (hazard ratio: 1.02, 95% CI: 1.00-1.05; P = .03), thrombi with mobile free edge (hazard ratio: 3.25, 95% CI: 1.25-8.44; P = .01), hypoechoic thrombi (hazard ratio: 2.86, 95% CI: 1.10-7.42; P = .03), and mass peak antegrade velocity (Va) ≥10 cm/s (hazard ratio: 8.79, 95% CI: 2.00-38.5; P = .004). By multivariable analysis, thrombi with mobile free edge (hazard ratio: 3.54, 95% CI: 1.23-10.2; P = .02), and mass peak Va ≥10 cm/s (hazard ratio: 7.97, 95% CI: 1.60-39.6; P = .01) retained statistical significance. Mass peak Va ≥10 cm/s predicted the composite end point with 94% sensitivity and 85% specificity (area under the curve = 0.86). In conclusion, PW-TDI allows objective prognostication of LV thrombi embolic risk.

Correlation Between Doppler Echocardiography and Right Heart Catheterisation-Derived Systolic and Mean Pulmonary Artery Pressures: Determinants of Discrepancies Between the Two Methods.

BACKGROUND: There is still controversy about whether transthoracic echocardiography (TTE) can provide reliable estimations of pulmonary artery pressures (PAP). The primary endpoint of this study was to evaluate the correlation between TTE and right heart catheterisation (RHC) in estimating systolic (SPAP) and mean (MPAP) pulmonary artery pressures. METHODS: Between January 2011 and December 2018, 141 consecutive patients (average age 63.6±11.5 years; 84 women) with suspected or confirmed pulmonary hypertension (PH) were enrolled into this retrospective observational monocentric study. All patients underwent TTE and, within 3 hours, RHC. The correlation between TTE and RHC in estimating both SPAP and MPAP was retrospectively determined. RESULTS: Seventeen (17) of the patients were excluded due to insufficient TTE signal quality. Of the remaining 124 patients, 18 had no PH. There was moderate correlation between both SPAP and MPAP estimated by TTE and those assessed by RHC (r=0.65 and r=0.60, respectively). Bland-Altman analysis revealed a bias of -11.9 mmHg (with the 95% limits of agreement ranging -45.4 to +21.5 mmHg) for SPAP estimation and -4.6 mmHg (with the 95% limits of agreement ranging -27.9 to +18.8 mmHg) for MPAP estimation, suggesting a general overestimation of PAP by TTE. The main factors responsible for discrepancies between TTE and RHC were: female gender, arrhythmic cardiac electrical activity, systemic arterial hypertension, and diuretic treatment. CONCLUSIONS: Transthoracic echocardiography frequently overestimated PAP in comparison with RHC, especially in hypertensive women with arrhythmias and under diuretic treatment.

Left Atrial Cavity Thrombus and Fatal Systemic Embolization in a Stroke Patient with Nonvalvular Atrial Fibrillation: A Caveat against Left Atrial Appendage Closure for Stroke Prevention.

An 88-year-old male with nonvalvular atrial fibrillation (NVAF) and severe congestive heart failure (HF), was admitted to the Neurological Intensive Care Unit because of the acute onset of aphasia and left hemiplegia. Transthoracic echocardiography revealed a left atrial (LA) cavity thrombus. Its "fatal" distal embolization to abdominal aorta occurred in a few days. These observations should lead to a cautious approach in proposing a percutaneous closure of LA appendage in older NVAF patients, with HF and/or left ventricular dysfunction and larger LA volumes, who are not adequately anticoagulated.

Speckle-Tracking Echocardiography for Cardioncological Evaluation in Bevacizumab-Treated Colorectal Cancer Patients.

Angiogenesis inhibitor Bevacizumab (BVZ) may lead to the development of adverse effects, including hypertension and cardiac ischemia. Whether assessment of changes in myocardial strain by two-dimensional speckle-tracking echocardiography (2D-STE) can be of value in detecting BVZ-mediated cardiotoxicity at an earlier stage is not known. We investigated whether 2D-STE can non-invasively detect early evidence of cardiotoxicity in metastatic colorectal cancer (mCRC) patients treated with BVZ. Between January and June 2019, 25 consecutive patients (71.8 ± 7.5 year/old, 17 males) with mCRC were prospectively enrolled. Patients underwent physical examination, blood tests, and conventional 2D-transthoracic echocardiography implemented with 2D-STE analysis, at baseline and at 3 and 6 months following treatment with BVZ (15 mg/kg every 15 days) + 5-fluorouracil/folinic acid plus oxaliplatin (FOLFOX i.v.). At 6-month follow-up, we assessed occurrence of global longitudinal strain (GLS) impairment (> 15% decrease in GLS compared with baseline) as primary end-point and a new-onset systemic hypertension (secondary end-point). On average, GLS showed a progressive significant impairment after BVZ, from - 17.4 ± 3.2% at baseline to - 16 ± 2.9% (p = 0.003) at 6-month follow-up; > 15% decrease in GLS (primary end-point) was detected in 9 patients (36%). All other strain parameters remained unchanged. New-onset systemic hypertension (secondary end-point) was diagnosed in five patients (20%). No significant changes were observed in serial high-sensitivity cardiac troponin I measurements. No patient developed significant changes in LV size or LV ejection fraction; no case of clinically symptomatic HF was observed during BVZ-treatment. Measurement of GLS by 2D-STE analysis can effectively detect BVZ-mediated cardiotoxicity at an early stage.

Early left atrial dysfunction in idiopathic pulmonary fibrosis patients without chronic right heart failure.

No data are actually available regarding the left atrial (LA) functional assessment by two-dimensional speckle tracking echocardiography (2D-STE) in early-stage idiopathic pulmonary fibrosis (IPF). The primary end-point of our study was to assess whether global LA peak strain (GLAPS), measured by 2D-STE analysis, may detect early alterations in LA function in IPF patients without right heart failure (RHF). Between September 2017 and January 2019, 50 consecutive IPF patients (73.8 ± 6.8 years, 36 males) without chronic RHF and 30 controls matched by age, sex and cardiovascular risk factors, were enrolled in an observational retrospective case-control study. All patients underwent a complete echocardiographic study implemented with 2D-STE analysis. GLAPS, left ventricular (LV) global longitudinal strain (GLS), right atrial (RA) reservoir strain (GSA+) and right ventricular (RV)-GLS were obtained in each patient. LVFP were significantly increased in IPF patients in comparison to controls (average E/e' ratio 14.4 ± 3.0 vs 9.6 ± 1.5, p < 0.0001), while LV-GLS was slightly reduced in IPF patients compared to controls (19.4 ± 3.6% vs 21.0 ± 2.2%, p = 0.03).Moreover, GLAPS was significantly impaired in IPF patients in comparison to controls (18.4 ± 3.7% vs 28.4 ± 5.6%, p < 0.0001).Finally, the two groups of patients did not show any statistically significant difference in both RA-GSA + (23.9 ± 3.7% vs 24.5 ± 4.0%, p = 0.49) and RV-GLS (- 22.6 ± 3.3% vs - 23.5 ± 3.0%, p = 0.22). Notably, LV-GLS was strongly inversely correlated both with RV/LV basal diameter ratio and TRV in IPF patients (r = - 0.87 and - 0.82, respectively) but not in controls (r = - 0.29 and - 0.27, respectively). This finding highlights a likely process of ventricular interdependence in non-advanced IPF, with consequent LV diastolic dysfunction and secondary impairment in LV-GLS and GLAPS. Early LA reservoir dysfunction in IPF patients may be secondary to LV diastolic dysfunction induced by ventricular interdependence and may develop before RV diastolic and systolic dysfunction.

False-positive electrocardiographic changes during exercise test in a patient with pectus excavatum.

Exercise-induced ST-segment changes simulating myocardial ischemia have been described in otherwise normal subjects during hyperventilation. We present the case of a 60-year-old man with pectus excavatum showing significant exercise-induced "pseudo-ischaemic" ST-segment changes with neither coronary artery disease nor anxiety-induced hyperventilation. We found no report of the possible causative role of a narrow antero-posterior chest diameter in inducing "pseudo-ischaemic" ST-segment changes during exercise stress test in the literature.

Mechanical atrial recovery after cardioversion in persistent atrial fibrillation evaluated by bidimensional speckle tracking echocardiography.

BACKGROUND: Atrial fibrillation induces reversible electrical and mechanical modifications (atrial remodeling). Atrial stunning is a mechanical dysfunction with preserved bioelectrical function, occurring after successful atrial fibrillation electrical cardioversion (ECV). Two-dimensional speckle tracking echocardiography is a new technology for evaluating atrial mechanical function. We assessed atrial mechanical function after ECV with serial two-dimensional speckle tracking echocardiography evaluations. The investigated outcome was left atrium mechanical recovery within 3 months. METHODS: A total of 36 patients [mean age 73 (7.9) years, 23 males] with persistent atrial fibrillation underwent conventional transthoracic and transesophageal echocardiography before ECV. Positive global atrial strain (GSA+) was assessed at 3 h, 1, 2, 3, 4 weeks and 3 months after ECV. Mechanical recovery was defined as the achievement of a GSA+ value of 21%. RESULTS: Independent predictors of GSA+ immediately after ECV (basal GSA+) were E/e' ratio and left atrial appendage anterograde flow velocity. During the follow-up, 25% of patients suffered atrial fibrillation recurrence. In 12/36 patients (33%) left atrium mechanical recovery was detected (mechanical recovery group), while in 15/36 (42%) recovery did not occur (no atrial mechanical recovery group). At univariate analysis, the variables associated with recovery, were basal GSA+ (P = 0.015) and maximal velocity left atrial appendage (P = 0.022). Female sex (P = 0.038), N-terminal pro-B type natriuretic peptide (P = 0.013), E/e' (P = 0.042) and the indexed left atrium volume (P = 0.019) were associated with the lack of left atrium mechanical recovery. CONCLUSION: In almost half of the patients, the left atrium did not resume mechanical activity within the 3 months after ECV, despite sinus rhythm recovery. The left atrium of these patients was larger, stiffer and their E/E' was higher, suggesting a higher endocavitary pressure compared with mechanical recovery patients. These findings might suggest an increased thromboembolic risk.

Incremental prognostic value of global left atrial peak strain in women with new-onset gestational hypertension.

BACKGROUND: Left atrial strain and strain rate parameters, measured by bidimensional-speckle tracking echocardiography, have been proposed as predictors of atrial fibrillation, stroke, congestive heart failure and cardiovascular death. However, they have not yet been tested in hypertensive disorders of pregnancy. The aim of this study was to assess the prognostic role of global left atrial peak strain (GLAPS) in a population of pregnant women with new-onset hypertension in a medium-term follow-up. METHODS: Twenty-seven consecutive women with new-onset hypertension after 20 weeks pregnancy and 23 age-matched, race-matched and gestational week-matched consecutive normotensive pregnant women were enrolled in this prospective study. All participants underwent a complete echocardiographic study with bidimensional-speckle tracking echocardiography and carotid examination. At 1-year follow-up, we evaluated the occurrence of persistent hypertension. RESULTS: In comparison with normotensive women, those hypertensive had a higher burden of cardiovascular risk factors, similar left atrial volume indexed (P = 0.14), but severely impaired left atrial strain (P < 0.0001) and strain rate values (P < 0.0001). At 1-year follow-up, persistent hypertension was documented in 59.3% of patients. At the univariate Cox analysis, the variables associated with the occurrence of the investigated outcome in all hypertensive pregnancies were SBP (hazard ratio 1.04, P = 0.04), DBP (hazard ratio 1.11, P = 0.01), mean arterial pressure (hazard ratio 1.09, P = 0.01) values and the GLAPS value (hazard ratio 0.85, P = 0.0019). The latter was significantly associated with the investigated outcome both in preeclamptic (hazard ratio 0.84, P = 0.02) and nonpreeclamptic pregnant women (hazard ratio 0.83, P = 0.04). The receiver operating characteristics curve analysis highlighted that a GLAPS value of 23.5% or less predicted persistent hypertension with sensitivity of 100% and specificity of 90.90%. CONCLUSION: In hypertensive pregnant women a GLAPS value of 23.5% or less reveals a greater severity of atrial cardiomyopathy and might predict postpregnancy persistent hypertension.

A Nonfatal Massive Pulmonary Embolism in a Very Old Patient: The Protective Filter-Effect of the Chiari Network.

The Chiari network, a net-like structure within the right atrium, has been described as an embryonic remnant of no clinical significance. Its role in facilitating paradoxical arterial embolic events and as a potential site for thrombus formation has been reported in the literature. This case illustrates the protective filter-effect of the Chiari network in a 92-year-old women who presented with the clinical signs and symptoms of acute cor pulmonale. Transthoracic echocardiography revealed a large, S-shaped, and extremely mobile right atrial thrombus within the Chiari network. Here, the authors describe how the Chiari network may have prevented the occurrence of a fatal pulmonary embolism acting as a protective factor.

Prognostic value of global left atrial peak strain in patients with acute ischemic stroke and no evidence of atrial fibrillation.

Prognostic stratification of acute ischemic stroke (AIS) patients without atrial fibrillation (AF) remains a challenge. Two-dimensional speckle tracking echocardiography (2D-STE) has recently been introduced for dynamic evaluation of left atrial function. However only few data are actually available regarding the application of 2D-STE in AIS patients. The aim of our study was to assess the prognostic role of global left atrial peak strain (GLAPS), measured by 2D-STE, in AIS patients without AF history. Eighty-five AIS patients (mean age 74.1 ± 12.1 years, 49 males) with normal sinus rhythm on ECG and without AF history were enrolled in the prospective study. All patients underwent a complete echocardiographic study with 2D-STE. At 1 year follow-up, we evaluated the occurrence of a composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. GLAPS was markedly reduced in AIS patients (15.71 ± 4.70%), without any statistically significant difference between the stroke subtypes. At 1-year follow-up, 14 deaths and 17 hospital readmissions were detected in AIS subjects. On a multivariate Cox model, variables independently associated with the occurrence of the composite endpoint were the "Rankin in" Scale (HR 1.69, p = 0.001), GFR (HR 0.98, p = 0.03) and the GLAPS value (HR 0.78, p < 0.0001). A GLAPS value ≤ 15.5% predicted the composite endpoint with sensitivity of 100% and specificity of 80%. A GLAPS value ≤ 15.5% reflects a more advanced atrial cardiomyopathy and might provide a reliable and useful prognostic risk stratification of AIS patients without AF history.

AnatoMy and physIopathoLogy of the heArt in a ceNtenarian cOhort (MILANO study).

Background: Centenarians are increasingly being encountered in clinical practice. The aim of the study was to characterize centenarians' clinical features and cardiovascular system. Methods: A prospective, observational, cross-sectional, case-control study included 118 hospitalized >100-year-old patients compared to 50 octogenarians, selected in Milan (Italy) from December 2010 to December 2017, to assess their clinical and echocardiographic characteristics. Results: Centenarians were mostly women with small body surface area; long history of hypertension; chronic renal failure; and low incidence of smoking, diabetes, dyslipidemia, hyperuricemia, coronary artery disease, atrial fibrillation, and cerebrovascular disease. They showed high prevalence of severe cognitive impairment and disability. Almost half of patients (46%) were hospitalized for congestive heart failure (HF), mostly diastolic (80% of cases). Centenarians' hearts had reduced left ventricular end-diastolic dimensions (25.3 ± 3.8 mm/m^2), increased septal thickness (13.3 ± 1.9 mm), and higher relative wall thickness (0.58 ± 0.1). The ejection fraction was usually normal and rarely depressed (57.1% ± 11.7%), whereas the E/e' ratio was considerably increased (17.0 ± 6.0). Noninvasive evaluation of ventricular-arterial coupling parameters revealed significantly higher values of LV end-diastolic elastance in all centenarians versus octogenarians (0.4 ± 01 mm Hg/mL/m^2 vs 0.18 ± 0.2 mm Hg/mL/m^2, P < .0001) and in centenarians with HF versus those without HF (0.5 ± 0.1 mm Hg/mL/m^2 vs 0.34 ± 0.1 mm Hg/mL/m^2, P < .0001). Conclusions: The centenarians' cardiovascular system manifested a significant increase in LV diastolic stiffness with consequent susceptibility to diastolic HF. A progressive afterload increase and a passive load independent mechanism could have contributed to such changes.

A New modified anthropometric haller index obtained without radiological exposure.

To validate a new modified method for measuring the anthropometric Haller index (HI), obtained without radiological exposure. This new method was based on the use of a rigid ruler and of a 2.5 MHz ultrasound transducer for the assessment of latero-lateral and antero-posterior chest diameters, respectively. We enrolled 100 consecutive patients (mean age 67.9 ± 14.5 years, 55% males), who underwent a two-plane CXR, for any clinical indication, over a four-month period. In all patients, the same radiologist calculated the conventional radiological HI (mean value 1.93 ± 0.35) and the same cardiologist used the above described new technique to measure the modified HI (mean value 1.99 ± 0.26). The Bland-Altman analysis showed tight limits of agreement (+ 0.37; - 0.51) between the two measurement methods, with a mild systematic overestimation of the new method as compared to the standard radiological HI. The Pearson's correlation analysis highlighted a strong correlation between the two methods (r = 0.81, p < 0.0001), while the Student's t test demonstrated a not statistically difference between the means (p = 0.12). The modified HI might allow a quick description of the chest conformation without radiological exposure and a more immediate comprehension of its possible influence on the cardiac kinetics and function, as assessed by echocardiography or other imaging modalities.

Hemodynamic Mechanisms of Exercise-Induced Pulmonary Hypertension in Patients with Lymphangioleiomyomatosis: The Role of Exercise Stress Echocardiography.

BACKGROUND: The pathogenesis of pulmonary hypertension (PH) in lymphangioleiomyomatosis (LAM) has not yet been completely clarified. The aim of this study was to conduct a noninvasive evaluation of the main hemodynamic mechanisms of exercise-induced PH in patients with LAM, assessed using exercise stress echocardiography. METHODS: Fifteen patients with LAM (mean age, 47 ± 13 years; all women) without resting PH were enrolled in a prospective single-center study and compared with 15 healthy female control subjects (mean age, 45.2 ± 8 years; P = .65). A complete echocardiographic study with Doppler tissue imaging was performed at baseline and during semisupine symptom-limited exercise testing to evaluate (1) left ventricular systolic and diastolic function, (2) right ventricular contractile function, (3) estimated pulmonary capillary wedge pressure, (4) estimated systolic and mean pulmonary artery pressure, and (5) estimated pulmonary vascular resistance. RESULTS: Compared with healthy control subjects, patients with LAM during exercise showed echocardiographic signs of right ventricular overload and right ventricular systolic dysfunction and significant increases in mean pulmonary artery pressure (14.4 ± 6.5 vs 4.2 ± 3.1 mm Hg, P < .0001), pulmonary vascular resistance (+68.3 ± 42.1 vs -0.1 ± 18.3 dyne-sec/cm5, P < .0001), and, unexpectedly, pulmonary capillary wedge pressure (+8.3 ± 5.3 vs -0.5 ± 1.3 mm Hg, P < .0001). CONCLUSIONS: Exercise-induced PH in patients with LAM could be related not only to hypoxic pulmonary vascular vasoconstriction during exercise (precapillary PH) but also to a significant exercise-induced increase in estimated pulmonary capillary wedge pressure, probably secondary to diastolic dysfunction (postcapillary PH).

Exercise and heart failure: an update.

The present update is dedicated to the evolution of the interaction between heart failure (HF) and exercise and how the scientific community has handled it. Indeed, on the one hand, HF is a leading cause of morbidity and mortality with a stable prevalence from 1998 onward varying between 6.3% and 13.3%. On the other hand, exercise is seen as a diagnostic and prognostic tool as well as a therapeutic intervention in chronic HF. More precisely, the knowledge, the clinical application, and the research interest on the mutual interactions between exercise and HF have different phases in disease progression: Before HF onset (past): exercise provides protective benefit in preventing HF (primary prevention). With HF present: exercise improvement with training provides benefits in HF (secondary prevention). The prediction of future in HF patients: exercise impairment, as a leading characteristic of HF, is used as a prognostic factor.