Management of valvular heart disease in patients with cancer: Multidisciplinary team, cancer-therapy related cardiotoxicity, diagnosis, transcatheter intervention, and cardiac surgery. Expert opinion of the Association on Valvular Heart Disease, Association of Cardiovascular Interventions, and Working Group on Cardiac Surgery of the Polish Cardiac Society.

The Association on Valvular Heart Disease, Association of Cardiovascular Interventions, and the Working Group on CardiacSurgery of the Polish Cardiac Society have released a position statement on risk factors, diagnosis, and management of patients with cancer and valvular heart disease (VHD). VHD can occur in patients with cancer in several ways, for example, it can exist or be diagnosed before cancer treatment, after cancer treatment, be an incidental finding during imaging tests, endocarditis related to immunosuppression, prolonged intravenous catheter use, or combination treatment, and nonbacterial thrombotic endocarditis. It is recommended to employ close cardiac surveillance for patients at high risk of complications during and after cancer treatment and for cancer treatments that may be cardiotoxic to be discussed by a multidisciplinary team. Patients with cancer and pre-existing severe VHD should be managed according to the 2021 European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) guidelines for VHD management, taking into consideration cancer prognosis and patient preferences.

The Impact of the COVID-19 Pandemic on the Organization of Cardio-Hematology Care-A Polish Single Center Experience.

Background and Objectives: We present a retrospective report on the cardio-hematological care of hematology patients at a university hospital in Poland during the COVID-19 pandemic. Materials and Methods: The number of hospitalizations at the Hematology Department and cardio-hematology consultations throughout 2019 and 2020 was analyzed. The types of cardiac procedures, risk factors, and complications were also assessed. Results: A significant reduction in the number of hospitalizations was observed in 2020 as compared to 2019. However, there were no significant differences in the incidence of hematological diseases between both of the analyzed years. In 2019, 299 cardiac consultations were performed in hematological patients, and there was a total of 352 such consultations performed in 2020 (p = 0.042). Less high-risk tests (transesophageal and stress echocardiography) were performed in 2020, in favor of the use of cardiac computed tomography in cardiac diagnostics as it was safer during the pandemic. At least one cardiovascular risk factor during cardiac consultation was noted in 42% and 48% of hematological patients in 2019 and 2020, respectively. Among 651 examined hematological patients, the most common findings were mild cardiac complications of hemato-oncological treatment, which were found in 57 patients. Conclusions: This study seems to confirm that during a pandemic there is an increased demand for well-organized cardio-hematology consultations.

Effective Balloon Pulmonary Angioplasty in a Patient with Chronic Thromboembolic Complications after Ventriculoatrial Shunt for Hydrocephalus in von Hippel-Lindau Disease.

Von Hippel-Lindau (VHL) disease along with chronic thromboembolic pulmonary hypertension (CTEPH) is a unique and unusual severe complication of ventriculoatrial (VA) shunt implantation in the treatment of hydrocephalus. To the best of our knowledge, this can be the first reported case of an effective treatment with balloon pulmonary angioplasty in a patient with VHL after VA shunt placement. The patient underwent six balloon pulmonary angioplasty procedures. All invasive procedures resulted in haemodynamic and functional improvement.

Updates for the diagnosis and management of cardiac amyloidosis.

A substantial increase in the interest in transthyretin cardiac amyloidosis (ATTR-CA) is a result of the constantly growing number of patients, the use of clear diagnostic protocols and the availability of the first selective drug for these patients. This has also raised the awareness of the disease among physicians of all specialties. The topic is particularly relevant to cardiologists, who use non-invasive multimodal imaging in their daily practice. The differential diagnosis of the causes of myocardial hypertrophy includes arterial hypertension, hypertrophic cardiomyopathy, aortic stenosis (AS), athletic heart syndrome, Fabry disease, and cardiac amyloidosis (CA). It turns out that in patients with myocardial hypertrophy >15 mm, amyloidosis is the most common cause of left ventricular (LV) hypertrophy. In parallel, CA is one of the most common infiltrative diseases leading to a clinical picture that may mimic heart failure with preserved ejection fraction (HFpEF). The accumulation of amyloid in the extracellular space impairs the diastolic function of the myocardium, which is observed as the restrictive cardiomyopathy phenotype. In advanced cases, the LV systolic function is also impaired. Moreover, protein deposits contribute to the disturbances of calcium metabolism and cell metabolism as well as to cardiotoxicity, leading to edema and damage to cardiomyocytes.

Polish Multicenter Registry (Pol-LAS-SE registry). Stress echocardiography in low-gradient aortic stenosis in Poland: numbers, settings, results, complications and clinical practice.

BACKGROUND: The diagnostic workup of low-gradient aortic stenosis (LG AS) is a challenge in clinical practice. AIMS: Our goal was to assess the diagnostic value of stress echocardiography (SE) performed in patients with undefined LG AS with low and preserved ejection fraction (EF) and the impact of its result on therapeutic decisions in Polish third level of reference. METHODS: All the patients with LG AS and with SE performed were recruited in 16 Polish cardiology departments between 2016 and 2019. The main exclusion criteria were as follows: moderate or severe aortic or mitral regurgitation and mitral stenosis. RESULTS: The study group included 163 patients (52% males) with LG AS who underwent SE for adequate diagnostic and therapeutic decision. In 14 patients DSE was non-diagnostic. The mean aortic valve (AV) pressure gradient was 24.1 (7.3) mm Hg, while an AV area was 0.86 (0.2) cm2. Among 149 patients with conclusive DSE, severe AS was found in 59.8%, pseudo-severe in 22%, and moderate AS in 18%. There were no cases of death or vascular events related to DSE. Among 142 patients 63 (44%) patients had an aortic valve intervention in a follow-up (median: 208 days; lower-upper quartile: 73-531 days). Based on the result of the DSE test, severe AS was significantly more often associated with qualification to interventional treatment compared to the moderate and pseudo-severe subgroups (P <0.0001). CONCLUSIONS: The DSE test in severe AS is a valuable diagnostic tool in patients with LG AS in Poland.

Cardiovascular risk factors among cancer patients qualified for systemic treatment. Analysis of a cardiovascular disease-free cohort from the Polish multicentre study ONCOECHO.

INTRODUCTION: Cancer therapies are currently more efficient at increasing the survival of patients (pts) with cancer. Unfortunately, the cardiovascular (CV) complications of cancer therapies may adversely affect improving results of treatment. The aim of the study was to evaluate the prevalence of classical CV risk factors among pts with de novo diagnosis of cancer and thus identify the cohort of pts with potentially increased future risk of CV complications. MATERIAL AND METHODS: The analysis is based on the database of the multicentre ONCOECHO study. Pts before systemic treatment (chemotherapy or targeted therapy) were included. The diagnostic datasets of resting electrocardiogram, blood samples, and transthoracic echocardiogram were analysed in 343 consecutive pts who were free from any cardiovascular disease that could adversely affect the introduced treatment. RESULTS: Our cohort included 4.4% of pts with kidney cancer, 7.3% with colorectal cancer, 26.5% with haematological malignancies (HM), and 61.8% with breast cancer. The risk estimated by SCORE was 4.56 ±5.07%. Breast cancer pts had lower cardiovascular risk than those with HM (p = 0.001) and kidney cancer (p = 0.002). Additionally, the HM group had much higher levels of natriuretic peptides (p < 0.001) and creatinine (p = 0.008) than pts with breast cancer. The comparison with the NATPOL population data showed that our pts were more often smokers, hypertensives, and diabetics, but less frequently presented with hypercholesterolaemia. CONCLUSIONS: Patients with new diagnosis of cancer, who are candidates for potentially cardiotoxic medical treatment, have increased prevalence of significant cardiovascular risk factors and therefore should be followed by a multidisciplinary team during the therapeutic process.

Prospective multicenter Polish Stress Echocardiography Registry (PolStress-Echopro) - the role in clinical practice.

BACKGROUND: Stress echocardiography (SE) is becoming an increasingly frequently performed diagnostic examination in Poland. After the published retrospective PolSTRESS Registry, this prospective study is the first one available so far. OBJECTIVES: The aim of the study was to analyze SE tests, taking into account the clinical characteristics of the patients, indications, applied protocols, and diagnostic and therapeutic decisions. MATERIAL AND METHODS: Reference cardiological centers in Poland were asked for a 1-month prospective analysis of the data obtained. The study included 189 SE examinations. To evaluate coronary artery disease (CAD) (178 tests), all 17 centers performed dobutamine SE (DSE) (100%), 3 centers (17%) performed pacing, while cycle ergometer and treadmill SE were performed by 1 (5%) and 2 (11%) centers, respectively. In patients with valvular heart disease (VHD) (11 tests), 3 centers (16%) performed SE to evaluate low-flow/low-gradient aortic stenosis (AS), 4 (22%) in asymptomatic AS and 1 (5%) to evaluate mitral regurgitation. RESULTS: For CAD assessment, a positive result was found in 37 (20%) patients, negative in 109 (61%) and nondiagnostic in 32 (19%). In the CAD group, coronarography was performed in 41 (23%) people. The analysis of the significance of the SE results for decision-making on interventional measures revealed that 30 patients (from the total study population of 189) were referred for the intervention. CONCLUSIONS: The most commonly used SE is the DSE. Negative test results allowed in almost half of the patients to resign from invasive coronarography. Stress echocardiography should be more frequently used in patients with VHD in the qualification for invasive treatment.

Stress echocardiography. Part II: Stress echocardiography in conditions other than coronary heart disease.

Stress echocardiography (stress echo), with use of both old and new ultrasonographic cardiac function imaging techniques, has nowadays become a widely available, safe and inexpensive diagnostic method. Cardiac stress, such as exercise or an inotropic agent, allows for dynamic assessment of a wide range of functional parameters describing ventricles, heart valves and pulmonary circulation. In addition to diagnosis of ischemic heart disease, stress echocardiography is also used in patients with acquired and congenital valvular defects, hypertrophic cardiomyopathy, dilated cardiomyopathy as well as diastolic and systolic heart failure. Physical exercise is the recommended stressor in patients with aortic and especially mitral valvular disease. Nevertheless, dobutamine stress echo is useful for the assessment of contractile and flow reserve in aortic stenosis with reduced left ventricular ejection fraction. Stress echo should always be performed by an appropriately trained cardiologist assisted by a nurse or another doctor, in the settings of an adequately equipped echocardiographic laboratory and with compliance to safety requirements. Moreover, continuous education of cardiologists performing stress echo is needed.Stress echocardiography (stress echo), with use of both old and new ultrasonographic cardiac function imaging techniques, has nowadays become a widely available, safe and inexpensive diagnostic method. Cardiac stress, such as exercise or an inotropic agent, allows for dynamic assessment of a wide range of functional parameters describing ventricles, heart valves and pulmonary circulation. In addition to diagnosis of ischemic heart disease, stress echocardiography is also used in patients with acquired and congenital valvular defects, hypertrophic cardiomyopathy, dilated cardiomyopathy as well as diastolic and systolic heart failure. Physical exercise is the recommended stressor in patients with aortic and especially mitral valvular disease. Nevertheless, dobutamine stress echo is useful for the assessment of contractile and flow reserve in aortic stenosis with reduced left ventricular ejection fraction. Stress echo should always be performed by an appropriately trained cardiologist assisted by a nurse or another doctor, in the settings of an adequately equipped echocardiographic laboratory and with compliance to safety requirements. Moreover, continuous education of cardiologists performing stress echo is needed.

Echocardiography in adults.

Transthoracic echocardiography is the primary non-invasive modality for anatomical and functional cardiac assessment. All one-, two-dimensional and Doppler modes use the same phenomenon, i.e. the piezoelectric effect, to visualize mobile cardiac structures and blood flow in cardiac cavities. Novel techniques for myocardial imaging, such as tissue Doppler and acoustic marker tracing, allow for the assessment of regional myocardial contractility of the left and the right ventricle. Cardiac assessment is performed in standard views characterized by an optimal acoustic window. The goal of each cardiac echo is to assess cardiac function and morphology using all available imaging modes. The evaluation of acquired valvular heart diseases should include morphological and functional changes indicative of the type (stenosis, regurgitation, complex defect) and the mechanism (Carpentier's classification of mitral regurgitation) of the defect, as well as its stage (mild, moderate, severe). The assessment of left and right ventricular function should involve the measurement of global and regional parameters. An echocardiographic report should also include information on septal continuity and the presence of additional structures or intracardiac masses.Transthoracic echocardiography is the primary non-invasive modality for anatomical and functional cardiac assessment. All one-, two-dimensional and Doppler modes use the same phenomenon, i.e. the piezoelectric effect, to visualize mobile cardiac structures and blood flow in cardiac cavities. Novel techniques for myocardial imaging, such as tissue Doppler and acoustic marker tracing, allow for the assessment of regional myocardial contractility of the left and the right ventricle. Cardiac assessment is performed in standard views characterized by an optimal acoustic window. The goal of each cardiac echo is to assess cardiac function and morphology using all available imaging modes. The evaluation of acquired valvular heart diseases should include morphological and functional changes indicative of the type (stenosis, regurgitation, complex defect) and the mechanism (Carpentier's classification of mitral regurgitation) of the defect, as well as its stage (mild, moderate, severe). The assessment of left and right ventricular function should involve the measurement of global and regional parameters. An echocardiographic report should also include information on septal continuity and the presence of additional structures or intracardiac masses.

Pol-CDRIE registry - 1-year observational data on patients hospitalized due to cardiac device-related infective endocarditis in Polish referential cardiology centres.

BACKGROUND: The rate of cardiac device-related infective endocarditis (CDRIE) is increasing worldwide, but no detailed data are available for Poland. AIMS: We aimed to evaluate clinical, diagnostic, and therapeutic data of patients hospitalized due to CDRIE in 22 Polish referential cardiology centers from May 1, 2016 to May 1, 2017. METHODS: Participating cardiology departments were asked to fill in a questionnaire that included data on the number of hospitalized patients, number and types of implanted cardiac electrotherapy devices, and number of infective endocarditis cases. We also collected clinical data and data regarding the management of patients with CDRIE. RESULTS: Overall, 99 621 hospitalizations were reported. Infective endocarditis unrelated to cardiac device was the cause of 596 admissions (0.6%), and CDRIE, of 195 (0.2%). Pacemaker was implanted in 91 patients with CDRIE (47%); cardioverter­defibrillator, in 51 (26%); cardiac resynchronization therapy­defibrillator, in 48 (25%); and cardiac resynchronization therapy­pacemaker, in 5 (2.5%). The most common symptoms were malaise (62%), fever/chills (61%), cough (21%), chest pain (19.5%), and inflammation of the device pocket (5.6%). Cultures were positive in 77.5% of patients. The cardiac device was removed in 91% of patients. The percutaneous approach was most common for cardiac device removal. All patients received antibiotic therapy, and 3 patients underwent a heart valve procedure. Transesophageal echocardiography was performed in 80% of patients. The most common complication was heart failure (25% of patients). CONCLUSIONS: The clinical profile, pathogen types, and management strategies in Polish patients with CDRIE are consistent with similar data from other European countries. Transesophageal echocardiography was performed less frequently than recommended. The removal rate in the Polish population is consistent with the general rates observed for interventional treatment in patients with CDRIE.

Are changes in heart rate, observed during dobutamine stress echocardiography, associated with a response to cardiac resynchronisation therapy in patients with severe heart failure? Results of a multicentre ViaCRT study.

BACKGROUND: According to current European Society of Cardiology guidelines for the diagnosis and treatment of heart failure (HF), cardiac resynchronisation therapy (CRT) is indicated in patients suffering from HF with reduced ejection fraction (EF) with significantly widened QRS complexes. The presence of vital myocardium proven by dobutamine stress echocardiography (DSE) is considered as a good prognostic factor for responsiveness to this treatment. Chronotropic incompetence is, on the other hand, a known factor of unfavourable outcome in HF. AIM: The aim of this study was to analyse the relationship between heart rate (HR) response during DSE and resultant changes in echocardiographic parameters determined prior to CRT and six weeks post-implantation of the CRT system. METHODS: The study included 72 men and 25 women with chronic HF and markedly deteriorated left ventricular (LV) sys-tolic function (EF < 35%). Low-dose DSE was performed prior to the CRT system implantation. Baseline echocardiographic parameters determined before CRT were compared to those measured six weeks after implantation. RESULTS: Implantation of the CRT system resulted in an improvement of LV systolic function. DSE showed a significant in-crease in HR, by 16.3 bpm on average. Patients with the least prominent increase in HR during DSE (< 7 bpm) presented with significantly greater end-diastolic LV dimension and volume, as well as with significantly lower EF than the subjects with the most evident increase in HR (> 24 bpm). Improvement in EF at six weeks was associated with lower baseline HR and its greater absolute and relative increase during DSE. Greater absolute increase in HR during DSE was also associated with more prominent decrease in systolic/diastolic LV volumes. CONCLUSIONS: Patients with better chronotropic response during DSE show significant improvement in LV parameters determined by echocardiography within six weeks of CRT. Chronotropic response to pharmacologic stress test may serve as a predictive factor in patients qualified for CRT.

Acute and chronic dissection of pulmonary artery: new challenges in pulmonary arterial hypertension?

Right ventricular failure is a leading cause of mortality in patients with pulmonary arterial hypertension (PAH). However, up to 25% of such patients die unexpectedly, without warning signs of hemodynamical decompensation. We previously documented that pulmonary artery (PA) dilatation significantly increases the risk of those deaths. Some of them may be due to dissection of PA resulting in cardiac tamponade. However, direct confirmation of this mechanism is difficult as most of such deaths occur outside hospitals. We present 4 patients with severe PAH and PA dilatation in whom PA dissection has been confirmed. Three patients had IPAH, one had PAH associated with congenital heart disease. All patients had mean pulmonary artery pressure (PAP) > 50 mmHg at diagnosis and dissection occurred late in the course of apparently well controlled disease (6 to 14 years). Several clinical elements were common to our patients - high systolic PAP, long lasting PH, progressive dilatation of PA to more than 50 mm with chest pain prior to dissection. However, clinical course followed three different patterns: sudden death due to cardiac tamponade, hemopericarditis caused by blood leaking from dissected aneurysm with imminent but not immediate cardiac tamponade, or chronic asymptomatic PA dissection. Indeed, two of our patients are alive and on lung transplantation waiting list for more than 2 years now. Further research is needed to suggest optimal management strategies for patients with stable PAH but significantly dilated proximal pulmonary arteries or confirmed PA dissection depending on the clinical presentation and expected outcome.

Chemotherapy and echocardiographic indices in patients with non-Hodgkin lymphoma: the ONCO-ECHO study.

The cardiotoxicity of chemotherapy (CTx) for non-Hodgkin's lymphomas is not well recognized. In order to facilitate individual risk counseling for patients, we analyzed the effect of CTx on echocardiographic indices in regard to clinical data in patients treated for non-Hodgkin's lymphoma (NHL). A prospective multicenter ONCO-ECHO trial included 67 patients with NHL (45 patients with DLBCL (diffuse large B cell lymphoma) and 22 with non-DLBCL). Patients received standard CTx, primarily R-CHOP, CHOP, R-COP and COP regimens. Clinical data and echocardiographic indices were obtained at baseline, 3-, 6- and 12-month follow-up. The primary end point representing CTx cardiotoxicity was defined as a ≥ 10% decrease in the left ventricular ejection fraction (LVEF) during 12-month observation. In a 12-month follow-up five (7.5%) deaths occurred, while no clinical manifestations of heart failure were reported. There was an increase in left ventricular end-systolic diameter (p = 0.002) and E/e' index (p = 0.036) in 12-month observation. Preexisting coronary artery disease was associated with significant decrease in the ΔLVEF (p = 0.008), increase in ΔLVEDV (p = 0.03) and ΔLVESV (p = 0.02) and increase in the Δ left atrium diameter (p = 0.02); while history of arterial hypertension was related to significant decrease in the ΔLVEF (p = 0.039), diabetes mellitus was related to significant increase in the ΔE/e' index (p = 0.002). The primary end point was reported in ten (14.9%) patients. There were no independent risk factors for cardiotoxicity in the study population. Chemotherapy administered to NHL patients may induce dilatation and impaired LV diastolic function. Standard cardiovascular risk factors may predispose patients to negative LV remodeling.

Polish Stress Echocardiography Registry (Pol-STRESS registry) - a multicentre study. Stress echocardiography in Poland: numbers, settings, results, and complications.

BACKGROUND: Stress echocardiography (SE) is widely used in Europe. No collective data have been available on the use of SE in Poland until now. AIM: To evaluate the number of SE investigations performed in Poland, their settings, complications, and results. METHODS: In this retrospective survey, referral cardiology centres in Poland were asked to fill in a questionnaire regarding SE examinations performed from May 1, 2014 to May 1, 2015. RESULTS: The study included data from 17 university hospitals and large community hospitals, which performed 4611 SE exa-minations, including 4408 tests in patients investigated for coronary artery disease (CAD) and 203 tests to evaluate valvular heart disease (VHD). To evaluate CAD, all centres performed dobutamine SE (100%), 10 centres performed pacing SE (58.8%), while cycle ergometer SE and treadmill SE were performed by six (35.3%) and five (29.4%) centres, respectively. Dipyridamole SE was performed in one centre. All evaluated centres (100%) performed SE to evaluate low-flow/low-gradient aortic stenosis, eight (47%) performed SE to evaluate asymptomatic aortic stenosis, and also eight (47%) performed SE to evaluate mitral regurgitation. The mean number of examinations per year was 271 per centre. Most centres performed more than 100 examinations per year (11 centres, 64.7%). We did not identify any cardiac death during SE examination in any of the centres. Myocardial infarction occurred in three (0.07%) patients. Non-sustained ventricular tachycardia occurred in 52 (1.1%) SE examinations. The rates of minor complications were low. SE to evaluate CAD was more commonly performed in the hospital settings using cycle ergometer (72.6%), treadmill (87.6%), and low-dose dobutamine (68.0%), while a dipyridamole test was more frequently employed in ambulatory patients (77.6%). No significant differences between the rates of examina-tions performed in the ambulatory and hospital settings were found for high-dose dobutamine and pacing SE. Examinations to evaluate VHD were significantly more frequently performed in the hospital settings. SE examinations accounted for more than one third of all stress tests performed in the surveyed centres over the study period. CONCLUSIONS: Stress echocardiography is a safe diagnostic method, and major complications are very rare. Despite European recommendations, SE examinations to evaluate CAD are performed less frequently than electrocardiographic exercise tests, although they already comprise a significant proportion of all stress tests. It seems reasonable to promote SE further for the evaluation of both CAD and VHD.

Role of low­dose dobutamine echocardiography in predicting response to biventricular pacing. Results from the multicenter Viability in Cardiac Resynchronisation Therapy (ViaCRT) study.

INTRODUCTION    The response to Cardiac Resynchronisation Therapy (CRT) varies significantly, resulting in lack of improvement among the substantial patients proportion.  OBJECTIVES    To identify mechanical dyssynchrony indices with combination of myocardial viability characteristics for predicting long-term response to CRT.  PATIENTS AND METHODS    ViaCRT was a multicentre study coordinated by the Working Group on Echocardiography of  Polish Cardiac Society. 127 patients with heart failure were assessed prospectively. Cardiac dyssynchrony indices and low-dose dobutamine response were determined by echocardiography prior to CRT. Improvement in Wall Motion Score Index (WMSI) or LVEF exceeding 20% at peak stress identified preserved contractile reserve.  RESULTS    After 12 months there was significantly different survival between subsets with and without viability characterised by WMSI decrease, corresponding to 1 (4.4%) and 20 (19.4%) fatal events respectively (p=0.048). The predictive value of LVEF gain at Dobutamine Stress Echocardiography (DSE) study was only significant at 6 months, with all-cause death occurring in 1 (1.6%) and 7 (12.1%) of patients with viable and non-viable myocardium respectively (p=0.029). Multivariate regression analysis identified the presence of septal flash and interventricular dyssynchrony as independent indices with the ability to predict echocardiographic response alone at 12 months. CONCLUSIONS    The study demonstrated a significant relationship between left ventricular contractile reserve at DSE and long-term all-cause mortality following CRT device implantation. Conversely, the presence of septal flash and interventricular dyssynchrony but not myocardial viability were predictive of the response to resynchronisation. The results indicate that interference of multiple different mechanisms may be responsible for the general effect following CRT.

Prognostic value of low-dose dobutamine stress echocardiography in patients with aortic stenosis and impaired left ventricular function.

INTRODUCTION: The aim of this multicenter, prospective study was to evaluate the long-term prognostic value of low-dose dobutamine stress echocardiography (LDDSE) in patients with aortic stenosis (AS) and depressed left ventricular (LV) function. MATERIAL AND METHODS: The study group comprised 39 patients (34 male, mean age 59 ±13 years) with AS (peak gradient > 25 mm Hg), LV ejection fraction (LVEF) ≤ 45% and low transaortic gradient (peak gradient ≤ 45 mm Hg, mean gradient ≤ 35 mm Hg). The qualification for subsequent therapeutic procedures was based on generally accepted indications. All patients underwent LDDSE and coronary angiography. Twelve months after LDDSE patients underwent control resting echocardiography and clinical evaluation. RESULTS: Twenty-seven (69.2%) patients had preserved contractile reserve. In this subgroup, true-severe AS was diagnosed in 12 patients, whereas pseudo-severe AS was found in 15 patients. Nine patients with true-severe AS, 2 patients with pseudo-severe AS and 7 patients without contractile reserve were referred for surgical treatment. The independent risk factors of death during follow-up were: aortic valve area (AVA) at peak stress < 0.8 cm(2) (OR 1.4; p = 0.003) and LVEF at rest < 35% (OR 6.8; p = 0.05). The independent risk factors of composite end-point (death or myocardial infarctions or pulmonary edema) were: AVA at stress < 0.8 cm(2) (OR 4.0; p = 0.03), absence of AVA increase during LDDSE (OR 5.7; p = 0.005), absence of contractile reserve (OR 4.5; p = 0.01) and presence of significant CAD (OR 6.9; p = 0.02). CONCLUSIONS: In patients with AS and depressed LVEF, LDDSE is a useful tool for long-term risk stratification.