Semiquantitative 18F-FDG PET/CT in monitoring glucocorticoid response of immunoglobulin G4-related effusive constrictive pericarditis: a case report.

BACKGROUND: Immunoglobulin G4 (IgG4)-related effusive constrictive pericarditis (ECP) is a rare manifestation of IgG4-related disease (IgG4-RD). It can lead to persistent pericardial fibrosis, resulting in cardiac tamponade, diastolic dysfunction, and heart failure. Glucocorticoids are the primary treatment for effectively reducing inflammation and preventing fibrosis. However, guidelines for monitoring treatment response are lacking and tapering glucocorticoid therapy for specific target organs remains a challenge. Recent studies on IgG4-RD have demonstrated that semiquantitative measurements of fluorine-18 fluorodeoxyglucose (18F-FDG) uptake in the main involved organs in positron emission tomography/computed tomography (PET/CT) scanning are correlated to disease activity. We present a case of IgG4-related ECP to demonstrate the usefulness of 18F-FDG PET/CT for diagnosing and treatment follow-up of IgG4-related ECP. CASE PRESENTATION: Herein, a 66-year-old woman diagnosed with IgG4-related ECP presented with breathlessness, leg swelling, rales, and fever. Laboratory tests revealed markedly elevated levels of C-reactive protein, and transthoracic echocardiography revealed constrictive physiology with effusion. High IgG4 levels suggested an immune-related pathogenesis, while viral and malignant causes were excluded. Subsequent pericardial biopsy revealed lymphocyte and plasma cell infiltration in the pericardium, confirming the diagnosis of IgG4-related ECP. 18F-FDG PET/CT revealed increased uptake of 18F-FDG in the pericardium, indicating isolated cardiac involvement of IgG4-RD. Treatment with prednisolone and colchicine led to a rapid improvement in the patient's condition within a few weeks. Follow-up imaging with 18F-FDG PET/CT after 3 months revealed reduced inflammation and improved constrictive physiology on echocardiography, leading to successful tapering of the prednisolone dose and discontinuation of colchicine. CONCLUSION: The rarity of IgG4-related ECP and possibility of multiorgan involvement in IgG4-RD necessitates a comprehensive diagnostic approach and personalized management. This case report highlights the usefulness of 18F-FDG PET/CT in the diagnosis and treatment follow-up of isolated pericardial involvement in IgG4-RD.

Echocardiographic Measurement of Left Atrial Strain　- A Key Requirement in Clinical Practice.

Unlike the left ventricle (LV), the left atrium (LA) has a thin-walled structure and has been regarded as a simple conduit chamber. However, the unique function of the LA to modulate LV filling has recently drawn much attention. Because LA structure and function are directly influenced by the LV filling pressure, LA assessment is an essential step in the diagnosis of diastolic dysfunction that can help predict new-onset atrial fibrillation, assess the risk of further embolic events, and identify high-risk patients for adverse cardiovascular events. Even in the recent era of multimodality imaging, 2-dimensional (2D) echocardiography is the most common imaging method and the central modality for evaluation of LA function. LA strain derived from 2D echocardiography can help assess LA function objectively and demonstrates the 3 distinct phasic motions of the LA cycle. Further, LA strain provides invaluable pathophysiologic information and helps to predict clinical prognosis in various cardiovascular diseases. In this review article, we focus on LA strain: basic concepts, advantages over conventional parameters, and some unresolved issues. Additionally, we present a brief history of the clinical evidence for LA strain. Through this review, we suggest echocardiography for LA strain assessment in clinical practice.

Surgical as Opposed to Transcatheter Aortic Valve Replacement Improves Basal Interventricular Septal Hypertrophy.

BACKGROUND: Basal interventricular septum (IVS) hypertrophy (BSH) with reduced basal IVS contraction and IVS-aorta angle is frequently associated with aortic stenosis (AS). BSH shape suggests compression by the longitudinally elongated ascending aorta, causing basal IVS thickening and contractile dysfunction, further suggesting the possibility of aortic wall shortening to improve the BSH. Surgical aortic valve replacement (SAVR), as opposed to transcatheter AVR (TAVR), includes aortic wall shortening by incision and stitching on the wall and may potentially improve BSH. We hypothesized that BSH configuration and its contraction improves after SAVR in patients with AS. Methods and Results: In 32 patients with SAVR and 36 with TAVR for AS, regional wall thickness and systolic contraction (longitudinal strain) of 18 left ventricular (LV) segments, and IVS-aorta angle were measured on echocardiography. After SAVR, basal IVS/average LV wall thickness ratio, basal IVS strain, and IVS-aorta angle significantly improved (1.11±0.24 to 1.06±0.17; -6.2±5.7 to -9.1±5.2%; 115±22 to 123±14°, P<0.001, respectively). Contractile improvement in basal IVS was correlated with pre-SAVR BSH (basal IVS/average LV wall thickness ratio or IVS-aorta angle: r=0.47 and 0.49, P<0.01, respectively). In contrast, BSH indices did not improve after TAVR. CONCLUSIONS: In patients with AS, SAVR as opposed to TAVR improves associated BSH and its functional impairment.

Impaired left ventricular diastolic function is related to the formation of left ventricular apical thrombus in patients with acute anterior myocardial infarction.

Left ventricular (LV) apical thrombus is a clinically important complication which can cause systemic embolization in patients with anterior acute myocardial infarction (AMI). Systolic dysfunction has been a risk factor for developing LV apical thrombus in AMI patients. However, the role of diastolic dysfunction in the development of LV apical thrombus in these patients is still unknown. We performed this study to evaluate whether diastolic dysfunction can influence the development of LV apical thrombus in anterior AMI patients. We retrospectively analyzed all consecutive anterior AMI patients with available echocardiographic images within 1 month from January 2005 to April 2016. After gathering clinical characteristics from their medical records, systolic and diastolic functions were analyzed from digitally stored echocardiographic images. We included a total of 1045 patients (748 males, mean age 64 ± 12 years) with anterior AMI, and 494 (47%) were diagnosed as STEMI. The incidence of LV apical thrombus was 3.3% (34/1045). The LV apical thrombus group had larger LV diastolic dimension, larger LV diastolic and systolic volumes, and lower LVEF than the no LV thrombus group. The LV apical thrombus group showed higher mitral E velocity over mitral annular E' velocity ratio, an indicator of LV end-diastolic pressure (P < 0.001). In the LV apical thrombus group, the incidence of grade 2 diastolic dysfunction (32 vs 12%, P = 0.001) and grade 3 diastolic dysfunction (26 vs 2%, P < 0.001) were significantly higher than in the no LV apical thrombus group. The presence of more than grade 2 diastolic dysfunction, LVEF and presence of LV apical aneurysm were statistically significant factors associated with LV apical thrombus after the multivariate analysis. In conclusion, along with LV systolic dysfunction and LV apical aneurysm, LV diastolic dysfunction was also related with the presence of LV apical thrombus in patients with anterior AMI.

Intrinsic changes of left ventricular function in patients with Behçet disease and comparison according to systemic disease activity.

PURPOSE: Although cardiac manifestation of Behçet disease (BD) has been described in sporadic reports, its timely diagnosis remains difficult. The objective of this study was to describe early cardiac manifestations of BD. We also performed a comprehensive classification of systemic BD activity and compared their cardiac manifestations. METHODS: A prospective screening using speckle tracking echocardiography was performed in 85 patients with BD who had no history of heart disease. After excluding subjects with left ventricular (LV) ejection fraction (LVEF) <50% (n = 1), atrial fibrillation (n = 2), or inadequate echocardiographic images (n = 1), we analyzed their clinical and echocardiographic parameters including LV global longitudinal strains (GLS) and compared them with those of an age- and gender-matched control group (n = 145). Systemic BD activity was classified as minimal (Group A), controlled (Group B), and active (Group C). RESULTS: In 81 study patients (59 females, age of 51 ± 11 years), echocardiography revealed a mean LVEF of 64 ± 5% without any significant valvular dysfunction or aortic aneurysm. Although there was no difference in LVEF between the control group and the patient group, the patient group showed significant reduction in GLS (-17.1 ± 2.9% vs -20.8 ± 2.2%, P < .001). Groups A (n = 21, 26%), B (n = 47, 58%), and C (n = 13, 58%) consistently showed reduction in GLS compared with the control group. However, there was no significant difference in cardiac manifestations among these groups according to systemic disease activity. CONCLUSION: Patients with BD present intrinsic LV dysfunction despite no apparent abnormality on routine echocardiography. However, their cardiac manifestations are not proportional to systemic BD activity.

Normal reference values of diastolic strain rate in healthy individuals: Chronological trends and the comparison according to genders.

PURPOSE: Recently, the diastolic strain rate (DSR) utilizing speckle-tracking echocardiography has been proposed as a novel parameter for left ventricular diastolic function. We aimed to present normal reference data for those in a large-sized, selected group of healthy individuals. METHODS: The current study was a part of the Normal echOcardiogRaphic Measurements in KoreAn popuLation (NORMAL), a prospective nationwide survey from 23 centers in Korea. We analyzed 447 subjects (age 48 ± 15 years, 234 females) without any history of cardiovascular disease and presented the early and late DSRs (SRe and SRa , respectively) in a total and gender-/age-specified groups. RESULTS: Among the total subjects, the mean SRe and SRa were 1.6 ± 0.4 S-1 and 0.8 ± 0.3 S-1 , respectively. With increasing age, there were significant trends of decreasing SRe and increasing SRa . Although both gender groups showed comparable age, the female group presented significantly higher SRe compared to male subjects with age of 20-59 years, which diminished after the age of 60 years. However, the SRa was comparable between genders in all age groups. On multiple linear regression, age showed independent associations with both SRe (ß = -0.132, P = .010) and SRa (ß = 0.440, P < .001), whereas gender did not show any association with SRe or SRa . CONCLUSION: We present normal reference data of a novel parameter, DSR, in a large-sized selected group with healthy Korean subjects. Additionally, we present significant age-related changes both in SRe and SRa without the impact of their gender.

Early surgery versus conventional treatment for infective endocarditis.

BACKGROUND: The timing and indications for surgical intervention to prevent systemic embolism in infective endocarditis remain controversial. We conducted a trial to compare clinical outcomes of early surgery and conventional treatment in patients with infective endocarditis. METHODS: We randomly assigned patients with left-sided infective endocarditis, severe valve disease, and large vegetations to early surgery (37 patients) or conventional treatment (39). The primary end point was a composite of in-hospital death and embolic events that occurred within 6 weeks after randomization. RESULTS: All the patients assigned to the early-surgery group underwent valve surgery within 48 hours after randomization, whereas 30 patients (77%) in the conventional-treatment group underwent surgery during the initial hospitalization (27 patients) or during follow-up (3). The primary end point occurred in 1 patient (3%) in the early-surgery group as compared with 9 (23%) in the conventional-treatment group (hazard ratio, 0.10; 95% confidence interval [CI], 0.01 to 0.82; P=0.03). There was no significant difference in all-cause mortality at 6 months in the early-surgery and conventional-treatment groups (3% and 5%, respectively; hazard ratio, 0.51; 95% CI, 0.05 to 5.66; P=0.59). The rate of the composite end point of death from any cause, embolic events, or recurrence of infective endocarditis at 6 months was 3% in the early-surgery group and 28% in the conventional-treatment group (hazard ratio, 0.08; 95% CI, 0.01 to 0.65; P=0.02). CONCLUSIONS: As compared with conventional treatment, early surgery in patients with infective endocarditis and large vegetations significantly reduced the composite end point of death from any cause and embolic events by effectively decreasing the risk of systemic embolism. (EASE ClinicalTrials.gov number, NCT00750373.).

Incidence and predictors of left atrial thrombus in patients with atrial fibrillation under anticoagulation therapy.

BACKGROUND: Left atrial thrombus (LAT) formation is associated with thromboembolic events. OBJECTIVE: To investigate the incidence and associated factors of LAT in patients with atrial fibrillation (AF) who had been receiving anticoagulation therapy for more than 4 weeks, and to develop a prediction model using clinical and echocardiographic features. METHODS: Medical records of 1,122 patients with AF (mean age, 59.4 ± 11.0 years, 58.3% male) who were on anticoagulation more than 4 weeks and underwent transesophageal echocardiography (TEE) were evaluated. The main outcome was the presence of LAT on TEE. RESULTS: Warfarin and non-vitamin K oral anticoagulants were used in 74.4% and 25.6% of the patients at the time of examination, respectively. LAT was present in 60 patients (5.3%). Presence of LAT on TEE was associated with age ≥ 75 years (odds ratio [OR] 2.13 [95% confidence interval, 0.94-4.58]), persistent/permanent AF (OR 2.61 [1.42-4.93]), CHA2DS2-VASc score ≥ 3 points (OR 1.91 [1.05-3.48]), left ventricular ejection fraction < 40% (OR 2.35 [1.07-4.81]), and severe left atrial enlargement (OR 3.52 [1.89-6.79]). The presence of moderate-to-severe mitral regurgitation was associated with a lower risk of LAT (OR 0.13 [0.04-0.34]). A scoring system composed of the aforementioned predictors showed excellent discrimination performance (area under the curve 0.791 [95% CI, 0.727-0.854]). CONCLUSIONS: LAT was present in a considerable number of patients who were already receiving anticoagulation therapy. A prediction model that combines clinical and echocardiographic predictors could be useful in distinguishing patients who require imaging evaluations before left atrial intervention.

Determination of Inoue Balloon Size by Analysis of Mitral Valve Geometry Using Three-Dimensional Transesophageal Echocardiography in Patients with Mitral Stenosis.

In percutaneous mitral balloon commissurotomy (PMBC) for patients with mitral stenosis (MS), the size of the balloon has traditionally been determined using a crude method based on the patient's height or body surface area. We aimed to evaluate the clinical value of balloon size selection by quantitatively analyzing mitral valve (MV) geometry using 3D transesophageal echocardiography (TEE). In 184 consecutive patients who underwent PMBC, the geometry of the MV annulus was analyzed during mid-diastole, including the measurement of lateral-medial diameters obtained from dedicated 3D software (LMD-3d) or from analysis using multiplanar reconstruction images (LMD-mpr). Patients were categorized into three groups: those with successful results after PMBC (SU group), those with residual mitral stenosis (MS, group), and those with significant MR (MR group). The SU, MS, and MR groups included 110, 50, and 17 patients, respectively. We compared three conventional formulas (Formula 1, 2, 3) based on the patient's height or body surface area with two new formulas derived from data in the SU group: balloon size = 0.0684 × LMD-3d + 24.309 (Formula 4) and 0.061 × LMD-mpr + 24.573 (Formula 5). Compared with the calculated balloon sizes using Formula 4, the inflated balloon sizes were significantly smaller (-0.78±1.02; p<0.001) in the MS group, while they were significantly larger (0.56±1.05; p=0.04) in the MR group. This pattern was also consistent in Formula 5. In conclusion, selecting the Inoue balloon inflation size based on the mitral annulus diameter determined by 3D TEE might be a reasonable approach.

Device Closure or Antithrombotic Therapy After Cryptogenic Stroke in Elderly Patients With a High-Risk Patent Foramen Ovale.

BACKGROUND AND PURPOSE: In young patients (aged 18-60 years) with patent foramen ovale (PFO)-associated stroke, percutaneous closure has been found to be useful for preventing recurrent ischemic stroke or transient ischemic attack (TIA). However, it remains unknown whether PFO closure is also beneficial in older patients. METHODS: Patients aged ≥60 years who had a cryptogenic stroke and PFO from ten hospitals in South Korea were included. The effect of PFO closure plus medical therapy over medical therapy alone was assessed by a propensity-score matching method in the overall cohort and in those with a high-risk PFO, characterized by the presence of an atrial septal aneurysm or a large shunt. RESULTS: Out of the 437 patients (mean age, 68.1), 303 (69%) had a high-risk PFO and 161 (37%) patients underwent PFO closure. Over a median follow-up of 3.9 years, recurrent ischemic stroke or TIA developed in 64 (14.6%) patients. In the propensity score-matched cohort of the overall patients (130 pairs), PFO closure was associated with a significantly lower risk of a composite of ischemic stroke or TIA (hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.24-0.84; P=0.012), but not for ischemic stroke. In a subgroup analysis of confined to the high-risk PFO patients (116 pairs), PFO closure was associated with significantly lower risks of both the composite of ischemic stroke or TIA (HR: 0.40; 95% CI: 0.21-0.77; P=0.006) and ischemic stroke (HR: 0.47; 95% CI: 0.23-0.95; P=0.035). CONCLUSION: Elderly patients with cryptogenic stroke and PFO have a high recurrence rate of ischemic stroke or TIA, which may be significantly reduced by device closure.

2023 Korean Society of Echocardiography position paper for the diagnosis and management of valvular heart disease, part II: mitral and tricuspid valve disease.

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the diagnosis and management of valvular heart diseases with referring to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee sought to reflect national data on the topic of valvular heart diseases published to date through a systematic literature search based on validity and relevance. In the part II of this article, we intend to present recommendations for diagnosis and treatment of mitral valve disease and tricuspid valve disease.

2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease.

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.

Imaging characteristics of ischemic strokes related to patent foramen ovale.

BACKGROUND AND PURPOSE: Subclinical atrial fibrillation (AF) and patent foramen ovale (PFO) are the major causes of cryptogenic stroke, and neuroimaging may help distinguish the cause. We compared the imaging characteristics of ischemic stroke caused by PFO (PFO-stroke) and AF (AF-stroke). METHODS: We recruited 117 patients with PFO-stroke and 358 patients with AF-stroke after excluding other causes. The lesion patterns were classified according to number, location, size, and pertinent vascular territory and were compared between the 2 groups. Occlusion of the corresponding artery and its recanalization rate were also investigated. RESULTS: The lesion pattern of a PFO-stroke was more frequently observed as a single cortical infarction (34.2% versus 3.1%; P<0.001) or multiple small (<15 mm) scattered lesions (23.1% versus 5.9%; P<0.001) and in the vertebrobasilar artery territory (44.4% versus 22.9%; P<0.001). By contrast, AF-stroke was more frequently observed as a large cortico-subcortical infarction or confluent lesion (>15 mm) with additional lesions in multicirculatory territories. For a PFO-stroke, occlusion of the corresponding vessel on angiography was less frequent (34.2% versus 71.5%; P<0.001), and the neurological deficit evaluated by the National Institutes of Health Stroke Scale was mild (3.48±4.16 versus 9.15±7.35; P<0.001). The recanalization rate was also lower (57.1% versus 78.3%; P=0.007). CONCLUSIONS: A PFO-stroke usually appears as a single cortical or multiple small ischemic lesions in the vertebrobasilar circulation without any visible vessel occlusion on angiography. The recanalization rate is significantly lower than in AF-stroke. These imaging characteristics of PFO-stroke may help to diagnose the mechanism and determine the treatment strategy.

Long-term luminal change after drug-eluting stent implantation: serial angiographic follow-up study of the ZEST randomized trial.

OBJECTIVE: To evaluate long-term patterns of luminal changes after implantation of different types of drug-eluting stents (DES), we analyzed the serial angiographic outcomes of patients implanted with zotarolimus-eluting stents (ZES), sirolimus-eluting stents (SES), or paclitaxel-eluting stents (PES). BACKGROUND: Little is known regarding long-term luminal changes after DES implantation. METHODS: As a subgroup analysis of the ZEST trial, we performed complete angiographic evaluation immediately after the procedure and at 9 months and 2 years in 111 patients with 165 lesions (36 patients with ZES, 40 with SES, and 35 with PES). RESULTS: Baseline clinical, angiographic, and procedural characteristics were similar among the three groups. Quantitative angiographic analysis revealed significant decreases in minimal luminal diameter 9 months after stent implantation in the ZES (from 2.71 ± 0.49 to 2.21 ± 0.42 mm, P < 0.001), SES (from 2.79 ± 0.49 to 2.58 ± 0.57 mm, P < 0.001), and PES (from 2.66 ± 0.45 to 2.19 ± 0.52 mm, P < 0.001) groups. However, significant late improvements with different degree in luminal diameter were observed between 9 months and 2 years in the ZES (from 2.21 ± 0.42 to 2.39 ± 0.58 mm, P = 0.001), SES (from 2.58 ± 0.57 to 2.66 ± 0.60 mm, P = 0.039), and PES (from 2.19 ± 0.52 to 2.43 ± 0.52 mm, P < 0.001) groups. CONCLUSION: Serial angiographic follow-up study revealed a biphasic luminal response after DES implantation, characterized by an early progression phase for the first 9 months and a late regression phase from 9 months to 2 years.

Epidemiologic Profile of Patients With Valvular Heart Disease in Korea: A Nationwide Hospital-Based Registry Study.

BACKGROUND: Valvular heart disease (VHD) is a common cause of cardiovascular morbidity and mortality worldwide; however, its epidemiological profile in Korea requires elucidation. METHODS: In this nationwide retrospective cohort study from the Korean valve survey, which collected clinical and echocardiographic data on VHD from 45 medical centers, we identified 4,089 patients with VHD between September and October 2019. RESULTS: The aortic valve was the most commonly affected valve (n = 1,956 [47.8%]), followed by the mitral valve (n = 1,598 [39.1%]) and tricuspid valve (n = 1,172 [28.6%]). There were 1,188 cases of aortic stenosis (AS) and 926 cases of aortic regurgitation. The most common etiology of AS was degenerative disease (78.9%). The proportion of AS increased with age and accounted for the largest proportion of VHD in patients aged 80-89 years. There were 1,384 cases of mitral regurgitation (MR) and 244 cases of mitral stenosis (MS). The most common etiologies for primary and secondary MR were degenerative disease (44.3%) and non-ischemic heart disease (63.0%), respectively, whereas rheumatic disease (74.6%) was the predominant cause of MS. There were 1,172 tricuspid regurgitation (TR) cases, of which 46.9% were isolated and 53.1% were associated with other valvular diseases, most commonly with MR. The most common type of TR was secondary (90.2%), while primary accounted for 6.1%. CONCLUSIONS: This report demonstrates the current epidemiological status of VHD in Korea. The results of this study can be used as fundamental data for developing Korean guidelines for VHD.

Percutaneous versus surgical revascularization in patients with ischemic mitral regurgitation.

BACKGROUND: The proper way of revascularization remains controversial in patients with ischemic mitral regurgitation (IMR). We sought to compare the long-term results of percutaneous coronary intervention (PCI) and surgical revascularization in IMR. METHODS AND RESULTS: From 1996 to 2008, 185 consecutive patients (132 men; age, 63 ± 9 years) with significant IMR underwent PCI (PCI group) (n=66) or coronary artery bypass graft surgery (OP group) (n=119). In the OP group, 68 (57%) patients also underwent concomitant mitral annuloplasty. Significant IMR was defined as functional MR occurring >1 week after myocardial infarction with an effective regurgitant orifice area ≥ 0.2 cm(2). During a median follow-up of 54 months, there were 2 operative mortalities, 26 cardiac deaths, and 11 heart failure hospitalizations in the OP group and 22 cardiac deaths and 10 heart failure hospitalizations in the PCI group. The survival and cardiac mortality rates were not significantly different between the 2 groups, but event-free survival rates were significantly higher in the OP group. For the 45 propensity score-matched pairs, the risk of cardiac events was significantly lower in the OP group than in the PCI group (hazard ratio, 0.499; 95% CI, 0.251 to 0.990; P=0.043). Compared with patients who underwent coronary artery bypass graft surgery alone, event-free survival rates were significantly higher in those who underwent additional mitral annuloplasty. CONCLUSIONS: Compared with PCI, surgical revascularization is associated with an improved long-term event-free survival, and concomitant mitral annuloplasty should be considered in patients with significant IMR.

Current Unmet Needs and Clues to the Solution in the Management of Tricuspid Regurgitation.

Although tricuspid regurgitation (TR) is a general medical issue with growing prevalence and socioeconomic burden, most clinicians have not paid much attention to TR in the past. Several problems of TR have been pointed out in clinical practice, which include: ambiguous clinical manifestations and the difficulty in initial detection, limitations in generally used diagnostic tools, the absence of objective criterion for therapeutic intervention, high operative morbidity and mortality, and lack of long-term clinical data after the intervention for TR. Therefore, patients with TR usually visit clinicians at a much-advanced state, and this delay gives a major dilemma in clinical decision-making in a routine clinical practice. To improve the clinical outcome of TR, we need more knowledge about TR for solving the current problems and making strategies for better clinical practice. With this background, we have discussed in the present article about the pathophysiology of TR and the problems frequently experienced by clinical physicians in the diagnosis and treatment of TR. Furthermore, we have discussed the future strategy to improve the treatment of TR.

Bicuspid aortic valve: evolving knowledge and new questions.

Bicuspid aortic valve (BAV), a common congenital anomaly with various morphological phenotypes, is also characterised by marked heterogeneity in clinical presentations including clinically silent condition with mild valvulo-aortopathy, progressive valvulopathy and complex valvulo-aortopathy with shorter life expectancy. The clinical importance of using a general and unified nosology for BAV is well-accepted by opinion leaders and an international consensus statement has been recently published, which will serve as an important scientific platform for BAV. This review describes the current knowledge of BAV based on clinical studies, addresses several unresolved issues requiring investigators' attention and highlights the necessity of prospective studies with a very long follow-up duration for better appreciation of BAV-associated valvulo-aortopathy. In addition, the progression of valvular calcification in patients with BAV and its potential contribution to development of valvulopathy will be discussed.

Rapid Development of Diffuse Myocardial Calcification in a Patient after Recovery from Sepsis and Renal Failure: A Case Report.

Myocardial calcification can develop owing to several conditions. It is a rare complication following sepsis and renal failure. We report a case of rapid development of left ventricular mid-wall calcification observed using CT and cardiac MRI in a patient after recovery from sepsis and acute renal failure.

Prognostic Impact of Left Atrial Strain After Mitral Valve Repair Surgery in Patients With Severe Mitral Regurgitation.

BACKGROUND AND OBJECTIVES: The prognostic value of left atrial (LA) function in terms of long-term clinical outcomes after mitral regurgitation (MR) surgery remains unclear. Therefore, we investigated the impact of preoperative LA global longitudinal strain (LAGLS) on the long-term postoperative clinical outcomes in chronic severe MR patients who underwent mitral valve (MV) repair surgery. METHODS: From January 2012 to December 2017, we analyzed 338 patients (mean age, 51.9±12.5 years; 218 males [64.5%]) treated with MV repair surgery for severe MR. The primary outcome was cardiovascular events, defined as the composite of all-cause death, newly developed atrial fibrillation (AF), and re-hospitalization for cardiovascular causes. RESULTS: During a median follow-up of 45 months (interquartile range, 26-65), 30 (8.9%) cardiovascular events, 5 (1.5%) all-cause death, 8 (2.4%) newly developed AF, and 26 (7.7%) re-hospitalizations occurred. On multivariable analysis, baseline LAGLS was an independent predictor of cardiovascular events (adjusted hazard ratio [HR], 0.91; 95% confidential interval [CI], 0.85-0.97; p=0.004) and re-hospitalization (adjusted HR, 0.93; 95% CI, 0.86-1.00; p=0.037). According to the optimal cutoff value of LAGLS, patients with low LAGLS (<23.6%) had a significantly higher risk of cardiovascular events (adjusted HR, 2.70; 95% CI, 1.04-7.00; p=0.041) than those with high LAGLS (≥23.6%). In a subgroup analysis, patients with high LAGLS had better clinical outcomes regardless of whether the patient had a LA volume index <60 mL/m². CONCLUSIONS: In patients with chronic severe MR who received successful MV repair surgery, preoperative LAGLS is an independent predictor of long-term postoperative outcomes.