Andrea Rossi

The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.

Objective: Left atrial volume (LAV) is a powerful predictor of outcome in patients with chronic heart failure (CHF) independently of symptomatic status, age and left ventricular (LV) function. It is unknown whether LAV provides independent and incremental information compared with exercise tolerance parameters. Methods: 273 patients with CHF (mean (SD) 62 (9) years; 13% female) prospectively underwent echocardiography and exercise testing with maximal oxygen consumption (Vo ₂). The primary end point was composite and included cardiac death, hospitalisation for worsening heart failure or cardiac transplantation. Results: At Cox proportional hazard analysis, LAV normalised for body surface area (LAV/BSA) was strongly associated with mortality (hazard ratio (HR) = 1.027 (95% CI 1.018 to 1.04), p2 and LV ejection fraction (EF) (HR = 1.014 (1.002 to 1.025), p = 0.02; HR = 0.95 (0.91 to 0.99), p = 0.02; HR = 0.89 (0.82 to 0.98), p = 0.02 for LAV/BSA, EF and Vo ₂, respectively). Receiver operator characteristic (ROC) curve analysis identified the best cut-off values for prediction of the end point. LAV/BSA >63 ml, EF 2 2. LAV, EF and Vo ₂ can be used to build a risk prediction model, which can be used clinically.

Left atrial evaluation is strongly linked to the history of cardiac imaging. In the past, the importance of this chamber has been largely downplayed because cineangiography could not visualize it directly. Nowadays echocardiography can easily assess left and right atrial size and function. Left atrial enlargement is frequent in many cardiac diseases. A main determinant of left atrial volume is ventricular diastolic function. It has recently been suggested that left atrial volume might be the morphophysiologic expression of chronic diastolic function. In fact the left atrium is exposed directly to left ventricular diastolic pressure through the open mitral valve and because of its thin wall structure it tends to dilate with increasing pressure. Other important determinants of atrial volume are the degree of ventricular remodeling, mitral regurgitation and the presence of atrial fibrillation. The degree of left atrial enlargement is associated with adverse prognosis in different clinical settings. Patients with dilated cardiomyopathy and with a left atrial volume > 68 ml/m2 have a 3.8-fold risk compared with those with smaller left atrial volume. The predictive value of left atrial volume is independent of left ventricular systolic and diastolic function, mitral regurgitation and atrial fibrillation. This is noteworthy because these factors are both determinant of left atrial volume and have a strong impact on outcome. It might be concluded that left atrial volume represents a powerful predictive marker because it is a window allowing comprehensive evaluation of several factors associated with bad prognosis, which are often difficult to document separately.

Objective: To analyse the relation between restrictive mitral pattern, amino-terminal propeptide of type III procollagen (PIIINP), and prognosis in patients with dilated cardiomyopathy. Design: Prospective cohort study of 106 patients with dilated cardiomyopathy. Setting: Tertiary care centre. Main outcome measures: PIIINP concentration, echocardiographic variables, oxygen consumption, hospitalisation for heart failure, and cardiac mortality were evaluated in patients grouped by the presence of non-restrictive (group 1), reversible (group 2), and irreversible restrictive mitral pattern (group 3). Results: Groups differed regarding left ventricular ejection fraction (group 1, mean (SD) 36 (6)%, group 2, 29 (8)%, group 3, 25 (6)%; p = 0.0001), left atrial ejection fraction (group 1, 0.47 (0.1)%, group 2, 0.43 (0.2)%, group 3, 0.26 (0.1)%; p < 0.0001), and PIIINP (p = 0.001). Multivariate analysis showed that PIIINP was related to mitral pattern (odds ratio 0.8, 95% confidence interval 0.23 to 1.4, p = 0.006) independently of left atrial and ventricular ejection fractions. After 21 months, survival was 88% and 34% (p = 0.0001) in patients with non-restrictive and irreversible restrictive mitral patterns, respectively. Conclusion: In patients with dilated cardiomyopathy, restrictive mitral pattern is associated with higher PIIINP and worse prognosis.

Background— Peak exercise oxygen consumption (V̇ o ₂ ) is crucial for the prognostic stratification of patients with congestive heart failure, but its hemodynamic determinants are still not completely understood. Aortic wall elasticity modulates left ventricular function and coronary blood flow. Whether an increased aortic pulse-wave velocity (PWV), a known marker of arterial stiffness, may predict peak V̇ o ₂ in patients with dilated cardiomyopathy (DCM) has to be clarified. Methods and Results— A total of 78 patients with clinical diagnosis of DCM (aged 62±11 years; female 29%; mean ejection fraction 34±9%) were selected. All patients underwent a complete echocardiographic-Doppler evaluation. Aortic PWV was measured by Doppler ultrasonography immediately before the exercise. A bicycle exercise test with expiratory gas exchange monitoring was performed to determine V̇ o ₂ . Plasma concentration of the amino-terminal propeptide of type III procollagen (PIIINP), a marker of extracellular matrix turnover, was determined. Mean PWV was 5.7±2.2 m/s, and V̇ o ₂ was 16.5±4.5 mL · kg ⁻¹ · min ⁻¹ . The hemodynamic variables correlated with V̇ o ₂ were PWV ( r =−0.39, P =0.0007) and stroke volume ( r =0.38, P =0.002). In a multivariate analysis, PWV ( P =0.04) and stroke volume ( P =0.05) were independently correlated with V̇ o ₂ , accounting for 34% of its variance. PIIINP levels correlated with PWV ( r =0.35, P =0.002) and a more restrictive diastolic filling pattern ( r =0.40, P =0.02). Conclusions— Increased aortic stiffness measured by PWV is an independent predictor of peak V̇ o ₂ and could partially explain exercise intolerance in patients with DCM.