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BackgroundDevelopment of left ventricle (LV) hypertrophy in aortic stenosis (AS) is accompanied by adaptive coronary flow regulation. We aimed to assess absolute coronary flow, microvascular resistance, coronary flow reverse (CFR) and microvascular resistance reserve (MRR) in patients with and without AS.MethodsAbsolute coronary flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and 29 controls, without AS, matched for age, gender, diabetes and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and left anterior descending artery (LAD)-specific mass were quantified by echocardiography and cardiac-CT.ResultsPatients with AS presented a significantly positive LV remodelling with lower global longitudinal strain and global work efficacy compared with controls. Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS (p=0.001). Compared with matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (p=0.009), resulting into lower CFR and MRR in the AS cohort compared with controls (p<0.005 for both). No differences were found in hyperaemic flow and resting and hyperaemic resistances. Hyperaemic myocardial perfusion (calculated as the ratio between the absolute coronary flow subtended to the LAD, expressed in mL/min/g), but not resting, was significantly lower in the AS group (p=0.035).ConclusionsIn patients with severe AS and non-obstructive coronary artery disease, with the progression of LV hypertrophy, the compensatory mechanism of increased resting flow maintains adequate perfusion at rest, but not during hyperaemia. As a consequence, both CFR and MRR are significantly impaired.

Background: Use of the current echocardiography-based indications for aortic regurgitation (AR) surgery might result in late valve replacement at the stage of irreversible myocardial damage. Therefore, we aimed to identify simple models combining multiple echocardiography or magnetic resonance imaging (MRI)–derived indices and natriuretic peptides (BNP [brain natriuretic peptide] or NT-proBNP [N-terminnal pro-B type natriuretic peptide]) to predict early disease decompensation in asymptomatic severe AR. Methods: This prospective and multicenter study included asymptomatic patients with severe AR, preserved left ventricular ejection fraction (>50%), and sinus rhythm. The echocardiography and MRI images were analyzed centrally in the CoreLab. The study end point was the onset of indication for aortic valve surgery as per current guidelines. Results: The derivative cohort consisted of 127 asymptomatic patients (age 45±14 years, 84% males) with 41 (32%) end points during a median follow-up of 1375 (interquartile range, 1041–1783) days. In multivariable Cox regression analysis, age, BNP, 3-dimensional vena contracta area, MRI left ventricular end-diastolic volume index, regurgitant volume, and a fraction were identified as independent predictors of end point (all P <0.05). However, a combined model including one parameter of AR assessment (MRI regurgitant volume or regurgitant fraction or 3-dimensional vena contracta area), 1 parameter of left ventricular remodeling (MRI left ventricular end-diastolic volume index or echocardiography 2-dimensional global longitudinal strain or E wave), and BNP showed significantly higher predictive accuracy (area under the curve, 0.74–0.81) than any parameter alone (area under the curve, 0.61–0.72). These findings were confirmed in the validation cohort (n=100 patients, 38 end points). Conclusions: In asymptomatic severe AR, multimodality and multiparametric model combining 2 imaging indices with natriuretic peptides, showed high accuracy to identify early disease decompensation. Further prospective studies are warranted to explore the clinical benefit of implementing these models to guide patient management. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02910349

BackgroundHeart valve clinics (HVC) have been introduced to manage patients with valvular heart disease within a multidisciplinary team.ObjectiveTo determine the outcome benefit of HVC approach compared with standard of care (SOC) for patients with moderate and asymptomatic severe aortic stenosis (mAS and asAS).MethodsSingle-centre, observational registry of patients with mAS and asAS with at least one cardiac ambulatory consultation at our Cardiovascular Centre. Based on the outpatient strategy, patients were divided into HVC group, if receiving at least one visit at HVC, and SOC group, if followed by routine cardiac consultations.Results2129 patients with mAS and asAS were divided into those followed in HVC (n=251) versus SOC group (n=1878). The mean age was 76.5±12.4 years; 919 (43.2%) had asAS. During a follow-up of 4.8±1.8 years, 822 patients (38.6%) died, 307 (14.4%) were hospitalised for heart failure and 596 (28%) underwent aortic valve replacement (AVR). After propensity score matching, the number of consultations per year, exercise stress tests, brain natriuretic peptide (BNP) determinations and CTs were higher in the HVC cohort (p<0.05 for all). A shorter time between indication of AVR and less advanced New York Heart Association class was reported in the HVC cohort (p<0.001 and p=0.032). Compared with SOC, the HVC approach was associated with reduced all-cause mortality (HR=0.63, 95% CI 0.40 to 0.98, p=0.038) and cardiovascular death (p=0.030). At multivariable analysis, the HVC remained an independent predictor of all-cause mortality (HR=0.54, 95% CI 0.34 to 0.85, p=0.007).ConclusionsIn patients with mAS and asAS, the HVC approach was associated with more efficient management and outcome benefit compared with SOC.

Aims Non‐invasive myocardial work (MW) is a validated index of left ventricular (LV) systolic performance, incorporating afterload and myocardial metabolism. The role of MW in predicting the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF) is still unknown. We aim to investigate the diagnostic performance of MW to predict the first de novo HFpEF hospitalization in ambulatory individuals with preserved LV ejection fraction. Methods and results Twenty‐nine patients with transthoracic echocardiography performed at least 6 months before the first HFpEF hospitalization were compared with 29 matched controls. MW was derived as the area of pressure–strain loop using speckle‐tracking and brachial artery blood pressure. Global work index, global constructive work, global wasted work (GWW), and global work efficiency (GWE) were collected. First HFpEF hospitalization and its combination with cardiovascular death [major adverse cardiovascular events (MACE)] and all‐cause of death [major adverse events (MAE)] were assessed. At baseline, future HFpEF patients showed lower global work index, global constructive work, GWE, and higher GWW than controls (all P < 0.05). At admission vs. baseline, GWE significantly decreased, and GWW increased in the HFpEF group (P < 0.05), whereas no significant difference was observed in the controls over time. GWW, with a cut‐off of 170 mmHg%, showed the largest area under the curve (AUC) to predict first HFpEF hospitalization [AUC = 0.80, 95% confidence interval (CI) 0.69–0.91, P < 0.001], MACE (AUC = 0.80, 95% CI 0.66–0.90, P < 0.001), and MAE (AUC = 0.79, 95% CI 0.62–0.88, P = 0.001). GWW > 170 mmHg% was associated with a 4‐fold increase of MACE (HR = 4.5, 95% CI 1.59–13.12, P = 0.005) and a 3‐fold higher risk of MAE (HR = 2.9, 95% CI 1.24–6.6, P = 0.014). Conclusions In ambulatory patients with preserved LV ejection fraction and risk factors, GWW showed high accuracy to predict the first HFpEF hospitalization and its combination with mortality. The GWW routine assessment may be clinically helpful in patients with dyspnoea.