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BACKGROUND: This study aimed to compare the incidence and prognostic implications of new-onset conduction disturbances after surgical aortic valve replacement (SAVR) in patients with bicuspid aortic valve (BAV) aortic stenosis (AS) versus patients with tricuspid aortic valve (TAV) AS (ie, BAV-AS and TAV-AS, respectively). Additionally, the study included stratification of BAV patients according to subtype.

METHODS: In this cohort study, the incidence of postoperative third-degree atrioventricular (AV) block with subsequent permanent pacemaker requirement and new-onset left bundle-branch block (LBBB) was investigated in 1147 consecutive patients without preoperative conduction disorder who underwent isolated SAVR (with or without ascending aortic surgery) between January 1, 2005, and December 31, 2022. The groups were stratified by aortic valve morphology (BAV, n=589; TAV, n=558). The outcomes of interests were new-onset third-degree AV block or new-onset LBBB during the index hospitalization. The impact of new-onset postoperative conduction disturbances on survival was investigated in BAV-AS and TAV-AS patients during a median follow-up of 8.2 years. BAV morphology was further categorized according to the Sievers and Schmidtke classification system (possible in 307 BAV-AS patients) to explore association between BAV subtypes and new-onset conduction disturbances after SAVR.

RESULTS: The overall incidence of third-degree AV block and new-onset LBBB after SAVR was 4.5% and 7.8%, respectively. BAV-AS patients had a higher incidence of both new-onset third-degree AV block (6.5% versus 2.5%; P=0.001) and new-onset LBBB (9.7% versus 5.7%; P=0.013) compared with TAV-AS patients. New-onset LBBB was associated with an increased all-cause mortality during follow-up (adjusted hazard ratio, 1.60 [95% CI, 1.12-2.30]; P=0.011), whereas new-onset third-degree AV block was not associated with worse prognosis. Subgroup analysis of the BAV cohort revealed that BAV-AS patients with fusion of the right- and non-coronary cusps had the highest risk of new-onset third-degree AV block (adjusted odds ratio [aOR], 8.33 [95% CI, 3.31-20.97]; P<0.001, with TAV as reference group) and new-onset LBBB (aOR, 4.03 [95% CI, 1.84-8.82]; P<0.001, with TAV as reference group), whereas no significant association was observed for the other BAV subtypes.

CONCLUSIONS: New-onset LBBB after SAVR is associated with increased all-cause mortality during follow-up, and is more frequent complication in BAV AS patients compared with TAV-AS patients. BAV-AS patients with fusion of the right- and non-coronary cusps have an increased risk for conduction disturbances after SAVR. This should be taken into consideration when managing these patients.

In August 2023 the European Society of Cardiology (ESC) published the new European guidelines for the management of infective endocarditis. Despite the severity of the disease with an often unfavorable prognosis and an increasing incidence, infective endocarditis remains a neglected area of research into cardiovascular and infectious diseases. Although large gaps of evidence exist the ESC guidelines provide several new and updated recommendations aiming to improve the management of infective endocarditis in clinical practice. Significant changes in the current ESC guidelines are primarily found in the areas of prevention including antibiotic prophylaxis, the role of the endocarditis team, diagnostic criteria, paradigm shift towards oral antibiotic treatment, timing and indications for surgical treatment as well as infections of cardiac implantable electronic devices.

Im August 2023 wurden die neuen europäischen Leitlinien zum Management der infektiösen Endokarditis durch die Europäische Gesellschaft für Kardiologie (ESC) publiziert. Trotz der Schwere der Erkrankung mit häufig ungünstiger Prognose sowie ansteigender Inzidenz bleibt die infektiöse Endokarditis ein vernachlässigtes Gebiet der kardiovaskulären und infektiologischen Forschung. Obwohl große Evidenzlücken existieren, beinhalten die ESC-Leitlinien zahlreiche neue und aktualisierte Empfehlungen, mit dem Ziel, das Management von Patienten mit infektiöser Endokarditis zu verbessern. Wesentliche Änderungen der aktuellen ESC-Leitlinien finden sich v. a. in den Bereichen Prävention inklusive Antibiotikaprophylaxe, Rolle eines Endokarditis-Teams, diagnostische Kriterien, Paradigmenwechsel der antibiotischen Therapie hin zur Oralisierung, Timing und Indikation der chirurgischen Therapie sowie Infektionen von kardialen implantierbaren elektronischen Devices.

AIMS: To investigate (i) the association between pre-operative left atrial (LA) reservoir strain and post-operative atrial fibrillation (AF) and (ii) the incidence of post-operative ischaemic stroke events separately in bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients after surgical aortic valve replacement for isolated severe aortic stenosis (AS).

METHODS AND RESULTS: We prospectively enrolled 227 patients (n = 133 BAV and n = 94 TAV) with isolated severe AS scheduled for aortic valve replacement. A comprehensive intra- and inter-observer validated pre-operative echocardiogram with an analysis of LA reservoir strain was performed. Post-operative AF was defined as a sustained (>30 s) episode of AF or atrial flutter. The timing of neurological events was defined in accordance with the Valve Academic Research Consortium-3 criteria for stroke. Post-operative AF occurred in 114 of 227 patients (50.2%), with no difference between BAV and TAV patients (48.1 vs. 53.1%, P = 0.452). Persisting post-operative AF at discharge was more frequent in BAV patients (29.7 vs. 8.0%, P = 0.005). Pre-operative LA reservoir strain was independently associated with post-operative AF (odds ratio = 1.064, 95% confidence interval 1.032-1.095, P < 0.001), with a significant interaction between LA reservoir strain and aortic valve morphology (P_interaction = 0.002). The cumulative transient ischemic attack (TIA)/stroke incidence during follow-up was significantly higher in BAV patients (19.1 vs. 5.8% at 5 years).

CONCLUSION: Pre-operative LA function was associated with post-operative AF after aortic valve replacement in BAV AS patients, while post-operative AF in TAV AS patients likely depends on transient post-operative alterations and traditional cardiovascular risk factors. TIA/stroke during follow-up was more common in BAV AS patients.

Background

Despite the availability of current antibiotic and surgical treatment options, infective endocarditis (IE) remains associated with a high mortality rate. Even though two-dimensional (2D) transesophageal echocardiography (TOE) is a major criteria in the diagnosis of IE, it is constrained by the single-plane orientation. Since three-dimensional (3D) TOE provides a comprehensive understanding of the cardiac architecture by allowing for a realistic visualization of the underlying structures in 3D space, it has attracted considerable interest in recent years.

Aim

The purpose of this narrative review is to discuss the advantages and pitfalls of 3D TOE in patients with IE, as well as to address emerging photo-realistic 3D techniques that have the potential to enhance the visualization of cardiac structures in this setting.

Results

According to recent research, 3D TOE acquisitions outperform 2D acquisitions in terms of vegetation identification accuracy and embolism risk assessment. By reporting a variety of findings that are missed with 2D TOE, but which are validated by surgical examination, 3D TOE further improves the ability to identify endocarditis complications on both native and prosthetic valves. In addition to conventional 3D TOE, future developments in 3D technology led to the development of transillumination and tissue-transparency rendering, which may improve anatomical understanding and depth perception. Due to the use of both conventional and novel 3D techniques, there are more patients who require surgical intervention, indicating that 3D TOE may have a clinical relevance on the surgical management.

Conclusion

3D TOE might fill the gaps left by 2D TOE in the diagnosis of IE.

Aims

Pulmonary vascular resistance (PVR) intimately correlates with right ventricular afterload and the development of secondary tricuspid regurgitation (sTR). We sought to investigate the prognostic roles of PVR derived by echocardiography in patients with sTR undergoing tricuspid annuloplasty (TA).

Methods and results

Data from 322 TA patients [median age (inter-quartile range): 65.0 (59.0-70.0) years; 35.7% males] were obtained from a prospective registry to determine the impact of PVR on the composite outcome [including all-cause mortality and heart failure (HF) hospitalization]. PVR was calculated by dividing the peak TR velocity by time-velocity integral of the right ven-tricular outflow tract followed by adding 0.16. During a median follow-up of 5.2 years, 108 adverse events occurred including 48 deaths and 60 HF readmissions. Baseline PVR >= 2 WU was independently associated with a higher risk of composite outcome (HR: 1.674, 95% CI: 1.028-2.726, P = 0.038). Baseline PVR outperforms both pulmonary artery systolic pressure (PASP) and the ratio of tricuspid annulus plane systolic excursion to PASP in terms of outcome prediction, with pronounced improvement of global model fit, reclassification, and discrimination. In 150 patients who received short-term echocardio-grams after surgery, the presence of post-operative PVR >= 2 WU (n = 20, 13.3%) was independently associated with the composite outcome (HR: 2.621, 95% CI: 1.292-5.319, P = 0.008).

Conclusion

PVR derived by echocardiography is an independent determinant of outcomes in patients undergoing TA for sTR. The in-clusion of non-invasive PVR may provide valuable information to improve patient selection and post-operative management in this population.

Background: Cardiac positron emission tomography (PET) offers non-invasive assessment of perfusion and left ventricular (LV) function from a single dynamic scan. However, no prior assessment of mitral regurgitation severity by PET has been presented. Application of indicator dilution techniques and gated image analyses to PET data enables calculation of forward stroke volume and total LV stroke volume. We aimed to evaluate a combination of these methods for measurement of regurgitant volume (RegVol) and fraction (RegF) using dynamic 15O-water and 11C-acetate PET in comparison to cardiovascular magnetic resonance (CMR).

Results: Twenty-one patients with severe primary mitral valve regurgitation underwent same-day dynamic PET examinations (O-15-water and C-11-acetate) and CMR. PET data were reconstructed into dynamic series with short time frames during the first pass, gated O-15-water blood pool images, and gated C-11-acetate myocardial uptake images. PET-based RegVol and RegF correlated strongly with CMR (RegVol: O-15-water r = 0.94, C-11-acetate r = 0.91 and RegF: O-15-water r = 0.88, C-11-acetate r = 0.84, p < 0.001). A systematic underestimation (bias) was found for PET (RegVol: O-15-water - 11 +/- 13 mL, p = 0.002, C-11-acetate - 28 +/- 16 mL, p < 0.001 and RegF: O-15-water - 4 +/- 6%, p = 0.01, C-11-acetate - 10 +/- 7%, p < 0.001). PET measurements in patients were compared to healthy volunteers (n = 18). Mean RegVol and RegF was significantly lower in healthy volunteers compared to patients for both tracers. The accuracy of diagnosing moderately elevated regurgitant volume (> 30mL) was 95% for O-15-water and 92% for C-11-acetate.

Conclusions: LV regurgitation severity quantified using cardiac PET correlated with CMR and showed high accuracy for discriminating patients from healthy volunteers.

This article presents a short overview of the history of echocardiography in Germany, from the experimental beginnings through the differentiation of special issues and techniques (e.g., transesophageal and contrast echocardiography) up to the current situation and impact of this imaging modality in the present day cardiology.

Der vorliegende Artikel gibt einen kurzgefassten Überblick über die Entwicklung der Echokardiographie in Deutschland, von ihren experimentellen Anfängen über die Ausdifferenzierung spezieller Fragestellungen und Techniken (z. B. transösophageale und Kontrastechokardiographie) bis zum aktuellen Stand und der Bedeutung dieser Bildgebungstechnik in der heutigen Kardiologie.