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AimsCardiac resynchronization therapy (CRT) in heart failure is limited by many non-responders. This study explores whether degree of wasted left ventricular (LV) work identifies CRT responders.Methods and resultsTwenty-one patients who received CRT according to guidelines were studied before and after 8 ± 3 months. By definition, segments that shorten in systole perform positive work, whereas segments that lengthen do negative work. Work was calculated from non-invasive LV pressure and strain by speckle tracking echocardiography. For each myocardial segment and for the entire LV, wasted work was calculated as negative work in percentage of positive work. LV wall motion score index (WMSI) was assessed by echocardiography. Response to CRT was defined as ≥15% reduction in end-systolic volume (ESV). Responder rate to CRT was 71%. In responders, wasted work for septum was 117 ± 102%, indicating more negative than positive work, and decreased to 14 ± 12% with CRT (P < 0.01). In the LV free wall, wasted work was 19 ± 16% and showed no significant change. Global LV wasted work decreased from 39 ± 21 to 17 ± 7% with CRT (P < 0.01). In non-responders, there were no significant changes. In multiple linear regression analysis, septal wasted work and WMSI were the only significant predictors of ESV reduction (β = 0.14, P = 0.01; β = 1.25, P = 0.03). Septal wasted work together with WMSI showed an area under the curve of 0.86 (95% confidence interval 0.71–1.0) for CRT response prediction.ConclusionWasted work in the septum together with WMSI was a strong predictor of response to CRT. This novel principle should be studied in future larger studies.

SNP and 8-bromo-cGMP cause a negative inotropic effect and depress the rate of recovery from intracellular acidification that is mediated by Na(+)-H+ exchange in normal adult rat myocytes. In contrast, SNP and 8-bromo-cGMP do not modify cell contraction or pHi in hypertrophied myocytes.

Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence‐based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear‐cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.

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Background Exercise capacity is a strong predictor of morbidity and mortality overall. In severe aortic stenosis (AS) ustained pressure overload during watchful waiting is associated with LV structural and functional deterioration and impaired clinical outcome both pre- and post aortic valve replacement (AVR). The effect of early surgical aortic valve replacement (SAVR) in asymptomatic patients with severe AS and normal left ventricular function on exercise capacity in unknown. Aim We investigated whether the early surgical AVR in truly asymptomatic patients with severe aortic stenosis and normal LVEF improves the exercise capacity. Methods This is a sub-analysis or the AVATAR trial (NCT02436655), which is international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity &gt;4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Patients underwent cardiopulmonary exercise testing (supine bicycle, ramp protocol, 15 W/min) at the baseline and 12 months following the randomization. Patients who had positive exercise testing at baseline visit were excluded. We compared the value of workload (in WATs), VO2 max, VO2 AT, VE/VCO2 and PETCO2 slope at the inclusion and at 12 months. Results Total of 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Mean LVEF and Vmax in early surgery and conservative treatment group were 70% and 4.5m/s and 69% and 4.5m/s, respectively. After 12 months in patients with conservative treatment there was a slight decrease in the values of workload, VO2 max, VO2 AT, VE/VCO2 and PETCO2 slope, but without statistical significance. However operated patients showed a significant increase in workload (115.4±38.4 watts at 12 months vs 104.8±42.2 at inclusion, p=0.038) and VO2 max (19.7±6.8 at 12 months vs 16.2±5.4 at the inclusion, p=0.048), while there was slight increase in the values of VO2 AT, VEVCO2 and PETCO2 but without statistical significance. Conclusion Early SAVR improve the functional capacity in asymptomatic patients with severe aortic stenosis and normal left ventricular ejection fraction Funding Acknowledgement Type of funding sources: None.

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