Ricci et al. Multimodality Imaging in Peripartum Cardiomyopathy KEY POINTS-Peripartum cardiomyopathy is a rare but potentially fatal disease requiring prompt identification and treatment. -Cardiac imaging plays a pivotal role for the diagnosis, risk stratification, and follow-up of peripartum cardiomyopathy and related complications. -Cardiovascular magnetic resonance is a high-throughput imaging modality providing relevant information for clinical decision-making and understanding of the pathophysiology underlying peripartum cardiomyopathy.

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Aims Multiple guidelines exist for the management of aortic stenosis (AS). We systematically reviewed current guidelines and recommendations, developed by national or international medical organizations, on management of AS to aid clinical decision making. Methods and results Publications in MEDLINE and EMBASE between June 1st, 2010 and January 15th, 2021 were identified. Additionally, the International Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations were searched. Two reviewers independently screened titles and abstracts. Two reviewers assessed rigor of guideline development and extracted the recommendations. Of the 7 guidelines and recommendations retrieved, 5 showed considerable rigor of development. Those rigorously developed, agreed on the definition of severe AS and diverse hemodynamic phenotypes, indications and contraindications for intervention in symptomatic severe AS, surveillance intervals in asymptomatic severe AS, and the importance of multidisciplinary teams (MDT) and shared decision-making. Discrepancies exist in age and surgical risk cut-offs for recommending surgical (SAVR) vs. transcatheter aortic valve implantation (TAVI), the use of biomarkers and complementary multimodality imaging for decision-making in asymptomatic patients and surveillance intervals for non-severe AS. Conclusions Contemporary guidelines for aortic stenosis management agree on the importance of MDT involvement and shared decision-making for individualized treatment and unanimously indicate valve replacement in severe, symptomatic AS. Discrepancies exist in thresholds for age and procedural risk used in choosing between SAVR and TAVI, role of biomarkers and complementary imaging modalities to define AS severity and risk of progression in asymptomatic patients.

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Funding Acknowledgements Type of funding sources: None. Background  Cardiac amyloidosis (CA) has been increasingly recognized in elderly patients with aortic stenosis (AS), but with uncertain prognostic significance. Objectives We performed a systematic review and meta-analysis to clarify whether concurrent CA portends excess mortality in patients with aortic stenosis AS. Methods Our systematic review of the literature published through June 2020, sought observational studies reporting summary-level outcome data of all-cause mortality in AS patients with or without concurrent CA. Pooled estimate of Mantel-Haenszel odds ratio (OR) and 95% confidence intervals (CIs) for all-cause death was assessed as the primary endpoint. We performed subgroup analysis stratified by severity of left ventricular hypertrophy (LVH) and study-level meta-regression analysis to explore the effect of covariates on summary effect size and to address statistical heterogeneity. Results We identified 4 studies including 609 AS patients (9% AS-CA; 69% men; age, 84 ± 5 years). The average follow-up was 20 ± 5 months. Compared with lone AS, AS-CA was associated with 2-fold increase in all-cause mortality (pooled OR: 2.30; 95% CI: 1.02-5.18; I2 = 62%). When analysed according to LVH severity, pooled ORs (95% CI) for all-cause mortality were 1.29 (0.65-2.22) for mild LVH (≤16 mm), and 4.81 (2.19-10.56) for moderate/severe LVH (>16 mm). Meta-regression analysis confirmed a stronger relationship proportional to the degree of LVH, regardless of age and aortic valve replacement, explaining between-study heterogeneity variance. Conclusions CA heralds significantly higher risk of all-cause death in elderly patients with AS. Severity of LVH appears to be a major prognostic determinant in patients with dual AS-CA pathology. Abstract Figure.

Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.