Aims  The aim of this study is to analyse the prognostic implications of right ventricular (RV) dysfunction as detected by strain analysis in patients with severe tricuspid regurgitation (TR). The evaluation of RV systolic function in presence of severe TR is of paramount importance for operative risk stratification; however, it remains challenging, as conventional echocardiographic indexes usually lead to overestimation. Methods and results We enrolled 250 consecutive patients with severe TR referred to our centre. Baseline clinical and echocardiographic data and follow-up outcomes were collected. Patients were predominantly female, with multiple cardiovascular risk factors and comorbidities, history of heart failure, and atrial fibrillation. Most of them had presented with clinical signs of RV heart failure (RVHF) and advanced New York Heart Association class. The RV strain analysis [both RV free wall longitudinal strain (RVFWLS) and RV global longitudinal strain (RVGLS)] reclassified ∼42–56% of patients with normal RV systolic function according to conventional parameters in patients with impaired RV systolic function. RVFWLS ≤17% (absolute values, AUC: 0.66, P = 0.002) predicted the presence of RVHF [odds ratio (OR) 0.93, P = 0.01]. At follow-up, patients with RVFWLS >14% (absolute values, AUC: 0.70, P = 0.001, sensitivity 72%, specificity 54%) showed a better survival (P = 0.01). Conclusion Different ranges of RVFWLS have different implications in patients with severe TR, allowing to identify a preclinical and a clinical window, with correlations to RVHF and survival.

Consecutive patients with left atrial appendage thrombosis can benefit from left atrial appendage closure with systematic preventive cerebral protection system deployment.

Background Limited clinical data exist describing the use of direct oral anticoagulants (DOACs) in patient with extreme body weight. Thus, the International Society of Thrombosis and Haemostasis (ISTH) recommends avoiding DOACs in patients with weight >120 Kg, and on the contrary, no restrictions exist for underweight patients. Objective To evaluate the effects of extreme body weight on DOAC activity and to compare the clinical outcomes of patients with an extreme body weight versus patients with a normal weight (61‐119 Kg) treated with DOACs. Methods Single tertiary care Italian centre multidisciplinary registry including nonvalvular atrial fibrillation (NVAF) patients treated with DOACs. Based on weight, three subcohorts were defined: (i) underweight patients (≤60 Kg); (ii) patients with a normal weight (61‐119 Kg, as control group); and (iii) overweight patients (≥120 Kg). Primary efficacy endpoint was 2‐year rate of thromboembolic events. Primary safety endpoint was 2‐year rate of major bleeding. Event‐free survival curves among groups were compared using Cox‐Mantel test. Results 812 NVAF patients were included, 108 patients weighed ≤60 Kg (13%, underweight), 688 weighed between 61 and 119 Kg (85%, normal weight), and 16 weighed ≥120 Kg (2%, overweight). In particular, among underweight patients, dabigatran was prescribed in 26% patients, apixaban in 27%, rivaroxaban in 28% and edoxaban in 22% ones. Instead, among overweight patients, 44% were treated with dabigatran, 25% with apixaban, 25% with rivaroxaban and 4% with edoxaban. Underweight patients were older, more frequently women, with lower creatinine clearance and a history of previous strokes, resulting in higher CHA2DS2‐VASc score than in both remaining groups. Up to 2 years, no statistically significant difference was observed between the three groups of weight for thromboembolic events (P = .765) and for overall bleeding (P = .125), but a trend towards decreased overall bleeding rates was noticed as weight increased (24.1% vs 16.7% vs 12.5%, respectively). Conclusion In this tertiary care centre registry, 15% of patients treated with DOACs presented an extreme weight. Compared to patients with a normal weight, no significant rates of thromboembolic events were observed for underweight or overweight patients. A trend towards decreased overall bleeding frequency as weight increased was highlighted up to 2 years. The present results should be considered as preliminary and hypothesis generating.

No abstract

Funding Acknowledgements Type of funding sources: None. BACKGROUND. Right ventricular-to-pulmonary artery (RV-PA) coupling integrates RV systolic function at a given afterload and has been shown to have a prognostic impact in different clinical settings. In the context of severe functional TR, it reflects RV adaptation to both volume and pressure overload. However, its prognostic relevance has not been extensively  examined in patients suffering from severe TR, and available data evaluated RV-PA coupling using the TAPSE/PASP ratio, with its intrinsic limitation especially in the setting of concomitant severe TR. In patients with severe TR, right ventricular free-wall longitudinal strain (RVFWLS) has been demonstrated to be more senstie in evaluation of subtle RV systolic dysfunction and to reclassify patients with impaired RV systolic function although conventional echocardiographic parameters within normal limits. PURPOSE.  To analyze whether the noninvasive evaluation of RV-PA coupling with the use of the RVFWLS/PASP ratio could improve risk stratification in patients with severe TR. METHODS. Baseline clinical and echcardiographic parameters and correlation with long-term outcome were assessed in 250 consecutive patients with severe TR referred at our center from December 2015 to December 2018. RESULTS. Patients were predominantly female, with severe cardiovascular risk factors and major comorbidities, history of heart failure (HF) and atrial fibrillation. RVFWLS/PASP ratio ≤ 0.32 (AUC 0.72, p < 0.001, sensitivity 70%, specificity 67%) marginally predicted the presence of baseline clinical RV HF (p = 0.05). After univariate and multivariate analyses, RV-PA coupling as assessed by RVFWLS/PASP ratio, but not by TAPSE/PASP, was independently associated with all-cause mortality (OR 0.007, p = 0.03) and, at follow-up, "RV-PA coupled patients", defined by RVFWLS/PASP ratio >0.26 (AUC 0.74, p < 0.001, sensitivity 77%, specificity 52%) showed higher surival rates (p = 0.02). CONCLUSIONS. RVFWLS/PASP ratio was systematically measured to possibly evaluate RV-PA coupling as a novel echocardiographic parameter in the context of patients with severe TR: it is independently associated with poor long-term prognosis and different values seem to improve irsk stratification in this cohort of patients.