Prospective study of patients with recent-onset DCM with cardiovascular magnetic resonance (CMR) assessment of ventricular structure and function, extracellular volume (T1 mapping), myocardial strain, myocardial scar (late gadolinium enhancement) and contractile reserve (dobutamine stress). Regression analyses were used to evaluate predictors of change in LV ejection fraction (LVEF) over 12 months. We evaluated 56 participants (34 DCM patients, median LVEF 43%; 22 controls). Absolute LV contractile reserve predicted change in LVEF (1% increase associated with 0.4% increase in LVEF at 12 months, P = 0.02). Baseline myocardial strain (P = 0.39 global longitudinal strain), interstitial myocardial fibrosis (P = 0.41), replacement myocardial fibrosis (P = 0.25), and right ventricular contractile reserve (P = 0.17) were not associated with LV reverse remodelling. There was a poor correlation between contractile reserve and either LV extracellular volume fraction (r = −0.22, P = 0.23) or baseline LVEF (r = 0.07, P = 0.62). Men were more likely to experience adverse LV remodelling (P = 0.01) but age (P = 0.88) and disease-modifying heart failure medication (beta-blocker, P = 0.28; angiotensin-converting enzyme inhibitor, P = 0.92) did not predict follow-up LVEF.

Rest AVA measured under normal flow rate conditions is likely to reflect the true severity of AS and unlikely to change significantly with SE. Flow normalization may only be required in patients with AVA <1 cm(2) and mean gradient <40 mm Hg when the rest flow rate is <200 ml/s.

Our case highlights the finding of an abnormal pulmonary valve on 2D echocardiography, confirmed to be of bicuspid morphology with 3D imaging. The use of biplane imaging both in transthoracic and transoesophageal echocardiography and routine use of three-dimensional views particularly in transoesophageal echocardiography are of incremental value in better delineating pulmonary valve anatomy.Learning points:Bicuspid pulmonary valve as an isolated clinical entity is a rare finding in clinical practice with an incidence of about 0.1%.The true prevalence of the condition may be underestimated because of difficulty in visualising the pulmonary valve en-face on standard two-dimensional echocardiography.Trans-oesophageal echocardiography may provide better visualization of the pulmonary valve when transthoracic images are affected by interference from the left lung.Routine use of 3D echocardiography with biplane and zoomed views should be advocated for a full morphological assessment of the pulmonary valve, whether imaging via the transthoracic or transoesophageal approach.

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