Attila Kovács

• MD; PhD; Dr Habil
• Professor (Associate) at Semmelweis University

Background: Evidence has shown the independent prognostic value of right ventricular (RV) function, even in patients with left-sided heart disease. The most widely used imaging technique to measure RV function is echocardiography; however, conventional 2-dimensional (2D) echocardiographic assessment is unable to leverage the same clinical informat...

Background: The right ventricle has a complex contraction pattern of uncertain clinical relevance. We aimed to assess the relationship between right ventricular (RV) contraction pattern and RV-pulmonary arterial (PA) coupling defined by the gold-standard pressure-volume loop-derived ratio of end-systolic/arterial elastance (Ees/Ea). Methods: Pro...

Aims: We aimed to confirm that three-dimensional echocardiography (3DE)-derived right ventricular (RV) ejection fraction (EF) is better associated with adverse cardiopulmonary outcomes than the conventional echocardiographic parameters. Methods: We performed a meta-analysis of studies reporting the impact of unit change of RVEF, tricuspid annula...

Aims: Right ventricular (RV) functional assessment is mainly limited to its longitudinal contraction. Dedicated 3-dimensional echocardiography (3DE) software enabled the separate assessment of the non-longitudinal components of RV ejection fraction (EF). The aims of this study were 1) to establish normal values for RV 3D-derived longitudinal, radi...

Background Three-dimensional (3D) echocardiography-derived right ventricular (RV) ejection fraction (EF) and global longitudinal strain (GLS) are valuable RV functional markers; nevertheless, they are substantially load-dependent. Global myocardial work index (GMWI) adjusts myocardial deformation to instantaneous pressure; therefore, it may better...

Background/Objectives: Donor-derived cell-free DNA (dd-cfDNA) is a marker of graft injury that increases in acute rejection and has excellent negative predictive value. Left ventricular global longitudinal strain (LVGLS) and strain-derived myocardial work indices are novel echocardiographic parameters with growing applications. Still, they have bee...

Risk stratification for cardiac surgery is a cornerstone of perioperative management. While the prognostic impact of severe right ventricular (RV) dysfunction is well understood, the added value of the RV mechanical pattern regarding risk prediction remains unknown. We sought to prospectively validate the predictive value of 3D RV mechanics for adv...

Body composition and cardiopulmonary exercise testing (CPET) are vital for optimizing sports performance, but the correlations between them are still underexplored. Our study aimed to investigate the relationships between body composition and specific CPET variables describing physical fitness in young athletes, also adjusting for age and height, i...

In patients with aortic stenosis (AS) evaluating left ventricular (LV) systolic function is challenging due to the influence of increased afterload on traditional measures. Myocardial work (MW) analysis, a novel echocardiographic method, adjusts myocardial deformation to instantaneous LV pressure, providing a more accurate reflection of LV contract...

Background/Introduction Accurate assessment of left ventricular (LV) and right ventricular (RV) systolic function is crucial in managing people with congenital heart disease (CHD), but can be challenging given the vast anatomic heterogeneity and varied surgical history in this population. While 3D echocardiography (3DE) is the most reproducible and...

Background The pressure-strain loop is a non-invasive alternative to the traditional pressure-volume analysis for calculating myocardial work. Incorporating volume into work calculations may be particularly beneficial in evaluating patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve intervention (TTVI), who often pre...

It is well known that left ventricular (LV) performance is substantially influenced by the corresponding loading conditions and LV synchrony. Notably, data are scarce about the interaction of these factors: previous studies suggest that patients with left bundle branch block (LBBB) has increased afterload sensitivity. This phenomenon may have speci...

Background Diastolic dysfunction (DD) often precedes symptomatic heart failure and is a predictor of adverse outcomes; thus, accurate assessment and grading are crucial for early interventions. Current guidelines recommend combining multiple echocardiographic parameters, including left atrial volume index (LAVi), for diagnosing DD in patients with...

Background With increasing life expectancy and aging of the population, aortic valve stenosis (AS) is now the most prevalent valvular disease in developed nations. Left ventricular (LV) functional assessment is challenging in this pressure-overloaded disease state, however, myocardial work analysis may overcome this issue by proving load-adjusted m...

Intense physical activity poses marked hemodynamic strain on the right ventricle (RV), as during exercise, RV is subjected to a proportionally higher pressure and volume overload than its left counterpart. While the morphological changes of the left ventricle can be characterized using pre-defined reference shapes (cone and sphere), the complex str...

Background 2D echocardiography requires multiple views for the assessment of left ventricular (LV) systolic function and does not enable the calculation of right ventricular (RV) ejection fraction (EF). 3D echocardiography (3DE) has clear incremental value over 2D echocardiography; nevertheless, its availability and feasibility is limited. Purpose...

Genetically determined left ventricular excessive trabeculation (LVET) has a wide clinical spectrum ranging from asymptomatic subjects to severe heart failure with arrhythmias and thromboembolic events. Unlike other cardiomyopathies, the relatives of LVET patients never reach the spotlight of guidelines and clinical practice, although these family...

BACKGROUND Right ventricular (RV) function has a well-established prognostic role in patients with severe mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (TEER) and is typically assessed using echocardiography-measured tricuspid annular plane systolic excursion. Recently, a deep learning model has been proposed that accuratel...

Background: Right ventricular (RV) function is inadequately investigated and routinely overlooked in transthyretin amyloid cardiomyopathy (ATTR-CM). Novel imaging distinguishers between intrinsic RV myocardial disease in ATTR-CM and primary RV overload disorder phenotypes may enhance mechanistic and pathophysiological understanding of RV dysfunctio...

The benefits of treadmill-based cardiopulmonary exercise testing (CPET) are well known. However, water polo trainings involve completely different movements in a distinct environment. Our objective was to analyze data from elite youth and adult water polo players, gathered through CPET and age- and sport-specific swimming tests. Resting and exercis...

Background: Right ventricular (RV) dysfunction is a common complication after myocardial infarction (MI) and a risk factor for adverse events. Effect of sacubitril/valsartan (S/V) on RV function in patients after MI is unknown. Hypothesis: RV dysfunction is associated with adverse events following high-risk MI and treatment with S/V attenuates adve...

Introduction Left ventricular (LV) lead position is strongly associated with the long-term outcome of patients undergoing de novo cardiac resynchronization therapy (CRT) implantation. However, data is scarce about patients who undergo upgrade CRT from right ventricular (RV) pacing. Aims To investigate the impact of the LV lead location on the prim...

Introduction Although the non-invasive diagnostic tools for stable coronary artery disease (CAD) have developed significantly over the past years, there is no resting parameter available to recognize functionally significant CAD. The role of the novel myocardial work index (myocardial work index - MWI) calculated by the pressure-strain loop created...

In aortic stenosis (AS) patients, assessment of left ventricular (LV) systolic function is complicated due to the significant impact of increased afterload on conventional parameters. Myocardial work (MW) analysis, a novel echocardiographic method adjusts myocardial deformation to instantaneous LV pressure which may better reflect the LV contractil...

Background Diastolic dysfunction (DD) often precedes symptomatic heart failure and is a predictor of adverse outcomes; thus, accurate assessment and grading are crucial for early interventions. Current guidelines recommend combining multiple echocardiographic parameters, including left atrial volume index (LAVi), for diagnosing DD in patients with...

Background Non-invasive left ventricular (LV) pressure-strain loop analysis is a novel technique for the evaluation of global myocardial work (GMW) that provides additional insights on LV contractility and energetics beyond traditional metrics, such as ejection fraction (EF) and global longitudinal strain (GLS). Despite its established value in num...

Background Little is known about acute changes in right ventricular (RV) function and geometry following transcatheter tricuspid edge-to-edge repair (T-TEER) or transcatheter tricuspid valve replacement (TTVR). Pressure-strain-volume loop-derived myocardial work metrics showed associations with myocardial energetics and contractility in conditions...

Introduction The BUDAPEST CRT Upgrade trial has established the strong clinical benefit of upgrading heart failure patients with a reduced left ventricular (LV) ejection fraction (HFrEF) and a high right ventricular pacing (RVP) burden to cardiac resynchronization therapy with defibrillator (CRT-D). Importantly, however, the CRT upgrade response is...

Introduction Sports achievements and performance are not solely based on outstanding endurance, especially in tactical and technical sports. Artificial intelligence (AI) can help us to identify correlations that can contribute to the successful preparation of athletes. Purpose Our aim was to further analyze and evaluate our previously initiated AI...

Aims Conventional echocardiographic parameters of right ventricular (RV) function are afterload-dependent. Therefore, incorporating RV pressures may enable the formulation of new parameters that reflect intrinsic RV function accurately. Accordingly, we sought to develop an artificial intelligence–based method to reconstruct the RV pressure curve ba...

Background There are few meta-analyses examining the prognostic value of right ventricular ejection fraction (RVEF) for a specific type of cardiovascular disease (CVD). The aim of this study was to compare the association of cardiac magnetic resonance (CMR)-derived RVEF with adverse outcomes for several specific types of CVD, using a robust Bayesia...

Aims The incidence of heart failure hospitalization is higher in women than in men after myocardial infarction (MI). Sex‐related differences in left ventricular (LV) remodelling may contribute to the differences in post‐MI outcomes. The aim of this study was to assess sex differences in echocardiographic parameters post‐MI, and whether the relation...

Background Cardiac rotational parameters in primary symptomatic left ventricular noncompaction (LVNC) with preserved left ventricular ejection fraction (LVEF) are not well understood. We aimed to analyze cardiac rotation measured with cardiac magnetic resonance feature-tracking (CMR-FT) and speckle-tracking echocardiography (Echo-ST) in LVNC morpho...

Aortic stenosis has become the most prevalent valvular disease with increasing life expectancy and the ageing of the population, representing a significant clinical burden for health care providers. Its treatment has been revolutionized by transcatheter aortic valve replacement (TAVR) as a safe and minimally invasive option for elderly patients. Le...

Mitral stenosis (MS) is a complex valvular pathology with significant clinical burden even today. Its effect on the right heart is often overlooked, despite it playing a considerable part in the symptomatic status. We enrolled 39 mitral valve stenosis patients and 39 age- and gender-matched healthy controls. They underwent conventional, speckle-tra...

Aim We aimed to externally validate the SEMMELWEIS-CRT score for predicting 1-year all-cause mortality in the European Cardiac Resynchronization Therapy (CRT) Survey I dataset – a large multi-center cohort of patients undergoing CRT implantation. Methods and results The SEMMELWEIS-CRT score is a machine learning-based tool trained for predicting a...

Aims: Recommendations on cardiac resynchronization therapy (CRT) in patients with atrial fibrillation or flutter (AF) are based on less robust evidence than those in sinus rhythm (SR). We aimed to assess the efficacy of CRT upgrade in the BUDAPEST-CRT Upgrade trial population by their baseline rhythm. Methods and results: Heart failure patients...

Diastolic dysfunction (DD) is a prevalent and clinically significant complication after heart transplantation (HTX). We aimed to characterize the diastolic function of HTX recipients with both short-term and long-term follow-ups by applying left atrial (LA) deformation analysis. We consecutively enrolled and followed up with 33 HTX patients. Three...

Introduction and aims Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly utilized therapeutic choice in patients with cardiogenic shock, however, high complication rate often counteracts with its beneficial cardiopulmonary effects. The assessment of left ventricular (LV) function in key in the management of this populati...

Introduction Radiofrequency catheter ablation has become increasingly important in the management of scar-related ventricular tachycardia (VT). Wide range of clinical and procedural predictors of VT recurrence and mortality are described by previous studies. However, currently known echocardiographic predictors are mainly limited to conventional ec...

Background Based on the results of the BUDAPEST-CRT Upgrade trial, in patients with intermittent or permanent right ventricular (RV) pacing and reduced left ventricular ejection fraction (HFrEF) upgrade to cardiac resynchronization therapy (CRT) reduces morbidity and mortality. Purpose Whether the substantial treatment effect of the CRT upgrade co...

Both heart failure with preserved ejection fraction (HFpEF) and non-alcoholic fatty liver disease (NAFLD) develop due to metabolic dysregulation, has similar risk factors (e.g., insulin resistance, systemic inflammation) and are unresolved clinical challenges. Therefore, the potential link between the two disease is important to study. We aimed to...

We aimed to evaluate clinical and prognostic significance of myocardial work parameters of the systemic right ventricle (SRV). Thirty-eight patients with the SRV underwent echocardiographic assessment of the SRV systolic function including 3D-echocardiography derived ejection fraction, 2D longitudinal strain and myocardial work analysis. The study...

The aim of this study was to characterize the right ventricular (RV) contraction pattern and its associations with exercise capacity in a large cohort of adolescent athletes using resting three-dimensional echocardiography (3DE). We enrolled 215 adolescent athletes (16±1 years, 169 males, 12±6 hours of training/week) and compared them to 38 age- an...

BACKGROUND High-power short-duration ablation has shown impressive efficacy and safety for pulmonary vein isolation (PVI); however, initial efficacy results with very high power short-duration ablation were discouraging. This study compared the long-term durability of PVI performed with a 90 versus 50 W power setting. METHODS Patients were randomi...

Conventional echocardiographic parameters of right ventricular (RV) function are heavily afterload-dependent. Therefore, the incorporation of the RV pressure curve may enable the formulation of new parameters that reflect intrinsic RV function more accurately. Accordingly, we sought to develop an artificial intelligence-based method that can recons...

Frailty is a complex clinical syndrome associated with aging and comorbidities, which correlates with unfavorable outcomes. However, in heart failure patients, frailty is very common, data is scarce about those, who are eligible for Cardiac Resynchronization Therapy (CRT) implantation. We investigated the incidence of frailty and the association of...

Choosing the optimal device during cardiac resynchronization therapy (CRT) upgrade can be challenging. Therefore, we sought to provide a solution for identifying patients in whom upgrading to a CRT-defibrillator (CRT-D) is associated with better long-term survival than upgrading to a CRT-pacemaker (CRT-P). To this end, we first applied topological...

Highlights of right ventricular characteristics of left ventricular noncompaction using 3D echocardiography. The aspects of right ventricular volumes and function investigated with 3D echocardiography in a large cohort of left ventricular noncompaction morphology (LVNC) population remains unclear. The objective of our research was to study the left...

Introduction Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with symptomatic heart failure with reduced ejection fraction (HFrEF) and prolonged QRS. However, approximately one-third of the implanted patients fail to show clinical improvement or reverse remodeling. The criteria by response have been rece...

Development of secondary tricuspid regurgitation (TR) is associated with poor outcomes in patients with left-sided cardiac diseases. Severe TR imposes substantial volume overload (VO) on the right ventricle (RV), inducing a vicious circle of progressive RV remodelling and dysfunction. Although previous studies have established the value of speckle...

Introduction In patients with left bundle branch block (LBBB) cardiac function has been found to be particularly sensitive to alterations in left ventricular (LV) afterload. Nevertheless, whether the detrimental hemodynamic effect of right ventricular pacing (RVP)-induced electromechanical dyssynchrony on LV function is also associated with afterlo...

Background The conventional echocardiographic parameters of the right ventricular (RV) systolic function (e.g., tricuspid annular plane systolic excursion - TAPSE, fractional area change – FAC, free wall longitudinal strain – FWLS) only partially portray the complex functional characteristics of the RV; therefore, they may fail to capture the full...

Global myocardial work index is a novel echocardiographic parameter of the left ventricular (LV) function, which may overcome the load-sensitvity of the traditional functional measures by measuring LV deformation in the context of simultaneous pressures. This approach may gain particular importance in pressure overload states, such as patients with...

Background In aortic valve stenosis, conventional echocardiographic parameters, such as ejection fraction (EF), are heavily influenced by the increased afterload caused by the valvular disease. Myocardial work index (GWI) quantifies myocardial deformation depending on the momentary LV pressure, potentially serving as a marker of LV contractility in...

Introduction Due to intensive sport adaptation, examinations of elite athletes are a special entity of cardiology. Cardiovascular follow-up of elite athletes is a significant method of supporting safe and successful sport. In many sports like water polo, training work takes place in different environments and with different forms of movement, then...

We thank Drs Lancellotti and Go for their observations and comments¹ on our recently published study,² in which we characterized the longitudinal and non-longitudinal components of right ventricular (RV) contraction in a large group of healthy subjects from the World Alliance of Societies of Echocardiography (WASE) study. Three-dimensional (3D) ima...

Background Reports of left ventricular noncompaction (LVNC) rarely include descriptions of the right ventricle (RV). This study aimed to describe the characteristics of the RV in LVNC patients with reduced LV function (LVNC-R) compared with patients with dilated cardiomyopathy (DCM) and subjects with LVNC with normal left ventricular ejection fract...

Cardiovascular diseases (CVDs) are the leading cause of death among elderly people. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is an important regulator of cholesterol metabolism. Herein, we investigated the role of PCSK9 in age-related CVD. Both in humans and rats, blood PCSK9 level correlated positively with increasing age and the deve...

Background and Aims De novo implanted cardiac resynchronisation therapy with defibrillator (CRT-D) reduces the risk of morbidity and mortality in patients with left bundle branch block, heart failure and reduced ejection fraction (HFrEF). However, among HFrEF patients with right ventricular pacing (RVP), the efficacy of CRT-D upgrade is uncertain....

Background Current guidelines recommend considering multiple factors while deciding between cardiac resynchronization therapy with a defibrillator (CRT-D) or a pacemaker (CRT-P). Nevertheless, it is still challenging to pinpoint those candidates who will benefit from choosing a CRT-D device in terms of survival. Objective We aimed to use topologic...

Background The right ventricle (RV) has complex geometry and function, with motion along three separate axes—longitudinal, radial, and anteroposterior. Quantitative assessment of RV function by two-dimension echocardiography (2DE) has been limited as a consequence of this complexity, whereas newer three dimensional (3D) analysis offers the potentia...

Introduction: Iron deficiency (ID) is one of the most common factors that may reduce sports performance, supplementation forms and doses are still not standardized in athletes. Our aim was to assess the iron status of young male basketball players and to study the effect of iron supplementation in a randomized placebo-controlled study. Hypothesis...

Funding Acknowledgements Type of funding sources: None. Background Impaired systolic function of the systemic right ventricle (SRV) is well-known factor associated with adverse outcomes in patients with transposition of great arteries after atrial switch operation or with congenitally corrected transposition of great arteries. A recently proposed...

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Project no. RRF-2.3.1-21-2022-00004 (MILAB) has been implemented with the support provided by the European Union. Introduction Cardiopulmonary exercise testing (CPET)-derived peak oxygen uptake (VO2/kg) is a well-established parameter of exercis...

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EFOP-3.6.3-VEKOP-16-2017-00009 project. Background The conventional echocardiographic parameters of the right ventricular (RV) systolic function (e.g., tricuspid annular plane systolic excursion - TAPSE, fractional area change - FAC) only partia...

Funding Acknowledgements Type of funding sources: None. Background Right ventricular (RV) function is strongly associated with the prognosis of patients with secondary tricuspid regurgitation (STR). However, the mechanical adaptations (contraction pattern) of the RV to volume overload associated with STR remain to be clarified. Purpose To investi...

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): SUPPORTED BY THE ÚNKP-22-3-I NEW NATIONAL EXCELLENCE PROGRAM OF THE MINISTRY FOR CULTURE AND INNOVATION FROM THE SOURCE OF THE NATIONAL RESEARCH, DEVELOPMENT AND INNOVATION FUND. Introduction Aortic valve stenosis is one of the most pr...

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by the ÚNKP-22-3-II New National Excellence Program of the Ministry for Culture and Innovation from the source of the National Research, Development and Innovation Fund. Introduction The development of secondary tricuspid reg...

Background Data are scarce concerning the exercise-induced structural and functional adaptations in adolescent athletes, especially concerning the right ventricle (RV). We aimed to characterize the RV contraction pattern and its associations with exercise capacity in a large cohort of adolescent athletes using 3D (three dimensional) echocardiograph...

Background We have previously published large-scale cardiac proteomic data from heart failure (HF) patients with ischaemic heart disease (IHD) (Circulation, 2021). No similar proteomics analyses are available on hearts from HF patients with dilated cardiomyopathy (DCM). Purpose To compare the effect of comorbidities, medications, and genetic mutat...

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Nemzeti Kardiovaszkuláris Laboratórium RRF-2.3.1-21-2022-00003. Background Frailty, characterized by loss of homeostatic reserves and increased vulnerability to physiological decompensation, results from an aggregation of insults across multiple...

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): TKP2021-EGA-23 János Bolyai Research Scholarship of the Hungarian Academy of Sciences. Introduction Recent experimental data indicates that patients with left bundle branch block are particularly sensitive to increased arterial afterlo...

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): An investigator-initiated study. Research grant received from Biosense Webster (IIS 653). Background Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. The high power short duration ablation has shown good efficacy and safety profi...

Background and aim Over the past decades, we have witnessed an immense expansion in the arsenal and performance of machine learning (ML) algorithms. One of the most important fields that could benefit from these advancements is biomedical science. To streamline the training and evaluation of binary classifiers, we constructed a universal and flexib...

Background: Right ventricular (RV) functional assessment is mainly limited to its longitudinal component. However, due to the complex orientation of the myofibers, the RV contraction involves coordinated motion along multiple planes. Recently developed 3-dimensional echocardiography (3DE) software has enabled the separate assessment of the non-long...