Journal: Eur Heart J Cardiovasc Imaging

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<div><h4>Machine learning identifies pathophysiologically and prognostically informative phenotypes among patients with mitral regurgitation undergoing transcatheter edge-to-edge repair.</h4><i>Trenkwalder T, Lachmann M, Stolz L, Fortmeier V, ... Hausleiter J, Xhepa E</i><br /><b>Aims</b><br />Patients with mitral regurgitation (MR) present with considerable heterogeneity in cardiac damage depending on underlying aetiology, disease progression, and comorbidities. This study aims to capture their cardiopulmonary complexity by employing a machine-learning (ML)-based phenotyping approach.<br /><b>Methods and results</b><br />Data were obtained from 1426 patients undergoing mitral valve transcatheter edge-to-edge repair (MV TEER) for MR. The ML model was developed using 609 patients (derivation cohort) and validated on 817 patients from two external institutions. Phenotyping was based on echocardiographic data, and ML-derived phenotypes were correlated with 5-year outcomes. Unsupervised agglomerative clustering revealed four phenotypes among the derivation cohort: Cluster 1 showed preserved left ventricular ejection fraction (LVEF; 56.5 ± 7.79%) and regular left ventricular end-systolic diameter (LVESD; 35.2 ± 7.52 mm); 5-year survival in Cluster 1, hereinafter serving as a reference, was 60.9%. Cluster 2 presented with preserved LVEF (55.7 ± 7.82%) but showed the largest mitral valve effective regurgitant orifice area (0.623 ± 0.360 cm2) and highest systolic pulmonary artery pressures (68.4 ± 16.2 mmHg); 5-year survival ranged at 43.7% (P-value: 0.032). Cluster 3 was characterized by impaired LVEF (31.0 ± 10.4%) and enlarged LVESD (53.2 ± 10.9 mm); 5-year survival was reduced to 38.3% (P-value: <0.001). The poorest 5-year survival (23.8%; P-value: <0.001) was observed in Cluster 4 with biatrial dilatation (left atrial volume: 312 ± 113 mL; right atrial area: 46.0 ± 8.83 cm2) although LVEF was only slightly reduced (51.5 ± 11.0%). Importantly, the prognostic significance of ML-derived phenotypes was externally confirmed.<br /><b>Conclusion</b><br />ML-enabled phenotyping captures the complexity of extra-mitral valve cardiac damage, which does not necessarily occur in a sequential fashion. This novel phenotyping approach can refine risk stratification in patients undergoing MV TEER in the future.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 03 Feb 2023; epub ahead of print</small></div>
Trenkwalder T, Lachmann M, Stolz L, Fortmeier V, ... Hausleiter J, Xhepa E
Eur Heart J Cardiovasc Imaging: 03 Feb 2023; epub ahead of print | PMID: 36735333
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<div><h4>Deep learning estimation of three-dimensional left atrial shape from two-chamber and four-chamber cardiac long axis views.</h4><i>Xu H, Williams SE, Williams MC, Newby DE, ... Niederer SA, Young AA</i><br /><b>Aims</b><br />Left atrial volume is commonly estimated using the bi-plane area-length method from two-chamber (2CH) and four-chamber (4CH) long axes views. However, this can be inaccurate due to a violation of geometric assumptions. We aimed to develop a deep learning neural network to infer 3D left atrial shape, volume and surface area from 2CH and 4CH views.<br /><b>Methods and results</b><br />A 3D UNet was trained and tested using 2CH and 4CH segmentations generated from 3D coronary computed tomography angiography (CCTA) segmentations (n = 1700, with 1400/100/200 cases for training/validating/testing). An independent test dataset from another institution was also evaluated, using cardiac magnetic resonance (CMR) 2CH and 4CH segmentations as input and 3D CCTA segmentations as the ground truth (n = 20). For the 200 test cases generated from CCTA, the network achieved a mean Dice score value of 93.7%, showing excellent 3D shape reconstruction from two views compared with the 3D segmentation Dice of 97.4%. The network also showed significantly lower mean absolute error values of 3.5 mL/4.9 cm2 for LA volume/surface area respectively compared to the area-length method errors of 13.0 mL/34.1 cm2 respectively (P < 0.05 for both). For the independent CMR test set, the network achieved accurate 3D shape estimation (mean Dice score value of 87.4%), and a mean absolute error values of 6.0 mL/5.7 cm2 for left atrial volume/surface area respectively, significantly less than the area-length method errors of 14.2 mL/19.3 cm2 respectively (P < 0.05 for both).<br /><b>Conclusions</b><br />Compared to the bi-plane area-length method, the network showed higher accuracy and robustness for both volume and surface area.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 02 Feb 2023; epub ahead of print</small></div>
Xu H, Williams SE, Williams MC, Newby DE, ... Niederer SA, Young AA
Eur Heart J Cardiovasc Imaging: 02 Feb 2023; epub ahead of print | PMID: 36725705
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<div><h4>The year 2021 in the European Heart Journal: Cardiovascular Imaging Part II.</h4><i>Cosyns B, Sade LE, Gerber BL, Gimelli A, ... Maurer G, Edvardsen T</i><br /><AbstractText>The European Heart Journal-Cardiovascular Imaging was launched in 2012 and has during these years become one of the leading multimodality cardiovascular imaging journals. The journal is currently ranked as Number 19 among all cardiovascular journals. It has an impressive impact factor of 9.130. The most important studies published in our Journal from 2021 will be highlighted in two reports. Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease, while Part I of the review has focused on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 31 Jan 2023; epub ahead of print</small></div>
Cosyns B, Sade LE, Gerber BL, Gimelli A, ... Maurer G, Edvardsen T
Eur Heart J Cardiovasc Imaging: 31 Jan 2023; epub ahead of print | PMID: 36718129
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<div><h4>Left atrial late gadolinium enhancement in patients with ischaemic stroke.</h4><i>Larsen BS, Bertelsen L, Christensen H, Hadad R, ... Vejlstrup N, Sajadieh A</i><br /><b>Aims</b><br />To evaluate the extent of left atrial (LA) fibrosis in patients with a recent stroke without atrial fibrillation and controls without established cardiovascular disease.<br /><b>Methods and results</b><br />This prospectively designed study used cardiac magnetic resonance to detect LA late gadolinium enhancement as a proxy for LA fibrosis. Between 2019 and 2021, we consecutively included 100 patients free of atrial fibrillation with recent ischaemic stroke (<30 days) and 50 age- and sex-matched controls. LA fibrosis assessment was achieved in 78 patients and 45 controls. Blinded to the cardiac magnetic resonance results, strokes were adjudicated according to modified Trial of Org 10172 in Acute Stroke Treatment classification as undetermined aetiology (n = 42) or as attributable to large- or small-vessel disease (n = 36). Patients with stroke had a larger extent of LA fibrosis [6.9%, interquartile range (IQR) 3.6-15.4%] than matched controls (4.2%, IQR 2.3-7.5%; P = 0.007). No differences in LA fibrosis were observed between patients with stroke of undetermined aetiology and those with large- or small-vessel disease (6.6%, IQR 3.8-16.0% vs. 6.9%, IQR 3.4-14.6%; P = 0.73).<br /><b>Conclusion</b><br />LA fibrosis was more extensive in patients with stroke than in age- and sex-matched controls. A similar extent of LA fibrosis was observed in patients with stroke of undetermined aetiology and stroke classified as attributable to large- or small-vessel disease. Our findings suggest that LA structural abnormality is more frequent in patients with stroke than in controls independent of aetiological classification.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 24 Jan 2023; epub ahead of print</small></div>
Larsen BS, Bertelsen L, Christensen H, Hadad R, ... Vejlstrup N, Sajadieh A
Eur Heart J Cardiovasc Imaging: 24 Jan 2023; epub ahead of print | PMID: 36691845
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<div><h4>Incremental diagnostic value of post-exercise lung congestion in heart failure with preserved ejection fraction.</h4><i>Kagami K, Obokata M, Harada T, Sorimachi H, ... Adachi T, Ishii H</i><br /><b>Aims</b><br />Lung ultrasound (LUS) may unmask occult heart failure with preserved ejection fraction (HFpEF) by demonstrating an increase in extravascular lung water (EVLW) during exercise. Here, we sought to examine the dynamic changes in ultrasound B-lines during exercise to identify the optimal timeframe for HFpEF diagnosis.<br /><b>Methods and results</b><br />Patients with HFpEF (n = 134) and those without HF (controls, n = 121) underwent a combination of exercise stress echocardiography and LUS with simultaneous expired gas analysis to identify exercise EVLW. Exercise EVLW was defined by B-lines that were newly developed or increased during exercise. The E/e\' ratio peaked during maximal exercise and immediately decreased during the recovery period in patients with HFpEF. Exercise EVLW was most prominent during the recovery period in patients with HFpEF, while its prevalence did not increase from peak exercise to the recovery period in controls. Exercise EVLW was associated with a higher E/e\' ratio and pulmonary artery pressure, lower right ventricular systolic function, and elevated minute ventilation to carbon dioxide production (VE vs. VCO2) slope during peak exercise. Increases in B-lines from rest to the recovery period provided an incremental diagnostic value to identify HFpEF over the H2FPEF score and resting left atrial reservoir strain.<br /><b>Conclusion</b><br />Exercise EVLW was most prominent early during the recovery period; this may be the optimal timeframe for imaging ultrasound B-lines. Exercise stress echocardiography with assessments of recovery EVLW may enhance the diagnosis of HFpEF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 24 Jan 2023; epub ahead of print</small></div>
Kagami K, Obokata M, Harada T, Sorimachi H, ... Adachi T, Ishii H
Eur Heart J Cardiovasc Imaging: 24 Jan 2023; epub ahead of print | PMID: 36691846
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<div><h4>Sex-specific aortic valve calcifications in patients undergoing transcatheter aortic valve implantation.</h4><i>Hokken TW, Veulemans V, Adrichem R, Ooms JF, ... Zeus T, Van Mieghem NM</i><br /><b>Aims</b><br />To study sex-specific differences in the amount and distribution of aortic valve calcification (AVC) and to correlate the AVC load with paravalvular leakage (PVL) post-transcatheter aortic valve intervention (TAVI).<br /><b>Methods and results</b><br />This registry included 1801 patients undergoing TAVI with a Sapien3 or Evolut valve in two tertiary care institutions. Exclusion criteria encompassed prior aortic valve replacement, suboptimal multidetector computed tomography (MDCT) quality, and suboptimal transthoracic echocardiography images. Calcium content and distribution were derived from MDCT. In this study, the median age was 81.7 (25th-75th percentile 77.5-85.3) and 54% male. Men, compared to women, were significantly younger [81.2 (25th-75th percentile 76.5-84.5) vs. 82.4 (78.2-85.9), P ≤ 0.01] and had a larger annulus area [512 mm2 (25th-75th percentile 463-570) vs. 405 mm2 (365-454), P < 0.01] and higher Agatston score [2567 (25th-75th percentile 1657-3913) vs. 1615 (25th-75th percentile 905-2484), P < 0.01]. In total, 1104 patients (61%) had none-trace PVL, 648 (36%) mild PVL, and 49 (3%) moderate PVL post-TAVI. There was no difference in the occurrence of moderate PVL between men and women (3% vs. 3%, P = 0.63). Cut-off values for the Agatston score as predictor for moderate PVL based on the receiver-operating characteristic curve were 4070 (sensitivity 0.73, specificity 0.79) for men and 2341 (sensitivity 0.74, specificity 0.73) for women.<br /><b>Conclusion</b><br />AVC is a strong predictor for moderate PVL post-TAVI. Although the AVC load in men is higher compared to women, there is no difference in the incidence of moderate PVL. Sex-specific Agatston score cut-offs to predict moderate PVL were almost double as high in men vs. women.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 21 Jan 2023; epub ahead of print</small></div>
Hokken TW, Veulemans V, Adrichem R, Ooms JF, ... Zeus T, Van Mieghem NM
Eur Heart J Cardiovasc Imaging: 21 Jan 2023; epub ahead of print | PMID: 36680538
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<div><h4>Pulmonary transit time of cardiovascular magnetic resonance perfusion scans for quantification of cardiopulmonary haemodynamics.</h4><i>Segeroth M, Winkel DJ, Strebel I, Yang S, ... Bremerich J, Haaf P</i><br /><b>Aims</b><br />Pulmonary transit time (PTT) is the time blood takes to pass from the right ventricle to the left ventricle via pulmonary circulation. We aimed to quantify PTT in routine cardiovascular magnetic resonance imaging perfusion sequences. PTT may help in the diagnostic assessment and characterization of patients with unclear dyspnoea or heart failure (HF).<br /><b>Methods and results</b><br />We evaluated routine stress perfusion cardiovascular magnetic resonance scans in 352 patients, including an assessment of PTT. Eighty-six of these patients also had simultaneous quantification of N-terminal pro-brain natriuretic peptide (NTproBNP). NT-proBNP is an established blood biomarker for quantifying ventricular filling pressure in patients with presumed HF. Manually assessed PTT demonstrated low inter-rater variability with a correlation between raters >0.98. PTT was obtained automatically and correctly in 266 patients using artificial intelligence. The median PTT of 182 patients with both left and right ventricular ejection fraction >50% amounted to 6.8 s (Pulmonary transit time: 5.9-7.9 s). PTT was significantly higher in patients with reduced left ventricular ejection fraction (<40%; P < 0.001) and right ventricular ejection fraction (<40%; P < 0.0001). The area under the receiver operating characteristics curve (AUC) of PTT for exclusion of HF (NT-proBNP <125 ng/L) was 0.73 (P < 0.001) with a specificity of 77% and sensitivity of 70%. The AUC of PTT for the inclusion of HF (NT-proBNP >600 ng/L) was 0.70 (P < 0.001) with a specificity of 78% and sensitivity of 61%.<br /><b>Conclusion</b><br />PTT as an easily, even automatically obtainable and robust non-invasive biomarker of haemodynamics might help in the evaluation of patients with dyspnoea and HF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Jan 2023; epub ahead of print</small></div>
Segeroth M, Winkel DJ, Strebel I, Yang S, ... Bremerich J, Haaf P
Eur Heart J Cardiovasc Imaging: 20 Jan 2023; epub ahead of print | PMID: 36662127
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<div><h4>Serum lipoprotein(a) and bioprosthetic aortic valve degeneration.</h4><i>Botezatu SB, Tzolos E, Kaiser Y, Cartlidge TRG, ... Zheng KH, Dweck MR</i><br /><b>Aims</b><br />Bioprosthetic aortic valve degeneration demonstrates pathological similarities to aortic stenosis. Lipoprotein(a) [Lp(a)] is a well-recognized risk factor for incident aortic stenosis and disease progression. The aim of this study is to investigate whether serum Lp(a) concentrations are associated with bioprosthetic aortic valve degeneration.<br /><b>Methods and results</b><br />In a post hoc analysis of a prospective multimodality imaging study (NCT02304276), serum Lp(a) concentrations, echocardiography, contrast-enhanced computed tomography (CT) angiography, and 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) were assessed in patients with bioprosthetic aortic valves. Patients were also followed up for 2 years with serial echocardiography. Serum Lp(a) concentrations [median 19.9 (8.4-76.4) mg/dL] were available in 97 participants (mean age 75 ± 7 years, 54% men). There were no baseline differences across the tertiles of serum Lp(a) concentrations for disease severity assessed by echocardiography [median peak aortic valve velocity: highest tertile 2.5 (2.3-2.9) m/s vs. lower tertiles 2.7 (2.4-3.0) m/s, P = 0.204], or valve degeneration on CT angiography (highest tertile n = 8 vs. lower tertiles n = 12, P = 0.552) and 18F-NaF PET (median tissue-to-background ratio: highest tertile 1.13 (1.05-1.41) vs. lower tertiles 1.17 (1.06-1.53), P = 0.889]. After 2 years of follow-up, there were no differences in annualized change in bioprosthetic hemodynamic progression [change in peak aortic valve velocity: highest tertile [0.0 (-0.1-0.2) m/s/year vs. lower tertiles 0.1 (0.0-0.2) m/s/year, P = 0.528] or the development of structural valve degeneration.<br /><b>Conclusion</b><br />Serum lipoprotein(a) concentrations do not appear to be a major determinant or mediator of bioprosthetic aortic valve degeneration.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Jan 2023; epub ahead of print</small></div>
Botezatu SB, Tzolos E, Kaiser Y, Cartlidge TRG, ... Zheng KH, Dweck MR
Eur Heart J Cardiovasc Imaging: 20 Jan 2023; epub ahead of print | PMID: 36662130
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<div><h4>The role of obesity-related cardiovascular remodelling in mediating incident cardiovascular outcomes: a population-based observational study.</h4><i>Szabo L, McCracken C, Cooper J, Rider OJ, ... Petersen SE, Raisi-Estabragh Z</i><br /><b>Aims</b><br />We examined associations of obesity with incident cardiovascular outcomes and cardiovascular magnetic resonance (CMR) phenotypes, integrating information from body mass index (BMI) and waist-to-hip ratio (WHR). Then, we used multiple mediation to define the role of obesity-related cardiac remodelling in driving obesity-outcome associations, independent of cardiometabolic diseases.<br /><b>Methods and results</b><br />In 491 606 UK Biobank participants, using Cox proportional hazard models, greater obesity (higher WHR, higher BMI) was linked to significantly greater risk of incident ischaemic heart disease, atrial fibrillation (AF), heart failure (HF), all-cause mortality, and cardiovascular disease (CVD) mortality. In combined stratification by BMI and WHR thresholds, elevated WHR was associated with greater risk of adverse outcomes at any BMI level. Individuals with overweight BMI but normal WHR had weaker disease associations. In the subset of participants with CMR (n = 31 107), using linear regression, greater obesity was associated with higher left ventricular (LV) mass, greater LV concentricity, poorer LV systolic function, lower myocardial native T1, larger left atrial (LA) volumes, poorer LA function, and lower aortic distensibility. Of note, higher BMI was linked to higher, whilst greater WHR was linked to lower LV end-diastolic volume (LVEDV). In Cox models, greater LVEDV and LV mass (LVM) were linked to increased risk of CVD, most importantly HF and an increased LA maximal volume was the key predictive measure of new-onset AF. In multiple mediation analyses, hypertension and adverse LV remodelling (higher LVM, greater concentricity) were major independent mediators of the obesity-outcome associations. Atrial remodelling and native T1 were additional mediators in the associations of obesity with AF and HF, respectively.<br /><b>Conclusions</b><br />We demonstrate associations of obesity with adverse cardiovascular phenotypes and their significant independent role in mediating obesity-outcome relationships. In addition, our findings support the integrated use of BMI and WHR to evaluate obesity-related cardiovascular risk.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Jan 2023; epub ahead of print</small></div>
Szabo L, McCracken C, Cooper J, Rider OJ, ... Petersen SE, Raisi-Estabragh Z
Eur Heart J Cardiovasc Imaging: 20 Jan 2023; epub ahead of print | PMID: 36660920
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<div><h4>Association of central obesity with unique cardiac remodelling in young adults born small for gestational age.</h4><i>Bernardino G, Sepúlveda-Martínez Á, Rodríguez-López M, Prat-González S, ... Bijnens B, Crispi F</i><br /><b>Aims</b><br />Being born small for gestational age (SGA, 10% of all births) is associated with increased risk of cardiovascular mortality in adulthood together with lower exercise tolerance, but mechanistic pathways are unclear. Central obesity is known to worsen cardiovascular outcomes, but it is uncertain how it affects the heart in adults born SGA. We aimed to assess whether central obesity makes young adults born SGA more susceptible to cardiac remodelling and dysfunction.<br /><b>Methods and results</b><br />A perinatal cohort from a tertiary university hospital in Spain of young adults (30-40 years) randomly selected, 80 born SGA (birth weight below 10th centile) and 75 with normal birth weight (controls) was recruited. We studied the associations between SGA and central obesity (measured via the hip-to-waist ratio and used as a continuous variable) and cardiac regional structure and function, assessed by cardiac magnetic resonance using statistical shape analysis. Both SGA and waist-to-hip were highly associated to cardiac shape (F = 3.94, P < 0.001; F = 5.18, P < 0.001 respectively) with a statistically significant interaction (F = 2.29, P = 0.02). While controls tend to increase left ventricular end-diastolic volumes, mass and stroke volume with increasing waist-to-hip ratio, young adults born SGA showed a unique response with inability to increase cardiac dimensions or mass resulting in reduced stroke volume and exercise capacity.<br /><b>Conclusion</b><br />SGA young adults show a unique cardiac adaptation to central obesity. These results support considering SGA as a risk factor that may benefit from preventive strategies to reduce cardiometabolic risk.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 16 Jan 2023; epub ahead of print</small></div>
Bernardino G, Sepúlveda-Martínez Á, Rodríguez-López M, Prat-González S, ... Bijnens B, Crispi F
Eur Heart J Cardiovasc Imaging: 16 Jan 2023; epub ahead of print | PMID: 36644919
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<div><h4>Left atrial reservoir strain as a novel predictor of new-onset atrial fibrillation in light-chain-type cardiac amyloidosis.</h4><i>Choi YJ, Kim D, Rhee TM, Lee HJ, ... Choi JO, Kim HK</i><br /><b>Aims</b><br />To investigate whether left arterial reservoir strain (LASr) could predict new-onset atrial fibrillation (NOAF) in patients with light-chain-type cardiac amyloidosis (ALCA).<br /><b>Methods and results</b><br />This study enrolled 427 patients with CA from two tertiary centres between 2005 and 2019. LASr was measured using a vendor-independent analysis programme. The primary outcome was NOAF. A total of 287 patients with ALCA were included [median age 63.0 (56.0-70.0) years, 53.3% male]. The median LASr was 13.9% (10.5-20.8%). During the median follow-up of 0.85 years, AF occurred in 34 patients (11.8%). In the receiver operating characteristics curve analysis, the optimal cut-off of LASr for predicting NOAF was 14.4%. Patients with LASr ≤14.4% had a higher risk of NOAF than those with LASr >14.4% (18.1% vs. 5.1%, P < 0.010). In the multivariate analysis adjusting for confounding factors, including left arterial volume index and left ventricular global longitudinal strain (LV-GLS), higher LASr (%) was independently associated with lower risk for NOAF [adjusted hazard ratio (aHR): 0.936, 95% confidence interval (95% CI): 0.879-0.997, P = 0.039]. Furthermore, LASr ≤14.4% was an independent predictor for NOAF (aHR: 3.370, 95% CI: 1.337-8.492, P = 0.010). This remained true after accounting for all-cause death as a competing risk. Compared with Model 1 (LV-GLS) and Model 2 (LV-GLS plus LAVI), Model 3, including LASr showed a better reclassification ability for predicting NOAF (net reclassification index = 0.735, P < 0.001 compared with Model 1; net reclassification index = 0.514, P = 0.003 compared with Model 2).<br /><b>Conclusion</b><br />LASr was an independent predictor of NOAF in patients with ALCA.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 13 Jan 2023; epub ahead of print</small></div>
Choi YJ, Kim D, Rhee TM, Lee HJ, ... Choi JO, Kim HK
Eur Heart J Cardiovasc Imaging: 13 Jan 2023; epub ahead of print | PMID: 36637873
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<div><h4>Non-invasive diagnosis of transthyretin cardiac amyloidosis utilizing typical late gadolinium enhancement pattern on cardiac magnetic resonance and light chains.</h4><i>Slivnick JA, Alvi N, Singulane CC, Scheetz S, ... Zareba KM, Patel AR</i><br /><b>Aims</b><br />While cardiac magnetic resonance (CMR) is often obtained early in the evaluation of suspected cardiac amyloidosis (CA), it currently cannot be utilized to differentiate immunoglobulin (AL) and transthyretin (ATTR) CA. We aimed to determine whether a novel CMR and light-chain biomarker-based algorithm could accurately diagnose ATTR-CA.<br /><b>Methods and results</b><br />Patients with confirmed AL or ATTR-CA with typical late gadolinium enhancement (LGE) and Look-Locker pattern for CA on CMR were retrospectively identified at three academic medical centres. Comprehensive light-chain analysis including free light chains, serum, and urine electrophoresis/immunofixation was performed. The diagnostic accuracy of the typical CMR pattern for CA in combination with negative light chains for the diagnosis of ATTR-CA was determined both in the entire cohort and in the subset of patients with invasive tissue biopsy as the gold standard. A total of 147 patients (age 70 ± 11, 76% male, 51% black) were identified: 89 ATTR-CA and 58 AL-CA. Light-chain biomarkers were abnormal in 81 (55%) patients. Within the entire cohort, the sensitivity and specificity of a typical LGE and Look-Locker CMR pattern and negative light chains for ATTR-CA was 73 and 98%, respectively. Within the subset with biopsy-confirmed subtype, the CMR and light-chain algorithm were 69% sensitive and 98% specific.<br /><b>Conclusion</b><br />The combination of a typical LGE and Look-Locker pattern on CMR with negative light chains is highly specific for ATTR-CA. The successful non-invasive diagnosis of ATTR-CA using CMR has the potential to reduce diagnostic and therapeutic delays and healthcare costs for many patients.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 10 Jan 2023; epub ahead of print</small></div>
Slivnick JA, Alvi N, Singulane CC, Scheetz S, ... Zareba KM, Patel AR
Eur Heart J Cardiovasc Imaging: 10 Jan 2023; epub ahead of print | PMID: 36624559
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<div><h4>Cardiac magnetic resonance in giant cell myocarditis: a matched comparison with cardiac sarcoidosis.</h4><i>Pöyhönen P, Nordenswan HK, Lehtonen J, Syväranta S, Shenoy C, Kupari M</i><br /><b>Aims</b><br />Giant cell myocarditis (GCM) is an inflammatory cardiomyopathy akin to cardiac sarcoidosis (CS). We decided to study the findings of GCM on cardiac magnetic resonance (CMR) imaging and to compare GCM with CS.<br /><b>Methods and results</b><br />CMR studies of 18 GCM patients were analyzed and compared with 18 CS controls matched for age, sex, left ventricular (LV) ejection fraction and presenting cardiac manifestations. The analysts were blinded to clinical data. On admission, the duration of symptoms (median) was 0.2 months in GCM vs. 2.4 months in CS (P = 0.002), cardiac troponin T was elevated (>50 ng/L) in 16/17 patients with GCM and in 2/16 with CS (P < 0.001), their respective median plasma B-type natriuretic propeptides measuring 4488 ng/L and 1223 ng/L (P = 0.011). On CMR imaging, LV diastolic volume was smaller in GCM (177 ± 32 mL vs. 211 ± 58 mL, P = 0.014) without other volumetric or wall thickness measurements differing between the groups. Every GCM patient had multifocal late gadolinium enhancement (LGE) in a distribution indistinguishable from CS both longitudinally, circumferentially, and radially across the LV segments. LGE mass averaged 17.4 ± 6.3% of LV mass in GCM vs 25.0 ± 13.4% in CS (P = 0.037). Involvement of insertion points extending across the septum into the right ventricular wall, the \"hook sign\" of CS, was present in 53% of GCM and 50% of CS.<br /><b>Conclusion</b><br />In GCM, CMR findings are qualitatively indistinguishable from CS despite myocardial inflammation being clinically more acute and injurious. When matched for LV dysfunction and presenting features, LV size and LGE mass are smaller in GCM.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 10 Jan 2023; epub ahead of print</small></div>
Pöyhönen P, Nordenswan HK, Lehtonen J, Syväranta S, Shenoy C, Kupari M
Eur Heart J Cardiovasc Imaging: 10 Jan 2023; epub ahead of print | PMID: 36624560
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<div><h4>The incremental value of multi-organ assessment of congestion using ultrasound in outpatients with heart failure.</h4><i>Pugliese NR, Pellicori P, Filidei F, Del Punta L, ... Cleland JGF, Masi S</i><br /><b>Aims</b><br />We investigated the prevalence and clinical value of assessing multi-organ congestion by ultrasound in heart failure (HF) outpatients.<br /><b>Methods and results</b><br />Ultrasound congestion was defined as inferior vena cava of ≥21 mm, highest tertile of lung B-lines, or discontinuous renal venous flow. Associations with clinical characteristics and prognosis were explored. We enrolled 310 HF patients [median age: 77 years, median NT-proBNP: 1037 ng/L, 51% with a left ventricular ejection fraction (LVEF) <50%], and 101 patients without HF. There were no clinical signs of congestion in 224 (72%) patients with HF, of whom 95 (42%) had at least one sign of congestion by ultrasound (P < 0.0001). HF patients with ≥2 ultrasound signs were older, and had greater neurohormonal activation, lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range: 6-15) months, 77 patients (19%) died or were hospitalized for HF. HF patients without ultrasound evidence of congestion had a similar outcome to patients without HF [reference; hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.86-1.35], while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4-63.6), even after adjusting for multiple clinical variables and NT-proBNP. Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a net reclassification improvement of 28% (P = 0.03).<br /><b>Conclusion</b><br />Simultaneous assessment of pulmonary, venous, and kidney congestion by ultrasound is feasible, fast, and identifies a high prevalence of sub-clinical congestion associated with poor outcomes.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 03 Jan 2023; epub ahead of print</small></div>
Pugliese NR, Pellicori P, Filidei F, Del Punta L, ... Cleland JGF, Masi S
Eur Heart J Cardiovasc Imaging: 03 Jan 2023; epub ahead of print | PMID: 36595324
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<div><h4>Warranty period of coronary computed tomography angiography and [15O]H2O positron emission tomography in symptomatic patients.</h4><i>Jukema R, Maaniitty T, van Diemen P, Berkhof H, ... Danad I, Knuuti J</i><br /><b>Aims</b><br />Data on the warranty period of coronary computed tomography angiography (CTA) and combined coronary CTA/positron emission tomography (PET) are scarce. The present study aimed to determine the event-free (warranty) period after coronary CTA and the potential additional value of PET.<br /><b>Method and results</b><br />Patients with suspected but not previously diagnosed coronary artery disease (CAD) who underwent coronary CTA and/or [15O]H2O PET were categorized based upon coronary CTA as no CAD, non-obstructive CAD, or obstructive CAD. A hyperaemic myocardial blood flow (MBF) ≤ 2.3 mL/min/g was considered abnormal. The warranty period was defined as the time for which the cumulative event rate of death and non-fatal myocardial infarction (MI) was below 5%. Of 2575 included patients (mean age 61.4 ± 9.9 years, 41% male), 1319 (51.2%) underwent coronary CTA only and 1237 (48.0%) underwent combined coronary CTA/PET. During a median follow-up of 7.0 years 163 deaths and 68 MIs occurred. The warranty period for patients with no CAD on coronary CTA was ≥10 years, whereas patients with non-obstructive CAD had a 5-year warranty period. Patients with obstructive CAD and normal hyperaemic MBF had a 2-year longer warranty period compared to patients with obstructive CAD and abnormal MBF (3 years vs. 1 year).<br /><b>Conclusion</b><br />As standalone imaging, the warranty period for normal coronary CTA is ≥10 years, whereas patients with non-obstructive CAD have a warranty period of 5 years. Normal PET yielded a 2-year longer warranty period in patients with obstructive CAD.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 31 Dec 2022; epub ahead of print</small></div>
Jukema R, Maaniitty T, van Diemen P, Berkhof H, ... Danad I, Knuuti J
Eur Heart J Cardiovasc Imaging: 31 Dec 2022; epub ahead of print | PMID: 36585755
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<div><h4>Emerging molecular imaging targets and tools for myocardial fibrosis detection.</h4><i>Barton AK, Tzolos E, Bing R, Singh T, ... Newby DE, Dweck MR</i><br /><AbstractText>Myocardial fibrosis is the heart\'s common healing response to injury. While initially seeking to optimize the strength of diseased tissue, fibrosis can become maladaptive, producing stiff poorly functioning and pro-arrhythmic myocardium. Different patterns of fibrosis are associated with different myocardial disease states, but the presence and quantity of fibrosis largely confer adverse prognosis. Current imaging techniques can assess the extent and pattern of myocardial scarring, but lack specificity and detect the presence of established fibrosis when the window to modify this process may have ended. For the first time, novel molecular imaging methods, including gallium-68 (68Ga)-fibroblast activation protein inhibitor positron emission tomography (68Ga-FAPI PET), may permit highly specific imaging of fibrosis activity. These approaches may facilitate earlier fibrosis detection, differentiation of active vs. end-stage disease, and assessment of both disease progression and treatment-response thereby improving patient care and clinical outcomes.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 28 Dec 2022; epub ahead of print</small></div>
Barton AK, Tzolos E, Bing R, Singh T, ... Newby DE, Dweck MR
Eur Heart J Cardiovasc Imaging: 28 Dec 2022; epub ahead of print | PMID: 36575058
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<div><h4>Added value of semi-quantitative analysis of [18F]FDG PET/CT for the diagnosis of device-related infections in patients with a left ventricular assist device.</h4><i>Ten Hove D, Wahadat AR, Slart RHJA, Wouthuyzen-Bakker M, ... Budde RPJ, Glaudemans AWJM</i><br /><b>Aims</b><br />Left ventricular assist devices (LVADs) improve quality of life and survival in patients with advanced heart failure, but device-related infections (DRIs) remain cumbersome. We evaluated the diagnostic capability of [18F]FDG PET/CT, factors affecting its accuracy, and the additive value of semi-quantitative analysis for the diagnosis of DRI.<br /><b>Methods and results</b><br />LVAD recipients undergoing [18F]FDG PET/CT between 2012 and 2020 for suspected DRI were retrospectively included. [18F]FDG PET/CT was performed and evaluated in accordance with EANM guidelines. The final diagnosis of DRI, based on multidisciplinary consensus and findings during surgery, whenever performed, was used as the reference for diagnosis. 41 patients were evaluated for 59 episodes of suspected DRI. The clinical evaluation established driveline infection in 32 (55%) episodes, central device infection in 6 (11%), and combined infection in 2 (4%). Visual analysis of [18F]FDG PET/CT achieved a sensitivity and specificity for driveline infections of 0.79 and 0.71, respectively, whereas semi-quantitative analysis achieved a sensitivity and specificity of 0.94 and 0.83, respectively. For central device component infection, visual analysis of [18F]FDG PET/CT achieved a sensitivity and specificity of 0.75 and 0.60, respectively. Semi-quantitative analysis using SUVratio achieved a sensitivity and specificity of 1.0 and 0.8, respectively. The increase of specificity for central component infection was statistically significant (P = 0.05).<br /><b>Conclusions</b><br />[18F]FDG PET/CT reliably predicts the presence of DRI in LVAD recipients. Semi-quantitative analysis may increase the specificity of [18F]FDG PET/CT for the analysis of central device component infection and should be considered in equivocal cases after visual analysis.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 27 Dec 2022; epub ahead of print</small></div>
Ten Hove D, Wahadat AR, Slart RHJA, Wouthuyzen-Bakker M, ... Budde RPJ, Glaudemans AWJM
Eur Heart J Cardiovasc Imaging: 27 Dec 2022; epub ahead of print | PMID: 36573930
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<div><h4>Predictors of late pulmonary vein reconnection in patients with arrhythmia recurrence after cryoballoon ablation-per vein analysis including cardiac computed tomography-based anatomic factors.</h4><i>Terasawa M, Chierchia GB, Housari MA, Bala G, ... de Asmundis C, Ströker E</i><br /><b>Aims</b><br />To identify predictors of individual late pulmonary vein (PV) reconnection after second-generation cryoballoon (CB2) ablation. Anatomic indicators of late pulmonary vein reconnection (LPVR) post-CB2 ablation have not yet been studied on an individual PV level, nor weighed against clinical and procedural factors.<br /><b>Methods and results</b><br />Clinical, procedural, and PV anatomic data from 125 patients with a repeat procedure for arrhythmia recurrence after index CB2 ablation were analyzed. Preprocedural computed tomography (CT) evaluated 486 PVs for measurement of size; shape (ovality index); carina width; and orientation angle in frontal (superior/inferior) and transversal (anterior/posterior) plane (with horizontal line 0° as reference and upper/lower half circle as positive/negative value, respectively). Durable isolation in all PVs was demonstrated in 50/125 (40%) patients. Late reconnection rates at the different PVs were as follows: 16% left superior (LS), 12% left inferior (LI), 17% right superior (RS), and 31% right inferior (RI) PV. Multivariable analysis performed per vein showed following independent determinants predicting LPVR: ovality index [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.07-2.41, P = 0.022] and carina width (OR 0.75, CI 0.59-0.96, P = 0.024) for LSPV; carina width (OR 0.71, CI 0.53-0.95, P = 0.020) for LIPV; frontal angle (OR 0.91, CI 0.87-0.95, P < 0.001) for RIPV; and transversal angle (OR 1.15, CI 1.03-1.31, P = 0.032) for RSPV.<br /><b>Conclusion</b><br />Cardiac CT-based evaluation of anatomic PV characteristics presented higher predictive value compared to clinical and procedural variables for individual LPVR after CB2 ablation. Pre-procedural identification of unfavourable PV anatomy might be important to tailor the ablation approach.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 23 Dec 2022; epub ahead of print</small></div>
Terasawa M, Chierchia GB, Housari MA, Bala G, ... de Asmundis C, Ströker E
Eur Heart J Cardiovasc Imaging: 23 Dec 2022; epub ahead of print | PMID: 36562390
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<div><h4>Exercise-dependent changes in ventricular-arterial coupling and aortopulmonary collateral flow in Fontan patients: a real-time CMR study.</h4><i>Latus H, Hofmann L, Gummel K, Khalil M, ... Jux C, Reich B</i><br /><b>Aims</b><br />Inefficient ventricular-arterial (V-A) coupling has been described in Fontan patients and may result in adverse haemodynamics. A varying amount of aortopulmonary collateral (APC) flow is also frequently present that increases volume load of the single ventricle. The aim of the study was to assess changes in V-A coupling and APC flow during exercise CMR.<br /><b>Methods and results</b><br />Eighteen Fontan patients (age 24 ± 3 years) and 14 controls (age 23 ± 4 years) underwent exercise CMR using a cycle ergometer. Ventricular volumetry and flow measurements in the ascending aorta (AAO), inferior (IVC), and superior (SVC) vena cava were assessed using real-time sequences during stepwise increases in work load. Measures of systemic arterial elastance Ea, ventricular elastance Ees, and V-A coupling (Ea/Ees) were assessed. APC flow was quantified as AAO - (SVC + IVC). Ea remained unchanged during all levels of exercise in both groups (P = 0.39 and P = 0.11). Ees increased in both groups (P = 0.001 and P < 0.001) with exercise but was lower in the Fontan group (P = 0.04). V-A coupling was impaired in Fontan patients at baseline (P = 0.04). Despite improvement during exercise (P = 0.002) V-A coupling remained impaired compared with controls (P = 0.001). Absolute APC flow in Fontan patients did not change during exercise even at maximum work load (P = 0.98).<br /><b>Conclusions</b><br />Inefficient V-A coupling was already present at rest in Fontan patients and aggravated during exercise due to a limited increase in ventricular contractility which demonstrates the importance of a limited functional reserve of the single ventricle. APC flow remained unchanged suggesting no further increase in volume load during exercise.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 19 Dec 2022; 24:88-97</small></div>
Latus H, Hofmann L, Gummel K, Khalil M, ... Jux C, Reich B
Eur Heart J Cardiovasc Imaging: 19 Dec 2022; 24:88-97 | PMID: 35045176
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<div><h4>Cardiovascular magnetic resonance-derived left ventricular intraventricular pressure gradients among patients with precapillary pulmonary hypertension.</h4><i>Vos JL, Leiner T, van Dijk APJ, Pedrizzetti G, ... Driessen MMP, Nijveldt R</i><br /><b>Aims</b><br />Precapillary pulmonary hypertension (pPH) affects left ventricular (LV) function by ventricular interdependence. Since LV ejection fraction (EF) is commonly preserved, LV dysfunction should be assessed with more sensitive techniques. Left atrial (LA) strain and estimation of LV intraventricular pressure gradients (IVPG) may be valuable in detecting subtle changes in LV mechanics; however, the value of these techniques in pPH is unknown. Therefore, the aim of our study is to evaluate LA strain and LV-IVPGs from cardiovascular magnetic resonance (CMR) cines in pPH patients.<br /><b>Methods and results</b><br />In this cross-sectional study, 31 pPH patients and 22 healthy volunteers underwent CMR imaging. Feature-tracking LA strain was measured on four- and two-chamber cines. LV-IVPGs (from apex-base) are computed from a formulation using the myocardial movement and velocity of the reconstructed 3D-LV (derived from long-axis cines using feature-tracking). Systolic function, both LV EF and systolic ejection IVPG, was preserved in pPH patients. Compared to healthy volunteers, diastolic function was impaired in pPH patients, depicted by (i) lower LA reservoir (36 ± 7% vs. 26 ± 9%, P < 0.001) and conduit strain (26 ± 6% vs. 15 ± 8%, P < 0.001) and (ii) impaired diastolic suction (-9.1 ± 3.0 vs. ‒6.4 ± 4.4, P = 0.02) and E-wave decelerative IVPG (8.9 ± 2.6 vs. 5.7 ± 3.1, P < 0.001). Additionally, 11 pPH patients (35%) showed reversal of IVPG at systolic-diastolic transition compared to none of the healthy volunteers (P = 0.002).<br /><b>Conclusions</b><br />pPH impacts LV function by altering diastolic function, demonstrated by an impairment of LA phasic function and LV-IVPG analysis. These parameters could therefore potentially be used as early markers for LV functional decline in pPH patients.<br /><br />© Crown copyright 2022.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 19 Dec 2022; 24:78-87</small></div>
Vos JL, Leiner T, van Dijk APJ, Pedrizzetti G, ... Driessen MMP, Nijveldt R
Eur Heart J Cardiovasc Imaging: 19 Dec 2022; 24:78-87 | PMID: 34993533
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<div><h4>Safety of transoesophageal echocardiography during structural heart disease interventions under procedural sedation: a single-centre study.</h4><i>Afzal S, Zeus T, Hofsähs T, Kuballa M, ... Kelm M, Hellhammer K</i><br /><b>Aims</b><br />The aim of this study was to determine the incidence of transoesophageal echocardiography (TOE)-related adverse events (AEs) during structural heart disease (SHD) interventions and to identify potential risk factors.<br /><b>Methods and results</b><br />We retrospectively analysed 898 consecutive patients undergoing TOE-guided SHD interventions under procedural sedation. TOE-related AEs were classified as bleeding complications, mechanical lesions, conversion to general anaesthesia with intubation, and the occurrence of pneumonia. A follow-up was conducted up to 3 months after the intervention. TOE-related AEs were observed in 5.3% of the patients (n = 48). The highest rate of AEs was observed in the percutaneous mitral valve repair (PMVR) group with 8.2% (n = 32), whereas 4.8% (n = 11) of the patients in the left atrial appendage group and 1.8% (n = 5) in the patent foramen ovale/atrial septal defect group developed a TOE-related AE (P = 0.001). The most frequent AE was pneumonia with an incidence of 2.6% (n = 26) in the total cohort. Bleeding events occurred in 1.8% (n = 16) of the patients, mostly in the PMVR group with 2.1% (n = 8). In the multivariate regression analysis, we found a lower haemoglobin {odds ratio (OR) [95% confidence interval (CI)]: 8.82 (0.68-0.98) P = 0.025} and an obstructive sleep apnoea syndrome (OSAS) [OR (95% CI): 2.51 (1.08-5.84) P = 0.033] to be associated with AE. Furthermore, AEs were related to procedural time [OR (95% CI): 1.01 (1.0-1.01) P = 0.056] and oral anticoagulation [OR (95% CI): 1.97 (0.9-4.3) P = 0.076] with borderline significance in the multivariate regression analysis. No persistent damages were observed.<br /><b>Conclusion</b><br />TOE-related AEs during SHD interventions are clinically relevant. It was highest in patients undergoing PMVR. A lower baseline haemoglobin level and an OSAS were found to be associated with the occurrence of a TOE-related AE.<br /><br />Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 19 Dec 2022; 24:68-77</small></div>
Afzal S, Zeus T, Hofsähs T, Kuballa M, ... Kelm M, Hellhammer K
Eur Heart J Cardiovasc Imaging: 19 Dec 2022; 24:68-77 | PMID: 34977935
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<div><h4>A three-dimensional atlas of child\'s cardiac anatomy and the unique morphological alterations associated with obesity.</h4><i>Marciniak M, van Deutekom AW, Toemen L, Lewandowski AJ, ... Jaddoe VWV, Lamata P</i><br /><b>Aims</b><br />Statistical shape models (SSMs) of cardiac anatomy provide a new approach for analysis of cardiac anatomy. In adults, specific cardiac morphologies associate with cardiovascular risk factors and early disease stages. However, the relationships between morphology and risk factors in children remain unknown. We propose an SSM of the paediatric left ventricle to describe its morphological variability, examine its relationship with biometric parameters and identify adverse anatomical remodelling associated with obesity.<br /><b>Methods and results</b><br />This cohort includes 2631 children (age 10.2 ± 0.6 years), mostly Western European (68.3%) with a balanced sex distribution (51.3% girls) from Generation R study. Cardiac magnetic resonance short-axis cine scans were segmented. Three-dimensional left ventricular (LV) meshes are automatically fitted to the segmentations to reconstruct the anatomies. We analyse the relationships between the LV anatomical features and participants\' body surface area (BSA), age, and sex, and search for features uniquely related to obesity based on body mass index (BMI). In the SSM, 19 modes described over 90% of the population\'s LV shape variability. Main modes of variation were related to cardiac size, sphericity, and apical tilting. BSA, age, and sex were mostly correlated with modes describing LV size and sphericity. The modes correlated uniquely with BMI suggested that obese children present with septo-lateral tilting (R2 = 4.0%), compression in the antero-posterior direction (R2 = 3.3%), and decreased eccentricity (R2 = 2.0%).<br /><b>Conclusions</b><br />We describe the variability of the paediatric heart morphology and identify anatomical features related to childhood obesity that could aid in risk stratification. Web service is released to provide access to the new shape parameters.<br /><br />© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1645-1653</small></div>
Marciniak M, van Deutekom AW, Toemen L, Lewandowski AJ, ... Jaddoe VWV, Lamata P
Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1645-1653 | PMID: 34931224
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<div><h4>Coexistence of calcified- and lipid-containing plaque components and their association with incidental rupture points in acute coronary syndrome-causing culprit lesions: results from the prospective OPTICO-ACS study.</h4><i>Abdelwahed YS, Nelles G, Frick C, Seppelt C, ... Landmesser U, Leistner DM</i><br /><b>Aims</b><br />Rupture of the fibrous cap (RFC) represents the main pathophysiological mechanism causing acute coronary syndromes (ACS). Destabilization due to plaque biomechanics is considered to be importantly involved, exact mechanisms triggering plaque ruptures are, however, unknown. This study aims at characterizing the relation between plaque components and rupture points at ACS-causing culprit lesions in a large cohort of ACS-patients assessed by high-resolution intracoronary imaging.<br /><b>Methods and results</b><br />Within the prospective, multicentric OPTICO-ACS study program, the ACS-causing culprit plaques of 282 consecutive patients were investigated following a standardized optical coherence tomography (OCT) imaging protocol. Each pullback was assessed on a frame-by-frame basis for the presence of lipid components (LC), calcium components (CC), and coexistence of both LC and CC (LCC) by two independent OCT-core labs. Of the 282 ACS-patients, 204 patients (72.3%) presented with ACS caused by culprit lesions with rupture of the fibrous cap (RFC-ACS) and 27.7% patients had ACS caused by culprit lesions with intact fibrous cap (IFC-ACS). When comparing RFC-ACS to IFC-ACS, a preferential occurrence of all three plaque components (LC, CC, and LCC) in RFC-ACS became apparent (P < 0.001). Within ruptured culprit lesions, the zone straight at the rupture point [extended rupture zone (RZ)] was characterized by similar (24.7% vs. 24.0%; P = ns) calcium content when compared with the proximal and distal border of the culprit lesion [border zone (BZ)]. The RZ displayed a significantly higher amount of both, LC (100% vs. 69.8%; P < 0.001) and LCC (22.7% vs. 6.8%; P < 0.001), when compared with the BZ. The relative component increase towards the RZ was particularly evident for LCC (+233.8%), while LC showed only a modest increase (+43.3%).<br /><b>Conclusions</b><br />Calcified- and lipid-containing components characterize ruptured fibrous cap ACS-causing culprit lesions. Their coexistence is accelerated directly at the ruptured point, suggesting a pathophysiological contribution in the development of RFC-ACS.<br /><br />Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1598-1605</small></div>
Abdelwahed YS, Nelles G, Frick C, Seppelt C, ... Landmesser U, Leistner DM
Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1598-1605 | PMID: 34904655
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<div><h4>Contraction patterns of the systemic right ventricle: a three-dimensional echocardiography study.</h4><i>Surkova E, Kovács A, Lakatos BK, Tokodi M, ... Senior R, Li W</i><br /><b>Aims</b><br />To investigate contraction patterns of the systemic right ventricle (SRV) in patients with transposition of great arteries (TGA) post-atrial switch operation and with congenitally corrected transposition of great arteries (ccTGA).<br /><b>Methods and results</b><br />Right ventricular (RV) volumes and ejection fraction (EF) were measured by three-dimensional echocardiography in 38 patients with the SRV (24 TGA and 14 ccTGA; mean age 45 ± 12 years, 63% male), and in 38 healthy volunteers. The RV contraction was decomposed along the longitudinal, radial, and anteroposterior directions providing longitudinal, radial, and anteroposterior EF (LEF, REF, and AEF, respectively) and their contributions to total right ventricular ejection fraction (LEFi, REFi, and AEFi, respectvely). SRV was significantly larger with lower systolic function compared with healthy controls. SRV EF and four-chamber longitudinal strain strongly correlated with B-type natriuretic peptide (BNP) level (Rho -0.73, P < 0.0001 and 0.70, P < 0.0001, respectively). In patients with TGA, anteroposterior component was significantly higher than longitudinal and radial components (AEF 17 ± 4.5% vs. REF 13 ± 4.9% vs. LEF 10 ± 3.3%, P < 0.0001; AEFi 0.48 ± 0.09 vs. REFi 0.38 ± 0.1 vs. LEFi 0.29 ± 0.08, P < 0.0001). In patients with ccTGA, there was no significant difference between three SRV components. AEFi was significantly higher in TGA subgroup compared with ccTGA (0.48 ± 0.09 vs. 0.36 ± 0.08, P = 0.0002).<br /><b>Conclusion</b><br />Contraction patterns of the SRV are different in TGA and ccTGA. Anteroposterior component is dominant in TGA providing compensation for impaired longitudinal and radial components, while in ccTGA all components contribute equally to the total EF. SRV EF and longitudinal strain demonstrate strong correlation with BNP level and should be a part of routine echocardiographic assessment of the SRV.<br /><br />Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1654-1662</small></div>
Surkova E, Kovács A, Lakatos BK, Tokodi M, ... Senior R, Li W
Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1654-1662 | PMID: 34928339
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<div><h4>Prevalence and risk of progressive aortic aneurysm and dissection in adults with conotruncal anomalies.</h4><i>Egbe AC, Miranda WR, Bonnichsen CR, Jain CC, ... Gandhi S, Connolly HM</i><br /><b>Aims</b><br />Conotruncal anomalies share common embryogenic defects of the outflow tracts and great arteries, which result in a predisposition to aortic aneurysms. The purpose of this study was to describe the prevalence and risk of progressive aortic aneurysms in adults with conotruncal anomalies.<br /><b>Methods and results</b><br />Retrospective study of adults with conotruncal anomalies that underwent cross-sectional imaging 2003-20. Aneurysm was defined as aortic root/mid-ascending aorta >2.1 mm/m2/>1.9 mm/m2, progressive aneurysm as increase by >2 mm, and severe aneurysm as dimension >50 mm. Of 2261 patients (38 ± 12 years; male 58%), 1167 (52%) had an aortic aneurysm, and 205 (14%) had a severe aortic aneurysm. Mean annual increase in aortic root/mid-ascending aorta was 0.3 ± 0.1 mm/0.2 ± 0.1 mm. The 3-, 5-, and 7-year cumulative incidence of the progressive aortic aneurysm was 4%, 7%, and 9%, respectively. The rate of aneurysm growth decreased with age, with no significant growth after age 40 years. There was an excellent correlation between aortic indices from cross-sectional imaging and echocardiography. Of 950 females, 184 had ≥1 pregnancy, and 81 (44%) of the 184 patients had aortic aneurysm prior to pregnancy. There was no aortic dissection or progression of the aortic aneurysm during pregnancy. Overall, there was no aortic dissection during 7984 patient-years of follow-up.<br /><b>Conclusions</b><br />Aortic aneurysm was common in patients with conotruncal anomalies. However, the risk of progressive aneurysm or dissection was low. Collectively, these data suggest a benign natural history and perhaps a less frequent need for cross-sectional imaging. Further studies are required to determine the optimal timing for surgical intervention in this population.<br /><br />Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1663-1668</small></div>
Egbe AC, Miranda WR, Bonnichsen CR, Jain CC, ... Gandhi S, Connolly HM
Eur Heart J Cardiovasc Imaging: 17 Dec 2022; 23:1663-1668 | PMID: 34939103
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<div><h4>Unfavourable outcomes in patients with heart failure with higher preserved left ventricular ejection fraction.</h4><i>Ohte N, Kikuchi S, Iwahashi N, Kinugasa Y, ... Seo Y, EASY HFpEF Investigators </i><br /><b>Aims</b><br />Newly introduced drugs for heart failure (HF) have been reported to improve the prognosis of HF with preserved ejection fraction (HFpEF) in the lower range of left ventricular ejection fraction (LVEF). We hypothesized that a higher LVEF is related to an unfavourable prognosis in patients with HFpEF.<br /><b>Methods and results</b><br />We tested this hypothesis by analysing the data from a prospective multicentre cohort study in 255 patients admitted to the hospital due to decompensated HF (LVEF > 40% at discharge). The primary endpoint of this study was a composite outcome of all-cause death and readmission due to HF, and the secondary endpoint was readmission due to HF. LVEF and the mitral E/e\' ratio were measured using echocardiography. In multicovariate parametric survival time analysis, LVEF [hazard ratio (HR) = 1.046 per 1% increase, P = 0.001], concurrent atrial fibrillation (AF) (HR = 3.203, P < 0.001), and E/e\' (HR = 1.083 per 1.0 increase, P < 0.001) were significantly correlated with the primary endpoint. In addition to these covariates, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) use was significantly correlated with the secondary endpoint (HR = 0.451, P = 0.008). Diagnostic performance plot analysis demonstrated that the discrimination threshold value for LVEF that could identify patients prone to reaching the primary endpoint was ≥57.2%. The prevalence of AF or E/e\' ratio did not differ significantly between patients with LVEF ≥ 58% and with 40% < LVEF < 58%.<br /><b>Conclusion</b><br />A higher LVEF is independently related to poor prognosis in patients with HFpEF, in addition to concurrent AF and an elevated E/e\' ratio. ACEI/ARB use, in contrast, was associated with improved prognosis, especially with regard to readmission due to HF.<br /><b>Clinical trial registration</b><br />https://www.umin.ac.jp/ctr/index.htm.<br /><b>Unique identifier</b><br />UMIN000017725.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 05 Dec 2022; epub ahead of print</small></div>
Ohte N, Kikuchi S, Iwahashi N, Kinugasa Y, ... Seo Y, EASY HFpEF Investigators
Eur Heart J Cardiovasc Imaging: 05 Dec 2022; epub ahead of print | PMID: 36464890
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<div><h4>Multi-modality imaging to guide the implantation of cardiac electronic devices in heart failure: is the sum greater than the individual components?</h4><i>Galli E, Baritussio A, Sitges M, Donnellan E, Jaber WA, Gimelli A</i><br /><AbstractText>Heart failure is a clinical syndrome with an increasing prevalence and incidence worldwide that impacts patients\' quality of life, morbidity, and mortality. Implantable cardioverter-defibrillator and cardiac resynchronization therapy are pillars of managing patients with HF and reduced left ventricular ejection fraction. Despite the advances in cardiac imaging, the assessment of patients needing cardiac implantable electronic devices relies essentially on the measure of left ventricular ejection fraction. However, multi-modality imaging can provide important information concerning the aetiology of heart failure, the extent and localization of myocardial scar, and the pathophysiological mechanisms of left ventricular conduction delay. This paper aims to highlight the main novelties and progress in the field of multi-modality imaging to identify patients who will benefit from cardiac resynchronization therapy and/or implantable cardioverter-defibrillator. We also want to underscore the boundaries that prevent the application of imaging-derived parameters to patients who will benefit from cardiac implantable electronic devices and orient the choice of the device. Finally, we aim at providing some reflections for future research in this field.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 02 Dec 2022; epub ahead of print</small></div>
Galli E, Baritussio A, Sitges M, Donnellan E, Jaber WA, Gimelli A
Eur Heart J Cardiovasc Imaging: 02 Dec 2022; epub ahead of print | PMID: 36458875
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<div><h4>Impact of wideband cardiac magnetic resonance on diagnosis, decision-making and outcomes in patients with implantable cardioverter defibrillators.</h4><i>Patel HN, Wang S, Rao S, Singh A, ... Mor-Avi V, Patel AR</i><br /><b>Aims</b><br />Although myocardial scar assessment using late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging is frequently indicated for patients with implantable cardioverter defibrillators (ICDs), metal artefact can degrade image quality. With the new wideband technique designed to mitigate device related artefact, CMR is increasingly used in this population. However, the common clinical indications for CMR referral and impact on clinical decision-making and prognosis are not well defined. Our study was designed to address these knowledge gaps.<br /><b>Methods and results</b><br />One hundred seventy-nine consecutive patients with an ICD (age 59 ± 13 years, 75% male) underwent CMR using cine and wideband pulse sequences for LGE imaging. Electronic medical records were reviewed to determine the reason for CMR referral, whether there was a change in clinical decision-making, and occurrence of major adverse cardiac events (MACEs). Referral indication was the most common evaluation of ventricular tachycardia (VT) substrate (n = 114, 64%), followed by cardiomyopathy (n = 53, 30%). Overall, CMR resulted in a new or changed diagnosis in 64 (36%) patients and impacted clinical management in 51 (28%). The effect on management change was highest in patients presenting with VT. A total of 77 patients (43%) experienced MACE during the follow-up period (median 1.7 years), including 65 in patients with evidence of LGE. Kaplan-Meier analysis showed that ICD patients with LGE had worse outcomes than those without LGE (P = 0.006).<br /><b>Conclusion</b><br />The clinical yield from LGE CMR is high and provides management changing and meaningful prognostic information in a significant proportion of patients with ICDs.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 02 Dec 2022; epub ahead of print</small></div>
Patel HN, Wang S, Rao S, Singh A, ... Mor-Avi V, Patel AR
Eur Heart J Cardiovasc Imaging: 02 Dec 2022; epub ahead of print | PMID: 36458878
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<div><h4>Sex- and age-specific normal values for automated quantitative pixel-wise myocardial perfusion cardiovascular magnetic resonance.</h4><i>Brown LAE, Gulsin GS, Onciul SC, Broadbent DA, ... Kellman P, Plein S</i><br /><b>Aims</b><br />Recently developed in-line automated cardiovascular magnetic resonance (CMR) myocardial perfusion mapping has been shown to be reproducible and comparable with positron emission tomography (PET), and can be easily integrated into clinical workflows. Bringing quantitative myocardial perfusion CMR into routine clinical care requires knowledge of sex- and age-specific normal values in order to define thresholds for disease detection. This study aimed to establish sex- and age-specific normal values for stress and rest CMR myocardial blood flow (MBF) in healthy volunteers.<br /><b>Methods and results</b><br />A total of 151 healthy volunteers recruited from two centres underwent adenosine stress and rest myocardial perfusion CMR. In-line automatic reconstruction and post processing of perfusion data were implemented within the Gadgetron software framework, creating pixel-wise perfusion maps. Rest and stress MBF were measured, deriving myocardial perfusion reserve (MPR) and were subdivided by sex and age. Mean MBF in all subjects was 0.62 ± 0.13 mL/g/min at rest and 2.24 ± 0.53 mL/g/min during stress. Mean MPR was 3.74 ± 1.00. Compared with males, females had higher rest (0.69 ± 0.13 vs. 0.58 ± 0.12 mL/g/min, P < 0.01) and stress MBF (2.41 ± 0.47 vs. 2.13 ± 0.54 mL/g/min, P = 0.001). Stress MBF and MPR showed significant negative correlations with increasing age (r = -0.43, P < 0.001 and r = -0.34, P < 0.001, respectively).<br /><b>Conclusion</b><br />Fully automated in-line CMR myocardial perfusion mapping produces similar normal values to the published CMR and PET literature. There is a significant increase in rest and stress MBF, but not MPR, in females and a reduction of stress MBF and MPR with advancing age, advocating the use of sex- and age-specific reference ranges for diagnostic use.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 02 Dec 2022; epub ahead of print</small></div>
Brown LAE, Gulsin GS, Onciul SC, Broadbent DA, ... Kellman P, Plein S
Eur Heart J Cardiovasc Imaging: 02 Dec 2022; epub ahead of print | PMID: 36458882
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<div><h4>Left ventricular non-compaction in paediatrics: a novel semi-automated imaging technique bridging imaging findings and clinical outcomes.</h4><i>Tadros HJ, Doan TT, Pednekar AS, Masand PM, ... Noel CV, Wilkinson JC</i><br /><b>Aims</b><br />We set out to design a reliable, semi-automated, and quantitative imaging tool using cardiac magnetic resonance (CMR) imaging that captures LV trabeculations in relation to the morphologic endocardial and epicardial surface, or perimeter-derived ratios, and assess its diagnostic and prognostic utility.<br /><b>Methods and results</b><br />We queried our institutional database between January 2008 and December 2018. Non-compacted (NC)-to-compacted (C) (NC/C) myocardium ratios were calculated and our tool was used to calculate fractal dimension (FD), total mass ratio (TMR), and composite surface ratios (SRcomp). NC/C, FD, TMR, and SRcomp were assessed in relation to LVNC diagnosis and outcomes. Univariate hazard ratios with cut-offs were performed using clinically significant variables to find \'at-risk\' patients and imaging parameters were compared in \'at-risk\' patients missed by Petersen Index (PI). Ninety-six patients were included. The average time to complete the semi-automated measurements was 3.90 min (SEM: 0.06). TMR, SRcomp, and NC/C were negatively correlated with LV ejection fraction (LVEF) and positively correlated with indexed LV end-systolic volumes (iLVESVs), with TMR showing the strongest correlation with LVEF (-0.287; P = 0.005) and SRcomp with iLVESV (0.260; P = 0.011). We found 29 \'at-risk\' patients who were classified as non-LVNC by PI and hence, were missed. When compared with non-LVNC and \'low-risk\' patients, only SRcomp differentiated between both groups (1.91 SEM 0.03 vs. 1.80 SEM 0.03; P = 0.019).<br /><b>Conclusion</b><br />This method of semi-automatic calculation of SRcomp captured changes in at-risk patients missed by standard methods, was strongly correlated with LVEF and LV systolic volumes and may better capture outcome events.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 28 Nov 2022; epub ahead of print</small></div>
Tadros HJ, Doan TT, Pednekar AS, Masand PM, ... Noel CV, Wilkinson JC
Eur Heart J Cardiovasc Imaging: 28 Nov 2022; epub ahead of print | PMID: 36441164
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<div><h4>Left ventricular anatomy in obstructive hypertrophic cardiomyopathy: beyond basal septal hypertrophy.</h4><i>Hermida U, Stojanovski D, Raman B, Ariga R, ... Watkins H, Lamata P</i><br /><b>Aims</b><br />Obstructive hypertrophic cardiomyopathy (oHCM) is characterized by dynamic obstruction of the left ventricular (LV) outflow tract (LVOT). Although this may be mediated by interplay between the hypertrophied septal wall, systolic anterior motion of the mitral valve, and papillary muscle abnormalities, the mechanistic role of LV shape is still not fully understood. This study sought to identify the LV end-diastolic morphology underpinning oHCM.<br /><b>Methods and results</b><br />Cardiovascular magnetic resonance images from 2398 HCM individuals were obtained as part of the NHLBI HCM Registry. Three-dimensional LV models were constructed and used, together with a principal component analysis, to build a statistical shape model capturing shape variations. A set of linear discriminant axes were built to define and quantify (Z-scores) the characteristic LV morphology associated with LVOT obstruction (LVOTO) under different physiological conditions and the relationship between LV phenotype and genotype. The LV remodelling pattern in oHCM consisted not only of basal septal hypertrophy but a combination with LV lengthening, apical dilatation, and LVOT inward remodelling. Salient differences were observed between obstructive cases at rest and stress. Genotype negative cases showed a tendency towards more obstructive phenotypes both at rest and stress.<br /><b>Conclusions</b><br />LV anatomy underpinning oHCM consists of basal septal hypertrophy, apical dilatation, LV lengthening, and LVOT inward remodelling. Differences between oHCM cases at rest and stress, as well as the relationship between LV phenotype and genotype, suggest different mechanisms for LVOTO. Proposed Z-scores render an opportunity of redefining management strategies based on the relationship between LV anatomy and LVOTO.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 28 Nov 2022; epub ahead of print</small></div>
Hermida U, Stojanovski D, Raman B, Ariga R, ... Watkins H, Lamata P
Eur Heart J Cardiovasc Imaging: 28 Nov 2022; epub ahead of print | PMID: 36441173
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<div><h4>Cardiac involvement in non-cirrhotic portal hypertension: MRI detects myocardial fibrosis and oedema similar to compensated cirrhosis.</h4><i>Isaak A, Chang J, Mesropyan N, Kravchenko D, ... Praktiknjo M, Luetkens JA</i><br /><b>Aims</b><br />The exact role of portal hypertension in cirrhotic cardiomyopathy remains unclear, and it is uncertain whether cardiac abnormalities also occur in non-cirrhotic portal hypertension (NCPH). This magnetic resonance imaging (MRI) study aimed to evaluate the presence of subclinical myocardial dysfunction, oedema, and fibrosis in NCPH.<br /><b>Methods and results</b><br />In this prospective study (2018-2022), participants underwent multiparametric abdominal and cardiac MRI including assessment of cardiac function, myocardial oedema, late gadolinium enhancement (LGE), and abdominal and cardiac mapping [T1 and T2 relaxation times, extracellular volume fraction (ECV)]. A total of 111 participants were included [44 participants with NCPH (48 ± 15 years; 23 women), 47 cirrhotic controls, and 20 healthy controls]. The cirrhotic group was dichotomized (Child A vs. Child B/C). NCPH participants demonstrated a more hyperdynamic circulation compared with healthy controls (cardiac index: 3.7 ± 0.6 vs. 3.2 ± 0.8 L/min/m², P = 0.004; global longitudinal strain: -27.3 ± 4.6 vs. -24.6 ± 3.5%, P = 0.022). The extent of abnormalities indicating myocardial fibrosis and oedema in NCPH was comparable with Child A cirrhosis (e.g. LGE presence: 32 vs. 33 vs. 69%, P = 0.004; combined T1 and T2 elevations: 46 vs. 27 vs. 69%, P = 0.017; NCPH vs. Child A vs. Child B/C). Correlations between splenic T1 and myocardial T1 values were found (r = 0.41; P = 0.007). Splenic T1 values were associated with the presence of LGE (odds ratio, 1.010; 95% CI: 1.002, 1.019; P = 0.013).<br /><b>Conclusion</b><br />MRI parameters of myocardial fibrosis and oedema were altered in participants with NCPH to a similar extent as in compensated cirrhosis and were associated with splenic markers of portal hypertension, indicating specific portal hypertensive cardiomyopathy.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 24 Nov 2022; epub ahead of print</small></div>
Isaak A, Chang J, Mesropyan N, Kravchenko D, ... Praktiknjo M, Luetkens JA
Eur Heart J Cardiovasc Imaging: 24 Nov 2022; epub ahead of print | PMID: 36423215
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<div><h4>Multicentric randomized evaluation of a tricuspid valve percutaneous repair system (clip for the tricuspid valve) in the treatment of severe secondary tricuspid regurgitation Tri.Fr Design paper.</h4><i>Donal E, Leurent G, Ganivet A, Lurz P, ... Trochu JN, Oger E</i><br /><b>Aims</b><br />Tricuspid regurgitation (TR) is associated with significant morbidity and mortality. Its independent prognostic role has been repeatedly demonstrated. However, this valvular heart condition is largely undertreated because of the increased risk of surgical repair. Recently, transcatheter techniques for the treatment of TR have emerged, but their implications for the clinical endpoints are still unknown.<br /><b>Methods and results</b><br />The Tri.fr trial will be a multicentre, controlled, randomized (1:1 ratio), superior, open-label, and parallel-group study conducted in 300 patients with severe secondary TR that is considered non-surgical by heart teams. Inclusion will be possible only after core laboratory review of transthoracic and transoesophageal echocardiography and after validation by the clinical eligibility committee. A description of the mechanisms of the TR will be conducted by the core laboratory. Atrial or ventricular impacts on the severity of the secondary TR will be taken into account for the randomization. The patients will be followed for 12-month, and the primary outcome will be the Packer composite clinical endpoint [combining New York Heart Association class, patient global assessment (PGA), and major cardiovascular events]. It will test the hypothesis that a tricuspid valve percutaneous repair strategy using a clip dedicated to the tricuspid valve is superior to best guideline-directed medical therapy in symptomatic patients with severe secondary TR.<br /><b>Conclusion</b><br />Tri.fr will be the first randomized, academic, multicentre study testing the value of percutaneous correction in patients with severe secondary TR.<br /><br />Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1617-1627</small></div>
Donal E, Leurent G, Ganivet A, Lurz P, ... Trochu JN, Oger E
Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1617-1627 | PMID: 34871375
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<div><h4>Does mechanical dyssynchrony in addition to QRS area ensure sustained response to cardiac resynchronization therapy?</h4><i>Wouters PC, van Everdingen WM, Vernooy K, Geelhoed B, ... Meine M, Cramer MJ</i><br /><b>Aims</b><br />Judicious patient selection for cardiac resynchronization therapy (CRT) may further enhance treatment response. Progress has been made by using improved markers of electrical dyssynchrony and mechanical discoordination, using QRSAREA, and systolic rebound stretch of the septum (SRSsept) or systolic stretch index (SSI), respectively. To date, the relation between these measurements has not yet been investigated.<br /><b>Methods and results</b><br />A total of 240 CRT patients were prospectively enrolled from six centres. Patients underwent standard 12-lead electrocardiography, and echocardiography, at baseline, 6-month, and 12-month follow-up. QRSAREA was derived using vectorcardiography, and SRSsept and SSI were measured using strain-analysis. Reverse remodelling was measured as the relative decrease in left ventricular end-systolic volume, indexed to body surface area (ΔLVESVi). Sustained response was defined as ≥15% decrease in LVESVi, at both 6- and 12-month follow-up. QRSAREA and SRSsept were both strong, multivariable adjusted, variables associated with reverse remodelling. SRSsept was associated with response, but only in patients with QRSAREA ≥ 120 μVs (AUC = 0.727 vs. 0.443). Combined presence of SRSsept ≥ 2.5% and QRSAREA ≥ 120 μVs significantly increased reverse remodelling compared with high QRSAREA alone (ΔLVESVi 38 ± 21% vs. 22 ± 21%). As a result, 92% of left bundle branch block (LBBB)-patients with combined electrical and mechanical dysfunction were \'sustained\' volumetric responders, as opposed to 51% with high QRSAREA alone.<br /><b>Conclusion</b><br />Parameters of mechanical dyssynchrony are better associated with response in the presence of a clear underlying electrical substrate. Combined presence of high SRSsept and QRSAREA, but not high QRSAREA alone, ensures a sustained response after CRT in LBBB patients.<br /><br />© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1628-1635</small></div>
Wouters PC, van Everdingen WM, Vernooy K, Geelhoed B, ... Meine M, Cramer MJ
Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1628-1635 | PMID: 34871385
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<div><h4>Prognostic value of functional tricuspid regurgitation quantified by cardiac magnetic resonance in heart failure.</h4><i>Seo J, Hong YJ, Batbayar U, Kim DY, ... Ha JW, Shim CY</i><br /><b>Aims</b><br />Quantitative assessment of tricuspid regurgitation (TR) is challenging, and the prognostic implications of cardiac magnetic resonance (CMR)-quantified measures of TR remain unclear in patients with heart failure with reduced ejection fraction (HFrEF). This study investigated the prognostic value of functional TR quantified by CMR in patients with HFrEF.<br /><b>Methods and results</b><br />A total of 262 patients with HFrEF who underwent CMR were analysed. Patients who had primary TR, who had acute HF, or for whom cardiac surgery was planned were excluded. TR volume and fraction were indirectly calculated via subtracting methods. The primary outcome was defined as a composite of all-cause death and hospitalization for HF. Renal outcome was defined as a composite of a decrease in estimated glomerular filtration rate ≥50% or progression to end-stage renal disease. During the follow-up period (median 921 days), 62 primary outcomes and 48 renal outcomes occurred. When divided into two or three groups based on TR fraction in Kaplan-Meier analysis, patients with higher TR fractions showed worse primary outcomes and renal outcomes than those with lower TR fractions. In Cox regression analysis, a 10% increase in TR fraction was significantly associated with primary outcome [hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.29-1.73, P < 0.001] and renal outcome (HR 1.31, 95% CI 1.12-1.55, P = 0.001). TR fraction exhibited a strong positive linear relationship with primary outcomes and renal outcomes in restricted cubic spline curves.<br /><b>Conclusion</b><br />CMR-quantified measures of TR were independently associated with adverse clinical outcomes in patients with HFrEF.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Nov 2022; epub ahead of print</small></div>
Seo J, Hong YJ, Batbayar U, Kim DY, ... Ha JW, Shim CY
Eur Heart J Cardiovasc Imaging: 17 Nov 2022; epub ahead of print | PMID: 36394340
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<div><h4>Prognostic implications of myocardial perfusion imaging by 82-rubidium positron emission tomography in male and female patients with angina and no perfusion defects.</h4><i>Rauf M, Hansen KW, Galatius S, Wiinberg N, ... Talleruphuus U, Prescott E</i><br /><b>Aims</b><br />Myocardial perfusion imaging with 82-rubidium positron emission tomography (82Rb-PET) is increasingly used to assess stable coronary artery disease (CAD). We aimed to evaluate the prognostic value of 82Rb-PET-derived parameters in patients with symptoms suggestive of CAD but no significant reversible or irreversible perfusion defects.<br /><b>Methods and results</b><br />Among 3726 consecutive patients suspected of stable CAD who underwent 82Rb-PET between January 2018 and August 2020, 2175 had no regional perfusion defects. Among these patients, we studied the association of 82Rb-PET-derived parameters with a composite endpoint of all-cause mortality, hospitalization for unstable angina pectoris, acute myocardial infarction, heart failure, or ischaemic stroke. During a median follow up of 1.7 years (interquartile range 1.1-2.5 years), there were 148 endpoints. Myocardial blood flow (MBF) reserve (MFR), MBF during stress, left ventricular ejection fraction (LVEF), LVEF-reserve, heart rate reserve, and Ca score were associated with adverse outcomes. In multivariable Cox model adjusted for patient and 82Rb-PET characteristics, MFR < 2 (hazard ratio (HR) 1.75, 95% confidence interval (CI) 1.24-2.48), LVEF (HR 1.38 per 10% decrease, 95% CI 1.24-1.54), and LVEF-reserve (HR 1.19 per 5% decrease, 95% CI 1.07-1.31) were significant predictors of endpoints. Results were consistent in subgroups defined by gender, history of ischaemic heart disease, low LVEF, and atrial fibrillation.<br /><b>Conclusion</b><br />MFR, LVEF, and LVEF-reserve derived from 82Rb-PET provide prognostic information on cardiovascular outcomes in patients with no perfusion defects. This may aid in identifying patients at risk and might provide an opportunity for preventive interventions.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Nov 2022; epub ahead of print</small></div>
Rauf M, Hansen KW, Galatius S, Wiinberg N, ... Talleruphuus U, Prescott E
Eur Heart J Cardiovasc Imaging: 17 Nov 2022; epub ahead of print | PMID: 36394344
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<div><h4>Wall shear stress angle is associated with aortic growth in bicuspid aortic valve patients.</h4><i>Minderhoud SCS, Roos-Hesselink JW, Chelu RG, Bons LR, ... Wentzel JJ, Hirsch A</i><br /><b>Aims</b><br />Aortic wall shear stress (WSS) distributions in bicuspid aortic valve (BAV) patients have been associated with aortic dilatation, but prospective, longitudinal data are missing. This study assessed differences in aortic WSS distributions between BAV patients and healthy controls and determined the association of WSS with aortic growth in patients.<br /><b>Methods and results</b><br />Sixty subjects underwent four-dimensional (4D) flow cardiovascular magnetic resonance of the thoracic aorta (32 BAV patients and 28 healthy controls). Peak velocity, pulse wave velocity, aortic distensibility, peak systolic WSS (magnitude, axial, and circumferential), and WSS angle were assessed. WSS angle is defined as the angle between the WSSmagnitude and WSSaxial component. In BAV patients, three-year computed tomography angiography-based aortic volumetric growth was determined in the proximal and entire ascending aorta. WSSaxial was significantly lower in BAV patients compared with controls (0.93 vs. 0.72 Pa, P = 0.047) and WSScircumferential and WSS angle were significantly higher (0.29 vs. 0.64 Pa and 18° vs. 40°, both P < 0.001). Significant volumetric growth of the proximal ascending aorta occurred in BAV patients (from 49.1 to 52.5 cm3, P = 0.003). In multivariable analysis corrected for baseline aortic volume and diastolic blood pressure, WSS angle was the only parameter independently associated with proximal aortic growth (P = 0.031). In the entire ascending aorta, besides the WSS angle, the WSSmagnitude was also independently associated with growth.<br /><b>Conclusion</b><br />Increased WSScircumferential and especially WSS angle are typical in BAV patients. WSS angle was found to predict aortic growth. These findings highlight the potential role of WSS measurements in BAV patients to stratify patients at risk for aortic dilation.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1680-1689</small></div>
Minderhoud SCS, Roos-Hesselink JW, Chelu RG, Bons LR, ... Wentzel JJ, Hirsch A
Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1680-1689 | PMID: 34977931
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<div><h4>Development and validation of an echocardiographic algorithm to predict long-term mitral and tricuspid regurgitation progression.</h4><i>Strom JB, Zhao Y, Shen C, Wasfy JH, ... Yeh RW, Manning WJ</i><br /><b>Aims</b><br />Prediction of mitral (MR) and tricuspid (TR) regurgitation progression on transthoracic echocardiography (TTE) is needed to personalize valvular surveillance intervals and prognostication.<br /><b>Methods and results</b><br />Structured TTE report data at Beth Israel Deaconess Medical Center, 26 January 2000-31 December 2017, were used to determine time to progression (≥1+ increase in severity). TTE predictors of progression were used to create a progression score, externally validated at Massachusetts General Hospital, 1 January 2002-31 December 2019. In the derivation sample (MR, N = 34 933; TR, N = 27 526), only 5379 (15.4%) individuals with MR and 3630 (13.2%) with TR had progression during a median interquartile range) 9.0 (4.1-13.4) years of follow-up. Despite wide inter-individual variability in progression rates, a score based solely on demographics and TTE variables identified individuals with a five- to six-fold higher rate of MR/TR progression over 10 years (high- vs. low-score tertile, rate of progression; MR 20.1% vs. 3.3%; TR 21.2% vs. 4.4%). Compared to those in the lowest score tertile, those in the highest tertile of progression had a four-fold increased risk of mortality. On external validation, the score demonstrated similar performance to other algorithms commonly in use.<br /><b>Conclusion</b><br />Four-fifths of individuals had no progression of MR or TR over two decades. Despite wide interindividual variability in progression rates, a score, based solely on TTE parameters, identified individuals with a five- to six-fold higher rate of MR/TR progression. Compared to the lowest tertile, individuals in the highest score tertile had a four-fold increased risk of mortality. Prediction of long-term MR/TR progression is not only feasible but prognostically important.<br /><br />Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1606-1616</small></div>
Strom JB, Zhao Y, Shen C, Wasfy JH, ... Yeh RW, Manning WJ
Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1606-1616 | PMID: 34849685
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<div><h4>18F-flurpiridaz positron emission tomography segmental and territory myocardial blood flow metrics: incremental value beyond perfusion for coronary artery disease categorization.</h4><i>Packard RRS, Votaw JR, Cooke CD, Van Train KF, Garcia EV, Maddahi J</i><br /><b>Aims</b><br />We determined the feasibility and diagnostic performance of segmental 18F-flurpiridaz myocardial blood flow (MBF) measurement by positron emission tomography (PET) compared with the standard territory method, and assessed whether flow metrics provide incremental diagnostic value beyond relative perfusion quantitation (PQ).<br /><b>Methods and results</b><br />All evaluable pharmacological stress patients from the Phase III trial of 18F-flurpiridaz were included (n = 245) and blinded flow metrics obtained. For each coronary territory, the segmental flow metric was defined as the lowest 17-segment stress MBF (SMBF), myocardial flow reserve (MFR), or relative flow reserve (RFR) value. Diagnostic performances of segmental and territory MBF metrics were compared by receiver operating characteristic (ROC) areas under the curve (AUC). A multiple logistic model was used to evaluate whether flow metrics provided incremental diagnostic value beyond PQ alone. The diagnostic performances of segmental flow metrics were higher than their territory counterparts; SMBF AUC = 0.761 vs. 0.737; MFR AUC = 0.699 vs. 0.676; and RFR AUC = 0.716 vs. 0.635, respectively (P < 0.001 for all). Similar results were obtained for per-vessel coronary artery disease (CAD) ≥70% stenosis categorization and per-patient analyses. Combinatorial analyses revealed that only SMBF significantly improved the diagnostic performance of PQ in CAD ≥50% stenoses, with PQ AUC = 0.730, PQ + segmental SMBF AUC = 0.782 (P < 0.01), and PQ + territory SMBF AUC = 0.771 (P < 0.05). No flow metric improved diagnostic performance when combined with PQ in CAD ≥70% stenoses.<br /><b>Conclusion</b><br />Assessment of segmental MBF metrics with 18F-flurpiridaz is feasible and improves flow-based epicardial CAD detection. When combined with PQ, only SMBF provides additive diagnostic performance in moderate CAD.<br /><br />Published by Oxford University Press on behalf of the European Society of Cardiology 2021.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1636-1644</small></div>
Packard RRS, Votaw JR, Cooke CD, Van Train KF, Garcia EV, Maddahi J
Eur Heart J Cardiovasc Imaging: 17 Nov 2022; 23:1636-1644 | PMID: 34928321
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<div><h4>Utility of cardiovascular magnetic resonance in patients with stable troponin elevation.</h4><i>Ananthakrishna R, Rajvi BP, Hancock DE, Kholmurodova F, ... Daril NDM, Selvanayagam JB</i><br /><b>Aims</b><br />Cardiovascular magnetic resonance (CMR) imaging has a potential role in the evaluation of symptomatic patients with stable troponin elevation; however, its utility remains unexplored. We sought to determine the incremental diagnostic value of CMR in this unique cohort and assess the long-term clinical outcomes.<br /><b>Methods and results</b><br />Two hundred twenty-five consecutive patients presenting with cardiac chest pain/dyspnoea, stable troponin elevation, and undergoing CMR assessment were identified retrospectively from registry database. The study cohort was prospectively followed for major adverse cardiac events (MACEs) (defined as composite of all-cause mortality and cardiovascular readmissions). The primary outcome measure was the diagnostic utility of CMR, i.e. percentage of patients for whom CMR identified the cause of stable troponin elevation. Secondary outcome measures included the incremental value of CMR and occurrence of MACE. CMR was able to identify the cause for stable troponin elevation in 160 (71%) patients. A normal CMR was identified in 17% and an inconclusive CMR in 12% of the patients. CMR changed the referral diagnosis in 59 (26%) patients. Utilizing a baseline prediction model (pre-CMR referral diagnosis), the net reclassification index was 0.11 and integrated discriminatory improvement index measured 0.33 following CMR. Over a median follow-up of 4.3 years (interquartile range 2.8-6.3), 72 (32%) patients experienced MACE.<br /><b>Conclusion</b><br />CMR identified a cause for stable troponin elevation in 7 of 10 cases, and a new diagnosis was evident in 1 of 4 cases. CMR improved the net reclassification of patients with stable troponin elevation.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 07 Nov 2022; epub ahead of print</small></div>
Ananthakrishna R, Rajvi BP, Hancock DE, Kholmurodova F, ... Daril NDM, Selvanayagam JB
Eur Heart J Cardiovasc Imaging: 07 Nov 2022; epub ahead of print | PMID: 36336838
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<div><h4>Cardiac computed tomography following Watchman FLX implantation: device-related thrombus or device healing?</h4><i>Kramer AD, Korsholm K, Jensen JM, Nørgaard BL, ... Alkhouli M, Nielsen-Kudsk JE</i><br /><b>Aims</b><br />Cardiac computed tomography (CT) is increasingly utilized during follow-up after left atrial appendage closure (LAAC). Hypoattenuated thickening (HAT) is a common finding and might represent either benign device healing or device-related thrombosis (DRT). The appearance and characteristics of HAT associated with the Watchman FLX have not been previously described. Therefore, we sought to investigate cardiac CT findings during follow-up after Watchman FLX implantation with a focus on HAT and DRT.<br /><b>Methods and results</b><br />Retrospective single-centre, observational study including all patients with successful Watchman FLX implantation and follow-up cardiac CT between March 2019 and September 2021 (n = 244). Blinded analysis of CT images was performed describing the localization, extent, and morphology of HAT and correlated to imaging and histology findings in a canine model. Relevant clinical and preclinical ethical approvals were obtained.Overall, HAT was present in 156 cases (64%) and could be classified as either subfabric hypoattenuation (n = 59), flat sessile HAT (n = 78), protruding sessile HAT (n = 16), or pedunculated HAT (n = 3). All cases of pedunculated HAT and five cases of protruding sessile HAT were considered as high-grade HAT (n = 7). Subfabric hypoattenuation and flat sessile HAT correlated with device healing and endothelialization in histological analysis of explanted devices.<br /><b>Conclusion</b><br />Subfabric hypoattenuation and flat sessile HAT are frequent CT findings for Watchman FLX, likely representing benign device healing and endothelialization. Pedunculated HAT and protruding HAT are infrequent CT findings that might represent DRT.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 07 Nov 2022; epub ahead of print</small></div>
Kramer AD, Korsholm K, Jensen JM, Nørgaard BL, ... Alkhouli M, Nielsen-Kudsk JE
Eur Heart J Cardiovasc Imaging: 07 Nov 2022; epub ahead of print | PMID: 36336848
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<div><h4>Morphological characteristics of lesions with thin cap fibroatheroma-a substudy from the COMBINE (OCT-FFR) trial.</h4><i>Roleder-Dylewska M, Gasior P, Hommels TM, Roleder T, ... Wojakowski W, Kedhi E</i><br /><b>Aims</b><br />To study if any qualitative or quantitative optical coherence tomography (OCT) variables in combination with thin cap fibroatheroma (TCFA) patients could improve the identification of lesions at risk for future major adverse cardiac events (MACEs).<br /><b>Methods and results</b><br />From the combined optical coherence tomography morphologic and fractional flow reserve hemodynamic assessment of non- culprit lesions to better predict adverse event outcomes in diabetes mellitus patients: COMBINE (OCT-FFR) trial database (NCT02989740), we performed a detailed assessment OCT qualitative and quantitative variables in TCFA carrying diabetes mellitus (DM) patients with vs. without MACE during follow-up. MACEs were defined as a composite of cardiac death, target vessel myocardial infarction, clinically driven target lesion revascularization, and hospitalization for unstable angina. From the 390 fractional flow reserve (FFR)-negative DM patients, 98 (25.2%) had ≥1 OCT-detected TCFA, of which 13 (13.3%) had MACE and 85 (86.7%) were event-free (non-MACE). The baseline characteristics were similar between both groups; however, a smaller minimal lumen area (MLA) and lower mean FFR value were observed in MACE group (1.80 vs. 2.50 mm2, P = 0.01, and 0.85 vs. 0.89, P = 0.02, respectively). Prevalence of healed plaque (HP) was higher in the MACE group (53.85 vs. 21.18%, P = 0.01). TCFA were predominantly located proximal to the MLA. TCFA area was smaller in the MACE group, while no difference was observed regarding the lesion area.<br /><b>Conclusion</b><br />Within TCFA carrying patients, a smaller MLA, lower FFR values, and TCFA location adjacent to a HP were associated with future MACE. Carpet-like measured lesion area surface was similar, while the TCFA area was smaller in the MACE arm, and predominantly located proximal to the MLA.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 07 Nov 2022; epub ahead of print</small></div>
Roleder-Dylewska M, Gasior P, Hommels TM, Roleder T, ... Wojakowski W, Kedhi E
Eur Heart J Cardiovasc Imaging: 07 Nov 2022; epub ahead of print | PMID: 36342269
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This program is still in alpha version.