<div><h4>Pathophysiologic and Prognostic Importance of Cardiac Power Output Reserve in Heart Failure with Preserved Ejection Fraction.</h4><i>Takizawa D, Harada T, Obokata M, Kagami K, ... Wada N, Ishii H</i><br /><b>Aims</b><br />Heart failure with preserved ejection fraction (HFpEF) is a syndrome characterized by multiple cardiac reserve limitations during exercise. Cardiac power output (CPO) is an index of global cardiac performance and can be estimated noninvasively by echocardiography. We hypothesized that CPO reserve during exercise would be associated with impaired cardiovascular reserve, exercise intolerance, and adverse outcomes in HFpEF.<br /><b>Methods and results</b><br />Exercise stress echocardiography was performed in 425 dyspneic patients (217 HFpEF and 208 non-HF controls) to estimate CPO at rest and during exercise. We classified patients with HFpEF based on the median value of changes in CPO from rest to peak exercise (ΔCPO >0.49 W/100 g). Patients with HFpEF and lower CPO reserve had poorer biventricular systolic function and impaired chronotropic response during exercise and worse aerobic capacity than controls and those with higher CPO reserve. During a median follow-up of 358 days, a composite outcome of all-cause mortality or HF events occurred in 30 patients. Patients with lower CPO reserve had a four and nearly 10-fold increased risk of the outcomes compared to those with higher CPO reserve and controls, respectively (hazard ratio [HR] 4.05, 95% confidence interval [CI] 1.16-10.1, p = 0.003 and HR, 9.61 [95%CI, 3.58-25.8], p < 0.0001). We further found that lower CPO reserve had an incremental prognostic value over the H2FPEF score and exercise duration. In contrast, resting CPO did not predict clinical outcomes in patients with HFpEF.<br /><b>Conclusions</b><br />Lower CPO reserve was associated with biventricular systolic dysfunction, chronotropic incompetence, exercise intolerance, and adverse outcomes in patients with 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: 21 Sep 2023; epub ahead of print</small></div>

<div><h4>The year 2022 in the European Heart Journal - Cardiovascular Imaging: Part I.</h4><i>Petersen SE, Muraru D, Westwood M, Dweck MR, ... Delgado V, Cosyns B</i><br /><AbstractText>The European Heart Journal - Cardiovascular Imaging with its over ten years existence is an established leading multimodality cardiovascular imaging journal. Pertinent publications including original research, how to papers, reviews, consensus documents, in our Journal from 2022 have been highlighted in two reports. Part I focuses on cardiomyopathies, heart failure, valvular heart disease and congenital heart disease and related emerging techniques and technologies.</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: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Non-invasive estimation of left ventricular systolic peak-pressure - a prerequisite to calculate myocardial work in hypertrophic obstructive cardiomyopathy.</h4><i>Batzner A, Hahn P, Morbach C, Störk S, ... Frantz S, Seggewiss H</i><br /><b>Aims</b><br />Myocardial work (MyW) is an echocardiographically derived parameter to estimate myocardial performance. The calculation of MyW utilizes pressure strain loops from global longitudinal strain and brachial blood pressure (BP) as surrogate of left ventricular systolic pressure (LVSP). Since LVSP cannot be equated with BP in hypertrophic obstructive cardiomyopathy (HOCM), we explored whether LVSP can be derived non-invasively by combining Doppler gradients and BP.<br /><b>Methods and results</b><br />We studied 20 consecutive patients (8 women, 12 men; mean age 57.0 ± 13.9 years; NYHA 2.1 ± 0.8; maximal septal thickness 24.7 ± 6.3 mm) with indication for first alcohol septal ablation. All measurements were performed simultaneously in the catheterization laboratory (CathLab) - invasively: ascending aortic and LV pressures; non-invasively: BP, maximal (CWmax) and mean (CWmean) Doppler gradients.LVSP was 188.9 ± 38.5 mmHg. Mean gradients of both methods were comparable (CathLab 34.3 ± 13.4 mmHg vs. CW 31.0 ± 13.7 mmHg). Maximal gradient was higher in echocardiography (64.5 ± 28.8 mmHg) compared to CathLab (54.8 ± 24.0 mmHg; p < 0.05). Adding BP (143.1 ± 20.6 mmHg) to CWmax resulted in higher (207.7 ± 38.0 mmHg; p < 0.001), whereas adding BP to CWmean in lower (174.1 ± 26.1 mmHg; p < 0.01) derived LVSP compared to measured LVSP. However, adding BP to averaged CWmax and CWmean, resulted in comparable results for measured and derived LVSP (190.9 ± 31.6 mmHg) yielding a favourable correlation (r = 0.87, p < 0.001) and a good level of agreement in the Bland Altman plot.<br /><b>Conclusion</b><br />Non-invasive estimation of LVSP in HOCM is feasible by combining conventional BP and averaged CWmean and CWmax gradients. Hereby, a more reliable estimation of MyW in HOCM may be feasible.<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: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Unraveling the Intricacies of Left Ventricular Hemodynamic Forces: Age and Gender-Specific Normative Values Assessed by Cardiac MRI in Healthy Adults.</h4><i>Yang W, Wang Y, Zhu L, Xu J, ... Zhao S, Lu M</i><br /><b>Aims</b><br />Hemodynamic forces(HDFs) provided a feasible method to early detect cardiac mechanical abnormalities by estimating the intraventricular pressure gradients. The novel advances in assessment of HDFs using routine cardiac magnetic resonance(CMR) cines shed new light on detection of preclinical dysfunction. However, definition of normal values for this new technique is the prerequisite for application in the clinic.<br /><b>Methods and results</b><br />A total of 218 healthy volunteers(38.1years ± 11.1; 111 male [50.9%]) were recruited and underwent CMR examinations with a 3.0 T scanner. Balanced steady state free precession breath hold cine images were acquired and HDF assessments were performed based on strain analysis. The normal values of longitudinal, transversal HDF strength(RMS) and ratio of transversal to longitudinal HDF were all evaluated in overall population as well as in both genders and in age-specific groups. The longitudinal RMS values(%) of HDFs were significantly higher in women (P < 0.05). Moreover, the HDF amplitudes significantly decreased with ageing in entire heartbeat, systole, diastole, systolic/diastolic transition and diastolic deceleration, while increased in atrial thrust. In multivariable linear regression analysis, age, heart rate and global longitudinal strain emerged as independent predictors of the amplitudes of longitudinal HDFs in entire heartbeat and systole, while left ventricular end-diastole volume index was also independently associated with longitudinal HDFs in diastole and diastolic deceleration(P < 0.05 for all).<br /><b>Conclusion</b><br />Our study provided comprehensive normal values of HDF assessments using CMR as well as presented with specific age and sex stratification. HDFs analyses can be performed with excellent intra and inter-observer reproducibility.<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: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Distal-Vessel Fractional Flow Reserve by Computed Tomography to Monitor Epicardial Coronary Artery Disease.</h4><i>Chen M, Almeida SO, Sayre JW, Karlsberg RP, Sevag Packard RR</i><br /><b>Aims</b><br />Coronary computed tomography angiography (CTA) and fractional flow reserve by computed tomography (FFR-CT) are increasingly utilized to characterize coronary artery disease (CAD). We evaluated the feasibility of distal-vessel FFR-CT as an integrated measure of epicardial CAD that can be followed serially, assessed the CTA parameters that correlate with distal-vessel FFR-CT, and determined the combination of clinical and CTA parameters that best predict distal-vessel FFR-CT and distal-vessel FFR-CT changes.<br /><b>Methods and results</b><br />Patients (n=71) who underwent serial CTA scans at ≥2 years interval (median=5.2 years) over a 14-year period were included in this retrospective study. Coronary arteries were analyzed blindly using artificial intelligence-enabled quantitative coronary CTA. Two investigators jointly determined the anatomic location and corresponding distal-vessel FFR-CT values at CT1 and CT2. 45.3% had no significant change, 27.8% an improvement, and 26.9% a worsening in distal-vessel FFR-CT at CT2. Stepwise multiple logistic regression analysis identified a four-parameter model consisting of stenosis diameter ratio, lumen volume, low density plaque volume, and age, that best predicted distal-vessel FFR-CT ≤0.80 with an area under the curve (AUC)=0.820 at CT1 and AUC=0.799 at CT2. Improvement of distal-vessel FFR-CT was captured by a decrease in high-risk plaque and increases in lumen volume and remodeling index (AUC=0.865), whereas increases in stenosis diameter ratio, medium density calcified plaque volume, and total cholesterol presaged worsening of distal-vessel FFR-CT (AUC=0.707).<br /><b>Conclusions</b><br />Distal-vessel FFR-CT permits the integrative assessment of epicardial atherosclerotic plaque burden in a vessel-specific manner and can be followed serially to determine changes in global CAD.<br /><br />Published by Oxford University Press on behalf of the European Society of Cardiology 2023.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 14 Sep 2023; epub ahead of print</small></div>

<div><h4>Noninvasive Assessment of Left Ventricular End-Diastolic Pressure Using Machine Learning Derived Phasic Left Atrial Strain.</h4><i>Gruca MM, Slivnick JA, Singh A, Cotella J, ... Su JL, Lang RM</i><br /><b>Background</b><br />While transthoracic echocardiography (TTE) assessment of left ventricular end-diastolic pressure (LVEDP) is critically important, the current paradigm is subject to error and indeterminate classification. Recently, peak left atrial strain (LAS) was found to be associated with LVEDP. We aimed to test the hypothesis that integration of the entire LAS time curve into a single parameter could improve the accuracy of peak LAS in the noninvasive assessment of LVEDP with TTE.<br /><b>Methods</b><br />We retrospectively identified 294 patients who underwent left heart catheterization and TTE within 24 hours. LAS curves were trained using machine learning (100 patients) to detect LVEDP>15mmHg, yielding the novel parameter LAS index (LASi). The accuracy of LASi was subsequently validated (194 patients), side-by-side with peak LAS and ASE/EACVI guidelines, against invasive filling pressures.<br /><b>Results</b><br />Within the validation cohort, invasive LVEDP was elevated in 116 (59.8%) patients. The overall accuracy of LASi, peak LAS and ASE/EACVI algorithm was 79%, 75%, and 76%, respectively (excluding 37 patients with indeterminate diastolic function by ASE/EACVI guidelines). When the number of LASi indeterminates (defined by near-zero LASi values) was matched to the ASE/EACVI guidelines (n=37), the accuracy of LASi improved to 87%. Importantly, among the 37 patients with ASE/EACVI-indeterminate diastolic function, LASi had an accuracy of 81%, compared to 76% for peak LAS.<br /><b>Conclusions</b><br />LASi allows the detection of elevated LVEDP using invasive measurements as a reference, at least as accurately as peak LAS and current diastolic function guidelines algorithm, with the advantage of no indeterminate classifications in patients with measurable LAS.<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: 14 Sep 2023; epub ahead of print</small></div>

<div><h4>Phenotyping left ventricular systolic dysfunction in asymptomatic individuals for improved risk stratification.</h4><i>Rauseo E, Abdulkareem M, Khan A, Cooper J, ... Slabaugh GG, Petersen SE</i><br /><b>Aims</b><br />Left ventricular systolic dysfunction (LSVD) is a heterogeneous condition with several factors influencing prognosis. Better phenotyping of asymptomatic individuals can inform preventative strategies. This study aims to explore the clinical phenotypes of LVSD in initially asymptomatic subjects and their association with clinical outcomes and cardiovascular abnormalities through multi-dimensional data clustering.<br /><b>Methods and results</b><br />Clustering analysis was performed on 60 clinically available variables from 1563 UK Biobank participants without pre-existing heart failure (HF) and with left ventricular ejection fraction (LVEF) < 50% on cardiovascular magnetic resonance (CMR) assessment. Risks of developing HF, other cardiovascular events, death, and a composite of major adverse cardiovascular events (MACE) associated with clusters were investigated. Cardiovascular imaging characteristics, not included in the clustering analysis, were also evaluated. Three distinct clusters were identified, differing considerably in lifestyle habits, cardiovascular risk factors, electrocardiographic parameters, and cardiometabolic profiles. A stepwise increase in risk profile was observed from Cluster 1 to Cluster 3, independent of traditional risk factors and LVEF. Compared with Cluster 1, the lowest risk subset, the risk of MACE ranged from 1.42 [95% confidence interval (CI): 1.03-1.96; P < 0.05] for Cluster 2 to 1.72 (95% CI: 1.36-2.35; P < 0.001) for Cluster 3. Cluster 3, the highest risk profile, had features of adverse cardiovascular imaging with the greatest LV re-modelling, myocardial dysfunction, and decrease in arterial compliance.<br /><b>Conclusions</b><br />Clustering of clinical variables identified three distinct risk profiles and clinical trajectories of LVSD amongst initially asymptomatic subjects. Improved characterization may facilitate tailored interventions based on the LVSD sub-type and improve clinical outcomes.<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: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>Non-invasive myocardial work in aortic stenosis - validation and improvement of left ventricular pressure estimation.</h4><i>Ribic D, Remme EW, Smiseth OA, Massey RJ, ... Broch K, Russell K</i><br /><b>Aims</b><br />The non-invasive myocardial work index (MWI) has been validated in patients without aortic stenosis (AS). A thorough assessment of methodological limitations is warranted before this index can be applied in patients with AS.<br /><b>Methods and results</b><br />We simultaneously measured left ventricular pressure (LVP) by a micromanometer-tipped catheter and obtained echocardiograms in 20 patients with severe AS. We estimated LVP curves and calculated pressure-strain loops using three different models: 1. The model validated in patients without AS; 2. The same model, but with pressure at aortic valve opening (AVO) adjusted to diastolic cuff pressure; and 3. A new model based on the invasive measurements from the AS patients. Valvular events were determined by echocardiography. Peak LVP was estimated as the sum of the mean aortic transvalvular gradient and systolic cuff pressure. In same-beat comparisons between invasive and estimated LVP curves, model 1 significantly overestimated early systolic pressure by 61 ± 5 mmHg at AVO compared to model 2 and 3. However, the average correlation coefficients between estimated and invasive LVP traces were excellent for all models and the overestimation had limited influence on MWI, with excellent correlation (r = 0.98, p < 0.001) and good agreement between the MWI calculated with estimated (all models) and invasive LVP.<br /><b>Conclusion</b><br />This study confirms the validity of the non-invasive MWI in patients with AS. The accuracy of estimated LVP curves improved when matching AVO to the diastolic pressure in the original model mirroring that of the AS-specific model. This may sequentially enhance accuracy of regional MVI assessment.<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: 06 Sep 2023; epub ahead of print</small></div>

<div><h4>Prognostic value of myocardial performance index in individuals with type 1 and type 2 diabetes: Thousand&1 and Thousand&2 studies.</h4><i>Bahrami HSZ, Jørgensen PG, Hove JD, Dixen U, ... Rossing P, Jensen MT</i><br /><b>Aims</b><br />Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in type 1 (T1D) and type 2 diabetes (T2D). Despite diabetes affects the myocardium, risk prediction models do not include myocardial function parameters. Myocardial performance index (MPI) reflects left ventricular function. The prognostic value of MPI has not been evaluated in large-scale diabetes populations.<br /><b>Methods and results</b><br />We evaluated two prospective cohort studies: Thousand&1 (1093 individuals with T1D) and Thousand&2 (1030 individuals with T2D). Clinical data, including echocardiography, were collected at baseline. We collected follow-up data from national registries. We defined major adverse cardiovascular events (MACE) as incident events of hospital admission for acute coronary syndrome, heart failure, stroke, or all-cause mortality. For included individuals (56% male, 54 ± 15 years, MPI 0.51 ± 0.1, 63% T1D), follow-up was 100% after median of 5.3 years (range: 4.8-6.3). MPI was associated with MACE (HR 1.2, 95%CI 1.0-1.3, P = 0.012, per 0.10-unit increase) and heart failure (HR 1.3, 95%CI 1.1-1.6, P = 0.005, per 0.10-unit increase) after adjusting for clinical and echocardiographic variables. MPI predicted MACE and heart failure better in T1D than T2D (P = 0.031 for interaction). MPI added discriminatory power to the Steno T1 Risk Engine, based on clinical characteristics, in predicting MACE [area under the curve (AUC) from 0.77 to 0.79, P = 0.030] and heart failure (AUC from 0.77 to 0.83, P = 0.009) in T1D.<br /><b>Conclusion</b><br />MPI is independently associated with MACE and heart failure in T1D but not T2D and improves prediction in T1D. Echocardiographic assessment in T1D may enhance risk prediction.<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: 28 Aug 2023; epub ahead of print</small></div>

<div><h4>In memoriam Liv Hatle 1936-2023, pioneering echocardiologist.</h4><i>Fraser AG, Sutherland GR, Bijnens B</i><br /><AbstractText>In our opinion, no abstract is needed or appropriate for this article, which is a combined obituary and summary of the Liv Hatle\'s contributions to echocardiography. It does not fit into any of the categories offered by the submission website. We can provide some sentences if requested.</AbstractText><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: 26 Aug 2023; epub ahead of print</small></div>

<div><h4>Competency-based cardiac imaging for patient-centred care. A statement of the European Society of Cardiology (ESC).</h4><i>Westwood M, Almeida AG, Barbato E, Delgado V, ... Achenbach S, Petersen SE</i><br /><AbstractText>Imaging plays an integral role in all aspects of managing heart disease and cardiac imaging is a core competency of cardiologists. The adequate delivery of cardiac imaging services requires expertise in both imaging methodology - with specific adaptations to imaging of the heart - as well as intricate knowledge of heart disease. The European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC have developed and implemented a successful education and certification programme for all cardiac imaging modalities. This programme equips cardiologists to provide high quality competency-based cardiac imaging services ensuring they are adequately trained and competent in the entire process of cardiac imaging, from the clinical indication via selecting the best imaging test to answer the clinical question, to image acquisition, analysis, interpretation, storage, repository, and results dissemination. This statement emphasizes the need for competency-based cardiac imaging delivery which is key to optimal, effective and efficient, patient care.</AbstractText><br /><br />This article has been co-published with permission in the European Heart Journal, European Heart Journal – Cardiovascular Imaging, and European Heart Journal – Imaging Methods and Practice. © 2023 the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 25 Aug 2023; epub ahead of print</small></div>

<div><h4>Three-Dimensional Echocardiographic Evaluation of Longitudinal and Non-Longitudinal Components of Right Ventricular Contraction Results from the World Alliance of Societies of Echocardiography Study.</h4><i>Cotella JI, Kovacs A, Addetia K, Fabian A, ... Lang RM, WASE Investigators </i><br /><b>Aims</b><br />Right ventricular (RV) functional assessment is mainly limited to its longitudinal contraction. Dedicated 3-dimensional echocardiography (3DE) software enabled the separate assessment of the non-longitudinal components of RV ejection fraction (EF). The aims of this study were 1) to establish normal values for RV 3D-derived longitudinal, radial, and anteroposterior EF (LEF, REF, AEF respectively) and their relative contributions to global RV EF, 2) to calculate 3D RV strain normal values and, 3) to determine sex, age and race related differences in these parameters in a large group of normal subjects (WASE study).<br /><b>Methods and results</b><br />3DE RV wide-angle datasets from 1043 prospectively enrolled healthy adult subjects, were analyzed to generate a 3D mesh model of the RV cavity (TomTec). Dedicated software (ReVISION) was used to analyze RV motion along the three main anatomical planes. The EF values corresponding to each plane were identified as LEF, REF, and AEF. Relative contributions were determined by dividing each EF component by the global RVEF. RV strain analysis included longitudinal, circumferential, and global area strains (GLS, GCS and GAS, respectively). Results were categorized by sex, age (18-40, 41-65 and >65 years) and race. Absolute REF, AEF, LEF and global RVEF were higher in women than in men (p < .001). With aging, both sexes exhibited a decline in all components of longitudinal shortening (p < .001), which was partially compensated in elderly women by an increase in radial contraction. Black subjects showed lower RV EF and GAS values compared to White and Asian subjects of the same sex (p < .001) and Black men showed significantly higher RV radial but lower longitudinal contributions to global RVEF compared to Asian and White men.<br /><b>Conclusions</b><br />3DE evaluation of the non-longitudinal components of RV contraction provides additional information regarding RV physiology, including sex, age and race - related differences in RV contraction patterns that may prove useful in disease states involving the right ventricle.<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: 21 Aug 2023; epub ahead of print</small></div>

<div><h4>Phenotyping Coronary Plaque by Computed Tomography in Premature Coronary Artery Disease.</h4><i>Rahoual G, Zeitouni M, Charpentier E, Ritvo PG, ... Redheuil A, Collet JP</i><br /><b>Aims</b><br />Premature coronary artery disease (CAD) is an aggressive disease with multiple recurrences mostly related to new coronary lesions. This study aimed to compare coronary plaque characteristics of individuals with premature CAD with those of incidental plaques found in matched individuals free of overt cardiovascular disease, using coronary computed tomography angiography (CCTA).<br /><b>Methods and results</b><br />Of 1552 consecutive individuals who underwent CCTA, 106 individuals with history of acute or stable obstructive CAD ≤45 years were matched by age, sex, smoking status, cardiovascular heredity, and dyslipidemia with 106 controls. CCTA were analyzed for CAD-RADS score, plaque composition, and high-risk plaque features (HRP), including spotty calcification, positive remodeling, low-attenuation, and napkin-ring sign. The characteristics of 348 premature CAD plaques were compared with those of 167 incidental coronary plaques of matched controls. The prevalence of non-calcified plaques was higher among individuals with premature CAD (65.1% vs. 30.2%, p < 0.001), as well as spotty calcification (42.5% vs. 17.9%, p < 0.001), positive remodeling (41.5% vs. 9.4%, p < 0.001), low-attenuation (24.5% vs. 3.8%, p < 0.001) and napkin-ring sign (1.9% vs. 0.0%). They exhibited an average of 2.2[2.7] HRP, while the control group displayed 0.4[0.8] HRP (p < 0.001). Within a median follow-up of 24[16,34] months, individuals with premature CAD and ischemic recurrence (n = 24) had more HRP (4.3[3.9]) than those without ischemic recurrence (1.5[1.9]), mostly non-calcified with low-attenuation and positive remodeling.<br /><b>Conclusion</b><br />Coronary atherosclerosis in individuals with premature CAD is characterized by a high and predominant burden of non-calcified plaque and unusual high prevalence of HRP, contributing to disease progression with multiple recurrences. A comprehensive qualitative CCTA assessment of plaque characteristics may further risk stratify our patients, beyond cardiovascular risk factors.<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: 19 Aug 2023; epub ahead of print</small></div>

<div><h4>Correlates and Prognostic Implications of LVEF Reduction After Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation.</h4><i>Shechter A, Kaewkes D, Lee M, Makar M, ... Makkar RR, Siegel RJ</i><br /><b>Aims</b><br />To explore the characteristics and outcomes of patients undergoing transcatheter edge-to-edge repair (TEER) for primary mitral regurgitation (MR) according to the presence of left ventricular ejection fraction (LVEF) reduction post-procedure.<br /><b>Methods and results</b><br />We retrospectively analyzed 317 individuals (median age 83 (IQR, 75-88) years, 197 (62.1%) males) treated with an isolated, first-time TEER that was concluded by a successful clip deployment. Stratified by LVEF change at 1-month compared to baseline, the cohort was evaluated for residual MR and heart failure (HF) indices up to 1-year, as well as all-cause mortality and HF hospitalizations at 2-years. Overall, 212 (66.9%) patients displayed LVEF reduction, which was mainly driven by lowered total stroke volume and diffuse hypocontractility. While postprocedural MR, transmitral mean pressure gradient, and functional status were comparable in the 2 study groups, patients with LVEF reduction exhibited a greater decline in filling pressures intra-procedurally; left ventricular mass index, pulmonary arterial systolic pressure, and serum natriuretic peptide level at 1-month; and walking limitation at 1-year. Also, by 2 years, they were less likely to die (13.3% vs 5.7%, p = 0.019), be readmitted for HF (17.1% vs 9.0%, p = 0.033), and experience either of the two (23.8% vs 12.7%, p = 0.012). Lastly, LVEF reduction was the only 1-month echocardiographic parameter to independently confer an attenuated risk for the composite of deaths or HF hospitalizations (HR 0.28, 95% CI 0.10-0.78, p = 0.016).<br /><b>Conclusion</b><br />LVEF reduction at 1-month post-TEER for primary MR is associated with better clinical outcomes, possibly reflecting a more pronounced unloading effect of the procedure.<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: 17 Aug 2023; epub ahead of print</small></div>

<div><h4>Determinants and Prognostic Implications of Left Atrial Reverse Remodeling After Coarctation of Aorta Repair in Adults.</h4><i>Egbe AC, Younis A, Miranda WR, Jain CC, Connolly HM, Borlaug BA</i><br /><b>Background</b><br />Left atrial (LA) dysfunction and atrial fibrillation are also relatively common in adults with coarctation of aorta (COA), and the severity of LA dysfunction is associated with higher risk of atrial fibrillation in this population. The purpose of this study was to determine whether LA function improved after COA repair (LA reverse remodeling), and the relationship between LA reverse remodeling and atrial fibrillation.<br /><b>Method</b><br />Retrospective cohort study of adults undergoing COA repair (2003-2020). LA reservoir strain was assessed preintervention and 12-24 months postintervention, using speckle tracking echocardiography. Incident atrial fibrillation was assessed from COA repair to last follow-up.<br /><b>Results</b><br />Of 261 adults that underwent COA repair (age 37 ± 13 years; males 148 [57%]), 124 (47%) and 137 (53%) presented with native versus recurrent COA, respectively. Of 261 patients, 231 (82%) and 48 (18%) underwent surgical and transcatheter COA repair, respectively. LA reservoir strain increased from 32 ± 8% (preintervention) to 39 ± 7% (post intervention), yielding a relative increase of 21 ± 5%. Older age (β±SE -0.16 ± 0.09 per 5-year, p = 0.02), higher systolic blood pressure (β±SE -0.12 ± 0.04 per 5 mmHg, p = 0.005), and higher residual COA mean gradient (β±SE -0.17 ± 0.06 per 5 mmHg, p = 0.002) postintervention were associated with less LA reverse remodeling, after adjustment for sex, hypertension diagnosis, and left ventricular indices. LA reverse remodeling (hazard ratio 0.97, 95% confidence interval 0.96-0.98 per 1% increase from preintervention LA function, p = 0.006) was associated with lower risk of atrial fibrillation after adjustment for age, sex, preintervention LA reservoir strain, and history of atrial fibrillation.<br /><b>Conclusions</b><br />COA repair resulted in improved LA function and decreased risk for atrial fibrillation, especially in patients without residual hypertension or significant residual COA gradient.<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: 16 Aug 2023; epub ahead of print</small></div>

<div><h4>The Diagnostic Performance of QFR and Perfusion Imaging in Patients with Prior Coronary Artery Disease.</h4><i>van Diemen PA, de Winter RW, Schumacher SP, Everaars H, ... Driessen RS, Danad I</i><br /><b>Aims</b><br />In chronic coronary syndrome (CCS) patients with documented coronary artery disease (CAD) ischemia detection by myocardial perfusion imaging (MPI) or an invasive approach are viable diagnostic strategies. We compared the diagnostic performance of quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR) in patients with prior CAD (previous percutaneous coronary intervention (PCI) and/or myocardial infarction (MI)).<br /><b>Methods and results</b><br />This PACIFIC-2 substudy evaluated 189 CCS patients with prior CAD for inclusion. Patients underwent SPECT, PET, and CMR followed by invasive coronary angiography with fractional flow reserve measurements of all major coronary arteries (N=567) except for vessels with a subtotal or chronic total occlusion. QFR computation was attempted in 488 (86%) vessels with measured FFR available (FFR ≤0.80 defined hemodynamically significant CAD). QFR analysis was successful in 334 (68%) vessels among 166 patients and demonstrated a higher accuracy (84%) and sensitivity (72%) compared to SPECT (66%, p<0.001 and 46%, p=0.001), PET (65%, p<0.001 and 58%, p=0.032), and CMR (72%, p<0.001 and 33%, p<0.001). Specificity of QFR (87%) was similar to CMR (83%, p=0.123) but higher than that of SPECT (71%, p<0.001) and PET (67%, p<0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, p<0.001), PET (0.66, p<0.001), and CMR (0.60, p<0.001).<br /><b>Conclusion</b><br />QFR correlated better with FFR in patients with prior CAD than MPI, as reflected in the higher diagnostic performance measures for detecting FFR-defined vessel-specific significant CAD.<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: 14 Aug 2023; epub ahead of print</small></div>

<div><h4>Late gadolinium enhancement distribution patterns in non-ischemic dilated cardiomyopathy: Genotype-phenotype correlation.</h4><i>de Frutos F, Ochoa JP, Fernández AI, Gallego-Delgado M, ... Garcia-Pavia P, Mirelis JG</i><br /><b>Aims</b><br />Late gadolinium enhancement (LGE) is frequently found in patients with dilated cardiomyopathy (DCM), there is little information about its frequency and distribution pattern according to underlying genetic substrate. We sought to describe LGE patterns according to genotype and to analyze the risk of major ventricular arrhythmias (MVA) according to patterns.<br /><b>Methods and results</b><br />Cardiac magnetic resonance findings and LGE distribution according to genetics was performed in a cohort of 600 DCM patients followed at 20 Spanish centers. After exclusion of individuals with multiple causative gene variants or with variants in infrequent DCM-causing genes, 577 patients (34% females, mean age 53.5 years, LVEF 36.9 ± 13.9%) conformed the final cohort. A causative genetic variant was identified in 219 (38%) patients and 147 (25.5%) had LGE. Significant differences were found comparing LGE patterns between genes (P < 0.001). LGE was absent or rare in patients with variants in TNNT2, RBM20 and MYH7 (0%, 5% and 20%, respectively). Patients with variants in DMD, DSP and FLNC showed predominance of LGE subepicardial pattern (50%, 41% and 18%, respectively) whereas patients with variants in TTN, BAG3, LMNA and MYBPC3 showed unspecific LGE patterns. Genetic yield differed according to LGE pattern. Patients with subepicardial, lineal midwall, transmural, right ventricular insertion points or with combination of LGE patterns showed increased risk of MVA compared with patients without LGE.<br /><b>Conclusion</b><br />LGE patterns in DCM has a specific distribution according to the affected gene. Certain LGE patterns are associated with increased risk of MVA and with increased yield of genetic testing.<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 Aug 2023; epub ahead of print</small></div>

<div><h4>Gene-Echocardiography: Refining Genotype-Phenotype Correlations in Hypertrophic Cardiomyopathy.</h4><i>Zhou N, Weng H, Zhao W, Tang L, ... Pan C, Shu X</i><br /><b>Aims</b><br />This study aims to clarify the association between hypertrophic patterns and genetic variants in hypertrophic cardiomyopathy (HCM) patients, contributing to the advancement of personalized management strategies for HCM.<br /><b>Methods and results</b><br />A comprehensive evaluation of genetic mutations was conducted in 392 HCM-affected families using Whole Exome Sequencing. Concurrently, relevant echocardiographic data from these individuals were collected. Our study revealed an increased susceptibility to enhanced septal and interventricular septal thickness in HCM patients harboring gene mutations compared to those without. Mid-septal hypertrophy was found to be associated predominantly with MYBPC3 variants, while a higher septum-to-posterior wall ratio correlated with MYH7 variants. Mutations in MYH7, MYBPC3, and other sarcomeric or myofilament genes (TNNI3, TPM1, TNNT2) showed a relationship with increased hypertrophy in the anterior wall, interventricular septum, and lateral wall of the left ventricle. In contrast, ALPK3-associated hypertrophy chiefly presented in the apical region, while hypertrophy related to TTN and OBSCN mutations exhibited a uniform distribution across the myocardium. Hypertrophic patterns varied with the type and category of gene mutations, offering valuable diagnostic insights.<br /><b>Conclusion</b><br />Our findings underscore a strong link between hypertrophic patterns and genetic variants in HCM, providing a foundation for more accurate genetic testing and personalized management of HCM patients. The novel concept of \"gene-echocardiography\" may enhance the precision and efficiency of genetic counseling and testing in HCM.<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: 10 Aug 2023; epub ahead of print</small></div>

<div><h4>Incident atrial functional mitral regurgitation in atrial fibrillation and sinus rhythm.</h4><i>Naser JA, Michelena HI, Lin G, Scott CG, ... Nkomo VT, Pislaru SV</i><br /><b>Aims</b><br />Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on incident AFMR are scarce. We aimed to study the incidence, risk factors and clinical significance of AFMR in AF or sinus rhythm (SR).<br /><b>Methods and results</b><br />Adults with new diagnosis of AF and adults in SR were identified. Patients with >mild MR at baseline, primary mitral disease, cardiomyopathy, left-sided valve disease, previous cardiac surgery, or with no follow-up echocardiogram were excluded. Diastolic dysfunction was indicated by ≥2/4 abnormal diastolic function parameters [mitral medial e\', mitral medial E/e\', tricuspid regurgitation velocity, left atrial volume index]. Overall, 1,747 patients with AF and 29,623 in SR were included. Incidence rate of >mild AFMR was 2.6 per 100-person year in AF and 0.7 per 100-person year in SR, p<.001. AF remained associated with AFMR in a propensity-score matched analysis based on age, sex, and comorbidities between AF and SR [hazard ratio: 3.80 (95% CI 3.04-4.76)]. Independent risk factors associated with incident AFMR were age ≥65 years, female sex, left atrial volume index, and diastolic dysfunction in both AF and SR, in addition to rate (vs rhythm) control in AF. Incident AFMR was independently associated with all-cause death in both groups (both p<.001).<br /><b>Conclusions</b><br />AF conferred three-fold increase in the risk of incident AFMR. Diastolic dysfunction, older age, left atrial size, and female sex were independent risk factors in both SR and AF, while rhythm control was protective. AFMR was universally associated with worse mortality.<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: 09 Aug 2023; epub ahead of print</small></div>

<div><h4>Myocardial structural and functional changes in cardiac amyloidosis - Insights from a prospective observational patient registry.</h4><i>Duca F, Rettl R, Kronberger C, Binder C, ... Kammerlander AA, Bonderman D</i><br /><b>Aims</b><br />The pathophysiological hallmark of cardiac amyloidosis (CA) is the deposition of amyloid within the myocardium. Consequently, extracellular volume (ECV) of affected patients increases. However, studies on ECV progression over time are lacking.We aimed to investigate the progression of ECV and its prognostic impact in CA patients.<br /><b>Methods and results</b><br />Serial cardiac magnetic resonance (CMR) examinations, including ECV quantification were performed in consecutive CA patients.Between 2012 and 2021, 103 CA patients underwent baseline and follow-up CMR, including ECV quantification.Median ECVs at baseline of the total (n = 103), transthyretin [(ATTR) n = 80], and [light chain (AL) n = 23] CA cohorts were 48.0%, 49.0%, and 42.6%. During a median period of 12 months, ECV increased significantly in all cohorts [change (Δ) + 3.5% interquartile range (IQR): -1.9 - + 6.9, p < 0.001; Δ + 3.5%, IQR: -2.0 - + 6.7, p < 0.001; Δ + 3.5%, IQR: -1.6 - + 9.1, p = 0.026). Separate analyses for treatment-naïve (n = 21) and treated (n = 59) ATTR patients revealed that the median change of ECV from baseline to follow-up was significantly higher among untreated patients (+5.7% versus +2.3%, p = 0.004).Survival analyses demonstrated that median change of ECV was a predictor of outcome [total: hazard ratio (HR): 1.095, 95% confidence-interval (CI): 1.047-1.0145, p < 0.001; ATTR: HR: 1.073, 95% CI: 1.015-1.134, p = 0.013; AL: HR: 1.131, 95% CI: 1.041-1.228, p = 0.003].<br /><b>Conclusion</b><br />The present study supports the use of serial ECV quantification in CA patients, as change of ECV was a predictor of outcome and could provide information in the evaluation of amyloid-specific treatments.<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: 07 Aug 2023; epub ahead of print</small></div>

<div><h4>Phenotyping heart failure by echocardiography: Imaging of ventricular function and haemodynamics at rest and exercise.</h4><i>Smiseth OA, Donal E, Boe E, Ha JW, Fernandes JF, Lamata P</i><br /><AbstractText>Traditionally, congestive heart failure was phenotyped by echocardiography or other imaging techniques according to left ventricular ejection fraction (LVEF). The more recent echocardiographic modality speckle tracking strain is complementary to LVEF, as it is more sensitive to diagnose mild systolic dysfunction. Furthermore, when LV systolic dysfunction is associated with a small, hypertrophic ventricle, EF is often normal or supernormal, whereas LV global longitudinal strain can reveal reduced contractility. In addition, segmental strain patterns may be used to identify specific cardiomyopathies which in some cases can be treated with patient-specific medicine. In heart failure with preserved LVEF (HFpEF), a diagnostic hallmark is elevated LV filling pressure, which can be diagnosed with good accuracy by applying a set of echocardiographic parameters. When patients with HFpEF often have normal filling pressure at rest, a non-invasive or invasive diastolic stress test may be used to identify abnormal elevation of filling pressure during exercise. The novel parameter LV work index which incorporates afterload, is a promising tool for quantification of LV contractile function and efficiency. Another novel modality is shear wave imaging for diagnosing stiff ventricles, but clinical utility remains to be determined. In conclusion, echocardiographic imaging of cardiac function should include LV strain as a supplementary method to LVEF. Echocardiographic parameters can identify elevated LV filling pressure with good accuracy and may be applied in the diagnostic work-up of patients suspected of HFpEF.</AbstractText><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: 05 Aug 2023; epub ahead of print</small></div>

<div><h4>Right Ventricular Myocardial Work for the Prediction of Early Right Heart Failure and Long-term Mortality After Left Ventricular Assist Device Implant.</h4><i>Landra F, Sciaccaluga C, Pastore MC, Gallone G, ... Cameli M, Mandoli GE</i><br /><b>Aims</b><br />Right heart failure(RHF) after LVAD implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular(RV) function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial Work(MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of RVMW to predict RHF and long-term mortality after LVAD implant.<br /><b>Methods and results</b><br />Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in 6 patients (26%). A lower RV Global Work Efficiency(RVGWE, OR 0.86, 95% CI 0.76-0.97, p = 0.014) was associated with the occurrence of early RHF. Among MW indices, performance for early RHF prediction was greatest for RVGWE (AUC 0.92) and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, p = 0.033).<br /><b>Conclusion</b><br />RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality.<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: 05 Aug 2023; epub ahead of print</small></div>

<div><h4>Normal Reference Values for Mitral Annular Plane Systolic Excursion by M-mode and Speckle-Tracking Echocardiography: A Prospective, Multicenter, Population-Based Study.</h4><i>Wang YH, Sun L, Li SW, Wang CF, ... Ren WD, Study Investigators </i><br /><b>Aims</b><br />Mitral annular plane systolic excursion (MAPSE) is a simple and reliable index for evaluating left ventricular (LV) systolic function, particularly in patients with poor image quality; however, the lack of reference values limits its widespread use. This study aimed to establish the normal ranges for MAPSE measured using motion mode (M-mode) and two-dimensional speckle-tracking echocardiography (2D-STE) and to explore its principal determinants.<br /><b>Methods and results</b><br />This multicenter, prospective, cross-sectional study included 1,952 healthy participants (840 men [43%]; age range, 18-80 years) from 55 centers. MAPSE was measured using M-mode echocardiography and 2D-STE. The results showed that women had a higher MAPSE than men and MAPSE decreased with age. The age- and sex-specific reference values for MAPSE were established for these two methods. Multiple linear regression analyses revealed that MAPSE on M-mode echocardiography correlated with age and MAPSE on 2D-STE with age, blood pressure, heart rate, and LV volume. Moreover, MAPSE measured by 2D-STE correlated more strongly with global longitudinal strain compared with that measured using M-mode echocardiography.<br /><b>Conclusion</b><br />Normal MAPSE reference values were established based on age and sex. Blood pressure, heart rate, and LV volume are potential factors that influence MAPSE and should be considered in clinical practice. Normal values are useful for evaluating the LV longitudinal systolic function, especially in patients with poor image quality, and may further facilitate the use of MAPSE in routine assessments.<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 Aug 2023; epub ahead of print</small></div>

<div><h4>CMR Reclassifies the Majority of Patients with Suspected MINOCA and non MINOCA.</h4><i>Liang K, Bisaccia G, Leo I, Williams MGL, ... Johnson TW, Bucciarelli-Ducci C</i><br /><b>Background</b><br />In approximately 5-15% of all cases of acute coronary syndromes (ACS) have unobstructed coronaries on angiography. Cardiac magnetic resonance (CMR) has proven useful to identify in most patients the underlying diagnosis associated with this presentation. However, the role of CMR to reclassify patients from the initial suspected condition has not been clarified.<br /><b>Aims</b><br />The aim of this study was to assess the proportion of patients with suspected MINOCA, or non-MINOCA, that CMR reclassifies with an alternative diagnosis from the original clinical suspicion.<br /><b>Methods and results</b><br />A retrospective cohort of patients in a tertiary cardiology centre was identified from a registry database. Patients who were referred for CMR for investigation of suspected MINOCA, and a diagnosis pre- and post-CMR was recorded to determine the proportion of diagnoses reclassified.A total of 888 patients were identified in the registry. CMR reclassified diagnosis in 78% of patients. Diagnosis of MINOCA was confirmed in only 243 patients (27%), whilst most patients had an alternative diagnosis (73%): myocarditis n = 217 (24%), Takotsubo syndrome n = 115 (13%), cardiomyopathies n = 97 (11%), normal CMR/non-specific n = 216 (24%).<br /><b>Conclusion</b><br />In a large single-centre cohort of patients presenting with acute coronary syndrome and unobstructed coronary arteries, most patients had a non-MINOCA diagnosis (73%) (myocarditis, TakoTsubo, cardiomyopathies or normal CMR/non-specific findings), whilst only a minority had confirmed MINOCA (27%). Performing CMR led to reclassifying patients\' diagnosis in 78% of cases, thus confirming its important clinical role and underscoring the clinical challenge in diagnosing MINOCA and non MINOCA conditions.<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: 01 Aug 2023; epub ahead of print</small></div>

<div><h4>Systolic anterior motion of the anterior mitral valve leaflet begins in subclinical hypertrophic cardiomyopathy.</h4><i>Seitler S, De Zoysa Anthony S, Obianyo CCC, Syrris P, ... Moon JC, Captur G</i><br /><b>Aims</b><br />Anterior mitral valve leaflet (AMVL) elongation is detectable in overt and subclinical hypertrophic cardiomyopathy (HCM). We sought to investigate the dynamic motion of the aorto-mitral apparatus to understand the behaviour of the AMVL, and mechanisms of left ventricular outflow tract obstruction (LVOTO) predisposition in HCM.<br /><b>Methods & results</b><br />Cardiovascular magnetic resonance imaging (CMR) using 1.5 Tesla scanner was performed on 36 HCM sarcomere gene mutation carriers without left ventricular hypertrophy (G + LVH-), 31 HCM patients with preserved ejection fraction carrying a pathogenic sarcomere gene mutation (G + LVH+), and 53 age, sex and BSA-matched healthy volunteers.Dynamic excursion of the aorto-mitral apparatus was assessed semi-automatically on breath-held 3-chamber cine steady-state free precession images. Four pre-defined regions of interest (ROI) were tracked: ROIPMVL: hinge point of the posterior MVL; ROITRIG: intertrigonal mitral annulus; ROIAMVL: AMVL tip; ROIAAO: anterior aortic annulus. Compared to controls, normalized two-dimensional displacement-versus-time plots in G + LVH- revealed subtle but significant systolic anterior motion (SAM) of the AMVL (P < 0.0001) and reduced longitudinal excursion of ROIAAO (P = 0.014) and ROIPMVL (P = 0.048). In overt and subclinical HCM, excursion of the ROITRIG/AMVL/PMVL was positively associated with burden of LV fibrosis (p < 0.028). As expected, SAM was observed in G + LVH + together with reduced longitudinal excursion of ROITRIG (P = 0.049) and ROIAAO (P = 0.008).<br /><b>Conclusion</b><br />Dyskinesia of the aorto-mitral apparatus, including SAM of the elongated AMVL, is detectable in subclinical HCM, before the development of LVH or LA enlargement. These data have the potential to improve our understanding of early phenotype development and LVOTO-predisposition in HCM.<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: 31 Jul 2023; epub ahead of print</small></div>

<div><h4>Efficacy on resynchronization and longitudinal contractile function comparing His-bundle pacing to conventional biventricular pacing. - A substudy to the His-alternative study.</h4><i>Højgaard EV, Philbert BT, Linde JJ, Winsløw UC, ... Vinther M, Risum N</i><br /><b>Aims</b><br />His-bundle pacing has emerged as a novel method to deliver cardiac resynchronization therapy (CRT). However, there are no data comparing conventional Biventricular (BiV)-CRT to His-CRT with regards to effects on mechanical dyssynchrony and longitudinal contractile function.<br /><b>Methods and results</b><br />Patients with symptomatic heart failure, left ventricular ejection fraction (LVEF) ≤ 35% and left bundle branch block (LBBB) by strict ECG criteria were randomized 1:1 to His-CRT or BiV-CRT. Two-dimensional strain echocardiography was performed prior to CRT implantation and at six months after implantation. Differences in changes in mechanical dyssynchrony (standard deviation of time-to-peak in 12 midventricular and basal segments) and regional longitudinal strain in the six left ventricular walls were compared between the BiV-CRT and His-CRT groups.In the on treatment analysis 31 received BiV-CRT and 19 His-CRT. In both groups mechanical dyssynchrony was significantly reduced after six months (BiV-group from 120 ms [±45] to 63 ms [±22], P < 0.001, His-group from 116 ms [±54] to 49 ms [±11], P < 0.001), but no significant differences in changes could be demonstrated between groups (-9.0 ms [-36; 18], P = 0.50). GLS improved in both groups (BiV-group from -9.1% [±2.7] to -10.7% [±2.6], P = 0.02, and His-group from -8.6% [±2.1] to -11.1% [±2.0], P < 0.001) but no significant differences in changes could be demonstrated from baseline to follow-up (-0.9 [-2.4; -0.6], P = 0.25) between groups. There were no regional differences between groups (P < 0.05, all).<br /><b>Conclusions</b><br />In heart failure patients with LBBB, BiV-CRT and His-CRT have comparable effects with regards to improvements in mechanical dyssynchrony and longitudinal contractile function.<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: 25 Jul 2023; epub ahead of print</small></div>

<div><h4>Global Constructive Work is associated with ventricular arrythmias after cardiac resynchronization therapy.</h4><i>Saffi H, Winsløw U, Sakthivel T, Højgaard EV, ... Bundgaard H, Risum N</i><br /><b>Aim</b><br />Non-invasive left ventricular (LV) pressure-strain loops provide a novel method for quantifying myocardial work by incorporating LV pressure in measurements of myocardial deformation. Early studies suggest that myocardial work parameters such as Global Constructive Work (GCW) could be useful and reliable in arrhythmia prediction particularly in patients undergoing cardiac resynchronization therapy.The aim of this study was to evaluate whether the magnitude of GCW was associated with occurrence of ventricular arrhythmias in patients after cardiac resynchronization therapy.<br /><b>Method and results</b><br />Patients on guideline-recommended treatment with a cardiac resynchronization therapy defibrillator (CRT-D) were evaluated by 2D speckle-tracking echocardiography including measurements of GCW at least six months after implantation. The primary outcome was a composite of appropriate defibrillator therapy and sustained ventricular arrhythmia under the monitor zone. A total of 162 patients (mean age 66 years (±10), 122 males (75%)), were included. 16 (10%) patients experienced the primary outcome during a median follow-up of 18 months (IQR: 12-25) after the index echocardiography. Patients with below-median GCW (<1,473 mmHg%) had a hazard ratio for the outcome of 8.14 [95% CI: 1.83-36.08], P = 0.006 compared to patients above the median in a univariate model and remained an independent predictor after multivariate adjustment for eGFR and QRS duration (hazard ratio 4.75 [95% CI: 1.01-22.28], P < 0.05.<br /><b>Conclusion</b><br />In patients treated with CRT-D, GCW below median level was associated with a 5-fold increase in risk of ventricular arrhythmias.<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: 25 Jul 2023; epub ahead of print</small></div>

<div><h4>Prognostic value of global myocardial flow reserve in patients with history of coronary artery bypass grafting.</h4><i>Al Rifai M, Ahmed AI, Saad JM, Alahdab F, Nabi F, Al-Mallah MH</i><br /><b>Aims</b><br />It is not well understood whether positron emission tomography (PET)-derived myocardial flow reserve (MFR) is prognostic among patients with prior coronary artery bypass grafting (CABG).<br /><b>Methods and results</b><br />Consecutive patients with a clinical indication for PET were enrolled in the Houston Methodist DeBakey Heart and Vascular Center PET registry and followed prospectively for incident outcomes. The primary outcome was a composite of all-cause death, myocardial infarction (MI)/unplanned revascularization, and heart failure admissions. Cox proportional hazards models were used to study the association between MFR (<2 vs. ≥2) and incident events adjusting for clinical and myocardial perfusion imaging variables. The study population consisted of 836 patients with prior CABG; mean (SD) age 68 (10) years, 53% females, 79% Caucasian, 36% non-Hispanic, and 66% with MFR <2. Over a median (interquartile range [IQR]) follow-up time of 12 (4-24) months, there were 122 incident events (46 HF admissions, 28 all-cause deaths, 23 MI, 22 PCI/3 repeat CABG 90 days after imaging). In adjusted analyses, patients with impaired MFR had a higher risk of the primary outcome [hazard ratio (HR) 2.06; 95% CI 1.23-3.44]. Results were significant for admission for heart failure admissions (HR 2.92; 95% CI 1.11-7.67) but not for all-cause death (HR 2.01, 95% CI 0.85-4.79), or MI/UR (HR 1.93, 95% CI 0.92-4.05).<br /><b>Conclusion</b><br />Among patients with a history of CABG, PET-derived global MFR <2 may identify those with a high risk of subsequent cardiovascular events, especially heart failure, independent of cardiovascular risk factors and perfusion data.<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 Jul 2023; epub ahead of print</small></div>

<div><h4>The added value of abnormal regional myocardial function for risk prediction in arrhythmogenic right ventricular cardiomyopathy.</h4><i>Kirkels FP, Rootwelt-Norberg C, Bosman LP, Aabel EW, ... Haugaa K, Teske AJ</i><br /><b>Background:</b><br/>& aims</b><br />A risk calculator for individualized prediction of first-time sustained ventricular arrhythmia (VA) in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients has recently been developed and validated (www.ARVCrisk.com). This study aimed to investigate whether regional functional abnormalities, measured by echocardiographic deformation imaging, can provide additional prognostic value.<br /><b>Methods & results</b><br />From two referral centres, 150 consecutive patients with a definite ARVC diagnosis, no prior sustained VA and an echocardiogram suitable for deformation analysis were included (aged 41±17 years, 50% female). During a median follow-up of 6.3 (IQR 3.1-9.8) years, 37 (25%) experienced a first-time sustained VA. All tested left and right ventricular (LV, RV) deformation parameters were univariate predictors for first-time VA. While LV function did not add predictive value in multivariate analysis, two RV deformation parameters did; RV free wall longitudinal strain and regional RV deformation patterns remained independent predictors after adjusting for the calculator-predicted risk (HR 1.07 [1.02-1.11]; p = 0.004 and 4.45 [1.07-18.57]; p = 0.040, respectively) and improved its discriminative value (from C-statistic 0.78 to 0.82 in both. Akaike information criterion change >2). Importantly, all patients who experienced VA within 5 years from the echocardiographic assessment had abnormal regional RV deformation patterns at baseline.<br /><b>Conclusions</b><br />This study showed that regional functional abnormalities measured by echocardiographic deformation imaging can further refine personalized arrhythmic risk prediction when added to the ARVC risk calculator. The excellent negative predictive value of normal RV deformation could support clinicians considering timing of ICD implantation in patients with intermediate arrhythmic 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 Jul 2023; epub ahead of print</small></div>

<div><h4>Left ventricular-global longitudinal strain as a prognosticator in hypertrophic cardiomyopathy with a low-normal left ventricular ejection fraction.</h4><i>Choi YJ, Lee HJ, Park JS, Park CS, ... Hwang IC, Kim HK</i><br /><b>Aims</b><br />To investigate the prognostic utility of left ventricular (LV)-global longitudinal strain (LV-GLS) in patients with hypertrophic cardiomyopathy (HCM) and an LV-ejection fraction (LVEF) of 50-60%.<br /><b>Methods and results</b><br />This retrospective cohort study included 349 patients with HCM and an LVEF of 50-60%. The primary outcome was a composite of cardiovascular death, including sudden cardiac death (SCD), and SCD-equivalent events. The secondary outcomes were SCD/SCD-equivalent events, cardiovascular death (including SCD), and all-cause death. The final analysis included 349 patients (mean age 59.2 ± 14.2 years, men 75.6%). During a median follow-up of 4.1 years, the primary outcome occurred in 26 (7.4%), while the secondary outcomes of SCD/SCD-equivalent events, cardiovascular death, and all-cause death occurred in 15 (4.2%), 20 (5.7%), and 34 (9.7%), respectively. After adjusting for age, atrial fibrillation, ischemic stroke, LVEF, and left atrial volume index, absolute LV-GLS (%) was independently associated with the primary outcome (adjusted HR 0.88, 95% CI 0.788-0.988, P = 0.029). According to receiver operating characteristic analysis, 10.5% is an optimal cutoff value for absolute LV-GLS in predicting the primary outcome. Patients with an absolute LV-GLS ≤ 10.5% had a higher risk of the primary outcome than those with an absolute LV-GLS > 10.5% (adjusted HR 2.54, 95% CI 1.117-5.787, P = 0.026). Absolute LV-GLS ≤10.5% was an independent predictor for each secondary outcome (P < 0.05).<br /><b>Conclusions</b><br />LV-GLS was an independent predictor of a composite of cardiovascular death, including SCD/SCD-equivalent events, in patients with HCM and an LVEF of 50-60%. Therefore, LV-GLS can help in risk stratification in these 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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 19 Jul 2023; epub ahead of print</small></div>

<div><h4>Tales from the future - Nuclear cardio-oncology, from prediction to diagnosis and monitoring.</h4><i>Mikail N, Chequer R, Imperiale A, Meisel A, ... Gebhard C, Rossi A</i><br /><AbstractText>Cancer and cardiovascular disease often share common risk factors, and patients with cardiovascular disease who develop cancer are at high risk of experiencing major adverse cardiac events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients\' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced noninvasive cardiac imaging has raised great interest in the early detection of cardiovascular diseases and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments, and discuss the specific role of nuclear cardiology alongside other noninvasive imaging techniques.</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: 19 Jul 2023; epub ahead of print</small></div>

<div><h4>Current Clinical Use of Speckle Tracking Strain Imaging: Insights from a Worldwide Survey from the European Association of Cardiovascular Imaging-EACVI.</h4><i>Sade LE, Joshi SS, Cameli M, Cosyns B, ... Sitges M, Dweck MR</i><br /><b>Background</b><br />Echocardiographic speckle-tracking strain imaging (STE) has been a major advance in myocardial function quantification. We aimed to explore current world-wide clinical application of STE.<br /><b>Methods</b><br />Access, feasibility, access, and clinical implementation of STE were investigated with a worldwide open-access online survey of the European Association of Cardiovascular Imaging (EACVI).<br /><b>Results</b><br />Participants (429 respondents, 77 countries) from tertiary centers (46%), private clinics or public hospitals (54%) using different vendors for data acquisition and analysis were represented. Despite almost universal access (98%) to STE, only 39% of the participants performed and reported STE results frequently (>50%). Incomplete training and time constraints were the main reasons for not using STE more regularly. STE was mainly used to assess the left ventricular (99%) and less frequently the right ventricular (57%) and the left atrial (46%) function. Cardiotoxicity (88%) and cardiac amyloidosis (87%) were the most frequent reasons for the clinical use of left ventricular STE. Left atrial STE was used most frequently for the diagnosis of diastolic dysfunction and right ventricular STE for the assessment of RV function in pulmonary hypertension (51%). Frequency of STE use, adherence to optimal techniques and clinical appropriateness of STE differed according to training experience and across vendors. Key suggestions outlined by respondents to increase the clinical use of STE included improved reproducibility (48%) and standardization of strain values across vendors (42%).<br /><b>Conclusions</b><br />Although STE is now readily available, it is underutilized in the majority of centers. Structured training, improved reproducibility and inter-vendor standardization may increase its uptake.<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: 18 Jul 2023; epub ahead of print</small></div>

<div><h4>Clinical Impact of OCT-Derived Suboptimal Stent Implantation Parameters and Definitions.</h4><i>Romagnoli E, Burzotta F, Vergallo R, Gatto L, ... Stone GW, Prati F</i><br /><b>Aims</b><br />Despite growing evidence supporting the clinical utility of optical coherence tomography (OCT)-guidance during percutaneous coronary interventions (PCIs), there is no common agreement as to the optimal stent implantation parameters that enhance clinical outcome.<br /><b>Methods and results</b><br />We retrospectively examined the predictive accuracy of suboptimal stent implantation definitions proposed from the CLI-OPCI II, ILUMIEN-IV OPTIMAL PCI, and FORZA studies for the long-term risk of device oriented cardiovascular events (DoCE) in the population of large all-comers CLI-OPCI project.A total of 1020 patients undergoing OCT-guided drug-eluting stent implantation in the CLI-OPCI registry with a median follow-up of 809 (quartiles 414-1376) days constituted the study population. According to CLI-OPCI II, ILUMIEN-IV OPTIMAL PCI, and FORZA criteria, the incidence of suboptimal stent implantation was31.8%, 58.1%, and 57.8%, respectively. By multivariable Cox analysis, suboptimal stent implantation criteria from the CLI-OPCI II (hazard ratio 2.75 [95% confidence interval 1.88-4.02], p<0.001) and ILUMIEN-IV OPTIMAL PCI (1.79 [1.18-2.71], p=0.006) studies, but not FORZA trial (1.11 [0.75-1.63], p=0.597), were predictive of DoCE. At long-term follow-up, stent edge disease with minimum lumen area <4.5mm2 (8.17 [5.32-12.53], p<0.001), stent edge dissection (2.38 [1.33-4.27], p=0.004) and minimum stent area <4.5mm2 (1.68 [1.13-2.51], p=0.011) were the main OCT predictors of DoCE.<br /><b>Conclusion</b><br />The clinical utility of OCT-guided PCI might depend on the metrics adopted to define suboptimal stent implantation. Uncovered disease at the stent border, stent edge dissection, and minimum stent area <4.5mm2 were the strongest OCT associates of stent failure.<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: 18 Jul 2023; epub ahead of print</small></div>

<div><h4>Prognostic significance of subpulmonary left ventricular size and function in patients with a systemic right ventricle.</h4><i>Surkova E, Constantine A, Xu Z, Segura de la Cal T, ... Dimopoulos K, Li W</i><br /><b>Aim</b><br />To assess the additional prognostic significance of echocardiographic parameters of subpulmonary left ventricular (LV) size and function in patients with a systemic right ventricle (SRV).<br /><b>Methods and results</b><br />All adults with a SRV who underwent transthoracic echocardiography in 2010-2018 at a large tertiary center were identified. Biventricular size and function were assessed at the most recent exam. The study endpoint was all-cause mortality or heart/heart-lung transplantation.We included 180 patients, 100(55.6%) male, mean age 42.4±12.3 years, of whom 103(57.2%) had undergone Mustard/Senning operations and 77(42.8%) had congenitally corrected transposition of great arteries.Over 4.9[3.8-5.7] years, 28(15.6%) patients died and 4(2.2%) underwent heart or heart-lung transplantation. Univariable predictors of the study endpoint included age, NYHA functional class III or IV, history of atrial arrhythmias, presence of pacemaker or cardioverter-defibrillator, high BNP, and echocardiographic markers of SRV and subpulmonary LV size and function. On multivariable Cox analysis of echocardiographic variables, indexed LV end-systolic diameter (ESDi; HR 2.77 [95%CI 1.35-5.68], p=0.01), LV fractional area change (FAC; HR 0.7 [95%CI 0.57-0.85], p=0.002), SRV basal diameter (HR 1.66 [95%CI 1.21-2.29], p=0.005), and SRV FAC (HR 0.65 [95%CI 0.49-0.87], p=0.008) remained predictive of mortality or transplantation. On ROC analysis, subpulmonary LV parameters performed better than SRV markers in predicting adverse events.<br /><b>Conclusions</b><br />SRV basal diameter, SRV FAC, LV ESDi, and LV FAC are significantly and independently associated with mortality and transplantation in adults with a SRV. Accurate echocardiographic assessment of both SRV and subpulmonary LV is therefore essential to inform risk stratification and management.<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: 15 Jul 2023; epub ahead of print</small></div>

<div><h4>Abnormal release of cardiac biomarkers in the presence of myocardial edema evaluated by cardiac magnetic resonance after uncomplicated revascularization procedures.</h4><i>Ribas FF, Hueb W, Rezende PC, Rochitte CE, ... Franchini Ramires JA, Kalil-Filho R</i><br /><b>Aims</b><br />To analyze the association of myocardial edema (ME), observed as high T2-signal intensity (HT2) in cardiac magnetic resonance imaging (CMR), with the release of cardiac biomarkers, ventricular ejection, and clinical outcomes after revascularization.<br /><b>Methods and results</b><br />Patients with stable coronary artery disease with indication for revascularization were included. Biomarker levels (Troponin I [c-TnI] and creatine-kinase MB [CK-MB]) and T2-weighted and late gadolinium enhancement (LGE) images were obtained before and after the percutaneous or surgical revascularization procedures. The association of HT2 with the levels of biomarkers, with and without LGE, evolution of ejection fraction (LVEF), and 5-year clinical outcomes were assessed. A total of 196 patients were divided into two groups: Group 1 (HT2, 40) and Group 2 (no HT2, 156). Both peak c-TnI (8.9 and 1.6 ng/mL) and peak CK-MB values (44.7 and 12.1 ng/mL) were significantly higher in Group 1. Based on the presence of new LGE, patients were stratified into Groups A (no HT2/LGE, 149), B (HT2, 9), C (LGE, 7), and D (both HT2/LGE, 31). The peak c-TnI and CK-MB values were 1.5 and 12.0, 5.4 and 44.7, 5.0 and 18.3, and 9.8 and 42.8 ng/mL in Groups A, B, C, and D, respectively, and were significantly different. Average LVEF decreased 4.4% in Group 1 and increased 2.2% in Group 2 (p=0.057).<br /><b>Conclusion</b><br />ME after revascularization procedures was associated with increased release of cardiac necrosis biomarkers, and a trend towards a difference in LVEF, indicating a role of ME in cardiac injury after interventions.<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: 15 Jul 2023; epub ahead of print</small></div>

<div><h4>Neuroticism personality traits are linked to adverse cardiovascular phenotypes in the UK Biobank.</h4><i>Mahmood A, Simon J, Cooper J, Murphy T, ... Maurovich-Horvat P, Petersen SE</i><br /><b>Aims</b><br />To evaluate the relationship between neuroticism personality traits and cardiovascular magnetic resonance (CMR) measures of cardiac morphology and function, considering potential differential associations in men and women.<br /><b>Methods and results</b><br />The analysis includes 36,309 UK Biobank participants (average age= 63.9±7.7 years; 47.8% men) with CMR available and neuroticism score assessed by the 12-item Eysenck Personality Questionnaire-Revised Short Form. CMR scans were performed on 1.5 Tesla scanners (MAGNETOM Aera, Siemens Healthcare, Erlangen, Germany) according to pre-defined protocols and analysed using automated pipelines. We considered measures of left ventricular (LV) and right ventricular (RV) structure and function, and indicators of arterial compliance. Multivariable linear regression was used to estimate association of neuroticism score with individual CMR metrics, with adjustment for age, sex, obesity, deprivation, smoking, diabetes, hypertension, hypercholesterolaemia, alcohol use, exercise, and education. Higher neuroticism scores were associated with smaller LV and RV end-diastolic volumes, lower LV mass, greater concentricity (higher LV mass to volume ratio), and higher native T1. Greater neuroticism was also linked to poorer LV and RV function (lower stroke volumes) and greater arterial stiffness. In sex-stratified analyses, the relationships between neuroticism and LV stroke volume, concentricity, and arterial stiffness were attenuated in women. In men, association (with exception of native T1) remained robust.<br /><b>Conclusion</b><br />Greater tendency towards neuroticism personality traits is linked to smaller, poorer functioning ventricles with lower LV mass, higher myocardial fibrosis, and higher arterial stiffness. These relationships are independent of traditional vascular risk factors and are more robust in men than 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: 13 Jul 2023; epub ahead of print</small></div>

<div><h4>Imaging for Implementation of Heart Failure Guidelines.</h4><i>Nagueh SF, Nabi F, Chang SM, Al-Mallah M, Shah DJ, Bhimaraj A</i><br /><AbstractText>The classification of heart failure with implications for pharmacological therapeutic interventions rests on defining ejection fraction (EF) which is an imaging parameter. Imaging can provide diagnostic clues as to etiology of heart failure, it can also guide and help assess response to treatment. Echocardiography, cardiac magnetic resonance, cardiac computed tomography, positron emission tomography, and Tc 99 m pyrophosphate scanning provide information about the etiology of heart failure. Further, echocardiography plays the primary role in the evaluation of LV diastolic function and the estimation of LV filling pressures both at rest and with exercise during diastolic stress testing. Heart failure guidelines recognize 4 stages (A, B, C, and D) for heart failure. Cardiac imaging along with risk factors and clinical status is needed for identifying these stages. There are joint societal echocardiographic guidelines by ASE (American Association of Echocardiography) and EACVI (European Association of Cardiovascular Imaging) that are applicable to the imaging of heart failure patients. There are also separate guidelines for the evaluation of patients being considered for left ventricular assist device implantation, and for multimodality imaging of patients with heart failure and preserved EF. Cardiac catheterization is needed in patients whose hemodynamic status is uncertain after clinical and echocardiographic evaluation and to evaluate for coronary artery disease. Myocardial biopsy can identify the presence of myocarditis or specific infiltrative diseases when the findings by noninvasive imaging are not conclusive.</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: 07 Jul 2023; epub ahead of print</small></div>

<div><h4>Investigation of Factors Determining Hemodynamic Relevance of Leaflet Thrombosis after TAVI.</h4><i>Soschynski M, Hein M, Capilli F, Hagar MT, ... Bamberg F, Tobias K</i><br /><b>Aims</b><br />To determine the conditions under which early hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve implantation (TAVI) becomes hemodynamically relevant.<br /><b>Methods and results</b><br />The study included 100 patients (age: 81.5 ± 5.5 years; female 63%), thereof 50 patients with HALT. After anonymization and randomization, blinded readers measured maximum thrombus thickness per prosthesis (MT_pr) and movement restriction (MR_pr) on ECG-gated whole heart cycle CTA. These measurements were compared with echocardiographic mean pressure gradient (mPG), its increase from baseline (ΔmPG) and doppler velocity index (DVI). Hemodynamic valve deterioration (HVD) was defined as mPG > 20mmHg. Age, body mass index, valve type, valve size, left ventricular ejection fraction and atrial fibrillation were considered as influencing factors.Multiple regression analysis revealed that only valve size (p = 0.001) and MT_pr (p = 0.02) had a significant influence on mPG. In an interaction model valve size moderated the effect of MT_pr on mPG significantly (p = 0.004). Subgroup analysis stratified by valve sizes showed a strong correlation between MT_pr and echocardiographic parameters for 23 mm valves (mPG: r = 0.57, ΔmPG: r = 0.68, DVI: r = 0.55, each with p < 0.001), but neither for 26 mm nor 29 mm valves (r < 0.2, p > 0.2 for all correlations). Six of seven prostheses with HVD had a 23 mm valve diameter, while one had 29 mm (p = 0.02).<br /><b>Conclusion</b><br />Early HALT rarely causes significant mPG increase. Our study shows that valve size is a key factor influencing the hemodynamic impact of HALT. In small valve sizes, mPG is more likely to increase. Our study is the first to offer in vivo evidence supporting previous in vitro findings on this topic.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Prognostic value of left ventricular myocardial work indices in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.</h4><i>Wu HW, Fortuni F, Butcher SC, van der Kley F, ... Bax JJ, Ajmone Marsan N</i><br /><b>Aims</b><br />Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess left ventricular (LV) function using pressure-strain loops taking into account LV afterload. The aim of this study was to evaluate the prognostic value of LVMW indices in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR).<br /><b>Methods and results</b><br />LV global work index (LV GWI), LV global constructive work (LV GCW), LV global wasted work (LV GWW) and LV global work efficiency (LV GWE) were calculated in 281 patients with severe AS (age 82, IQR 78-85 years, 52% male) prior to the TAVR procedure. LV systolic pressure was derived non-invasively by adding the mean aortic gradient to the brachial systolic pressure to adjust for afterload and calculate LVMW indices. Overall, the average LV GWI was 1872 ± 753 mmHg%, GCW 2240 ± 797 mmHg%, GWW 200 (IQR 127-306) mmHg% and GWE 89 (IQR 84-93)%. During a median follow-up of 52 (IQR 41-67) months, 64 patients died. While LV GWI was independently associated with all-cause mortality (HR per-tertile-increase 0.639; 95%CI 0.463-0.883; P = 0.007), LV GCW, GWW and GWE were not. When added to a basal model, LV GWI yielded a higher increase in predictivity compared to the LVEF as well as LV GLS and LV GCW, and also across the different hemodynamic categories (including low-flow low-gradient) of AS.<br /><b>Conclusion</b><br />LV GWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Women in Cardiovascular Imaging: A Call for Action to Address Ongoing Challenges.</h4><i>Joshi SS, Kadavath S, Mandoli GE, Gimelli A, ... Almeida AG, Julia G</i><br /><b>Aims</b><br />The EACVI Scientific Initiatives Committee and the EACVI women\'s taskforce conducted a global survey to evaluate the barriers faced by women in cardiovascular imaging (WICVi).<br /><b>Methods and results</b><br />In a prospective international survey, we assessed the barriers faced at work by WICVi. 314 participants from 53 countries responded. The majority were married (77%) and had children (68%), but most reported no flexibility in their work schedule during their pregnancy or after their maternity leave. More than half of the women reported experiencing unconscious bias (68%), verbal harassment (59%), conscious bias (51%), anxiety (70%), lack of motivation (60%), impostor syndrome (54%) and burnout (61%) at work. Furthermore, 1 in 5 respondents had experienced sexual harassment, although this was rarely reported formally.The majority reported availability of mentorship (73%), which was mostly rated as \'good\' or \'very good\'. Whilst more than two thirds of respondents (69%) now reported being well trained and qualified to take on leadership roles in their departments, only a third had been afforded that opportunity. Despite the issues highlighted by this survey,  > 80% of the participating WICVi would still choose cardiovascular imaging if they could restart their career.<br /><b>Conclusion</b><br />The survey has highlighted important issues faced by WICVi. Whilst progress has been made in areas such as mentorship and training, other issues including bullying, bias and sexual harassment are still widely prevalent requiring urgent action by the global cardiovascular imaging community to collectively address and resolve these challenges.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Association Between Remnant Cholesterol and Progression of Bioprosthetic Valve Degeneration.</h4><i>Li Z, Zhang B, Salaun E, Côté N, ... Wu Y, Clavel MA</i><br /><b>Aims</b><br />Remnant cholesterol (RC) seems associated with native aortic stenosis. Bioprosthetic valve degeneration may share similar lipid-mediated pathways with aortic stenosis. We aimed to investigate the association of RC with the progression of bioprosthetic aortic valve degeneration and ensuing clinical outcomes.<br /><b>Methods and results</b><br />We enrolled 203 patients with a median of 7.0 years (interquartile range: 5.1-9.2) after surgical aortic valve replacement. RC concentration was dichotomized by the top RC tertile (23.7 mg/dl). At 3-year follow-up, 121 patients underwent follow-up visit for the assessment of annualized change in aortic valve calcium density (AVCd). RC levels showed a curvilinear relationship with an annualized progression rate of AVCd, with increased progression rates when RC >23.7 mg/dl (p = 0.008). There were 99 deaths and 46 aortic valve re-interventions in 133 patients during a median clinical follow-up of 8.8 (8.7-9.6) years. RC >23.7 mg/dl was independently associated with mortality or re-intervention (hazard ratio: 1.98; 95% confidence interval: 1.31-2.99; p = 0.001).<br /><b>Conclusions</b><br />Elevated RC is independently associated with faster progression of bioprosthetic valve degeneration and increased risk of all-cause mortality or aortic valve re-intervention.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Multi-Modality Imaging in Aortic Stenosis an EACVI Clinical Consensus Document.</h4><i>Dweck MR, Loganath K, Bing R, Treibel TA, ... Otto CM, Pibarot P</i><br /><AbstractText>In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk-stratification and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. CT is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose, however contrast computed tomography techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance and computed tomography will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.</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: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>Coronary microevaginations characterize culprit plaques and their inflammatory microenvironment in a subtype of acute coronary syndrome with intact fibrous cap: results from the prospective translational OPTICO-ACS study.</h4><i>Seppelt C, Abdelwahed YS, Meteva D, Nelles G, ... Landmesser U, Leistner DM</i><br /><b>Aims</b><br />Coronary microevaginations (CME) represent an outward bulge of coronary plaques and have been introduced as a sign of adverse vascular remodeling following coronary device implantation. However, their role in atherosclerosis and plaque destabilization in the absence of coronary intervention is unknown. This study aimed to investigate CME as a novel feature of plaque vulnerability and to characterize its associated inflammatory cell-vessel-wall interactions.<br /><b>Methods and results</b><br />557 patients from the translational OPTICO-ACS study program underwent optical coherence tomography (OCT) imaging of culprit vessel and simultaneous immunophenotyping of the culprit lesion (CL). 258 CLs had ruptured- (RFC) and 100 had intact fibrous cap (IFC) ACS as an underlying pathophysiology. CME were significantly more frequent in CL as compared to non-CL (25% vs. 4%, p < 0.001) and were more frequently observed in lesions with IFC-ACS as compared to RFC-ACS (55.0% vs. 12.7%, p < 0.001). CME were particularly prevalent in IFC-ACS causing CLs independent of a coronary bifurcation (IFC-ICB) as compared to IFC-ACS with an association to a coronary bifurcation (IFC-ACB, 65.4% vs. 43.7%, p = 0.030). CME emerged as the strongest independent predictor of IFC-ICB (RR 3.36, 95%CI 1.67; 6.76, p = 0.001) by multivariable regression analysis. IFC-ICB demonstrated an enrichment of monocytes in both, culprit blood analysis (Culprit ratio: 1.1 ± 0.2 vs. 0.9 ± 0.2, p = 0.048) and aspirated culprit thrombi (326 ± 162 cells/mm2 vs. 96 ± 87 cells/mm2; p = 0.017), whilst IFC-ACB confirmed the accumulation of CD4+-T-Cells as recently described.<br /><b>Conclusion</b><br />This study provides novel evidence for a pathophysiological involvement of CME in the development of IFC-ACS and provides first evidence for a distinct pathophysiological pathway for IFC-ICB, driven by CME-derived flow disturbances and inflammatory activation involving the innate immune system.<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: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>The role of imaging in the selection of patients for HFpEF therapy.</h4><i>Baron T, Gerovasileiou S, Flachskampf FA</i><br /><AbstractText>Heart failure with preserved ejection fraction (HFpEF) traditionally has been characterized as a form of heart failure without therapeutic options, in particular with a lack of response to the established therapies of heart failure with reduced ejection fraction (HFrEF). However, this is no longer true. Besides physical exercise, risk factor modification, aldosterone blocking agents, and sodium-glucose cotransporter 2 inhibitors, specific therapies are emerging for specific HFpEF etiologies, such as hypertrophic cardiomyopathy or cardiac amyloidosis. This development justifies increased efforts to arrive at specific diagnoses within the umbrella of HFpEF. Cardiac imaging plays by far the largest role in this effort and is discussed in the following review.</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: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>Right ventricular to pulmonary artery coupling and outcome in patients with cardiac amyloidosis.</h4><i>Tomasoni D, Adamo M, Porcari A, Aimo A, ... Emdin M, Metra M</i><br /><b>Aims</b><br />To investigate the prognostic value of the right ventricle-to-pulmonary artery (RV-PA) coupling in patients with either transthyretin (ATTR) or immunoglobulin light-chain (AL) cardiac amyloidosis (CA).<br /><b>Methods and results</b><br />Overall, 283 patients with CA from 3 Italian high-volume centres were included (median age 76 years; 63% males; 53% with ATTR-CA, 47% with AL-CA). The RV-PA coupling was evaluated through tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. The median value of TAPSE/PASP was 0.45 (0.33-0.63) mm/mmHg. Patients with a TAPSE/PASP ratio <0.45 were older, had lower systolic blood pressure, more severe symptoms, higher cardiac troponin and NT-proBNP levels, greater left ventricular (LV) thickness, and worse LV systolic and diastolic function. A TAPSE/PASP ratio <0.45 was independently associated with a higher risk of all-cause death or HF hospitalization (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.32-2.96; p = 0.001) and all-cause death (HR 2.18; 95% CI, 1.31-3.62; p = 0.003). The TAPSE/PASP ratio reclassified the risk of both endpoints (net reclassification index 0.46 [95%CI 0.18-0.74], p = 0.001, and 0.49 [0.22-0.77] p < 0.001, respectively), while TAPSE or PASP alone did not (all p > 0.05). The prognostic impact of TAPSE/PASP ratio was significant both in AL-CA patients (HR for the composite endpoint 2.47, 95% CI 1.58-3.85; p < 0.001) and in ATTR-CA (HR 1.81, 95% CI 1.11-2.95; p = 0.017). Receiver operating characteristic curve showed that the optimal cut-off for predicting prognosis was 0.47 mm/mmHg.<br /><b>Conclusion</b><br />In patients with CA, RV-PA coupling predicted the risk of mortality or HF hospitalization. TAPSE/PASP ratio had a better performance than TAPSE or PASP in predicting prognosis.<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: 28 Jun 2023; epub ahead of print</small></div>

<div><h4>The Primary Cardiomyopathy of Systemic Sclerosis on Cardiovascular Magnetic Resonance Imaging.</h4><i>Chhikara S, Kanda A, Ogugua FM, Rouf R, ... Molitor JA, Shenoy C</i><br /><b>Aims</b><br />Cardiac disease in systemic sclerosis (SSc) may be primary or secondary to other disease manifestations of SSc. The prevalence of the primary cardiomyopathy of SSc is unknown. Cardiovascular magnetic resonance imaging (CMR) can help accurately determine the presence and cause of cardiomyopathy. We aimed to investigate the prevalence, the CMR features, and the prognostic implications of the primary cardiomyopathy of SSc.<br /><b>Methods and results</b><br />We conducted a retrospective cohort study of consecutive patients with SSc who had a clinical CMR for suspected cardiac involvement. We identified the prevalence, the CMR features of the primary cardiomyopathy of SSc, and its association with the long-term incidence of death or major adverse cardiac events (MACE): heart failure hospitalization, ventricular assist device implantation, heart transplantation, and sustained ventricular tachycardia. Of 130 patients with SSc, 80% were women, and the median age was 58 years. On CMR, 22% had an abnormal left ventricular ejection fraction (LVEF), and 40% had late gadolinium enhancement (LGE). The prevalence of the primary cardiomyopathy of SSc was 21%. A third of these patients had a distinct LGE phenotype. Over a median follow-up of 3.6 years after the CMR, patients with the primary cardiomyopathy of SSc had a greater incidence of death or MACE (adjusted hazard ratio 2.01; 95% confidence interval 1.03-3.92; p=0.041).<br /><b>Conclusion</b><br />The prevalence of the primary cardiomyopathy of SSc was 21%, with a third demonstrating a distinct LGE phenotype. The primary cardiomyopathy of SSc was independently associated with a greater long-term incidence of death or MACE.<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: 26 Jun 2023; epub ahead of print</small></div>