Journal: Eur Heart J Cardiovasc Imaging

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Abstract

Anatomical and functional coronary imaging to predict long-term outcome in patients with suspected coronary artery disease: the EVINCI-outcome study.

Neglia D, Liga R, Caselli C, Carpeggiani C, ... Knuuti J,
Aims
To investigate the prognostic relevance of coronary anatomy, coronary function, and early revascularization in patients with stable coronary artery disease (CAD).
Methods and results
From March 2009 to June 2012, 430 patients with suspected CAD (61 ± 9 years, 62% men) underwent coronary anatomical imaging by computed tomography coronary angiography (CTCA) and coronary functional imaging followed by invasive coronary angiography (ICA) if at least one non-invasive test was abnormal. Obstructive CAD was documented by ICA in 119 patients and 90 were revascularized within 90 days of enrolment. Core laboratory analysis showed that 134 patients had obstructive CAD by CTCA (>50% stenosis in major coronary vessels) and 79 significant ischaemia by functional imaging [>10% left ventricular (LV) myocardium]. Over mean follow-up of 4.4 years, major adverse events (AEs) (all-cause death, non-fatal myocardial infarction, or hospital admission for unstable angina or heart failure) or AEs plus late revascularization (LR) occurred in 40 (9.3%) and 58 (13.5%) patients, respectively. Obstructive CAD at CTCA was the only independent imaging predictor of AEs [hazard ratio (HR) 3.2, 95% confidence interval (CI) 1.10-9.30; P = 0.033] and AEs plus LR (HR 4.3, 95% CI 1.56-11.81; P = 0.005). Patients with CAD in whom early revascularization was performed in the presence of ischaemia and deferred in its absence had fewer AEs, similar to patients without CAD (HR 2.0, 95% CI 0.71-5.51; P = 0.195).
Conclusion
Obstructive CAD imaged by CTCA is an independent predictor of clinical outcome. Early management of CAD targeted to the combined anatomical and functional disease phenotype improves clinical outcome.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 07 Nov 2019; epub ahead of print
Neglia D, Liga R, Caselli C, Carpeggiani C, ... Knuuti J,
Eur Heart J Cardiovasc Imaging: 07 Nov 2019; epub ahead of print | PMID: 31701136
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Abstract

Vascular age derived from coronary artery calcium score on the risk stratification of individuals with heterozygous familial hypercholesterolaemia.

Miname MH, Bittencourt MS, Pereira AC, Jannes CE, ... Nasir K, Santos RD
Aims
The objective of this study was to evaluate if vascular age derived from coronary artery calcium (CAC) score improves atherosclerosis cardiovascular disease (ASCVD) risk discrimination in primary prevention asymptomatic heterozygous familial hypercholesterolaemia (FH) patients undergoing standard lipid-lowering therapy.
Methods and results
Two hundred and six molecularly confirmed FH individuals (age 45 ± 14 years, 36% males, baseline LDL-cholesterol 6.2 ± 2.2 mmol/L; 239 ± 85mg/dL) were followed by 4.4 ± 2.9 years (median: 3.7 years, interquartile ranges 2.7-6.8). CAC measurement was performed, and lipid-lowering therapy was optimized according to FH guidelines. Vascular age was derived from CAC and calculated according to the Multi Ethnic Study of Atherosclerosis algorithm. Risk estimation based on the Framingham equations was calculated for both biological (bFRS) and vascular (vaFRS) age. During follow-up, 15 ASCVD events (7.2%) were documented. The annualized rate of events for bFRS <10%, 10-20%, and >20% was respectively: 8.45 [95% confidence interval (CI) 3.17-22.52], 23.28 (95% CI 9.69-55.94), and 28.13 (95% CI 12.63-62.61) per 1000 patients. The annualized rate of events for vaFRS <10%, 10-20%, and >20% was respectively: 0, 0, and 50.37 (95% CI 30.37-83.56) per 1000 patients. vaFRS presented a better discrimination for ASCVD events compared to bFRS 0.7058 (95% CI 0.5866-0.8250) vs. vaFRS 0.8820 (95% CI 0.8286-0.9355), P = 0.0005.
Conclusion
CAC derived vascular age can improve ASCVD risk discrimination in primary prevention FH subjects. This tool may help further stratify risk in FH patients already receiving lipid-lowering medication who might be candidates for further treatment with newer therapies.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 07 Nov 2019; epub ahead of print
Miname MH, Bittencourt MS, Pereira AC, Jannes CE, ... Nasir K, Santos RD
Eur Heart J Cardiovasc Imaging: 07 Nov 2019; epub ahead of print | PMID: 31702778
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Abstract

Myocardial fibrosis in arrhythmogenic cardiomyopathy: a genotype-phenotype correlation study.

Segura-Rodríguez D, Bermúdez-Jiménez FJ, Carriel V, López-Fernández S, ... Tercedor L, Jiménez-Jáimez J
Aims
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a life-threatening entity with a highly heterogeneous genetic background. Cardiac magnetic resonance (CMR) imaging can identify fibrofatty scar by late gadolinium enhancement (LGE). Our aim is to investigate genotype-phenotype correlation in ARVC/D mutation carriers, focusing on CMR-LGE and myocardial fibrosis patterns.
Methods and results
A cohort of 44 genotyped patients, 33 with definite and 11 with borderline ARVC/D diagnosis, was characterized using CMR and divided into groups according to their genetic condition (desmosomal, non-desmosomal mutation, or negative). We collected information on cardiac volumes and function, as well as LGE pattern and extension. In addition, available ventricular myocardium samples from patients with pathogenic gene mutations were histopathologically analysed. Half of the patients were women, with a mean age of 41.6 ± 17.5 years. Next-generation sequencing identified a potential pathogenic mutation in 71.4% of the probands. The phenotype varied according to genetic status, with non-desmosomal male patients showing lower left ventricular (LV) systolic function. LV fibrosis was similar between groups, but distribution in non-desmosomal patients was frequently located at the posterolateral LV wall; a characteristic LV subepicardial circumferential LGE pattern was significantly associated with ARVC/D caused by desmin mutation. Histological analysis showed increased fibrillar connective tissue and intercellular space in all the samples.
Conclusion
Desmosomal and non-desmosomal mutation carriers showed different morphofunctional features but similar LV LGE presence. DES mutation carriers can be identified by a specific and extensive LV subepicardial circumferential LGE pattern. Further studies should investigate the specificity of LGE in ARVC/D.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 07 Nov 2019; epub ahead of print
Segura-Rodríguez D, Bermúdez-Jiménez FJ, Carriel V, López-Fernández S, ... Tercedor L, Jiménez-Jáimez J
Eur Heart J Cardiovasc Imaging: 07 Nov 2019; epub ahead of print | PMID: 31702781
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Abstract

Imaging in ESC clinical guidelines: chronic coronary syndromes.

Saraste A, Barbato E, Capodanno D, Edvardsen T, ... Wijns W, Knuuti J

The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). The 2019 guideline identified six common clinical scenarios of CCS defined by the different evolutionary phases of coronary artery disease (CAD), excluding the situations in which an acute coronary event, often with coronary thrombus formation, dominates the clinical presentation. This review aims at providing a summary of novel or revised concepts in the guidelines together with the recent data underlying the major changes on the use of cardiac imaging in patients with suspected or known CCS. Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of CAD based on age, sex and symptoms have been adjusted substantially downward as compared with 2013 ESC guidelines. Further, the impact of various risk factors and modifiers on the pre-test probability was highlighted and a new concept of \'Clinical likelihood of CAD\' was introduced. Recommendations regarding diagnostic tests to establish or rule-out obstructive CAD have been updated with recent data on their diagnostic performance in different patient groups and impact on patient outcome. As the initial strategy to diagnose CAD in symptomatic patients, non-invasive functional imaging for myocardial ischaemia, coronary computed tomography angiography or invasive coronary angiography combined with functional evaluation may be used, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests instead of the exercise electrocardiogram are recommended when following the non-invasive diagnostic strategy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1187-1197
Saraste A, Barbato E, Capodanno D, Edvardsen T, ... Wijns W, Knuuti J
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1187-1197 | PMID: 31642920
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Abstract

Carotid intraplaque neovascularization predicts coronary artery disease and cardiovascular events.

Mantella LE, Colledanchise KN, Hétu MF, Feinstein SB, Abunassar J, Johri AM
Aims
It is thought that the majority of cardiovascular (CV) events are caused by vulnerable plaque. Such lesions are rupture prone, in part due to neovascularization. It is postulated that plaque vulnerability may be a systemic process and that vulnerable lesions may co-exist at multiple sites in the vascular bed. This study sought to examine whether carotid plaque vulnerability, characterized by contrast-enhanced ultrasound (CEUS)-assessed intraplaque neovascularization (IPN), was associated with significant coronary artery disease (CAD) and future CV events.
Methods and results
We investigated carotid IPN using carotid CEUS in 459 consecutive stable patients referred for coronary angiography. IPN was graded based on the presence and location of microbubbles within each plaque (0, not visible; 1, peri-adventitial; and 2, plaque core). The grades of each plaque were averaged to obtain an overall score per patient. Coronary plaque severity and complexity was also determined angiographically. Patients were followed for 30 days following their angiogram. This study found that a higher CEUS-assessed carotid IPN score was associated with significant CAD (≥50% stenosis) (1.8 ± 0.4 vs. 0.5 ± 0.6, P < 0.0001) and greater complexity of coronary lesions (1.7 ± 0.5 vs. 1.3 ± 0.8, P < 0.0001). Furthermore, an IPN score ≥1.25 could predict significant CAD with a high sensitivity (92%) and specificity (89%). The Kaplan-Meier analysis demonstrated a significantly higher proportion of participants having CV events with an IPN score ≥1.25 (P = 0.004).
Conclusion
Carotid plaque neovascularization was found to be predictive of significant and complex CAD and future CV events. CEUS-assessed carotid IPN is a clinically useful tool for CV risk stratification in high-risk cardiac patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1239-1247
Mantella LE, Colledanchise KN, Hétu MF, Feinstein SB, Abunassar J, Johri AM
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1239-1247 | PMID: 31621834
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Impact:
Abstract

Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease.

Juarez-Orozco LE, Saraste A, Capodanno D, Prescott E, ... Wijns W, Knuuti J
Aims
To provide a pooled estimation of contemporary pre-test probabilities (PTPs) of significant coronary artery disease (CAD) across clinical patient categories, re-evaluate the utility of the application of diagnostic techniques according to such estimates, and propose a comprehensive diagnostic technique selection tool for suspected CAD.
Methods and results
Estimates of significant CAD prevalence across sex, age, and type of chest pain categories from three large-scale studies were pooled (n = 15 815). The updated PTPs and diagnostic performance profiles of exercise electrocardiogram, invasive coronary angiography, coronary computed tomography angiography (CCTA), positron emission tomography (PET), stress cardiac magnetic resonance (CMR), and SPECT were integrated to define the PTP ranges in which ruling-out CAD is possible with a post-test probability of <10% and <5%. These ranges were then integrated in a new colour-coded tabular diagnostic technique selection tool. The Bayesian relationship between PTP and the rate of diagnostic false positives was explored to complement the characterization of their utility. Pooled CAD prevalence was 14.9% (range = 1-52), clearly lower than that used in current clinical guidelines. Ruling-out capabilities of non-invasive imaging were good overall. The greatest ruling-out capacity (i.e. post-test probability <5%) was documented by CCTA, PET, and stress CMR. With decreasing PTP, the fraction of false positive findings rapidly increased, although a lower CAD prevalence partially cancels out such effect.
Conclusion
The contemporary PTP of significant CAD across symptomatic patient categories is substantially lower than currently assumed. With a low prevalence of the disease, non-invasive testing can rarely rule-in the disease and focus should shift to ruling-out obstructive CAD. The large proportion of false positive findings must be taken into account when patients with low PTP are investigated.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1198-1207
Juarez-Orozco LE, Saraste A, Capodanno D, Prescott E, ... Wijns W, Knuuti J
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1198-1207 | PMID: 30982851
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Abstract

Fast manual long-axis strain assessment provides optimized cardiovascular event prediction following myocardial infarction.

Schuster A, Backhaus SJ, Stiermaier T, Kowallick JT, ... Thiele H, Eitel I
Aims
Cardiovascular magnetic resonance feature tracking (CMR-FT) global longitudinal strain (GLS) provides incremental prognostic value following acute myocardial infarction (AMI) but requires substantial post-processing. Alternatively, manual global long-axis strain (LAS) can be easily assessed from standard steady state free precession images. We aimed to define the prognostic value of LAS in a large multicentre study in patients following AMI.
Methods and results
A total of 1235 patients with myocardial infarction [n = 795 with ST-elevation myocardial infarction (STEMI) and 440 with non-ST-elevation myocardial infarction (NSTEMI)] underwent cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention in eight centres across Germany. Assessment of LAS was performed in a blinded core-laboratory measuring the systolic shortening between the epicardial apical border and the middle of a line connecting the origins of the mitral leaflets. Primary clinical endpoint was the occurrence of major adverse clinical events (MACE) including death, reinfarction, and congestive heart failure within 1 year after AMI. During 1-year follow-up, 76 patients suffered from MACE. Impaired LAS was associated with higher MACE occurrence both in STEMI (P < 0.001) and NSTEMI (P = 0.001) patients. Association of LAS remained significant (P = 0.017) after correction for univariate significant parameters for MACE prediction. C-statistics revealed incremental value of additional LAS assessment for optimized event prediction compared with left ventricular ejection fraction (MACE P = 0.044; mortality P = 0.013) and a combination of established clinical and imaging parameters (MACE P = 0.084; mortality P = 0.027), but not CMR-FT GLS (MACE P = 0.075; mortality P = 0.380).
Conclusion
LAS provides software independent, widely available, easy and fast approximation of longitudinal left ventricular shortening early after reperfused AMI with incremental prognostic value beyond established risk stratification parameters.
Clinical trials.gov
NCT00712101 and NCT01612312.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1262-1270
Schuster A, Backhaus SJ, Stiermaier T, Kowallick JT, ... Thiele H, Eitel I
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1262-1270 | PMID: 31329854
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Abstract

The impact of visceral and general obesity on vascular and left ventricular function and geometry: a cross-sectional magnetic resonance imaging study of the UK Biobank.

van Hout MJP, Dekkers IA, Westenberg JJM, Schalij MJ, Scholte AJHA, Lamb HJ
Aims 
We aimed to evaluate the associations of body fat distribution with cardiovascular function and geometry in the middle-aged general population.
Methods and results 
Four thousand five hundred and ninety participants of the UK Biobank (54% female, mean age 61.1 ± 7.2 years) underwent cardiac magnetic resonance for assessment of left ventricular (LV) parameters [end-diastolic volume (EDV), ejection fraction (EF), cardiac output (CO), and index (CI)] and magnetic resonance imaging for body composition analysis [subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT)]. Body fat percentage (BF%) was assessed by bioelectrical impedance. Linear regressions were performed to assess the impact of visceral (VAT) and general (SAT and BF%) obesity on cardiac function and geometry. Visceral obesity was associated with a smaller EDV [VAT: β -1.74 (-1.15 to -2.33)], lower EF [VAT: β -0.24 (-0.12 to -0.35), SAT: β 0.02 (-0.04 to 0.08), and BF%: β 0.02 (-0.02 to 0.06)] and the strongest negative association with CI [VAT: β -0.05 (-0.06 to -0.04), SAT: β -0.02 (-0.03 to -0.01), and BF% β -0.01 (-0.013 to -0.007)]. In contrast, general obesity was associated with a larger EDV [SAT: β 1.01 (0.72-1.30), BF%: β 0.37 (0.23-0.51)] and a higher CO [SAT: β 0.06 (0.05-0.07), BF%: β 0.02 (0.01-0.03)]. In the gender-specific analysis, only men had a significant association between VAT and EF [β -0.35 (-0.19 to -0.51)].
Conclusion 
Visceral obesity was associated with a smaller LV EDV and subclinical lower LV systolic function in men, suggesting that visceral obesity might play a more important role compared to general obesity in LV remodelling.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 12 Nov 2019; epub ahead of print
van Hout MJP, Dekkers IA, Westenberg JJM, Schalij MJ, Scholte AJHA, Lamb HJ
Eur Heart J Cardiovasc Imaging: 12 Nov 2019; epub ahead of print | PMID: 31722392
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Abstract

Relationship between patient presentation and morphology of coronary atherosclerosis by quantitative multidetector computed tomography.

de Knegt MC, Linde JJ, Fuchs A, Pham MHC, ... Kofoed KF,
Aims
Quantitative computed tomography (QCT) allows assessment of morphological features of coronary atherosclerosis. We aimed to test the hypothesis that clinical patient presentation is associated with distinct morphological features of coronary atherosclerosis.
Methods and results
A total of 1652 participants, representing a spectrum of clinical risk profiles [787 asymptomatic individuals from the general population, 468 patients with acute chest pain without acute coronary syndrome (ACS), and 397 patients with acute chest pain and ACS], underwent multidetector computed tomography. Of these, 274 asymptomatic individuals, 254 patients with acute chest pain without ACS, and 327 patients with acute chest pain and ACS underwent QCT to assess coronary plaque volumes and proportions of dense calcium (DC), fibrous, fibro fatty (FF), and necrotic core (NC) tissue. Furthermore, the presence of vulnerable plaques, defined by plaque volume and tissue composition, was examined. Coronary plaque volume increased significantly with worsening clinical risk profile [geometric mean (95% confidence interval): 148 (129-166) mm3, 257 (224-295) mm3, and 407 (363-457) mm3, respectively, P < 0.001]. Plaque composition differed significantly across cohorts, P < 0.0001. The proportion of DC decreased, whereas FF and NC increased with worsening clinical risk profile (mean proportions DC: 33%, 23%, 23%; FF: 50%, 61%, 57%; and NC: 17%, 17%, 20%, respectively). Significant differences in plaque composition persisted after multivariable adjustment for age, gender, body surface area, hypertension, statin use at baseline, diabetes, smoking, family history of ischaemic heart disease, total plaque volume, and tube voltage, P < 0.01.
Conclusion
Coronary atherosclerotic plaque volume and composition are strongly associated to clinical presentation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1221-1230
de Knegt MC, Linde JJ, Fuchs A, Pham MHC, ... Kofoed KF,
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1221-1230 | PMID: 30325406
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Abstract

The year 2018 in the European Heart Journal-Cardiovascular Imaging: Part II.

Cosyns B, Haugaa KH, Gerber BL, Gimelli A, ... Maurer G, Edvardsen T

European Heart Journal - Cardiovascular Imaging was launched in 2012 as a multimodality cardiovascular imaging journal. It has gained an impressive impact factor during its first 5 years and is now established as one of the top cardiovascular journals and has become the most important cardiovascular imaging journal in Europe. The most important studies from 2018 will be highlighted in two reports. Part I of the review has focused on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on cardiomyopathies, congenital heart diseases, valvular heart diseases, and heart failure.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1337-1344
Cosyns B, Haugaa KH, Gerber BL, Gimelli A, ... Maurer G, Edvardsen T
Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1337-1344 | PMID: 31750534
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Abstract

Pre-test probability prediction in patients with a low to intermediate probability of coronary artery disease: a prospective study with a fractional flow reserve endpoint.

Winther S, Nissen L, Westra J, Schmidt SE, ... Bøtker HE, Bøttcher M
Aims
European and North American guidelines currently recommend pre-test probability (PTP) stratification based on simple probability models in patients with suspected coronary artery disease (CAD). However, no unequivocal recommendation has yet been established. We aimed to compare the ability of risk factors and different PTP stratification models to predict haemodynamically obstructive CAD with fractional flow reserve (FFR) as reference in low to intermediate probability patients.
Methods and results
We prospectively included 1675 patients with low to intermediate risk who had been referred to coronary computed tomography angiography (CTA). Patients with coronary stenosis were subsequently investigated by invasive coronary angiography (ICA) with FFR measurement if indicated. Discrimination and calibration were assessed for four models: the updated Diamond-Forrester (UDF), the CAD Consortium Basic, the Clinical, and the Clinical + Coronary artery calcium score (CACS). At coronary CTA, 24% of patients were diagnosed with a suspected stenosis and 10% had haemodynamically obstructive CAD at the ICA. Calibration for all CAD Consortium models increased compared with the UDF score. However, all models overestimated the probability of haemodynamically obstructive CAD. Discrimination increased by area under the receiver operating curve from 67% to 86% for UDF vs. CAD Consortium Clinical + CACS. The proportion of low-probability patients (pre-test score < 15%) was for the UDF, CAD Consortium Basic, Clinical, and Clinical + CACS: 14%, 58%, 51%, and 66%, respectively. The corresponding negative predictive values were 97%, 94%, 95%, and 98%, respectively.
Conclusion
CAD Consortium models improve PTP stratification compared with the UDF score, mainly due to superior calibration in low to intermediate probability patients. Adding the coronary calcium score to the models substantially increases discrimination.
Clinical trials. gov identifier
NCT02264717.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1208-1218
Winther S, Nissen L, Westra J, Schmidt SE, ... Bøtker HE, Bøttcher M
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1208-1218 | PMID: 31083725
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Abstract

Long-term prognostic utility of computed tomography coronary angiography in older populations.

Gnanenthiran SR, Naoum C, Leipsic JA, Achenbach S, ... Kritharides L, Min JK
Aims
The long-term prognostic value of coronary computed tomography angiography (CCTA)-identified coronary artery disease (CAD) has not been evaluated in elderly patients (≥70 years). We compared the ability of coronary CCTA to predict 5-year mortality in older vs. younger populations.
Methods and results
From the prospective CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, we analysed CCTA results according to age <70 years (n = 7198) vs. ≥70 years (n = 1786). The severity of CAD was classified according to: (i) maximal stenosis degree per vessel: none, non-obstructive (1-49%), or obstructive (>50%); (ii) segment involvement score (SIS): number of segments with plaque. Cox-proportional hazard models assessed the relationship between CCTA findings and time to mortality. At a mean 5.6 ± 1.1 year follow-up, CCTA-identified CAD predicted increased mortality compared with patients with a normal CCTA in both <70 years [non-obstructive hazard ratio (HR) confidence interval (CI): 1.70 (1.19-2.41); one-vessel: 1.65 (1.03-2.67); two-vessel: 2.24 (1.21-4.15); three-vessel/left main: 4.12 (2.27-7.46), P < 0.001] and ≥70 years [non-obstructive: 1.84 (1.15-2.95); one-vessel: HR (CI): 2.28 (1.37-3.81); two-vessel: 2.36 (1.33-4.19); three-vessel/left main: 2.41 (1.33-4.36), P = 0.014]. Similarly, SIS was predictive of mortality in both <70 years [SIS 1-3: 1.57 (1.10-2.24); SIS ≥4: 2.42 (1.65-3.57), P < 0.001] and ≥70 years [SIS 1-3: 1.73 (1.07-2.79); SIS ≥4: 2.45 (1.52-3.93), P < 0.001]. CCTA findings similarly predicted long-term major adverse cardiovascular outcomes (MACE) (all-cause mortality, myocardial infarction, and late revascularization) in both groups compared with patients with no CAD.
Conclusion
The presence and extent of CAD is a meaningful stratifier of long-term mortality and MACE in patients aged <70 years and ≥70 years old. The presence of obstructive and non-obstructive disease and the burden of atherosclerosis determined by SIS remain important predictors of prognosis in older populations.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1279-1286
Gnanenthiran SR, Naoum C, Leipsic JA, Achenbach S, ... Kritharides L, Min JK
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1279-1286 | PMID: 30993334
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Abstract

Differential association between the progression of coronary artery calcium score and coronary plaque volume progression according to statins: the Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography Imaging (PARADIGM) study.

Lee SE, Sung JM, Andreini D, Budoff MJ, ... Min JK, Chang HJ
Aims
Coronary artery calcium score (CACS) is a strong predictor of major adverse cardiac events (MACE). Conversely, statins, which markedly reduce MACE risk, increase CACS. We explored whether CACS progression represents compositional plaque volume (PV) progression differently according to statin use.
Methods and results
From a prospective multinational registry of consecutive patients (n = 2252) who underwent serial coronary computed tomography angiography (CCTA) at a ≥ 2-year interval, 654 patients (61 ± 10 years, 56% men, inter-scan interval 3.9 ± 1.5 years) with information regarding the use of statins and having a serial CACS were included. Patients were divided into non-statin (n = 246) and statin-taking (n = 408) groups. Coronary PVs (total, calcified, and non-calcified; sum of fibrous, fibro-fatty, and lipid-rich) were quantitatively analysed, and CACS was measured from both CCTAs. Multivariate linear regression models were constructed for both statin-taking and non-statin group to assess the association between compositional PV change and change in CACS. In multivariate linear regression analysis, in the non-statin group, CACS increase was positively associated with both non-calcified (β = 0.369, P = 0.004) and calcified PV increase (β = 1.579, P < 0.001). However, in the statin-taking group, CACS increase was positively associated with calcified PV change (β = 0.756, P < 0.001) but was negatively associated with non-calcified PV change (β = -0.194, P = 0.026).
Conclusion
In the non-statin group, CACS progression indicates the progression of both non-calcified and calcified PV progression. However, under the effect of statins, CACS progression indicates only calcified PV progression, but not non-calcified PV progression. Thus, the result of serial CACS should be differently interpreted according to the use of statins.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1307-1314
Lee SE, Sung JM, Andreini D, Budoff MJ, ... Min JK, Chang HJ
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1307-1314 | PMID: 30789215
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Abstract

Identification of invasive and radionuclide imaging markers of coronary plaque vulnerability using radiomic analysis of coronary computed tomography angiography.

Kolossváry M, Park J, Bang JI, Zhang J, ... Koo BK, Maurovich-Horvat P
Aims
Identification of invasive and radionuclide imaging markers of coronary plaque vulnerability by a single, widely available non-invasive technique may provide the opportunity to identify vulnerable plaques and vulnerable patients in broad populations. Our aim was to assess whether radiomic analysis outperforms conventional assessment of coronary computed tomography angiography (CTA) images to identify invasive and radionuclide imaging markers of plaque vulnerability.
Methods and results
We prospectively included patients who underwent coronary CTA, sodium-fluoride positron emission tomography (NaF18-PET), intravascular ultrasound (IVUS), and optical coherence tomography (OCT). We assessed seven conventional plaque features and calculated 935 radiomic parameters from CTA images. In total, 44 plaques of 25 patients were analysed. The best radiomic parameters significantly outperformed the best conventional CT parameters to identify attenuated plaque by IVUS [fractal box counting dimension of high attenuation voxels vs. non-calcified plaque volume, area under the curve (AUC): 0.72, confidence interval (CI): 0.65-0.78 vs. 0.59, CI: 0.57-0.62; P < 0.001], thin-cap fibroatheroma by OCT (fractal box counting dimension of high attenuation voxels vs. presence of low attenuation voxels, AUC: 0.80, CI: 0.72-0.88 vs. 0.66, CI: 0.58-0.73; P < 0.001), and NaF18-positivity (surface of high attenuation voxels vs. presence of two high-risk features, AUC: 0.87, CI: 0.82-0.91 vs. 0.65, CI: 0.64-0.66; P < 0.001).
Conclusion
Coronary CTA radiomics identified invasive and radionuclide imaging markers of plaque vulnerability with good to excellent diagnostic accuracy, significantly outperforming conventional quantitative and qualitative high-risk plaque features. Coronary CTA radiomics may provide a more accurate tool to identify vulnerable plaques compared with conventional methods. Further larger population studies are warranted.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1250-1258
Kolossváry M, Park J, Bang JI, Zhang J, ... Koo BK, Maurovich-Horvat P
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1250-1258 | PMID: 30838375
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Impact:
Abstract

Strain-oriented strategy for guiding cardioprotection initiation of breast cancer patients experiencing cardiac dysfunction.

Santoro C, Esposito R, Lembo M, Sorrentino R, ... Arpino G, Galderisi M
Aims
This study assessed the impact of the strain-guided therapeutic approach on cancer therapy-related cardiac dysfunction (CTRCD) and rate of cancer therapy (CT) interruption in breast cancer.
Methods and results
We enrolled 116 consecutive female patients with HER2-positive breast cancer undergoing a standard protocol by EC (epirubicine + cyclophosphamide) followed by paclitaxel + trastuzumab (TRZ). Coronary artery, valvular and congenital heart disease, heart failure, primary cardiomyopathies, permanent or persistent atrial fibrillation, and inadequate echo-imaging were exclusion criteria. Patients underwent an echo-Doppler exam with determination of ejection fraction (EF) and global longitudinal strain (GLS) at baseline and every 3 months during CT. All patients developing subclinical (GLS drop >15%) or overt CTRCD (EF reduction <50%) initiated cardiac treatment (ramipril+ carvedilol). In the 99.1% (115/116) of patients successfully completing CT, GLS and EF were significantly reduced and E/e\' ratio increased at therapy completion. Combined subclinical and overt CTRCD was diagnosed in 27 patients (23.3%), 8 at the end of EC and 19 during TRZ courses. Of these, 4 (3.4%) developed subsequent overt CTRCD and interrupted CT. By cardiac treatment, complete EF recovery was observed in two of these patients and partial recovery in one. These patients with EF recovery re-started and successfully completed CT. The remaining patient, not showing EF increase, permanently stopped CT. The other 23 patients with subclinical CTRCD continued and completed CT.
Conclusion
These findings highlight the usefulness of \'strain oriented\' approach in reducing the rate of overt CTRCD and CT interruption by a timely cardioprotective treatment initiation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permiss[email protected]

Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1345-1352
Santoro C, Esposito R, Lembo M, Sorrentino R, ... Arpino G, Galderisi M
Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1345-1352 | PMID: 31326981
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Impact:
Abstract

Referral of patients for fractional flow reserve using quantitative flow ratio.

Smit JM, Koning G, van Rosendael AR, El Mahdiui M, ... Bax JJ, Scholte AJ
Aims
Quantitative flow ratio (QFR) is a recently developed technique to calculate fractional flow reserve (FFR) based on 3D quantitative coronary angiography and computational fluid dynamics, obviating the need for a pressure-wire and hyperaemia induction. QFR might be used to guide patient selection for FFR and subsequent percutaneous coronary intervention (PCI) referral in hospitals not capable to perform FFR and PCI. We aimed to investigate the feasibility to use QFR to appropriately select patients for FFR referral.
Methods and results
Patients who underwent invasive coronary angiography in a hospital where FFR and PCI could not be performed and were referred to our hospital for invasive FFR measurement, were included. Angiogram images from the referring hospitals were retrospectively collected for QFR analysis. Based on QFR cut-off values of 0.77 and 0.86, our patient cohort was reclassified to \'no referral\' (QFR ≥0.86), referral for \'FFR\' (QFR 0.78-0.85), or \'direct PCI\' (QFR ≤0.77). In total, 290 patients were included. Overall accuracy of QFR to detect an invasive FFR of ≤0.80 was 86%. Based on a QFR cut-off value of 0.86, a 50% reduction in patient referral for FFR could be obtained, while only 5% of these patients had an invasive FFR of ≤0.80 (thus, these patients were incorrectly reclassified to the \'no referral\' group). Furthermore, 22% of the patients that still need to be referred could undergo direct PCI, based on a QFR cut-off value of 0.77.
Conclusion
QFR is feasible to use for the selection of patients for FFR referral.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1231-1238
Smit JM, Koning G, van Rosendael AR, El Mahdiui M, ... Bax JJ, Scholte AJ
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1231-1238 | PMID: 30535361
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Impact:
Abstract

Duration of early systolic lengthening: prognostic potential in the general population.

Brainin P, Biering-Sørensen SR, Møgelvang R, Jensen JS, Biering-Sørensen T
Background
When the left ventricle pressure rises during early systole, myocardial fibres with reduced contractility tend to stretch instead of shortening. This interval is known as duration of early systolic lengthening (DESL). We sought to investigate if DESL provides prognostic information on cardiovascular events.
Methods and results
In this prospective study we included 1210 participants from a low-risk general population who underwent speckle tracking echocardiography (men 41%, mean age 56 years, SD 16). Primary endpoints were incident heart failure (HF), myocardial infarction (MI), and cardiovascular death (CVD). We defined DESL as time from onset of Q-wave on the electrocardiogram to peak positive systolic strain. In addition, we assessed the ratio between DESL and duration of cardiac systole, DESLsystole.During median follow-up of 16 years, 90 (7%) developed HF, 50 (4%) MI, and 70 (6%) experienced CVD. Both DESL [hazard ratio (HR) 1.58 95%CI 1.16-2.15, P = 0.004 per 10 ms increase] and DESLsystole (HR 1.74 95%CI 1.24-2.47, P = 0.001 per 1% increase) were predictors of HF. Similarly, DESL (HR 1.40 95%CI 1.09-1.78, P = 0.007 per 10 ms increase) and DESLsystole (HR 1.58 95%CI 1.01-2.49, P = 0.047 per 1% increase) were predictors of MI. No associations were found with CVD. After adjusting for clinical and echocardiographic parameters, the associations remained significant. DESLsystole was superior to systolic echocardiographic parameters for predicting HF (P = 0.012).
Conclusion
DESL and the novel index of DESLsystole provide independent and novel prognostic information on the risk of HF and MI in the general population. Evaluation of DESL should be explored in future echocardiographic studies.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 18 Oct 2019; epub ahead of print
Brainin P, Biering-Sørensen SR, Møgelvang R, Jensen JS, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 18 Oct 2019; epub ahead of print | PMID: 31628809
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Impact:
Abstract

Risk stratification by assessment of coronary artery disease using coronary computed tomography angiography in diabetes and non-diabetes patients: a study from the Western Denmark Cardiac Computed Tomography Registry.

Olesen KKW, Riis AH, Nielsen LH, Steffensen FH, ... Sørensen HT, Maeng M
Aims
We examined whether severity of coronary artery disease (CAD) measured by coronary computed tomography angiography can be used to predict rates of myocardial infarction (MI) and death in patients with and without diabetes.
Methods and results
A cohort study of consecutive patients (n = 48 731) registered in the Western Denmark Cardiac Computed Tomography Registry from 2008 to 2016. Patients were stratified by diabetes status and CAD severity (no, non-obstructive, or obstructive). Endpoints were MI and death. Event rates per 1000 person-years, unadjusted and adjusted incidence rate ratios were computed. Median follow-up was 3.6 years. Among non-diabetes patients, MI event rates per 1000 person-years were 1.4 for no CAD, 4.1 for non-obstructive CAD, and 9.1 for obstructive CAD. Among diabetes patients, the corresponding rates were 2.1 for no CAD, 4.8 for non-obstructive CAD, and 12.6 for obstructive CAD. Non-diabetes and diabetes patients without CAD had similar low rates of MI [adjusted incidence rate ratio 1.40, 95% confidence interval (CI): 0.71-2.78]. Among diabetes patients, the adjusted risk of MI increased with severity of CAD (no CAD: reference; non-obstructive CAD: adjusted incidence rate ratio 1.71, 95% CI: 0.79-3.68; obstructive CAD: adjusted incidence rate ratio 4.42, 95% CI: 2.14-9.17). Diabetes patients had higher death rates than non-diabetes patients, irrespective of CAD severity.
Conclusion
In patients without CAD, diabetes patients have a low risk of MI similar to non-diabetes patients. Further, MI rates increase with CAD severity in both diabetes and non-diabetes patients; with diabetes patients with obstructive CAD having the highest risk of MI.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1271-1278
Olesen KKW, Riis AH, Nielsen LH, Steffensen FH, ... Sørensen HT, Maeng M
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1271-1278 | PMID: 31220229
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Impact:
Abstract

Cardiovascular risk is associated with a transmural gradient of myocardial oxygenation during adenosine infusion.

Luu JM, Schmidt A, Flewitt J, Mikami Y, Ter Keurs H, Friedrich MG
Aims
In patients with coronary artery disease (CAD), a transmural gradient of myocardial perfusion has been repeatedly observed, with the subendocardial layer showing more pronounced perfusion deficits. Oxygenation-sensitive cardiovascular magnetic resonance (OS-CMR) allows for monitoring transmural changes of myocardial oxygenation in vivo. We hypothesized that OS-CMR could help identify a transmural oxygenation gradient as a disease marker in patients at risk for CAD.
Methods and results
We assessed 34 patients with known CAD and 28 subjects with coronary risk factors but no evidence of significant CAD. Results were compared with 11 healthy volunteers. OS-CMR was performed at 1.5 T, applying a T2*-weighted cine steady state free precession sequence at baseline and during infusion of adenosine. A reader blinded to patient data quantified the relative change of myocardial oxygenation in OS-CMR, defined by the change of signal intensity (ΔSI%) between baseline and during adenosine infusion in the entire myocardium, the subepicardial layer, and the subendocardial layer. SI changes were homogenous throughout the myocardium in healthy subjects, whereas both, patients with risk factors only and patients with CAD, had a significantly smaller ΔSI% in the subendocardial layer than in the subendocardial layer. Both patient groups had an overall decreased ΔSI% across all layers when compared with healthy subjects (P < 0.05).
Conclusion
Even in the absence of overt CAD, cardiovascular risk factors are associated with a transmural gradient of the myocardial oxygenation response to adenosine as assessed by OS-CMR. An inducible transmural oxygenation gradient may serve as a non-invasive marker for cardiovascular risk.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1287-1295
Luu JM, Schmidt A, Flewitt J, Mikami Y, Ter Keurs H, Friedrich MG
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1287-1295 | PMID: 30590548
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Abstract

Hybrid coronary computed tomography angiography and positron emission tomography myocardial perfusion imaging in evaluation of recurrent symptoms after coronary artery bypass grafting.

Maaniitty T, Jaakkola S, Saraste A, Knuuti J
Aims
Recurrent chest pain after coronary artery bypass grafting (CABG) poses a diagnostic challenge. We hypothesized that combining anatomy of bypass grafts and native coronary arteries with ischaemia detection by hybrid imaging could be used to gain valuable and complementary information in patients with recurrent symptoms after CABG.
Methods and results
We analysed 36 consecutive patients (67 ± 9 years, 81% male) who had undergone hybrid imaging using coronary computed tomography angiography (CCTA) and [15O]H2O positron emission tomography (PET) myocardial perfusion imaging due to recurrent symptoms after CABG. Coronary tree and left ventricular myocardium were divided into three main territories, yielding a total of 108 coronary territories in 36 patients. The presence of obstructive (≥50%) stenosis and the patency of grafts were evaluated by CCTA, while myocardial ischaemia was assessed by quantitative adenosine-stress PET. Altogether 28 (78%) of the 36 study patients presented with matched PET/CCTA abnormalities. Forty-one coronary territories were supplied by non-obstructed bypass grafts or native coronary arteries (protected territory). However, 12 (29%) of these presented with a perfusion defect. In six cases, the perfusion defect involved myocardium distal to the graft-coronary anastomosis, as interpreted on the PET/CCTA fusion images. In turn, in 48 coronary territories the supplying artery was obstructed on CCTA (unprotected territory). Of these, 41 (85%, P < 0.001 vs. protected) presented with abnormal perfusion, involving myocardium distal to the anastomosis in 29 cases.
Conclusion
Hybrid imaging provides complementary information on the presence and localization of atherosclerotic lesions and myocardial perfusion abnormalities in symptomatic patients with previous CABG.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1298-1304
Maaniitty T, Jaakkola S, Saraste A, Knuuti J
Eur Heart J Cardiovasc Imaging: 31 Oct 2019; 20:1298-1304 | PMID: 30388202
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Impact:
Abstract

Magnetic resonance hyperpolarization imaging detects early myocardial dysfunction in a porcine model of right ventricular heart failure.

Agger P, Hyldebrandt JA, Hansen ESS, Omann C, ... Nielsen PM, Laustsen C
Aims
Early detection of heart failure is important for timely treatment. During the development of heart failure, adaptive intracellular metabolic processes that evolve prior to macro-anatomic remodelling, could provide an early signal of impending failure. We hypothesized that metabolic imaging with hyperpolarized magnetic resonance would detect the early development of heart failure before conventional echocardiography could reveal cardiac dysfunction.
Methods and results
Five 8.5 kg piglets were subjected to pulmonary banding and subsequently examined by [1-13C]pyruvate hyperpolarization, conventional magnetic resonance imaging, echocardiography, and blood testing, every 4 weeks for 16 weeks. They were compared with a weight matched, healthy control group. Conductance catheter examination at the end of the study showed impaired right ventricular systolic function along with compromised left ventricular diastolic function. After 16 weeks, we saw a significant decrease in the conversion ratio of pyruvate/bicarbonate in the left ventricle from 0.13 (0.04) in controls to 0.07 (0.02) in animals with pulmonary banding, along with a significant increase in the lactate/bicarbonate ratio to 3.47 (1.57) compared with 1.34 (0.81) in controls. N-terminal pro-hormone of brain natriuretic peptide was increased by more than 300%, while cardiac index was reduced to 2.8 (0.95) L/min/m2 compared with 3.9 (0.95) in controls. Echocardiography revealed no changes.
Conclusion
Hyperpolarization detected a shift towards anaerobic metabolism in early stages of right ventricular dysfunction, as evident by an increased lactate/bicarbonate ratio. Dysfunction was confirmed with conductance catheter assessment, but could not be detected by echocardiography. Hyperpolarization has a promising future in clinical assessment of heart failure in both acquired and congenital heart disease.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:93-101
Agger P, Hyldebrandt JA, Hansen ESS, Omann C, ... Nielsen PM, Laustsen C
Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:93-101 | PMID: 31329841
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Impact:
Abstract

Pulmonary hypertension detection by computed tomography pulmonary transit time in heart failure with reduced ejection fraction.

Colin GC, Pouleur AC, Gerber BL, Poncelet PA, ... Gevenois PA, Ghaye B
Aims
To evaluate the relationships between pulmonary transit time (PTT), cardiac function, and pulmonary haemodynamics in patients with heart failure with reduced ejection fraction (HFrEF) and to explore how PTT performs in detecting pulmonary hypertension (PH).
Methods and results
In this prospective study, 57 patients with advanced HFrEF [49 men, 51 years ± 8, mean left ventricular (LV) ejection fraction 26% ± 8] underwent echocardiography, right heart catheterization, and cardiac computed tomography (CT). PTT was measured as the time interval between peaks of attenuation in right ventricle (RV) and LV and was compared between patients with or without PH and 15 controls. PTT was significantly longer in HFrEF patients with PH (21 s) than in those without PH (11 s) and controls (8 s) (P < 0.001) but not between patients without PH and controls (P = 0.109). PTT was positively correlated with pulmonary artery wedge pressure (PAWP) (r = 0.74), mean pulmonary artery pressure (r = 0.68), N-terminal pro-B-type natriuretic peptide (r = 0.60), mitral (r = 0.54), and tricuspid (r = 0.37) regurgitation grades, as well as with LV, RV, and left atrial volumes (r from 0.39 to 0.64) (P < 0.01). PTT was negatively correlated with cardiac index (r = -0.63) as well as with LV (r = -0.66) and RV (r = -0.74) ejection fractions. PAWP, cardiac index, mitral regurgitation grade, and RV end-diastolic volume were all independent predictors of PTT. PTT value ≥14 s best-detected PH with 91% sensitivity and 88% specificity (area under the receiver operating characteristic curve: 0.95).
Conclusion
In patients with HFrEF, PTT correlates with cardiac function and pulmonary haemodynamics, is determined by four independent parameters, and performs well in detecting PH.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 05 Dec 2019; epub ahead of print
Colin GC, Pouleur AC, Gerber BL, Poncelet PA, ... Gevenois PA, Ghaye B
Eur Heart J Cardiovasc Imaging: 05 Dec 2019; epub ahead of print | PMID: 31808507
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Impact:
Abstract

Native T1 time of right ventricular insertion points by cardiac magnetic resonance: relation with invasive haemodynamics and outcome in heart failure with preserved ejection fraction.

Nitsche C, Kammerlander AA, Binder C, Duca F, ... Hengstenberg C, Mascherbauer J
Aims
Increased afterload to the right ventricle (RV) has been shown to induce myocardial fibrosis at the RV insertion points (RVIPs). Such changes can be discrete but potentially detected by cardiac magnetic resonance (CMR) T1-mapping. Whether RVIP fibrosis is associated with prognosis in heart failure with preserved ejection fraction (HFpEF) is unknown.
Methods and results
We prospectively investigated 167 consecutive HFpEF patients, a population frequently suffering from post-capillary pulmonary hypertension, who underwent CMR including T1-mapping. About 92.8% also underwent right heart catheterization for haemodynamic assessment.Native T1 times were 995 ± 73 ms at the anterior and 1040 ± 90 ms at the inferior RVIP. By Spearman\'s rank order testing, RVIP T1 times were significantly correlated with pulmonary artery pressure (mean PAP, r = 0.313 and 0.311 for anterior and inferior RVIP), pulmonary artery wedge pressure (r = 0.301 and 0.251) and right atrial pressure (r = 0.245 and 0.185; P for all <0.05). During a mean follow-up of 43.2 ± 22.6 months, 30 (18.0%) subjects died. By multivariable Cox regression, NTproBNP [Hazard ratio (HR) 2.105, 95% confidence interval (CI) 1.332-3.328; P = 0.001], systolic PAP (HR 1.618, 95% CI 1.175-2.230; P = 0.003), and native T1 time of the anterior RVIP (HR 1.659, 95% CI 1.125-2.445; P = 0.011) were significantly associated with outcome. Also, by Kaplan-Meier analysis, T1 times at the anterior RVIPs had a significant effect on survival (log-rank, P = 0.002).
Conclusion
Interstitial expansion of the anterior RVIP as detected by CMR T1-mapping reflects haemodynamic alterations, and is independently related with prognosis in HFpEF.

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Eur Heart J Cardiovasc Imaging: 07 Sep 2019; epub ahead of print
Nitsche C, Kammerlander AA, Binder C, Duca F, ... Hengstenberg C, Mascherbauer J
Eur Heart J Cardiovasc Imaging: 07 Sep 2019; epub ahead of print | PMID: 31495874
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Impact:
Abstract

The cardiac isovolumetric contraction time is an independent predictor of incident atrial fibrillation and adverse outcomes following first atrial fibrillation event in the general population.

Alhakak AS, Brainin P, Møgelvang R, Jensen GB, Jensen JS, Biering-Sørensen T
Aims
Colour tissue Doppler imaging (TDI) M-mode through the mitral leaflet is an easy and precise method to obtain cardiac time intervals including the isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT), and ejection time (ET). The myocardial performance index (MPI) was defined as [(IVCT + IVRT)/ET]. Our aim was to investigate if cardiac time intervals can be used to predict atrial fibrillation (AF) in the general population.
Methods and results
A total of 1915 participants from the general population underwent a health examination including TDI echocardiography. The primary endpoint was AF, and the secondary endpoint was complicated AF as assessed by the occurrence of either stroke or heart failure (HF) after the diagnosis of AF. Participants with known AF were excluded (n = 54). During a median follow-up of 11 years, 166 participants (9%) were diagnosed with AF and of these 44 participants (27%) developed HF or stroke. Assessing the association between IVCT and incident AF, the risk increased with 27% per 10 ms increase in IVCT [per 10 ms increase: hazard ratio (HR) 1.27, 95% confidence interval (CI) (1.17-1.38); P < 0.001]. The association remained significant after multivariable adjustment [per 10 ms increase: HR 1.22, 95% CI (1.09-1.35); P < 0.001]. No associations between the IVRT, ET, MPI, and AF remained significant after multivariable adjustment. The IVCT also predicted complicated AF and the association remained significant even after multivariable adjustment [per 10 ms increase: HR 1.39, 95% CI (1.06-1.81); P = 0.015].
Conclusion
In the general population, the IVCT provides novel and independent prognostic information on the long-term risk of AF. Additionally, the IVCT can identify persons in risk of complicated AF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:49-57
Alhakak AS, Brainin P, Møgelvang R, Jensen GB, Jensen JS, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:49-57 | PMID: 31050712
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Impact:
Abstract

Risk stratifying asymptomatic left ventricular systolic dysfunction in the community: beyond left ventricular ejection fraction.

Burocchi S, Gori M, Cioffi G, Calabrese A, ... Gavazzi A, Senni M
Aims
Midwall fractional shortening (MWFS) is a measure of left ventricular (LV) systolic function that is more reliable in case of concentric LV geometry compared to LV ejection fraction (LVEF). We hypothesized that MWFS might predict heart failure (HF) and death in a high-risk asymptomatic population, beyond other echocardiographic parameters.
Methods and results
Among 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in northern Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for HF. Baseline evaluation included clinical visit, electrocardiogram, N-terminal pro-brain natriuretic peptide (NT-proBNP), and echocardiogram. Mean age of the population was 69 ± 7 years, 56% were men, 88% had hypertension, mean LVEF was 61 ± 9%, and mean MWFS 16.2 ± 3.3. During a median follow-up of 5.7 years, 95 subjects experienced HF/death events. At Cox analysis, lower MWFS was the only echocardiographic parameter, among structural/functional ones, associated with higher risk of HF/death [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.84-0.95, Padjusted < 0.001]. The risk of HF/death related to clinical data and NT-proBNP (baseline model) was reclassified by echocardiography only when MWFS was included into the model (baseline C-statistics 0.761; adding conventional structural/functional echocardiographic data 0.776, P = 0.09; adding MWFS 0.791, P = 0.007). Compared to subjects with normal LVEF and MWFS, only subjects with combined systolic dysfunction (11% of the population) were at higher risk (P = 0.001 for both abnormal; P > 0.24 for either LVEF or MWFS abnormal).
Conclusion 
DAVID-Berg data suggest to include MWFS assessment in clinical practice, a simple and reliable echocardiographic parameter able to improve risk stratification in subjects at high risk for HF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 05 Dec 2019; epub ahead of print
Burocchi S, Gori M, Cioffi G, Calabrese A, ... Gavazzi A, Senni M
Eur Heart J Cardiovasc Imaging: 05 Dec 2019; epub ahead of print | PMID: 31808506
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Impact:
Abstract

Associations of recreational and non-recreational physical activity with coronary artery calcium density vs. volume and cardiovascular disease events: the Multi-Ethnic Study of Atherosclerosis.

Thomas IC, Takemoto ML, Forbang NI, Larsen BA, ... Budoff MJ, Criqui MH
Aims 
The benefits of physical activity (PA) on cardiovascular disease (CVD) are well known. However, studies suggest PA is associated with coronary artery calcium (CAC), a subclinical marker of CVD. In this study, we evaluated the associations of self-reported recreational and non-recreational PA with CAC composition and incident CVD events. Prior studies suggest high CAC density may be protective for CVD events.
Methods and results 
We evaluated 3393 participants of the Multi-Ethnic Study of Atherosclerosis with prevalent CAC. After adjusting for demographics, the highest quintile of recreational PA was associated with 0.07 (95% confidence interval 0.01-0.13) units greater CAC density but was not associated with CAC volume. In contrast, the highest quintile of non-recreational PA was associated with 0.08 (0.02-0.14) units lower CAC density and a trend toward 0.13 (-0.01 to 0.27) log-units higher CAC volume. There were 520 CVD events over a 13.7-year median follow-up. Recreational PA was associated with lower CVD risk (hazard ratio 0.88, 0.79-0.98, per standard deviation), with an effect size that was not changed with adjustment for CAC composition or across levels of prevalent CAC.
Conclusion 
Recreational PA may be associated with a higher density but not a higher volume of CAC. Non-recreational PA may be associated with lower CAC density, suggesting these forms of PA may not have equivalent associations with this subclinical marker of CVD. While PA may affect the composition of CAC, the associations of PA with CVD risk appear to be independent of CAC.

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Eur Heart J Cardiovasc Imaging: 30 Oct 2019; epub ahead of print
Thomas IC, Takemoto ML, Forbang NI, Larsen BA, ... Budoff MJ, Criqui MH
Eur Heart J Cardiovasc Imaging: 30 Oct 2019; epub ahead of print | PMID: 31670763
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Impact:
Abstract

Potential usefulness and clinical relevance of a novel left atrial filling index to estimate left ventricular filling pressures in patients with preserved left ventricular ejection fraction.

Braunauer K, Düngen HD, Belyavskiy E, Aravind-Kumar R, ... Pieske-Kraigher E, Morris DA
Aims
The aim of this study was to examine the potential usefulness and clinical relevance of a novel left atrial (LA) filling index using 2D speckle-tracking transthoracic echocardiography to estimate left ventricular (LV) filling pressures in patients with preserved LV ejection fraction (LVEF).
Methods and results
The LA filling index was calculated as the ratio of the mitral early-diastolic inflow peak velocity (E) over LA reservoir strain (i.e. E/LA strain ratio). This index showed a good diagnostic performance to determine elevated LV filling pressures in a test-cohort (n = 31) using invasive measurements of LV end-diastolic pressure (area under the curve 0.82, cut-off > 3.27 = sensitivity 83.3%, specificity 78.9%), which was confirmed in a validation-cohort (patients with cardiovascular risk factors; n = 486) using the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging criteria (cut-off > 3.27 = sensitivity 88.1%, specificity 77.6%) and in a specificity-validation cohort (patients free of cardiovascular risk factors, n = 120; cut-off > 3.27 = specificity 98.3%). Regarding the clinical relevance of the LA filling index, an elevated E/LA strain ratio (>3.27) was significantly associated with the risk of heart failure hospitalization at 2 years (odds ratio 4.3, 95% confidence interval 1.8-10.5), even adjusting this analysis by age, sex, renal failure, LV hypertrophy, or abnormal LV global longitudinal systolic strain.
Conclusion
The findings from this study suggest that a novel LA filling index using 2D speckle-tracking echocardiography could be of potential usefulness and clinical relevance in estimating LV filling pressures in patients with preserved LVEF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 17 Nov 2019; epub ahead of print
Braunauer K, Düngen HD, Belyavskiy E, Aravind-Kumar R, ... Pieske-Kraigher E, Morris DA
Eur Heart J Cardiovasc Imaging: 17 Nov 2019; epub ahead of print | PMID: 31740950
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Impact:
Abstract

Subclinical leaflet thrombosis is associated with impaired reverse remodelling after transcatheter aortic valve implantation.

Szilveszter B, Oren D, Molnár L, Apor A, ... Maurovich-Horvat P, Merkely B
Aims
Cardiac CT is increasingly applied for planning and follow-up of transcatheter aortic valve implantation (TAVI). However, there are no data available on reverse remodelling after TAVI assessed by CT. Therefore, we aimed to evaluate the predictors and the prognostic value of left ventricular (LV) reverse remodelling following TAVI using CT angiography.
Methods and results
We investigated 117 patients with severe, symptomatic aortic stenosis (AS) who underwent CT scanning before and after TAVI procedure with a mean follow-up time of 2.6 years after TAVI. We found a significant reduction in LV mass (LVM) and LVM indexed to body surface area comparing pre- vs. post-TAVI images: 180.5 ± 53.0 vs. 137.1 ± 44.8 g and 99.7 ± 25.4 vs. 75.4 ± 19.9 g/m2, respectively, both P < 0.001. Subclinical leaflet thrombosis (SLT) was detected in 25.6% (30/117) patients. More than 20% reduction in LVM was defined as reverse remodelling and was detected in 62.4% (73/117) of the patients. SLT, change in mean pressure gradient on echocardiography and prior myocardial infarction was independently associated with LV reverse remodelling after adjusting for age, gender, and traditional risk factors (hypertension, body mass index, diabetes mellitus, and hyperlipidaemia): OR = 0.27, P = 0.022 for SLT and OR = 0.22, P = 0.006 for prior myocardial infarction, OR = 1.51, P = 0.004 for 10 mmHg change in mean pressure gradient. Reverse remodelling was independently associated with favourable outcomes (HR = 0.23; P = 0.019).
Conclusion
TAVI resulted in a significant LVM regression on CT. The presence of SLT showed an inverse association with LV reverse remodelling and thus it may hinder the beneficial LV structural changes. Reverse remodelling was associated with improved long-term prognosis.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 29 Oct 2019; epub ahead of print
Szilveszter B, Oren D, Molnár L, Apor A, ... Maurovich-Horvat P, Merkely B
Eur Heart J Cardiovasc Imaging: 29 Oct 2019; epub ahead of print | PMID: 31665257
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Abstract

The feasibility and clinical implication of tricuspid regurgitant velocity and pulmonary flow acceleration time evaluation for pulmonary pressure assessment during exercise stress echocardiography.

Wierzbowska-Drabik K, Picano E, Bossone E, Ciampi Q, Lipiec P, Kasprzak JD
Aims
Echocardiography can estimate pulmonary arterial pressure (PAP) from tricuspid regurgitation velocity (TRV) or acceleration time (ACT) of pulmonary flow. We assessed the feasibility of TRV and ACT measurements during exercise stress echocardiography (ESE) and their correlation in all stages of ESE.
Methods and results
We performed ESE in 102 subjects [mean age 49 ± 17 years, 50 females, 39 healthy, 30 with cardiovascular risk factors, and 33 with pulmonary hypertension (PH)] referred for the assessment of exercise tolerance and ischaemia exclusion. ESE was performed on cycloergometer with the load increasing by 25 W for each 2 min. Assessment of TRV with continuous wave and ACT with pulsed Doppler were attempted in 306 time points: at rest, peak exercise, and recovery. In 20 PH patients we evaluated the correlations of TRV and ACT with invasively measured PAP. The success rate was 183/306 for TRV and 304/306 for ACT (feasibility: 60 vs. 99%, P < 0.0001). There was a close correlation between TRV and ACT: r = 0.787, P < 0.001 and ACT at peak ≤67 ms showed 94% specificity for elevated systolic PAP detection. Moreover, TRV and ACT at peak exercise reflected better that resting data the invasive systolic PAP and mean PAP with r = 0.76, P = 0.0004 and r = -0.67, P = 0.0018, respectively.
Conclusion
ACT is closely correlated with and substantially more feasible than TRV during ESE and inclusion of both parameters (TRACT approach) expands the possibility of PAP assessment, especially at exercise when TRV feasibility is the lowest but correlation with invasive PAP seems to increase.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1027-1034
Wierzbowska-Drabik K, Picano E, Bossone E, Ciampi Q, Lipiec P, Kasprzak JD
Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1027-1034 | PMID: 30824900
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Impact:
Abstract

Cardiac perfusion, structure, and function in type 2 diabetes mellitus with and without diabetic complications.

Sørensen MH, Bojer AS, Broadbent DA, Plein S, Madsen PL, Gæde P
Aims
Coronary microvascular disease (CMD) is a known complication in type 2 diabetes mellitus (T2DM). We examined the relationship between diabetic complications, left ventricular (LV) function and structure and myocardial perfusion reserve (MPR) as indicators of CMD in patients with T2DM and control subjects.
Methods and results
This was a cross-sectional study of 193 patients with T2DM and 25 controls subjects. Patients were grouped as uncomplicated diabetes (n = 71) and diabetes with complications (albuminuria, retinopathy, and autonomic neuropathy). LV structure, function, adenosine stress, and rest myocardial perfusion were evaluated by cardiovascular magnetic resonance. Echocardiography was used to evaluate diastolic function. Patients with uncomplicated T2DM did not have significantly different LV mass and E/e* but decreased MPR (3.8 ± 1.0 vs. 5.1 ± 1.5, P < 0.05) compared with controls. T2DM patients with albuminuria and retinopathy had decreased MPR (albuminuria: 2.4 ± 0.9 and retinopathy 2.6 ± 0.7 vs. 3.8 ± 1.0, P < 0.05 for both) compared with uncomplicated T2DM patients, along with significantly higher LV mass (149 ± 39 and 147 ± 40 vs. 126 ± 33 g, P < 0.05) and E/e* (8.3 ± 2.8 and 8.1 ± 2.2 vs. 7.0 ± 2.5, P < 0.05). When entered in a multiple regression model, reduced MPR was associated with increasing E/e* and albuminuria and retinopathy were associated with reduced MPR.
Conclusions
Patients with uncomplicated T2DM have reduced MPR compared with control subjects, despite equivalent LV mass and E/e*. T2DM patients with albuminuria or retinopathy have reduced MPR and increased LV mass and E/e* compared with patients with uncomplicated T2DM. E/e* and MPR are significantly associated after adjustment for age, hypertension, and LV mass, suggesting a link between CMD and cardiac diastolic function.
Clinical trial registration
https://www.clinicaltrials.org. Unique identifier: NCT02684331.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 22 Oct 2019; epub ahead of print
Sørensen MH, Bojer AS, Broadbent DA, Plein S, Madsen PL, Gæde P
Eur Heart J Cardiovasc Imaging: 22 Oct 2019; epub ahead of print | PMID: 31642902
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Impact:
Abstract

Quantitative assessment of effective regurgitant orifice: impact on risk stratification, and cut-off for severe and torrential tricuspid regurgitation grade.

Peri Y, Sadeh B, Sherez C, Hochstadt A, ... Keren G, Topilsky Y
Aims 
Asses the added value of quantitative evaluation of tricuspid regurgitation (TR), the proper cut-off value for severe TR and \'torrential TR\' based on outcome data. The added value of quantitative evaluation of TR, and the cut-off values associated with increased mortality are unknown.
Methods and results
In patients with all-cause TR assessed both qualitatively and quantitatively by proximal iso-velocity surface area method, long-term and 1-year outcome analysis was conducted. Thresholds for excess mortality were assessed using spline curves, receiver-operating characteristic curves, and minimum P-value analysis. The study involved 676 patients with all-cause TR (age 73.9 ± 14 years, male 45%, ejection fraction 52.9 ± 14%). Effective regurgitant orifice (ERO) was strongly associated with decreased survival in unadjusted [hazard ratio (HR) 2.38 (1.79-3.01), P < 0.0001 per 0.1 cm2 increment] and adjusted [2.6 (1.25-5.0), P = 0.01] analyses. Quantitative grading was superior to qualitative grading in prediction of outcome (P < 0.01). The optimal cut-off value for the best separation in survival between groups of patients with severe vs. lesser degree of TR was 0.35 cm2 [P < 0.0001, HR =2.0 (1.5-2.7)]. ERO negatively impacted survival, even when including only the subgroup of patients with severe TR [HR 1.5 (1.01-2.3); P = 0.04]. The optimal threshold corresponding for the best separation for survival between groups of patients with severe vs. \'torrential\' TR was 0.7 cm2 [P = 0.005, HR =2.6 (1.2-5.1)].
Conclusion 
TR can be severe and even \'torrential\' and is associated with excess mortality. Quantitative assessment of TR by ERO measurement is a powerful independent predictor of outcome, superior to standard qualitative assessment. The optimal cut-off above which mortality is increased is 0.35 cm2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR >0.7 cm2 is associated with poorer survival compared to patients with severe TR (ERO > 0.4 cm2 and <0.7 cm2).

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 22 Oct 2019; epub ahead of print
Peri Y, Sadeh B, Sherez C, Hochstadt A, ... Keren G, Topilsky Y
Eur Heart J Cardiovasc Imaging: 22 Oct 2019; epub ahead of print | PMID: 31642895
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Impact:
Abstract

Prognostic implications of left ventricular global longitudinal strain in patients with bicuspid aortic valve disease and preserved left ventricular ejection fraction.

Kong WKF, Vollema EM, Prevedello F, Perry R, ... Delgado V, Bax JJ
Aims
In patients with bicuspid aortic valve (BAV) and preserved left ventricular (LV) ejection fraction (EF), the frequency of impaired LV global longitudinal strain (GLS) and its prognostic implications are unknown. The present study evaluated the proportion and prognostic value of impaired LV GLS in patients with BAV and preserved LVEF.
Methods and results
Five hundred and thirteen patients (68% men; mean age 44 ± 18 years) with BAV and preserved LVEF (>50%) were divided into five groups according to the type of BAV dysfunction: (i) normal function BAV, (ii) mild aortic stenosis (AS) or aortic regurgitation (AR), (iii) ≥moderate isolated AS, (iv) ≥moderate isolated AR, and (v) ≥moderate mixed AS and AR. LV systolic dysfunction based on 2D speckle-tracking echocardiography was defined as a cut-off value of LVGLS (-13.6%). The primary outcome was aortic valve intervention or all-cause mortality. The proportion of patients with LVGLS ≤-13.6% was the highest in the normal BAV group (97%) and the lowest in the group with moderate and severe mixed AS and AR (79%). During a median follow-up of 10 years, 210 (41%) patients underwent aortic valve replacement and 17 (3%) died. Patients with preserved LV systolic function (LVGLS ≤ -13.6%) had significantly better event-free survival compared to those with impaired LV systolic function (LVGLS > -13.6%). LVGLS was independently associated with increased risk of events (mainly aortic valve replacement): hazard ratio 1.09; P < 0.001.
Conclusion
Impaired LVGLS in BAV with preserved LVEF is not infrequent and was independently associated with increased risk of events (mainly aortic valve replacement events).

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 20 Oct 2019; epub ahead of print
Kong WKF, Vollema EM, Prevedello F, Perry R, ... Delgado V, Bax JJ
Eur Heart J Cardiovasc Imaging: 20 Oct 2019; epub ahead of print | PMID: 31633159
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Impact:
Abstract

Significant functional mitral regurgitation affects left atrial function in heart failure patients: haemodynamic correlations and prognostic implications.

Palmiero G, Melillo E, Ferro A, Carlomagno G, ... Ascione L, Caso P
Aims
Functional mitral regurgitation (FMR) is a well-known pathophysiological factor in heart failure (HF) patients, and left atrial function (LAF) is a novel determinant of clinical status and outcome in this setting. However, little is known about the pathophysiological role of FMR on LAF in HFrEF patients. Aim of this study is to explore the possible interplay between the severity of FMR and LAF in heart failure with reduce ejection fraction (HFrEF) patients and their possible consequences.
Methods and results
We studied 97 consecutive patients with FMR classified in two groups: mild-to-moderate MR ore less (FMR group, n = 38) and moderate-to-severe or more (SFMR group, n = 59). Using the phasic method, left atrial contractile, conduit, reservoir, and total emptying function (TLAEF) were calculated to assess LAF. SFMR group showed significantly lower values of LAF compared to FMR group. LA dysfunction (LA-dys) was defined for TLAEF values below the median and groups divided in four subgroups based on its presence. Patient with LA-Dys in SFMR group showed a worse clinical status, higher incidence of right ventricular dysfunction (RV-Dys), and pulmonary hypertension (PH), and a significant worse clinical survival compared to all other groups.
Conclusion
In our study, the survival was significantly lower in SFMR/LA-Dys+ group. Furthermore, LA-Dys was strongly related with worse clinical status and higher incidence of PH and RV-Dys. These results suggest that in patients with SFMR and HFrEF, LA-Dys may represent both a marker of more advanced disease and a novel prognostic factor.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1012-1019
Palmiero G, Melillo E, Ferro A, Carlomagno G, ... Ascione L, Caso P
Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1012-1019 | PMID: 30863840
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Abstract

Multicentre reference values for cardiac magnetic resonance imaging derived ventricular size and function for children aged 0-18 years.

van der Ven JPG, Sadighy Z, Valsangiacomo Buechel ER, Sarikouch S, ... Boersma E, Helbing WA
Aims
Cardiovascular magnetic resonance (CMR) imaging is an important tool in the assessment of paediatric cardiac disease. Reported reference values of ventricular volumes and masses in the paediatric population are based on small cohorts and several methodologic differences between studies exist. We sought to create steady-state free precession (SSFP) CMR reference values for biventricular volumes and mass by combining data of previously published studies and re-analysing these data in a standardized manner.
Methods and results
A total of 141 healthy children (68 boys) from three European centres underwent cine-SSFP CMR imaging. Cardiac structures were manually contoured for end-diastolic and end-systolic phases in the short-axis orientation according to current standardized CMR post-processing guidelines. Volumes and masses were derived from these contours. Age-related reference curves were constructed using the lambda mu sigma method. Median age was 12.7 years (range 0.6-18.5). We report biventricular volumes and masses, unindexed and indexed for body surface area, stratified by age groups. In general, boys had approximately 15% higher biventricular volumes and masses compared with girls. Only in children aged <6 years old no gender differences could be observed. Left ventricle ejection fraction was slightly higher in boys in this study population (median 67% vs. 65%, P = 0.016). Age-related reference curves showed non-linear relations between age and cardiac parameters.
Conclusion
We report volumetric SSFP CMR imaging reference values for children aged 0-18 years old in a relatively large multi-centre cohort. These references can be used in the follow-up of paediatric cardiac disease and for research purposes.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:102-113
van der Ven JPG, Sadighy Z, Valsangiacomo Buechel ER, Sarikouch S, ... Boersma E, Helbing WA
Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:102-113 | PMID: 31280290
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Abstract

Highlights of the 14th International Conference on Nuclear Cardiology and Cardiac Computed Tomography.

Hyafil F, Jaber WA, Neglia D

The 14th International Conference on Nuclear Cardiology and Cardiac Computed Tomography was held from 12 May to 14 May 2019 in Lisbon, Portugal. In this article, the three Congress Programme Committee Chairs summarize selected highlights of the presented abstracts and lectures.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 25 Oct 2019; epub ahead of print
Hyafil F, Jaber WA, Neglia D
Eur Heart J Cardiovasc Imaging: 25 Oct 2019; epub ahead of print | PMID: 31665263
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Abstract

Relationship between epicardial adipose tissue and coronary vascular function in patients with suspected coronary artery disease and normal myocardial perfusion imaging.

Nappi C, Ponsiglione A, Acampa W, Gaudieri V, ... Imbriaco M, Cuocolo A
Aims
We evaluated the relationship between epicardial adipose tissue (EAT) and coronary vascular function assessed by rubidium-82 (82Rb) positron emission tomography/computed tomography (PET/CT) in patients with suspected coronary artery disease (CAD).
Methods and results
The study population included 270 patients with suspected CAD and normal myocardial perfusion at stress-rest 82Rb PET/CT. Coronary artery calcium (CAC) score and EAT volume were measured. Absolute myocardial blood flow (MBF) was computed in mL/min/ from the dynamic rest and stress imaging. Myocardial perfusion reserve (MPR) was defined as the ratio of hyperaemic to baseline MBF and it was considered reduced when <2. MPR was normal in 177 (65%) patients and reduced in 93 (35%). Patients with impaired MPR were older (P < 0.001) and had higher CAC score values (P = 0.033), EAT thickness (P = 0.009), and EAT volume (P < 0.001). At univariable logistic regression analysis, age, heart rate reserve (HRR), CAC score, EAT thickness, and EAT volume resulted significant predictors of reduced MPR, but only age (P = 0.002), HRR (P = 0.021), and EAT volume (P = 0.043) were independently associated with reduced MPR, at multivariable analysis. In patients with CAC score 0 (n = 114), a significant relation between EAT volume and MPR (P = 0.014) was observed, while the relationship was not significant (P = 0.21) in patients with CAC score >0 (n = 156).
Conclusion
In patients with suspected CAD and normal myocardial perfusion, EAT volume predicts hyperaemic MBF and reduced MPR, confirming that visceral pericardium fat may influence coronary vascular function. Thus, EAT evaluation has a potential role in the early identification of coronary vascular dysfunction.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1379-1387
Nappi C, Ponsiglione A, Acampa W, Gaudieri V, ... Imbriaco M, Cuocolo A
Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1379-1387 | PMID: 31302673
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Impact:
Abstract

Regional myocardial work by cardiac magnetic resonance and non-invasive left ventricular pressure: a feasibility study in left bundle branch block.

Larsen CK, Aalen JM, Stokke C, Fjeld JG, ... Smiseth OA, Hopp E
Aims
Regional myocardial work may be assessed by pressure-strain analysis using a non-invasive estimate of left ventricular pressure (LVP). Strain by speckle tracking echocardiography (STE) is not always accessible due to poor image quality. This study investigated the estimation of regional myocardial work from strain by feature tracking (FT) cardiac magnetic resonance (CMR) and non-invasive LVP.
Methods and results
Thirty-seven heart failure patients with reduced ejection fraction, left bundle branch block (LBBB), and no myocardial scar were compared to nine controls without LBBB. Circumferential strain was measured by FT-CMR in a mid-ventricular short-axis cine view, and longitudinal strain by STE. Segmental work was calculated by pressure-strain analysis. Twenty-five patients underwent 18F-fluorodeoxyglucose (FDG) positron emission tomography. Segmental values were reported as percentages of the segment with maximum myocardial FDG uptake. In LBBB patients, net CMR-derived work was 51 ± 537 (mean ± standard deviation) in septum vs. 1978 ± 1084 mmHg·% in the left ventricular (LV) lateral wall (P < 0.001). In controls, however, there was homogeneous work distribution with similar values in septum and the LV lateral wall (non-significant). Reproducibility was good. Segmental CMR-derived work correlated with segmental STE-derived work and with segmental FDG uptake (average r = 0.71 and 0.80, respectively).
Conclusion
FT-CMR in combination with non-invasive LVP demonstrated markedly reduced work in septum compared to the LV lateral wall in patients with LBBB. Work distribution correlated with STE-derived work and energy demand as reflected in FDG uptake. These results suggest that FT-CMR in combination with non-invasive LVP is a relevant clinical tool to measure regional myocardial work.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 09 Oct 2019; epub ahead of print
Larsen CK, Aalen JM, Stokke C, Fjeld JG, ... Smiseth OA, Hopp E
Eur Heart J Cardiovasc Imaging: 09 Oct 2019; epub ahead of print | PMID: 31599327
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Impact:
Abstract

Prognostic value of [15O]H2O positron emission tomography-derived global and regional myocardial perfusion.

Bom MJ, van Diemen PA, Driessen RS, Everaars H, ... Danad I, Knaapen P
Aims
To evaluate the prognostic value of global and regional quantitative [15O]H2O positron emission tomography (PET) perfusion.
Methods and results
In this retrospective study, 648 patients with suspected or known coronary artery disease (CAD) who underwent [15O]H2O PET were followed for the occurrence of death and myocardial infarction (MI). Global and regional hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) were obtained from [15O]H2O PET. During median follow-up of 6.9 (5.0-7.9) years, 64 (9.9%) patients experienced the composite of death (36-5.6%) and MI (28-4.3%). Impaired global hMBF (<2.65 mL/min/g) and CFR (<2.88) were both significant prognostic factors for death/MI after adjusting for clinical characteristics (both P < 0.001). However, after adjusting for clinical parameters and the combined use of hMBF and CFR, only hMBF remained an independent prognostic factor (P = 0.04). For regional perfusion, both impaired hMBF (<2.10 mL/min/g) and CFR (<2.07) demonstrated prognostic value for events (both P < 0.001). Similarly, after adjusting for clinical characteristics and combined use of hMBF and CFR, only hMBF had independent prognostic value (P = 0.04). The combination of global and regional perfusion did not improve prognostic performance over either global (P = 0.55) or regional perfusion (P = 0.37) alone.
Conclusion
Global and regional hMBF and CFR were all prognostic factors for death and MI. However, for both global and regional perfusion, hMBF remained the only independent prognostic factor after adjusting for the combined use of hMBF and CFR. Additionally, integrating global and regional perfusion did not increase prognostic performance compared to either regional or global perfusion alone.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 15 Oct 2019; epub ahead of print
Bom MJ, van Diemen PA, Driessen RS, Everaars H, ... Danad I, Knaapen P
Eur Heart J Cardiovasc Imaging: 15 Oct 2019; epub ahead of print | PMID: 31620792
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Impact:
Abstract

Prognostic implications of global, left ventricular myocardial work efficiency before cardiac resynchronization therapy.

van der Bijl P, Vo NM, Kostyukevich MV, Mertens B, ... Delgado V, Bax JJ
Aims
Cardiac resynchronization therapy (CRT) restores mechanical efficiency to the failing left ventricular (LV) by resynchronization of contraction. Global, LV myocardial work efficiency (GLVMWE) can be quantified non-invasively with echocardiography. The prognostic implication of GLVMWE remains unexplored, and we therefore related GLVMWE before CRT to long-term prognosis.
Methods and results
Data were analysed from an ongoing registry of patients with Class I indications for CRT. GLVMWE was defined as the ratio of constructive work in all LV segments, divided by the sum of constructive and wasted work in all LV segments, as a percentage. It was derived from speckle tracking strain echocardiography and non-invasive blood pressure measurements, taken pre-CRT. Patients were dichotomized according to baseline, median GLVMWE [75%; interquartile range (IQR) 66-81%]. A total of 153 patients (66 ± 10 years, 72% male, 48% ischaemic heart disease) were analysed. After a median follow-up of 57 months (IQR 28-76 months), 31% of patients died. CRT recipients with less efficient baseline energetics (GLVMWE <75%) demonstrated lower event rates than patients with more efficient baseline energetics (GLVMWE ≥75%) (log-rank test, P = 0.029). On multivariable analysis, global LV wasted work ratio <75% pre-CRT was independently associated with a decreased risk of all-cause mortality (hazard ratio 0.48, 95% confidence interval 0.25-0.92; P = 0.027), suggesting that the potential for improvement in LV efficiency is important for CRT benefit.
Conclusion
GLVMWE can be derived non-invasively from speckle tracking strain echocardiography and non-invasive blood pressure recordings. A lower GLVMWE before CRT is independently associated with improved long-term outcome.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1388-1394
van der Bijl P, Vo NM, Kostyukevich MV, Mertens B, ... Delgado V, Bax JJ
Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1388-1394 | PMID: 31131394
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Impact:
Abstract

Clarifying the anatomy of common arterial trunk: a clinical study of 70 patients.

Gupta SK, Aggarwal A, Shaw M, Gulati GS, ... Airan B, Anderson RH
Aims
Anatomic variations in hearts with common arterial trunk are well-known, although there is no large study of living patients. Detailed knowledge of the origins of the pulmonary and coronary arteries is vital for surgical management. We sought to clarify the variations using computed tomography.
Methods and results
We prospectively studied 70 consecutive patients using echocardiography and computed tomography. In 63 (90%) patients, there was aortic dominance, while 7 (10%) had dominance of the pulmonary component. In 27 (43%) patients with aortic dominance, part of the pulmonary segment arose from a truncal valvar sinus. A long confluent pulmonary channel was more common in patients with sinusal origin compared to those with non-sinusal origin of the pulmonary segment (19 vs. 0; P = 0.0005). Close proximity between the orifices of the coronary arteries and the pulmonary component was also more frequent with sinusal origin (21 vs. 6; P < 0.001) with 5 (19%) patients having pulmonary flow obstructed by a truncal valvar leaflet.
Conclusion
Sinusal origin of the pulmonary component is common with aortic dominance, frequently in association with a long confluent pulmonary segment, which may be in close proximity to the origin of a coronary artery. One-fifth of patients with sinusal origin of pulmonary component have a truncal valvar leaflet obstructing the pulmonary orifice. These morpho-anatomic findings have important implications for management.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 18 Oct 2019; epub ahead of print
Gupta SK, Aggarwal A, Shaw M, Gulati GS, ... Airan B, Anderson RH
Eur Heart J Cardiovasc Imaging: 18 Oct 2019; epub ahead of print | PMID: 31628808
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Impact:
Abstract

Valvular calcification and risk of peripheral artery disease: the Multi-Ethnic Study of Atherosclerosis (MESA).

Garg PK, Buzkova P, Meyghani Z, Budoff MJ, ... Cushman M, Allison M
Aims
The detection of cardiac valvular calcification on routine imaging may provide an opportunity to identify individuals at increased risk for peripheral artery disease (PAD). We investigated the associations of aortic valvular calcification (AVC) and mitral annular calcification (MAC) with risk of developing clinical PAD or a low ankle-brachial index (ABI).
Methods and results
AVC and MAC were measured on cardiac computed tomography in 6778 Multi-Ethnic Study of Atherosclerosis participants without baseline PAD between 2000 and 2002. Clinical PAD was ascertained through 2015. Incident low ABI, defined as ABI <0.9 and decline of ≥0.15, was assessed among 5762 individuals who had an ABI >0.9 at baseline and at least one follow-up ABI measurement 3-10 years later. Adjusted Cox proportional hazards and Poisson regression modelling were used to determine the association of valvular calcification with clinical PAD and low ABI, respectively. There were 117 clinical PAD and 198 low ABI events that occurred over a median follow-up of 14 years and 9.2 years, respectively. The presence of MAC was associated with an increased risk of clinical PAD [hazard ratio 1.79; 95% confidence interval (CI) 1.04-3.05] but not a low ABI (rate ratio 1.28; 95% CI 0.75-2.19). No significant associations were noted for the presence of AVC and risk of either clinical PAD.
Conclusion
MAC is associated with an increased risk of developing clinical PAD. Future studies are needed to corroborate our findings and better understand whether MAC holds any predictive value as a risk marker for PAD.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 17 Nov 2019; epub ahead of print
Garg PK, Buzkova P, Meyghani Z, Budoff MJ, ... Cushman M, Allison M
Eur Heart J Cardiovasc Imaging: 17 Nov 2019; epub ahead of print | PMID: 31740939
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Impact:
Abstract

EACVI survey on standardization of cardiac chambers quantification by transthoracic echocardiography.

Ajmone Marsan N, Michalski B, Cameli M, Podlesnikar T, ... Dweck MR, Haugaa KH
Aims
To evaluate standard reporting of cardiac chambers size and function by transthoracic echocardiography (TTE), the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of three-dimensional echocardiography (3DE) and speckle tracking-derived myocardial deformation imaging (STE) was explored.
Methods and results
A total of 96 European Echocardiography Laboratories from 22 different countries responded to the survey, which consisted of 20 questions. For most of the standard parameters of cardiac chamber size and function, answers from the centres were homogeneous and demonstrated good adherence to current recommendations. In particular, all centres assessed left ventricular (LV) and left atrial (LA) size combining diameter measurements with volumes obtained using the bi-plane Simpson\'s method. More variability was observed in the measurements of the right heart chambers and thoracic aorta. Interestingly, >90% of centres had access to 3DE and STE; however, the large majority of centres reserved the use of these techniques for selected cases, particularly for the measure of 3D LV volumes and ejection fraction and global longitudinal strain in patients being considered for cardiac device implantation, surgical intervention (valvular heart disease) or screened for cardiotoxicity. Only 10% of centres used 3DE for right ventricular and LA volumes. Also, <30% of the centres used LA strain imaging.
Conclusion
In Europe, a good adherence to current recommendations was observed for most of the standard parameters of cardiac chambers quantification by TTE. Advanced echocardiography modalities, such as 3DE and STE, are widely available but used only in selected cases.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 08 Dec 2019; epub ahead of print
Ajmone Marsan N, Michalski B, Cameli M, Podlesnikar T, ... Dweck MR, Haugaa KH
Eur Heart J Cardiovasc Imaging: 08 Dec 2019; epub ahead of print | PMID: 31819943
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Impact:
Abstract

Predictive value of non-invasive right ventricle to pulmonary circulation coupling in systemic lupus erythematosus patients with pulmonary arterial hypertension.

Guo X, Lai J, Wang H, Tian Z, ... Liu Y, Zeng X
Aims
Pulmonary arterial hypertension (PAH) is a serious and devastating complication of systemic lupus erythematosus (SLE), especially when the right ventricle (RV) fails. Whether the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) measured by echocardiography as a simple surrogate of RV to pulmonary circulation (PC) coupling predicts the outcome of SLE-associated PAH has not been investigated.
Methods and results
Between February 2010 and August 2015, 112 consecutive patients with a diagnosis of SLE-associated PAH confirmed by right heart catheterization were enrolled prospectively. The endpoint was a composite of all-cause mortality and clinical worsening. Baseline clinical characteristics and echocardiographic assessment were analysed. Among all the patients, 47 (42%) patients experienced the endpoint (mean follow-up period 18.1 ± 12.0 months), including 20 patients who died during a median follow-up period of 48.5 months. Multivariable Cox regression analysis showed that TAPSE/PASP ratio [hazard ratio (HR) 0.004, P = 0.017] and 6-min walk distance (6MWD) (HR 0.997, P = 0.036) were the independent predictors for the endpoint. A three-group prediction risk was created based on combined assessment of the TAPSE/PASP ratio and 6MWD relative to their cut-off values. The patients with the worse RV-PC coupling (TAPSE/PASP <0.184 mm/mmHg) and the lower 6MWD (<395 m) had the highest risk (HR 4.62, confidence interval 2.27-9.41, P < 0.001) of experiencing the endpoint.
Conclusion
The TAPSE/PASP ratio, combined with 6MWD, provides clinical and prognostic insights into patients with SLE-associated PAH. A low TAPSE/PASP and low 6MWD identifies the subgroup of patients with high risk of poor prognosis.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 22 Dec 2019; epub ahead of print
Guo X, Lai J, Wang H, Tian Z, ... Liu Y, Zeng X
Eur Heart J Cardiovasc Imaging: 22 Dec 2019; epub ahead of print | PMID: 31872222
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Impact:
Abstract

Ventricular response to dobutamine stress cardiac magnetic resonance imaging is associated with adverse outcome during 8-year follow-up in patients with repaired Tetralogy of Fallot.

van den Bosch E, Cuypers JAAE, Luijnenburg SE, Duppen N, ... Kapusta L, Helbing WA
Aims
The aim of this study was to evaluate the possible value of dobutamine stress cardiac magnetic resonance imaging (CMR) to predict adverse outcome in Tetralogy of Fallot (TOF) patients.
Methods and results
In previous prospective multicentre studies, TOF patients underwent low-dose dobutamine stress CMR (7.5 µg/kg/min). Subsequently, during regular-care patient follow-up, patients were assessed for reaching the composite endpoint (cardiac death, arrhythmia-related hospitalization, or cardioversion/ablation, VO2 max ≤65% of predicted). A normal stress response was defined as a decrease in end-systolic volume (ESV) and increase in ejection fraction. The relative parameter change during stress was calculated as relative parameter change = [(parameterstress - parameterrest)/parameterrest] * 100. The predictive value of dobutamine stress CMR for the composite endpoint was determined using time-to-event analyses (Kaplan-Meier) and Cox proportional hazard analysis. We studied 100 patients [67 (67%) male, median age at baseline CMR 17.8 years (interquartile range 13.5-34.0), age at TOF repair 0.9 years (0.6-2.1)]. After a median follow-up of 8.6 years (6.7-14.1), 10 patients reached the composite endpoint. An abnormal stress response (30% vs. 4.4%, P = 0.021) was more frequently observed in composite endpoint patients. Also in endpoint patients, the relative decrease in right ventricular ESV decreased less during stress compared with the patients without an endpoint (-17 ± 15 vs. -26 ± 13 %, P = 0.045). Multivariable analyses identified an abnormal stress response (hazard ratio 10.4; 95% confidence interval 2.5-43.7; P = 0.001) as predictor for the composite endpoint.
Conclusion
An abnormal ventricular response to dobutamine stress is associated with adverse outcome in patients with repaired TOF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 08 Oct 2019; epub ahead of print
van den Bosch E, Cuypers JAAE, Luijnenburg SE, Duppen N, ... Kapusta L, Helbing WA
Eur Heart J Cardiovasc Imaging: 08 Oct 2019; epub ahead of print | PMID: 31596460
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Impact:
Abstract

Impact of pectus excavatum on cardiac morphology and function according to the site of maximum compression: effect of physical exertion and respiratory cycle.

Rodriguez-Granillo GA, Raggio IM, Deviggiano A, Bellia-Munzon G, ... Carrascosa P, Martinez-Ferro M
Aims
Previous studies have demonstrated diverse cardiac manifestations in patients with pectus excavatum (PEX), although mostly addressing morphological or physiological impact as separate findings. Using multimodality imaging, we evaluated the impact of PEX on cardiac morphology and function according to the site of maximum compression, and the effect of exertion and breathing.
Methods and results
All patients underwent chest computed tomography, cardiac magnetic resonance (CMR), and stress echocardiography (echo) in order to establish surgical candidacy. We evaluated diastolic function and trans-tricuspid gradient during stress (echo); and systolic function and respiratory-related septal wall motion abnormalities (CMR). Patients were classified according to the site of cardiac compression as type 0 (without cardiac compression); type 1 (right ventricle); and type 2 [right ventricle and atrioventricular (AV) groove]. Fifty-nine patients underwent multimodality imaging, with a mean age of 19.5 ± 5.9 years. Compared with a sex and age matched control group, peak exercise capacity was lower in patients with PEX (8.4 ± 2.0 METs vs. 15.1 ± 4.6 METs, P < 0.0001). At stress, significant differences were found between groups regarding left ventricular E/A (P = 0.004) and e/a ratio (P = 0.005), right ventricular E/A ratio (P = 0.03), and trans-tricuspid gradient (P = 0.001). At CMR, only 9 (15%) patients with PEX had normal septal motion, whereas 17 (29%) had septal flattening during inspiration. Septal motion abnormalities were significantly related to the cardiac compression classification (P < 0.0001).
Conclusions
The present study demonstrated that patients with PEX, particularly those with compression affecting the right ventricle and AV groove, manifest diverse cardiac abnormalities that are mostly related to exertion, inspiration, and diastolic function.

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Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:77-84
Rodriguez-Granillo GA, Raggio IM, Deviggiano A, Bellia-Munzon G, ... Carrascosa P, Martinez-Ferro M
Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:77-84 | PMID: 30938414
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Impact:
Abstract

The role of 99mTc-HMPAO-labelled white blood cell scintigraphy in the diagnosis of cardiac device-related infective endocarditis.

Holcman K, Małecka B, Rubiś P, Ząbek A, ... Podolec P, Kostkiewicz M
Aims
The hybrid technique of single-photon emission tomography and computed tomography with technetium99m-hexamethylpropyleneamine oxime-labelled leucocytes (99mTc-HMPAO-SPECT/CT) is an emerging diagnostic technique in patients with cardiac device-related infective endocarditis (CDRIE). This prospective study assessed the 99mTc-HMPAO-SPECT/CT diagnostic profile and its added value to the modified Duke criteria (mDuke) in CDRIE diagnostic work-up.
Methods and results
The study examined 103 consecutive patients with suspected CDRIE, who underwent 99mTc-HMPAO-SPECT/CT. Diagnostic accuracy was calculated based on a final clinical CDRIE diagnosis, including microbiology, echocardiography, and a 6-month follow-up. Subsequently, we compared the diagnostic value of the initial mDuke classification with a classification including 99mTc-HMPAO-SPECT/CT positive results as an additional major CDRIE criterion: mDuke-SPECT/CT.Overall, CDRIE was diagnosed in 31 (31%) patients, whereas 35 (34%) 99mTc-HMPAO-SPECT/CT were positive. 99mTc-HMPAO-SPECT/CT was characterized by 86% accuracy, 0.69 Cohen\'s kappa coefficient, 84% sensitivity, 88% specificity, 93% negative, and 74% positive predictive values. The original mDuke displayed 83% accuracy, 0.52 kappa, whereas mDuke-SPECT/CT had 88% accuracy, and 0.73 kappa. Compared with mDuke, mDuke-SPECT/CT showed significantly higher sensitivity (87% vs. 48%, P < 0.001). According to mDuke, 49.5% of patients had possible CDRIE, and after reclassification, that figure dropped to 37%. Furthermore, having assessed the diagnosis categorization improvement following the incorporation of 99mTc-HMPAO-SPECT/CT, the net reclassification index value was found to be 31.4%.
Conclusion
In patients with CDRIE, 99mTc-HMPAO-SPECT/CT provides high diagnostic accuracy, whereas a negative scan excludes CDRIE with high probability. Inclusion of 99mTc-HMPAO-SPECT/CT into mDuke diagnostic criteria yields significantly higher sensitivity and a reduction in possible CDRIE diagnoses.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 10 Oct 2019; epub ahead of print
Holcman K, Małecka B, Rubiś P, Ząbek A, ... Podolec P, Kostkiewicz M
Eur Heart J Cardiovasc Imaging: 10 Oct 2019; epub ahead of print | PMID: 31605137
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Impact:
Abstract

Use of echocardiography to stratify the risk of atrial fibrillation: comparison of left atrial and ventricular strain.

Kawakami H, Ramkumar S, Pathan F, Wright L, Marwick TH
Aims
Although both left atrial (LA) and ventricular (LV) dysfunction has been accepted as an important risk factor of atrial fibrillation (AF), usefulness of LA and LV strain has not been fully compared for prediction of AF. The aims of this study were to clarify the associations of both LA and LV strain with AF and to compare their predictive values in the risk stratification for AF.
Methods and results
We evaluated 531 consecutive patients (median age 67 years, 56% male), with no history of AF who underwent echocardiography after cryptogenic stroke. Standard echocardiographic parameters were measured, and speckle-tracking was used to measure LA (reservoir, pump, and conduit strain) and LV strain (global longitudinal strain, GLS). The baseline clinical and echocardiographic parameters of the patients who developed AF and those who did not were compared. Median 36 months of follow-up, 61 patients (11%) had newly diagnosed AF. LA pump strain and GLS were significantly and independently associated with AF and provided incremental predictive value over clinical and standard echocardiographic parameters. Areas under the receiver-operating curves for GLS (0.841) were comparable to LA pump (0.825) and reservoir (0.851) strain. However, predictive value of both strains was different between patients with and without LA enlargement at the time of transthoracic echocardiography screening. LA strain was more useful than LV strain in patients with normal LA volumes, while LV strain was more useful than LA strain in patients with abnormal LA volumes.
Conclusion
Both LA and LV strain are significantly and independently associated with AF and provide incremental predictive value over clinical and standard echocardiographic parameters. However, priorities of strain assessment are different depends on patients\' condition at the time of echocardiography.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print
Kawakami H, Ramkumar S, Pathan F, Wright L, Marwick TH
Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print | PMID: 31578558
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Impact:
Abstract

Usefulness of myocardial work measurement in the assessment of left ventricular systolic reserve response to spironolactone in heart failure with preserved ejection fraction.

Przewlocka-Kosmala M, Marwick TH, Mysiak A, Kosowski W, Kosmala W
Aims
Improvement in left ventricular (LV) systolic reserve, including exertional increase in global longitudinal strain (GLS), may contribute to the clinical benefit from therapeutic interventions in heart failure with preserved ejection fraction (HFpEF). However, GLS is an afterload-dependent parameter, and its measurements may not adequately reflect myocardial contractility recruitment with exercise. The estimation of myocardial work (MW) allows correction of GLS for changing afterload. We sought to investigate the associations of GLS and MW parameters with the response of exercise capacity to spironolactone in HFpEF.
Methods and results
We analysed 114 patients (67 ± 8 years) participating in the STRUCTURE study (57 randomized to spironolactone and 57 to placebo). Resting and immediately post-exercise echocardiograms were performed at baseline and at 6-month follow-up. The following indices of MW were assessed: global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency. The amelioration of exercise intolerance at follow-up in the spironolactone group was accompanied by a significant improvement in exertional increase in GCW (P = 0.002) but not in GLS and other MW parameters. Increase in exercise capacity at 6 months was independently correlated with change in exertional increase in GCW from baseline to follow-up (β = 0.24; P = 0.009) but not with GLS (P = 0.14); however, no significant interaction with the use of spironolactone on peak VO2 was found (P = 0.97).
Conclusion
GCW as a measure of LV contractile response to exertion is a better determinant of exercise capacity in HFpEF than GLS. Improvement in functional capacity during follow-up is associated with improvement in exertional increment of GCW.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1138-1146
Przewlocka-Kosmala M, Marwick TH, Mysiak A, Kosowski W, Kosmala W
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1138-1146 | PMID: 31502637
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Impact:
Abstract

Carotid arterial stiffness is increased and related to left ventricular function in patients with hypertrophic cardiomyopathy.

Roşca M, Mandeş L, Ciupercă D, Călin A, ... Ginghină C, Popescu BA
Aims
To assess the carotid mechanical properties in patients with hypertrophic cardiomyopathy and the relation between arterial stiffness and left ventricular function in this setting.
Methods and results
We have prospectively enrolled 71 patients (52 ± 16 years, 34 men) with hypertrophic cardiomyopathy, divided into two groups depending on the presence (46 patients) or absence (25 patients) of cardiovascular risk factors associated with increased arterial stiffness. Twenty-five normal subjects similar by age and gender with hypertrophic cardiomyopathy patients without risk factors formed the control group. A comprehensive echocardiography was performed in all subjects. Carotid arterial stiffness index (β index), pressure-strain elastic modulus, arterial compliance, and pulse wave velocity were also obtained using an echo-tracking system. β index, pulse wave velocity, and pressure-strain elastic modulus were significantly higher in hypertrophic cardiomyopathy patients without risk factors compared to controls. After linear regression analysis, the increase in carotid β index was independently correlated with the presence of hypertrophic cardiomyopathy [beta = 0.49, 95% confidence interval (CI) = 1.04-3.02; P < 0.001]. In the entire hypertrophic cardiomyopathy population arterial stiffness parameters correlated with age, gender, hypertension degree, presence of hypercholesterolaemia, and the E/e\' ratio. In multivariable analysis, β index (beta = 0.36, 95% CI = 0.32-1.25; P = 0.001), global left ventricular longitudinal strain, and the presence of left ventricular outflow tract obstruction were independently correlated with the E/e\' ratio.
Conclusion
In patients with hypertrophic cardiomyopathy arterial stiffness is increased independently of age or presence of cardiovascular risk factors. Carotid artery stiffness is independently related to left ventricular filling pressure, increased arterial stiffness representing a possible marker of a more severe phenotype.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print
Roşca M, Mandeş L, Ciupercă D, Călin A, ... Ginghină C, Popescu BA
Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print | PMID: 31580440
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Impact:
Abstract

Right ventricular systolic dysfunction but not dilatation correlates with prognostically significant reductions in exercise capacity in repaired Tetralogy of Fallot.

Rashid I, Mahmood A, Ismail TF, O\'Meagher S, ... Celermajer D, Puranik R
Aims
The optimal timing for pulmonary valve replacement in asymptomatic patients with repaired Tetralogy of Fallot (rTOF) and pulmonary regurgitation remains uncertain but is often guided by increases in right ventricular (RV) end-diastolic volume. As cardiopulmonary exercise testing (CPET) performance is a strong prognostic indicator, we assessed which cardiovascular magnetic resonance (CMR) parameters correlate with reductions in exercise capacity to potentially improve identification of high-risk patients.
Methods and results
In all, 163 patients with rTOF (mean age 24.5 ± 10.2 years) who had previously undergone CMR and standardized CPET protocols were included. The indexed right and left ventricular end-diastolic volumes (RVEDVi, LVEDVi), right and left ventricular ejection fractions (RVEF, LVEF), indexed RV stroke volume (RVSVi), and pulmonary regurgitant fraction (PRF) were quantified by CMR and correlated with CPET-determined peak oxygen consumption (VO2) or peak work. On univariable analysis, there was no significant correlation between RVEDVi and PRF with peak VO2 or peak work (% Jones-predicted). In contrast, RVEF and RVSVi had significant correlations with both peak VO2 and peak work that remained significant on multivariable analysis. For a previously established prognostic peak VO2 threshold of <27 mL/kg/min, receiver-operating characteristic curve analysis demonstrated a Harrell\'s c of 0.70 for RVEF (95% confidence interval 0.61-0.79) with a sensitivity of 88% for RVEF <40%.
Conclusion
In rTOF, CMR indices of RV systolic function are better predictors of CPET performance than RV size. An RVEF <40% may be useful to identify prognostically significant reductions in exercise capacity in patients with varying degrees of RV dilatation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print
Rashid I, Mahmood A, Ismail TF, O'Meagher S, ... Celermajer D, Puranik R
Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print | PMID: 31578553
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Impact:
Abstract

Left ventricular remodelling and change in left ventricular global longitudinal strain after cardiac resynchronization therapy: prognostic implications.

van der Bijl P, Kostyukevich MV, Khidir M, Ajmone Marsan N, Delgado V, Bax JJ
Aims
Cardiac resynchronization therapy (CRT) can reduce left ventricular end-systolic volume (LVESV), and a decrease of ≥15% is defined as a response. CRT can also improve LV global longitudinal strain (GLS). Changes in LVESV and LV GLS are individually associated with outcome post-CRT. We investigated LVESV and LV GLS changes and prognostic implications of improvement in LVESV and/or LV GLS, compared with no improvement in either parameter.
Methods and results
Baseline and 6-month echocardiograms were analysed from CRT recipients with heart failure. LV reverse remodelling was defined as a ≥15% reduction in LVESV at 6 months post-CRT. A ≥5% absolute improvement in LV GLS was defined as a change in LV GLS. A total of 1185 patients were included (mean age 65 ± 10 years, 73% male), and those with an improvement in LVESV and LV GLS (n = 131, 11.1%) had significantly lower mortality compared with other groups. On multivariable analysis, an improvement in both LVESV and LV GLS [hazard ratio (HR): 0.47; 95% confidence interval (CI): 0.31-0.71; P < 0.001] or an improvement in either LVESV or LV GLS (HR: 0.57; 95% CI: 0.47-0.71; P < 0.001) were independently associated with better prognosis, compared with no improvement in either parameter.
Conclusion
Either a reduction in LVESV and/or an improvement in LV GLS at 6 months post-CRT are independently associated with improved long-term prognosis, compared with no change in both LVESV and LV GLS. This supports the use of LV GLS as a meaningful parameter in defining CRT response.

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Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1112-1119
van der Bijl P, Kostyukevich MV, Khidir M, Ajmone Marsan N, Delgado V, Bax JJ
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1112-1119 | PMID: 31329827
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Impact:
Abstract

Predictors of 18F-sodium fluoride uptake in patients with stable coronary artery disease and adverse plaque features on computed tomography angiography.

Kwiecinski J, Dey D, Cadet S, Lee SE, ... Slomka PJ, Berman DS
Aims
In patients with stable coronary artery disease (CAD) and high-risk plaques (HRPs) on coronary computed tomography angiography (CTA), we sought to define qualitative and quantitative CTA predictors of abnormal coronary 18F-sodium fluoride uptake (18F-NaF) by positron emission tomography (PET).
Methods and results
Patients undergoing coronary CTA were screened for HRP. Those who presented with ≥3 CTA adverse plaque features (APFs) including positive remodelling; low attenuation plaque (LAP, <30 HU), spotty calcification; obstructive coronary stenosis ≥50%; plaque volume >100 mm3 were recruited for 18F-NaF PET. In lesions with stenosis ≥25%, quantitative plaque analysis and maximum 18F-NaF target to background ratios (TBRs) were measured. Of 55 patients, 35 (64%) manifested coronary 18F-NaF uptake. Of 68 high-risk lesions 49 (70%) had increased PET tracer activity. Of the APFs, LAP had the highest sensitivity (39.4%) and specificity (98.3%) for predicting 18F-NaF uptake. TBR values were higher in lesions with LAP compared to those without [1.6 (1.3-1.8) vs. 1.1 (1.0-1.3), P = 0.01]. On adjusted multivariable regression analysis, LAP (both qualitative and quantitative) was independently associated with plaque TBR [LAP qualitative: β = 0.47, 95% confidence interval (CI) 0.30-0.65; P < 0.001] and (LAP volume: β = 0.20 per 10 mm3, 95% CI 0.13-0.27; P < 0.001).
Conclusion
In stable CAD patients with HRP, LAP is predictive of 18F-NaF coronary uptake, but 18F-NaF is often seen in the absence of LAP. If 18F-NaF uptake is shown to be associated with adverse outcomes and becomes clinically used, the presence of LAP may define patients who would not benefit from the added testing.

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Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:58-66
Kwiecinski J, Dey D, Cadet S, Lee SE, ... Slomka PJ, Berman DS
Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:58-66 | PMID: 31211387
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Impact:
Abstract

The impact of aortic valve replacement on survival in patients with normal flow low gradient severe aortic stenosis: a propensity-matched comparison.

Saeed S, Vamvakidou A, Seifert R, Khattar R, Li W, Senior R
Aims
To assess the survival benefit of aortic valve replacement (AVR) in patients with normal flow low gradient severe aortic stenosis (AS).
Methods and results
A retrospective study of prospectively collected data of 276 patients (mean age 75 ± 15 years, 51% male) with normal transaortic flow [flow rate (FR) ≥200 mL/s or stroke volume index (SVi) ≥35 mL/m2] and severe AS (aortic valve area <1.0 cm2). The outcome measure was all-cause mortality. Of the 276 patients, 151 (55%) were medically treated, while 125 (45%) underwent an AVR. Over a mean follow-up of 3.2 ± 1.8 years (range 0-6.9 years), a total of 96 (34.8%) deaths occurred: 17 (13.6%) in AVR group vs. 79 (52.3%) in those medically treated, when transaortic flow was defined by FR (P < 0.001). When transaortic flow was defined by SVi, a total of 79 (31.3%) deaths occurred: 18 (15.1%) in AVR group vs. 61 (45.9%) in medically treated (P < 0.001). In a propensity-matched multivariable Cox regression analysis adjusting for age, gender, body surface area, smoking, hypertension, diabetes mellitus, atrial fibrillation, peripheral vascular disease, chronic kidney disease, left ventricular ejection fraction, left ventricular mass, and mean aortic gradient, not having AVR was associated with a 6.3-fold higher hazard ratio (HR) of all-cause mortality [HR 6.28, 95% confidence interval (CI) 3.34-13.16; P < 0.001] when flow was defined by FR. In the SVi-guided model, it was 3.83-fold (HR 3.83, 95% CI 2.30-6.37; P < 0.001).
Conclusion
In patients with normal flow low gradient severe AS, AVR was associated with a significantly improved survival compared with those who received standard medical treatment.

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Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1094-1101
Saeed S, Vamvakidou A, Seifert R, Khattar R, Li W, Senior R
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1094-1101 | PMID: 31327014
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Impact:
Abstract

Mechanisms of mitral regurgitation after percutaneous mitral valve repair with the MitraClip.

Ikenaga H, Makar M, Rader F, Siegel RJ, ... Makkar RR, Shiota T
Aims
We sought to find the morphological mechanisms of recurrent mitral regurgitation (MR) after MitraClip procedure using 3D transoesophageal echocardiography (TOE).
Methods and results
Of 478 consecutive patients treated with the initial MitraClip procedure, 41 patients who underwent repeat mitral valve (MV) transcatheter or surgical intervention for recurrent MR were retrospectively reviewed. Using 3D-TOE, we investigated morphological changes of MV leading to repeat MV intervention. Aetiology of MR at the index intervention was primary in 24 (59%) and secondary in 17 (41%) patients. In the primary MR group, worsening leaflet prolapse at the clip site caused recurrent MR in 12 (50%) patients, while 7 (29%) patients had a leaflet tear at the clip site. Acute single leaflet device detachment was seen in four patients and one patient had recurrent MR between the plug and the clip. In secondary MR, left ventricular (LV)/left atrial dilation caused recurrent MR in 13 (76%) patients. Significant increase in the LV end-diastolic volume and tenting height were observed from post-index procedure to repeat intervention (LV end-diastolic volume; from 205 to 237 ml, P < 0.001, tenting height; from 0.8 to 1.3 cm, P < 0.001). New emergent leaflet prolapse/flail was seen in 3 (18%) patients, suggesting iatrogenic MR.
Conclusion
Mechanisms of recurrent MR after MitraClip procedure varied and depended on the underlying MV pathology: in primary MR, worsening mitral leaflet prolapse and in secondary MR, progressive LV dilation with worsening tenting were the main causes of recurrent MR.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 11 Oct 2019; epub ahead of print
Ikenaga H, Makar M, Rader F, Siegel RJ, ... Makkar RR, Shiota T
Eur Heart J Cardiovasc Imaging: 11 Oct 2019; epub ahead of print | PMID: 31605479
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Impact:
Abstract

Prognostic value of right ventricular free wall longitudinal strain in a large cohort of outpatients with left-side heart disease.

Gavazzoni M, Badano LP, Vizzardi E, Raddino R, ... Metra M, Muraru D
Aims
Right ventricular free wall longitudinal strain (RVFWLS) has been proposed as an accurate and sensitive measure of right ventricular function that could integrate other conventional parameters such as tricuspid annulus plane systolic excursion (TAPSE) and fractional area change (FAC%). The aim of the present study was to evaluate the relationship between RVFWLS and outcomes in stable asymptomatic outpatients with left-sided structural heart disease.
Methods and results
We enrolled 458 asymptomatic patients with left-side heart diseases and any ejection fraction who were referred for echocardiography to two Italian centres. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome of this analysis. After a mean follow-up of 5.4 ± 1.2 years, 145 patients (31%) reached the combined endpoint. Most of echocardiographic parameters were related to outcomes, including right ventricular functional parameters. Mean value of RVFWLS in our cohort was -21 ± 8% and it was significantly related to the combined endpoint and in multivariable Cox-regression model; when tested with other echocardiographic parameters that were significantly related to outcome at univariate analysis, RVFWLS maintained its independent association with outcome (hazard ratio 0.963, 95% confidence interval 0.948-0.978; P = 0.0001). The best cut-off value of RVFWLS to predict outcome was -22% (area under the curve 0.677; P < 0.001; sensitivity 70%; 65% specificity).
Conclusion
RVFWLS may help clinicians to identify patients with left-sided structural heart disease at higher risk for first heart failure hospitalization and death for any cause.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 08 Oct 2019; epub ahead of print
Gavazzoni M, Badano LP, Vizzardi E, Raddino R, ... Metra M, Muraru D
Eur Heart J Cardiovasc Imaging: 08 Oct 2019; epub ahead of print | PMID: 31596464
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Impact:
Abstract

Time course of left ventricular remodelling and mechanics after aortic valve surgery: aortic stenosis vs. aortic regurgitation.

Vollema EM, Singh GK, Prihadi EA, Regeer MV, ... Bax JJ, Delgado V
Aims
Pressure overload in aortic stenosis (AS) and both pressure and volume overload in aortic regurgitation (AR) induce concentric and eccentric hypertrophy, respectively. These structural changes influence left ventricular (LV) mechanics, but little is known about the time course of LV remodelling and mechanics after aortic valve surgery (AVR) and its differences in AS vs. AR. The present study aimed to characterize the time course of LV mass index (LVMI) and LV mechanics [by LV global longitudinal strain (LV GLS)] after AVR in AS vs. AR.
Methods and results
Two hundred and eleven (61 ± 14 years, 61% male) patients with severe AS (63%) or AR (37%) undergoing surgical AVR with routine echocardiographic follow-up at 1, 2, and/or 5 years were evaluated. Before AVR, LVMI was larger in AR patients compared with AS. Both groups showed moderately impaired LV GLS, but preserved LV ejection fraction. After surgery, both groups showed LV mass regression, although a more pronounced decline was seen in AR patients. Improvement in LV GLS was observed in both groups, but characterized by an initial decline in AR patients while LV GLS in AS patients remained initially stable.
Conclusion
In severe AS and AR patients undergoing AVR, LV mass regression and changes in LV GLS are similar despite different LV remodelling before AVR. In AR, relief of volume overload led to reduction in LVMI and an initial decline in LV GLS. In contrast, relief of pressure overload in AS was characterized by a stable LV GLS and more sustained LV mass regression.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1105-1111
Vollema EM, Singh GK, Prihadi EA, Regeer MV, ... Bax JJ, Delgado V
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1105-1111 | PMID: 30932153
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Impact:
Abstract

Longitudinal patterns of N-terminal pro B-type natriuretic peptide, troponin T, and C-reactive protein in relation to the dynamics of echocardiographic parameters in heart failure patients.

Klimczak-Tomaniak D, van den Berg VJ, Strachinaru M, Akkerhuis KM, ... van Dalen BM, Kardys I
Aims
To further elucidate the nature of the association between N-terminal pro-B type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-TnT), C-reactive protein (CRP), and clinical outcome, we examined the relationship between serial simultaneous measurements of echocardiographic parameters and these biomarkers in chronic heart failure (CHF) patients.
Methods and results
In 117 CHF patients with ejection fraction ≤50%, NT-proBNP, hs-TnT, and CRP were measured simultaneously with echocardiographic evaluation at 6-month intervals until the end of 30 months follow-up or until an adverse clinical event occurred. Linear mixed effects models were used for data-analysis. Median follow-up was 2.2 years (interquartile range 1.5-2.6). We performed up to six follow-up evaluations with 55% of patients having at least three evaluations performed. A model containing all three biomarkers revealed that doubling of NT-proBNP was associated with a decrease in left ventricular ejection fraction by 1.83 (95% confidence interval -2.63 to -1.03)%, P < 0.0001; relative increase in mitral E/e\' ratio by 12 (6-18)%, P < 0.0001; relative increase in mitral E/A ratio by 16 (9-23)%, P < 0.0001; decrease in tricuspid annular plane systolic excursion by 0.66 (-1.27 to -0.05) mm, P = 0.03; rise in tricuspid regurgitation peak systolic gradient by 2.74 (1.43-4.05) mmHg, P = 0.001; and increase in left ventricular and atrial dimensions, P < 0.05. Hs-TnT and CRP showed significant associations with some echocardiographic parameters after adjustment for clinical covariates, but after adjustment for the other biomarkers the associations were not significant.
Conclusion
Serum NT-proBNP independently reflects changes in echocardiographic parameters of systolic function, left ventricular filling pressures, estimated pulmonary pressure, and chamber dimensions. Our results support further studies on NT-proBNP as a surrogate marker for haemodynamic congestion and herewith support its potential value for therapy guidance.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 08 Oct 2019; epub ahead of print
Klimczak-Tomaniak D, van den Berg VJ, Strachinaru M, Akkerhuis KM, ... van Dalen BM, Kardys I
Eur Heart J Cardiovasc Imaging: 08 Oct 2019; epub ahead of print | PMID: 31596459
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Impact:
Abstract

Prognostic value of ratio of transmitral early filling velocity to early diastolic strain rate in patients with Type 2 diabetes.

Lassen MCH, Jensen MT, Biering-Sørensen T, Møgelvang R, ... Rossing P, Jørgensen PG
Aims
The ratio of early mitral inflow velocity to global diastolic strain rate (E/e\'sr) has recently emerged as a novel measure of left ventricular filling pressure. E/e\'sr has in previous studies demonstrated to have good prognostic value in various patient populations. The aim of this study is to investigate the prognostic value of E/e\'sr in a large cohort of patients with Type 2 diabetes in relation to cardiovascular morbidity and mortality.
Methods and results
In this prospective study, 848 Type 2 diabetic patients (mean age 63.6 ± 10.3 years, 64.7% male) underwent comprehensive echocardiographic examination including 2D speckle tracking in which E/e\'sr along with novel and conventional echocardiographic variables were obtained. During follow-up (median: 4.8 years, interquartile range: 4.0-5.3), 122 (14.1%) met the composite outcome of cardiovascular disease, hospitalization, and mortality. Both E/e\'sr and E/e\' were significantly associated with the outcome [E/e\'sr: hazard ratio (HR) 1.07, 95% confidence interval (CI): 1.05-1.10; P < 0.001, per 0.10 m increase] and (E/e\': HR 1.07, 95% CI: 1.05-1.10; P = 0.001, per 1 unit increase). E/e\'sr remained an independent predictor after multivariable adjustment for demographical, clinical, and echocardiographic parameters (HR 1.06, 95% CI: 1.01-1.12; P = 0.032, per 10 cm increase). The same was true for E/e\' (HR 1.09, 95% CI: 1.04-1.14; P < 0.001, per 1 unit increase). Additionally, E/e\'sr provided incremental prognostic information beyond the UK \'Prospective Diabetes Study risk engine\' 0.72 (0.68-0.77) vs. 0.74 (0.70-79), P = 0.040.
Conclusion
In patients with Type 2 diabetes, E/e\'sr provides independent and incremental prognostic information regarding cardiovascular morbidity and mortality.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1171-1178
Lassen MCH, Jensen MT, Biering-Sørensen T, Møgelvang R, ... Rossing P, Jørgensen PG
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1171-1178 | PMID: 31329838
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Impact:
Abstract

Aortic growth rates are not increased in Turner syndrome-a prospective CMR study.

Mortensen KH, Wen J, Erlandsen M, Trolle C, ... Andersen NH, Gravholt CH
Background
Aortic disease is a key determinant of outcomes in Turner syndrome (TS). The present study characterized aortic growth rates and outcomes over nearly a decade in adult women with TS.
Methods and results
Prospective observational study assessing aortic diameters twice with cardiovascular magnetic resonance imaging in women with TS [N = 91; mean follow-up 8.8 ± 3.3 (range 1.6-12.6) years] and healthy age-matched female controls [N = 37; mean follow-up 6.7 ± 0.5 (range 5.9-8.1) years]. Follow-up also included aortic outcomes and mortality, antihypertensive treatment and ambulatory blood pressure. Aortic growth rates were similar or smaller in TS, but the variation was larger. The proximal aorta in TS grew by 0.20 ± 0.26 (mid-ascending) to 0.32 ± 0.36 (sinuses) mm/year. This compared to 0.26 ± 0.14 (mid-ascending) and 0.32 ± 0.17 (sinuses) mm/year in the controls. During 799 years at risk, 7 suffered an aortic outcome (1 aortic death, 2 aortic dissections, 2 aortic interventions, 2 surgical aortic listings) with further 2 aortic valve replacements. At baseline, two women were excluded. One died during subacute aortic surgery (severe dilatation) and one had a previously undetected type A dissection. The combined aortic outcome rate was 1126 per 100 000 observation years. The aortic and all-cause mortality rates were 1 per 799 years (125 deaths per 100 000 observation years) and 9 per 799 years (1126 deaths per 100 000 observation years). Aortic growth patterns were particularly perturbed in bicuspid aortic valves (BAV) and aortic coarctation (CoA).
Conclusion
Aortic growth rates in TS are not increased. BAVs and CoA are major factors that impact aortic growth. Aortic outcomes remain a concern.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1164-1170
Mortensen KH, Wen J, Erlandsen M, Trolle C, ... Andersen NH, Gravholt CH
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1164-1170 | PMID: 31329837
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Impact:
Abstract

Clinical utility of the 2016 ASE/EACVI recommendations for the evaluation of left ventricular diastolic function in the stratification of post-discharge prognosis in patients with acute heart failure.

Machino-Ohtsuka T, Seo Y, Ishizu T, Hamada-Harimura Y, ... Aonuma K, Ieda M
Aims
Left ventricular diastolic dysfunction (LVDD) has prognostic significance in heart failure (HF). We aimed to assess the impact of LVDD grade stratified by the updated 2016 echocardiographic algorithm (DD2016) on post-discharge outcomes in patients admitted for acute HF and compare with the previous 2009 algorithm (DD2009).
Methods and results
The study included 481 patients hospitalized for acute decompensated HF. Comprehensive echocardiography and LVDD evaluation were performed just before hospital discharge. The primary endpoint was a composite of cardiovascular death and readmission for HF. The concordance between DD2016 and DD2009 was moderate (κ = 0.44, P < 0.001); the reclassification rate was 39%. During the follow-up (median: 15 months), 127 (26%) patients experienced the primary endpoint. In the Kaplan-Meier analysis, Grade III in DD2016 showed a lower event-free survival rate than Grades I and II (log rank, P < 0.001 and P = 0.048, respectively) and was independently associated with a higher incidence of the primary endpoint than Grade I [hazard ratio 1.89; 95% confidence interval (CI) 1.17-3.04; P = 0.009]. Grade II or III in DD2016, reflecting elevation of left ventricular (LV) filling pressure, added an incremental predictive value of the primary endpoint to clinical variables irrespective of LV ejection fraction. DD2016 was comparable to DD2009 in predicting the endpoint (net reclassification improvement = 11%; 95% CI -7% to 30%, P = 0.23).
Conclusion
Despite simplification of the algorithm for LVDD evaluation, the prognostic value of DD2016 for post-discharge cardiovascular events in HF patients was maintained and not compromised in comparison with DD2009.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1129-1137
Machino-Ohtsuka T, Seo Y, Ishizu T, Hamada-Harimura Y, ... Aonuma K, Ieda M
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1129-1137 | PMID: 31074794
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Impact:
Abstract

Right ventricular strain rate during exercise accurately identifies male athletes with right ventricular arrhythmias.

Claeys M, Claessen G, Claus P, De Bosscher R, ... Heidbuchel H, La Gerche A
Aims
Athletes with right ventricular (RV) arrhythmias, even in the absence of desmosomal mutations, may have subtle RV abnormalities which can be unmasked by deformation imaging. As exercise places a disproportionate stress on the right ventricle, evaluation of cardiac function and deformation during exercise might improve diagnostic performance.
Methods and results
We performed bicycle stress echocardiography in 17 apparently healthy endurance athletes (EAs), 12 non-athletic controls (NAs), and 17 athletes with RV arrhythmias without desmosomal mutations (EI-ARVCs) and compared biventricular function at rest and during low (25% of upright peak power) and moderate intensity (60%). At rest, we observed no differences in left ventricular (LV) or RV function between groups. During exercise, however, the increase in RV fractional area change (RVFAC), RV free wall strain (RVFWSL), and strain rate (RVFWSRL) were significantly attenuated in EI-ARVCs as compared to EAs and NAs. At moderate exercise intensity, EI-ARVCs had a lower RVFAC, RVFWSL, and RVFWSRL (all P < 0.01) compared to the control groups. Exercise-related increases in LV ejection fraction, strain, and strain rate were also attenuated in EI-ARVCs (P < 0.05 for interaction). Exercise but not resting parameters identified EI-ARVCs and RVFWSRL with a cut-off value of >-2.35 at moderate exercise intensity had the greatest accuracy to detect EI-ARVCs (area under the curve 0.95).
Conclusion
Exercise deformation imaging holds promise as a non-invasive diagnostic tool to identify intrinsic RV dysfunction concealed at rest. Strain rate appears to be the most accurate parameter and should be incorporated in future, prospective studies to identify subclinical disease in an early stage.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print
Claeys M, Claessen G, Claus P, De Bosscher R, ... Heidbuchel H, La Gerche A
Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print | PMID: 31578557
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Impact:
Abstract

Clinical impact of native T1 mapping for detecting myocardial impairment in takotsubo cardiomyopathy.

Aikawa Y, Noguchi T, Morita Y, Tateishi E, ... Fukuda T, Yasuda S
Aims
To investigate the clinical impact of T1 mapping for detecting myocardial impairment in takotsubo cardiomyopathy (TTC) over time.
Methods and results
In 23 patients with the apical ballooning type of TTC, the following 3T magnetic resonance (MR) examinations were performed at baseline and 3 months after TTC onset: T2-weighted imaging, T2 mapping, native T1 mapping, extracellular volume fraction (ECV), and late gadolinium enhancement. Eight healthy controls underwent the same MR examinations. Serial echocardiography was performed daily for ≥7 days and monthly until 3 months after onset. The median time from onset to MR examination was 7 days. During the acute phase, patients had, relative to controls, higher native T1 (1438 ± 162 vs. 1251 ± 90 ms, P < 0.001), ECV (35 ± 5% vs. 29 ± 4%, P < 0.001), and T2 (90 ± 34 vs. 68 ± 12 ms, P < 0.001) for the entire heart. Per-region analysis showed that higher native T1 and T2 in the basal region were correlated with lower left ventricular ejection fraction (r = -0.599, P = 0.004 and r = -0.598, P = 0.003, respectively). Receiver operator characteristic analysis showed that the area under the curve for native T1 (0.96) was significantly larger than that for T2 (0.86; P = 0.005) but similar to that for ECV (0.92; P = 0.104). At 3-month follow-up, native T1, ECV, and T2 in the apical region remained significantly elevated in all patients with TTC. The number of left ventricular (LV) segments with elevated native T1 (cut-off value 1339 ms) was significantly correlated with prolonged LV wall motion recovery time (r = 0.494, P = 0.027).
Conclusion
Characterization of myocardium with native T1 mapping is a promising method for predicting LV wall motion restoration in TTC.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1147-1155
Aikawa Y, Noguchi T, Morita Y, Tateishi E, ... Fukuda T, Yasuda S
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1147-1155 | PMID: 30879048
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Impact:
Abstract

Long-term prognostic value of morphological plaque features on coronary computed tomography angiography.

Finck T, Stojanovic A, Will A, Hendrich E, ... Hausleiter J, Hadamitzky M
Aims
To investigate the incremental prognostic value of morphological plaque features beyond clinical risk and coronary stenosis levels. Although associated with the degree of coronary stenosis, most cardiac events occur on the basis of ruptured non-obstructive plaques and consecutive vessel thrombosis. As such, identification of vulnerable plaques is paramount for cardiovascular risk prediction and treatment decisions.
Methods and results
A total of 1615 patients with suspected but not previously diagnosed coronary artery disease (CAD) were examined by coronary computed tomography angiography and morphological plaque features were assessed. Mean follow-up was 10.5 (interquartile range 9.2-11.4) years. Cox proportional hazards analysis was used for the composite endpoint of cardiac death and non-fatal myocardial infarction. The study endpoint was reached in 51 patients (36 cardiac deaths, 15 non-fatal myocardial infarctions). In addition to quantitative parameters (presence of any calcified/non-calcified plaque or elevated plaque load), morphologic plaque features such as a spotty or gross calcification pattern and napkin-ring sign (NRS) were predictive for events. However, only spotty calcified plaques and NRS could confer additive prognostic value beyond clinical risk and coronary stenosis level. In a stepwise approach, endpoint prediction beyond clinical risk (Morise score) could be improved by inclusion of CAD severity (χ2 of 27.5, P < 0.001) and further discrimination for spotty calcified plaques (χ2 of 3.89, P = 0.049).
Conclusion
Improved cardiovascular risk prediction beyond clinical risk and coronary stenosis levels can be made by discriminating for the presence of spotty calcified plaques. Thus, an intensified prophylactic anti-atherosclerotic treatment appears to be warranted in patients with coronary plaques that show spotty calcifications.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print
Finck T, Stojanovic A, Will A, Hendrich E, ... Hausleiter J, Hadamitzky M
Eur Heart J Cardiovasc Imaging: 02 Oct 2019; epub ahead of print | PMID: 31578556
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Impact:
Abstract

Multimodality imaging in the diagnosis, risk stratification, and management of patients with dilated cardiomyopathies: an expert consensus document from the European Association of Cardiovascular Imaging.

Donal E, Delgado V, Bucciarelli-Ducci C, Galli E, ... Popescu BA,

Dilated cardiomyopathy (DCM) is defined by the presence of left ventricular or biventricular dilatation and systolic dysfunction in the absence of abnormal loading conditions or coronary artery disease sufficient to explain these changes. This is a heterogeneous disease frequently having a genetic background. Imaging is important for the diagnosis, the prognostic assessment and for guiding therapy. A multimodality imaging approach provides a comprehensive evaluation of all the issues related to this disease. The present document aims to provide recommendations for the use of multimodality imaging according to the clinical question. Selection of one or another imaging technique should be based on the clinical condition and context. Techniques are presented with the aim to underscore what is \'clinically relevant\' and what are the tools that \'can be used\'. There remain some gaps in evidence on the impact of multimodality imaging on the management and the treatment of DCM patients where ongoing research is important.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1075-1093
Donal E, Delgado V, Bucciarelli-Ducci C, Galli E, ... Popescu BA,
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1075-1093 | PMID: 31504368
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Impact:
Abstract

Assessment of left ventricular outflow tract and aortic root: comparison of 2D and 3D transthoracic echocardiography with multidetector computed tomography.

Visby L, Kristensen CB, Pedersen FHG, Sigvardsen PE, ... Hassager C, Møgelvang R
Aims
Accurate echocardiographic assessment of left ventricular outflow tract (LVOT) and the aortic root is necessary for risk stratification and choice of appropriate treatment in patients with pathologies of the aortic valve and aortic root. Conventional 2D transthoracic echocardiographic (TTE) assessment is based on the assumption of a circular shaped LVOT and aortic root, although previous studies have indicated a more ellipsoid shape. 3D TTE and multidetector computed tomography (MDCT) applies planimetry and are not dependent on geometrical assumptions. The aim was to test accuracy, feasibility, and reproducibility of 3D TTE compared to 2D TTE assessment of LVOT and aortic root areas, with MDCT as reference.
Methods and results
We examined 51 patients with 2D/3D TTE and MDCT at the same day. All patients were re-examined with 2D/3D TTE on a different day to evaluate 2D and 3D re-test variability. Areas of LVOT, aortic annulus, and sinus were assessed using 2D, 3D TTE, and MDCT. Both 2D/3D TTE underestimated the areas compared to MDCT; however, 3D TTE areas were significantly closer to MDCT-areas. 2D vs. 3D mean MDCT-differences: LVOT 1.61 vs. 1.15 cm2, P = 0.019; aortic annulus 1.96 vs. 1.06 cm2, P < 0.001; aortic sinus 1.66 vs. 1.08 cm2, P = 0.015. Feasibility was 3D 76-79% and 2D 88-90%. LVOT and aortic annulus areas by 3D TTE had lowest variabilities; intraobserver coefficient of variation (CV) 9%, re-test variation CV 18-20%.
Conclusion
Estimation of LVOT and aortic root areas using 3D TTE is feasible, more precise and more accurate than 2D TTE.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1156-1163
Visby L, Kristensen CB, Pedersen FHG, Sigvardsen PE, ... Hassager C, Møgelvang R
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1156-1163 | PMID: 30879047
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Impact:
Abstract

Deterioration of biventricular strain is an early marker of cardiac involvement in confirmed sarcoidosis.

Kusunose K, Fujiwara M, Yamada H, Nishio S, ... Wakatsuki T, Sata M
Aims
Risk assessment of developing cardiac involvement in systemic sarcoidosis can be challenging because of limited data. Recently, attention has been given to left ventricular and right ventricular (LV and RV) involvement in cardiac sarcoidosis (CS) and its prevalence, relevance, and prognostic value. The aim of this study was to assess the role of biventricular strain to predict prognosis in confirmed sarcoidosis patients.
Methods and results
LV and RV longitudinal strains (LSs) were evaluated by 2D speckle tracking in 139 consecutive confirmed sarcoidosis patients without other pre-existing structural heart diseases, and 52 age- and gender-matched control subjects. The primary endpoint was CS-related events (cardiac death or development of cardiac involvement). Sarcoidosis without cardiac involvement had significantly lower LV and RV free wall LS compared with control subjects. Basal LS had a higher area under the curve for differentiation of sarcoidosis in patients without cardiac involvement compared to control (cut-off value: -18% with 89% sensitivity and 69% specificity). During a median period of 50 months, the occurrence of CS-related events was observed in 20 patients. In a multivariate analysis, basal LV LS and RV free wall LS were associated with the events [hazard ratio (HR) 0.72, P < 0.001 and HR: 0.83, P = 0.006, respectively]. Patients with impaired biventricular function had significantly shorter event-free survival than those with preserved biventricular function (P < 0.001).
Conclusion
Deterioration of biventricular strain was associated with CS-related events. This information might be useful for clinical evaluation and follow-up in sarcoidosis.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 29 Sep 2019; epub ahead of print
Kusunose K, Fujiwara M, Yamada H, Nishio S, ... Wakatsuki T, Sata M
Eur Heart J Cardiovasc Imaging: 29 Sep 2019; epub ahead of print | PMID: 31566217
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Impact:
Abstract

Cardiovascular risk scoring and magnetic resonance imaging detected subclinical cerebrovascular disease.

Anand SS, Tu JV, Desai D, Awadalla P, ... Friedrich MG,
Aims
Cardiovascular risk factors are used for risk stratification in primary prevention. We sought to determine if simple cardiac risk scores are associated with magnetic resonance imaging (MRI)-detected subclinical cerebrovascular disease including carotid wall volume (CWV), carotid intraplaque haemorrhage (IPH), and silent brain infarction (SBI).
Methods and results
A total of 7594 adults with no history of cardiovascular disease (CVD) underwent risk factor assessment and a non-contrast enhanced MRI of the carotid arteries and brain using a standardized protocol in a population-based cohort recruited between 2014 and 2018. The non-lab-based INTERHEART risk score (IHRS) was calculated in all participants; the Framingham Risk Score was calculated in a subset who provided blood samples (n = 3889). The association between these risk scores and MRI measures of CWV, carotid IPH, and SBI was determined. The mean age of the cohort was 58 (8.9) years, 55% were women. Each 5-point increase (∼1 SD) in the IHRS was associated with a 9 mm3 increase in CWV, adjusted for sex (P < 0.0001), a 23% increase in IPH [95% confidence interval (CI) 9-38%], and a 32% (95% CI 20-45%) increase in SBI. These associations were consistent for lacunar and non-lacunar brain infarction. The Framingham Risk Score was also significantly associated with CWV, IPH, and SBI. CWV was additive and independent to the risk scores in its association with IPH and SBI.
Conclusion
Simple cardiovascular risk scores are significantly associated with the presence of MRI-detected subclinical cerebrovascular disease, including CWV, IPH, and SBI in an adult population without known clinical CVD.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 29 Sep 2019; epub ahead of print
Anand SS, Tu JV, Desai D, Awadalla P, ... Friedrich MG,
Eur Heart J Cardiovasc Imaging: 29 Sep 2019; epub ahead of print | PMID: 31565735
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Impact:
Abstract

Left atrial strain: a multi-modality, multi-vendor comparison study.

Pathan F, Zainal Abidin HA, Vo QH, Zhou H, ... Marwick TH, Nagel E
Aims
Left atrial (LA) strain is a prognostic biomarker with utility across a spectrum of acute and chronic cardiovascular pathologies. There are limited data on intervendor differences and no data on intermodality differences for LA strain. We sought to compare the intervendor and intermodality differences between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) derived LA strain. We hypothesized that various components of atrial strain would show good intervendor and intermodality correlation but that there would be systematic differences between vendors and modalities.
Methods and results
We evaluated 54 subjects (43 patients with a clinical indication for CMR and 11 healthy volunteers) in a study comparing TTE- and CMR-derived LA reservoir strain (ƐR), conduit strain (ƐCD), and contractile strain (ƐCT). The LA strain components were evaluated using four dedicated types of post-processing software. We evaluated the correlation and systematic bias between modalities and within each modality. Intervendor and intermodality correlation was: ƐR [intraclass correlation coefficient (ICC 0.64-0.90)], ƐCD (ICC 0.62-0.89), and ƐCT (ICC 0.58-0.77). There was evidence of systematic bias between vendors and modalities with mean differences ranging from (3.1-12.2%) for ƐR, ƐCD (1.6-8.6%), and ƐCT (0.3-3.6%). Reproducibility analysis revealed intraobserver coefficient of variance (COV) of 6.5-14.6% and interobserver COV of 9.9-18.7%.
Conclusion
Vendor derived ƐR, ƐCD, and ƐCT demonstrates modest to excellent intervendor and intermodality correlation depending on strain component examined. There are systematic differences in measurements depending on modality and vendor. These differences may be addressed by future studies, which, examine calibration of LA geometry/higher frame rate imaging, semi-quantitative approaches, and improvements in reproducibility.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 16 Dec 2019; epub ahead of print
Pathan F, Zainal Abidin HA, Vo QH, Zhou H, ... Marwick TH, Nagel E
Eur Heart J Cardiovasc Imaging: 16 Dec 2019; epub ahead of print | PMID: 31848575
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Impact:
Abstract

Derivation and validation of a mortality risk prediction model using global longitudinal strain in patients with acute heart failure.

Hwang IC, Cho GY, Choi HM, Yoon YE, ... Kim YJ, Sohn DW
Aims
To develop a mortality risk prediction model in patients with acute heart failure (AHF), using left ventricular (LV) function parameters with clinical factors.
Methods and results
In total, 4312 patients admitted for AHF were retrospectively identified from three tertiary centres, and echocardiographic parameters including LV ejection fraction (LV-EF) and LV global longitudinal strain (LV-GLS) were measured in a core laboratory. The full set of risk factors was available in 3248 patients. Using Cox proportional hazards model, we developed a mortality risk prediction model in 1859 patients from two centres (derivation cohort) and validated the model in 1389 patients from one centre (validation cohort). During 32 (interquartile range 13-54) months of follow-up, 1285 patients (39.6%) died. Significant predictors for mortality were age, diabetes, diastolic blood pressure, body mass index, natriuretic peptide, glomerular filtration rate, failure to prescribe beta-blockers, failure to prescribe renin-angiotensin system blockers, and LV-GLS; however, LV-EF was not a significant predictor. Final model including these predictors to estimate individual probabilities of mortality had C-statistics of 0.75 [95% confidence interval (CI) 0.73-0.78; P < 0.001] in the derivation cohort and 0.78 (95% CI 0.75-0.80; P < 0.001) in the validation cohort. The prediction model had good performance in both heart failure (HF) with reduced EF, HF with mid-range EF, and HF with preserved EF.
Conclusion
We developed a mortality risk prediction model for patients with AHF incorporating LV-GLS as the LV function parameter, and other clinical factors. Our model provides an accurate prediction of mortality and may provide reliable risk stratification in AHF patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 08 Dec 2019; epub ahead of print
Hwang IC, Cho GY, Choi HM, Yoon YE, ... Kim YJ, Sohn DW
Eur Heart J Cardiovasc Imaging: 08 Dec 2019; epub ahead of print | PMID: 31819981
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Impact:
Abstract

Echocardiographic features in antiphospholipid-negative Sneddon\'s syndrome and potential association with severity of neurological symptoms or recurrence of strokes: a longitudinal cohort study.

Assan F, de Zuttere D, Bottin L, Tavolaro S, ... Francès C, Chasset F
Aims
Sneddon\'s syndrome (SS) may be classified as antiphospholipid positive (aPL+) or negative (aPL- SS). An association between Libman-Sacks (LS) endocarditis and strokes has been described in aPL+ patients. To describe cardiac involvement in aPL- SS and assess the potential association between LS endocarditis and severity or recurrence of neurological symptoms.
Methods and results
This longitudinal cohort study included aPL- SS patients followed in our departments between 1991 and June 2018. All patients underwent transthoracic 2D and Doppler echocardiography at diagnosis. Follow-up echocardiography was performed annually and the potential relationship between LS endocarditis development and neurovascular relapse as well as long-term cardiac worsening was prospectively assessed. We included 61 patients [52 women; median age 45 (range 24-60)]. For valvular involvement, 36 (59%) patients showed leaflet thickening; 18 (29.5%) had LS endocarditis at baseline. During a median follow-up of 72 months, LS endocarditis developed in eight (17.4%) patients, and 13 (28.3%) showed significant worsening of their cardiac status, including two who needed valvular replacement. After adjusting for baseline antithrombotic treatment regimen, neither the presence of LS endocarditis at baseline nor development during follow-up was associated with neurological relapse [hazard ratio (HR): 1.06, 95% confidence interval (CI): 0.33-4.74, P = 0.92] and [HR: 0.38, 95% CI: 0.02-1.89, P = 0.31], respectively.
Conclusion
A long-term follow-up is needed to detect cardiac complications in aPL- SS. No change in neurological relapse was observed in patients presenting LS endocarditis occurrence during follow-up without any modification in antithrombotic treatment. Further research is necessary to assess the usefulness of treatment escalation in these patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 02 Jan 2020; epub ahead of print
Assan F, de Zuttere D, Bottin L, Tavolaro S, ... Francès C, Chasset F
Eur Heart J Cardiovasc Imaging: 02 Jan 2020; epub ahead of print | PMID: 31898726
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Impact:
Abstract

Accuracy of fully automated right ventricular quantification software with 3D echocardiography: direct comparison with cardiac magnetic resonance and semi-automated quantification software.

Otani K, Nabeshima Y, Kitano T, Takeuchi M
Aims
The aim of this study was to determine the accuracy and reproducibility of a novel, fully automated 3D echocardiography (3DE) right ventricular (RV) quantification software compared with cardiac magnetic resonance (CMR) and semi-automated 3DE RV quantification software.
Methods and results
RV volumes and the RV ejection fraction (RVEF) were measured using a fully automated software (Philips), a semi-automated software (TomTec), and CMR in 100 patients who had undergone both CMR and 3DE examinations on the same day. The feasibility of the fully automated software was 91%. Although the fully automated software, without any manual editing, significantly underestimated RV end-diastolic volume (bias: -12.6 mL, P < 0.001) and stroke volume (-5.1 mL, P < 0.001) compared with CMR, there were good correlations between the two modalities (r = 0.82 and 0.78). No significant differences in RVEF between the fully automated software and CMR were observed, and there was a fair correlation (r = 0.72). The RVEF determined by the semi-automated software was significantly larger than that by CMR or the fully automated software (P < 0.001). The fully automated software had a shorter analysis time compared with the semi-automated software (15 s vs. 120 s, P < 0.001) and had a good reproducibility.
Conclusion
A novel, fully automated 3DE RV quantification software underestimated RV volumes but successfully approximated RVEF when compared with CMR. No inferiority of this software was observed when compared with the semi-automated software. Rapid analysis and higher reproducibility also support the routine adoption of this method in the daily clinical workflow.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print
Otani K, Nabeshima Y, Kitano T, Takeuchi M
Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print | PMID: 31549722
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Impact:
Abstract

Tricuspid regurgitation and long-term clinical outcomes.

Chorin E, Rozenbaum Z, Topilsky Y, Konigstein M, ... Keren G, Banai S
Aims
Tricuspid regurgitation (TR) is a frequent echocardiographic finding; however, its effect on outcome is unclear. The objectives of current study were to evaluate the impact of TR severity on heart failure hospitalization and mortality.
Methods and results
We retrospectively reviewed consecutive echocardiograms performed between 2011 and 2016 at the Tel-Aviv Medical Center. TR severity was determined using semi-quantitative approach including colour jet area, vena contracta width, density of continuous Doppler jet, hepatic vein flow pattern, trans-tricuspid inflow pattern, annular diameter, right ventricle, and right atrial size. Major comorbidities, re-admissions and all-cause mortality were extracted from the electronic health records. The final analysis included 33 305 patients with median follow-up period of 3.34 years (interquartile range 2.11-4.54). TR (≥mild) was present in 31% of our cohort. One-year mortality rates were 7.7% for patients with no/trivial TR, 16.8% for patients with mild TR, 29.5% for moderate TR, and 45.6% for patients with severe TR (P < 0.001). Univariate and multivariate analyses demonstrated a positive correlation between TR severity and overall mortality and rates of heart failure re-admission after adjustment for potential confounders. The proportional hazards method for overall mortality showed that patients with moderate [hazard ratio (HR) 1.15, 95% confidence interval (CI) 1.02-1.3, P = 0.024] and severe TR (HR 1.43, 95% CI 1.08-1.88, P = 0.011) had a worse prognosis than those with no or minimal TR.
Conclusions
The presence of any degree of TR is associated with adverse clinical outcome. At least moderate TR is independently associated with increased mortality.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print
Chorin E, Rozenbaum Z, Topilsky Y, Konigstein M, ... Keren G, Banai S
Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print | PMID: 31544933
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Impact:
Abstract

Intra-procedural monitoring protocol using routine transthoracic echocardiography with backup trans-oesophageal probe in transcatheter aortic valve replacement: a single centre experience.

Stella S, Melillo F, Capogrosso C, Fisicaro A, ... Margonato A, Agricola E
Aim
The aim of this study is to describe our 9-year experience in transcatheter aortic valve replacement (TAVR) using transthoracic echocardiography (TTE) as a routine intra-procedural imaging modality with trans-oesophageal echocardiography (TEE) as a backup.
Methods and results
From January 2008 to December 2017, 1218 patients underwent transfemoral TAVR at our Institution. Except the first 20 cases, all procedures have been performed under conscious sedation, with fluoroscopic guidance and TTE imaging monitoring. Once the TTE resulted suboptimal for final result assessment or a complication was either suspected or identified on TTE, TEE evaluation was promptly performed under general anaesthesia. Only 24 (1.9%) cases required a switch to TEE: 6 cases for suboptimal TTE prosthetic valve leak (PVL) quantification; 12 cases for haemodynamic instability; 2 cases for pericardial effusion without haemodynamic instability; 4 cases for urgent TAVR. The 30-days and 1-year all-cause mortality were 2.1% and 10.2%, respectively. Cardiac mortality at 30-days and 1-year follow-up were 0.6% and 4.1%, respectively. Intra-procedural and pre-discharge TT evaluation showed good agreement for PVL quantification (k agreement: 0.827, P = 0.005).
Conclusion
TTE monitoring seems a reasonable imaging tool for TAVR intra-procedural monitoring without delay in diagnosis of complications and a reliable paravalvular leak assessment. However, TEE is undoubtedly essential in identifying the exact mechanism in most of the complications.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:85-92
Stella S, Melillo F, Capogrosso C, Fisicaro A, ... Margonato A, Agricola E
Eur Heart J Cardiovasc Imaging: 31 Dec 2019; 21:85-92 | PMID: 30977790
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Impact:
Abstract

European Association of Cardiovascular Imaging expert consensus paper: a comprehensive review of cardiovascular magnetic resonance normal values of cardiac chamber size and aortic root in adults and recommendations for grading severity.

Petersen SE, Khanji MY, Plein S, Lancellotti P, Bucciarelli-Ducci C

This consensus paper provides a framework for grading of severity of cardiovascular magnetic resonance (CMR) imaging-based assessment of chamber size, function, and aortic measurements. This does not currently exist for CMR measures. Differences exist in the normal reference values between echocardiography and CMR along with differences in methods used to derive these. We feel that this document will significantly complement the current literature and provide a practical guide for clinicians in daily reporting and interpretation of CMR scans. This manuscript aims to complement a recent comprehensive review of CMR normal value publications to recommend cut-off values required for severity grading. Standardization of severity grading for clinically useful CMR parameters is encouraged to lead to clearer and easier communication with referring clinicians and may contribute to better patient care. To this end, the European Association of Cardiovascular Imaging (EACVI) has formed this expert panel that has critically reviewed the literature and has come to a consensus on approaches to severity grading for commonly quantified CMR parameters.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print
Petersen SE, Khanji MY, Plein S, Lancellotti P, Bucciarelli-Ducci C
Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print | PMID: 31544926
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Impact:
Abstract

Plaque quantification by coronary computed tomography angiography using intravascular ultrasound as a reference standard: a comparison between standard and last generation computed tomography scanners.

Conte E, Mushtaq S, Pontone G, Li Piani L, ... Montorsi P, Andreini D
Aims
The emerging role of coronary computed tomography angiography (CCTA) as a non-invasive tool for atherosclerosis evaluation is supported by data reporting a good correlation between CCTA and intravascular ultrasound (IVUS) for plaque volume quantification. Aim of the present study was to evaluate whether a last generation CT-scanner may improve coronary plaque volume assessment using IVUS as standard-of-reference.
Methods and results
From a registry of 1915 consecutive, all-comers, patients who underwent a clinically indicated IVUS evaluation we enrolled 59 patients who underwent CCTA with a 64-slice CT (Group 1) and 59 patients who underwent CCTA with whole-heart coverage CT scanner (Group 2). Patients who underwent CCTA with unfavourable heart rhythm were not excluded from the analysis. Image quality (4-point Likert scale) focused on plaque analysis was evaluated. Plaque volume quantification by CCTA was compared to IVUS. No difference in clinical characteristics was found between Group 1 and Group 2. Plaque volume quantification by CCTA was considered not feasible in 11 plaques of Group 1 and in 4 plaques of Group 2 (P = 0.09). Higher correlation for plaque volume quantification by CCTA vs. IVUS was demonstrated in Group 2 when compared with Group 1 (r = 0.9888 vs. 0.9499; P < 0.0001). The Bland-Altman analysis showed plaque volume overestimation by CCTA of 11.9 mm3 in Group 1 and 4 mm2 in Group 2 (P < 0.001). Effective radiation dose of CCTA was significantly lower in Group 2 vs. Group 1 (2.7 ± 0.9 vs. 8.1 ± 3.6 mSv, respectively; P < 0.001).
Conclusions
CCTA using a new scanner generation showed to be an accurate non-invasive tool to assess and quantify coronary plaque volume.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Jan 2020; 21:191-201
Conte E, Mushtaq S, Pontone G, Li Piani L, ... Montorsi P, Andreini D
Eur Heart J Cardiovasc Imaging: 31 Jan 2020; 21:191-201 | PMID: 31093656
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Impact:
Abstract

The relation of structural valve deterioration to adverse remodelling and outcome in patients with biological heart valve prostheses.

Issa IF, Dahl JS, Poulsen SH, Waziri F, ... Søgaard P, Møller JE
Aims
Native valve aortic stenosis is associated with adverse remodelling of the left ventricle and remodelling is stopped or even reversed with aortic valve replacement (AVR). However, the degeneration of bioprostheses and development of structural valve deterioration (SVD) may affect this.
Methods and results
To assess the association with SVD, remodelling and outcome 451 patients from a single surgical centre who had undergone AVR with a Mitroflow pericardial bioprosthesis were studied. All patients were assessed in 2014 and a subgroup of patients (N = 327) were re-exanimated again after at least 18 months [median time of 27 (interquartile range, IQR 26-33) months] including echocardiography, measurements of N-terminal pro-brain natriuretic peptide, and assessment of functional status. SVD was based on echocardiography. Moderate SVD was present in 63 patients (14%) and severe SVD in 19 (4%), in the subgroup with follow-up echocardiography 48 patients (15%) patients had moderate to severe SVD at first examination. Patients with SVD had significantly greater increase in left ventricular (LV) mass index [21.6 g/m2 (IQR 5.7-48.3 g/m2) vs. 9.1 g/m2 (-8.6 to 27.3 g/m2), P = 0.01]. Further, patients with SVD had lower LV ejection fraction [55% (IQR 51-62%) vs. 60% (IQR 54-63%), P = 0.01] at follow-up. During follow-up, 94 patients (21%) met the composite endpoint of death or reoperation due to SVD and 41 patient readmitted for heart failure. In multivariable Cox regression analysis, severe SVD [hazard ratio (HR) 2.64 (1.37-5.07), P = 0.004] was associated with composite endpoint, and readmission for heart failure [HR 3.82 (1.53-9.51), P = 0.004].
Conclusion
SVD in aortic bioprostheses is associated with adverse LV remodelling and adverse outcome.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 12 Jan 2020; epub ahead of print
Issa IF, Dahl JS, Poulsen SH, Waziri F, ... Søgaard P, Møller JE
Eur Heart J Cardiovasc Imaging: 12 Jan 2020; epub ahead of print | PMID: 31942609
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Impact:
Abstract

Improved regional myocardial blood flow and flow reserve after coronary revascularization as assessed by serial 15O-water positron emission tomography/computed tomography.

Aikawa T, Naya M, Koyanagawa K, Manabe O, ... Tamaki N, Anzai T
Aims
Myocardial perfusion imaging without and with quantitative myocardial blood flow (MBF) and myocardial flow reserve (MFR) plays an important role in the diagnosis and risk stratification of patients with stable coronary artery disease (CAD). We aimed to quantify the effects of coronary revascularization on regional stress MBF and MFR and to determine whether the presence of subendocardial infarction was associated with these changes.
Methods and results
Forty-seven patients with stable CAD were prospectively enrolled. They underwent 15O-water positron emission tomography at baseline and 6 months after optimal medical therapy alone (n = 16), percutaneous coronary intervention (PCI) (n = 18), or coronary artery bypass grafting (CABG) (n = 13). Stenosis of ≥50% diameter was detected in 98/141 vessels (70%). The regional MFR was significantly increased from baseline to follow-up [1.84 (interquartile range, IQR 1.28-2.17) vs. 2.12 (IQR 1.69-2.63), P < 0.001] in vessel territories following PCI or CABG due to an increase in the stress MBF [1.33 (IQR 0.97-1.67) mL/g/min vs. 1.64 (IQR 1.38-2.17) mL/g/min, P < 0.001], whereas there was no significant change in the regional stress MBF or MFR in vessel territories without revascularization. A multilevel mixed-effects models adjusted for baseline characteristics, subendocardial infarction assessed by cardiovascular magnetic resonance imaging, and intra-patient correlation showed that the degree of angiographic improvement after coronary revascularization was significantly associated with increased regional stress MBF and MFR (P < 0.05 for all).
Conclusion
Coronary revascularization improved the regional stress MBF and MFR in patients with stable CAD. The magnitude of these changes was associated with the extent of revascularization independent of subendocardial infarction.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print
Aikawa T, Naya M, Koyanagawa K, Manabe O, ... Tamaki N, Anzai T
Eur Heart J Cardiovasc Imaging: 22 Sep 2019; epub ahead of print | PMID: 31544927
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Impact:
Abstract

Quantitative estimation of extravascular lung water volume and preload by dynamic 15O-water positron emission tomography.

Nielsen RR, Sörensen J, Tolbod L, Alstrup AKO, ... Frøkier J, Harms HJ
Aims
Left ventricular filling pressure (preload) can be assessed by pulmonary capillary wedge pressure (PCWP) during pulmonary arterial catheterization (PAC). An emerging method [pulse indexed contour cardiac output (PICCO)] can estimate preload by global end-diastolic volume (GEDV) and congestion as extravascular lung water (EVLW) content. However, no reliable quantitative non-invasive methods are available. Hence, in a porcine model of pulmonary congestion, we evaluated EVLW and GEDV by positron emission tomography (PET). The method was applied in 35 heart failure (HF) patients and 9 healthy volunteers.
Methods and results
Eight pigs were studied. Pulmonary congestion was induced by a combination of beta-blockers, angiotensin-2 agonist and saline infusion. PAC, PICCO, computerized tomography, and 15O-H2O-PET were performed. EVLW increased from 521 ± 76 to 973 ± 325 mL (P < 0.001) and GEDV from 1068 ± 170 to 1254 ± 85 mL (P < 0.001). 15O-H2O-PET measures of EVLW increased from 566 ± 151 to 797 ± 231 mL (P < 0.001) and GEDV from 364 ± 60 to 524 ± 92 mL (P < 0.001). Both EVLW and GEDV measured with PICCO and 15O-H2O-PET correlated (r2 = 0.40, P < 0.001; r2 = 0.40, P < 0.001, respectively). EVLW correlated with Hounsfield units (HU; PICCO: r2 = 0.36, P < 0.001, PET: r2 = 0.46, P < 0.001) and GEDV with PCWP (PICCO: r2 = 0.20, P = 0.01, PET: r2 = 0.29, P = 0.002). In human subjects, measurements were indexed (I) for body surface area. Neither EVLWI nor HU differed between chronic stable HF patients and healthy volunteers (P = 0.11, P = 0.29) whereas GEDVI was increased in HF patients (336 ± 66 mL/m2 vs. 276 ± 44 mL/m2, P = 0.01).
Conclusion
The present study demonstrates that 15O-H2O-PET can assess pulmonary congestion and preload quantitatively. Hence, prognostic information from 15O-H2O-PET examinations should be evaluated in clinical trials.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1120-1128
Nielsen RR, Sörensen J, Tolbod L, Alstrup AKO, ... Frøkier J, Harms HJ
Eur Heart J Cardiovasc Imaging: 30 Sep 2019; 20:1120-1128 | PMID: 30887037
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Impact:
Abstract

EACVI survey on multimodality training in ESC countries.

Cameli M, Marsan NA, D\'Andrea A, Dweck MR, ... Fox KF, Haugaa KH

One of the missions of the European Association of Cardiovascular Imaging (EACVI) is \'to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging\'. The future of imaging involves multimodality so each imager should have the incentive and the possibility to improve its knowledge in other cardiovascular techniques. This article presents the results of a 20 questions survey carried out in cardiovascular imaging (CVI) centres across Europe. The aim of the survey was to assess the situation of experience and training of CVI in Europe, the availability and organization of modalities in each centre and to ask for vision about potential improvements in CVI at national and European level.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1332-1336
Cameli M, Marsan NA, D'Andrea A, Dweck MR, ... Fox KF, Haugaa KH
Eur Heart J Cardiovasc Imaging: 30 Nov 2019; 20:1332-1336 | PMID: 31750533
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Impact:
Abstract

Morpho-metabolic post-surgical patterns of non-infected prosthetic heart valves by [18F]FDG PET/CTA: \"normality\" is a possible diagnosis.

Roque A, Pizzi MN, Fernández-Hidalgo N, Permanyer E, ... Tornos P, Aguadé-Bruix S
Aims
To define characteristic PET/CTA patterns of FDG uptake and anatomic changes following prosthetic heart valves (PVs) implantation over time, to help not to misdiagnose post-operative inflammation and avoid false-positive cases.
Methods and results
Prospective evaluation of 37 post-operative patients without suspected infection that underwent serial cardiac PET/CTA examinations at 1, 6, and 12 months after surgery, in which metabolic features (FDG uptake distribution pattern and intensity) and anatomic changes were evaluated. Standardized uptake values (SUVs) were obtained and a new measure, the valve uptake index (VUI), (SUVmax-SUVmean)/SUVmax, was tested to homogenize SUV results.In total, 111 PET/CTA scans were performed in 37 patients (19 aortic and 18 mitral valves). FDG uptake was visually detectable in 79.3% of patients and showed a diffuse, homogeneous distribution pattern in 93%. Quantitative analysis yielded a mean maximum standardized uptake value (SUVmax) of 4.46 ± 1.50 and VUI of 0.35 ± 0.10. There were no significant differences in FDG distribution or uptake values between 1, 6, or 12 months. No abnormal anatomic changes or endocarditis lesions were detected in any patient during follow-up.
Conclusions
FDG uptake, often seen in recently implanted PVs, shows a characteristic pattern of post-operative inflammation and, in the absence of associated anatomic lesions, could be considered a normal finding. These features remain stable for at least 1 year after surgery, so questioning the recommended 3-month safety period. A new measure, the VUI, can be useful for evaluating the FDG distribution pattern.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 19 Sep 2019; epub ahead of print
Roque A, Pizzi MN, Fernández-Hidalgo N, Permanyer E, ... Tornos P, Aguadé-Bruix S
Eur Heart J Cardiovasc Imaging: 19 Sep 2019; epub ahead of print | PMID: 31539031
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Impact:
Abstract

Development and prognostic validation of partition values to grade right ventricular dysfunction severity using 3D echocardiography.

Muraru D, Badano LP, Nagata Y, Surkova E, ... Palermo C, Takeuchi M
Aims
Transthoracic 3D echocardiography (3DE) has been shown to be feasible and accurate to measure right ventricular (RV) ejection fraction (EF) when compared with cardiac magnetic resonance (CMR). However, RV EF, either measured with CMR or 3DE, has always been reported as normal (RV EF > 45%) or abnormal (RV EF ≤ 45%). We therefore sought to identify the partition values of RV EF to stratify RV dysfunction in mildly, moderately, or severely reduced as we are used to do with the left ventricle.
Methods and results
We used 3DE to measure RV EF in 412 consecutive patients (55 ± 18 years, 65% men) with various cardiac conditions who were followed for 3.7 ± 1.4 years to obtain the partition values which defined mild, moderate, and severe reduction of RV EF (derivation cohort). Then, the prognostic value of these partition values was tested in an independent population of 446 patients (67 ± 14 years, 58% men) (validation cohort). During follow-up, we recorded 59 cardiac deaths (14%) in the derivation cohort. Using K-Adaptive partitioning for survival data algorithm we identified four groups of patients with significantly different mortality according to RV EF: very low > 46%, 40.9% < low ≤ 46%, 32.1% < moderate ≤ 40.9%, and high ≤ 32.1%. To make the partition values easier to remember, we approximated them to 45%, 40%, and 30%. During 4.1 ± 1.2 year follow-up, 38 cardiac deaths and 88 major adverse cardiac events (MACE) (cardiac death, non-fatal myocardial infarction, ventricular fibrillation, or admission for heart failure) occurred in the validation cohort. The partition values of RV EF identified in the derivation cohort were able to stratify both the risk of cardiac death (log-rank = 100.1; P < 0.0001) and MACEs (log-rank = 117.6; P < 0.0001) in the validation cohort too.
Conclusion
Our study confirms the independent prognostic value of RV EF in patients with heart diseases, and identifies the partition values of RV EF to stratify the risk of cardiac death and MACE.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 19 Sep 2019; epub ahead of print
Muraru D, Badano LP, Nagata Y, Surkova E, ... Palermo C, Takeuchi M
Eur Heart J Cardiovasc Imaging: 19 Sep 2019; epub ahead of print | PMID: 31539046
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Impact:
Abstract

Non-invasive assessment of ventriculo-arterial coupling using aortic wave intensity analysis combining central blood pressure and phase-contrast cardiovascular magnetic resonance.

Bhuva AN, D\'Silva A, Torlasco C, Nadarajan N, ... Manisty CH, Hughes AD
Background
Wave intensity analysis (WIA) in the aorta offers important clinical and mechanistic insight into ventriculo-arterial coupling, but is difficult to measure non-invasively. We performed WIA by combining standard cardiovascular magnetic resonance (CMR) flow-velocity and non-invasive central blood pressure (cBP) waveforms.
Methods and results
Two hundred and six healthy volunteers (age range 21-73 years, 47% male) underwent sequential phase contrast CMR (Siemens Aera 1.5 T, 1.97 × 1.77 mm2, 9.2 ms temporal resolution) and supra-systolic oscillometric cBP measurement (200 Hz). Velocity (U) and central pressure (P) waveforms were aligned using the waveform foot, and local wave speed was calculated both from the PU-loop (c) and the sum of squares method (cSS). These were compared with CMR transit time derived aortic arch pulse wave velocity (PWVtt). Associations were examined using multivariable regression. The peak intensity of the initial compression wave, backward compression wave, and forward decompression wave were 69.5 ± 28, -6.6 ± 4.2, and 6.2 ± 2.5 × 104 W/m2/cycle2, respectively; reflection index was 0.10 ± 0.06. PWVtt correlated with c or cSS (r = 0.60 and 0.68, respectively, P < 0.01 for both). Increasing age decade and female sex were independently associated with decreased forward compression wave (-8.6 and -20.7 W/m2/cycle2, respectively, P < 0.01) and greater wave reflection index (0.02 and 0.03, respectively, P < 0.001).
Conclusion
This novel non-invasive technique permits straightforward measurement of wave intensity at scale. Local wave speed showed good agreement with PWVtt, and correlation was stronger using the cSS than the PU-loop. Ageing and female sex were associated with poorer ventriculo-arterial coupling in healthy individuals.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 08 Sep 2019; epub ahead of print
Bhuva AN, D'Silva A, Torlasco C, Nadarajan N, ... Manisty CH, Hughes AD
Eur Heart J Cardiovasc Imaging: 08 Sep 2019; epub ahead of print | PMID: 31501858
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Abstract

A machine learning cardiac magnetic resonance approach to extract disease features and automate pulmonary arterial hypertension diagnosis.

Swift AJ, Lu H, Uthoff J, Garg P, ... Wild JM, Kiely DG
Aims
Pulmonary arterial hypertension (PAH) is a progressive condition with high mortality. Quantitative cardiovascular magnetic resonance (CMR) imaging metrics in PAH target individual cardiac structures and have diagnostic and prognostic utility but are challenging to acquire. The primary aim of this study was to develop and test a tensor-based machine learning approach to holistically identify diagnostic features in PAH using CMR, and secondarily, visualize and interpret key discriminative features associated with PAH.
Methods and results
Consecutive treatment naive patients with PAH or no evidence of pulmonary hypertension (PH), undergoing CMR and right heart catheterization within 48 h, were identified from the ASPIRE registry. A tensor-based machine learning approach, multilinear subspace learning, was developed and the diagnostic accuracy of this approach was compared with standard CMR measurements. Two hundred and twenty patients were identified: 150 with PAH and 70 with no PH. The diagnostic accuracy of the approach was high as assessed by area under the curve at receiver operating characteristic analysis (P < 0.001): 0.92 for PAH, slightly higher than standard CMR metrics. Moreover, establishing the diagnosis using the approach was less time-consuming, being achieved within 10 s. Learnt features were visualized in feature maps with correspondence to cardiac phases, confirming known and also identifying potentially new diagnostic features in PAH.
Conclusion
A tensor-based machine learning approach has been developed and applied to CMR. High diagnostic accuracy has been shown for PAH diagnosis and new learnt features were visualized with diagnostic potential.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 29 Jan 2020; epub ahead of print
Swift AJ, Lu H, Uthoff J, Garg P, ... Wild JM, Kiely DG
Eur Heart J Cardiovasc Imaging: 29 Jan 2020; epub ahead of print | PMID: 31998956
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Abstract

Criteria for surveys: from the European Association of Cardiovascular Imaging Scientific Initiatives Committee.

Haugaa KH, Marsan NA, Cameli M, D\'Andrea A, ... Maurer G, Edvardsen T

The European Association of Cardiovascular Imaging (EACVI) is committed to maintaining the highest standards of professional excellence in all aspects of cardiovascular imaging. The mission of the EACVI is to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging with a particular focus on education, training, scientific initiatives, and research. The EACVI established the Scientific Initiatives Committee (SIC) in December 2018. This committee has responsibility for surveys among imagers, patients\' surveys and surveys including data from clinical practice. The current document describes the aims of the EACVI SIC and the creation of the international EACVI survey network. This document summarizes the EACVI\'s standards for the survey questions and standards for writing the papers with the results of the surveys. These are in accordance with previous recommendations and were approved by the EACVI SIC and the EACVI Board in 2019.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:963-966
Haugaa KH, Marsan NA, Cameli M, D'Andrea A, ... Maurer G, Edvardsen T
Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:963-966 | PMID: 31436816
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Abstract

Atrial mechanics and their prognostic impact in Takotsubo syndrome: a cardiovascular magnetic resonance imaging study.

Backhaus SJ, Stiermaier T, Lange T, Chiribiri A, ... Eitel I, Schuster A
Aims
The exact pathophysiology of Takotsubo syndrome (TTS) remains not fully understood with most studies focussing on ventricular pathology. Since atrial involvement may have a significant role, we assessed the diagnostic and prognostic potential of atrial cardiovascular magnetic resonance feature tracking (CMR-FT) in TTS.
Methods and results
This multicentre study recruited 152 TTS patients who underwent CMR on average within 3 days after hospitalization. Reservoir [total strain εs and peak positive strain rate (SR) SRs], conduit (passive strain εe and peak early negative SRe), and booster pump function (active strain εa and peak late negative SRa) were assessed in a core laboratory. Results were compared with 21 control patients with normal biventricular function. A total of 20 patients underwent follow-up CMR (median 3.5 months, interquartile range 3-5). All patients were approached for general follow-up. Left atrial (LA) but not right atrial (RA) reservoir and conduit function were impaired during the acute phase (εs: P = 0.043, εe: P < 0.001, SRe: P = 0.047 vs. controls) and recovered until follow-up (εs: P < 0.001, SRs: P = 0.04, εe: P = 0.001, SRe: P = 0.04). LA and RA booster pump function were increased in the acute setting (LA-εa: P = 0.045, SRa: P = 0.002 and RA-εa: P = 0.004, SRa: P = 0.002 vs. controls). LA-εs predicted mortality [hazard ratio 1.10, 95% confidence interval (CI) 1.01-1.20; P = 0.037] irrespectively of established cardiovascular risk factors (P = 0.019, multivariate analysis) including left ventricular ejection fraction (LVEF) (area under the curve 0.71, 95% CI 0.55-0.86, P = 0.048).
Conclusion
TTS pathophysiology comprises transient impairments in LA reservoir and conduit functions and enhanced bi-atrial active booster pump functions. Atrial CMR-FT may evolve as a superior marker of adverse events over and above established parameters such as LVEF and atrial volume.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1059-1069
Backhaus SJ, Stiermaier T, Lange T, Chiribiri A, ... Eitel I, Schuster A
Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1059-1069 | PMID: 30649241
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Abstract

Imaging for screening cardiovascular involvement in patients with systemic rheumatologic diseases: more questions than answers.

Sade LE, Akdogan A

Cardiovascular involvement due to systemic rheumatologic diseases (SRDs) remains largely underdiagnosed despite causing excess mortality and limiting the favourable effect of therapeutic developments on survival. Traditional risk scoring systems are poorly calibrated for SRD patients. There is an unmet need to develop a cardiovascular (CV) risk stratification tool and screening algorithm for CV involvement dedicated to asymptomatic patients with SRDs. Even though accelerated atherosclerosis is the most prominent cause of major CV events, a more comprehensive approach is crucial to detect different pathological processes associated with SRDs that are leading to CV complications. In that regard, incorporation of imaging parameters obtained from echocardiography and carotid ultrasound (CUS) might help to improve risk models, to detect and monitor subclinical CV involvement. These two imaging modalities should be an integral part of screening SRD patients with suspicion of CV involvement on top of electrocardiogram (ECG). Cardiac magnetic resonance and multi-slice computerized tomography angiography and nuclear imaging modalities seem very important to complement echocardiography and CUS for further evaluation. However, to answer the question \'Should asymptomatic patients with SRDs undergo screening with echocardiography and CUS on top of ECG?\' necessitates large studies performing cardiac screening with a standard approach by using these imaging methods to obtain longitudinal data with hard CV outcomes.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:967-978
Sade LE, Akdogan A
Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:967-978 | PMID: 31230066
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Impact:
Abstract

Mid-term outcome of severe tricuspid regurgitation: are there any differences according to mechanism and severity?

Santoro C, Marco Del Castillo A, González-Gómez A, Monteagudo JM, ... Zamorano Gomez JL, Fernández-Golfín C
Aims
Patients with significant tricuspid regurgitation (TR) addressed according the new classification in torrential TR may have different prognosis compared with just severe TR patients. We sought to determine distribution and mechanism of consecutive severe TR patients, in accordance with aetiology and severity by applying the new proposed classification scheme and their long-term outcomes.
Methods and results
Between January and December 2013, 249 patients with significant TR referred to the cardiac imaging unit (mean age 79.9 ± 10.2 years; 29.8% female) were included. Patients were divided according to aetiology in six groups, and TR severity was reclassified into severe, massive, and torrential TR. The follow-up period was of 313 ± 103 days. When considering cardiovascular mortality, patients in the massive/torrential group showed the highest number of events (P < 0.007). Patients with TR due to pulmonary diseases had the worst prognosis according to different aetiology. Noteworthy, the best predictors for the combined endpoint [cardiovascular mortality and readmission admission for heart failure (HF)] were TR severity according to the new classification [hazard ratio (HR) 2.48, 95% confidence interval (CI) 1.25-4.93] and clinical scores such as New York Heart Association classification and congestive status (HR 1.78, 95% CI 1.28-2.49; HR 2.08, 95% CI 1.06-4.06, respectively).
Conclusion
Patients with massive/torrential TR and patients with comorbidities, especially pulmonary disease, were identified as populations at higher risk of death and readmission for HF. New classification scheme and clinical assessment may establish who may benefit the most of intensive therapeutic treatments and intervention on the tricuspid valve.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1035-1042
Santoro C, Marco Del Castillo A, González-Gómez A, Monteagudo JM, ... Zamorano Gomez JL, Fernández-Golfín C
Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:1035-1042 | PMID: 30830219
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Abstract

Non-invasive in vivo imaging of acute thrombosis: development of a novel factor XIIIa radiotracer.

Andrews JPM, Portal C, Walton T, Macaskill MG, ... Newby DE, Tavares AAS
Aims
Cardiovascular thrombosis is responsible a quarter of deaths annually worldwide. Current imaging methods for cardiovascular thrombosis focus on anatomical identification of thrombus but cannot determine thrombus age or activity. Molecular imaging techniques hold promise for identification and quantification of thrombosis in vivo. Our objective was to assess a novel optical and positron-emitting probe targeting Factor XIIIa (ENC2015) as biomarker of active thrombus formation.
Methods and results
Optical and positron-emitting ENC2015 probes were assessed ex vivo using blood drawn from human volunteers and passed through perfusion chambers containing denuded porcine aorta as a model of arterial injury. Specificity of ENC2015 was established with co-infusion of a factor XIIIa inhibitor. In vivo18F-ENC2015 biodistribution, kinetics, radiometabolism, and thrombus binding were characterized in rats. Both Cy5 and fluorine-18 labelled ENC2015 rapidly and specifically bound to thrombi. Thrombus uptake was inhibited by a factor XIIIa inhibitor. 18F-ENC2015 remained unmetabolized over 8 h when incubated in ex vivo human blood. In vivo, 42% of parent radiotracer remained in blood 60 min post-administration. Biodistribution studies demonstrated rapid clearance from tissues with elimination via the urinary system. In vivo,18F-ENC2015 uptake was markedly increased in the thrombosed carotid artery compared to the contralateral patent artery (mean standard uptake value ratio of 2.40 vs. 0.74, P < 0.0001).
Conclusion 
ENC2015 rapidly and selectively binds to acute thrombus in both an ex vivo human translational model and an in vivo rodent model of arterial thrombosis. This probe holds promise for the non-invasive identification of thrombus formation in cardiovascular disease.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 12 Aug 2019; epub ahead of print
Andrews JPM, Portal C, Walton T, Macaskill MG, ... Newby DE, Tavares AAS
Eur Heart J Cardiovasc Imaging: 12 Aug 2019; epub ahead of print | PMID: 31408105
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Impact:
Abstract

Impact of aortic stenosis on layer-specific longitudinal strain: relationship with symptoms and outcome.

Ilardi F, Marchetta S, Martinez C, Sprynger M, ... Dulgheru R, Lancellotti P
Aims
The present study sought to assess the impact of aortic stenosis (AS) on myocardial function as assessed by layer-specific longitudinal strain (LS) and its relationship with symptoms and outcome.
Methods and results
We compared 211 patients (56% males, mean age 73 ± 12 years) with severe AS and left ventricular ejection fraction (LVEF) ≥50% (114 symptomatic, 97 asymptomatic) with 50 controls matched for age and sex. LS was assessed from endocardium, mid-myocardium, and epicardium by 2D speckle-tracking echocardiography. Despite similar LVEF, multilayer strain values were significantly lower in symptomatic patients, compared to asymptomatic and controls [global LS: 17.9 ± 3.4 vs. 19.1 ± 3.1 vs. 20.7 ± 2.1%; endocardial LS: 20.1 ± 4.9 vs. 21.7 ± 4.2 vs. 23.4 ± 2.5%; epicardial LS: 15.8 ± 3.1 vs. 16.8 ± 2.8 vs. 18.3 ± 1.8%; P < 0.001 for all]. On multivariable logistic regression analysis, endocardial LS was independently associated to symptoms (P = 0.012), together with indexed left atrial volume (P = 0.006) and LV concentric remodelling (P = 0.044). During a mean follow-up of 22 months, 33 patients died of a cardiovascular event. On multivariable Cox-regression analysis, age (P = 0.029), brain natriuretic peptide values (P = 0.003), LV mass index (P = 0.0065), LV end-systolic volume (P = 0.012), and endocardial LS (P = 0.0057) emerged as independently associated with cardiovascular death. The best endocardial LS values associated with outcome was 20.6% (sensitivity 70%, specificity 52%, area under the curve = 0.626, P = 0.022). Endocardial LS (19.1 ± 3.3 vs. 20.7 ± 3.3, P = 0.02) but not epicardial LS (15.2 ± 2.8 vs. 15.9 ± 2.5, P = 0.104) also predicted the outcome in patients who were initially asymptomatic.
Conclusion
In patients with severe AS, LS impairment involves all myocardial layers and is more prominent in the advanced phases of the disease, when the symptoms occur. In this setting, the endocardial LS is independently associated with symptoms and patient outcome.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 28 Aug 2019; epub ahead of print
Ilardi F, Marchetta S, Martinez C, Sprynger M, ... Dulgheru R, Lancellotti P
Eur Heart J Cardiovasc Imaging: 28 Aug 2019; epub ahead of print | PMID: 31504364
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Abstract

Focal scar and diffuse myocardial fibrosis are independent imaging markers in repaired tetralogy of Fallot.

Cochet H, Iriart X, Allain-Nicolaï A, Camaioni C, ... Montaudon M, Thambo JB
Aims
To identify the correlates of focal scar and diffuse fibrosis in patients with history of tetralogy of Fallot (TOF) repair.
Methods and results
Consecutive patients with prior TOF repair underwent electrocardiogram, 24-h Holter, transthoracic echocardiography, exercise testing, and cardiac magnetic resonance (CMR) including cine imaging to assess ventricular volumes and ejection fraction, T1 mapping to assess left ventricular (LV) and right ventricular (RV) diffuse fibrosis, and free-breathing late gadolinium-enhanced imaging to quantify scar area at high spatial resolution. Structural imaging data were related to clinical characteristics and functional imaging markers. Cine and T1 mapping results were compared with 40 age- and sex-matched controls. One hundred and three patients were enrolled (age 28 ± 15 years, 36% women), including 36 with prior pulmonary valve replacement (PVR). Compared with controls, TOF showed lower LV ejection fraction (LVEF) and RV ejection fraction (RVEF), and higher RV volume, RV wall thickness, and native T1 and extracellular volume values on both ventricles. In TOF, scar area related to LVEF and RVEF, while LV and RV native T1 related to RV dilatation. On multivariable analysis, scar area and LV native T1 were independent correlates of ventricular arrhythmia, while RVEF was not. Patients with history of PVR showed larger scars on RV outflow tract but shorter LV and RV native T1.
Conclusion
Focal scar and biventricular diffuse fibrosis can be characterized on CMR after TOF repair. Scar size relates to systolic dysfunction, and diffuse fibrosis to RV dilatation. Both independently relate to ventricular arrhythmias. The finding of shorter T1 after PVR suggests that diffuse fibrosis may reverse with therapy.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:990-1003
Cochet H, Iriart X, Allain-Nicolaï A, Camaioni C, ... Montaudon M, Thambo JB
Eur Heart J Cardiovasc Imaging: 31 Aug 2019; 20:990-1003 | PMID: 30993335
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Impact:

This program is still in alpha version.