Journal: Eur Heart J Cardiovasc Imaging

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Abstract

Impact of left atrial strain mechanics on exercise intolerance and need for septal reduction therapy in hypertrophic cardiomyopathy.

Saijo Y, Van Iterson E, Vega Brizneda M, Desai MY, ... Griffin BP, Xu B
Aims
We sought to assess the relationship between left atrial (LA) strain mechanics and exercise intolerance, and to evaluate the prognostic impact of LA strain mechanics on clinical deterioration necessitating septal reduction therapy in hypertrophic cardiomyopathy (HCM).
Methods and results
Consecutive HCM patients who underwent exercise stress echocardiography and cardiopulmonary exercise testing on the same day between October 2015 and April 2019 were enrolled prospectively. LA strain mechanics were analysed using speckle tracking echocardiography. LA stiffness was calculated as the ratio of E/e\' ratio to LA reservoir strain. The study cohort was divided into four groups based on the quartile of percent-predicted peak VO2, and exercise intolerance was defined as the lowest quartile (≤51%). Of 532 patients studied (mean age: 51 ± 15 years, 42% female), 138 patients demonstrated exercise intolerance. As exercise capacity worsened, LA strain mechanics worsened along a continuum (P < 0.001). LA contractile strain with a cut-off of -13.9% was optimal at identifying exercise intolerance. On multivariable analysis, worse LA contractile strain was an independent predictor for exercise intolerance (P = 0.002). Of patients with left ventricular outflow tract obstruction, patients with LA stiffness worse than the median value (≥0.41) were significantly more likely to require septal reduction therapy than those with better LA stiffness (P = 0.026).
Conclusion
Worse LA contractile strain was an independent predictor for exercise intolerance in HCM. Patients with worse LA stiffness had a higher probability of clinical deterioration necessitating septal reduction therapy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 17 Jan 2021; epub ahead of print
Saijo Y, Van Iterson E, Vega Brizneda M, Desai MY, ... Griffin BP, Xu B
Eur Heart J Cardiovasc Imaging: 17 Jan 2021; epub ahead of print | PMID: 33462591
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Abstract

Long-term risk of sudden cardiac death in hypertrophic cardiomyopathy: a cardiac magnetic resonance outcome study.

Greulich S, Seitz A, Herter D, Günther F, ... Sechtem U, Mahrholdt H
Aims
Sudden cardiac death (SCD) is an appalling complication of hypertrophic cardiomyopathy (HCM). There is an ongoing discussion about the optimal SCD risk stratification strategy since established SCD risk models have suboptimal discriminative power. The aim of this study was to evaluate the prognostic value of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) for SCD risk stratification compared to the European Society of Cardiology (ESC) SCD risk score and traditional risk factors in an >10-year follow-up.
Methods and results
Two hundred and twenty consecutive patients with HCM and LGE-CMR were enrolled. Follow-up data were available in 203 patients (median age 58 years, 61% male) after a median follow-up period of 10.4 years. LGE was present in 70% of patients with a median LGE amount of 1.6%, the median ESC 5-year SCD risk score was 1.84. In the overall cohort, SCD rates were 2.3% at 5 years, 4.8% at 10 years, and 15.7% at 15 years, independent from established risk models. An LGE amount of >5% left ventricular (LV) mass portends the highest risk for SCD with SCD prevalences of 5.5% at 5 years, 13.0% at 10 years, and 33.3% at 15 years. Conversely, patients with no or ≤5% LGE of LV mass have favourable prognosis.
Conclusions
LGE-CMR in HCM patients allows effective 10-year SCD risk stratification beyond established risk factors. LGE amount might be added to established risk models to improve its discriminatory power. Specifically, patients with >5% LGE should be carefully monitored and might be adequate candidates for primary prevention implantable cardioverter-defibrillator during the clinical long-term course.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 16 Jan 2021; epub ahead of print
Greulich S, Seitz A, Herter D, Günther F, ... Sechtem U, Mahrholdt H
Eur Heart J Cardiovasc Imaging: 16 Jan 2021; epub ahead of print | PMID: 33458753
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Abstract

Anthracyclines and regional myocardial damage in breast cancer patients. A multicentre study from the Working Group on Drug Cardiotoxicity and Cardioprotection, Italian Society of Cardiology (SIC).

Zito C, Manganaro R, Cusmà Piccione M, Madonna R, ... Carerj S, Tocchetti CG
Aims
In breast cancer (BC) patients treated with anthracyclines-based therapies, we aim at assessing whether adjuvant drugs impact cardiac function differently and whether their cardiotoxicity has a regional pattern.
Methods and results
In a multicentre study, 146 BC patients (56 ± 11 years) were prospectively enrolled and divided into three groups according to the received treatments: AC/EC-Group (doxorubicin or epirubicin + cyclophosphamide), AC/EC/Tax-Group (AC/EC + taxanes), FEC/Tax-Group (fluorouracil + EC + taxanes). Fifty-six patients of the total cohort also received trastuzumab. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) were calculated before starting chemotherapy (T0), at 3 months (T3), at 6 (T6), and 12 months (T12). A ≥10% drop of EF, while remaining within the normal range, was reached at T6 in 25.3% of patients from the whole cohort with an early decrease only in FEC/Tax-Group (P = 0.04). A ≥15% GLS reduction was observed in many more (61.6%) patients. GLS decreased early both in the whole population (P < 0.001) and in the subgroups. The FEC-Tax Group showed the worst GLS at T6. Trastuzumab further worsened GLS at T12 (P = 0.031). A significant reduction of GLS was observed in all LV segments and was more relevant in the anterior septum and apex.
Conclusions
The decrease of GLS is more precocious and pronounced in BC patients who received FEC + taxanes. Cardiac function further worsens after 6 months of adjuvant trastuzumab. All LV segments are damaged, with the anterior septum and the apex showing the greatest impairments.

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: 11 Jan 2021; epub ahead of print
Zito C, Manganaro R, Cusmà Piccione M, Madonna R, ... Carerj S, Tocchetti CG
Eur Heart J Cardiovasc Imaging: 11 Jan 2021; epub ahead of print | PMID: 33432333
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Abstract

Eosinophilic heart disease: diagnostic and prognostic assessment by cardiac magnetic resonance.

Antonopoulos AS, Azzu A, Androulakis E, Tanking C, Papagkikas P, Mohiaddin RH
Aims 
Eosinophilic heart disease (EHD) is a rare cardiac condition with a wide spectrum of phenotypes. The diagnostic and prognostic value of cardiac magnetic resonance (CMR) in EHD remains unknown.
Methods and results 
This was a retrospective analysis of 250 patients with eosinophilia referred for a CMR scan (period 2000-2020). CMR data sets and clinical/laboratory data were collected. Patients were followed up for a mean of 24 months (range 1-224) for the composite endpoint of death, acute coronary syndrome, hospitalization for acute heart failure, malignant ventricular arrhythmias, or the need for implantable cardiac defibrillator/pacemaker. The main objectives were to explore the diagnostic value of CMR in EHD; relationships between cardiac function, late gadolinium enhancement (LGE), and EHD phenotypes; and the prognostic value of fibrosis and oedema by CMR. The prevalence of findings compatible with EHD was 39% (patients with cardiac symptoms: 57% vs. screening: 20%, P < 0.001). EHD phenotypes included subendocardial LGE (n = 58), mid-wall/subepicardial LGE (n = 26), pericarditis (n = 5) or dilated cardiomyopathy (n = 8). Myocardial oedema was present in 10% of patients. Intracardiac thrombi (7%) were associated with EHD phenotype (χ2=47.3, P = 1.3×10-8). LGE extent correlated with LVEDVi (rho = 0.268, P = 5.3×10-5) and LVEF (rho=-0.415, P = 8.6×10-11). A CMR scan positive for EHD [hazard ratio (HR) = 5.61, 95% confidence interval (CI): 1.82-17.89, P = 0.0026] or a subendocardial LGE pattern (HR = 5.13, 95% CI: 1.29-20.38, P = 0.020) were independently associated with the composite clinical endpoint.
Conclusion 
The diagnostic yield of CMR screening in patients with persistent eosinophilia, even if asymptomatic, is high. The extent of subendocardial fibrosis correlates with LV remodelling and independently predicts clinical outcomes in patients with eosinophilia.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 11 Jan 2021; epub ahead of print
Antonopoulos AS, Azzu A, Androulakis E, Tanking C, Papagkikas P, Mohiaddin RH
Eur Heart J Cardiovasc Imaging: 11 Jan 2021; epub ahead of print | PMID: 33432319
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Abstract

Current use of cardiac magnetic resonance in tertiary referral centres for the diagnosis of cardiomyopathy: the ESC EORP Cardiomyopathy/Myocarditis Registry.

Mizia-Stec K, Charron P, Gimeno Blanes JR, Elliott P, ... Caforio ALP,
Aims 
Cardiac magnetic resonance (CMR) is recommended in the diagnosis of cardiomyopathies, but it is time-consuming, expensive, and limited in availability in some European regions. The aim of this study was to determine the use of CMR in cardiomyopathy patients enrolled into the European Society of Cardiology (ESC) cardiomyopathy registry [part of the EURObservational Research Programme (EORP)].
Methods and results 
Three thousand, two hundred, and eight consecutive adult patients (34.6% female; median age: 53.0 ± 15 years) with cardiomyopathy were studied: 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM), and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC). CMR scans were performed at baseline in only 29.4% of patients. CMR utilization was variable according to cardiomyopathy subtypes: from 51.1% in ARVC to 36.4% in RCM, 33.8% in HCM, and 20.6% in DCM (P < 0.001). CMR use in tertiary referral centres located in different European countries varied from 1% to 63.2%. Patients undergoing CMR were younger, less symptomatic, less frequently had implantable cardioverter-defibrillator (ICD)/pacemaker implanted, had fewer cardiovascular risk factors and comorbidities (P < 0.001). In 28.6% of patients, CMR was used along with transthoracic echocardiography (TTE); 67.6% patients underwent TTE alone, and 0.9% only CMR.
Conclusion 
Less than one-third of patients enrolled in the registry underwent CMR and the use varied greatly between cardiomyopathy subtypes, clinical profiles of patients, and European tertiary referral centres. This gap with current guidelines needs to be considered carefully by scientific societies to promote wider availability and use of CMR in patients with cardiomyopathies.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Imaging: 07 Jan 2021; epub ahead of print
Mizia-Stec K, Charron P, Gimeno Blanes JR, Elliott P, ... Caforio ALP,
Eur Heart J Cardiovasc Imaging: 07 Jan 2021; epub ahead of print | PMID: 33417664
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Abstract

Role of cardiovascular magnetic resonance imaging in cardio-oncology.

Saunderson CED, Plein S, Manisty CH

Advances in cancer therapy have led to significantly longer cancer-free survival times over the last 40 years. Improved survivorship coupled with increasing recognition of an expanding range of adverse cardiovascular effects of many established and novel cancer therapies has highlighted the impact of cardiovascular disease in this population. This has led to the emergence of dedicated cardio-oncology services that can provide pre-treatment risk stratification, surveillance, diagnosis, and monitoring of cardiotoxicity during cancer therapies, and late effects screening following completion of treatment. Cardiovascular imaging and the development of imaging biomarkers that can accurately and reliably detect pre-clinical disease and enhance our understanding of the underlying pathophysiology of cancer treatment-related cardiotoxicity are becoming increasingly important. Multi-parametric cardiovascular magnetic resonance (CMR) is able to assess cardiac structure, function, and provide myocardial tissue characterization, and hence can be used to address a variety of important clinical questions in the emerging field of cardio-oncology. In this review, we discuss the current and potential future applications of CMR in the investigation and management of cancer patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 05 Jan 2021; epub ahead of print
Saunderson CED, Plein S, Manisty CH
Eur Heart J Cardiovasc Imaging: 05 Jan 2021; epub ahead of print | PMID: 33404058
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Impact:
Abstract

Prevalence, multimodality imaging characterization, and mid-term prognosis of quadricuspid aortic valves: an analysis of eight cases, based on 160 004 exams performed during 12 years in a tertiary care hospital.

Manuel AM, Ladeiras-Lopes R, Ribeiro J, Ferreira ND, ... Braga P, Fontes-Carvalho R
Aims
Quadricuspid aortic valve (QAV) is a rare abnormality, which may cause aortic regurgitation (AR) requiring surgical intervention in some patients. The characteristics associated with aortic valve functional degeneration in patients with QAV are still unknown. The aim of this study is to describe QAV prevalence, characterize the disease by multimodality imaging, evaluate predictors of severe AR, and assess mid-term prognosis.
Methods and results
Retrospective search in imaging exams database of one tertiary centre, for patients diagnosed with QAV between January 2007 and September 2019. QAV was characterized by cardiac computed tomography, transthoracic/transoesophageal echocardiography, and cardiac magnetic resonance. A total of 160 004 exams were reviewed and eight patients with QAV were identified (50% men, mean age 53.5 ± 10.7 years). The prevalence of QAV was 0.005%. During a median follow-up of 52 months (interquartile range 16-88), there were no deaths. Seven patients (88%) had pure AR (three severe, one moderate, and three mild) and one patient (12%) had moderate AR and moderate aortic stenosis. Three patients (38%) with severe AR underwent valve surgery (two replacements and one repair). Analysis of predictors of severe AR was not statistically significant.
Conclusion
QAV is a rare congenital cardiac defect, with a prevalence of 0.005% in our study. Its predominant functional abnormality was regurgitation and about one-third of the patients required aortic valve surgery. Multimodality imaging may play a pivotal role in assessing patients with QAV with significant valve dysfunction or associated congenital heart disease and improve their treatment strategy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 04 Jan 2021; epub ahead of print
Manuel AM, Ladeiras-Lopes R, Ribeiro J, Ferreira ND, ... Braga P, Fontes-Carvalho R
Eur Heart J Cardiovasc Imaging: 04 Jan 2021; epub ahead of print | PMID: 33400773
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Abstract

Echocardiographic evaluation of patients undergoing cancer therapy.

Frey MK, Bergler-Klein J

As advances in oncology therapies lead to significant improvement in life expectancy of many cancer entities, short-, and long-term cardiac side effects of oncology treatments gain increasing importance. In search of new screening modalities, echocardiography currently presents the best established and clinically easily feasible tool to detect cardiotoxicity in patients undergoing cancer therapy. This review focusses on the most commonly used oncology therapies and aims to give a practical approach to guide clinicians caring for this growing number of patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Cardiovasc Imaging: 03 Jan 2021; epub ahead of print
Frey MK, Bergler-Klein J
Eur Heart J Cardiovasc Imaging: 03 Jan 2021; epub ahead of print | PMID: 33393591
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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: 31 Dec 2020; 22:119-128
Assan F, de Zuttere D, Bottin L, Tavolaro S, ... Francès C, Chasset F
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:119-128 | PMID: 31898726
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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: 31 Dec 2020; 22:82-91
Issa IF, Dahl JS, Poulsen SH, Waziri F, ... Søgaard P, Møller JE
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:82-91 | PMID: 31942609
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Abstract

Left ventricular myocardial crypts: morphological patterns and prognostic implications.

Sigvardsen PE, Pham MHC, Kühl JT, Fuchs A, ... Køber L, Kofoed KF
Aims 
Left ventricular (LV) myocardial crypts are considered a subtle marker of hypertrophic cardiomyopathy. However, crypts have also been observed in seemingly healthy individuals and it is unknown whether myocardial crypts are associated with adverse outcome.
Methods and results 
Myocardial crypts were defined as invaginations traversing >50% of the myocardial wall and assessed using contrast-enhanced cardiac computed tomography in 10 097 individuals from the Copenhagen General Population Study. Number of crypts, location, shape, penetrance, and volume were assessed. The endpoint was a composite of major adverse cardiovascular events and defined as death, myocardial infarction, heart failure, or stroke. Cox regression models were adjusted for clinical variables, medical history, electrocardiographic parameters, and cardiac chamber sizes. A total of 1199 LV myocardial crypts were identified in 915 (9.1%) individuals. Seven hundred (6.9%) had one crypt and 215 (2.1%) had multiple crypts. During a median follow-up of 4.0 years (interquartile range 1.5-6.7), major adverse cardiovascular events occurred in 619 individuals. Individuals with one or multiple crypts had a hazard ratio for major adverse cardiovascular events of 1.00 [95% confidence interval (CI): 0.72-1.40; P = 0.98] and 0.90 (95% CI: 0.47-1.75; P = 0.76), respectively, compared with those with no crypts. No specific pattern of crypt location, shape, penetrance, or volume was associated to an increased hazard ratio for major adverse cardiovascular events.
Conclusion 
LV myocardial crypts are frequent in the general population and are not associated with intermediate-term major adverse cardiovascular events.

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: 31 Dec 2020; 22:75-81
Sigvardsen PE, Pham MHC, Kühl JT, Fuchs A, ... Køber L, Kofoed KF
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:75-81 | PMID: 32083645
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Abstract

Prognostic significance of cardiac I-123-metaiodobenzylguanidine imaging in patients with reduced, mid-range, and preserved left ventricular ejection fraction admitted for acute decompensated heart failure: a prospective study in Osaka Prefectural Acute Heart Failure Registry (OPAR).

Seo M, Yamada T, Tamaki S, Watanabe T, ... Sakata Y, Fukunami M
Aims
Cardiac 123I-metaiodobenzylguanidine (123I-MIBG) imaging provides prognostic information in patients with chronic heart failure (HF). However, there is little information available on the prognostic role of cardiac 123I-MIBG imaging in patients admitted for acute decompensated heart failure (ADHF), especially relating to reduced ejection fraction [HFrEF; left ventricular ejection fraction (LVEF) < 40%], mid-range ejection fraction (HFmrEF; 40% ≤ LVEF < 50%) and preserved ejection fraction (HFpEF; LVEF ≥ 50%).
Methods and results
We studied 349 patients admitted for ADHF and discharged with survival. Cardiac 123I-MIBG imaging, echocardiography, and venous blood sampling were performed just before discharge. The cardiac 123I-MIBG heart-to-mediastinum ratio (late H/M) was measured on the chest anterior view images obtained at 200 min after the isotope injection. The endpoint was cardiac events defined as unplanned HF hospitalization and cardiac death. During a follow-up period of 2.1 ± 1.4 years, 128 patients had cardiac events (45/127 in HFrEF, 28/78 in HFmrEF, and 55/144 in HFpEF). On multivariable Cox analysis, late H/M was significantly associated with cardiac events in overall cohort (P = 0.0038), and in subgroup analysis of each LVEF subgroup (P = 0.0235 in HFrEF, P = 0.0119 in HFmEF and P = 0.0311 in HFpEF). Kaplan-Meier analysis showed that patients with low late H/M (defined by median) had significantly greater risk of cardiac events in overall cohort (49% vs. 25% P < 0.0001) and in each LVEF subgroup (HFrEF: 48% vs. 23% P = 0.0061, HFmrEF: 51% vs. 21% P = 0.0068 and HFpEF: 50% vs. 26% P = 0.0026).
Conclusion
Cardiac sympathetic nerve dysfunction was associated with poor outcome in ADHF patients irrespective of HFrEF, HFmrEF, or HFpEF.

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Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:58-66
Seo M, Yamada T, Tamaki S, Watanabe T, ... Sakata Y, Fukunami M
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:58-66 | PMID: 32091079
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Abstract

The relation between cardiac 123I-mIBG scintigraphy and functional response 1 year after CRT implantation.

Verschure DO, Poel E, De Vincentis G, Frantellizzi V, ... de Groot JR, Verberne HJ
Aims 
Cardiac resynchronization therapy (CRT) is a disease-modifying therapy in patients with chronic heart failure (CHF). Current guidelines ascribe CRT eligibility on three parameters only: left ventricular ejection fraction (LVEF), QRS duration, and New York Heart Association (NYHA) functional class. However, one-third of CHF patients does not benefit from CRT. This study evaluated whether 123I-meta-iodobenzylguanidine (123I-mIBG) assessed cardiac sympathetic activity could optimize CRT patient selection.
Methods and results 
A total of 78 stable CHF subjects (age 66.8 ± 9.6 years, 73% male, LVEF 25.2 ± 6.7%, QRS duration 153 ± 23 ms, NYHA 2.2 ± 0.7) referred for CRT implantation were enrolled. Subjects underwent 123I-mIBG scintigraphy prior to implantation. Early and late heart-to-mediastinum (H/M) ratio and 123I-mIBG washout were calculated. CRT response was defined as either an increase of LVEF to >35%, any improvement in LVEF of >10%, QRS shortening to <150 ms, or improvement in NYHA class of >1 class. In 33 patients LVEF increased to >35%, QRS decreased <150 ms in 36 patients, and NYHA class decreased in 33 patients. Late H/M ratio and hypertension were independent predictors of LVEF improvement to >35% (P = 0.0014 and P = 0.0149, respectively). In addition, early H/M ratio, LVEF, and absence of diabetes mellitus (DM) were independent predictors for LVEF improvement by >10%. No independent predictors were found for QRS shortening to <150 ms or improvement in NYHA class.
Conclusion 
Early and late H/M ratio were independent predictors of CRT response when improvement of LVEF was used as measure of response. Therefore, cardiac 123I-mIBG scintigraphy may be used as a tool to optimize selection of subjects that might benefit from CRT.

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

Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:49-57
Verschure DO, Poel E, De Vincentis G, Frantellizzi V, ... de Groot JR, Verberne HJ
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:49-57 | PMID: 32259839
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Abstract

Left ventricular trabeculation and major adverse cardiovascular events: the Copenhagen General Population Study.

Sigvardsen PE, Fuchs A, Kühl JT, Afzal S, ... Nordestgaard BG, Kofoed KF
Aims 
Prominent left ventricular trabeculations is a phenotypic trait observed in cardiovascular diseases. In the general population, the extent of left ventricular trabeculations is highly variable, yet it is unknown whether increased trabeculation is associated with adverse outcome.
Methods and results 
Left ventricular trabeculated mass (g/m2) was measured with contrast-enhanced cardiac computed tomography in 10 097 individuals from the Copenhagen General Population Study. The primary endpoint was a composite of major adverse cardiovascular events and defined as death, heart failure, myocardial infarction, or stroke. The secondary endpoints were the individual components of the primary endpoint. Cox regression models were adjusted for clinical parameters, medical history, electrocardiographic parameters, and cardiac chamber sizes. The mean trabeculated mass was 19.1 g/m2 (standard deviation 4.9 g/m2). During a median follow-up of 4.0 years (interquartile range 1.5-6.7), 710 major adverse cardiovascular events occurred in 619 individuals. Individuals with a left ventricular trabeculated mass in the highest quartile had a hazard ratio for major adverse cardiovascular events of 1.64 [95% confidence interval (CI) 1.30-2.08; P < 0.001] compared to those in the lowest quartile. Corresponding hazard ratios were 2.08 (95% CI 1.38-3.14; P < 0.001) for death, 2.63 (95% CI 1.61-4.31; P < 0.001) for heart failure, 1.08 (95% CI 0.56-2.08; P = 0.82) for myocardial infarction, and 1.07 (95% CI 0.72-1.57; P = 0.74) for stroke.
Conclusion 
Increased left ventricular trabeculation is independently associated with an increased rate of major adverse cardiovascular events in the general population.

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: 31 Dec 2020; 22:67-74
Sigvardsen PE, Fuchs A, Kühl JT, Afzal S, ... Nordestgaard BG, Kofoed KF
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:67-74 | PMID: 32386205
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Abstract

The value of septal rebound stretch analysis for the prediction of volumetric response to cardiac resynchronization therapy.

Salden OAE, Zweerink A, Wouters P, Allaart CP, ... Prinzen FW, Cramer MJ
Aims
Patient selection for cardiac resynchronization therapy (CRT) may be enhanced by evaluation of systolic myocardial stretching. We evaluate whether systolic septal rebound stretch (SRSsept) derived from speckle tracking echocardiography is a predictor of reverse remodelling after CRT and whether it holds additive predictive value over the simpler visual dyssynchrony assessment by apical rocking (ApRock).
Methods and results
The association between SRSsept and change in left ventricular end-systolic volume (ΔLVESV) at 6 months of follow-up was assessed in 200 patients. Subsequently, the additive predictive value of SRSsept over the assessment of ApRock was evaluated in patients with and without left bundle branch block (LBBB) according to strict criteria. SRSsept was independently associated with ΔLVESV (β 0.221, P = 0.002) after correction for sex, age, ischaemic cardiomyopathy, QRS morphology and duration, and ApRock. A high SRSsept (≥optimal cut-off value 2.4) also coincided with more volumetric responders (ΔLVESV ≥ -15%) than low SRSsept in the entire cohort (70.0% and 56.4%), in patients with strict LBBB (83.3% vs. 56.7%, P = 0.024), and non-LBBB (70.7% vs. 46.3%, P = 0.004). Moreover, in non-LBBB patients, SRSsept held additional predictive information over the assessment of ApRock alone since patients that showed ApRock and high SRSsept were more often volumetric responder than those with ApRock but low SRSsept (82.8% vs. 47.4%, P = 0.001).
Conclusion
SRSsept is strongly associated with CRT-induced reduction in left ventricular end-systolic volume and holds additive prognostic information over QRS morphology and ApRock. Our data suggest that CRT patient selection may be improved by assessment of SRSsept, especially in the important subgroup without strict LBBB.
Clinical trial registration
The MARC study was registered at clinicaltrials.gov: NCT01519908.

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: 31 Dec 2020; 22:37-45
Salden OAE, Zweerink A, Wouters P, Allaart CP, ... Prinzen FW, Cramer MJ
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:37-45 | PMID: 32699908
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Impact:
Abstract

Age- and sex-related features of atherosclerosis from coronary computed tomography angiography in patients prior to acute coronary syndrome: results from the ICONIC study.

Conte E, Dwivedi A, Mushtaq S, Pontone G, ... Chang HJ, Andreini D
Aims
Although there is increasing evidence supporting coronary atherosclerosis evaluation by coronary computed tomography angiography (CCTA), no data are available on age and sex differences for quantitative plaque features. The aim of this study was to investigate sex and age differences in both qualitative and quantitative atherosclerotic features from CCTA prior to acute coronary syndrome (ACS).
Methods and results
Within the ICONIC study, in which 234 patients with subsequent ACS were propensity matched 1:1 with 234 non-event controls, our current subanalysis included only the ACS cases. Both qualitative and quantitative advance plaque analysis by CCTA were performed by a core laboratory. In 129 cases, culprit lesions identified by invasive coronary angiography at the time of ACS were co-registered to baseline CCTA precursor lesions. The study population was then divided into subgroups according to sex and age (<65 vs. ≥ 65 years old) for analysis. Older patients had higher total plaque volume than younger patients. Within specific subtypes of plaque volume, however, only calcified plaque volume was higher in older patients (135.9 ± 163.7 vs. 63.8 ± 94.2 mm3, P < 0.0001, respectively). Although no sex-related differences were recorded for calcified plaque volume, females had lower fibrous and fibrofatty plaque volume than males (Fibrofatty volume 29.6 ± 44.1 vs. 75.3 ± 98.6 mm3, P = 0.0001, respectively). No sex-related differences in the prevalence of qualitative high-risk plaque features were found, even after separate analyses considering age were performed.
Conclusion
Our data underline the importance of age- and sex-related differences in coronary atherosclerosis presentation, which should be considered during CCTA-based atherosclerosis quantification.

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: 31 Dec 2020; 22:24-33
Conte E, Dwivedi A, Mushtaq S, Pontone G, ... Chang HJ, Andreini D
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:24-33 | PMID: 32793985
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Impact:
Abstract

Reclassification of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted vs. measured indexed effective orifice area.

Ternacle J, Guimaraes L, Vincent F, Côté N, ... Pibarot P, Rodés-Cabau J
Aims
The objective was to compare the incidence and impact on outcomes of measured (PPMM) vs. predicted (PPMP) prosthesis-patient mismatch following transcatheter aortic valve replacement (TAVR).
Methods and results
All consecutives patients who underwent TAVR between 2007 and 2018 were included. Effective orifice area (EOA) was measured by Doppler-echocardiography using the continuity equation and predicted according to the normal reference for each model and size of valve. PPM was defined using EOA indexed (EOAi) to body surface area as moderate if ≤0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 (respectively, ≤ 0.70 and ≤ 0.55 cm2/m2 if body mass index ≥ 30 kg/m2). The outcome endpoints were high residual gradient (≥20 mmHg) and the composite of cardiovascular mortality and hospital readmission for heart failure at 1 year. Overall, 1088 patients underwent a TAVR (55% male, age 79.1 ± 8.4 years, and STS score 6.6 ± 4.7%); balloon-expandable device was used in 83%. Incidence of moderate (10% vs. 27%) and severe (1% vs. 17%) PPM was markedly lower when defined by predicted vs. measured EOAi (P < 0.001). Balloon-expandable device implantation (OR: 1.90, P = 0.029) and valve-in-valve procedure (n = 118; OR: 3.21, P < 0.001) were the main factors associated with PPM occurrence. Compared with measured PPM, predicted PPM showed stronger association with high residual gradient. Severe measured or predicted PPM was not associated with clinical outcomes.
Conclusion
The utilization of the predicted EOAi reclassifies the majority of patients with PPM to no PPM following TAVR. Compared with measured PPM, predicted PPM had stronger association with haemodynamic outcomes, while both methods were not associated with clinical outcomes.

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: 31 Dec 2020; 22:11-20
Ternacle J, Guimaraes L, Vincent F, Côté N, ... Pibarot P, Rodés-Cabau J
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:11-20 | PMID: 32995865
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Impact:
Abstract

EACVI survey on investigations and imaging modalities in chronic coronary syndromes.

Bularga A, Saraste A, Fontes-Carvalho R, Holte E, ... Haugaa KH, Dweck MR
Aims
The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with suspected and confirmed chronic coronary syndromes.
Methods and results
One-hundred and ten imaging centres from 37 countries across the world responded to the survey. Most non-invasive investigations for coronary artery disease were widely available, except cardiovascular magnetic resonance (available 40% centres). Coronary computed tomography angiography (CCTA) and nuclear scans were reported by a multi-disciplinary team in only a quarter of centres. In the initial assessment of patients presenting with chest pain, only 32% of respondents indicated that they rely on pre-test probability for selecting the optimal imaging test while 31% proceed directly to CCTA. In patients with established coronary artery disease and recurrent chest pain, respondents opted for stress echocardiography (27%) and nuclear stress perfusion scans (26%). In asymptomatic patients with coronary artery disease and an obstructive (>70%) right coronary artery stenosis, 58% of respondents were happy to pursue medical therapy without further testing or intervention. This proportion fell to 29% with left anterior descending artery stenosis and 1% with left main stem obstruction. In asymptomatic patients with evidence of moderate-to-severe myocardial ischaemia (15%), only 18% of respondents would continue medical therapy without further investigation.
Conclusion
Despite guidelines recommendations pre-test probability is used to assess patients with suspected coronary artery in a minority of centres, one-third of centres moving directly to CCTA. Clinicians remain reticent to pursue a strategy of optimal medical therapy without further investigation or intervention in patients with controlled symptoms but obstructive coronary artery stenoses or myocardial ischaemia.

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

Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:1-7
Bularga A, Saraste A, Fontes-Carvalho R, Holte E, ... Haugaa KH, Dweck MR
Eur Heart J Cardiovasc Imaging: 31 Dec 2020; 22:1-7 | PMID: 33165600
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Impact:
Abstract

Right ventricular function and outcome in patients undergoing transcatheter aortic valve replacement.

Koschutnik M, Dannenberg V, Nitsche C, Donà C, ... Kammerlander AA, Mascherbauer J
Aims
Right ventricular dysfunction (RVD) on echocardiography has been shown to predict outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). However, a comparison with the gold standard, RV ejection fraction (EF) on cardiovascular magnetic resonance (CMR), has never been performed.
Methods and results
Consecutive patients scheduled for TAVR underwent echocardiography and CMR. RV fractional area change (FAC), tricuspid annular plane systolic excursion, RV free-lateral-wall tissue Doppler (S\'), and strain were assessed on echocardiography, and RVEF on CMR. Patients were prospectively followed. Adjusted regression analyses were used to report the strength of association per 1-SD decline for each RV function parameter with (i) N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels, (ii) prolonged in-hospital stay (>14 days), and (iii) a composite of heart failure hospitalization and death. Two hundred and four patients (80.9 ± 6.6 y/o; 51% female; EuroSCORE-II: 6.3 ± 5.1%) were included. At a cross-sectional level, all RV function parameters were associated with NT-proBNP levels, but only FAC and RVEF were significantly associated with a prolonged in-hospital stay [adjusted odds ratio 1.86, 95% confidence interval (CI) 1.07-3.21; P = 0.027 and 2.29, 95% CI 1.43-3.67; P = 0.001, respectively]. A total of 56 events occurred during follow-up (mean 13.7 ± 9.5 months). After adjustment for the EuroSCORE-II, only RVEF was significantly associated with the composite endpoint (adjusted hazard ratio 1.70, 95% CI 1.32-2.20; P < 0.001).
Conclusion
RVD as defined by echocardiography is associated with an advanced disease state but fails to predict outcomes after adjustment for pre-existing clinical risk factors in TAVR patients. In contrast, RVEF on CMR is independently associated with heart failure hospitalization and death.

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: 29 Dec 2020; epub ahead of print
Koschutnik M, Dannenberg V, Nitsche C, Donà C, ... Kammerlander AA, Mascherbauer J
Eur Heart J Cardiovasc Imaging: 29 Dec 2020; epub ahead of print | PMID: 33377480
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Impact:
Abstract

Interplay between right atrial function and liver stiffness in adults with repaired right ventricular outflow obstructive lesions.

Li VW, So EK, Li W, Chow PC, Cheung YF
Aims
This study determined the associations between right atrial (RA) and right ventricular (RV) mechanics and liver stiffness in adults with repaired tetralogy of Fallot (TOF), pulmonary atresia with intact ventricular septum (PAVIS), and pulmonary stenosis (PS).
Methods and results
Ninety subjects including 26 repaired TOF, 24 PAIVS, and 20 PS patients and 20 controls were studied. Hepatic shear wave velocity and tissue elasticity (E), measures of liver stiffness, were assessed by two-dimensional shear wave elastography, while RA and RV mechanics were assessed by speckle tracking echocardiography. Deformation analyses revealed worse RV systolic strain and strain rate, and RA peak positive and total strain, and strain rates at ventricular systole and at early diastole in all of the patient groups compared with controls (all P < 0.05). Compared with controls, all of the patient groups had significantly greater shear wave velocity and hepatic E-value (all P < 0.05). Shear wave velocity and hepatic E-value correlated negatively with RV systolic strain rate, and RA positive strain, total strain, and strain rate at ventricular systole and at early diastole (all P < 0.05). Multivariate analyses revealed RA strain rate at early diastole (P = 0.015, P < 0.001), maximum RA size (P < 0.001, P < 0.001), and severity of pulmonary regurgitation (P = 0.05, Pp = 0.014) as significant correlates of shear wave velocity and hepatic E-value.
Conclusion
In adults with repaired TOF, PAIVS, and PS, RA dysfunction and pulmonary regurgitation are associated with liver stiffness.

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: 25 Dec 2020; epub ahead of print
Li VW, So EK, Li W, Chow PC, Cheung YF
Eur Heart J Cardiovasc Imaging: 25 Dec 2020; epub ahead of print | PMID: 33367540
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Impact:
Abstract

Practical cardiovascular imaging approach to diagnose immune checkpoint inhibitor myocarditis.

Kondapalli L, Medina T, Groves DW

Immuno-oncology employs various therapeutic strategies that harness a patient\'s own immune system to fight disease and has been a promising new strategy for cancer therapy over the last decade. Immune checkpoint inhibitors (ICI), are monoclonal antibodies, that increase antitumor immunity by blocking intrinsic down-regulators of immunity, such as cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death 1 (PD-1) or its ligand, programmed cell death ligand 1 (PD-L1). Seven ICIs are currently approved by the Food and Drug Administration and have increased the overall survival for patients with various cancer subtypes. These are used either as single agents or in combination with other checkpoint inhibitors, small molecular kinase inhibitors or cytotoxic chemotherapies. There are also many other immune modifying agents including other checkpoint inhibitor antibodies that are under investigation in clinical trials.

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: 23 Dec 2020; epub ahead of print
Kondapalli L, Medina T, Groves DW
Eur Heart J Cardiovasc Imaging: 23 Dec 2020; epub ahead of print | PMID: 33367684
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Impact:
Abstract

EACVI survey on the management of patients with patent foramen ovale and cryptogenic stroke.

D\'Andrea A, Dweck MR, Holte E, Fontes-Carvalho R, ... Diener HC, Haugaa KH
Aims 
The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the current practice for the assessment and management of patients with suspected patent foramen ovale (PFO) and cryptogenic stroke.
Methods and results 
In total, 79 imaging centres from 34 countries across the world responded to the survey, which comprised 17 questions. Most non-invasive investigations for PFO were widely available in the responding centres, with the exception of transcranial colour Doppler which was only available in 70% of sites, and most commonly performed by neurologists. Standard transthoracic echocardiography, with or without bubbles, was considered the first-level test for suspected PFO in the majority of the centres, whereas transoesophageal echocardiography was an excellent second-level modality. Most centres would rule out atrial fibrillation (AF) as a source of embolism in all patients with cryptogenic stroke (63%), with the remainder reserving investigation for patients with multiple AF risk factors (33%). Cardiac magnetic resonance was the preferred tool for identifying other unusual aetiologies, like cardiac masses or thrombi. After PFO closure, there was variation in the use of antiplatelet therapy: a quarter recommended treatment for life, while only 12% recommended 5 years as stipulated in the guidelines (12%). Antibiotic prophylaxis prior to dental or endoscopic procedures was not recommended in 41% of centres, contrary to what the guidelines recommended.
Conclusion 
Our survey revealed a variable adherence to the current recommendations for the diagnosis and management of patients with cryptogenic stroke and PFO. Efforts should focus on optimizing and standardizing diagnostic tests and treatment of this condition.

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: 20 Dec 2020; epub ahead of print
D'Andrea A, Dweck MR, Holte E, Fontes-Carvalho R, ... Diener HC, Haugaa KH
Eur Heart J Cardiovasc Imaging: 20 Dec 2020; epub ahead of print | PMID: 33346351
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Impact:
Abstract

Imaging the adult with simple shunt lesions: position paper from the EACVI and the ESC WG on ACHD. Endorsed by AEPC (Association for European Paediatric and Congenital Cardiology).

Budts W, Miller O, Babu-Narayan SV, Li W, ... Gatzoulis M, Di Salvo G

In 2018, the position paper \'Imaging the adult with congenital heart disease: a multimodality imaging approach\' was published. The paper highlights, in the first part, the different imaging modalities applied in adult congenital heart disease patients. In the second part, these modalities are discussed more detailed for moderate to complex anatomical defects. Because of the length of the paper, simple lesions were not touched on. However, imaging modalities to use for simple shunt lesions are still poorly known. One is looking for structured recommendations on which they can rely when dealing with an (undiscovered) shunt lesion. This information is lacking for the initial diagnostic process, during repair and at follow-up. Therefore, this paper will focus on atrial septal defect, ventricular septal defect, and persistent arterial duct. Pre-, intra-, and post-procedural imaging techniques will be systematically discussed. This position paper will offer algorithms that might help at a glance. The document is prepared for general cardiologists, trainees, medical students, imagers/technicians to select the most appropriate imaging modality and to detect the requested information for each specific lesion. It might serve as reference to which researchers could refer when setting up a (imaging) study.

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: 17 Dec 2020; epub ahead of print
Budts W, Miller O, Babu-Narayan SV, Li W, ... Gatzoulis M, Di Salvo G
Eur Heart J Cardiovasc Imaging: 17 Dec 2020; epub ahead of print | PMID: 33338215
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Impact:
Abstract

A comparison of the clinical efficacy of echocardiography and magnetic resonance for chronic aortic regurgitation.

Postigo A, Pérez-David E, Revilla A, Raquel LA, ... J Alberto SR, Bermejo J
Aims
Timing surgery in chronic aortic regurgitation (AR) relies mostly on echocardiography. However, cardiac magnetic resonance (CMR) may be more accurate for quantifying regurgitation and left ventricular (LV) remodelling. We aimed to compare the technical and clinical efficacies of echocardiography and CMR to account for the severity of the disease, the degree of LV remodelling, and predict AR-related outcomes.
Methods and results
We studied 263 consecutive patients with isolated AR undergoing echocardiography and CMR. After a median follow-up of 33 months, 76 out of 197 initially asymptomatic patients reached the primary endpoint of AR-related events: 6 patients (3%) were admitted for heart failure, and 70 (36%) underwent surgery. Adjusted survival models based on CMR improved the predictions of the primary endpoint based on echocardiography: R2 = 0.37 vs. 0.22, χ2 = 97 vs. 49 (P < 0.0001), and C-index = 0.80 vs. 0.70 (P < 0.001). This resulted in a net classification index of 0.23 (0.00-0.46, P = 0.046) and an integrated discrimination improvement of 0.12 (95% confidence interval 0.08-0.58, P = 0.02). CMR-derived regurgitant fraction (<28, 28-37, or >37%) and LV end-diastolic volume (<83, 183-236, or >236 mL) adequately stratified patients with normal EF. The agreement between techniques for grading AR severity and assessing LV dilatation was poor, and CMR showed better reproducibility.
Conclusions
CMR improves the clinical efficacy of ultrasound for predicting outcomes of patients with AR. This is due to its better reproducibility and accuracy for grading the severity of the disease and its impact on the LV. Regurgitant fraction, LV ejection fraction, and end-diastolic volume obtained by CMR most adequately predict AR-related events.

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: 16 Dec 2020; epub ahead of print
Postigo A, Pérez-David E, Revilla A, Raquel LA, ... J Alberto SR, Bermejo J
Eur Heart J Cardiovasc Imaging: 16 Dec 2020; epub ahead of print | PMID: 33332549
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Impact:
Abstract

Prognostic significance of aortic valve calcium in relation to coronary artery calcification for long-term, cause-specific mortality: results from the CAC Consortium.

Han D, Cordoso R, Whelton S, Rozanski A, ... Blaha MJ, Berman DS
Aims
Aortic valve calcification (AVC) has been shown to be associated with increased cardiovascular disease (CVD) risk; however, whether this is independent of traditional risk factors and coronary artery calcification (CAC) remains unclear.
Methods and results
From the multicentre CAC Consortium database, 10 007 patients (mean 55.8±11.7 years, 64% male) with concomitant CAC and AVC scoring were included in the current analysis. AVC score was quantified using the Agatston score method and categorized as 0, 1-99, and ≥100. The endpoints were all-cause, CVD, and coronary heart disease (CHD) deaths. AVC (AVC>0) was observed in 1397 (14%) patients. During a median 7.8 (interquartile range: 4.7-10.6) years of study follow-up, 511 (5.1%) deaths occurred; 179 (35%) were CVD deaths, and 101 (19.8%) were CHD deaths. A significant interaction between CAC and AVC for mortality was observed (P<0.001). The incidence of mortality events increased with higher AVC; however, AVC ≥100 was not independently associated with all-cause, CVD, and CHD deaths after adjusting for CVD risk factors and CAC (P=0.192, 0.063, and 0.206, respectively). When further stratified by CAC<100 or ≥100, AVC ≥100 was an independent predictor of all-cause and CVD deaths only in patients with CAC <100, after adjusting for CVD risk factors and CAC [hazard ratio (HR): 1.93, 95% confidence interval (CI): 1.14-3.27; P=0.013 and HR: 2.71, 95% CI: 1.15-6.34; P=0.022, respectively].
Conclusion
Although the overall prognostic significance of AVC was attenuated after accounting for CAC, high AVC was independently associated with all-cause and CVD deaths in patients with low coronary atherosclerosis burden.

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: 16 Dec 2020; epub ahead of print
Han D, Cordoso R, Whelton S, Rozanski A, ... Blaha MJ, Berman DS
Eur Heart J Cardiovasc Imaging: 16 Dec 2020; epub ahead of print | PMID: 33331631
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Impact:
Abstract

How to perform a cardio-thoracic magnetic resonance imaging in COVID-19: comprehensive assessment of heart, pulmonary arteries, and lung parenchyma.

Galea N, Catapano F, Marchitelli L, Cundari G, ... Catalano C, Francone M

We proposed a combined cardiothoracic-MRI (CaTh-MRI) protocol for the comprehensive assessment of cardiovascular structures, lung parenchyma, and pulmonary arterial tree, in COVID-19 patients with progressive worsening of clinical conditions and/or suspicion of acute-onset myocardial inflammation. A 25-minutes fast protocol was also conceived for unstable or uncooperative patients by restricting the number of sequences to those necessary to rule out myocardial and to assess pulmonary involvement. In patients requiring CMR characterization of myocardial damage, the addition of lung and thoracic vessel evaluation is of clinical benefit at a minimal time expense.

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: 15 Dec 2020; epub ahead of print
Galea N, Catapano F, Marchitelli L, Cundari G, ... Catalano C, Francone M
Eur Heart J Cardiovasc Imaging: 15 Dec 2020; epub ahead of print | PMID: 33325495
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Impact:
Abstract

Computed tomography angiography-derived extracellular volume fraction predicts early recovery of left ventricular systolic function after transcatheter aortic valve replacement.

Han D, Tamarappoo B, Klein E, Tyler J, ... Makkar R, Friedman J
Aims 
Recovery of left ventricular ejection fraction (LVEF) after aortic valve replacement has prognostic importance in patients with aortic stenosis (AS). The mechanism by which myocardial fibrosis impacts LVEF recovery in AS is not well characterized. We sought to evaluate the predictive value of extracellular volume fraction (ECV) quantified by cardiac CT angiography (CTA) for LVEF recovery in patients with AS after transcatheter aortic valve replacement (TAVR).
Methods and results 
In 109 pre-TAVR patients with LVEF <50% at baseline echocardiography, CTA-derived ECV was calculated as the ratio of change in CT attenuation of the myocardium and the left ventricular (LV) blood pool before and after contrast administration. Early LVEF recovery was defined as an absolute increase of ≥10% in LVEF measured by post-TAVR follow-up echocardiography within 6 months of the procedure. Early LVEF recovery was observed in 39 (36%) patients. The absolute increase in LVEF was 17.6 ± 8.8% in the LVEF recovery group and 0.9 ± 5.9% in the no LVEF recovery group (P < 0.001). ECV was significantly lower in patients with LVEF recovery compared with those without LVEF recovery (29.4 ± 6.1% vs. 33.2 ± 7.7%, respectively, P = 0.009). In multivariable analysis, mean pressure gradient across the aortic valve [odds ratio (OR): 1.07, 95% confidence interval (CI): 1.03-1.11, P: 0.001], LV end-diastolic volume (OR: 0.99, 95% CI: 0.98-0.99, P: 0.035), and ECV (OR: 0.92, 95% CI: 0.86-0.99, P: 0.018) were independent predictors of early LVEF recovery.
Conclusion 
Increased myocardial ECV on CTA is associated with impaired LVEF recovery post-TAVR in severe AS patients with impaired LV systolic function.

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: 15 Dec 2020; epub ahead of print
Han D, Tamarappoo B, Klein E, Tyler J, ... Makkar R, Friedman J
Eur Heart J Cardiovasc Imaging: 15 Dec 2020; epub ahead of print | PMID: 33324979
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Impact:
Abstract

Additional prognostic value of heart rate reserve over left ventricular contractile reserve and coronary flow velocity reserve in diabetic patients with negative vasodilator stress echocardiography by regional wall motion criteria.

Cortigiani L, Ciampi Q, Carpeggiani C, Lisi C, Bovenzi F, Picano E
Aims 
In diabetic patients, a blunted left ventricular contractile reserve (LVCR) and/or a reduced coronary flow velocity reserve (CFVR) identify patients at higher risk in spite of stress echocardiography (SE) negative for ischaemia. Cardiac autonomic dysfunction contributes to risk profile independently of inducible ischaemia and can be assessed with heart rate reserve (HRR). We sought to assess the added prognostic value of HRR to LVCR and CFVR in diabetic patients with non-ischaemic SE.
Methods and results 
Six-hundred and thirty-six diabetic patients (age 68 ± 9 years, 396 men, ejection fraction 58 ± 10%) with sinus rhythm on resting electrocardiogram underwent dipyridamole SE in a two-centre prospective study with assessment of wall motion, force-based LVCR (stress/rest ratio, normal value > 1.1), CFVR of the left anterior descending coronary artery (stress/rest ratio, normal value >2.0), and HRR (stress/rest ratio, normal value >1.22). All-cause death was the only considered endpoint. During a median follow-up of 39 months, 94 (15%) patients died. Independent predictors of death were abnormal CFVR [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.0-2.52, P = 0.05], reduced LVCR (HR 1.76, 95% CI 1.15-2.69, P = 0.009), and blunted HRR (HR 1.92, 95% CI 1.24-2.96, P = 0.003). Eight-year death rate was 9% for patients with triple negativity (n = 252; 40%), 18% for those with single positivity (n = 216; 34%), 36% with double positivity (n = 124; 19%), and 64% for triple positivity (n = 44; 7%) (P < 0.0001).
Conclusion 
Diabetic patients with dipyridamole SE negative for ischaemia still may have a significant risk in presence of an abnormal LVCR and/or CFVR and/or HRR, which assess the underlying myocardial, microvascular, and cardiac autonomic dysfunction.
Clinical trials
Gov Identifier NCT 030.49995.

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: 13 Dec 2020; epub ahead of print
Cortigiani L, Ciampi Q, Carpeggiani C, Lisi C, Bovenzi F, Picano E
Eur Heart J Cardiovasc Imaging: 13 Dec 2020; epub ahead of print | PMID: 33313642
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Impact:
Abstract

Prognostic value of vasodilator stress perfusion CMR in patients with previous coronary artery bypass graft.

Kinnel M, Sanguineti F, Pezel T, Unterseeh T, ... Louvard Y, Garot J
Aims 
The accuracy and prognostic value of stress perfusion cardiac magnetic resonance (CMR) are established in coronary artery disease (CAD) patients. Because myocardial contrast kinetics may be altered after coronary artery bypass graft (CABG), most studies excluded CABG patients. This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in CABG patients.
Methods and results 
Consecutive CABG patients referred for stress CMR were retrospectively included and followed for the occurrence of major adverse cardiovascular events (MACE) including cardiovascular (CV) death or non-fatal myocardial infarction (MI). Cox regression analyses were performed to determine the prognostic association of inducible ischaemia and late gadolinium enhancement (LGE) by CMR. Of 866 consecutive CABG patients, 852 underwent the stress CMR protocol and 771 (89%) completed the follow-up [median (interquartile range) 4.2 (3.3-6.2) years]. There were 85 MACE (63 CV deaths and 22 non-fatal MI). Using Kaplan-Meier analysis, the presence of inducible ischaemia identified the occurrence of MACE [hazard ratio (HR) 3.52, 95% confidence interval (CI): 2.27-5.48; P < 0.001] and CV death (HR 2.55, 95% CI: 1.52-4.25; P < 0.001). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischaemia was an independent predictor of a higher incidence of MACE (HR 3.22, 95% CI: 2.06-5.02; P < 0.001) and CV death (HR 2.15, 95% CI: 1.28-3.62; P = 0.003), and the same was observed for LGE (both P = 0.02).
Conclusion 
Stress CMR has a good discriminative prognostic value in patients after CABG, with a higher incidence of MACE and CV death in patients with inducible ischaemia and/or LGE.

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 Dec 2020; epub ahead of print
Kinnel M, Sanguineti F, Pezel T, Unterseeh T, ... Louvard Y, Garot J
Eur Heart J Cardiovasc Imaging: 12 Dec 2020; epub ahead of print | PMID: 33313780
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Abstract

Sex-specific associations between alcohol consumption, cardiac morphology, and function as assessed by magnetic resonance imaging: insights form the UK Biobank Population Study.

Simon J, Fung K, Kolossváry M, Sanghvi MM, ... Maurovich-Horvat P, Petersen SE
Aims
Data regarding the effects of regular alcohol consumption on cardiac anatomy and function are scarce. Therefore, we sought to determine the relationship between regular alcohol intake and cardiac structure and function as evaluated with cardiac magnetic resonance imaging.
Methods and results
Participants of the UK Biobank who underwent cardiac magnetic resonance were enrolled in our analysis. Data regarding regular alcohol consumption were obtained from questionnaires filled in by the study participants. Exclusion criteria were poor image quality, missing, or incongruent data regarding alcohol drinking habits, prior drinking, presence of heart failure or angina, and prior myocardial infarction or stroke. Overall, 4335 participants (61.5 ± 7.5 years, 47.6% male) were analysed. We used multivariate linear regression models adjusted for age, ethnicity, body mass index, smoking, hypertension, diabetes mellitus, physical activity, cholesterol level, and Townsend deprivation index to examine the relationship between regular alcohol intake and cardiac structure and function. In men, alcohol intake was independently associated with marginally increased left ventricular end-diastolic volume [β = 0.14; 95% confidence interval (CI) = 0.05-0.24; P = 0.004], left ventricular stroke volume (β = 0.08; 95% CI = 0.03-0.14; P = 0.005), and right ventricular stroke volume (β = 0.08; 95% CI = 0.02-0.13; P = 0.006). In women, alcohol consumption was associated with increased left atrium volume (β = 0.14; 95% CI = 0.04-0.23; P = 0.006).
Conclusion
Alcohol consumption is independently associated with a marginal increase in left and right ventricular volumes in men, but not in women, whereas alcohol intake showed an association with increased left atrium volume in women. Our results suggest that there is only minimal relationship between regular alcohol consumption and cardiac morphology and function in an asymptomatic middle-aged population.

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: 11 Dec 2020; epub ahead of print
Simon J, Fung K, Kolossváry M, Sanghvi MM, ... Maurovich-Horvat P, Petersen SE
Eur Heart J Cardiovasc Imaging: 11 Dec 2020; epub ahead of print | PMID: 33313691
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Abstract

Prevalence and clinical implications of valvular calcification on coronary computed tomography angiography.

Williams MC, Massera D, Moss AJ, Bing R, ... Newby DE, Dweck MR
Aims
Valvular heart disease can be identified by calcification on coronary computed tomography angiography (CCTA) and has been associated with adverse clinical outcomes. We assessed aortic and mitral valve calcification in patients presenting with stable chest pain and their association with cardiovascular risk factors, coronary artery disease, and cardiovascular outcomes.
Methods and results
In 1769 patients (58 ± 9 years, 56% male) undergoing CCTA for stable chest pain, aortic and mitral valve calcification were quantified using Agatston score. Aortic valve calcification was present in 241 (14%) and mitral calcification in 64 (4%). Independent predictors of aortic valve calcification were age, male sex, hypertension, diabetes mellitus, and cerebrovascular disease, whereas the only predictor of mitral valve calcification was age. Patients with aortic and mitral valve calcification had higher coronary artery calcium scores and more obstructive coronary artery disease. The composite endpoint of cardiovascular mortality, non-fatal myocardial infarction, or non-fatal stroke was higher in those with aortic [hazard ratio (HR) 2.87; 95% confidence interval (CI) 1.60-5.17; P < 0.001] or mitral (HR 3.50; 95% CI 1.47-8.07; P = 0.004) valve calcification, but this was not independent of coronary artery calcification or obstructive coronary artery disease.
Conclusion
Aortic and mitral valve calcification occurs in one in six patients with stable chest pain undergoing CCTA and is associated with concomitant coronary atherosclerosis. Whilst valvular calcification is associated with a higher risk of cardiovascular events, this was not independent of the burden of coronary artery disease.

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

Eur Heart J Cardiovasc Imaging: 10 Dec 2020; epub ahead of print
Williams MC, Massera D, Moss AJ, Bing R, ... Newby DE, Dweck MR
Eur Heart J Cardiovasc Imaging: 10 Dec 2020; epub ahead of print | PMID: 33306104
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Abstract

Mitral annulus disjunction is associated with adverse outcome in Marfan and Loeys-Dietz syndromes.

Chivulescu M, Krohg-Sørensen K, Scheirlynck E, Lindberg BR, ... Lingaas PS, Haugaa KH
Aims
We aimed to assess the prevalence of mitral annulus disjunction (MAD) and to explore the association with aortic disease and mitral valve surgery in patients with Marfan syndrome (MFS) and Loeys-Dietz syndrome (LDS).
Methods and results
We included consecutive MFS patients fulfilling Revised Ghent Criteria and LDS patients fulfilling Loeys-Dietz Revised Nosology. MAD was identified by echocardiography and was quantified as the longitudinal distance from the ventricular myocardium to the hinge point of the posterior mitral leaflet. Aortic events were defined as aortic dissection or prophylactic aortic surgery. We recorded the need of mitral valve surgery including mitral valve repair or replacement. We included 168 patients (103 with MFS and 65 with LDS). The prevalence of MAD was 41%. MAD was present in all age groups. Aortic events occurred in 112 (67%) patients (27 with dissections and 85 with prophylactic surgical interventions). Patients with MAD were younger at aortic event than those without MAD (log rank = 0.02) Patients with aortic events had greater MAD distance in posterolateral wall [8 (7-10) mm vs. 7 (6-8) mm, P = 0.04]. Mitral events occurred more frequently in patients with MAD (P < 0.001).
Conclusion
MAD was highly prevalent in patients with MFS and LDS. MAD was a marker of severe disease including aortic events at younger age and need of mitral valve surgery. Screening patients with MFS an LDS for MAD may provide prognostic information and may be relevant in planning surgical intervention. Detection of MAD in patients with MFS and LDS may infer closer clinical follow-up from younger age.

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

Eur Heart J Cardiovasc Imaging: 05 Dec 2020; epub ahead of print
Chivulescu M, Krohg-Sørensen K, Scheirlynck E, Lindberg BR, ... Lingaas PS, Haugaa KH
Eur Heart J Cardiovasc Imaging: 05 Dec 2020; epub ahead of print | PMID: 33280029
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Impact:
Abstract

Long-term prognostic value of late gadolinium enhancement and periprocedural myocardial infarction after uncomplicated revascularization: MASS-V follow-up.

Linhares-Filho J, Hueb W, Lima E, Rezende P, ... Ramires J, Kalil-Filho R
Aims
Cardiac biomarkers elevation is common after revascularization, even in absence of periprocedural myocardial infarction (PMI) detection by imaging methods. Thus, late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) may be useful on PMI diagnosis and prognosis. We sought to evaluate long-term prognostic value of PMI and new LGE after revascularization.
Methods and results
Two hundred and two patients with multivessel coronary disease and preserved ventricular function who underwent elective revascularization were included, of whom 136 (67.3%) underwent coronary artery bypass grafting and 66 (32.7%) percutaneous coronary intervention. The median follow-up was 5 years (4.8-5.8 years). Cardiac biomarkers measurement and LGE-CMR were performed before and after procedures. The Society for Cardiovascular Angiography and Interventions definition was used to assess PMI. Primary endpoint was composed of death, infarction, additional revascularization, or cardiac hospitalization. Primary endpoint was observed in 29 (14.3%) patients, of whom 13 (14.9%) had PMI and 16 (13.9%) did not (P = 0.93). Thirty-six (17.8%) patients had new LGE. Twenty (12.0%) events occurred in patients without new LGE and 9 (25.2%) in patients with it (P = 0.045). LGE was also associated to increased mortality, with 4 (2.4%) and 4 (11.1%) deaths in subjects without and with it (P = 0.02). LGE was the only independent predictor of primary endpoint and mortality (P = 0.03 and P = 0.02). Median LGE mass was estimated at 4.6 g. Patients with new LGE had a greater biomarkers release (median troponin: 8.9 ng/mL vs. 1.8 ng/mL and median creatine kinase-MB: 38.0 ng/mL vs. 12.3 ng/mL; P < 0.001 in both comparisons).
Conclusions
New LGE was shown to be better prognostic predictor than biomarker-only PMI definition after uncomplicated revascularization. Furthermore, new LGE was the only independent predictor of cardiovascular events and mortality.
Clinical trial registration
http://www.controlled-trials.com/ISRCTN09454308.

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: 05 Dec 2020; epub ahead of print
Linhares-Filho J, Hueb W, Lima E, Rezende P, ... Ramires J, Kalil-Filho R
Eur Heart J Cardiovasc Imaging: 05 Dec 2020; epub ahead of print | PMID: 33280019
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Abstract

Right atrial volume is a major determinant of tricuspid annulus area in functional tricuspid regurgitation: a three-dimensional echocardiographic study.

Muraru D, Addetia K, Guta AC, Ochoa-Jimenez RC, ... Badano LP, Lang RM
Aims
The aim of this study is to explore the relationships of tricuspid annulus area (TAA) with right atrial maximal volume (RAVmax) and right ventricular end-diastolic volume (RVEDV) in healthy subjects and patients with functional tricuspid regurgitation (FTR) of different aetiologies and severities.
Methods and results
We enrolled 280 patients (median age 66 years, 59% women) with FTR due to left heart disease (LHD), pulmonary hypertension (PH), corrected tetralogy of Fallot (TOF), chronic atrial fibrillation (AF), and 210 healthy volunteers (45 years, 53% women). We measured TAA at mid-systole and end-diastole, tenting volume of tricuspid leaflets, RAVmax, and RVEDV by 3D echocardiography. Irrespective of TA measurement timing, TAA correlated more closely with RAVmax than with RVEDV in both controls and FTR patients. On multivariable analysis, RAVmax was the most important determinant of TAA, accounting for 41% (normals) and 56% (FTR) of TAA variance. In FTR patients, age, RVEDV, and left ventricular ejection fraction were also independently correlated with TAA. RAVmax (AUC = 0.81) and TAA (AUC = 0.78) had a greater ability than RVEDV (AUC = 0.72) to predict severe FTR (P < 0.05). Among FTR patients, those with AF had the largest RAVmax and smallest RVEDV. RAVmax and TA were significantly dilated in all FTR groups, except in TOF. PH and TOF had largest RVEDV, yet tenting volume was increased only in PH and LHD.
Conclusion
RA volume is a major determinant of TAA, and RA enlargement is an important mechanism of TA dilation in FTR irrespective of cardiac rhythm and RV loading conditions.

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: 01 Dec 2020; epub ahead of print
Muraru D, Addetia K, Guta AC, Ochoa-Jimenez RC, ... Badano LP, Lang RM
Eur Heart J Cardiovasc Imaging: 01 Dec 2020; epub ahead of print | PMID: 33387441
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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: 30 Nov 2020; 21:1405-1411
Burocchi S, Gori M, Cioffi G, Calabrese A, ... Gavazzi A, Senni M
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1405-1411 | PMID: 31808506
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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: 30 Nov 2020; 21:1412-1420
Hwang IC, Cho GY, Choi HM, Yoon YE, ... Kim YJ, Sohn DW
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1412-1420 | PMID: 31819981
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Abstract

Characteristics of non-culprit plaques in acute coronary syndrome patients with layered culprit plaque.

Russo M, Kim HO, Kurihara O, Araki M, ... Fuster V, Jang IK
Aims 
Layered plaques represent signs of previous plaque destabilization. A recent study showed that acute coronary syndrome (ACS) patients with layered culprit plaque have more vulnerability at the culprit lesion and systemic inflammation. We aimed to compare the characteristics of non-culprit plaques between patients with or without layered plaque at the culprit lesion. We also evaluated the characteristics of layered non-culprit plaques, irrespective of culprit plaque phenotype.
Methods and results
We studied ACS patients who had undergone pre-intervention optical coherence tomography (OCT) imaging. The number of non-culprit lesions was evaluated on coronary angiogram and morphological characteristics of plaques were studied by OCT. In 349 patients, 99 (28.4%) had layered culprit plaque. The number of non-culprit plaques in patients with or without layered culprit plaque was similar (3.2 ± 0.8 and 2.8 ± 0.8, P = 0.23). Among 465 non-culprit plaques, 145 from patients with layered culprit plaque showed a higher prevalence of macrophage infiltration (71.0% vs. 60.9%, P = 0.050). When analysed irrespective of culprit plaque phenotype, layered non-culprit plaques showed higher prevalence of lipid (93.3% vs. 86.0%, P = 0.028), thin cap fibroatheroma (29.7% vs. 13.7%, P < 0.001), and macrophage infiltration (82.4% vs. 54.0%, P < 0.001) than non-layered plaques. Plaques with layered phenotype at both culprit and non-culprit lesions had the highest vulnerability.
Conclusion 
In ACS patients, those with layered phenotype at the culprit lesion demonstrated greater macrophage infiltration at the non-culprit sites. Layered plaque at the non-culprit lesions was associated with more features of plaque vulnerability, particularly when the culprit lesion also had a layered 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: 30 Nov 2020; 21:1421-1430
Russo M, Kim HO, Kurihara O, Araki M, ... Fuster V, Jang IK
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1421-1430 | PMID: 31848590
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Abstract

Differing mechanisms of atrial fibrillation in athletes and non-athletes: alterations in atrial structure and function.

Trivedi SJ, Claessen G, Stefani L, Flannery MD, ... Thomas L, La Gerche A
Aims
Atrial fibrillation (AF) is more common in athletes and may be associated with adverse left atrial (LA) remodelling. We compared LA structure and function in athletes and non-athletes with and without AF.
Methods and results
Individuals (144) were recruited from four groups (each n = 36): (i) endurance athletes with paroxysmal AF, (ii) endurance athletes without AF, (iii) non-athletes with paroxysmal AF, and (iv) non-athletic healthy controls. Detailed echocardiograms were performed. Athletes had 35% larger LA volumes and 51% larger left ventricular (LV) volumes vs. non-athletes. Non-athletes with AF had increased LA size compared with controls. LA/LV volume ratios were similar in both athlete groups and non-athlete controls, but LA volumes were differentially increased in non-athletes with AF. Diastolic function was impaired in non-athletes with AF vs. non-athletes without, while athletes with and without AF had normal diastolic function. Compared with non-AF athletes, athletes with AF had increased LA minimum volumes (22.6 ± 5.6 vs. 19.2 ± 6.7 mL/m2, P = 0.033), with reduced LA emptying fraction (0.49 ± 0.06 vs. 0.55 ± 0.12, P = 0.02), and LA expansion index (1.0 ± 0.3 vs. 1.2 ± 0.5, P = 0.03). LA reservoir and contractile strain were decreased in athletes and similar to non-athletes with AF.
Conclusion
Functional associations differed between athletes and non-athletes with AF, suggesting different pathophysiological mechanisms. Diastolic dysfunction and reduced strain defined non-athletes with AF. Athletes had low atrial strain and those with AF had enlarged LA volumes and reduced atrial emptying, but preserved LV diastolic parameters. Thus, AF in athletes may be triggered by an atrial myopathy from exercise-induced haemodynamic stretch consequent to increased cardiac output.

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: 30 Nov 2020; 21:1374-1383
Trivedi SJ, Claessen G, Stefani L, Flannery MD, ... Thomas L, La Gerche A
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1374-1383 | PMID: 32757003
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Abstract

Quantification of hypo-attenuated leaflet thickening after transcatheter aortic valve implantation: clinical relevance of hypo-attenuated leaflet thickening volume.

Karády J, Apor A, Nagy AI, Kolossváry M, ... Maurovich-Horvat P, Merkely B
Aims 
Our aim was to establish an objective, quantitative methodology for volumetric hypo-attenuated leaflet thickening (HALT) diagnosis and evaluate its clinical significance.
Methods and results 
We prospectively enrolled 144 patients who underwent transcatheter aortic valve implantation (TAVI) between 2011 and 2016. At inclusion, cardiac computed tomography angiography (CTA), transthoracic echocardiography, and brain magnetic resonance imaging (MRI) were performed. We quantified HALT on CTA datasets by segmenting the inner volume of TAVI frame at the level of leaflets and extracted voxels between a threshold of -200 to 200 HU based on prior recommendation. The median HALT volume was 72 [inter-quartile range (IQR): 1-154] mm3 (intra- and inter-reader agreement: intra-class correlation coefficient = 0.92 and 0.94, respectively) and 79% (n = 87/111) of the patients had HALT >0 mm3. In multivariate linear regression, oral anti-coagulation (β: -0.32; 95% CI: -0.62 to -0.01; P = 0.004) and history of myocardial infarction (β: 0.32; 95% CI: 0.01-0.63; P = 0.043) were associated with HALT quantity. Log-transformed HALT volume was associated with elevated (>13 mmHg) aortic mean gradient (AMG, OR: 12.85; 95% CI: 1.96-152.93; P = 0.021) and moderate-to-severe valvular degeneration (AMG ≥ 20 mmHg or ΔAMG ≥ 10 mmHg; OR: 10.56; 95% CI: 1.44-148.71; P = 0.046) but did not predict ischaemic brain lesions on MRI or all-cause death after a median follow-up of 29 (IQR: 11-29) months (all P > 0.05).
Conclusion
Through systematic analysis of asymptomatic patients with TAVI, an objective and reproducible methodology was feasible for volumetric measurement of HALT. Anti-coagulation might have a protective effect against HALT. Ischaemic brain lesions and all-cause death were not associated with HALT; nevertheless, it might deteriorate prosthesis function due to its association with elevated AMG.
Clinical trial registration
http//:www.ClinicalTrials.gov; NCT02826200.

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: 30 Nov 2020; 21:1395-1404
Karády J, Apor A, Nagy AI, Kolossváry M, ... Maurovich-Horvat P, Merkely B
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1395-1404 | PMID: 32756984
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Abstract

Left atrial structure and function among different subtypes of atrial fibrillation: an echocardiographic substudy of the AMIO-CAT trial.

Olsen FJ, Darkner S, Chen X, Pehrson S, ... Svendsen JH, Biering-Sørensen T
Aims 
Little is known about cardiac structure and function among atrial fibrillation (AF) subtypes; paroxysmal AF vs. persistent AF (PxAF), and across AF burden. We sought to assess differences in left atrial (LA) measures by AF subtype and burden.
Methods and results 
This was a cross-sectional echocardiographic substudy of a randomized trial of AF patients scheduled for catheter ablation. Patients had an echocardiogram performed 0-90 days prior to study inclusion. We performed conventional echocardiographic measures, left ventricular (LV) and LA speckle tracking. Measures were compared between AF subtype and burden (0%, 0-99%, and 99-100%) determined by 72-h Holter monitoring. Of 212 patients, 107 had paroxysmal AF and 105 had PxAF. Those with PxAF had significantly reduced systolic function (LV ejection fraction: 48% vs. 53%; P < 0.001), larger end-systolic and end-diastolic LA volumes (LAVi and LAEDVi), reduced LA emptying fraction (LAEF: 29% vs. 36%, P < 0.001), and reduced LA strain (LAs) (LAs: 20% vs. 26%, P < 0.001). LA measures remained significantly lower in PxAF after multivariable adjustments. All LA measures and measures of systolic function were significantly impaired in patients with 99-100% AF burden, whereas all measures were similar between the other groups (LAVi: 40mL/m2 vs. 33mL/m2 vs. 34mL/m2; LAEDVi: 31mL/m2 vs. 21mL/m2 vs. 22mL/m2, LA emptying fraction: 23% vs. 35% vs. 36%, LAs: 16% vs. 25% vs. 25%, for 99-100%, 0-99%, and 0% AF, respectively, P < 0.001 for all). These differences were consistent after multivariable adjustments.
Conclusion 
LA mechanics differ between AF subtype and burden and these characteristics influence the clinical interpretation of these measures.

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Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1386-1394
Olsen FJ, Darkner S, Chen X, Pehrson S, ... Svendsen JH, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1386-1394 | PMID: 32783051
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Impact:
Abstract

Apical hypertrophic cardiomyopathy with left ventricular apical aneurysm: prevalence, cardiac magnetic resonance characteristics, and prognosis.

Yang K, Song YY, Chen XY, Wang JX, ... Lu MJ, Zhao SH
Aims
Hypertrophic cardiomyopathy (HCM) with left ventricular apical aneurysm (LVAA) is associated with an increased risk of adverse cardiovascular events. However, the clinical significance of LVAA in apical HCM (ApHCM) has not been reported. This study aimed to investigate the prevalence, cardiac magnetic resonance (CMR) characteristics, and prognosis of LVAA in ApHCM patients.
Methods and results
A total of 1332 consecutive ApHCM patients confirmed by CMR in our hospital were retrospectively analysed. LVAAs were identified in 31 patients of all ApHCM patients (2.3%, 31/1332). Besides, 31 age- and gender-matched ApHCM patients without LVAA were used for comparison. Of the 31 aneurysm patients (mean age, 53.8 ± 15.1 years old), 28 (90.3%) had clinical symptoms, and 3 (9.7%) had a family history of HCM. The rate of missed diagnosis of echocardiography for detecting LVAA was 64.5% (20/31), most (90%, 18/20) of unidentified LVAAs by echocardiography were small aneurysms (<20 mm). Compared with ApHCM patients without LVAA, the proportion of systolic mid-cavity obstruction and late gadolinium enhancement (LGE) presence, and the LGE extent in ApHCM patients with LVAA were significantly higher (all P<0.05). The Kaplan-Meier curves showed that the event-free survival rate in ApHCM patients with LVAA was significantly lower than that in ApHCM patients without LVAA (log rank, P = 0.010).
Conclusion
ApHCM with LVAA is a very rare condition, which is often missed by echocardiography and could be reliably detected with CMR and is associated with a higher risk of adverse cardiovascular events compared with ApHCM without LVAA.

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Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1341-1350
Yang K, Song YY, Chen XY, Wang JX, ... Lu MJ, Zhao SH
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1341-1350 | PMID: 32888301
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Impact:
Abstract

Implementation of coronary computed tomography angiography as nationally recommended first-line test in patients with suspected chronic coronary syndrome: impact on the use of invasive coronary angiography and revascularization.

Nissen L, Winther S, Schmidt M, Rønnow Sand NP, ... Bøtker HE, Bøttcher M
Aims 
To investigate the impact of applying coronary computed tomography angiography (CCTA), as the recommended first-line diagnostic test in patients with suspected chronic coronary syndrome (CCS) on the use of invasive coronary angiography (ICA) and revascularization practice.
Methods and results 
We included all patients undergoing a first-time CCTA (n = 53555) and first-time ICA (n = 41451) from 2008 to 2017 due to suspected CCS in Western Denmark (3.3 million inhabitants). The number of CCTA procedures increased from 352 (2008) to 7739 (2017) (2098%), ICA examinations declined from 4538 to 3766 (17%). The average proportion of no- or non-obstructive coronary artery disease by CCTA was 77.5%. Referral to ICA after CCTA occurred in 16.9% of patients in 2008-10 vs. 13.9% in 2014-17 (P < 0.0001). Revascularization in patients referred to ICA after CCTA increased from 33.8% in 2008-10 vs. 44.4% in 2014-17 (P < 0.0001). The revascularization proportion in patients undergoing ICA with no preceding CCTA was 32.3% in 2008-10 vs. 33.3% in (2014-17) (P = 0.1063). Stratified by age, the overall revascularization proportion increased in the younger age groups and was unchanged or decreased in older age groups: <50 years: 60% increase, 50-59 years: 33% increase, 60-69 years: 0%, and >70 years: 9.5% decrease.
Conclusion 
The introduction of CCTA as a first-line diagnostic test in patients with suspected CCS does not associate with increased use of invasive angiography and seems to have facilitated a more appropriate revascularization practice.

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: 30 Nov 2020; 21:1353-1362
Nissen L, Winther S, Schmidt M, Rønnow Sand NP, ... Bøtker HE, Bøttcher M
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1353-1362 | PMID: 32888290
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Impact:
Abstract

The year 2019 in the European Heart Journal - Cardiovascular Imaging: part II.

Cosyns B, Haugaa KH, Gerber B, Gimelli A, ... Popescu BA, Edvardsen T

The European Heart Journal - Cardiovascular Imaging was launched in 2012 and has during these years become one of the leading multimodality cardiovascular imaging journal. The journal is now established as one of the top cardiovascular journals and is the most important cardiovascular imaging journal in Europe. The most important studies published in our Journal from 2019 will be highlighted in two reports. Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease. While Part I of the review has focused on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging.

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: 30 Nov 2020; 21:1331-1340
Cosyns B, Haugaa KH, Gerber B, Gimelli A, ... Popescu BA, Edvardsen T
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1331-1340 | PMID: 33188688
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Impact:
Abstract

Procedural recommendations of cardiac PET/CT imaging: standardization in inflammatory-, infective-, infiltrative-, and innervation- (4Is) related cardiovascular diseases: a joint collaboration of the EACVI and the EANM: summary.

Slart RHJA, Glaudemans AWJM, Gheysens O, Lubberink M, ... Erba PA,

With this summarized document we share the standard for positron emission tomography (PET)/(diagnostic)computed tomography (CT) imaging procedures in cardiovascular diseases that are inflammatory, infective, infiltrative, or associated with dysfunctional innervation (4Is) as recently published in the European Journal of Nuclear Medicine and Molecular Imaging. This standard should be applied in clinical practice and integrated in clinical (multicentre) trials for optimal standardization of the procedurals and interpretations. A major focus is put on procedures using [18F]-2-fluoro-2-deoxyglucose ([18F]FDG), but 4Is PET radiopharmaceuticals beyond [18F]FDG are also described in this summarized document. Whilst these novel tracers are currently mainly applied in early clinical trials, some multicentre trials are underway and we foresee in the near future their use in clinical care and inclusion in the clinical guidelines. Diagnosis and management of 4Is related cardiovascular diseases are generally complex and often require a multidisciplinary approach by a team of experts. The new standards described herein should be applied when using PET/CT and PET/magnetic resonance, within a multimodality imaging framework both in clinical practice and in clinical trials for 4Is cardiovascular indications.

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

Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1320-1330
Slart RHJA, Glaudemans AWJM, Gheysens O, Lubberink M, ... Erba PA,
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1320-1330 | PMID: 33245759
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Impact:
Abstract

Training, competence, and quality improvement in echocardiography: the European Association of Cardiovascular Imaging Recommendations: update 2020.

Popescu Chair BA, Stefanidis A, Fox KF, Cosyns B, ... Edvardsen T,

The primary mission of the European Association of Cardiovascular Imaging (EACVI) is \'to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging\'. Echocardiography is a key component in the evaluation of patients with known or suspected cardiovascular disease and is essential for the high quality and effective practice of clinical cardiology. The EACVI aims to update the previously published recommendations for training, competence, and quality improvement in echocardiography since these activities are increasingly recognized by patients, physicians, and payers. The purpose of this document is to provide the general requirements for training and competence in echocardiography, to outline the principles of quality evaluation, and to recommend a set of measures for improvement, with the ultimate goal of raising the standards of echocardiographic practice. Moreover, the document aims to provide specific guidance for advanced echo techniques, which have dramatically evolved since the previous publication in 2009.

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: 30 Nov 2020; 21:1305-1319
Popescu Chair BA, Stefanidis A, Fox KF, Cosyns B, ... Edvardsen T,
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1305-1319 | PMID: 33245758
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Impact:
Abstract

New expectations for diastolic function assessment in transthoracic echocardiography based on a semi-automated computing of strain-volume loops.

Hubert A, Le Rolle V, Galli E, Bidaud A, Hernandez A, Donal E
Aims
Early diagnosis of heart failure with preserved ejection fraction (HFpEF) by determination of diastolic dysfunction is challenging. Strain-volume loop (SVL) is a new tool to analyse left ventricular function. We propose a new semi-automated method to calculate SVL area and explore the added value of this index for diastolic function assessment.
Method and results
Fifty patients (25 amyloidosis, 25 HFpEF) were included in the study and compared with 25 healthy control subjects. Left ventricular ejection fraction was preserved and similar between groups. Classical indices of diastolic function were pathological in HFpEF and amyloidosis groups with greater left atrial volume index, greater mitral average E/e\' ratio, faster tricuspid regurgitation (P < 0.0001 compared with controls). SVL analysis demonstrated a significant difference of the global area between groups, with the smaller area in amyloidosis group, the greater in controls and a mid-range value in HFpEF group (37 vs. 120 vs. 72 mL.%, respectively, P < 0.0001). Applying a linear discriminant analysis (LDA) classifier, results show a mean area under the curve of 0.91 for the comparison between HFpEF and amyloidosis groups.
Conclusion
SVLs area is efficient to identify patients with a diastolic dysfunction. This new semi-automated tool is very promising for future development of automated diagnosis with machine-learning algorithms.

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: 30 Nov 2020; 21:1366-1371
Hubert A, Le Rolle V, Galli E, Bidaud A, Hernandez A, Donal E
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1366-1371 | PMID: 33245757
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Impact:
Abstract

How to measure left ventricular myocardial work by pressure-strain loops.

Smiseth OA, Donal E, Penicka M, Sletten OJ

Myocardial work is calculated from non-invasive left ventricular pressure and strain by speckle tracking echocardiography. Myocardial work provides diagnostic information beyond what is achieved from left ventricular ejection fraction and strain since it incorporates afterload, and provides a measure of myocardial efficiency. The method can be used to calculate global as well as segmental work. The work method was recently shown to be of clinical value in selection of patients for cardiac resynchronization therapy. Several other clinical applications are currently tested.

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: 29 Nov 2020; epub ahead of print
Smiseth OA, Donal E, Penicka M, Sletten OJ
Eur Heart J Cardiovasc Imaging: 29 Nov 2020; epub ahead of print | PMID: 33257982
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Impact:
Abstract

Prognostic validation of partition values for quantitative parameters to grade functional tricuspid regurgitation severity by conventional echocardiography.

Muraru D, Previtero M, Ochoa-Jimenez RC, Guta AC, ... Parati G, Badano LP
Aims
Quantitative echocardiography parameters are seldom used to grade tricuspid regurgitation (TR) severity due to relative paucity of validation studies and lack of prognostic data. To assess the relationship between TR severity and the composite endpoint of death and hospitalization for congestive heart failure (CHF); and to identify the threshold values of vena contracta width (VCavg), effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFr) to define low, intermediate, and high-risk TR based on patients\' outcome data.
Methods and results
A cohort of 296 patients with at least mild TR underwent 2D, 3D, and Doppler echocardiography. We built statistical models (adjusted for age, NYHA class, left ventricular ejection fraction, and pulmonary artery systolic pressure) for VCavg, EROA, RegVol, and RegFr to study their relationships with the hazard of outcome. The tertiles of the derived hazard values defined the threshold values of the quantitative parameters for TR severity grading. During 47-month follow-up, 32 deaths and 72 CHF occurred. Event-free rate was 14%, 48%, and 93% in patients with severe, moderate, and mild TR, respectively. Severe TR was graded as VCavg > 6 mm, EROA > 0.30 cm2, RegVol > 30 mL, and RegF > 45%.
Conclusion
This outcome study demonstrates the prognostic value of quantitative parameters of TR severity and provides prognostically meaningful threshold values to grade TR severity in low, intermediate, and high risk.

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: 27 Nov 2020; epub ahead of print
Muraru D, Previtero M, Ochoa-Jimenez RC, Guta AC, ... Parati G, Badano LP
Eur Heart J Cardiovasc Imaging: 27 Nov 2020; epub ahead of print | PMID: 33247930
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Impact:
Abstract

Size-adjusted aortic valve area: refining the definition of severe aortic stenosis.

Vulesevic B, Kubota N, Burwash IG, Cimadevilla C, ... Beauchesne L, Messika-Zeitoun D
Aims
Severe aortic valve stenosis (AS) is defined by an aortic valve area (AVA) <1 cm2 or an AVA indexed to body surface area (BSA) <0.6 cm/m2, despite little evidence supporting the latter approach and important intrinsic limitations of BSA indexation. We hypothesized that AVA indexed to height (H) might be more applicable to a wide range of populations and body morphologies and might provide a better predictive accuracy.
Methods and results
In 1298 patients with degenerative AS and preserved ejection fraction from three different countries and continents (derivation cohort), we aimed to establish an AVA/H threshold that would be equivalent to 1.0 cm2 for defining severe AS. In a distinct prospective validation cohort of 395 patients, we compared the predictive accuracy of AVA/BSA and AVA/H. Correlations between AVA and AVA/BSA or AVA/H were excellent (all R2 > 0.79) but greater with AVA/H. Regressions lines were markedly different in obese and non-obese patients with AVA/BSA (P < 0.0001) but almost identical with AVA/H (P = 0.16). AVA/BSA values that corresponded to an AVA of 1.0 cm2 were markedly different in obese and non-obese patients (0.48 and 0.59 cm2/m2) but not with AVA/H (0.61 cm2/m for both). Agreement for the diagnosis of severe AS (AVA < 1 cm2) was significantly higher with AVA/H than with AVA/BSA (P < 0.05). Similar results were observed across the three countries. An AVA/H cut-off value of 0.6 cm2/m [HR = 8.2(5.6-12.1)] provided the best predictive value for the occurrence of AS-related events [absolute AVA of 1 cm2: HR = 7.3(5.0-10.7); AVA/BSA of 0.6 cm2/m2 HR = 6.7(4.4-10.0)].
Conclusion
In a large multinational/multiracial cohort, AVA/H was better correlated with AVA than AVA/BSA and a cut-off value of 0.6 cm2/m provided a better diagnostic and prognostic value than 0.6 cm2/m2. Our results suggest that severe AS should be defined as an AVA < 1 cm2 or an AVA/H < 0.6 cm2/m rather than a BSA-indexed value of 0.6 cm2/m2.

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: 27 Nov 2020; epub ahead of print
Vulesevic B, Kubota N, Burwash IG, Cimadevilla C, ... Beauchesne L, Messika-Zeitoun D
Eur Heart J Cardiovasc Imaging: 27 Nov 2020; epub ahead of print | PMID: 33247914
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Impact:
Abstract

Myocardial perfusion scintigraphy for risk stratification of patients with coronary artery disease: the AMICO registry.

Gimelli A, Pugliese NR, Buechel RR, Coceani M, ... Kaufmann PA, Marzullo P
Aims
We assessed the prognostic value of myocardial perfusion scintigraphy (MPS) with cadmium-zinc-telluride in addition to clinical and coronary anatomy analysis.
Methods and results
We prospectively enrolled 1464 patients (26% females, 69.5 ± 10.4 years) referred for stress-rest MPS. All the patients underwent invasive coronary angiography (1171, 80%) or coronary computed tomography angiography (293, 20%). We defined a composite endpoint of cardiovascular death and non-fatal MI. After an 8-year follow-up, summed stress score (SSS) had the highest accuracy in predicting primary endpoint with a ROC-derived cut-off of SSS >8 (>10% myocardium). SSS >8 portended the lowest survival probability at Kaplan-Meier analysis (P < 0.0001 for the composite endpoint and individual components). The Cox-regression analysis indicated SSS as an independent predictor of the composite endpoint, along with fasting blood glucose and total cholesterol and contrary to coronary anatomy parameters. Patients with SSS >8 treated with optimal medical therapy (OMT) had the largest area of necrosis, the lower ischaemic burden, the most compromised LV systo-diastolic function and the highest LV mass, but received a less aggressive treatment in comparison to early revascularized patients. Survival analysis revealed patients with SSS ≤8 had the greater freedom from events, irrespective of the treatment strategy, while the group with SSS >8 and OMT had the worst outcome, followed by patients with SSS >8 and early revascularization (log-rank test: all P < 0.0001).
Conclusion
MPS-SSS constitutes a strong independent predictor of future adverse events after adjustment for multiple clinical parameters and coronary angiography. In particular, MPS could help risk stratification of patients who did not undergo early revascularization.

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: 27 Nov 2020; epub ahead of print
Gimelli A, Pugliese NR, Buechel RR, Coceani M, ... Kaufmann PA, Marzullo P
Eur Heart J Cardiovasc Imaging: 27 Nov 2020; epub ahead of print | PMID: 33247905
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Impact:
Abstract

Non-calcific aortic tissue quantified from computed tomography angiography improves diagnosis and prognostication of patients referred for transcatheter aortic valve implantation.

Grodecki K, Tamarappoo BK, Huczek Z, Jedrzejczyk S, ... Filipiak KJ, Dey D
Aims
We aimed to investigate the role of aortic valve tissue composition from quantitative cardiac computed tomography angiography (CTA) in patients with severe aortic stenosis (AS) for the differentiation of disease subtypes and prognostication after transcatheter aortic valve implantation (TAVI).
Methods and results
Our study included 447 consecutive AS patients from six high-volume centres reporting to a prospective nationwide registry of TAVI procedures (POL-TAVI), who underwent cardiac CTA before TAVI, and 224 matched controls with normal aortic valves. Components of aortic valve tissue were identified using semi-automated software as calcific and non-calcific. Volumes of each tissue component and composition [(tissue component volume/total tissue volume) × 100%] were quantified. Relationship of aortic valve composition with clinical outcomes post-TAVI was evaluated using Valve Academic Research Consortium (VARC)-2 definitions.High-gradient (HG) AS patients had significantly higher aortic tissue volume compared to low-flow low-gradient (LFLG)-AS (1672.7 vs. 1395.3 mm3, P < 0.001) as well as controls (509.9 mm3, P < 0.001), but increased non-calcific tissue was observed in LFLG compared to HG patients (1063.6 vs. 860.2 mm3, P < 0.001). Predictive value of aortic valve calcium score [area under the curve (AUC) 0.989, 95% confidence interval (CI): 0.981-0.996] for severe AS was improved after addition of non-calcific tissue volume (AUC 0.995, 95% CI: 0.991-0.999, P = 0.011). In the multivariable analysis of clinical and quantitative computed tomography parameters of aortic valve tissue, non-calcific tissue volume [odds ratio (OR) 5.2, 95% CI 1.8-15.4, P = 0.003] and history of stroke (OR 2.6, 95% CI 1.1-6.5, P = 0.037) were independent predictors of 30-day major adverse cardiovascular event (MACE).
Conclusion
Quantitative CTA assessment of aortic valve tissue volume and composition can improve detection of severe AS, differentiation between HG and LFLG-AS in patients referred for TAVI as well as prediction of 30-day MACEs post-TAVI, over the current clinical standard.

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: 27 Nov 2020; epub ahead of print
Grodecki K, Tamarappoo BK, Huczek Z, Jedrzejczyk S, ... Filipiak KJ, Dey D
Eur Heart J Cardiovasc Imaging: 27 Nov 2020; epub ahead of print | PMID: 33247903
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Impact:
Abstract

Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors.

Baritussio A, Biglino G, Scatteia A, De Garate E, ... Diab I, Bucciarelli-Ducci C
Aims
Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation.
Methods and results
We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P < 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass >4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005).
Conclusions
We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable 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: 27 Nov 2020; epub ahead of print
Baritussio A, Biglino G, Scatteia A, De Garate E, ... Diab I, Bucciarelli-Ducci C
Eur Heart J Cardiovasc Imaging: 27 Nov 2020; epub ahead of print | PMID: 33247898
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Impact:
Abstract

Computed tomography imaging needs for novel transcatheter tricuspid valve repair and replacement therapies.

Hell MM, Emrich T, Kreidel F, Kreitner KF, ... Münzel T, von Bardeleben RS

Transcatheter tricuspid valve therapies are an emerging field in structural heart interventions due to the rising number of patients with severe tricuspid regurgitation and the high risk for surgical treatment. Computed tomography (CT) allows exact measurements of the annular plane, evaluation of adjacent structures, assessment of the access route, and can also be used to identify optimal fluoroscopic projection planes to enhance periprocedural imaging. This review provides an overview of current transcatheter tricuspid valve repair and replacement therapies and to what extent CT can support these interventions.

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: 27 Nov 2020; epub ahead of print
Hell MM, Emrich T, Kreidel F, Kreitner KF, ... Münzel T, von Bardeleben RS
Eur Heart J Cardiovasc Imaging: 27 Nov 2020; epub ahead of print | PMID: 33247897
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Impact:
Abstract

Relative clinical value of coronary computed tomography and stress echocardiography-guided management of stable chest pain patients: a propensity-matched analysis.

Vamvakidou A, Danylenko O, Pradhan J, Kelshiker M, ... Sethi A, Senior R
Aims
The European Society of Cardiology recommends coronary computed tomography (CCT) for the assessment of low-risk patients with suspected stable angina. We aimed to assess in a real-life setting the relative clinical value of stress echocardiography (SE)- and CCT-guided management in this population.
Methods and results
Patients with stable chest pain and no prior history of coronary artery disease (CAD) who underwent CCT or SE as the initial investigative strategy were propensity-matched (990 patients each group-age: 59 ± 13.2 years, males: 47.9%) to account for baseline differences in cardiovascular risk factors. Inconclusive tests were 6% vs. 3% (P < 0.005) in CCT vs. SE. Severe (≥70% stenosis) on CCT and inducible ischaemia on SE detected obstructive CAD by invasive coronary angiography in 63% vs. 57% patients (P = 0.33). Over the follow-up period (median 717, interquartile range 93-1069 days) more patients underwent invasive coronary angiography (21.5% vs. 7.3%, P < 0.005), revascularization (7.3% vs. 3.5%, P < 0.005), further functional testing 33.4% vs. 8.7% (P < 0.005), but more patients were prescribed statins 8.8% vs. 3.8% (P < 0.005) in the CCT vs. the SE arm, respectively. Combined all-cause mortality and acute myocardial infarction was low-CCT-2.3% and SE-3.3%-with no significant difference (P = 0.16).
Conclusion
Initial SE-guided management was similar for the detection of obstructive CAD, demonstrated better resource utilization, but was associated with reduced prescription of statins although with no difference in medium-term outcome compared to CCT in this very low-risk population. However, a randomized study with longer follow-up is needed to confirm the clinical value of our findings.

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: 23 Nov 2020; epub ahead of print
Vamvakidou A, Danylenko O, Pradhan J, Kelshiker M, ... Sethi A, Senior R
Eur Heart J Cardiovasc Imaging: 23 Nov 2020; epub ahead of print | PMID: 33232454
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Impact:
Abstract

Long-term outcomes and left ventricular diastolic function of sarcomere mutation-positive and mutation-negative patients with hypertrophic cardiomyopathy: a prospective cohort study.

Chen CJ, Su MM, Liao YC, Chang FL, ... Lai LP, Juang JJ
Aims
Hypertrophic cardiomyopathy (HCM) is an inheritable disease that leads to sudden cardiac death and heart failure (HF). Sarcomere mutations (SMs) have been associated with HF. However, the differences in ventricular function between SM-positive and SM-negative HCM patients are poorly characterized.
Methods and results 
Of the prospectively enrolled 374 unrelated HCM patients in Taiwan, 115 patients underwent both 91 cardiomyopathy-related gene screening and cardiovascular magnetic resonance (45.6 ± 10.6 years old, 76.5% were male). Forty pathogenic/likely pathogenic mutations were identified in 52 patients by next-generation sequencing. The SM-positive group were younger at first cardiovascular event (P = 0.04) and progression to diastolic HF (P = 0.02) with higher N-terminal pro-brain natriuretic peptide (NT-proBNP) [New York Heart Association (NYHA) Class III/IV symptoms with left ventricular ejection fraction > 55%] than the SM-negative group (P < 0.001). SM-positive patients had a greater extent of late gadolinium enhancement (P = 0.01), larger left atrial diameter (P = 0.03), higher normalized peak filling rate (PFR) and PFR ratio, and a greater reduction in global longitudinal strain than SM-negative patients (all P ≤ 0.01). During mean lifelong follow-up time (49.2 ± 15.6 years), SM-positive was a predictor of earlier HF (NYHA Class III/IV symptoms) after multivariate adjustment (hazard ratio 3.5; 95% confidence interval 1.3-9.7; P = 0.015).
Conclusion
SM-positive HCM patients had a higher extent of myocardial fibrosis and more severe ventricular diastolic dysfunction than those without, which may contribute to earlier onset of advanced HF, suggesting the importance of close surveillance and early treatment throughout life.

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: 21 Nov 2020; epub ahead of print
Chen CJ, Su MM, Liao YC, Chang FL, ... Lai LP, Juang JJ
Eur Heart J Cardiovasc Imaging: 21 Nov 2020; epub ahead of print | PMID: 33221870
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Impact:
Abstract

Comparative differences in the atherosclerotic disease burden between the epicardial coronary arteries: quantitative plaque analysis on coronary computed tomography angiography.

Bax AM, van Rosendael AR, Ma X, van den Hoogen IJ, ... Shaw LJ,
Aims
Anatomic series commonly report the extent and severity of coronary artery disease (CAD), regardless of location. The aim of this study was to evaluate differences in atherosclerotic plaque burden and composition across the major epicardial coronary arteries.
Methods and results
A total of 1271 patients (age 60 ± 9 years; 57% men) with suspected CAD prospectively underwent coronary computed tomography angiography (CCTA). Atherosclerotic plaque volume was quantified with categorization by composition (necrotic core, fibrofatty, fibrous, and calcified) based on Hounsfield Unit density. Per-vessel measures were compared using generalized estimating equation models. On CCTA, total plaque volume was lowest in the LCx (10.0 ± 29.4 mm3), followed by the RCA (32.8 ± 82.7 mm3; P < 0.001), and LAD (58.6 ± 83.3 mm3; P < 0.001), even when correcting for vessel length or volume. The prevalence of ≥2 high-risk plaque features, such as positive remodelling or spotty calcification, occurred less in the LCx (3.8%) when compared with the LAD (21.4%) or RCA (10.9%, P < 0.001). In the LCx, the most stenotic lesion was categorized as largely calcified more often than in the RCA and LAD (55.3% vs. 39.4% vs. 32.7%; P < 0.001). Median diameter stenosis was also lowest in the LCx (16.2%) and highest in the LAD (21.3%; P < 0.001) and located more distal along the LCx when compared with the RCA and LAD (P < 0.001).
Conclusion
Atherosclerotic plaque, irrespective of vessel volume, varied across the epicardial coronary arteries; with a significantly lower burden and different compositions in the LCx when compared with the LAD and RCA. These volumetric and compositional findings support a diverse milieu for atherosclerotic plaque development and may contribute to a varied acute coronary risk between the major epicardial coronary arteries.

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: 19 Nov 2020; epub ahead of print
Bax AM, van Rosendael AR, Ma X, van den Hoogen IJ, ... Shaw LJ,
Eur Heart J Cardiovasc Imaging: 19 Nov 2020; epub ahead of print | PMID: 33215192
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Impact:
Abstract

Myocardial damage assessed by late gadolinium enhancement on cardiovascular magnetic resonance imaging in cancer patients treated with anthracyclines and/or trastuzumab.

Modi K, Joppa S, Chen KA, Athwal PSS, ... Blaes AH, Shenoy C
Aims
In cancer patients with cardiomyopathy related to anthracyclines and/or trastuzumab, data regarding late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging are confusing. The prevalence ranges from 0% to 30% and the patterns are ill-defined. Whether treatment with anthracyclines and/or trastuzumab is associated with LGE is unclear. We aimed to investigate these topics in a large cohort of consecutive cancer patients with suspected cardiotoxicity from anthracyclines and/or trastuzumab.
Methods and results
We studied 298 patients, analysed the prevalence, patterns, and correlates of LGE, and determined their causes. We compared the findings with those from 100 age-matched cancer patients who received neither anthracyclines nor trastuzumab. Amongst those who received anthracyclines and/or trastuzumab, 31 (10.4%) had LGE. It had a wide range of extent (3.9-34.7%) and locations. An ischaemic pattern was present in 20/31 (64.5%) patients. There was an alternative explanation for the non-ischaemic LGE in 7/11 (63.6%) patients. In the age-matched patients who received neither anthracyclines nor trastuzumab, the prevalence of LGE was higher at 27.0%, while the extent of LGE and the proportion with ischaemic pattern were not different.
Conclusion
LGE was present in only a minority. Its patterns and locations did not fit into a single unique profile. It had alternative explanations in virtually all cases. Finally, LGE was also present in cancer patients who received neither anthracyclines nor trastuzumab. Therefore, treatment with anthracyclines and/or trastuzumab is unlikely to be associated with LGE. The absence of LGE can help distinguish anthracycline- and/or trastuzumab-related cardiomyopathy from unrelated cardiomyopathies.

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: 18 Nov 2020; epub ahead of print
Modi K, Joppa S, Chen KA, Athwal PSS, ... Blaes AH, Shenoy C
Eur Heart J Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33211843
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Impact:
Abstract

Left ventricular segmental strain and the prediction of cancer therapy-related cardiac dysfunction.

Demissei BG, Fan Y, Qian Y, Cheng HG, ... Davatzikos C, Ky B
Aims
We aimed to determine the early changes and predictive value of left ventricular (LV) segmental strain measures in women with breast cancer receiving doxorubicin.
Methods and results
In a cohort of 237 women with breast cancer receiving doxorubicin with or without trastuzumab, 1151 echocardiograms were prospectively acquired over a median (Q1-Q3) of 7 (2-24) months. LV ejection fraction (LVEF) and 36 segmental strain measures were core lab quantified. A supervised machine learning (ML) model was then developed using random forest regression to identify segmental strain measures predictive of nadir LVEF post-doxorubicin completion. Cancer therapy-related cardiac dysfunction (CTRCD) was defined as a ≥10% absolute LVEF decline pre-treatment to a value <50%. Median (Q1-Q3) baseline age was 48 (41-57) years. Thirty-five women developed CTRCD, and eight of these developed symptomatic heart failure. From pre-treatment to doxorubicin completion, longitudinal strain worsened across the basal and mid-LV segments but not in the apical segments; circumferential strain worsened primarily in the septum; radial strain worsened uniformly and transverse strain remained unchanged across all LV segments. In the ML model, anterolateral and inferoseptal circumferential strain were the most predictive features; longitudinal and transverse strain in the basal inferoseptal, anterior, basal anterolateral, and apical lateral segments were also top predictive features. The addition of predictive segmental strain measures to a model including age, cancer therapy regimen, hypertension, and LVEF increased the area under the curve (AUC) from 0.70 (95% confidence interval (CI) 0.60-0.80) to 0.87 (95% CI 0.81-0.92), ΔAUC = 0.18 (95% CI 0.08-0.27) for the prediction of CTRCD.
Conclusion
Our findings suggest that segmental strain measures can enhance cardiotoxicity risk prediction in women with breast cancer receiving doxorubicin.

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: 17 Nov 2020; epub ahead of print
Demissei BG, Fan Y, Qian Y, Cheng HG, ... Davatzikos C, Ky B
Eur Heart J Cardiovasc Imaging: 17 Nov 2020; epub ahead of print | PMID: 33206976
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Impact:
Abstract

Left atrial mechanics for secondary prevention from embolic stroke of undetermined source.

Sade LE, Keskin S, Can U, Çolak A, ... Özin B, Müderrisoğlu H
Aims 
Anticoagulation is not justified unless atrial fibrillation (AF) is detected in cryptogenic stroke (CS) patients. We sought to explore whether left atrial (LA) remodelling is associated with embolic stroke of undetermined source (ESUS).
Methods and results 
In this prospective study, we evaluated consecutively 186 patients in sinus rhythm who presented with an acute ischaemic stroke (embolic and non-embolic) and sex- and age-matched controls. We performed continuous electrocardiogram (ECG) monitoring to capture paroxysmal AF episodes as recommended by the guidelines. After 12 months of follow-up, continuous ECG monitoring was repeated in patients with undetected AF episodes. We quantified LA reservoir and contraction strain (LASr and LASct) by speckle-tracking, LA volumes by 3D echocardiography. Out of 186 patients, 149 were enrolled after comprehensive investigation for the source of ischaemic stroke and divided into other cause (OC) (n = 52) and CS (n = 97) groups. CS patients were also subdivided into AF (n = 39) and ESUS (n = 58) groups. Among CS patients, LA strain predicted AF independently from CHARGE-AF score and LA volume indices. ESUS group, despite no captured AF, had significantly worse LA metrics than OC and control groups. AF group had the worst LA metrics. Moreover, LASr predicted both CS (embolic stroke with and without AF) and ESUS (embolic stroke with no detected AF) independently from LAVImax and CHA2DS2-VASc score. LASr >26% yielded 86% sensitivity, 92% specificity, 92% positive, and 86% negative predictive values for the identification of ESUS (areas under curve: 0.915, P < 0.0001, 95% confidence interval: 0.86-0.97).
Conclusion 
Echocardiographic quantification of LA remodelling has great potential for secondary prevention from ESUS.

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: 17 Nov 2020; epub ahead of print
Sade LE, Keskin S, Can U, Çolak A, ... Özin B, Müderrisoğlu H
Eur Heart J Cardiovasc Imaging: 17 Nov 2020; epub ahead of print | PMID: 33206942
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Impact:
Abstract

Defining the prognostic value of [15O]H2O positron emission tomography-derived myocardial ischaemic burden.

van Diemen PA, Wijmenga JT, Driessen RS, Bom MJ, ... Danad I, Knaapen P
Aims 
Myocardial ischaemic burden (IB) is used for the risk stratification of patients with coronary artery disease (CAD). This study sought to define a prognostic threshold for quantitative [15O]H2O positron emission tomography (PET)-derived IB.
Methods and results 
A total of 623 patients with suspected or known CAD who underwent [15O]H2O PET perfusion imaging were included. The endpoint was a composite of death and non-fatal myocardial infarction (MI). A hyperaemic myocardial blood flow (hMBF) and myocardial flow reserve (MFR)-derived IB were determined. During a median follow-up time of 6.7 years, 62 patients experienced an endpoint. A hMBF IB of 24% and MFR IB of 28% were identified as prognostic thresholds. Patients with a high hMBF or MFR IB (above threshold) had worse outcome compared to patients with a low hMBF IB [annualized event rates (AER): 2.8% vs. 0.6%, P < 0.001] or low MFR IB [AER: 2.4% vs. 0.6%, P < 0.001]. Patients with a concordant high IB had the worst outcome (AER: 3.1%), whereas patients with a concordant low or discordant IB result had similar and low AERs of 0.5% and 0.9% (P = 0.953), respectively. Both thresholds were of prognostic value beyond clinical characteristics, however, only the hMBF IB threshold remained predictive when adjusted for clinical characteristics and combined use of the hMBF and MFR thresholds.
Conclusion 
A hMBF IB ≥24% was a stronger predictor of adverse outcome than an MFR IB ≥28%. Nevertheless, classifying patients according to concordance of IB result allowed for the identification of low- and high-risk 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: 16 Nov 2020; epub ahead of print
van Diemen PA, Wijmenga JT, Driessen RS, Bom MJ, ... Danad I, Knaapen P
Eur Heart J Cardiovasc Imaging: 16 Nov 2020; epub ahead of print | PMID: 33200201
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Impact:
Abstract

Manganese-enhanced magnetic resonance imaging in dilated cardiomyopathy and hypertrophic cardiomyopathy.

Spath NB, Singh T, Papanastasiou G, Kershaw L, ... Newby DE, Semple SI
Aims
The aim of this study is to quantify altered myocardial calcium handling in non-ischaemic cardiomyopathy using magnetic resonance imaging.
Methods and results
Patients with dilated cardiomyopathy (n = 10) or hypertrophic cardiomyopathy (n = 17) underwent both gadolinium and manganese contrast-enhanced magnetic resonance imaging and were compared with healthy volunteers (n = 20). Differential manganese uptake (Ki) was assessed using a two-compartment Patlak model. Compared with healthy volunteers, reduction in T1 with manganese-enhanced magnetic resonance imaging was lower in patients with dilated cardiomyopathy [mean reduction 257 ± 45 (21%) vs. 288 ± 34 (26%) ms, P < 0.001], with higher T1 at 40 min (948 ± 57 vs. 834 ± 28 ms, P < 0.0001). In patients with hypertrophic cardiomyopathy, reductions in T1 were less than healthy volunteers [mean reduction 251 ± 86 (18%) and 277 ± 34 (23%) vs. 288 ± 34 (26%) ms, with and without fibrosis respectively, P < 0.001]. Myocardial manganese uptake was modelled, rate of uptake was reduced in both dilated and hypertrophic cardiomyopathy in comparison with healthy volunteers (mean Ki 19 ± 4, 19 ± 3, and 23 ± 4 mL/100 g/min, respectively; P = 0.0068). In patients with dilated cardiomyopathy, manganese uptake rate correlated with left ventricular ejection fraction (r2 = 0.61, P = 0.009). Rate of myocardial manganese uptake demonstrated stepwise reductions across healthy myocardium, hypertrophic cardiomyopathy without fibrosis and hypertrophic cardiomyopathy with fibrosis providing absolute discrimination between the healthy myocardium and fibrosed myocardium (mean Ki 23 ± 4, 19 ± 3, and 13 ± 4 mL/100 g/min, respectively; P < 0.0001).
Conclusion
The rate of manganese uptake in both dilated and hypertrophic cardiomyopathy provides a measure of altered myocardial calcium handling. This holds major promise for the detection and monitoring of dysfunctional myocardium, with the potential for early intervention and prognostication.

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

Eur Heart J Cardiovasc Imaging: 16 Nov 2020; epub ahead of print
Spath NB, Singh T, Papanastasiou G, Kershaw L, ... Newby DE, Semple SI
Eur Heart J Cardiovasc Imaging: 16 Nov 2020; epub ahead of print | PMID: 33200175
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Impact:
Abstract

Quantitative cardiovascular magnetic resonance myocardial perfusion mapping to assess hyperaemic response to adenosine stress.

Kotecha T, Monteagudo JM, Martinez-Naharro A, Chacko L, ... Rakhit R, Fontana M
Aims
Assessment of hyperaemia during adenosine stress cardiovascular magnetic resonance (CMR) remains a clinical challenge with lack of a gold-standard non-invasive clinical marker to confirm hyperaemic response. This study aimed to validate maximum stress myocardial blood flow (SMBF) measured using quantitative perfusion mapping for assessment of hyperaemic response and compare this to current clinical markers of adenosine stress.
Methods and results
Two hundred and eighteen subjects underwent adenosine stress CMR. A derivation cohort (22 volunteers) was used to identify a SMBF threshold value for hyperaemia. This was tested in a validation cohort (37 patients with suspected coronary artery disease) who underwent invasive coronary physiology assessment on the same day as CMR. A clinical cohort (159 patients) was used to compare SMBF to other physiological markers of hyperaemia [splenic switch-off (SSO), heart rate response (HRR), and blood pressure (BP) fall]. A minimum SMBF threshold of 1.43 mL/g/min was derived from volunteer scans. All patients in the coronary physiology cohort demonstrated regional maximum SMBF (SMBFmax) >1.43 mL/g/min and invasive evidence of hyperaemia. Of the clinical cohort, 93% had hyperaemia defined by perfusion mapping compared to 71% using SSO and 81% using HRR. There was no difference in SMBFmax in those with or without SSO (2.58 ± 0.89 vs. 2.54 ± 1.04 mL/g/min, P = 0.84) but those with HRR had significantly higher SMBFmax (2.66 1.86 mL/g/min, P < 0.001). HRR >15 bpm was superior to SSO in predicting adequate increase in SMBF (AUC 0.87 vs. 0.62, P < 0.001).
Conclusion
Adenosine-induced increase in myocardial blood flow is accurate for confirmation of hyperaemia during stress CMR studies and is superior to traditional, clinically used markers of adequate stress such as SSO and BP response.

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: 13 Nov 2020; epub ahead of print
Kotecha T, Monteagudo JM, Martinez-Naharro A, Chacko L, ... Rakhit R, Fontana M
Eur Heart J Cardiovasc Imaging: 13 Nov 2020; epub ahead of print | PMID: 33188683
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Impact:
Abstract

Right ventricular myocardial work: proof-of-concept for non-invasive assessment of right ventricular function.

Butcher SC, Fortuni F, Montero-Cabezas JM, Abou R, ... Bax JJ, Delgado V
Aims
Right ventricular myocardial work (RVMW) is a novel method for non-invasive assessment of right ventricular (RV) function utilizing RV pressure-strain loops. This study aimed to explore the relationship between RVMW and invasive indices of right heart catheterization (RHC) in a cohort of patients with heart failure with reduced left ventricular ejection fraction (HFrEF), and to compare values of RVMW with those of a group of patients without cardiovascular disease.
Methods and results
Non-invasive analysis of RVMW was performed in 22 HFrEF patients [median age 63 (59-67) years] who underwent echocardiography and invasive RHC within 48 h. Conventional RV functional measurements, RV global constructive work (RVGCW), RV global work index (RVGWI), RV global wasted work (RVGWW), and RV global work efficiency (RVGWE) were analysed and compared with invasively measured stroke volume and stroke volume index. Non-invasive analysis of RVMW was also performed in 22 patients without cardiovascular disease to allow for comparison between groups. None of the conventional echocardiographic parameters of RV systolic function were significantly correlated with stroke volume or stroke volume index. In contrast, one of the novel indices derived non-invasively by pressure-strain loops, RVGCW, demonstrated a moderate correlation with invasively measured stroke volume and stroke volume index (r = 0.63, P = 0.002 and r = 0.59, P = 0.004, respectively). RVGWI, RVGCW, and RVGWE were significantly lower in patients with HFrEF compared to a healthy cohort, while values of RVGWW were significantly higher.
Conclusion
RVGCW is a novel parameter that provides an integrative analysis of RV systolic function and correlates more closely with invasively measured stroke volume and stroke volume index than other standard echocardiographic parameters.

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 Nov 2020; epub ahead of print
Butcher SC, Fortuni F, Montero-Cabezas JM, Abou R, ... Bax JJ, Delgado V
Eur Heart J Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33184656
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Impact:
Abstract

Prognostic implication of CT-FFR based functional SYNTAX score in patients with de novo three-vessel disease.

Qiao HY, Li JH, Schoepf UJ, Bayer RR, ... Lu GM, Zhang LJ
Aims
This study was aimed at investigating whether a machine learning (ML)-based coronary computed tomographic angiography (CCTA) derived fractional flow reserve (CT-FFR) SYNTAX score (SS), \'Functional SYNTAX score\' (FSSCTA), would predict clinical outcome in patients with three-vessel coronary artery disease (CAD).
Methods and results
The SS based on CCTA (SSCTA) and ICA (SSICA) were retrospectively collected in 227 consecutive patients with three-vessel CAD. FSSCTA was calculated by combining the anatomical data with functional data derived from a ML-based CT-FFR assessment. The ability of each score system to predict major adverse cardiac events (MACE) was compared. The difference between revascularization strategies directed by the anatomical SS and FSSCTA was also assessed. Two hundred and twenty-seven patients were divided into two groups according to the SSCTA cut-off value of 22. After determining FSSCTA for each patient, 22.9% of patients (52/227) were reclassified to a low-risk group (FSSCTA ≤ 22). In the low- vs. intermediate-to-high (>22) FSSCTA group, MACE occurred in 3.2% (4/125) vs. 34.3% (35/102), respectively (P < 0.001). The independent predictors of MACE were FSSCTA (OR = 1.21, P = 0.001) and diabetes (OR = 2.35, P = 0.048). FSSCTA demonstrated a better predictive accuracy for MACE compared with SSCTA (AUC: 0.81 vs. 0.75, P = 0.01) and SSICA (0.81 vs. 0.75, P < 0.001). After FSSCTA was revealed, 52 patients initially referred for CABG based on SSCTA would have been changed to PCI.
Conclusion
Recalculating SS by incorporating lesion-specific ischaemia as determined by ML-based CT-FFR is a better predictor of MACE in patients with three-vessel CAD. Additionally, the use of FSSCTA may alter selected revascularization strategies 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: 12 Nov 2020; epub ahead of print
Qiao HY, Li JH, Schoepf UJ, Bayer RR, ... Lu GM, Zhang LJ
Eur Heart J Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33184644
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Impact:
Abstract

Usefulness of left atrial strain for predicting incident atrial fibrillation and ischaemic stroke in the general population.

Alhakak AS, Biering-Sørensen SR, Møgelvang R, Modin D, ... Gislason G, Biering-Sørensen T
Aims
Left atrial enlargement predicts incident atrial fibrillation (AF). However, the prognostic value of peak atrial longitudinal strain (PALS) for predicting incident AF in participants from the general population is currently unknown. Our aim was to investigate if PALS can be used to predict AF and ischaemic stroke in the general population.
Methods and results
A total of 400 participants from the general population underwent a health examination, including two-dimensional speckle tracking echocardiography of the left atrium. The primary endpoint was incident AF at follow-up. All participants with known AF and prior stroke at baseline were excluded (n = 54). The secondary endpoint consisted of the composite of AF and ischaemic stroke. During a median follow-up of 16 years, 36 participants (9%) were diagnosed with incident AF and 30 (7%) experienced an ischaemic stroke, resulting in 66 (16%) experiencing the composite outcome. PALS was a univariable predictor of AF [per 5% decrease: hazard ratio (HR) 1.42; 95% confidence interval (CI) (1.19-1.69), P < 0.001]. However, the prognostic value of PALS was modified by age (P = 0.002 for interaction). After multivariable adjustment PALS predicted AF in participants aged <65 years [per 5% decrease: HR 1.46; 95% CI (1.06-2.02), P = 0.021]. In contrast, PALS did not predict AF in participants aged ≥65 years after multivariable adjustment [per 5% decrease: HR 1.05; 95% CI (0.81-1.35), P = 0.72]. PALS also predicted the secondary endpoint in participants aged <65 years and the association remained significant after multivariable adjustment.
Conclusion
In a low-risk general population, PALS provides novel prognostic information on the long-term risk of AF and ischaemic stroke in participants aged <65 years.

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: 10 Nov 2020; epub ahead of print
Alhakak AS, Biering-Sørensen SR, Møgelvang R, Modin D, ... Gislason G, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 10 Nov 2020; epub ahead of print | PMID: 33175146
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Impact:
Abstract

Pressure-volume loop validation of TAPSE/PASP for right ventricular arterial coupling in heart failure with pulmonary hypertension.

Schmeisser A, Rauwolf T, Groscheck T, Kropf S, ... Steendijk P, Braun-Dullaeus RC
Aims
The aim of this study was to validate the tricuspid annular plane systolic excursion/systolic pulmonary artery (PA) pressure (TAPSE/PASP) ratio with the invasive pressure-volume (PV) loop-derived end-systolic right ventricular (RV) elastance/PA elastance (Ees/Ea) ratio in patients with heart failure with reduced ejection fraction (HFREF) and secondary pulmonary hypertension (PH).
Methods and results
The relationship of TAPSE and TAPSE/PASP with RV-PV loop (single-beat)-derived contractility Ees, afterload Ea, and Ees/Ea was assessed in 110 patients with HFREF with and without secondary PH. The results were compared with other surrogate parameters such as the fractional area change/PASP ratio. The association of the surrogates with all-cause mortality was evaluated. In patients with PH (n = 74, 67%), TAPSE significantly correlated with Ees (r = 0.356), inverse with Ea (r = -0.514) but was most closely associated with Ees/Ea (r = 0.77). Placing TAPSE in a ratio with PASP slightly reduced the relationship to Ees/Ea (r = 0.71) but was more closely related to the parameters of PA vascular load, diastolic RV function, and RV energetics. The area under the curve of TAPSE/PASP and TAPSE for discriminating overall survival in receiver operating characteristic analysis was not different (P = 0.78. Prognostic relevant cut-offs were 17 mm for TAPSE and 0.38 mm/mmHg for TAPSE/PASP. Both parameters in multivariate cox regression remained independently prognostically relevant.
Conclusion
TAPSE is an easily and reliably obtainable and valid surrogate parameter for RV-PA coupling in PH due to HFREF. Putting TAPSE into a ratio with PASP did not further improve the coupling information or prognostic assessment.
Trial identifier
DRKS-German Clinical Trials Register (DRKS00011133; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011133).

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: 08 Nov 2020; epub ahead of print
Schmeisser A, Rauwolf T, Groscheck T, Kropf S, ... Steendijk P, Braun-Dullaeus RC
Eur Heart J Cardiovasc Imaging: 08 Nov 2020; epub ahead of print | PMID: 33167032
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Impact:
Abstract

Cardiovascular magnetic resonance imaging in the UK Biobank: a major international health research resource.

Raisi-Estabragh Z, Harvey NC, Neubauer S, Petersen SE

The UK Biobank (UKB) is a health research resource of major international importance, incorporating comprehensive characterization of >500 000 men and women recruited between 2006 and 2010 from across the UK. There is prospective tracking of health outcomes for all participants through linkages with national cohorts (death registers, cancer registers, electronic hospital records, and primary care records). The dataset has been enhanced with the UKB imaging study, which aims to scan a subset of 100 000 participants. The imaging protocol includes magnetic resonance imaging of the brain, heart, and abdomen, carotid ultrasound, and whole-body dual X-ray absorptiometry. Since its launch in 2015, over 48 000 participants have completed the imaging study with scheduled completion in 2023. Repeat imaging of 10 000 participants has been approved and commenced in 2019. The cardiovascular magnetic resonance (CMR) scan provides detailed assessment of cardiac structure and function comprising bright blood anatomic assessment (sagittal, coronal, and axial), left and right ventricular cine images (long and short axes), myocardial tagging, native T1 mapping, aortic flow, and imaging of the thoracic aorta. The UKB is an open access resource available to health researchers across all scientific disciplines from both academia and industry with no preferential access or exclusivity. In this paper, we consider how we may best utilize the UKB CMR data to advance cardiovascular research and review notable achievements to date.

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

Eur Heart J Cardiovasc Imaging: 08 Nov 2020; epub ahead of print
Raisi-Estabragh Z, Harvey NC, Neubauer S, Petersen SE
Eur Heart J Cardiovasc Imaging: 08 Nov 2020; epub ahead of print | PMID: 33164079
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Impact:
Abstract

External elastic lamina vs. luminal diameter measurement for determining stent diameter by optical coherence tomography: an ILUMIEN III substudy.

Shlofmitz E, Jeremias A, Parviz Y, Karimi Galougahi K, ... Shlofmitz RA, Ali ZA
Aims
Optical coherence tomography (OCT)-guided external elastic lamina (EEL)-based stent sizing is safe and as effective as intravascular ultrasound in achieving post-procedural lumen dimensions. However, when compared with automated lumen diameter (LD) measurements, this approach is time-consuming. We aimed to compare vessel diameter measurements and stent diameter selection using either of these approaches and examined whether applying a correction factor to automated LD measurements could result in selecting similar stent diameters to the EEL-based approach.
Methods and results
We retrospectively compared EEL-based measurements vs. automated LD in reference segments in 154 OCT acquisitions and derived a correction factor for stent sizing using the ratio of EEL to LD measurements. We then prospectively applied the correction factor in 119 OCT acquisitions. EEL could be adequately identified in 100 acquisitions (84%) at the distal reference to allow vessel diameter measurement. Vessel diameters were larger with EEL-based vs. LD measurements at both proximal (4.12 ± 0.74 vs. 3.14 ± 0.67 mm, P < 0.0001) and distal reference segments (3.34 ± 0.75 vs. 2.64 ± 0.65 mm, P < 0.0001). EEL-based downsizing led to selection of larger stents vs. an LD-based upsizing approach (3.33 ± 0.47 vs. 2.70 ± 0.44, P < 0.0001). Application of correction factors to LD [proximal 1.32 (IQR 1.23-1.37) and distal 1.25 (IQR 1.19-1.36)] resulted in discordance in stent sizing by >0.25 mm in 63% and potentially hazardous stent oversizing in 41% of cases.
Conclusion
EEL-based stent downsizing led to selection of larger stent diameters vs. LD upsizing. While applying a correction factor to automated LD measurements resulted in similar mean diameters to EEL-based measurements, this approach cannot be used clinically due to frequent and potentially hazardous stent over-sizing.

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: 08 Nov 2020; epub ahead of print
Shlofmitz E, Jeremias A, Parviz Y, Karimi Galougahi K, ... Shlofmitz RA, Ali ZA
Eur Heart J Cardiovasc Imaging: 08 Nov 2020; epub ahead of print | PMID: 33167000
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Impact:
Abstract

Stress CMR in patients with obesity: insights from the Stress CMR Perfusion Imaging in the United States (SPINS) registry.

Ge Y, Steel K, Antiochos P, Bingham S, ... Simonetti OP, Kwong RY
Aims
Non-invasive assessment and risk stratification of coronary artery disease in patients with large body habitus is challenging. We aim to examine whether body mass index (BMI) modifies the prognostic value and diagnostic utility of stress cardiac magnetic resonance imaging (CMR) in a multicentre registry.
Methods and results
The SPINS Registry enrolled consecutive intermediate-risk patients who presented with a clinical indication for stress CMR in the USA between 2008 and 2013. Baseline demographic data including BMI, CMR indices, and ratings of study quality were collected. Primary outcome was defined by a composite of cardiovascular death and non-fatal myocardial infarction. Of the 2345 patients with available BMI included in the SPINS cohort, 1177 (50%) met criteria for obesity (BMI ≥ 30) with 531 (23%) at or above Class 2 obesity (BMI ≥ 35). In all BMI categories, >95% of studies were of diagnostic quality for cine, perfusion, and late gadolinium enhancement (LGE) sequences. At a median follow-up of 5.4 years, those without ischaemia and LGE experienced a low annual rate of hard events (<1%), across all BMI strata. In patients with obesity, both ischaemia [hazard ratio (HR): 2.14; 95% confidence interval (CI): 1.30-3.50; P = 0.003] and LGE (HR: 3.09; 95% CI: 1.83-5.22; P < 0.001) maintained strong adjusted association with the primary outcome in a multivariable Cox regression model. Downstream referral rates to coronary angiography, revascularization, and cost of care spent on ischaemia testing did not significantly differ within the BMI categories.
Conclusion
In this large multicentre registry, elevated BMI did not negatively impact the diagnostic quality and the effectiveness of risk stratification of patients referred for stress CMR.

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: 08 Nov 2020; epub ahead of print
Ge Y, Steel K, Antiochos P, Bingham S, ... Simonetti OP, Kwong RY
Eur Heart J Cardiovasc Imaging: 08 Nov 2020; epub ahead of print | PMID: 33166994
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Impact:
Abstract

Independent and incremental prognostic value of semiquantitative measures of tricuspid regurgitation severity in heart failure with preserved ejection fraction.

Harada T, Obokata M, Omote K, Iwano H, ... Anzai T, Kurabayashi M
Aims
This study sought to determine the independent and incremental prognostic value of semiquantitative measures of tricuspid regurgitation (TR) severity over right heart remodelling and pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF).
Methods and results
Echocardiography was performed on 311 HFpEF patients. TR severity was defined by the semiquantitative measures [i.e. vena contracta width (VCW) and jet area] and by the guideline-based integrated qualitative approach (absent, mild, moderate, or severe). All-cause mortality or heart failure hospitalization occurred in 101 patients over a 2.1-year median follow-up. There was a continuous association between TR severity and the composite outcome with a hazard ratio (HR) of 1.17 per 1 mm increase of VCW [95% confidence interval (CI) 1.08-1.26, P < 0.0001]. Compared with patients with the lowest VCW category (≤1 mm), RV-adjusted HRs for the outcome were 1.99 (95% CI 1.05-3.77), 2.63 (95% CI 1.16-5.95), and 5.00 (95% CI 1.60-15.7) for 1-3, 3-7, and ≥7 mm VCW categories, respectively. TR severity as defined by the guideline-based approach showed a similarly graded association, but it was no longer significant in models including PH. In contrast, VCW remained independently and incrementally associated with the outcome after adjusting for established prognostic factors, as well as RV diameter and PH (fully adjusted HR 1.14 per 1 mm, 95% CI 1.02-1.27, P = 0.02; χ2 58.8 vs. 51.5, P = 0.03).
Conclusion
The current data highlight the potential value of the semiquantitative measures of TR severity for the risk stratification in patients with HFpEF.

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: 06 Nov 2020; epub ahead of print
Harada T, Obokata M, Omote K, Iwano H, ... Anzai T, Kurabayashi M
Eur Heart J Cardiovasc Imaging: 06 Nov 2020; epub ahead of print | PMID: 33159785
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Abstract

The cardiac impact of cisplatin-based chemotherapy in survivors of testicular cancer: a 30-year follow-up.

Bjerring AW, Fosså SD, Haugnes HS, Nome R, ... Edvardsen T, Sarvari SI
Aims
Cisplatin-based chemotherapy (CBCT) is essential in the treatment of metastatic testicular cancer (TC) but has been associated with long-term risk of cardiovascular morbidity and mortality. Furthermore, cisplatin can be detected in the body decades after treatment. We aimed to evaluate the long-term impact of CBCT on cardiac function and morphology in TC survivors 30 years after treatment.
Methods and results
TC survivors treated with CBCT (1980-94) were recruited from the longitudinal Norwegian Cancer Study in Testicular Cancer Survivors and compared with a control group matched for sex, age, smoking status, and heredity for coronary artery disease. All participants underwent laboratory tests, blood pressure measurement, and 2D and 3D echocardiography including 2D speckle-tracking strain analyses. Ninety-four TC survivors, on average 60 ± 9 years old, received a median cumulative cisplatin dose of 780 mg (IQR 600-800). Compared with controls, TC survivors more frequently used anti-hypertensive (55% vs. 24%, P < 0.001) and lipid-lowering medication (44% vs. 18%, P < 0.001). TC survivors had worse diastolic function parameters with higher E/e\'-ratio (9.8 ± 3.2 vs. 7.7 ± 2.5, P < 0.001), longer mitral deceleration time (221 ± 69 vs. 196 ± 57ms, P < 0.01), and higher maximal tricuspid regurgitation velocity (25 ± 7 vs. 21 ± 4 m/s, P = 0.001). The groups did not differ in left or right ventricular systolic function, prevalence of arrhythmias, or valvular heart disease. Cumulative cisplatin dose did not correlate with cardiac parameters.
Conclusion
No signs of overt or subclinical reduction in systolic function were identified. Long-term cardiovascular adverse effects three decades after CBCT may be limited to metabolic dysfunction and worse diastolic function in TC survivors.

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

Eur Heart J Cardiovasc Imaging: 04 Nov 2020; epub ahead of print
Bjerring AW, Fosså SD, Haugnes HS, Nome R, ... Edvardsen T, Sarvari SI
Eur Heart J Cardiovasc Imaging: 04 Nov 2020; epub ahead of print | PMID: 33152065
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Abstract

Diastolic dysfunction and mortality in 436 360 men and women: the National Echo Database Australia (NEDA).

Playford D, Strange G, Celermajer DS, Evans G, ... Stewart S, Prior D
Aims 
To examine the characteristics/prognostic impact of diastolic dysfunction (DD) according to 2016 American Society of Echocardiography (ASE) and European Society of Cardiovascular Imaging (ESCVI) guidelines, and individual parameters of DD.
Methods and results 
Data were derived from a large multicentre mortality-linked echocardiographic registry comprising 436 360 adults with ≥1 diastolic function measurement linked to 100 597 deaths during 2.2 million person-years follow-up. ASE/European Association of Cardiovascular Imaging (EACVI) algorithms could be applied in 392 009 (89.8%) cases; comprising 11.4% of cases with \'reduced\' left ventricular ejection fraction (LVEF < 50%) and 88.6% with \'preserved\' LVEF (≥50%). Diastolic function was indeterminate in 21.5% and 62.2% of \'preserved\' and \'reduced\' LVEF cases, respectively. Among preserved LVEF cases, the risk of adjusted 5-year cardiovascular-related mortality was elevated in both DD [odds ratio (OR) 1.31, 95% confidence interval (CI) 1.22-1.42; P < 0.001] and indeterminate status cases (OR 1.11, 95% CI 1.04-1.18; P < 0.001) vs. no DD. Among impaired LVEF cases, the equivalent risk of cardiovascular-related mortality was 1.51 (95% CI 1.15-1.98, P < 0.001) for increased filling pressure vs. 1.25 (95% CI 0.96-1.64, P = 0.06) for indeterminate status. Mitral E velocity, septal e\' velocity, E:e\' ratio, and LAVi all correlated with mortality. On adjusted basis, pivot-points of increased risk for cardiovascular-related mortality occurred at 90 cm/s for E wave velocity, 9 cm/s for septal e\' velocity, an E:e\' ratio of 9, and an LAVi of 32 mL/m2.
Conclusion 
ASE/EACVI-classified DD is correlated with increased mortality. However, many cases remain \'indeterminate\'. Importantly, when analysed individually, mitral E velocity, septal e\' velocity, E:e\' ratio, and LAVi revealed clear pivot-points of increased risk of cardiovascular-related mortality.

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

Eur Heart J Cardiovasc Imaging: 02 Nov 2020; epub ahead of print
Playford D, Strange G, Celermajer DS, Evans G, ... Stewart S, Prior D
Eur Heart J Cardiovasc Imaging: 02 Nov 2020; epub ahead of print | PMID: 33245344
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Abstract

Prognostic durability of coronary computed tomography angiography.

Chow BJW, Yam Y, Small G, Wells GA, ... Ruddy TD, Hossain A
Aims 
This large prospective cohort study sought to confirm the incremental prognostic value of coronary computed tomographic angiography (CCTA) measured over a prolonged follow-up duration. CCTA has diagnostic and prognostic value but data supporting its long-term prognostic value in a large prospectively recruited cohort with suspected coronary artery disease (CAD) has been limited.
Methods and results 
Consecutive patients (without history of myocardial infarction, revascularization, cardiac transplantation, and congenital heart disease) were prospectively enrolled. CCTA was evaluated for CAD severity, total plaque score (TPS), and left ventricular ejection fraction. Patients were followed for major adverse events (MAE) and major adverse cardiac events (MACE).Over a total of 99 months, 8667 consecutive CCTA patients (mean age = 57.1 ± 11.1 years, 52.9% men) were prospectively enrolled and followed for a mean duration of 7.0 ± 2.6 years. At follow-up, there were a total of 723 MAE, 278 MACE, 547 all-cause deaths, 110 cardiac deaths, and 104 non-fatal myocardial infarction. Patients without coronary atherosclerosis at the time of CCTA had a very low annual event rate for both MAE and MACE (0.45%/year and 0.19%/year, respectively). Both MAE and MACE increased with increasing TPS and severity of CAD. In patients with non-obstructive CAD and who were statin-naive, TPS ≥5 had MACE rates >0.75%/year. Patients with high-risk CAD had an annual MAE and MACE rates of 3.52%/year and 2.58%/year, respectively. Adjusted hazard ratio of the severity of CAD based on multivariable analyses indicated that the prognostic values were incremental.
Conclusion 
CCTA has independent and incremental prognostic value that is durable over time. The absence of coronary atherosclerosis portends an excellent prognosis. Patients with increasing non-obstructive plaque burden have worse prognosis and a TPS threshold ≥5 may identify a population that may benefit from statin therapy.

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: 27 Oct 2020; epub ahead of print
Chow BJW, Yam Y, Small G, Wells GA, ... Ruddy TD, Hossain A
Eur Heart J Cardiovasc Imaging: 27 Oct 2020; epub ahead of print | PMID: 33111135
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Abstract

Pericoronary adipose tissue computed tomography attenuation distinguishes different stages of coronary artery disease: a cross-sectional study.

Lin A, Nerlekar N, Yuvaraj J, Fernandes K, ... Dey D, Wong DTL
Aims 
Vascular inflammation inhibits local adipogenesis in pericoronary adipose tissue (PCAT) and this can be detected on coronary computed tomography angiography (CCTA) as an increase in CT attenuation of PCAT surrounding the proximal right coronary artery (RCA). In this cross-sectional study, we assessed the utility of PCAT CT attenuation as an imaging biomarker of coronary inflammation in distinguishing different stages of coronary artery disease (CAD).
Methods and results
Sixty patients with acute myocardial infarction (MI) were prospectively recruited to undergo CCTA within 48 h of admission, prior to invasive angiography. These participants were matched to patients with stable CAD (n = 60) and controls with no CAD (n = 60) by age, gender, BMI, risk factors, medications, and CT tube voltage. PCAT attenuation around the proximal RCA was quantified per-patient using semi-automated software. Patients with MI had a higher PCAT attenuation (-82.3 ± 5.5 HU) compared with patients with stable CAD (-90.6 ± 5.7 HU, P < 0.001) and controls (-95.8 ± 6.2 HU, P < 0.001). PCAT attenuation was significantly increased in stable CAD patients over controls (P = 0.01). The association of PCAT attenuation with stage of CAD was independent of age, gender, cardiovascular risk factors, epicardial adipose tissue volume, and CCTA-derived quantitative plaque burden. No interaction was observed for clinical presentation (MI vs. stable CAD) and plaque burden on PCAT attenuation.
Conclusion
PCAT CT attenuation as a quantitative measure of global coronary inflammation independently distinguishes patients with MI vs. stable CAD vs. no CAD. Future studies should assess whether this imaging biomarker can track patient responses to therapies in different stages of CAD.

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: 26 Oct 2020; epub ahead of print
Lin A, Nerlekar N, Yuvaraj J, Fernandes K, ... Dey D, Wong DTL
Eur Heart J Cardiovasc Imaging: 26 Oct 2020; epub ahead of print | PMID: 33106867
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Abstract

Myocardial work assessment in severe aortic stenosis undergoing transcatheter aortic valve replacement.

Jain R, Bajwa T, Roemer S, Huisheree H, ... Tajik AJ, Khandheria BK
Aims
Myocardial work is a novel echocardiographic algorithm that corrects speckle-tracking-derived global longitudinal strain (GLS) for afterload using non-invasive systolic blood pressure as a surrogate for left ventricular systolic pressure (LVSP). Yet, in patients with severe aortic stenosis, non-invasive systolic blood pressure does not equal LVSP.
Methods and results
We evaluated 35 patients with severe aortic stenosis who underwent transcatheter aortic valve replacement (TAVR). Transthoracic echocardiography, including myocardial mechanics, was performed pre- and post-TAVR. We performed simultaneous echocardiographic and cardiac catheterization measurements in 23 of the 35 patients at the time of TAVR. Peak and mean aortic gradients were calculated from echocardiographic and cardiac catheterization data. Peak-to-peak LV-aortic gradient correlated highly with mean LV-aortic gradient (r = 0.96); measured LVSP correlated highly with our novel method of non-invasively estimated LVSP (non-invasive systolic blood pressure cuff + Doppler-derived mean aortic gradient, r = 0.92). GLS improved from pre- to post-TAVR (-14.2% ± 4.3 vs. -15.1% ± 3.2), and myocardial work reduced from corrected pre-TAVR to post-TAVR (global work index: 1856.2 mmHg% ± 704.6 vs. 1534.8 ± 385.0).
Conclusion
We propose that non-invasive assessment of myocardial work can be reliably performed in aortic stenosis by the addition of mean aortic gradient to non-invasive systolic blood pressure. From this analysis, we note the novel and unique finding that GLS can improve as myocardial work reduces post-TAVR in patients with severe aortic stenosis. Both GLS and myocardial work post-TAVR remain below normal values, requiring further studies.

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: 26 Oct 2020; epub ahead of print
Jain R, Bajwa T, Roemer S, Huisheree H, ... Tajik AJ, Khandheria BK
Eur Heart J Cardiovasc Imaging: 26 Oct 2020; epub ahead of print | PMID: 33106854
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This program is still in alpha version.