Journal: Eur Heart J Cardiovasc Imaging

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Abstract

Comparing echocardiographic characteristics in genotype positive-phenotype positive hypertrophic cardiomyopathy and hypertensive left ventricular hypertrophy.

de la Rosa A, Shah M, Shiota T, Siegel R, Rader F
Aims
There is little information about hypertrophic cardiomyopathy (HCM) with pathologic genetic mutations and concurrent hypertension (HTN). Hypertensive left ventricular hypertrophy (LVH) does not exclude an underlying genetic aetiology.
Methods and results
This was a single-centre case-control study of 39 adults with pathologic HCM mutations, confirmed by genetic testing, compared to 39 age- and gender-matched patients with hypertensive LVH. The gene-positive HCM cohort was further stratified by the coexisting presence or absence of HTN. Clinical and echocardiographic characteristics were compared. Of 39 gene-positive HCM, 43.6% (17/39) had concurrent HTN. The gene-positive HCM cohort had larger left atrial (LA) area (22.1 cm2 vs. 18.9 cm2, P = 0.002), more diastolic predominant pulmonary vein flow (38.5% vs. 7.7%, P = 0.001), and more moderate diastolic dysfunction (33.3% vs. 12.8%, P = 0.032) when compared with the hypertensive LVH cohort. Greater left ventricular (LV) mass (277.7 g vs. 207.7 g, P = 0.025), increased frequency of severe LVH (58.8% vs. 27.3%, P = 0.047), and more abnormal global longitudinal strain (GLS) (-14.1% vs. -16.9%, P = 0.049) was observed in the gene-positive HCM cohort with concurrent HTN.
Conclusion
Gene-positive HCM, compared to hypertensive LVH, is characterized by more advanced diastolic dysfunction and larger LA size. Gene-positive HCM patients with concomitant HTN had greater LV mass, more severe LVH, and more abnormal GLS, suggesting HTN may negatively affect the progression of myocardial dysfunction in genetic HCM. LVH out-of-proportion to pressure burden in HTN patients should raise suspicion of underlying genetic HCM.

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: 24 Oct 2021; epub ahead of print
de la Rosa A, Shah M, Shiota T, Siegel R, Rader F
Eur Heart J Cardiovasc Imaging: 24 Oct 2021; epub ahead of print | PMID: 34694376
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Abstract

Visual echocardiographic scoring system of the left ventricular filling pressure and outcomes of heart failure with preserved ejection fraction.

Murayama M, Iwano H, Obokata M, Harada T, ... Kurabayashi M, Anzai T
Aims
Elevated left ventricular filling pressure (LVFP) is a powerful indicator of worsening clinical outcomes in heart failure with preserved ejection fraction (HFpEF); however, detection of elevated LVFP is often challenging. This study aimed to determine the association between the newly proposed echocardiographic LVFP parameter, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score, and clinical outcomes of HFpEF.
Methods and results
We retrospectively investigated 310 well-differentiated HFpEF patients in stable conditions. VMT was scored from 0 to 3 using two-dimensional echocardiographic images, and VMT ≥2 was regarded as a sign of elevated LVFP. The primary endpoint was a composite of cardiac death or heart failure hospitalization during the 2 years after the echocardiographic examination. In all patients, Kaplan-Meier curves showed that VMT ≥2 (n = 54) was associated with worse outcomes than the VMT ≤1 group (n = 256) (P < 0.001). Furthermore, VMT ≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (AF) (P = 0.026). In the adjusted model, VMT ≥2 was independently associated with the primary outcome (hazard ratio 2.60, 95% confidence interval 1.46-4.61; P = 0.001). Additionally, VMT scoring provided an incremental prognostic value over clinically relevant variables and diastolic function grading (χ2 10.8-16.3, P = 0.035).
Conclusions
In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it could also predict clinical outcomes in HFpEF patients with AF.

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

Eur Heart J Cardiovasc Imaging: 24 Oct 2021; epub ahead of print
Murayama M, Iwano H, Obokata M, Harada T, ... Kurabayashi M, Anzai T
Eur Heart J Cardiovasc Imaging: 24 Oct 2021; epub ahead of print | PMID: 34694368
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Abstract

Phenotyping hypertrophic cardiomyopathy using cardiac diffusion magnetic resonance imaging: the relationship between microvascular dysfunction and microstructural changes.

Das A, Kelly C, Teh I, Nguyen C, ... Schneider JE, Dall\'Armellina E
Aims
Microvascular dysfunction in hypertrophic cardiomyopathy (HCM) is predictive of clinical decline, however underlying mechanisms remain unclear. Cardiac diffusion tensor imaging (cDTI) allows in vivo characterization of myocardial microstructure by quantifying mean diffusivity (MD), fractional anisotropy (FA) of diffusion, and secondary eigenvector angle (E2A). In this cardiac magnetic resonance (CMR) study, we examine associations between perfusion and cDTI parameters to understand the sequence of pathophysiology and the interrelation between vascular function and underlying microstructure.
Methods and results
Twenty HCM patients underwent 3.0T CMR which included: spin-echo cDTI, adenosine stress and rest perfusion mapping, cine-imaging, and late gadolinium enhancement (LGE). Ten controls underwent cDTI. Myocardial perfusion reserve (MPR), MD, FA, E2A, and wall thickness were calculated per segment and further divided into subendocardial (inner 50%) and subepicardial (outer 50%) regions. Segments with wall thickness ≤11 mm, MPR ≥2.2, and no visual LGE were classified as \'normal\'. Compared to controls, \'normal\' HCM segments had increased MD (1.61 ± 0.09 vs. 1.46 ± 0.07 × 10-3 mm2/s, P = 0.02), increased E2A (60 ± 9° vs. 38 ± 12°, P < 0.001), and decreased FA (0.29 ± 0.04 vs. 0.35 ± 0.02, P = 0.002). Across all HCM segments, subendocardial regions had higher MD and lower MPR than subepicardial (MDendo 1.61 ± 0.08 × 10-3 mm2/s vs. MDepi 1.56 ± 0.18 × 10-3 mm2/s, P = 0.003, MPRendo 1.85 ± 0.83, MPRepi 2.28 ± 0.87, P < 0.0001).
Conclusion
In HCM patients, even in segments with normal wall thickness, normal perfusion, and no scar, diffusion is more isotropic than in controls, suggesting the presence of underlying cardiomyocyte disarray. Increased E2A suggests the myocardial sheetlets adopt hypercontracted angulation in systole. Increased MD, most notably in the subendocardium, is suggestive of regional remodelling which may explain the reduced subendocardial blood flow.

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

Eur Heart J Cardiovasc Imaging: 24 Oct 2021; epub ahead of print
Das A, Kelly C, Teh I, Nguyen C, ... Schneider JE, Dall'Armellina E
Eur Heart J Cardiovasc Imaging: 24 Oct 2021; epub ahead of print | PMID: 34694365
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Abstract

CAD-RADS may underestimate coronary plaque progression as detected by serial CT angiography.

Szilveszter B, Vattay B, Bossoussou M, Vecsey-Nagy M, ... Maurovich-Horvat P, Kolossváry M
Aims
We wished to assess whether different clinical definitions of coronary artery disease (CAD) [segment stenosis and involvement score (SSS, SIS), Coronary Artery Disease-Reporting and Data System (CAD-RADS)] affect which patients are considered to progress and which risk factors affect progression.
Methods and results
We enrolled 115 subsequent patients (60.1 ± 9.6 years, 27% female) who underwent serial coronary computed tomography angiography (CTA) imaging with >1year between the two examinations. CAD was described using SSS, SIS, and CAD-RADS. Linear mixed models were used to investigate the effects of risk factors on the overall amount of CAD and the effect on annual progression rate of different definitions. Coronary plaque burdens were SSS 4.63 ± 4.06 vs. 5.67 ± 5.10, P < 0.001; SIS 3.43 ± 2.53 vs. 3.89 ± 2.65, P < 0.001; CAD-RADS 0:8.7% vs. 0.0% 1:44.3% vs. 40.9%, 2:34.8% vs. 40.9%, 3:7.0% vs. 9.6% 4:3.5% vs. 6.1% 5:1.7% vs. 2.6%, P < 0.001, at baseline and follow-up, respectively. Overall, 53.0%, 29.6%, and 28.7% of patients progressed over time based on SSS, SIS, and CAD-RADS, respectively. Of the patients who progressed based on SSS, only 54% showed changes in CAD-RADS. Smoking and diabetes increased the annual progression rate of SSS by 0.37/year and 0.38/year, respectively (both P < 0.05). Furthermore, each year increase in age raised SSS by 0.12 [confidence interval (CI) 0.05-0.20, P = 0.001] and SIS 0.10 (CI 0.06-0.15, P < 0.001), while female sex was associated with 2.86 lower SSS (CI -4.52 to -1.20, P < 0.001) and 1.68 SIS values (CI -2.65 to -0.77, P = 0.001).
Conclusion
CAD-RADS could not capture the progression of CAD in almost half of patients with serial CTA. Differences in CAD definitions may lead to significant differences in patients who are considered to progress, and which risk factors are considered to influence progression.

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: 22 Oct 2021; epub ahead of print
Szilveszter B, Vattay B, Bossoussou M, Vecsey-Nagy M, ... Maurovich-Horvat P, Kolossváry M
Eur Heart J Cardiovasc Imaging: 22 Oct 2021; epub ahead of print | PMID: 34687544
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Abstract

The impact of atrial fibrillation and stroke risk factors on left atrial blood flow characteristics.

Spartera M, Stracquadanio A, Pessoa-Amorim G, Von Ende A, ... Wijesurendra RS, Casadei B
Aims 
Altered left atrial (LA) blood flow characteristics account for an increase in cardioembolic stroke risk in atrial fibrillation (AF). Here, we aimed to assess whether exposure to stroke risk factors is sufficient to alter LA blood flow even in the presence of sinus rhythm (SR).
Methods and results 
We investigated 95 individuals: 37 patients with persistent AF, who were studied before and after cardioversion [Group 1; median CHA2DS2-VASc = 2.0 (1.5-3.5)]; 35 individuals with no history of AF but similar stroke risk to Group 1 [Group 2; median CHA2DS2-VASc = 3.0 (2.0-4.0)]; and 23 low-risk individuals in SR [Group 3; median CHA2DS2-VASc = 0.0 (0.0-0.0)]. Cardiac function and LA flow characteristics were evaluated using cardiac magnetic resonance. Before cardioversion, Group 1 displayed impaired left ventricular (LV) and LA function, reduced LA flow velocities and vorticity, and a higher normalized vortex volume (all P < 0.001 vs. Groups 2 and 3). After restoration of SR at ≥4-week post-cardioversion, LV systolic function and LA flow parameters improved significantly (all P < 0.001 vs. pre-cardioversion) and were no longer different from those in Group 2. However, in the presence of SR, LA flow peak and mean velocity, and vorticity were lower in Groups 1 and 2 vs. Group 3 (all P < 0.01), and were associated with impaired LA emptying fraction (LAEF) and LV diastolic dysfunction.
Conclusion 
Patients at moderate-to-high stroke risk display altered LA flow characteristics in SR in association with an LA myopathic phenotype and LV diastolic dysfunction, regardless of a history of AF.

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

Eur Heart J Cardiovasc Imaging: 22 Oct 2021; epub ahead of print
Spartera M, Stracquadanio A, Pessoa-Amorim G, Von Ende A, ... Wijesurendra RS, Casadei B
Eur Heart J Cardiovasc Imaging: 22 Oct 2021; epub ahead of print | PMID: 34687541
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Abstract

Speckle-tracking-based global longitudinal and circumferential strain detect early signs of antibody-mediated rejection in heart transplant patients.

Ciarka A, Cordeiro F, Droogne W, Van Cleemput J, Voigt JU
Aims
Acute rejection is an important cause of mortality after heart transplant (HTx), but symptoms develop only when myocardial damage is already extensive. We sought to investigate if echocardiographic parameters can detect and predict an acute cellular rejection (ACR) or antibody-mediated rejection (AMR) episode in HTx patients.
Methods and results
Data of 403 consecutive HTx recipients between 2003 and 2020 from our centre were reviewed. Patients with severe ACR (n = 10) and AMR (n = 7) were identified. Each HTx patient presenting with rejection was matched to a control HTx patient. Echocardiographic variables from the moment of rejection and 3, 6, and 12 months before were analysed and compared among groups. At acute rejection episode, patients with rejection had lower values of global longitudinal strain (GLS), global circumferential strain (GCS), and left ventricular ejection fraction (LVEF) compared to controls. HTx patients with AMR showed a progressive decline of GLS and GCS in the months preceding acute rejection, while controls and ACR patients had stable strain values except for the moment of rejection. In our cohort, a GLS cut-off lower than 15.5% and a GCS cut-off lower than 15.2% could distinguish with a sensitivity and specificity of 100.0% AMR from controls 3 months before rejection. LVEF and other conventional echo parameters could not differentiate among groups.
Conclusion
GLS and GCS show a progressive decrease months before AMR becomes clinically apparent. Our data suggest that global strain assessment by echocardiography allows an early detection of a developing AMR, which could improve the clinical management of HTx 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: 22 Oct 2021; epub ahead of print
Ciarka A, Cordeiro F, Droogne W, Van Cleemput J, Voigt JU
Eur Heart J Cardiovasc Imaging: 22 Oct 2021; epub ahead of print | PMID: 34687539
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Abstract

Reduced global longitudinal strain as a marker for early detection of Fabry cardiomyopathy.

Lu DY, Huang WM, Wang WT, Hung SC, ... Niu DM, Yu WC
Aims
Fabry cardiomyopathy (FC) is characterized by progressive left ventricular hypertrophy (LVH). Conventional echocardiography is not sensitive in detecting preclinical FC before the development of LVH. We aim to investigate whether myocardial deformation analysis is useful to detect preclinical FC before LVH.
Methods and results
One hundred and sixty patients carrying mutated gene were prospectively enrolled, including 86 patients without LVH and 74 patients with LVH. Another 33 healthy individuals were also included for comparison. Standard transthoracic two-dimensional, Doppler, tissue Doppler echocardiography and deformation analysis were performed. The mean age of the overall 193 subjects was 48 ± 15 years, with 51% men. Fabry patients with LVH were older, more often to be men. They also had the worst diastolic function as evidenced by the largest left atrium, lowest E/A, and highest E/e\' ratio. The global longitudinal strain (GLS) deteriorated with the development of LVH (control vs. LVH- patients vs. LVH+ patients = -21.2 ± 2.7 vs. -19.0 ± 2.9 vs. -16.5 ± 4.2%, P < 0.001). Despite similar LV systolic, diastolic function, and LV mass, LVH- Fabry patients still had a reduced GLS as well as regional longitudinal strains at mid-to-apical, anterior, and inferolateral wall when compared to healthy subjects. The basal longitudinal strain was consistently worse in male patients than in female patients, irrespective of LVH.
Conclusion
Reduced GLS could be a marker of early FC before the development of LVH.

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: 22 Oct 2021; epub ahead of print
Lu DY, Huang WM, Wang WT, Hung SC, ... Niu DM, Yu WC
Eur Heart J Cardiovasc Imaging: 22 Oct 2021; epub ahead of print | PMID: 34687538
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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: 18 Oct 2021; 22:1264-1272
Kinnel M, Sanguineti F, Pezel T, Unterseeh T, ... Louvard Y, Garot J
Eur Heart J Cardiovasc Imaging: 18 Oct 2021; 22:1264-1272 | PMID: 33313780
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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: 18 Oct 2021; 22:1257-1263
Han D, Cordoso R, Whelton S, Rozanski A, ... Blaha MJ, Berman DS
Eur Heart J Cardiovasc Imaging: 18 Oct 2021; 22:1257-1263 | PMID: 33331631
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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: 18 Oct 2021; 22:1285-1294
Li VW, So EK, Li W, Chow PC, Cheung YF
Eur Heart J Cardiovasc Imaging: 18 Oct 2021; 22:1285-1294 | PMID: 33367540
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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: 18 Oct 2021; 22:1295-1303
Koschutnik M, Dannenberg V, Nitsche C, Donà C, ... Kammerlander AA, Mascherbauer J
Eur Heart J Cardiovasc Imaging: 18 Oct 2021; 22:1295-1303 | PMID: 33377480
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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: 18 Oct 2021; 22:1273-1284
Antonopoulos AS, Azzu A, Androulakis E, Tanking C, Papagkikas P, Mohiaddin RH
Eur Heart J Cardiovasc Imaging: 18 Oct 2021; 22:1273-1284 | PMID: 33432319
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Abstract

99mTc-DPD scintigraphy in immunoglobulin light chain (AL) cardiac amyloidosis.

Quarta CC, Zheng J, Hutt D, Grigore SF, ... Hawkins PN, Wechalekar AD
Aims
Technetium-99m-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD scintigraphy) is recognized as highly accurate for the non-invasive diagnosis of transthyretin (ATTR) cardiac amyloidosis (CA). A proportion of patients with immunoglobulin light chain (AL) CA have also been reported to show cardiac 99mTc-DPD uptake. Herein, we assessed the frequency and degree of cardiac 99mTc-DPD uptake and its clinical significance among patients with AL CA.
Methods and results
Between 2010 and 2017, 292 consecutive patients with AL CA underwent 99mTc-DPD scintigraphy and were included in this study: 114 (39%) had cardiac 99mTc-DPD uptake: grade 1 in 75%, grade 2 in 17%, and grade 3 in 8% of cases. Patients with cardiac 99mTc-DPD uptake had poorer cardiac systolic function and higher N-terminal pro-brain natriuretic peptide. No differences were noted in cardiac magnetic resonance parameters between patients with and without cardiac 99mTc-DPD uptake (N = 19 and 42, respectively). Patients with cardiac 99mTc-DPD uptake showed a trend to worse survival than those with no uptake (log-rank P = 0.056). Among 22 patients who underwent serial 99mTc-DPD scintigraphy, 5 (23%) showed reduction in the grade of cardiac uptake.
Conclusions
In this large cohort of patients with AL CA, 99mTc-DPD scintigraphy ∼40% of cases showed cardiac uptake, including grade 2-3 in 10% of all patients (25% of those with cardiac 99mTc-DPD uptake). Cardiac 99mTc-DPD uptake was associated with poorer cardiac function and outcomes. These data highlight the critical importance of ruling out AL amyloidosis in all patients with cardiac 99mTc-DPD uptake to ensure such patients are not assumed to have ATTR CA.

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

Eur Heart J Cardiovasc Imaging: 18 Oct 2021; 22:1304-1311
Quarta CC, Zheng J, Hutt D, Grigore SF, ... Hawkins PN, Wechalekar AD
Eur Heart J Cardiovasc Imaging: 18 Oct 2021; 22:1304-1311 | PMID: 34254119
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Abstract

Coronary CT angiography-derived fractional flow reserve in-stable angina: association with recurrent chest pain.

Tækker Madsen K, Veien KT, Larsen P, Husain M, ... Jensen LO, Sand NPR
Aims
The aim of this study was to evaluate the association between coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) and recurrent chest pain (CP) at 1-year follow-up in patients with stable angina pectoris (SAP).
Methods and results
Study of patients (n = 267) with SAP who underwent CCTA and FFRCT testing; 236 (88%) underwent invasive coronary angiography; and 87 (33%) were revascularized. Symptomatic status at 1-year follow-up was gathered by a structured interview. Three different FFRCT algorithms were applied using the following criteria for abnormality: (i) 2 cm-FFRCT ≤0.80; (ii) d-FFRCT ≤0.80; and (iii) a combination in which both a d-FFRCT ≤0.80 and a ΔFFRCT ≥0.06 must be present in the same vessel (c-FFRCT). Patients were classified into two groups based on the FFRCT test result and revascularization: completely revascularized/normal (CRN), patients in whom all coronary arteries with an abnormal FFRCT test result were revascularized or patients with completely normal FFRCT test results, and incompletely revascularized (IR), patients in whom ≥1 coronary artery with an abnormal FFRCT test result was not revascularized. Recurrent CP was present in 62 (23%) patients. Classification of patients (CRN or IR) was significantly associated with recurrent CP for all applied FFRCT interpretation algorithms. When applying the c-FFRCT algorithm, the association with recurrent CP was found, irrespective of the extent of coronary calcification and the degree of coronary stenosis. A negative association between per-patient minimal d-FFRCT and recurrent CP was demonstrated, P < 0.005.
Conclusion
An abnormal FFRCT test result is associated with an increased risk of recurrent CP in patients with new-onset SAP.

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

Eur Heart J Cardiovasc Imaging: 17 Oct 2021; epub ahead of print
Tækker Madsen K, Veien KT, Larsen P, Husain M, ... Jensen LO, Sand NPR
Eur Heart J Cardiovasc Imaging: 17 Oct 2021; epub ahead of print | PMID: 34661645
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Impact:
Abstract

Left atrial strain predicts incident atrial fibrillation in the general population: the Copenhagen City Heart Study.

Hauser R, Nielsen AB, Skaarup KG, Lassen MCH, ... Møgelvang R, Biering-Sørensen T
Background
Left atrial (LA) strain parameters have been demonstrated to be valuable predictors of atrial fibrillation (AF) in several patient cohorts. The purpose of this study was to investigate whether LA strain, assessed by two-dimensional speckle-tracking echocardiography, can be used to predict the development of AF in the general population.
Methods and results
This prospective longitudinal study included 4466 participants from the fifth Copenhagen City Heart Study. All participants underwent a health examination, including echocardiographic measurements of LA strain. Participants with prevalent AF at baseline were excluded. The primary endpoint was incident AF. During a median follow-up period of 5.3 years, 154 (4.3%) participants developed AF. In univariable analysis, peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA strain during the conduit phase were significantly associated with the development of AF. PALS [hazard ratio (HR) 1.05, 95% confidence interval (CI) (1.03-1.07), P < 0.001, per 1% decrease] and PACS (HR 1.08, 95% CI (1.05-1.12), P < 0.001, per 1% decrease] remained independent predictors of AF in multivariable analysis. In addition, PALS and PACS remained significantly associated with AF development even in participants with normal-sized atria and normal left ventricular (LV) systolic function.
Conclusion
In the general population, PALS and PACS independently predict incident AF. These findings remained consistent even in participants with normal-sized LA and normal LV systolic function.

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: 10 Oct 2021; epub ahead of print
Hauser R, Nielsen AB, Skaarup KG, Lassen MCH, ... Møgelvang R, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 10 Oct 2021; epub ahead of print | PMID: 34632488
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Impact:
Abstract

Normal values and reference ranges for left atrial strain by speckle-tracking echocardiography: the Copenhagen City Heart Study.

Nielsen AB, Skaarup KG, Hauser R, Johansen ND, ... Møgelvang R, Biering-Sørensen T
Aims 
Left atrial (LA) function assessed by two-dimensional speckle-tracking echocardiography has shown increasing clinical and prognostic significance. We sought to establish age- and sex-based normative values of LA strain in the general population and to assess the prognostic yield of lower limits of normality of LA strain in relation to future atrial fibrillation (AF).
Methods and results 
We determined normative values of peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA strain during the conduit phase (LACS) in 1641 healthy participants included in the fifth Copenhagen City Heart Study. In a secondary analysis, a validation cohort of 2016 participants, regardless of health status, were included to assess the prognostic value of the established reference values. In the healthy cohort, median age was 46 years (interquartile range 32-57), 62% were female. Median PALS, PACS, and LACS and corresponding limits of normality in the healthy participants were 39.4% (23.0-67.6%), 15.5% (6.4-28.0%), and 23.7% (8.8-44.8%), respectively. There was a tendency of lower values of PALS and LACS in males and older participants, while PACS tended to increase with advancing age. The established lower limits of normality showed high specificity (range 93-94%) regarding future AF, implying a low risk of developing AF in participants with LA strain above the lower limits of normality in their respective sex and age group.
Conclusion 
We report normal values for LA strain stratified by sex and age. The lower limits of normality showed high specificity regarding future AF.

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: 10 Oct 2021; epub ahead of print
Nielsen AB, Skaarup KG, Hauser R, Johansen ND, ... Møgelvang R, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 10 Oct 2021; epub ahead of print | PMID: 34632487
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Impact:
Abstract

Automated left atrial volume measurement by two-dimensional speckle-tracking echocardiography: feasibility, accuracy, and reproducibility.

Florescu DR, Badano LP, Tomaselli M, Torlasco C, ... Parati G, Muraru D
Aims
A byproduct of left atrial (LA) strain analysis is the automated measurement of LA maximal volume (LAVmax), which may decrease the time of echocardiography reporting, and increase the reproducibility of the LAVmax measurement. However, the automated measurement of LAVmax by two-dimensional speckle-tracking analysis (2DSTE) has never been validated. Accordingly, we sought to (i) assess the feasibility of automated LAVmax measurement by 2DSTE; (ii) compare the automated LAVmax by 2DSTE with conventional two-dimensional (2DE) biplane and three-dimensional echocardiography (3DE) measurements; and (iii) evaluate the accuracy and reproducibility of the three echocardiography techniques.
Methods and results
LAVmax (34-197 mL) were obtained from 198/210 (feasibility 94%) consecutive patients (median age 67 years, 126 men) by 2DSTE, 2DE, and 3DE. 2DE and 2DSTE measurements resulted in similar LAVmax values [bias = 1.5 mL, limits of agreement (LOA) ± 7.5 mL], and slightly underestimated 3DE LAVmax (biases = -5 mL, LOA ± 17 mL and -6 mL, LOA ± 16 mL, respectively). LAVmax by 2DSTE and 2DE were strongly correlated to those obtained by cardiac magnetic resonance (CMR) (r = 0.946 and r = 0.935, respectively; P < 0.001). However, LAVmax obtained by 2DSTE (bias = -9.5 mL, LOA ± 16 mL) and 2DE (bias = -8 mL, LOA ± 17 mL) were significantly smaller than those measured by CMR. Conversely, 3DE LAVmax were similar to CMR (bias = -2 mL, LOA ± 10 mL). Excellent intra- and inter-observer intraclass correlations were found for 3DE (0.995 and 0.995), 2DE (0.990 and 0.988), and 2DSTE (0.990 and 0.989).
Conclusion
Automated LAVmax measurement by 2DSTE is highly feasible, highly reproducible, and provided similar values to conventional 2DE calculations in consecutive patients with a wide range of LAVmax.

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 Oct 2021; epub ahead of print
Florescu DR, Badano LP, Tomaselli M, Torlasco C, ... Parati G, Muraru D
Eur Heart J Cardiovasc Imaging: 03 Oct 2021; epub ahead of print | PMID: 34606605
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Impact:
Abstract

Imaging of the left atrium: pathophysiology insights and clinical utility.

Smiseth OA, Baron T, Marino PN, Marwick TH, Flachskampf FA
Left atrial imaging and detailed knowledge of its pathophysiology, especially in the context of heart failure, have become an increasingly important clinical and research focus. This development has been accelerated by the growth of non-invasive imaging modalities, advanced image processing techniques, such as strain imaging, and the parallel emergence of catheter-based left atrial interventions like pulmonary vein ablation, left atrial appendage occlusion, and others. In this review, we focus on novel imaging methods for the left atrium, their pathophysiological background, and their clinical relevance for various cardiac conditions and diseases.

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: 02 Oct 2021; epub ahead of print
Smiseth OA, Baron T, Marino PN, Marwick TH, Flachskampf FA
Eur Heart J Cardiovasc Imaging: 02 Oct 2021; epub ahead of print | PMID: 34601594
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Impact:
Abstract

Greater plaque burden and cholesterol content may explain an increased incidence of non-culprit events in diabetic patients: a Lipid-Rich Plaque substudy.

Demola P, Di Mario C, Torguson R, Ten Cate T, ... Mintz GS, Waksman R
Aims 
Diabetes mellitus (DM) is associated with increased cardiovascular morbidity and mortality. The multicentre, prospective Lipid-Rich Plaque trial (LRP) examined non-culprit (NC) non-obstructive coronary segments with a combined near-infrared spectroscopy (NIRS)-intravascular ultrasound (IVUS) catheter. This study assessed the differences in NC plaque characteristics and their influence on major adverse cardiac events (MACE) in diabetic and non-diabetic patients.
Methods and results 
Patients with known DM status were divided into no diabetes, diabetes not treated with insulin (non-ITDM), and insulin-treated diabetes (ITDM). The association between presence and type of DM and NC-MACE was assessed at both the patient and coronary segment levels by Cox proportional regression modelling. Out of 1552 patients enrolled, 1266 who had their diabetes status recorded were followed through 24 months. Female sex, hypertension, chronic kidney disease, peripheral vascular disease, and high body mass index were significantly more frequent in diabetic patients. The ITDM group had more diseased vessels, at least one NC segment with a maxLCBI4 mm ≥400 in 46.2% of patients, and maxLCBI4 mm ≥400 in nearly one out of six Ware segments (15.2%, 125/824 segments). The average maxLCBI4 mm significantly increased from non-diabetic patients (NoDM) to non-insulin-treated diabetic patients (non-ITDM) to insulin-treated diabetic patients (ITDM; 137.7 ± 161.9, 154.8 ± 173.6, 182.9 ± 193.2, P < 0.001, respectively). In patients assigned to follow-up (692 ± 129 days), ITDM doubled the incidence of NC-MACE compared with the absence of diabetes (15.7% vs. 6.9%, P = 0.0008). The presence of maxLCBI4 mm>400 further increased the NC-MACE rate to 21.6% (Kaplan-Meier estimate).
Conclusion 
Cholesterol-rich NC plaques detected by NIRS-IVUS were significantly more frequent in diabetic patients, especially those who were insulin-treated, and were associated with an increased NC-MACE during follow-up.

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: 25 Sep 2021; epub ahead of print
Demola P, Di Mario C, Torguson R, Ten Cate T, ... Mintz GS, Waksman R
Eur Heart J Cardiovasc Imaging: 25 Sep 2021; epub ahead of print | PMID: 34568945
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Impact:
Abstract

CArdiac MagnEtic resonance assessment of bi-Atrial fibrosis in secundum atrial septal defects patients: CAMERA-ASD study.

O\'Neill L, Sim I, O\'Hare D, Whitaker J, ... O\'Neill MD, Williams SE
Aims
Atrial septal defects (ASD) are associated with atrial arrhythmias, but the arrhythmia substrate in these patients is poorly defined. We hypothesized that bi-atrial fibrosis is present and that right atrial fibrosis is associated with atrial arrhythmias in ASD patients. We aimed to evaluate the extent of bi-atrial fibrosis in ASD patients and to investigate the relationships between bi-atrial fibrosis, atrial arrhythmias, shunt fraction, and age.
Methods and results
Patients with uncorrected secundum ASDs (n = 36; 50.4 ± 13.6 years) underwent cardiac magnetic resonance imaging with atrial late gadolinium enhancement. Comparison was made to non-congenital heart disease patients (n = 36; 60.3 ± 10.5 years) with paroxysmal atrial fibrillation (AF). Cardiac magnetic resonance parameters associated with atrial arrhythmias were identified and the relationship between bi-atrial structure, age, and shunt fraction studied. Bi-atrial fibrosis burden was greater in ASD patients than paroxysmal AF patients (20.7 ± 14% vs. 10.1 ± 8.6% and 14.8 ± 8.5% vs. 8.6 ± 6.1% for right and left atria respectively, P = 0.001 for both). In ASD patients, right atrial fibrosis burden was greater in those with than without atrial arrhythmias (33.4 ± 18.7% vs. 16.8 ± 10.3%, P = 0.034). On receiver operating characteristic analysis, a right atrial fibrosis burden of 32% had a 92% specificity and 71% sensitivity for predicting the presence of atrial arrhythmias. Neither age nor shunt fraction was associated with bi-atrial fibrosis burden.
Conclusion
Bi-atrial fibrosis burden is greater in ASD patients than non-congenital heart disease patients with paroxysmal AF. Right atrial fibrosis is associated with the presence of atrial arrhythmias in ASD patients. These findings highlight the importance of right atrial fibrosis to atrial arrhythmogenesis in ASD patients.

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

Eur Heart J Cardiovasc Imaging: 25 Sep 2021; epub ahead of print
O'Neill L, Sim I, O'Hare D, Whitaker J, ... O'Neill MD, Williams SE
Eur Heart J Cardiovasc Imaging: 25 Sep 2021; epub ahead of print | PMID: 34568942
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Impact:
Abstract

Applying machine learning to detect early stages of cardiac remodelling and dysfunction.

Sabovčik F, Cauwenberghs N, Kouznetsov D, Haddad F, ... Vens C, Kuznetsova T
Aims
Both left ventricular (LV) diastolic dysfunction (LVDD) and hypertrophy (LVH) as assessed by echocardiography are independent prognostic markers of future cardiovascular events in the community. However, selective screening strategies to identify individuals at risk who would benefit most from cardiac phenotyping are lacking. We, therefore, assessed the utility of several machine learning (ML) classifiers built on routinely measured clinical, biochemical, and electrocardiographic features for detecting subclinical LV abnormalities.
Methods and results
We included 1407 participants (mean age, 51 years, 51% women) randomly recruited from the general population. We used echocardiographic parameters reflecting LV diastolic function and structure to define LV abnormalities (LVDD, n = 252; LVH, n = 272). Next, four supervised ML algorithms (XGBoost, AdaBoost, Random Forest (RF), Support Vector Machines, and Logistic regression) were used to build classifiers based on clinical data (67 features) to categorize LVDD and LVH. We applied a nested 10-fold cross-validation set-up. XGBoost and RF classifiers exhibited a high area under the receiver operating characteristic curve with values between 86.2% and 88.1% for predicting LVDD and between 77.7% and 78.5% for predicting LVH. Age, body mass index, different components of blood pressure, history of hypertension, antihypertensive treatment, and various electrocardiographic variables were the top selected features for predicting LVDD and LVH.
Conclusion
XGBoost and RF classifiers combining routinely measured clinical, laboratory, and electrocardiographic data predicted LVDD and LVH with high accuracy. These ML classifiers might be useful to pre-select individuals in whom further echocardiographic examination, monitoring, and preventive measures are warranted.

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 Sep 2021; 22:1208-1217
Sabovčik F, Cauwenberghs N, Kouznetsov D, Haddad F, ... Vens C, Kuznetsova T
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1208-1217 | PMID: 32588036
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Impact:
Abstract

Prognostic value of left ventricular remodelling index in idiopathic dilated cardiomyopathy.

Xu Y, Lin J, Liang Y, Wan K, ... Han Y, Chen Y
Aims
To evaluate the prognostic value of left ventricular (LV) remodelling index (RI) in idiopathic dilated cardiomyopathy (DCM) patients.
Methods and results
We prospectively enrolled 412 idiopathic DCM patients and 130 age- and sex-matched healthy volunteers who underwent cardiovascular magnetic resonance imaging between September 2013 and March 2018. RI was defined as the cubic root of the LV end-diastolic volume divided by the mean LV wall thickness on basal short-axis slice. The primary endpoint included all-cause mortality and heart transplantation. The secondary endpoint included the primary endpoint and heart failure (HF) readmission. During the median follow-up of 28.1 months (interquartile range: 19.3-43.0 months), 62 (15.0%) and 143 (34.7%) patients reached the primary and secondary endpoints, respectively. Stepwise multivariate Cox regression showed that RI [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.11-1.30, P < 0.001], late gadolinium enhancement (LGE) presence and log (N-terminal pro-B-type natriuretic peptide) were independent predictors of the primary endpoint, while RI (HR 1.15, 95% CI 1.08-1.23, P < 0.001) and extracellular volume were independent predictors of the secondary endpoint. The addition of RI to LV ejection fraction (EF) and LGE presence showed significantly improved global χ2 for predicting primary and secondary endpoints (both P < 0.001). Furthermore, RI derived from echocardiography also showed independent prognostic value for primary and secondary endpoints with clinical risk factors.
Conclusions
RI is an independent predictor of all-cause mortality, heart transplantation, and HF readmission in DCM patients and provides incremental prognostic value to LVEF and LGE presence.

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 Sep 2021; 22:1197-1207
Xu Y, Lin J, Liang Y, Wan K, ... Han Y, Chen Y
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1197-1207 | PMID: 32658979
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Impact:
Abstract

The use of echo density to quantify pulmonary right-to-left shunt in transthoracic contrast echocardiography.

Kroon S, Van Thor MCJ, Vorselaars VMM, Hosman AE, ... Mager HJ, Post MC
Aims
Transthoracic contrast echocardiography (TTCE) is the recommended screening tool to detect pulmonary right-to-left shunt (RLS) caused by pulmonary arteriovenous malformations (PAVMs). We assessed a novel method to quantify the RLS using the change in echo density (ED) following contrast injection.
Methods and results
An analysis of 437 consecutive patients [58% female, 47 years, interquartile range (IQR) 33-60] who underwent TTCE for the detection of a pulmonary RLS. Using ImageJ (National Institutes of Health), the change in ED was measured for each patient. This method was strongly correlated (Spearman\'s ρ = 0.89; P < 0.0001) with our standard method based on a four-point grading scale (no, mild, moderate, and severe RLS). In patients without a history of embolotherapy (n = 334), a PAVM was detected with chest computed tomography (CT) in 66 and embolotherapy was judged possible in 35 of these patients. The median increase in ED was higher in the latter: +20.1% (IQR 12.3-34.0) compared to non-treatable PAVM +0.2% (IQR -0.2 to 1.1). The specificity to detect treatable PAVMs increased from 87% to 90% when using the novel method without affecting the sensitivity (of 100%). Using the optimal cut-off value of +4.5% increase in ED, 8/74 (11%) needed chest CT-scans-individuals with a moderate or severe RLS-were no longer required without missing any treatable PAVM.
Conclusions
The use of ED quantification for pulmonary RLS is promising; resulting in a substantial decrease in the number of chest CT scans needed. However, this method and the threshold should be validated in an independent study 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: 19 Sep 2021; 22:1190-1196
Kroon S, Van Thor MCJ, Vorselaars VMM, Hosman AE, ... Mager HJ, Post MC
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1190-1196 | PMID: 32667638
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Impact:
Abstract

Three-dimensional right ventricular shape and strain in congenital heart disease patients with right ventricular chronic volume loading.

Moceri P, Duchateau N, Gillon S, Jaunay L, ... Ferrari E, Sermesant M
Aims
Right ventricular (RV) function assessment is crucial in congenital heart disease patients, especially in atrial septal defect (ASD) and repaired Tetralogy of Fallot (TOF) patients with pulmonary regurgitation (PR). In this study, we aimed to analyse both 3D RV shape and deformation to better characterize RV function in ASD and TOF-PR.
Methods and results
We prospectively included 110 patients (≥16 years old) into this case-control study: 27 ASD patients, 28 with TOF, and 55 sex- and age-matched healthy controls. Endocardial tracking was performed on 3D transthoracic RV echocardiographic sequences and output RV meshes were post-processed to extract local curvature and deformation. Differences in shape and deformation patterns between subgroups were quantified both globally and locally. Curvature highlights differences in RV shape between controls and patients while ASD and TOF-PR patients are similar. Conversely, strain highlights differences between controls and TOF-PR patients while ASD and controls are similar [global area strain: -31.5 ± 5.8% (controls), -34.1 ± 7.9% (ASD), -24.8 ± 5.7% (TOF-PR), P < 0.001, similar significance for longitudinal and circumferential strains]. The regional and local analysis highlighted differences in particular in the RV free wall and the apical septum.
Conclusion
Chronic RV volume loading results in similar RV shape remodelling in both ASD and TOF patients while strain analysis demonstrated that RV strain is only reduced in the TOF group. This suggests a fundamentally different RV remodelling process between both 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: 19 Sep 2021; 22:1174-1181
Moceri P, Duchateau N, Gillon S, Jaunay L, ... Ferrari E, Sermesant M
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1174-1181 | PMID: 32756985
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Impact:
Abstract

Test-retest reliability of left and right ventricular systolic function by new and conventional echocardiographic and cardiac magnetic resonance parameters.

Houard L, Militaru S, Tanaka K, Pasquet A, ... Pouleur AC, Gerber BL
Aims 
Reproducible evaluation of left (LV) and right ventricular (RV) function is crucial for clinical decision-making and risk stratification. We evaluated whether speckle-tracking echocardiography (STE) and cardiac magnetic resonance feature-tracking (cMR-FT) global longitudinal (GLS) and circumferential strains allow better test-retest reproducibility of LV and RV systolic function than conventional cMR and echocardiographic parameters.
Methods and results 
Thirty healthy volunteers and 20 chronic heart failure patients underwent cMR and STE twice on separate days to evaluate test-retest coefficient of variation (CV), intraclass correlation coefficient (ICC) and estimated sample sizes for significant changes in LV and RV function. Among LV parameters, cMR-left ventricular ejection fraction (LVEF) had the highest reproducibility (CV = 6.7%, ICC = 0.98), significantly better than cMR-FT-GLS (CV = 15.1%, ICC = 0.84), global circumferential strains (CV = 11.5%, ICC = 0.94) and echocardiographic LVEF (CV = 11.3%, ICC = 0.93). STE-LV-GLS (CV = 8.9%, ICC = 0.94) had significantly better reproducibility than cMR-FT-LV-GLS. Among RV parameters, STE-RV-GLS (CV = 7.3%, ICC = 0.93) had significantly better CV than cMR-right ventricular ejection fraction (RVEF) (CV = 13%, ICC = 0.82). cMR-FT-RV-GLS (CV = 43%, ICC = 0.39) performed poorly with significantly lower reproducibility than all other RV parameters. Owing to their superior interstudy reproducibility, cMR-LVEF (n = 12), cMR-RVEF (n = 41), STE-LV-GLS and STE-RV-GLS (both n = 14) were the parameters allowing the lowest calculated sample sizes to detect 10% change in LV or RV systolic function.
Conclusion 
STE-LV-GLS and STE-RV-GLS showed higher test-retest reliability than other echocardiographic measurements of LV and RV function. They also allowed smaller calculated sample sizes, supporting the use of STE-LV and RV-GLS for longitudinal follow-up of LV and RV 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: 19 Sep 2021; 22:1157-1167
Houard L, Militaru S, Tanaka K, Pasquet A, ... Pouleur AC, Gerber BL
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1157-1167 | PMID: 32793957
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Impact:
Abstract

Clinical outcomes following real-world computed tomography angiography-derived fractional flow reserve testing in chronic coronary syndrome patients with calcification.

Nørgaard BL, Mortensen MB, Parner E, Leipsic J, ... Bøtker HE, Jensen JM
Aims 
This study sought to investigate outcomes following a normal CT-derived fractional flow reserve (FFRCT) result in patients with moderate stenosis and coronary artery calcification, and to describe the relationship between the extent of calcification, stenosis, and FFRCT.
Methods and results
Data from 975 consecutive patients suspected of chronic coronary syndrome with stenosis (30-70%) determined by computed CT angiography and FFRCT to guide downstream management decisions were reviewed. Median (range) follow-up time was 2.2 (0.5-4.2) years. Coronary artery calcium (CAC) scores were ≥400 in 25%, stenosis ≥50% in 83%, and FFRCT >0.80 in 51% of the patients. There was a lower incidence of the composite endpoint (death, myocardial infarction, hospitalization for unstable angina, and unplanned coronary revascularization) at 4.2 years in patients with any CAC and FFRCT > 0.80 vs. FFRCT ≤ 0.80 (3.9% and 8.7%, P = 0.04), however, in patients with CAC scores ≥400 the risk difference between groups did not reach statistical significance, 4.2% vs. 9.7% (P = 0.24). A negative relationship between CAC scores and FFRCT irrespective of stenosis severity was demonstrated.
Conclusion
FFRCT shows promise in identifying patients with stenosis and calcification who can be managed without further downstream testing. Moreover, an inverse relationship between CAC levels and FFRCT was demonstrated. Studies are needed to further assess the clinical utility of FFRCT in patients with extensive coronary calcification.

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 Sep 2021; 22:1182-1189
Nørgaard BL, Mortensen MB, Parner E, Leipsic J, ... Bøtker HE, Jensen JM
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1182-1189 | PMID: 32793947
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Impact:
Abstract

Predictors of left ventricular reverse remodelling after coarctation of aorta intervention.

Egbe AC, Miranda WR, Connolly HM
Aims
Several coarctation of aorta (COA) severity indices are used for timing of COA intervention, and to define severity of residual coarctation post-intervention. However, it is unclear how many of these COA indices are required in order to recommend intervention, and what degree of residual coarctation results in suboptimal recovery of the left ventricle (LV). Our aim was to assess the correlation between different COA indices and effects of chronic LV pressure overload (LV hypertrophy, diastolic, and systolic dysfunction), and to determine the effect of residual coarctation on LV reverse remodelling after COA intervention.
Methods and results
COA severity indices were defined as Doppler COA gradient, systolic blood pressure (SBP, upper-to-lower-extremity SBP gradient, aortic isthmus ratio. LV remodelling indices were defined as LV mass index (LVMI), LV global longitudinal strain (LVGLS), e\' and E/e\'. LV reverse remodelling was defined as the difference between indices obtained pre-intervention and 5-year post-intervention (delta LVMI, e\', E/e\', LVGLS).Of the COA indices analysed in 546 adult COA patients, aortic isthmus ratio had the strongest correlation with LVMI (β ± standard error -28.3 ± 14.1, P < 0.001), LVGLS (1.51 ± 0.42, P = 0.005), e\' (3.11 ± 1.10, P = 0.014), and E/e\' (-13.4 ± 6.67, P = 0.008). Residual aortic isthmus ratio also had the strongest correlation with LV reverse remodelling, and residual aortic isthmus ratio <0.7 was predictive of suboptimal LV reverse remodelling post-intervention.
Conclusion
Considering the known prognostic implications of LV remodelling and reverse remodelling in response to pressure overload, these results support the use of aortic isthmus ratio for timing of COA intervention, and for prognostication post-intervention.

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 Sep 2021; 22:1168-1173
Egbe AC, Miranda WR, Connolly HM
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1168-1173 | PMID: 33020809
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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: 19 Sep 2021; 22:1142-1148
Vulesevic B, Kubota N, Burwash IG, Cimadevilla C, ... Beauchesne L, Messika-Zeitoun D
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1142-1148 | PMID: 33247914
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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.

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Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1149-1156
Baritussio A, Biglino G, Scatteia A, De Garate E, ... Diab I, Bucciarelli-Ducci C
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1149-1156 | PMID: 33247898
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Impact:
Abstract

EACVI survey on the evaluation of left ventricular diastolic function.

Sitges M, Ajmone Marsan N, Cameli M, D\'Andrea A, ... Haugaa KH, Dweck MR
Aims
The aim of this study is to analyse how current recommendations on left ventricular (LV) diastolic function assessment have been adopted. Identifying potential discrepancies between recommendations and everyday clinical practice would enable us to better understand and address the remaining challenges in this controversial and complex field.
Methods and results
A total of 93 centres, mainly from tertiary care settings, responded to the survey. More than three-quarters (77%) of centres follow the 2016 ASE/EACVI recommendations for LV diastolic function evaluation in patients with preserved ejection fraction based upon e\', E/e\', tricuspid regurgitation velocity, and left atrial (LA) volume. These recommendations were generally preferred to the previous 2009 version. Many centres also consider strain assessments in the LV (48%) and left atrium (53%) as well as diastolic stress echocardiography (33%) to be useful as additional assessments of LV diastolic function. Echocardiographic assessments of LV diastolic function were used frequently to guide therapy in 72% of centres.
Conclusion
There is widespread adoption of current recommendation on the evaluation of LV diastolic function and these are frequently used to guide patient management. Many centres now also consider LV and LA strain assessments useful in the clinical assessment of diastolic function. These may be considered in future recommendations.

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Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1098-1105
Sitges M, Ajmone Marsan N, Cameli M, D'Andrea A, ... Haugaa KH, Dweck MR
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1098-1105 | PMID: 33969402
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Impact:
Abstract

Ring-like late gadolinium enhancement for predicting ventricular tachyarrhythmias in non-ischaemic dilated cardiomyopathy.

Chen W, Qian W, Zhang X, Li D, ... Xu Y, Zou J
Aims
Myocardial fibrosis is associated with clinical ventricular tachyarrhythmia (VTA) events in patients with non-ischaemic dilated cardiomyopathy (DCM). Subepicardial or mid-wall ring-like late gadolinium enhancement (LGE) has received increasing attention in recent years. The aim of this study was to investigate the relationship between ring-like LGE and VTAs in DCM.
Methods and results
Patients diagnosed with non-ischaemic DCM who underwent cardiac magnetic resonance with LGE imaging at baseline were investigated. The composite outcome was the occurrence of VTAs defined as sustained ventricular tachycardia, ventricular fibrillation/flutter, aborted sudden cardiac death (SCD), SCD, and appropriate implantable cardioverter-defibrillator intervention. The final cohort comprised 157 patients, including 36 (22.9%) in no LGE group, 48 (30.6%) in focal LGE group, 40 (25.5%) in multi-focal LGE group, and 33 (21%) in ring-like LGE group. Ring-like LGE group patients were younger compared to focal and multi-focal LGE group (P < 0.001) with higher left ventricular ejection fraction (33.0% vs. 24.4% vs. 22.1%, P < 0.001). After a median of 13 ± 7 months follow-up, compared to patients with no LGE, the hazard ratios (HRs) with 95% confidence intervals (CIs) for VTAs were 2.90 (0.56-15.06), 5.55 (1.21-25.44), and 11.75 (2.66-51.92) for patients with focal LGE, multi-focal LGE, and ring-like LGE, respectively. After multivariable adjustment, ring-like LGE group remained associated with increased risk of VTAs (adjusted HR 10.00, 95% CI 1.54-64.98; P = 0.016) independent of the global LGE burden.
Conclusion
The ring-like pattern of LGE is independently associated with an increased risk of VTAs in patients with non-ischaemic DCM.

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Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1130-1138
Chen W, Qian W, Zhang X, Li D, ... Xu Y, Zou J
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1130-1138 | PMID: 34160025
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Impact:
Abstract

Left ventricular remodelling in mitral valve prolapse patients: implications of apical papillary muscle insertion.

Moura-Ferreira S, Vandenberk B, Masci PG, Dresselaers T, ... Willems R, Bogaert J
Aims
Mitral valve prolapse (MVP) causes left ventricular (LV) remodelling even in the absence of significant mitral regurgitation. To evaluate whether apical insertion of the papillary muscle (PM) influences the pattern and severity of MVP-related LV remodelling.
Methods and results
All MVP patients who underwent CMR at our institution between December 2008 and December 2019 were included, thoroughly reviewed and grouped according to apical/non-apical PM insertion. Apical PM insertion was found in 53/92 patients (58%) and associated with mitral leaflet thickening (P < 0.01) and a trend towards higher prevalence of mitral annular disjunction (P = 0.05). Whereas no differences in ventricular volumes or ejection fraction were found, patients with apical PM insertion showed more lateral wall remodelling with mid lateral wall thinning [2.1 (1.8-2.5) vs. 4.0 (3.5-5.0) mm, P < 0.01], increased LV eccentricity and a lower GCS at this level (15 ± 3% vs. 20 ± 3%, P < 0.01). In long-axis direction, increased end-diastolic mid lateral wall angulation was found (i.e. angle <155° measured in the thinnest point of the mid lateral wall in four-chamber view) with a higher angle variation during systole (25 ± 11° vs. 17 ± 8°, P < 0.01). Remarkably, PM fibrosis was significantly more frequent in patients with apical PM insertion (i.e. 66% vs. 28%, P < 0.01). Finally, a higher burden of premature ventricular complexes (>5%) and non-sustained ventricular tachyarrhythmias was found in patients with apical PM insertion: 53% vs. 25% (P = 0.04) and 38% vs. 18% (P = 0.04), respectively.
Conclusion
Apical PM insertion is part of the phenotypic spectrum of MVP, impacts significantly LV remodelling, and potentially may be related to increased ventricular arrhythmogenicity.

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Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1119-1128
Moura-Ferreira S, Vandenberk B, Masci PG, Dresselaers T, ... Willems R, Bogaert J
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1119-1128 | PMID: 34279022
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Abstract

Differences in mitral valve geometry between atrial and ventricular functional mitral regurgitation in patients with atrial fibrillation: a 3D transoesophageal echocardiography study.

Uno G, Omori T, Shimada S, Rader F, Siegel RJ, Shiota T
Aims
This study investigated geometric differences in mitral valve apparatus between atrial functional mitral regurgitation (A-FMR) and functional mitral regurgitation (FMR) with left ventricular (LV) dysfunction in patients with atrial fibrillation (AF) using 3D transoesophageal echocardiography (TOE).
Methods and results 
In total, 135 moderate or greater FMR patients with persistent AF or atrial flutter underwent 3D TOE. Fifty-six patients had A-FMR, defined as preserved LV ejection fraction (LVEF) of ≥50% and normal LV wall motion. Seventy-nine patients had ventricular FMR (V-FMR), defined as LV dysfunction (LVEF of <50%) or LV wall motion abnormality. To evaluate mitral leaflet coaptation, the coapted area was calculated as follows: total leaflet area (TLA) in end-diastole - closed leaflet area in mid-systole. Although annular area (AA) did not significantly differ between the two groups, TLA was significantly smaller in A-FMR than in V-FMR (P = 0.005). TLA/AA, indicating the degree of the leaflet remodelling, was significantly smaller in A-FMR than in V-FMR (P < 0.001). A-FMR had significantly smaller posterior mitral leaflet tethering height and angle measured at three anteroposterior planes (lateral, central, and medial) than V-FMR (all P < 0.001). However, vena contracta width (VCW) measured on long-axis view on TOE and coapted area, which correlated with VCW (r = -0.464, P < 0.001), were similar between the two groups.
Conclusion
Mitral leaflet remodelling may be less in A-FMR compared with V-FMR. However, leaflet tethering was smaller in A-FMR than in V-FMR, and this may result in a similar degree of mitral leaflet coaptation and mitral regurgitation severity.

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Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1106-1116
Uno G, Omori T, Shimada S, Rader F, Siegel RJ, Shiota T
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1106-1116 | PMID: 34405882
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Abstract

Level 1 of Entrustable Professional Activities in adult echocardiography: a position statement from the EACVI regarding the training and competence requirements for selecting and interpreting echocardiographic examinations.

Stankovic I, Muraru D, Fox K, Di Salvo G, ... Julien Magne, Leyla Elif Sade; and by the Chair of the 2020-2022 EACVI Scientific Documents Committee: Erwan Donal.
The goal of Level 1 training in echocardiography is to enable the trainee to select echocardiography appropriately for the evaluation of a specific clinical question, and then to interpret the report. It is not the goal of Level 1 training to teach how to perform the examination itself-that is the goal of higher levels of training. However, understanding the principles, indications, and findings of this crucial technique is valuable to many medical professionals including outside cardiology. This should be seen as part of a general understanding of cardiac imaging modalities. The purpose of this position statement is to define the scope and outline the general requirements for Level 1 training and competence in echocardiography. Moreover, the document aims to make a clear distinction between Level 1 competence in echocardiography and focus cardiac ultrasound (FoCUS).

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Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1091-1097
Stankovic I, Muraru D, Fox K, Di Salvo G, ... Julien Magne, Leyla Elif Sade; and by the Chair of the 2020-2022 EACVI Scientific Documents Committee: Erwan Donal.
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; 22:1091-1097 | PMID: 34383895
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Abstract

Evolution of right and left ventricle routine and speckle-tracking echocardiography in patients recovering from coronavirus disease 2019: a longitudinal study.

Baruch G, Rothschild E, Sadon S, Szekely Y, ... Kapusta L, Topilsky Y
Aims
We aim to assess changes in routine echocardiographic and longitudinal strain parameters in patients recovering from Coronavirus disease 2019 during hospitalization and at 3-month follow-up.
Methods and results
Routine comprehensive echocardiography and STE of both ventricles were performed during hospitalization for acute coronavirus disease 2019 (COVID-19) infection as part of a prospective pre-designed protocol and compared with echocardiography performed ∼3 months after recovery in 80 patients, using a similar protocol. Significantly improved right ventricle (RV) fractional area change, longer pulmonary acceleration time, lower right atrial pressure, and smaller RV end-diastolic and end-systolic area were observed at the recovery assessment (P < 0.05 for all). RV global longitudinal strain improved at the follow-up evaluation (23.2 ± 5 vs. 21.7 ± 4, P = 0.03), mostly due to improvement in septal segments. Only eight (10%) patients recovering from COVID-19 infection had abnormal ejection fraction (EF) at follow-up. However, LV related routine (E, E/e\', stroke volume, LV size), or STE parameters did not change significantly from the assessment during hospitalization. A significant proportion [36 (45%)] of patients had some deterioration of longitudinal strain at follow-up, and 20 patients (25%) still had abnormal LV STE ∼3 months after COVID-19 acute infection.
Conclusion
In patients previously discharged from hospitalization due to COVID-19 infection, RV routine echocardiographic and RV STE parameters improve significantly concurrently with improved RV haemodynamics. In contrast, a quarter of patients still have LV systolic dysfunction based on STE cut-offs. Moreover, LV STE does not improve significantly, implying subclinical LV dysfunction may be part and parcel of recovering from COVID-19 infection.

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Eur Heart J Cardiovasc Imaging: 19 Sep 2021; epub ahead of print
Baruch G, Rothschild E, Sadon S, Szekely Y, ... Kapusta L, Topilsky Y
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; epub ahead of print | PMID: 34542601
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Impact:
Abstract

Long-term prognostic value of ischaemia and cardiovascular magnetic resonance-related revascularization for stable coronary disease, irrespective of patient\'s sex: a large retrospective study.

Pezel T, Garot P, Kinnel M, Hovasse T, ... Unterseeh T, Garot J
Aims
To assess the sex-specific, long-term prognostic value of myocardial ischaemia induced by stress cardiovascular magnetic resonance (CMR) and early CMR-related revascularization in consecutive patients from a large registry.
Methods and results
Between 2008 and 2010, all consecutive patients referred for stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular mortality or recurrent non-fatal myocardial infarction (MI). Early CMR-related revascularization was defined as any revascularization within 90 days after CMR. Among 3664 patients (56.9% male, mean age 69.9 ± 11.8 years), 472 (12.9%) had MACE (163 women and 309 men) after a median follow-up of 8.8 (IQR 6.9-9.5) years. Inducible ischaemia and late gadolinium enhancement (LGE) by CMR were associated with MACE in women and men (all P < 0.001). In multivariable Cox regression, inducible ischaemia, LGE, and CMR-related revascularization were independent predictors of MACE both in women [heart rate (HR) 4.79, 95% confidence interval (CI) 2.17-9.10; HR 1.82, 95% CI 1.22-2.71; HR 0.71, 95% CI 0.54-0.92, respectively; all P < 0.001] and men (HR 3.88, 95% CI 2.33-5.98; HR 1.48, 95% CI 1.16-1.89; HR 0.78, 95% CI 0.65-0.97, respectively; all P < 0.001). The addition of CMR-parameters led to improved model discrimination for MACE (C-statistic 0.61 vs. 0.71; NRI = 0.212; IDI = 0.032) for both women and men. CMR-related revascularization was associated with a lower incidence of MACE in patients with left ventricular ejection fraction (LVEF)<50%.
Conclusion
Inducible ischaemia and early CMR-related revascularization were good long-term predictors of MACE irrespective of sex. CMR-related revascularization was associated with a lower MACE incidence in the sole sub-set of patients with LVEF < 50%.

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: 19 Sep 2021; epub ahead of print
Pezel T, Garot P, Kinnel M, Hovasse T, ... Unterseeh T, Garot J
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; epub ahead of print | PMID: 34542596
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Abstract

Supplementary role of left ventricular global longitudinal strain for predicting sudden cardiac death in hypertrophic cardiomyopathy.

Lee HJ, Kim HK, Lee SC, Kim J, ... Cho GY, Kim YJ
Aims
We investigated the prognostic role of left ventricular global longitudinal strain (LV-GLS) and its incremental value to established risk models for predicting sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM).
Methods and results
LV-GLS was measured with vendor-independent software at a core laboratory in a cohort of 835 patients with HCM (aged 56.3 ± 12.2 years) followed-up for a median of 6.4 years. The primary endpoint was SCD events, including appropriate defibrillator therapy, within 5 years after the initial evaluation. The secondary endpoint was a composite of SCD events, heart failure admission, heart transplantation, and all-cause mortality. Twenty (2.4%) and 85 (10.2%) patients experienced the primary and secondary endpoints, respectively. Lower absolute LV-GLS quartiles, especially those worse than the median (-15.0%), were associated with progressively higher SCD event rates (P = 0.004). LV-GLS was associated with an increased risk for the primary endpoint, independent of the LV ejection fraction, apical aneurysm, and 2014 European Society of Cardiology (ESC) risk score [adjusted hazard ratio (aHR) 1.14, 95% confidence interval (CI) 1.02-1.28] or 2011 American College of Cardiology/American Heart Association (ACC/AHA) risk factors (aHR 1.18, 95% CI 1.05-1.32). LV-GLS was also associated with a higher risk for the composite secondary endpoint (aHR 1.06, 95% CI 1.01-1.12). The addition of LV-GLS enhanced the performance of the ESC risk score (C-statistic 0.756 vs. 0.842, P = 0.007) and the 2011 ACC/AHA risk factor strategy (C-statistic 0.743 vs. 0.814, P = 0.007) for predicting SCD.
Conclusion
LV-GLS is an important prognosticator in patients with HCM and provides additional information to established risk stratification strategies for predicting SCD.

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: 19 Sep 2021; epub ahead of print
Lee HJ, Kim HK, Lee SC, Kim J, ... Cho GY, Kim YJ
Eur Heart J Cardiovasc Imaging: 19 Sep 2021; epub ahead of print | PMID: 34542591
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Abstract

Association of coronary artery calcium score with qualitatively and quantitatively assessed adverse plaque on coronary CT angiography in the SCOT-HEART trial.

Osborne-Grinter M, Kwiecinski J, Doris M, McElhinney P, ... Dey D, Williams MC
Aims
Coronary artery calcification is a marker of cardiovascular risk, but its association with qualitatively and quantitatively assessed plaque subtypes is unknown.
Methods and results
In this post-hoc analysis, computed tomography (CT) images and 5-year clinical outcomes were assessed in SCOT-HEART trial participants. Agatston coronary artery calcium score (CACS) was measured on non-contrast CT and was stratified as zero (0 Agatston units, AU), minimal (1-9 AU), low (10-99 AU), moderate (100-399 AU), high (400-999 AU), and very high (≥1000 AU). Adverse plaques were investigated by qualitative (visual categorization of positive remodelling, low-attenuation plaque, spotty calcification, and napkin ring sign) and quantitative (calcified, non-calcified, low-attenuation, and total plaque burden; Autoplaque) assessments. Of 1769 patients, 36% had a zero, 9% minimal, 20% low, 17% moderate, 10% high, and 8% very high CACS. Amongst patients with a zero CACS, 14% had non-obstructive disease, 2% had obstructive disease, 2% had visually assessed adverse plaques, and 13% had low-attenuation plaque burden >4%. Non-calcified and low-attenuation plaque burden increased between patients with zero, minimal, and low CACS (P < 0.001), but there was no statistically significant difference between those with medium, high, and very high CACS. Myocardial infarction occurred in 41 patients, 10% of whom had zero CACS. CACS >1000 AU and low-attenuation plaque burden were the only predictors of myocardial infarction, independent of obstructive disease, and 10-year cardiovascular risk score.
Conclusion
In patients with stable chest pain, zero CACS is associated with a good but not perfect prognosis, and CACS cannot rule out obstructive coronary artery disease, non-obstructive plaque, or adverse plaque phenotypes, including low-attenuation plaque.

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: 15 Sep 2021; epub ahead of print
Osborne-Grinter M, Kwiecinski J, Doris M, McElhinney P, ... Dey D, Williams MC
Eur Heart J Cardiovasc Imaging: 15 Sep 2021; epub ahead of print | PMID: 34529050
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Abstract

Optimal echocardiographic assessment of myocardial dysfunction for arrhythmic risk stratification in phospholamban mutation carriers.

Taha K, Verstraelen TE, de Brouwer R, de Bruin-Bon RHACM, ... van den Berg MP, Teske AJ
Aims 
Phospholamban (PLN) p.Arg14del mutation carriers are at risk of developing malignant ventricular arrhythmias (VAs) and/or heart failure. Currently, left ventricular ejection fraction (LVEF) plays an important role in risk assessment for VA in these individuals. We aimed to study the incremental prognostic value of left ventricular mechanical dispersion (LVMD) by echocardiographic deformation imaging for prediction of sustained VA in PLN p.Arg14del mutation carriers.
Methods and results
We included 243 PLN p.Arg14del mutation carriers, which were classified into three groups according to the \'45/45\' rule: (i) normal left ventricular (LV) function, defined as preserved LVEF ≥45% with normal LVMD ≤45 ms (n = 139), (ii) mechanical LV dysfunction, defined as preserved LVEF ≥45% with abnormal LVMD >45 ms (n = 63), and (iii) overt LV dysfunction, defined as reduced LVEF <45% (n = 41). During a median follow-up of 3.3 (interquartile range 1.8-6.0) years, sustained VA occurred in 35 individuals. The negative predictive value of having normal LV function at baseline was 99% [95% confidence interval (CI): 92-100%] for developing sustained VA. The positive predictive value of mechanical LV dysfunction was 20% (95% CI: 15-27%). Mechanical LV dysfunction was an independent predictor of sustained VA in multivariable analysis [hazard ratio adjusted for VA history: 20.48 (95% CI: 2.57-162.84)].
Conclusion 
LVMD has incremental prognostic value on top of LVEF in PLN p.Arg14del mutation carriers, particularly in those with preserved LVEF. The \'45/45\' rule is a practical approach to echocardiographic risk stratification in this challenging group of patients. This approach may also have added value in other diseases where LVEF deterioration is a relative late marker of myocardial dysfunction.

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

Eur Heart J Cardiovasc Imaging: 12 Sep 2021; epub ahead of print
Taha K, Verstraelen TE, de Brouwer R, de Bruin-Bon RHACM, ... van den Berg MP, Teske AJ
Eur Heart J Cardiovasc Imaging: 12 Sep 2021; epub ahead of print | PMID: 34516619
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Impact:
Abstract

Mitral annular calcification and valvular dysfunction: multimodality imaging evaluation, grading, and management.

Xu B, Kocyigit D, Wang TKM, Tan CD, ... Unai S, Griffin BP
Mitral annular calcification (MAC) refers to calcium deposition in the fibrous skeleton of the mitral valve. It has many cardiovascular associations, including mitral valve dysfunction, elevated cardiovascular risk, arrhythmias, and endocarditis. Echocardiography conventionally is the first-line imaging modality for anatomic assessment, and evaluation of mitral valve function. Cardiac computed tomography (CT) has demonstrated importance as an imaging modality for the evaluation and planning of related procedures. It also holds promise in quantitative grading of MAC. Currently, there is no universally accepted definition or classification system of MAC severity. We review the multimodality imaging evaluation of MAC and associated valvular dysfunction and propose a novel classification system based on qualitative and quantitative measurements derived from echocardiography and cardiac CT.

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Eur Heart J Cardiovasc Imaging: 08 Sep 2021; epub ahead of print
Xu B, Kocyigit D, Wang TKM, Tan CD, ... Unai S, Griffin BP
Eur Heart J Cardiovasc Imaging: 08 Sep 2021; epub ahead of print | PMID: 34591959
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Impact:
Abstract

Comparison of left atrial strain measured by feature tracking computed tomography and speckle tracking echocardiography in patients with aortic stenosis.

Hirasawa K, Kuneman JH, Singh GK, Gegenava T, ... Bax JJ, Delgado V
Aims
Peak left atrial longitudinal strain (PALS) is a marker of the left atrial (LA) reservoir function. Novel feature tracking (FT) software allows assessment of LA strain from multidetector computed tomography (MDCT) data. This study aimed at evaluating the agreement between speckle tracking echocardiography (STE) and FT MDCT for the measurement of PALS in patients with sinus rhythm (SR) and with atrial fibrillation (AF).
Methods and results
The current study included 318 patients (80 ± 7 years, 54% male) with dynamic MDCT data acquired prior to transcatheter aortic valve implantation. PALS was measured by transthoracic echocardiography using STE (PALSecho) and MDCT using dedicated FT software (PALSCT). In the overall population, the median values of PALSecho and PALSCT were 19.0 [interquartile range (IQR) 12.0-25.0] % and 15.3 (IQR 9.2-19.7) %, respectively. High correlation between PALSecho and PALSCT was observed (r = 0.789, P < 0.001) with a mean bias of -3.7%. The correlation between PALSecho and PALSCT was better among patients with SR (N = 258; r = 0.704, P < 0.001) as compared to patients with AF (N = 60; r = 0.622, P < 0.001).
Conclusion
PALSecho and PALSCT showed a good agreement in patients with severe aortic stenosis (AS) regardless of the cardiac rhythm. FT MDCT may be an important adjuvant modality for assessing LA reservoir function in patients with severe AS.

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: 06 Sep 2021; epub ahead of print
Hirasawa K, Kuneman JH, Singh GK, Gegenava T, ... Bax JJ, Delgado V
Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print | PMID: 34491334
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Impact:
Abstract

Association of aortic valvular complex calcification burden with procedural and long-term clinical outcomes after transcatheter aortic valve replacement.

Ko E, Kang DY, Ahn JM, Kim TO, ... Park SJ, Park DW
Aims
This study aimed to assess the impact of valvular/subvalvular calcium burden on procedural and long-term outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).
Methods and results
In this prospective observational cohort study, we included patients with AS undergoing TAVR between March 2010 and December 2019. Calcium burden at baseline was quantified using multidetector computed tomography and the patients were classified into tertile groups according to the amount of calcium. Procedural outcomes [paravalvular leakage (PVL) or permanent pacemaker insertion (PPI)] and 12-month clinical outcomes (composite of death, stroke, or rehospitalization, and all-cause mortality) were assessed. A total of 676 patients (age, 79.8 ± 5.4 years) were analysed. The 30-day rates of moderate or severe PVL (P-for-trend = 0.03) and PPI (P-for-trend = 0.002) proportionally increased with the tertile levels of calcium volume. The 12-month rate of primary composite outcomes was 34.2% in low-tertile, 23.9% in middle-tertile, and 25.8% in high-tertile groups (log-rank P = 0.02). After multivariable adjustment, the risk for primary composite outcomes at 12 months was not significantly different between the tertile groups of calcium volume [reference = low-tertile; middle-tertile, hazard ratio (HR) 0.81; 95% confidence interval (CI) 0.54-1.22; P = 0.31; high-tertile, HR 0.93; 95% CI 0.56-1.57; P = 0.80]. A similar pattern was observed for all-cause mortality.
Conclusion
The rates of PVL and PPI proportionally increased according to the levels of valvular/subvalvular calcium volume, while the adjusted risks for composite outcomes and mortality at 12 months were not significantly different.

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: 06 Sep 2021; epub ahead of print
Ko E, Kang DY, Ahn JM, Kim TO, ... Park SJ, Park DW
Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print | PMID: 34491331
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Impact:
Abstract

Aortic valve calcification among elderly males from the general population, associated echocardiographic findings, and clinical implications.

Khurrami L, Møller JE, Lindholt JS, Dahl JS, ... Lambrechtsen J, Diederichsen ACP
Aims
Aortic valve calcification (AVC) detected by non-contrast computed tomography (NCCT) associates with morbidity and mortality in patients with aortic valve stenosis. However, the importance of AVC in the general population is sparsely evaluated. We intend to describe the associations between AVC score on NCCT and echocardiographic findings as left atrial (LA) dilatation, left ventricular (LV) hypertrophy, aortic valve area (AVA), peak velocity, mean gradient, and aortic valve replacement (AVR) in a population with AVC scores ≥300 AU.
Methods and results
Of 10 471 males aged 65-74 years from the Danish Cardiovascular Screening trial (DANCAVAS), participants with AVC score ≥300 AU were invited for transthoracic echocardiography and 828 (77%) of 1075 accepted the invitation. AVC scores were categorized (300-599, 600-799, 800-1199, and ≥1200 AU). AVR was obtained from registries. AVC was significantly associated with a steady increase in LA dilation (10.5%, 16.3%, 15.8%, 19.6%, P = 0.031), LV hypertrophy (3.9%, 6.6%, 8.9%, 10.1%, P = 0.021), peak velocity (1.7, 1.9, 2.1, 2.8 m/s, P = 0001), mean gradient (6, 8, 11, 19 mmHg, P = 0.0001), and a decrease in AVA (2.0, 1.9, 1.7, 1.3 cm2, P = 0.0001). The area under the curve was 0.79, 0.93, and 0.92 for AVA ≤1.5 cm2, peak velocity ≥3.0 m/s, and mean gradient ≥20 mmHg, respectively, and the associated optimal AVC score thresholds were 734, 1081, and 1019 AU. AVC > 1200 AU was associated with AVR (P < 0.0001).
Conclusion
Among males from the background population, increasing AVC scores were associated with LA dilatation, LV hypertrophy, AVA, peak aortic velocity, mean aortic gradient, and AVR.

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: 06 Sep 2021; epub ahead of print
Khurrami L, Møller JE, Lindholt JS, Dahl JS, ... Lambrechtsen J, Diederichsen ACP
Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print | PMID: 34491310
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Impact:
Abstract

Sex differences in left ventricular remodelling in patients with severe aortic valve stenosis.

Kuneman JH, Singh GK, Milhorini Pio S, Hirasawa K, ... Delgado V, Bax JJ
Aims 
Women with severe aortic stenosis (AS) have better long-term outcome after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared with men. Whether this is related to sex differences in left ventricular (LV) remodelling is unknown. The aim of this study was to examine the sex differences in LV remodelling with multidetector row computed tomography (MDCT) and outcome in patients with severe AS undergoing TAVI between 2007 and 2018.
Methods and results 
A total of 289 patients (age 80 ± 6 years, 54% male) were included. LV volumes, mass, and function were analysed on pre-procedural MDCT scans. Women showed smaller LV volumes and mass compared with men. Patients were classified into four LV remodelling patterns: concentric hypertrophy (50%) was the most frequent pattern of LV remodelling followed by eccentric hypertrophy (33%), normal geometry (13%), and concentric remodelling (4%). Men showed more concentric remodelling compared with women (91% vs. 9%, respectively, P = 0.011). However, no differences were observed in the remaining LV remodelling patterns. During a median follow-up of 3.8 (IQR 2.2-5.1) years after TAVI, 87 (30%) patients died. Women demonstrated better outcome after TAVI compared with men (log-rank χ2 = 4.29, P = 0.038). No association was observed between the interaction of the LV remodelling patterns and sex with outcome.
Conclusion 
LV concentric hypertrophy and eccentric hypertrophy are similarly observed in men and women with severe AS but concentric remodelling was more common in men. Women demonstrated better outcome after TAVI when compared with men. The interaction between the LV remodelling patterns and sex was not associated with survival.

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: 31 Aug 2021; epub ahead of print
Kuneman JH, Singh GK, Milhorini Pio S, Hirasawa K, ... Delgado V, Bax JJ
Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print | PMID: 34468719
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Impact:
Abstract

Measurement of compensatory arterial remodelling over time with serial coronary computed tomography angiography and 3D metrics.

van den Hoogen IJ, van Rosendael AR, Lin FY, Gianni U, ... Shaw LJ, Bax JJ
Aims
The magnitude of alterations in which coronary arteries remodel and narrow over time is not well understood. We aimed to examine changes in coronary arterial remodelling and luminal narrowing by three-dimensional (3D) metrics from serial coronary computed tomography angiography (CCTA).
Methods and results
From a multicentre registry of patients with suspected coronary artery disease who underwent clinically indicated serial CCTA (median interscan interval = 3.3 years), we quantitatively measured coronary plaque, vessel, and lumen volumes on both scans. Primary outcome was the per-segment change in coronary vessel and lumen volume from a change in plaque volume, focusing on arterial remodelling. Multivariate generalized estimating equations including statins were calculated comparing associations between groups of baseline percent atheroma volume (PAV) and location within the coronary artery tree. From 1245 patients (mean age 61 ± 9 years, 39% women), a total of 5721 segments were analysed. For each 1.00 mm3 increase in plaque volume, the vessel volume increased by 0.71 mm3 [95% confidence interval (CI) 0.63 to 0.79 mm3, P < 0.001] with a corresponding reduction in lumen volume by 0.29 mm3 (95% CI -0.37 to -0.21 mm3, P < 0.001). Serial 3D arterial remodelling and luminal narrowing was similar in segments with low and high baseline PAV (P ≥ 0.496). No differences were observed between left main and non-left main segments, proximal and distal segments and side branch and non-side branch segments (P ≥ 0.281).
Conclusions
Over time, atherosclerotic coronary plaque reveals prominent outward arterial remodelling that co-occurs with modest luminal narrowing. These findings provide additional insight into the compensatory mechanisms involved in the progression of coronary atherosclerosis.

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: 31 Aug 2021; epub ahead of print
van den Hoogen IJ, van Rosendael AR, Lin FY, Gianni U, ... Shaw LJ, Bax JJ
Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print | PMID: 34468717
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Abstract

Changes in left atrial structure and function over a decade in the general population.

Olsen FJ, Johansen ND, Skaarup KG, Lassen MCH, ... Møgelvang R, Biering-Sørensen T
Aims
Assessing left atrial (LA) size and function is an important part of the echocardiographic examination. We sought to assess how LA size and function develop over time, and which clinical characteristics promote atrial remodelling.
Methods and results
We examined longitudinal changes of the LA between two visits in the Copenhagen City Heart Study (n = 1065). The median time between the examinations was 10.4 years. LA measurements included: maximal LA volume (LAVmax), minimal LA volume (LAVmin), and LA emptying fraction (LAEF). Clinical and echocardiographic accelerators were determined from linear regression. The value of LA remodelling for predicting incident atrial fibrillation (AF) and heart failure (HF) was examined by Cox proportional hazards regressions. During follow-up, LAVmax and LAVmin significantly increased by 8.3 and 3.5 mL/m2, respectively. LAEF did not change. Age and AF were the most impactful clinical accelerators of LA remodelling with standardized beta-coefficients of 0.17 and 0.28 for changes in LAVmax, and 0.18 and 0.38 for changes in LAVmin, respectively. Left ventricular (LV) systolic function, diameter, and mass were also significant accelerators of LA remodelling. Changes in both LAVmax and LAVmin were significantly associated with incident AF [n = 46, ΔLAVmax: HR = 1.06 (1.03-1.09), P < 0.001 and ΔLAVmin: HR = 1.14 (1.10-1.18), P < 0.001, per 1 mL/m2 increase] and HF [n = 27, ΔLAVmax: HR = 1.08 (1.04-1.12), P < 0.001 and ΔLAVmin: HR = 1.13 (1.09-1.18), P < 0.001, per 1 mL/m2 increase].
Conclusion
Both maximal and minimal LA volume increase over time. Clinical accelerators included age and AF. LV structure and systolic function also accelerate LA remodelling. LA remodelling poses an increased risk of clinical outcomes.

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: 31 Aug 2021; epub ahead of print
Olsen FJ, Johansen ND, Skaarup KG, Lassen MCH, ... Møgelvang R, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print | PMID: 34468711
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Impact:
Abstract

The year 2020 in the European Heart Journal - Cardiovascular Imaging: part I.

Edvardsen T, Donal E, Marsan NA, Maurovich-Horvat P, ... Petersen SE, Cosyns B
The European Heart Journal - Cardiovascular Imaging was launched in 2012 and has during these 9 years become one of the leading multimodality cardiovascular imaging journals. The journal is currently ranked as number 20 among all cardiovascular journals. Our journal is well 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 in 2020 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

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: 30 Aug 2021; epub ahead of print
Edvardsen T, Donal E, Marsan NA, Maurovich-Horvat P, ... Petersen SE, Cosyns B
Eur Heart J Cardiovasc Imaging: 30 Aug 2021; epub ahead of print | PMID: 34463734
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Impact:
Abstract

Clinical impact of left atrial appendage filling defects in patients undergoing transcatheter aortic valve implantation.

Okuno T, Lanz J, Stortecky S, Heg D, ... Windecker S, Pilgrim T
Aims
Incidental detection of left atrial appendage (LAA) filling defects is a common finding on multi-detector computed tomography in aortic stenosis patients under evaluation for transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence of LAA filling defects before TAVI and its impact on clinical outcomes.
Methods and results
In a prospective registry, LAA filling defects were retrospectively evaluated and categorized into one of four sub-types: thrombus-like, heterogeneous, horizontal, and Hounsfield Unit (HU)-run-off. The primary endpoint was the composite of cardiovascular death or disabling stroke up to 1-year follow-up. Among 1621 patients undergoing TAVI between August 2007 and June 2018, LAA filling defects were present in 177 patients (11%), and categorized as thrombus-like in 22 (1.4%), heterogeneous in 37 (2.3%), horizontal in 80 (4.9%), and HU-run-off in 38 (2.4%). Compared to patients with normal LAA filling, patients with LAA filling defects had greater prevalence of atrial fibrillation (84.7% vs. 26.4%, P < 0.001) and history of cerebrovascular events (16.4% vs. 10.9%, P = 0.045). The primary endpoint occurred in 131 patients (9.2%) with normal LAA filling and in 36 patients (21.2%) with LAA filling defects (P < 0.001). Subgroup analysis suggested that the risk of disabling stroke was greatest in the thrombus-like pattern (23.0%), followed by the HU-run-off (8.0%), the heterogeneous (6.2%), and the horizontal pattern (1.2%).
Conclusion
LAA filling defects were observed in 11% of aortic stenosis patients undergoing TAVI and associated with an increased risk of cardiovascular death and disabling stroke up to 1 year following TAVI.
Trial registration
https://www.clinicaltrials.gov. NCT01368250.

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Eur Heart J Cardiovasc Imaging: 30 Aug 2021; epub ahead of print
Okuno T, Lanz J, Stortecky S, Heg D, ... Windecker S, Pilgrim T
Eur Heart J Cardiovasc Imaging: 30 Aug 2021; epub ahead of print | PMID: 34463717
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Abstract

Adverse right ventricular remodelling, function, and stress responses in obesity: insights from cardiovascular magnetic resonance.

Lewis AJM, Abdesselam I, Rayner JJ, Byrne J, ... Neubauer S, Rider OJ
Aims
We aimed to determine the effect of increasing body weight upon right ventricular (RV) volumes, energetics, systolic function, and stress responses using cardiovascular magnetic resonance (CMR).
Methods and results
We first determined the effects of World Health Organization class III obesity [body mass index (BMI) > 40 kg/m2, n = 54] vs. healthy weight (BMI < 25 kg/m2, n = 49) upon RV volumes, energetics and systolic function using CMR. In less severe obesity (BMI 35 ± 5 kg/m2, n = 18) and healthy weight controls (BMI 21 ± 1 kg/m2, n = 9), we next performed CMR before and during dobutamine to evaluate RV stress response. A subgroup undergoing bariatric surgery (n = 37) were rescanned at median 1 year to determine the effects of weight loss. When compared with healthy weight, class III obesity was associated with adverse RV remodelling (17% RV end-diastolic volume increase, P < 0.0001), impaired cardiac energetics (19% phosphocreatine to adenosine triphosphate ratio reduction, P < 0.001), and reduction in RV ejection fraction (by 3%, P = 0.01), which was related to impaired energetics (R = 0.3, P = 0.04). Participants with less severe obesity had impaired RV diastolic filling at rest and blunted RV systolic and diastolic responses to dobutamine compared with healthy weight. Surgical weight loss (34 ± 15 kg weight loss) was associated with improvement in RV end-diastolic volume (by 8%, P = 0.006) and systolic function (by 2%, P = 0.03).
Conclusion
Increasing body weight is associated with significant alterations in RV volumes, energetic, systolic function, and stress responses. Adverse RV modelling is mitigated with weight loss. Randomized trials are needed to determine whether intentional weight loss improves symptoms and outcomes in patients with obesity and heart failure.

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

Eur Heart J Cardiovasc Imaging: 27 Aug 2021; epub ahead of print
Lewis AJM, Abdesselam I, Rayner JJ, Byrne J, ... Neubauer S, Rider OJ
Eur Heart J Cardiovasc Imaging: 27 Aug 2021; epub ahead of print | PMID: 34453521
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Impact:
Abstract

Risk prediction in patients with COVID-19 based on haemodynamic assessment of left and right ventricular function.

Taieb P, Szekely Y, Lupu L, Ghantous E, ... Banai S, Topilsky Y
Aims
Cardiovascular involvement is common in COVID-19. We sought to describe the haemodynamic profiles of hospitalized COVID-19 patients and determine their association with mortality.
Methods and results
Consecutive hospitalized patients diagnosed with COVID-19 infection underwent clinical evaluation using the Modified Early Warning Score (MEWS) and a full non-invasive echocardiographic haemodynamic evaluation, irrespective of clinical indication, as part of a prospective predefined protocol. Patients were stratified based on filling pressure and output into four groups. Multivariable Cox-Hazard analyses determined the association between haemodynamic parameters with mortality. Among 531 consecutive patients, 44% of patients had normal left ventricular (LV) and right ventricular (RV) haemodynamic status. In contrast to LV haemodynamic parameters, RV parameters worsened with higher MEWS stage. While RV parameters did not have incremental risk prediction value above MEWS, LV stroke volume index, E/e\' ratio, and LV stroke work index were all independent predictors of outcome, particularly in severe disease. Patients with LV or RV with high filling pressure and low output had the worse outcome, and patients with normal haemodynamics had the best (P < 0.0001).
Conclusion
In hospitalized patients with COVID-19, almost half have normal left and right haemodynamics at presentation. RV but not LV haemodynamics are related to easily obtainable clinical parameters. LV but not RV haemodynamics are independent predictors of mortality, mostly in patients with severe disease.

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: 27 Aug 2021; epub ahead of print
Taieb P, Szekely Y, Lupu L, Ghantous E, ... Banai S, Topilsky Y
Eur Heart J Cardiovasc Imaging: 27 Aug 2021; epub ahead of print | PMID: 34453517
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Impact:
Abstract

Left atrial strain is a predictor of left ventricular systolic and diastolic reverse remodelling in CRT candidates.

Galli E, Oger E, Aalen JM, Duchenne J, ... Smiseth OA, Donal E
Aims
The left atrium (LA) has a pivotal role in cardiac performance and LA deformation is a well-known prognostic predictor in several clinical conditions including heart failure with reduced ejection fraction. The aim of this study is to investigate the effect of cardiac resynchronization therapy (CRT) on both LA morphology and function and to assess the impact of LA reservoir strain (LARS) on left ventricular (LV) systolic and diastolic remodelling after CRT.
Methods and results
Two hundred and twenty-one CRT-candidates were prospectively included in the study in four tertiary centres and underwent echocardiography before CRT-implantation and at 6-month follow-up (FU). CRT-response was defined by a 15% reduction in LV end-systolic volume. LV systolic and diastolic remodelling were defined as the percent reduction in LV end-systolic and end-diastolic volume at FU. Indexed LA volume (LAVI) and LV-global longitudinal (GLS) strain were the main parameters correlated with LARS, with LV-GLS being the strongest determinant of LARS (r = -0.59, P < 0.0001). CRT induced a significant improvement in LAVI and LARS in responders (both P < 0.0001). LARS was an independent predictor of both LV systolic and diastolic remodelling at follow-up (r = -0.14, P = 0.049 and r = -0.17, P = 0.002, respectively).
Conclusion
CRT induces a significant improvement in LAVI and LARS in responders. In CRT candidates, the evaluation of LARS before CRT delivery is an independent predictor of LV systolic and diastolic remodelling at FU.

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: 24 Aug 2021; epub ahead of print
Galli E, Oger E, Aalen JM, Duchenne J, ... Smiseth OA, Donal E
Eur Heart J Cardiovasc Imaging: 24 Aug 2021; epub ahead of print | PMID: 34432006
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Impact:
Abstract

Novel insights into the athlete\'s heart: is myocardial work the new champion of systolic function?

Tokodi M, Oláh A, Fábián A, Lakatos BK, ... Kovács A, Radovits T
Aims
We sought to investigate the correlation between speckle-tracking echocardiography (STE)-derived myocardial work (MW) and invasively measured contractility in a rat model of athlete\'s heart. We also assessed MW in elite athletes and explored its association with cardiopulmonary exercise test (CPET)-derived aerobic capacity.
Methods and results
Sixteen rats underwent a 12-week swim training program and were compared to controls (n = 16). STE was performed to assess global longitudinal strain (GLS), which was followed by invasive pressure-volume analysis to measure contractility [slope of end-systolic pressure-volume relationship (ESPVR)]. Global MW index (GMWI) was calculated from GLS curves and left ventricular (LV) pressure recordings. In the human investigations, 20 elite swimmers and 20 healthy sedentary controls were enrolled. GMWI was calculated through the simultaneous evaluation of GLS and non-invasively approximated LV pressure curves at rest. All subjects underwent CPET to determine peak oxygen uptake (VO2/kg). Exercised rats exhibited higher values of GLS, GMWI, and ESPVR than controls (-20.9 ± 1.7 vs. -17.6 ± 1.9%, 2745 ± 280 vs. 2119 ± 272 mmHg·%, 3.72 ± 0.72 vs. 2.61 ± 0.40 mmHg/μL, all PExercise < 0.001). GMWI correlated robustly with ESPVR (r = 0.764, P < 0.001). In humans, regular exercise training was associated with decreased GLS (-17.6 ± 1.5 vs. -18.8 ± 0.9%, PExercise = 0.002) but increased values of GMWI at rest (1899 ± 136 vs. 1755 ± 234 mmHg·%, PExercise = 0.025). GMWI exhibited a positive correlation with VO2/kg (r = 0.527, P < 0.001).
Conclusions
GMWI precisely reflected LV contractility in a rat model of exercise-induced LV hypertrophy and captured the supernormal systolic performance in human athletes even at rest. Our findings endorse the utilization of MW analysis in the evaluation of the athlete\'s heart.

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

Eur Heart J Cardiovasc Imaging: 24 Aug 2021; epub ahead of print
Tokodi M, Oláh A, Fábián A, Lakatos BK, ... Kovács A, Radovits T
Eur Heart J Cardiovasc Imaging: 24 Aug 2021; epub ahead of print | PMID: 34432004
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Abstract

A simplified wall-based model for regional innervation/perfusion mismatch assessed by cardiac 123I-mIBG and rest 99mTc-tetrofosmin SPECT to predict arrhythmic events in ischaemic heart failure.

Verschure DO, Poel E, Travin MI, Henzlova MJ, ... Jacobson AF, Verberne HJ
Aims
Cardiac 123iodine-meta-iodobenzylguanidine (123I-mIBG) single-photon emission computed tomography (SPECT) imaging provides information on regional myocardial innervation. However, the value of the commonly used 17-segment summed defect score (SDS) as a prognostic marker is uncertain. The present study examined whether a simpler regional scoring approach for evaluation of 123I-mIBG SPECT combined with rest 99mTc-tetrofosmin SPECT myocardial perfusion imaging could improve prediction of arrhythmic events (AEs) in patients with ischaemic heart failure (HF).
Methods and results
Five hundred and two ischaemic HF subjects of the ADMIRE-HF study with complete cardiac 123I-mIBG and rest 99mTc-tetrofosmin SPECT studies were included. Both SPECT image sets were read together by two experienced nuclear imagers and scored by consensus. In addition to standard 17-segment scoring, the readers classified walls (i.e. anterior, lateral, inferior, septum and apex) as normal, matched defect, mismatched (innervation defect > perfusion defect), or reverse mismatched (perfusion defect > innervation defect). Cox proportional hazards ratios (HRs) were used to determine if age, body mass index, functional class, left ventricular ejection fraction (LVEF), B-type natriuretic peptide (BNP), norepinephrine, 123I-mIBG SDS, 99mTc-tetrofosmin SDS, innervation/perfusion mismatch SDS, and our simplified visual innervation/perfusion wall classification were associated with occurrence of AEs (i.e. sudden cardiac death, sustained ventricular tachycardia, resuscitated cardiac arrest, appropriate implantable cardioverter-defibrillator therapy). At 2-year median follow-up, 52 subjects (10.4%) had AEs. Subjects with 1 or 2 mismatched walls were twice as likely to have AEs compared with subjects with either 0 or 3-5 mismatched walls (16.3% vs. 8.3%, P = 0.010). Cox regression analyses showed that patients with a visual mismatch in 1-2 walls had an almost two times higher risk of AEs [HR 2.084 (1.109-3.914), P = 0.001]. None of the other innervation, perfusion and mismatch scores using standard 17 segments were associated with AEs. BNP (ng/L) was the only non-imaging parameter associated with AEs.
Conclusion
A visual left ventricular wall-level based scoring method identified highest AE risk in ischaemic HF subjects with intermediate levels of innervation/perfusion mismatches. This simple technique for the evaluation of SPECT studies, which are often challenging in HF subjects, seems to be superior to the 17-segment scoring method.

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

Eur Heart J Cardiovasc Imaging: 23 Aug 2021; epub ahead of print
Verschure DO, Poel E, Travin MI, Henzlova MJ, ... Jacobson AF, Verberne HJ
Eur Heart J Cardiovasc Imaging: 23 Aug 2021; epub ahead of print | PMID: 34427293
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Impact:
Abstract

Prognostic implications of left heart diastolic dysfunction in adults with coarctation of aorta.

Egbe AC, Miranda WR, Oh JK, Connolly HM
Aims
The prognostic implication of left atrial (LA) dysfunction and left ventricular diastolic dysfunction (LVDD) in patients with coarctation of aorta (COA) is unknown. The purpose of this study was to determine whether LA dysfunction and LVDD were associated with mortality in COA patients.
Methods and results
This is a retrospective review of adults (age ≥18 years) with repaired COA that underwent transthoracic echocardiogram (2000-18). LVDD was determined using the 2016 guidelines for LV diastolic function assessment, and LA dysfunction was assessed using LA reservoir strain. Of 721 patients, LV diastolic function could be determined in 635 (88%); and 414 (65%) had no LVDD, while 146 (23%), 53 (8%), and 22 (4%) had Grade I/II/III LVDD, respectively. The mean LA reservoir strain was 39 ± 11%, and patients were divided into quartiles: top quartile (reference group), mild LA dysfunction, moderate LA dysfunction, and severe LA dysfunction. Grade III LVDD (but not Grades I and II) was associated with death/transplant. On the other hand, there was an incremental risk of death/transplant across LA strain quartiles: mild LA dysfunction [hazard ratio (HR) 1.16, 1.04-2.06], moderate LA dysfunction (HR 1.75, 1.27-3.58), and severe LA dysfunction (HR 3.49, 1.88-7.16). Of 86 patients with indeterminate diastolic function, there was a trend towards a lower 5-year transplant-free survival in patients with LA dysfunction vs. normal LA function (83% vs. 91%, P = 0.06).
Conclusion
LA dysfunction (but not LVDD) was associated with incremental risk of mortality and thus can be used for prognostication in all patients including those with indeterminate diastolic function.

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: 22 Aug 2021; epub ahead of print
Egbe AC, Miranda WR, Oh JK, Connolly HM
Eur Heart J Cardiovasc Imaging: 22 Aug 2021; epub ahead of print | PMID: 34423358
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Impact:
Abstract

Impaired myocardial work efficiency in heart failure with preserved ejection fraction.

D\'Andrea A, Ilardi F, D\'Ascenzi F, Bandera F, ... D\'Alto M, Cameli M
Aims
Heart failure with preserved ejection fraction (HFpEF) is a growing public health problem. Impairment in left ventricular (LV) diastolic function has been proposed as a key pathophysiologic determinant. However, the role of concomitant systolic dysfunction despite preserved LV ejection fraction (LVEF) has not been well characterized. To analyse LV myocardial deformation, diastolic function, and contractile reserve (CR) in patients with HFpEF at rest and while during exercise, as well as their correlation with functional capacity.
Methods and results
Standard echo, lung ultrasound, LV 2D speckle-tracking strain, and myocardial work efficiency (MWE) were performed at rest and during exercise in 230 patients with HFpEF (female sex 61.2%; 71.3 ± 5.3 years) in 150 age- and sex-comparable healthy controls. LV mass index and LAVI were significantly increased in HFpEF. Conversely, global longitudinal strain (GLS) and MWE were consequently reduced in HFpEF patients. During effort, HFpEF showed reduced exercise time, capacity, and VO2 peak. Increase in LVEF and LV GLS was significantly lower in HFpEF patients, while LV E/e\' ratio, pulmonary pressures, and B-lines by lung ultrasound rose. A multivariable analysis outlined that LV MWE at rest was closely related to maximal Watts reached (beta coefficient: 0.43; P < 0.001), peak VO2 (beta: 0.50; P < 0.001), LV E/e\' (beta: 0.52, P < 0.001), and number of B-lines during effort (beta: -0.36; P < 0.01).
Conclusions
The lower resting values of LV GLS and MWE in HFpEF patients suggest an early subclinical myocardial damage, which seems to be closely associated with lower exercise capacity, greater pulmonary congestion, and blunted LV contractile reserve during effort.

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: 18 Aug 2021; epub ahead of print
D'Andrea A, Ilardi F, D'Ascenzi F, Bandera F, ... D'Alto M, Cameli M
Eur Heart J Cardiovasc Imaging: 18 Aug 2021; epub ahead of print | PMID: 34410362
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Abstract

Predicting future left anterior descending artery events from non-culprit lesions: insights from the Lipid-Rich Plaque study.

Kuku KO, Garcia-Garcia HM, Doros G, Mintz GS, ... Waksman R, LRP Investigators
Aims
The left anterior descending (LAD) artery is the most frequently affected site by coronary artery disease. The prospective Lipid Rich Plaque (LRP) study, which enrolled patients undergoing imaging of non-culprits followed over 2 years, reported the successful identification of coronary segments at risk of future events based on near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) lipid signals. We aimed to characterize the plaque events involving the LAD vs. non-LAD segments.
Methods and results
LRP enrolled 1563 patients from 2014 to 2016. All adjudicated plaque events defined by the composite of cardiac death, cardiac arrest, non-fatal myocardial infarction, acute coronary syndrome, revascularization by coronary bypass or percutaneous coronary intervention, and rehospitalization for angina with >20% stenosis progression and reported as non-culprit lesion-related major adverse cardiac events (NC-MACE) were classified by NIRS-IVUS maxLCBI4 mm (maximum 4-mm Lipid Core Burden Index) ≤400 or >400 and association with high-risk-plaque characteristics, plaque burden ≥70%, and minimum lumen area (MLA) ≤4 mm2. Fifty-seven events were recorded with more lipid-rich plaques in the LAD vs. left circumflex and right coronary artery; 12.5% vs. 10.4% vs. 11.3%, P = 0.097. Unequivocally, a maxLCBI4 mm >400 in the LAD was more predictive of NC-MACE [hazard ratio (HR) 4.32, 95% confidence interval (CI) (1.93-9.69); P = 0.0004] vs. [HR 2.56, 95% CI (1.06-6.17); P = 0.0354] in non-LAD segments. MLA ≤4 mm2 within the maxLCBI4 mm was significantly higher in the LAD (34.1% vs. 25.9% vs. 13.7%, P < 0.001).
Conclusion
Non-culprit lipid-rich segments in the LAD were more frequently associated with plaque-level events. LAD NIRS-IVUS screening may help identify patients requiring intensive surveillance and medical treatment.

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: 18 Aug 2021; epub ahead of print
Kuku KO, Garcia-Garcia HM, Doros G, Mintz GS, ... Waksman R, LRP Investigators
Eur Heart J Cardiovasc Imaging: 18 Aug 2021; epub ahead of print | PMID: 34410335
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Abstract

Adaptive development of concomitant secondary mitral and tricuspid regurgitation after transcatheter aortic valve replacement.

Winter MP, Bartko PE, Krickl A, Gatterer C, ... Hengstenberg C, Goliasch G
Aims
Concomitant secondary atrioventricular regurgitation is frequent in patients with severe aortic stenosis scheduled for transcatheter aortic valve replacement (TAVR). The future implications of leaving associated valve lesions untreated after TAVR remain unknown. Aim of the present study was to characterize the evolution of concomitant secondary atrioventricular regurgitations and to evaluate their impact on long-term prognosis.
Methods and results
We prospectively enrolled 429 consecutive TAVR patients. All patients underwent comprehensive clinical, laboratory, and echocardiographic assessments prior to TAVR, at discharge, and yearly thereafter. All-cause mortality was chosen as primary study endpoint. At baseline, severe concomitant secondary mitral regurgitation (sMR) was present in 54 (13%) and severe concomitant secondary tricuspid regurgitation (sTR) in 75 patients (17%). After TAVR 59% of patients with severe sMR at baseline experienced sMR regression, whereas analogously sTR regressed in 43% of patients with severe sTR. Persistence of sTR and sMR were associated with excess mortality after adjustment for our bootstrap-selected confounder model with an adjusted HR of 2.44 (95% CI 1.15-5.20, P = 0.021) for sMR and of 2.09 (95% CI 1.20-3.66, P = 0.01) for sTR. Patients showing regression of atrioventricular regurgitation exhibited survival rates indistinguishable to those seen in patients without concomitant atrioventricular regurgitation (sMR: P = 0.83; sTR: P = 0.74).
Conclusion
Concomitant secondary atrioventricular regurgitation in patients with severe AS is a highly dynamic process with up to half of all patients showing regression of associated valvular regurgitation after TAVR and subsequent favourable post-interventional outcome. Persistent atrioventricular regurgitation is a major determinant of unfavourable outcome after TAVR and proposes a window of early sequel intervention.

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 Aug 2021; 22:1045-1053
Winter MP, Bartko PE, Krickl A, Gatterer C, ... Hengstenberg C, Goliasch G
Eur Heart J Cardiovasc Imaging: 13 Aug 2021; 22:1045-1053 | PMID: 32561917
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Abstract

How-to: Focus Cardiac Ultrasound in acute settings.

Soliman-Aboumarie H, Breithardt OA, Gargani L, Trambaiolo P, Neskovic AN
Focus cardiac ultrasound (FoCUS) provides vital information at at the bedside which has the potential of improving outcomes in the acute settings. FoCUS could help the clinicians in their daily clinical decision-making while applied within the clinical context as an extension of bedside clinical examination. FoCUS practitioners should be aware of their own limitations with the importance of the timely referral for comprehensive Echocardiography whenever required.

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 Aug 2021; epub ahead of print
Soliman-Aboumarie H, Breithardt OA, Gargani L, Trambaiolo P, Neskovic AN
Eur Heart J Cardiovasc Imaging: 11 Aug 2021; epub ahead of print | PMID: 34382077
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Abstract

Role of non-invasive multimodality imaging in autoimmune pericarditis.

Jain V, Chhabra G, Chetrit M, Bansal A, ... Cremer PC, Klein AL
Systemic autoimmune diseases are an important cause of pericardial involvement and contribute to up to ∼22% cases of pericarditis with a known aetiology. The underlying mechanism for pericardial involvement varies with each systemic disease and leads to a poor understanding of its management. Multimodality imaging establishes the diagnosis and determines the type and extent of pericardial involvement. In this review, we elaborate upon various pericardial syndromes associated with different systemic autoimmune and autoinflammatory diseases and the multitude of imaging modalities that can be used to further characterize autoimmune pericardial involvement. Lastly, these forms of pericarditis have a greater likelihood of recurrence, and clinicians need to understand their unique treatment approaches to improve patient outcomes.

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: 31 Jul 2021; epub ahead of print
Jain V, Chhabra G, Chetrit M, Bansal A, ... Cremer PC, Klein AL
Eur Heart J Cardiovasc Imaging: 31 Jul 2021; epub ahead of print | PMID: 34333596
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Abstract

Non-invasive characterization of pleural and pericardial effusions using T1 mapping by magnetic resonance imaging.

Rosmini S, Seraphim A, Knott K, Brown JT, ... Moon JC, Manisty C
Aims
Differentiating exudative from transudative effusions is clinically important and is currently performed via biochemical analysis of invasively obtained samples using Light\'s criteria. Diagnostic performance is however limited. Biochemical composition can be measured with T1 mapping using cardiovascular magnetic resonance (CMR) and hence may offer diagnostic utility for assessment of effusions.
Methods and results
A phantom consisting of serially diluted human albumin solutions (25-200 g/L) was constructed and scanned at 1.5 T to derive the relationship between fluid T1 values and fluid albumin concentration. Native T1 values of pleural and pericardial effusions from 86 patients undergoing clinical CMR studies retrospectively analysed at four tertiary centres. Effusions were classified using Light\'s criteria where biochemical data was available (n = 55) or clinically in decompensated heart failure patients with presumed transudative effusions (n = 31). Fluid T1 and protein values were inversely correlated both in the phantom (r = -0.992) and clinical samples (r = -0.663, P < 0.0001). T1 values were lower in exudative compared to transudative pleural (3252 ± 207 ms vs. 3596 ± 213 ms, P < 0.0001) and pericardial (2749 ± 373 ms vs. 3337 ± 245 ms, P < 0.0001) effusions. The diagnostic accuracy of T1 mapping for detecting transudates was very good for pleural and excellent for pericardial effusions, respectively [area under the curve 0.88, (95% CI 0.764-0.996), P = 0.001, 79% sensitivity, 89% specificity, and 0.93, (95% CI 0.855-1.000), P < 0.0001, 95% sensitivity; 81% specificity].
Conclusion
Native T1 values of effusions measured using CMR correlate well with protein concentrations and may be helpful for discriminating between transudates and exudates. This may help focus the requirement for invasive diagnostic sampling, avoiding unnecessary intervention in patients with unequivocal transudative effusions.

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: 29 Jul 2021; epub ahead of print
Rosmini S, Seraphim A, Knott K, Brown JT, ... Moon JC, Manisty C
Eur Heart J Cardiovasc Imaging: 29 Jul 2021; epub ahead of print | PMID: 34331054
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Abstract

Deep learning for vessel-specific coronary artery calcium scoring: validation on a multi-centre dataset.

Winkel DJ, Suryanarayana VR, Ali AM, Görich J, ... Schoepf UJ, Rapaka S
Aims
To present and validate a fully automated, deep learning (DL)-based branch-wise coronary artery calcium (CAC) scoring algorithm on a multi-centre dataset.
Methods and results
We retrospectively included 1171 patients referred for a CAC computed tomography examination. Total CAC scores for each case were manually evaluated by a human reader. Next, each dataset was fully automatically evaluated by the DL-based software solution with output of the total CAC score and sub-scores per coronary artery (CA) branch [right coronary artery (RCA), left main (LM), left anterior descending (LAD), and circumflex (CX)]. Three readers independently manually scored the CAC for all CA branches for 300 cases from a single centre and formed the consensus using a majority vote rule, serving as the reference standard. Established CAC cut-offs for the total Agatston score were used for risk group assignments. The performance of the algorithm was evaluated using metrics for risk class assignment based on total Agatston score, and unweighted Cohen\'s Kappa for branch label assignment. The DL-based software solution yielded a class accuracy of 93% (1085/1171) with a sensitivity, specificity, and accuracy of detecting non-zero coronary calcium being 97%, 93%, and 95%. The overall accuracy of the algorithm for branch label classification was 94% (LM: 89%, LAD: 91%, CX: 93%, RCA: 100%) with a Cohen\'s kappa of k = 0.91.
Conclusion
Our results demonstrate that fully automated total and vessel-specific CAC scoring is feasible using a DL-based algorithm. There was a high agreement with the manually assessed total CAC from a multi-centre dataset and the vessel-specific scoring demonstrated consistent and reproducible results.

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: 28 Jul 2021; epub ahead of print
Winkel DJ, Suryanarayana VR, Ali AM, Görich J, ... Schoepf UJ, Rapaka S
Eur Heart J Cardiovasc Imaging: 28 Jul 2021; epub ahead of print | PMID: 34322693
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Abstract

Left atrial appendage thrombus and cerebrovascular events post-transcatheter aortic valve implantation.

van Wiechen MP, Faure ME, Hokken TW, Ooms JF, ... Budde RPJ, Van Mieghem NM
Aims
To elucidate the frequency and clinical impact of left atrial appendage thrombus (LAAT) in patients set for transcatheter aortic valve implantation (TAVI).
Methods and results
All patients undergoing TAVI between January 2014 and June 2020 with analysable multislice computed tomography (MSCT) for LAAT were included. Baseline and procedural characteristics were collected, pre-procedural MSCT\'s were retrospectively analysed for LAAT presence. The primary endpoint was defined as the cumulative incidence of any cerebrovascular event (stroke or transient ischaemic attack) within the first year after TAVI. A Cox proportional hazards model was used to identify predictors.A total of 1050 cases had analysable MSCT. Median age was 80 [interquartile range (IQR) 74-84], median Society of Thoracic Surgeons\' Predicted Risk Of Mortality (STS-PROM) was 3.4% (IQR 2.3-5.5). Thirty-six percent were on oral anticoagulant therapy for atrial fibrillation (AF). LAAT was present in 48 (4.6%) of cases. Patients with LAAT were at higher operative risk [STS-PROM: 4.9% (2.9-7.1) vs. 3.4% (2.3-5.5), P = 0.01], had worse systolic left ventricular function [EF 52% (35-60) vs. 55% (45-65), P = 0.01] and more permanent pacemakers at baseline (35% vs. 10%, P < 0.01). All patients with LAAT had a history of AF and patients with LAAT were more often on vitamin K antagonist-treatment than patients without LAAT [43/47 (91%) vs. 232/329 (71%), P < 0.01]. LAAT [hazard ratio (HR) 2.94 (1.39-6.22), P < 0.01] and the implantation of more than one valve [HR 4.52 (1.79-11.25), P < 0.01] were independent predictors for cerebrovascular events.
Conclusion
Patients with MSCT-identified LAAT were at higher risk for cerebrovascular events during the first year after TAVI.

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: 27 Jul 2021; epub ahead of print
van Wiechen MP, Faure ME, Hokken TW, Ooms JF, ... Budde RPJ, Van Mieghem NM
Eur Heart J Cardiovasc Imaging: 27 Jul 2021; epub ahead of print | PMID: 34322706
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This program is still in alpha version.